Administrative Order No. 2005 - 0021

July 15, 2005

ADMINISTRATIVE ORDER

No. 2005 – 0021

GUIDELINES ON THE MANAGEMENT AND CONTROL OF MENINGOCOCCAL DISEASE

I.     BACKGROUND

Meningococcemia or the septicemic form of the disease is one of the 16 diseases targeted by the National Epidemic Sentinel Surveillance System (NESSS), which is based on 200 sentinel hospitals all over the country. An average of 100 meningococcemia cases is reported every year, without seasonal variation.

The largest recorded outbreak of meningococcal disease in the Philippine started at the end of September 2004 in the Cordillera Administrative Region. The epidemic strain was serogroup A, sequence type 7. Over 150 cases and 40 deaths were identified by the end of February 2005. The unexpected and unusual increase of meningococcal disease caused public anxiety and brought serious effects on the economy. Meningococcemia, the septicemic form of meningococcal disease led to severe disease and death to at least 50% of cases in the early stage of the outbreak.

Meningococcal disease is caused by Neisseira meningitidis, a gram–negative diplococcus. Of the 13 serogroups of N. meningitides, most disease is due to serogroup A, B, C, Y and W–135.

The bacteria spread from an infected carried to another person and is transmitted by droplets or secretions from the upper respiratory tract. The bacteria are very fragile and do not survive in natural conditions outside the human body. N. meningitidis is a normal inhabitant of the human nasopharynx and carriage of meningococci is relatively common. Increased rates of meningococcal carriage have been observed in smokers, overcrowded households, and military recruits.

Meningococcal disease usually presents as meningitis or septicemia, or a combination of the two. Septicemia, with or without meningitis, can be particularly severe and has considerably greater mortality than meningococcal meningitis. Meningococcal septicemia (also known as meningocococcemia) can have a fulminant and rapidly fatal course which causes meningococcal disease.

Severe skin lesions may lead to gangrene and limb amputation. In the severe form of the disease, fulminant septicemia, the patient’s condition deteriorates very rapidly with circulatory shock and may die within 24 hours.

II.   STATEMENT / DECLARATION OF POLICY

1. To reduce the fatality of meningococcemia, immediate treatment with antibiotics should be instituted and all health facilities should have standby stocks of benzyl penicillin for immediate treatment of meningococcemia.

2. All health facilities should immediately report any suspect case of meningococcal disease so that public health measures are carried out to prevent its spread.

3. Tracing and chemoprophylaxis of contacts of patients should be carried out as soon as notified.

4. Routine vaccination against meningococcal disease is not recommended.

5. Decision on vaccination against meningococcal disease shall be based on the attack rate, fatality, age group affected.

6. A system and network for surveillance and reporting of meningococcal disease from the local level shall be developed and strengthened.

7. A mechanism for disseminating information of the management and control of meningococcal diseases to government and private health workers shall be established.

8. Support from and collaboration among government, non–government and private organizations shall be sought for the dissemination of this guidelines.

9. This management policy shall be subject to continuing review and evaluation by technical experts.

III.   OBJECTIVES

A.  General Objective:

To reduce mortality and morbidity due to meningococcal disease

B.  Specific Objective:

1. To ensure early recognition and early treatment of meningococcal disease.

2. To ensure appropriate management of meningococcal disease in the hospital setting by providing a standard set of guidelines.

3. To provide guidance for surveillance of meningococcal disease and for laboratory diagnosis of cases.

4. To provide a common definition of terms and to identify the appropriate prevention and control measures.

IV.   SCOPE OR SPHERE OF APPLICATION

This Administrative Order shall serve as a reference for public health managers, health care workers and other interested groups and stakeholders for common understanding of terminologies and public health responses to effectively control meningococcal disease outbreaks.  

V.   IMPLEMENTING GUIDELINES

A. Case Definitions

B. Early recognition and treatment, mode of administration and transfer to hospital

1.     Early recognition

2.     Early treatment

3.     Transfer to Hospital

a. Health workers should refer and transfer patient to the appropriate hospital immediately. If patient is critically ill, a health worker, preferably a physician should accompany the patient.

b. Any of the following signs and symptoms present will warrant immediate transfer:

·  A hemorrhagic rash;

·  Changes in level of consciousness;

·  Signs of meningeal irritation;

·  Patient is a close contact of a diagnosed case of meningococcal disease eve if the current patient received chemoprophylaxis.

c. The hospital where the patient is to be transferred should be informed ahead of time. The Provincial or City Health Office or RESU should be informed of the case so that contact tracing can be immediately initiated.  

C. Clinical Management in the Hospital Setting

The clinical management of meningococcal disease consists of the following: (1) Diagnostic work–up (2) use of antibiotics, (3) Supportive therapy and (4) Chemopropylaxis

1. Diagnostic work–up

a. Routine examination

·       CBC typing with platelet count

·       Blood culture

·       Gram stain of CSF

·       CSF qualitative and quantitative analysis

·       Culture of blood and CSF

b. As must as possible, blood culture should be obtained prior to administration of antibiotics, but obtaining samples should not delay initiation of antibiotic therapy.

c. A lumbar puncture should be performed if the patient is stable. For patients who are unstable or have clinical manifestations of coagulopathy, the lumbar puncture may be deferred. CSF obtained after initiation of antibiotic therapy may be sterile but pleocytosis will be evident.

D.     Chemoprophylaxis

E. Laboratory Diagnosis

(See Annex for details on laboratory processing, referral and reporting)

1. Collection of Samples

a. Samples should be collected by the attending physician at the time of admission, before antibiotic therapy is started and should always be transported and analyzed immediately at room temperature.

b. All samples must be handled in sterile condition and consequently, must be sent to the bacteriology laboratory first.

·  Blood (for all cases)

Adult:

Extract 10 ml blood

Inoculate 4 ml in BHI broth (2ml each in 2 “20 ml” BHI broth)

Child:

Extract 8 ml blood

Inoculate 2 ml “20 ml” BHI broth)

Plain tube:      3 ml (acute sera) upon admission

                        3 ml (convalescent sera) before discharge

EDTA tube:     3 ml (part will be used for CBC and platelet count)

Note:   Among the above, BHI broth is the highest priority

·  Cerebrospinal Fluid (CSF)

Collect 2ml CSF if clinical signs suggest meningitis (in addition to the blood samples) into 3 sterile tubes/vials labeled 1,2 and 3

·  Post mortem sample (CSF or blood) can be tested but must be collected as soon as possible

2. Transport to the Laboratory after Collection

a. Specimen, particularly CSF, should always be transported immediately to the laboratory at room temperature.

b. Proper handling should be observed to avoid breakage and hazard of infection. Consequently, sample delivery to the laboratory should be done by hospital personnel and not entrusted to the watcher or family or patient, to avoid delay.

3. Recording

a. Laboratory form for the specimen should be filled up by the medical technologists for completeness of data.

b. The specimen is processed (Annex A) and a copy of the initial laboratory results should be provided immediately to the admitting physician and the PESU/CESU.

c. All specimens of suspect meningococcal disease cases should be sent to the Research Institute for Tropical Medicine (RITM). A copy of the laboratory results should be sent to the referring hospital and to the RESU.

F.      Infection Control

G.    Surveillance

H.    Public Health Management

1. Sporadic Cases

a. Prophylaxis

b. Contact tracing

c. Chemoprophylaxis regimens for High Risk contacts and people with invasive meningococcal disease 

d. Vaccination

2.  Outbreaks

a. Establishment of an Operations Center or Command Post

·  Following the confirmation of a meningococcal disease outbreak, an Operations Center or Command Post should be established.

·  A task force should be organized at the Center to coordinate public health actions: contact tracing, chemoprophylaxis, vaccination of close contacts, public education, intensified surveillance, and information and media management.

·  Composition:

Ø  Field Operations

Ø  Epidemiology and Surveillance

Ø  Hospital Operations

Ø  Laboratory

Ø  Communications Depending on circumstances

Such groups may include field epidemiologists, public health physicians, medical microbiologists, infectious disease specialists, pediatricians, public health nurses and media liaison officers. Each group has a leader, preferably, somebody from the local area.

A reporting system with clear reporting relationships must be established to ensure that the public, media and key individuals, including those from other organizations (e.g. local government units, educational institutions), are kept informed.

The size of each group and the frequency of meetings will vary according to the nature and extent of the outbreak.

·  Functions of each group

Ø  Field Operations Group

Ø  Epidemiology and Surveillance Group

Ø  Laboratory Group

o  Collection, transport, processing and referral of CSF, blood samples of suspected meningococcal cases.

o  Linkage with the epidemiology and Surveillance group with the Hospital Group.

·   Communications Group

I.  Vaccination

1.     Meningococcal Vaccine

2.     Recommendation on Use of Meningococcal Vaccine

3.     Mass Immunization Campaigns

a. Rationale of Mass Immunization

b. Vaccination Recommendation for Organization – based outbreaks

c. Community outbreaks

d. Steps that should be taken by public health administrators for Mass vaccination

VI.  EFFECTIVITY

This order shall take effect 15 days after filing from the UP Law Center or upon posting/publication in the DOH intranet.

FRANCISCO T. DUQUE III, MD, MSc

Secretary of Health

This order was deliberately shortened to only highlight work that are related to a medical technologist

ANNEX A

LABORATORY DIAGNOSIS

PROCESSING OF LABORATORY SAMPLES AND REPORTING

A. In hospitals with capability in culture and identification of isolates:

1. Processing of samples

a. Blood samples

(1)   BHI broth with blood

Incubate at 35^oC. Observe for signs of growth (turbidity, lysis). Subculture on chocolate agar and/or blood agar plate after overnight incubation, 48 hours, 3 days, 5 days and 7 days of incubation. Incubate plates up to 48 hours at 35^oC in CO₂ incubator or in a candle jar.

(2)   Plain tube

Centrifuge and collect the serum in a cryovial, indicate in the label if acute sera or convalescent sera, keep at 4^oC.

(3)   EDTA tube

Separate 0.8 ml in another tube and use for CBC and platelet tests. centrifuge the rest and aseptically collect the plasma and the buffy coat in a cryovial, keep at 4^oC.

b.  Cerebrospinal Fluid (CSF)

(1)   Inoculate TI (trans–isolate) medium aseptically with 0.5 ml of CSF, 1 drop onto Chocolate Agar Plate (CAP). Streak for isolation, then inoculate in CO₂ incubator if available or in candle jar at 35^oC. If no growth after overnight incubation, re–incubate CAP for another 24 hours.

(2)   Put one (1) drop in BHI broth. Incubate at 35^oC overnight. Subculture on CAP, then incubate plate at 35^oC up to 48 hours. Proceed to “identification of isolates.”

(3)   Perform WBC count in hemocytometer

(4)   Put 1 drop on slide for Gram staining (use the pellet after centrifugation if volume is sufficient).

(5)   Put 1 drop on slide for differential count (Giemsa staining)

·  If required, give 0.5 ml to the Chemistry laboratory to determine protein and glucose concentration.

·  If there is no growth after one (1) day of incubation of the CAP and there are no bacteria on the gram staining, but the CSF (microbiologic and chemical) results are consistent with bacterial meningitis, Latex Agglutination Test can be performed (if available).

·  Keep the remaining CSF at 4^oC.

2.  Identification of the isolates

(a)   Macroscopic examination of colonies: grayish translucent small (1mm) colonies.

(b)   Gram staining: gram negative, coffee bean shaped diplococcus (ensure purity)

(c)    Oxidase test: positive (blue or purple color)

(d)   Carbohydrate Utilization test (on CTA): glucose and maltose positive (yellow) lactose and sucrose negative (no change in color)

Note:   Isolates from a hospital laboratory will be forwarded to the Referral Hospital laboratory for identification at room temperature.

B. In other Hospital Laboratories with no capabilities in culture and identification of isolates:

1. Preliminary Processing

a. Blood

(1)   BHI broth with blood:

Incubate at 35^oC overnight (less than 37^oC) if with incubator. If without incubator, leave at room temperature until transport. Do no refrigerate. Do not put in a box with cold packs.

(2)   Plain tube

Centrifuge and collect the serum in a cryovial, indicate the level if acute sera or convalescent sera, keep at 4^oC.

(3)   EDTA tube

Separate 0.8 ml in another tube and use for CBC platelet. Centrifuge the rest and collect aseptically the plasma and the buffy coat in a cryovial tube, keep at 4^oC.

b.  Cerebrospinal Fluid

(1)   Inoculate TI (trans–isolate) medium aseptically with 0.5 ml of CSF. Incubate overnight at 35^oC. A cotton–plugged sterile needle should be inserted to TI medium before incubating inside CO₂ incubator. In the absence of TI medium, use BHI broth (for blood culture). If without incubator, leave at room temperature until transport.

(2)   Perform WBC count in hemocytometer from #3 vial/tube.

(3)   Put 1 drop on slide for Gram staining (use the pellet after centrifugation if volume is sufficient).

(4)   Put 1 drop on slide for differential count (Giemsa staining)

–    If required, give 0.5 ml to the chemistry lab to determine protein and

      glucose concentration.

–       Keep all the rest of the CSF at 4^oC.

C. Referral and Transport to a hospital with capability in culture and isolate identification

1. Blood and CSF

Incubated BHI broth with blood and CSF in Trans–Isolate (TI) medium will be sent for culture, isolation and identification to a hospital with capability. Remove plugged sterile needle before transport to avoid spillage of sample.

Both incubated samples should be transported at room temperature. Upon reaching the referral hospital, a cotton–plugged sterile needle should be inserted to TI medium before incubating inside CO₂ incubator.

2. Serum, plasma and extra CSF

Serum, plasma and extra CSF samples must be transported to the referral hospital with ice packs (cold temperature)

·  All samples will be sent with the referral form of the laboratory

D. All laboratories: Referral of isolates and specimen to the National Reference Laboratory (RITM)

For all suspected cases, serum (from plain tube), plasma (from EDTA tube) and the isolate (if available) will be sent to RITM with the referral form. Referral system for the region will be centralized, the Referral Hospital laboratory in the region being the coordinating center.

All samples and isolates must be sent to the referral hospital for identification and transport to the National Reference Laboratory (RITM) with the referral form (transport at 4^oC for serum and plasma, room temperature for the isolates).

E. For the Referral Hospital Laboratory

1. Isolates: transport to RITM at room temperature or 4^oC either in tube, plate media or on fiber–tipped applicator swab in silica gel packages (if silica gel is used, seal properly around the stick to prevent exposure to oxygen during transport).

2. Serum, plasma and extra CSF samples: transport at 4^oC

3. All the samples must be labeled with the complete name, age and sex of the patient and type of specimen.

4. All samples including isolates should be sent with the laboratory form for meningococcal disease suspected cases.

F.  Reporting of Results

1. Referral Hospital laboratory

Results (preliminary and final) will be forwarded to the isolation ward (where patient is confined), CDP annex, Chief of Hospital, Regional Director and RESU/NEC.

2. Other hospital laboratories

Results (CSF cell count, gram stain, differential count, sugar and protein) will be forwarded to the isolation ward, Chief of Hospital, Provincial Health Officer, Regional Director and RESU/NEC.