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Osigwe: Mass vaccination for Meningitis is sacrosanct

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The Nigeria Centre for Disease Control (NCNC) has confirmed the outbreak of Cerebro Spinal Meningitis (CSM), in five states across the country, with 109 deaths at weekend. In this interview, Agabi Osigwe, a Consultant Physician and Neurologist with Lagos University Teaching Hospital (LUTH), told PAUL ADUNWOKE how to treat, manage and prevent CSM infections.

What is meningitis?
MENINGITIS refers to an infection of the coverings of meninges, and fluid cerebrospinal fluid surrounding the brain and spinal cord. It is a major cause of death and disability worldwide.

What are the causes of meningitis?
Meningitis can be caused by an array of infectious agents, which include, bacteria, viruses, fungi and parasites. Of the many causes of meningitis, bacterial meningitis is the most serious, because its onset is rapid and the infection is associated with a significant risk of death. Several different bacteria can cause meningitis and they vary by age group and regions of the world. Beyond the perinatal period, three organisms: Neisseria meningitidis, haemophilus influenzae, and streptococcus pneumoniae are responsible for most cases of bacterial meningitis.

The bacterium, neisseria meningitides, also known as meningococcus, is the most important microorganism causing meningitis, as it is responsible for cases of the life-threatening epidemic cerebrospinal meningitis. About 12 serogroups of neisseria meningitidis have been identified. Serogroups A, B, C, W, X and Y are known to cause epidemics affecting both the young and old. A few individuals harbour meningococcus in their nasopharynx, nose and throat region, without developing any disease and are termed asymptomatic carriers. These asymptomatic carriers serve as reservoir for meningococcus and can facilitate the spread of the infection.

What are the risk factors for developing meningitis?
Nigeria lies within the meningitis belt of Africa. This is a semi-arid part of our continent stretching from Senegal in the west to Ethiopia in the east, involving about 26 countries with a population of over 260 million people. Countries within the meningitis belt suffer the highest burden of epidemic meningitis. The whole of northern Nigeria lies within this belt and is prone to epidemics of neisseria menigitidis.

Epidemics of meningitis occur during the dry season between December to June, when dusty winds, cold nights and upper respiratory tract infections combine to damage the protective coatings of the airways, thus increasing the risk of infection and colonisation by neisseria meningitidis. The disease is transmitted from person to person through droplet from respiratory and throat secretions by infected persons or carriers. Transmission is also facilitated by close contacts with cases of the disease or carriers, overcrowded housing and travels to areas with known cases of the illness.

What are the signs and symptoms of meningitis?
The clinical hallmark of meningitis is fever, headache and neck stiffness and pains. Other features include sensitivity to light, termed photophobia, nausea, vomiting, poor appetite, altered level of consciousness presenting as confusion or disorientation, seizures, coma and death. In addition, meningococcal meningitis may manifest with skin rashes. In infants, symptoms may be non-specific and include fever, irritability, poor feeding, vomiting, lethargy and bulging fontanelle.

What should be the next step in case of symptoms?
Meningitis is a life-threatening medical emergency. Death from meningitis can occur within a few days. Although most people recover from meningitis, it can, however, leave in its trail such devastating permanent disabilities as brain damage, hearing impairment, gait abnormalities and cognitive challenges. It is, therefore, important that the symptoms of meningitis be appreciated as emergency and should prompt quick and early hospital visit.

Attempts should not be made to manage the symptoms of meningitis at home under any guise. Early presentation and detection and prompt medical therapy are known to improve outcome in patients with meningitis. Close contacts of persons with meningitis, who are not manifesting the symptoms of the disease, are also encouraged to visit the hospital for prophylactic and preventive treatment and care.

How should meningitis be diagnosed?
Meningitis can be diagnosed on the strength of the presenting clinical features signs and symptoms, alone. Laboratory investigations are necessary to confirm the diagnosis. In cases, where the index of suspicion is high for meningitis, medical treatment is instituted immediately and laboratory work up follows thereafter. The gold standard investigation in meningitis is a lumbar puncture and cerebrospinal fluid analysis. This is an aseptic procedure, where a sample of cerebrospinal fluid is collected via a needle placed at the lower back.

This sample is then analysed in the laboratory, the causative organism cultured, grown and antibiotics sensitivity and susceptibility performed. In selected cases, especially when complications are present, a brain imaging, brain computed tomography scan, CT scan, maybe required. A brain imaging is not required in most cases of meningitis. Other investigations such as blood culture, where the organism is grown from a specimen of blood and other blood work up may be done. Nasopharyngeal swab test may be carried out amongst asymptomatic close contacts of cases to identify nasopharyngeal carriers.

What are the possible treatments for meningitis?
Treatment for acute bacterial meningitis is started with high dose broad-spectrum intravenous antibiotics and a short course of steroids in a hospital setting preferably, in an intensive care unit. With antibiotic sensitivity results, specific narrow spectrum antibiotics may then be employed, while broad-spectrum antibiotics may be discontinued.

Patients also receive other general conservative care, such as intravenous fluids replacements, correction of electrolyte disturbances, prevention of possible complications, and general nursing care. Some patients with complications may require neurosurgical interventions. Preventive medications are administered to close contacts of subjects with meningococcal meningitis and asymptomatic nasopharyngeal carriers. Where meningitis is caused by viruses or fungi organisms, antivirals and antifungal medications are utilised respectively.

How can meningitis be prevented?
Vaccination is the most efficacious method of preventing meningitis and several vaccines are available to control and prevent the dreaded epidemic meningococcal meningitis disease, cerebrospinal meningitis, a meningococcal A conjugate vaccine, C conjugate vaccines, tetravalent A, C, Y and W conjugate vaccines and meningococcal polysaccharide vaccines. Mass vaccination is, therefore, sacrosanct if the battle against epidemics of meningococcal meningitis is to be achieved. Avoidance of close contact with cases of meningitis, avoiding overcrowding and limitation of travels to areas with cases of the diseases are other potential preventive strategies.

I would like to appeal to any individual with symptoms suggestive of meningitis, as discussed above, to please seek urgent medical attention. I would also want to join in encouraging individuals living within the meningitis belt to please submit to vaccination, as meningitis is a life-threatening condition with potentially devastating long-term complications. It is better prevented than cured.



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