Controlling Spread of Meningococcal Infection

A. Isolation and Quarantine Requirements

Minimum Period of Isolation of Patient

Until 24 hours after the initiation of appropriate antibiotic therapy.

Minimum Period of Quarantine of Contacts

None.

B. Chemoprophylaxis is recommended for the following:

Case:

If neither a third generation cephlosporin nor ciprofloxacin was given as treatment, patients with meningococcal invasive disease should receive antibiotic prophylaxis prior to discharge to ensure elimination of nasopharyngeal carriage

Contacts:

Because the rate of secondary disease for close contacts is highest immediately after onset of disease in the index patient, antimicrobial chemoprophylaxis should be administered as soon as possible (ideally <24 hours after identification of the index patient). Conversely, chemoprophylaxis administered >14 days after onset of illness in the index patient is probably of limited or no value.

Chemoprophylaxis is indicated for persons who in the 7 days before onset of illness or until 24 hours after the case had begun an effective antibiotic had close contact with the case. The definition of close contact is not precise but is intended to include to include persons who have had prolonged (8 hours or more) contact while in close proximity (3 feet is the general limit for large-droplet spread) to the case who have been directly exposed to the cases oral secretions. Close contact examples include:

• Household contact,
• Child care contact,
• Direct saliva contact with the case through kissing or sharing items like toothbrushes, water bottles or eating utensils,
• Mouth – to – mouth resuscitation or unprotected contact during endotracheal intubation,
• Frequently slept or ate in the same dwelling,
• Passengers seated directly next to the index case during airline flights lasting more than 8 hours, and
• Laboratory workers
  • All laboratory work with cultures of known or suspect N. meningitidis must be performed inside a biological safety cabinet. If a laboratory worker has been exposed via manipulating a known N. meningitidis culture outside of a biological safety cabinet, prophylactic antibiotic treatment is recommended to reduce the risk of infection and colonization. 

Contacts who have previously received meningococcal vaccination should still receive chemoprophylaxis. Contacts should receive chemoprophylaxis as soon as possible, preferably within 24 hours after the index case has been identified, though diminishing levels of benefit may still be realized even with delays of up to 2 weeks.

Close contact does not include casual contacts at work or school or hospital employees who give routine care, even with 8 hours of contact within the previous week

Contacts of the case should be identified and referred to their healthcare provider for antibiotic prophylaxis.  

Any contact that develops symptoms suggestive of meningococcal disease within 3-4 weeks after exposure should be evaluated promptly by a physician.

Recommendations for chemoprophylaxis are based on the assumption that persons of any age may be susceptible to meningococcal infections. Refer to table 2-4. Routine throat or nasopharyngeal culture of contacts is not helpful in determining who warrants chemoprophylaxis and unnecessarily delays the process.

Table 2-4. Chemoprophylaxis of Contacts to Meningococcal Disease

Note on Rifampin:

*Rifampin is not recommended for pregnant women who are contacts of cases because the effect of Rifampin on the fetus has not been established.  If contact is pregnant have her contact her OB/GYN doctor immediately for consultation on appropriate antibiotic prophylaxis.

*Side effects of Rifampin include: orange discoloration of urine, discoloration of soft contact lenses (removal recommended for duration of chemoprophylaxis), decreased effectiveness of oral contraceptives, discoloration of teeth, nausea, vomiting, and diarrhea.  These are uncommon when giving only 4 doses for prophylaxis.

**Ciprofloxacin is not usually recommended for persons younger than 18 years of age or for pregnant or lactating women, because studies in animals have shown it causes cartilage damage in immature animals. The drug can be used for chemoprophylaxis in children when no acceptable alternative is available. There have been no reports of irreversible adverse effects in cartilage or age-associated adverse events among children and adolescents.

Resource available in the Disease Information tab, I. Additional Information section: Neisseria Meningitidis Invasive Disease Chemoprophylaxis Algorithm.

Rifampin Preparations for Administration (Meningococcal disease)

Persons taking rifampin should be informed that orange discoloration of urine, discoloration of soft contact lenses, and decreased effectiveness of oral contraceptives could occur.

Rifampin prophylaxis is best administered through the private physician and local pharmacy. However occasionally help must be given, i.e., contact has no doctor, pharmacy closed or has no rifampin.  In these cases, call CADE. Dosages are calculated on weight and a prescription label with directions should accompany any rifampin dispensed.

There are two satisfactory procedures for the administration of rifampin to young children.

1. Rifampin Suspension may be available at the local pharmacy. When stored in the refrigerator, this suspension is stable for six weeks. In order to assure a uniform dosage, it is extremely important to shake the suspension vigorously just before the administration of each dose to the patient.
2. Applesauce Mix*
   • Empty the contents of one rifampin 300 mg capsule in six teaspoons of applesauce and mix thoroughly (preparation contains 50 mg/5 ml per teaspoon).
   • Dosage must be calculated and family counseled on number of teaspoons to administer.
   • Unused applesauce mixed with rifampin should be immediately discarded. New applesauce-rifampin mix should be made for each dose.

* Preparation of Choice

Note: Rifampin administration has not been approved in any other preparation or solution.

If the contact’s healthcare provider is not available, contact the local board of health physician or CADE for assistance.

C.  Managing Special Situations

Child Care

Please contact CADE (800) 362-2736 immediately to discuss.

A case of invasive meningococcal illness in a child care setting often causes panic among parents and the community. Although the risk of transmission in this setting remains relatively low, chemoprophylaxis for all the children in the child care class or the child care facility may be recommended because the physical interactions between young children often involve direct saliva contact.

Chemoprophylaxis is recommended for:

All children and employees in child care who have had direct saliva contact or have been in the same classroom with the case in the week before onset or until 24 hours after the case was started on an effective antibiotic.

Surveillance for additional cases of disease should also be heightened. Contact the CADE to report suspect or confirmed cases in a child care (or any other setting). An epidemiologist will assist to ensure contacts are identified and notified. In addition, surveillance for new cases of disease should continue at the facility for at least 2 incubation periods (20 days) after the onset of the first case. If multiple cases occur, contact CADE immediately and continue surveillance for 2 incubation periods after the onset of the last case.

Resources in this manual:

• Fact Sheet for Child Care Administrators
• Parent and Employee Advisory Letter, Meningococcal Disease in a Child Care Center (case reported within 14 days after case’s last day in child care)
• Parent and Employee Advisory Letter, Meningococcal Disease in a Child Care Center (case reported more than 14 days after case’s last day in child care)

School

A case of invasive meningococcal illness in a school often causes panic among parents and the community. Although the risk of transmission in a school remains relatively low, the age and activities of the case will determine the extent of chemoprophylaxis necessary. Because the physical interactions between children often involve direct saliva contact, chemoprophylaxis for all the children in the case’s class may be recommended, e.g. mentally handicapped students or very young children. An elementary, high school, or college student usually has a more defined group of close contacts and chemoprophylaxis may be more targeted.

Careful assessment and identification of contacts is needed to define the scope of chemoprophylaxis recommended. An epidemiologist will work with the local health agency to ensure an assessment and identification of contacts is completed and those needing post exposure prophylaxis are notified. Surveillance for additional cases of disease should also be heightened. Contact CADE to report suspect or confirmed cases. In addition, surveillance for new cases of disease should continue at the school for at least 20 days after the onset of the case. If multiple cases occur, contact CADE immediately and continue surveillance for 2 incubation periods (20 days) after the onset of the last case.

Community Residential Program

If a case of meningococcal disease occurs in a residential program, close contacts of the case should be referred to their healthcare provider for chemoprophylaxis. The activity in the facility should be assessed to determine the level of interaction between residents. The facility may be considered a “household setting” and require chemoprophylaxis of all residents, or the chemoprophylaxis may be more targeted. Contact the CADE for assistance in following up a case of invasive meningococcal disease in residential programs. In addition, surveillance for new cases of disease in the facility should continue for at least 2 incubation periods (20 days) after the onset of the first case. If multiple cases occur, contact CADE immediately and continue surveillance for 2 incubation periods after the onset of the last case.

Reported Incidence Is Higher than Usual/Outbreak Suspected

If the number of reported cases in a jurisdiction is higher than usual for the time of year, or if an outbreak is suspected, contact CADE immediately at (800) 362-2736. This situation may warrant an investigation of clustered cases to determine a course of action to prevent further cases. The IDPH can perform surveillance for clusters of illness that may cross several county lines and therefore be difficult to identify at a local level.  To assist in outbreak identification, it is critical that all invasive site Neisseria meningococcal isolates are sent to State Hygienic Laboratory (SHL) for serogrouping.

Preventive Measures

Personal Preventive Measures/Education

To prevent additional cases:

Refer close contacts to healthcare providers for appropriate chemoprophylaxis.
Advise contacts of signs and symptoms of illness and refer them to their healthcare provider should they experience any symptoms compatible with invasive meningococcal disease.
Provide contacts with a Meningococcal Disease Fact Sheet.
To avoid future exposures, advise individuals to:

• Practice good hygiene and handwashing technique.
• Avoid sharing food, beverages, cigarettes or eating utensils.
• Consider immunization in certain circumstances (see below).

Immunization

Several meningococcal polysaccharide vaccines protecting against four serogroups (A, C, Y, and W-135) of N. meningitidis are are available.  All 11-12 years olds should be vaccinated with meningococcal conjugate vaccine (MCV4). A booster dose should be given at age 16 years. For adolescents who receive the first dose at age 13 through 15 years, a one-time booster dose should be administered, preferably at age 16 through 18 years, before the peak in increased risk. Adolescents who receive their first dose of MCV4 at or after age 16 years do not need a booster dose.

Certain countries have licensed meningococcal serogroup B vaccines, but as yet are not routinely available in the US.

The Advisory Committee on Immunization Practices (ACIP) recommends that a student entering college get a booster dose of vaccine if they received the vaccine more than 5 years before starting college or if they never received one.

The vaccine is also recommended for travelers to countries where meningitis is endemic, certain high-risk individuals (those with terminal complement component deficiencies and those with anatomic or functional asplenia), laboratory personnel who are exposed routinely to N. meningitidis in solution that may be aerosolized, college freshman living in dormitories, military recruits, and in the case of an outbreak of invasive disease.

Meningococcal conjugated vaccine (MCV4) is preferable to meningococcal polysaccharide vaccine (MPSV4) for vaccination of children aged 2-10 years who are at increased risk for meningococcal disease. These children include travelers to or residents of countries in which meningococcal disease is hyperendemic or epidemic, children who have terminal complement component deficiencies and children who have anatomic or functional asplenia. Additionally, MCV4 is preferred to MPSV4 for use among children aged 2-10 years for control of meningococcal disease outbreaks.

The ACIP recommends that healthcare providers of college students provide information to students and their parents about meningococcal disease and the benefits of vaccination. In particular, vaccination should be made easily available to freshman students, (especially those living in group settings like dorms). Iowa law requires that colleges with on campus housing educate incoming students on the vaccine. 

N. meningitidis is spread through direct contact with oral or nasal secretions of a carrier. A closed setting such as a college dormitory, combined with high-risk behaviors in college students (alcohol consumption, exposure to tobacco smoke, sharing food or beverages, activities involving the exchange of saliva, etc.), may cause some college students to be at greater risk for invasive infection. Healthcare providers should discuss these risk factors and the likelihood that their patients will be involved in high-risk behaviors when evaluating patients for the administration of meningococcal vaccine.

Iowa Dept. of Public Health, Revised  7/15