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Living the Life of MeningitisLauren PalmerNorthern Arizona UniversityAbstractThis project was designed to address how thousands of people around the world die every year from a vaccine-preventable disease, such as meningococcal disease (meningitis). The idea of this document on meningitis is to address the severity of the lack in medical care and supplies to the area of sub-Saharan Africa and other developing countries that lead to prevalent disease. It mentions how quickly the disease can spread and cause serious damage to the body. This project addresses the importance of vaccinations for anyone that lives in a country where meningitis is common. In addition, it addresses how industrialized countries are working to show support and inform the dangers of health discrepancies. This document shows how people have to live without a choice because they do not have effortless access to vaccines or proper health care. Meningitis is not a threat to the United States, but thousands of people in the developing world continue to suffer from the lack of treatment. Keywords: Meningitis, vaccinations, cerebral spinal fluid (CSF), meningococcal disease, lumbar puncture, sepsis, New Zealand, serogroups A, B, C, W135 and Y, Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae, meningitis belt, sub-Saharan Africa, bacterial meningitis.Living the Life of MeningitisI. Part 1: Person, Place, Time Inside the U.S.A. Meningitis1. Meningitis is an infectious disease, and can be a life-threatening illness. It is an inflammation (swelling) of the protective membranes covering the brain and spinal cord. A bacterial or viral infection of the fluid surrounding the brain and spinal cord usually causes the swelling (Centers for Disease Control and Prevention, 2018a). The most common causes of bacterial meningitis are Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae, which are all respiratory pathogens. Once acquired, each species can colonize the mucosa of the nasopharynx and oropharynx, which is known as pharyngeal carriage. From there, they may cross the mucosa and enter the blood. Once in the blood, they can reach the meninges, causing meningitis (Centers for Disease Control and Prevention, 2012). 2. Meningitis infects about?600- 1,000 people in the United States annually (National Meningitis Association, 2014). Fortunately, the rates of the disease have been declining in the United States since the late 1990s. 3. Meningitis Specificsa. Meningococcal disease is not highly infectious. It only infects humans, so there is no animal reservoir. Transmission requires close or prolonged contact for respiratory secretions to be exchanged, so it is often family members of someone with the infection who may be at risk. Transmission may occur through household or kissing contacts, but close contact can occur in residential accommodation, such as college dorm rooms. Schools, military bases and other large or overcrowded gatherings can also provide an opportunity for the spread of infection. Smoking is considered a risk factor for both carriage and transmission, as are the winter months, and recent infection with influenza. Foreign travel to Africa or Saudi Arabia mainly exposes travelers to serogroups A, C, W135 and Y, but infection with meningococcal B is possible. Age is an important factor, with the highest risk groups being babies aged one year and under, and young people aged 15-19 (Willcox, 2012, p.?51-52). b. Meningitis is often difficult to diagnose in the early stages, but initial recognition is vital if the chances of disease and death are to be reduced. Early symptoms and signs can be similar to other common viral illnesses, such as influenza, including fever, headache, nausea, muscle and joint pain. The onset of disease is rapid and symptoms can occur in any order; some may not appear at all (Donovan & Blewitt, 2010, p.?31). Other symptoms may include sudden high fever, stiff neck, severe headache that seems different than normal, headache with nausea or vomiting, confusion or difficulty concentrating, seizures, sleepiness or difficulty waking, sensitivity to light, no appetite or thirst, and skin rash (Mayo Clinic, 2017).c. The most common symptom of this disease is a headache, which is due to direct stimulation of the sensory terminals located in the meninges by bacterial infection. Bacterial products and mediators of inflammation released by inflammation not only directly cause pain but also induce sensitization of meningeal nociceptors and neuropeptide release. The septic meningeal inflammation that explains the headache is similar to the aseptic inflammation that is presumed to occur at the neurovascular junction of meningeal/dural blood vessels during migraine attacks (Gladstone & Bigal, 2010, p.?301).d. The main diagnostic tool in defining bacterial meningitis is cerebral spinal fluid (CSF) examination by lumbar puncture. It is a procedure that collects CSF and tests it for any signs of bacteria related to meningitis. Typically, patients with bacterial meningitis will have elevated opening pressure, high white blood cell count, and high protein and decreased glucose levels (Drugs & Therapy Perspectives, 2010, p.?19). e. Treatment depends on the type of meningitis diagnosed. Most types require antibiotics, but the more severe type- bacterial meningitis requires a little more work. Acute bacterial meningitis must be treated immediately with intravenous antibiotics and, more recently, corticosteroids. This helps to ensure recovery and reduce the risk of complications, such as brain swelling and seizures (Mayo Clinic, 2017). B. Data and Measures Used1. The three types of epidemiological measures used for tracking and reporting meningitis are Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and Confederation of Meningitis Organizations. a. Over 1.2 million cases of bacterial meningitis are estimated to occur worldwide each year. The incidence and case-fatality rates for bacterial meningitis vary by region, country, pathogen, and age group. Without treatment, the case-fatality rate can be as high as 70 percent, and one in five survivors may be left with permanent sequelae including hearing loss, neurologic disability, or loss of a limb (Centers for Disease Control and Prevention, 2012).?b. Meningococcal meningitis is observed worldwide but the highest burden of the disease is in the meningitis belt of sub-Saharan Africa, stretching from Senegal in the west to Ethiopia in the east. As of February, 2018, around 30,000 cases are still reported each year from that area (World Health Organization, 2018).c. There are 170,000 annual deaths related to meningitis worldwide, with bacterial meningitis being the most severe and common form. Even with prompt diagnosis and treatment, approximately?10- 20% of patients with bacterial meningitis will die within 24 to 48 hours?after the onset of symptoms, and around 10-30% will sustain permanent damage and disability (Confederation of Meningitis Organizations, 2018).C. Patterns of Disease in the United States1. Compared to Africa, which is considered the highest region of the meningitis disease, the United States has one of the lowest patterns of disease. a. In 2016, there were about 370 total cases of meningococcal disease reported in the United States (2018c). b. Acute viral infections of the CNS are slightly more frequent in males and are distributed across all age groups. The ethnic distribution reflects the population of this area (Calleri, Libanore, Corcione, De Rosa, & Caramello, 2017, p.?228). Meningitis is more frequent than meningo-encephalitis/encephalitis. The latter is slightly more common in males, and the mean age is higher, suggesting that elderly people are more prone to parenchimal involvement, or to neurologic symptoms in general, or experience different aetiologies (Calleri, Libanore, Corcione, De Rosa, & Caramello, 2017, p.?230).c. The National Notifiable Diseases Surveillance System?Data came up with the epidemiology data for meningitis regarding race between the years 2006–2015. Information on race was available for 81.9% case patients; 75.8% cases occurred among white patients, 17.4% among black patients, and 6.8% cases among patients of other racial groups. The incidence of meningococcal disease among black persons was 0.27 cases per 100,000 compared with 0.20 cases per 100,000 among white personsand 0.20 cases per 100,000 among other race groups combined (MacNeil, Blain, Wang, & Cohn, 2017, p.?1,278). In other words, there is not a definite answer on which group the disease affects most.d. Anyone can get meningococcal disease, but rates of disease are highest in children younger than 1 year old, followed by a second peak in adolescence. Among adolescents and young adults, those 16 through 23 years old have the highest rates of meningococcal disease (2018c).e. Outbreaks of meningococcal disease are rare in the United States. In fact, only about 2 to 3 out of every 100 cases are related to outbreaks. However, the onset of an outbreak is unpredictable and the outcomes can be devastating to affected communities and organizations (2018b). This is why it is critical for communities around the world, especially developing countries get access to vaccinations.?f. Meningitis may cause raised intracranial pressure secondary to mass effect (also seen in brain tumors), and hydrocephalus. In untreated cases, this can lead to ischemia or to herniation of the brainstem (coning) and brain death. Early recognition and treatment of the infection itself may prevent complications and improve outcome. The presentation in children with meningitis can vary with the child's age (Paul, Smith, Green, Smith-Collins, & Chinthapalli, 2013, p.?33). 2. An interesting discovery I came across was an article about a meningitis outbreak in 2016 among gay and bisexual men in Chicago. As of April?2016, this meningococcal disease outbreak includes nine?confirmed cases, including one death. In New York City, the last case of an outbreak among MSM was reported in December 2014. The outbreak, which began in August 2010, included at least 22 cases and seven deaths. Clusters and isolated cases among gay men and MSM have occurred in other parts of the country such as Los Angeles, Minnesota (National Meningitis Association, 2016). This made things interesting regarding outbreaks here in the United States. It also educated me about another potential disease that can be transmitted the same way as a sexually transmitted disease. II. Part 2: Person, Place, Time Outside the United StatesA. Patterns of Disease Outside the United States1. Africa and New Zealanda. The first records of meningitis epidemics in Africa were in the early 1900's when mortality rates were 75 to 80 percent. The development of vaccines was in its infancy at this time but American scientist Simon Flexner developed a meningococcal antiserum prepared from horses that was administered via intrathecal injection and reduced the mortality rate to 30 percent. The advent of sulphonamides and subsequently penicillin reduced the case fatality rate to 15 percent by the mid 20th century. Morbidity and mortality rates still vary considerably according to geographical region, and large epidemics can occur in Africa as well as sporadic cases anywhere in the world (Driver, 2013, p.?32).b. Meningococcal disease is found worldwide, with the highest incidence of disease found in the ‘meningitis belt’ of sub-Saharan Africa. In this region, major epidemics occur every 5 to 12 years with attack rates reaching 1,000 cases per 100,000 population. Other regions of the world experience lower overall rates of disease and occasional outbreaks, with annual attack rates of around 0.3 to 3 per 100,000 population (Centers for Disease Control and Prevention, 2017).c. There was a recent study done in New Zealand regarding meningitis statistics by race. Ethnic group was recorded for all notified meningococcal disease cases in 2013. The highest disease rate was the Māori ethnic group (3.4 per 100 000 population, 23 cases), followed by the Pacific Peoples (3.3 per 100 000 population, 9 cases) and European or Other (1.1 per 100 000 population, 34 cases) ethnic groups. In 2013, the age-standardized meningococcal disease rates for the Pacific Peoples (3.1 per 100 000 population, 9 cases) and Māori (2.6 per 100 000 population, 23 cases) ethnic groups were also higher than the rate for the European or Other ethnic group (1.2 per 100 000 population, 34 cases). For the ethnic groups for which the rate was calculated, the highest disease rate by age group in 2013 was in the Māori ethnic group for those aged less than one year (32.3 per 100 000 population, 5 cases) (Institute of Environmental Science and Research Ltd (ESR), 2014, p.?18). d. There was a study done that estimated global and regional morbidity from acute bacterial meningitis in children ages 0-4. The median incidence per 100?000 child-years was highest in the African region- 143.6, followed by Western Pacific region with 42.9, the Eastern Mediterranean regionwith 34.3, South East Asia with 26.8, Europe with 20.8, and American region with 16.6. The median case-fatality rate was also highest in the African region (31.3%). Globally, the median incidence for all 71 studies was 34.0 per 100?000 child-years, with a median case-fatality rate of 14.4% (Luk?i? et al., 2013, p.?510).e. A New Zealand study marked geographic variations in the numbers of notified cases and rates of meningococcal disease that has been observed since 2013. In 2013, cases of meningococcal disease were spread through 17 of the 20 District Health Boards (DHB) with 1–12 cases per DHB. No cases were reported in Wairarapa, Nelson Marlborough, and West Coast DHBs. The highest rates of disease were in Counties Manukau (2.3 per 100 000 population, 12 cases) and Southern (2.3 per 100 000 population, 7 cases) DHBs (Institute of Environmental Science and Research Ltd (ESR), 2014, p.?16).f. Neisseria meningitis exclusively infects humans. Serogroups A, B, C, W, X, and Y accounting for nearly all disease. Serogroup distribution varies globally, with serogroup A predominant in Africa, and serogroups B, C, and Y observed in Asia, Europe, and the Americas with variable frequency. Serogroup distribution is also dependent on age. In the USA, bacterial meningitis accounts for approximately 65% of infant disease, while serogroups C and Y cause the majority of disease in adolescents, and serogroup Y predominates in the elderly. In countries with serogroup C conjugate vaccine programs, bacterial meningitis is now the cause of over 75 % of disease. The highest disease incidence is in sub-Saharan Africa, ranging from 10–25 per 100,000 during non-epidemic periods and up to over 1,000 per 100,000 during epidemic years. The incidence in Canada, the USA, and Europe varies substantially by country, ranging from 0.35 per 100,000 to 3 per 100,000 individuals per year (Cohn & Harrison, 2013, p.?1,148).2. During my research of meningitis, I came across several articles that talk about the relationship between meningitis and sepsis. Meningitis due to an infection can cause a serious condition called?sepsis. Sometimes incorrectly called?blood poisoning, sepsis is the body’s often deadly response to infection. Sepsis kills and disables millions and requires early suspicion and rapid treatment for survival. Sepsis and septic shock can result from an infection anywhere in the body, such as?pneumonia,?influenza, or?urinary tract infections. Worldwide, one-third of people who develop sepsis die. Many who do survive are left with life-changing effects, such as?post-traumatic stress disorder?(PTSD), chronic pain and fatigue, organ dysfunction (organs don’t work properly) and/or?amputations (Sepsis Alliance, 2017). B. Summary and Conclusion1. Meningitis is an infectious disease, and can be a life-threatening illness. While the disease may not be very common in the United States, it is still an issue in developing countries. With the help of health promotion and disease prevention around the world, there has been success in lowering the number of cases. a. In 2017, the Centers for Disease Control and Prevention recommended use of available vaccines to help prevent meningitis outbreaks. They recommend vaccination with a meningococcal conjugate vaccine for all preteens and teens at 11 to 12 years old, with a booster dose at 16 years old. Teens and young adults (16 through 23 year olds) also may be vaccinated with a serogroup B meningococcal vaccine (Centers for Disease Control and Prevention, 2017). In addition, implementations of meningitis vaccination programs were put into place in 2010. In collaboration with the World Health Organization, CDC leads an international consortium called MenAfriNet to strengthen meningitis surveillance in sub-Saharan Africa in order to evaluate the impact of MenAfriVac? on the incidence of meningococcal disease due to serogroup A as well as to monitor the emergence of disease and epidemics due to other serogroups (Centers for Disease Control and Prevention, 2017). With the help of these programs, people in sub-Saharan Africa have access to much needed vaccinations.While doing the research for this project, I realized how lucky we are to live in a country that offers many benefits to our health. We often take for granted having very little amounts of deadly disease outbreaks. It is really sad that a lot of people in developing countries have to live in such poor conditions that it is near impossible to keep away from disease. I am impressed and grateful for programs that bring vaccinations and other medical supplies to these people. 2. The economic impact meningitis has on the United States is nothing compared to the developing countries. The United States has the advantage of offering easy access to vaccinations and other healthcare services. Unfortunately, the developing countries are the ones who suffer the most because they are humble and uneducated about disease. As mentioned before, there are 170,000 annual deaths related to meningitis worldwide, with bacterial meningitis being the most severe and common form. With that many cases, it is a major economic impact, but with these improved surveillance systems, those numbers will improve. ReferencesCalleri,?G., Libanore,?V., Corcione,?S., De Rosa,?F.?G., & Caramello,?P. (2017). A retrospective study of viral central nervous system infections: relationship amongst aetiology, clinical course and outcome. Infection, 45(2), 227-231. doi:10.1007/s15010-017-0993-4Centers for Disease Control and Prevention. (2012, March 15). Chapter 2: Epidemiology of meningitis caused by Neisseria meningitidis, streptococcus pneumonia, and Haemophilus influenza. Retrieved from for Disease Control and Prevention. (2017, July 3). Meningococcal global in other countries. Retrieved from for Disease Control and Prevention. (2018, April 9). Meningitis. Retrieved from for Disease Control and Prevention. (2018, April 9). Meningococcal outbreaks. Retrieved from for Disease Control and Prevention. (2018, May 10). Meningococcal surveillance. Retrieved from of Meningitis Organizations. (2018). Facts about meningitis. Retrieved from ., & Harrison,?L.?H. (2013). Meningococcal vaccines: Current issues and future strategies. Drugs, 73(11), 1147-1155. doi:10.1007/s40265-013-0079-2Donovan,?C., & Blewitt,?J. (2010). Signs, symptoms and management of bacterial meningitis. Pediatric Care, 22(9), 30-35. doi:10.7748/paed2010.11.22.9.30.c8066Driver,?C. (2013). Meningococcal disease: diagnosis and prevention. Primary Health Care, 23(2), 32-36. doi:10.7748/phc2013.03.23.2.32.e702Drugs & Therapy Perspectives. (2010). Initiate appropriate antibacterial and adjunctive therapies when treating bacterial meningitis. Drugs & Therapy Perspectives, 26(8), 19-22. doi:10.2165/11205430-000000000-00000Gladstone,?J., & Bigal,?M.?E. (2010). Headaches attributable to infectious diseases. Current Pain and Headache Reports, 14(4), 299-308. doi:10.1007/s11916-010-0125-7Institute of Environmental Science and Research Ltd (ESR). (2014). The epidemiology of meningococcal disease in New Zealand in 2013 (FW14023). Retrieved from ., Muli?,?R., Falconer,?R., Orban,?M., Sidhu,?S., & Rudan,?I. (2013). Estimating global and regional morbidity from acute bacterial meningitis in children: Assessment of the evidence. Croatian Medical Journal, 54(6), 510-518. doi:10.3325/cmj.2013.54.510MacNeil,?J.?R., Blain,?A.?E., Wang,?X., & Cohn,?A.?C. (2017). Current epidemiology and trends in meningococcal disease- United States, 1996–2015. Clinical Infectious Diseases, 66(8), 1276-1281. doi:10.1093/cid/cix993Mayo Clinic. (2017, December 23). Meningitis. Retrieved from Meningitis Association. (2014, November 12). Statistics and disease facts. Retrieved from Meningitis Association. (2016, October). Meningitis in gay, bisexual and men who have sex with men (MSM). Retrieved from ., Smith,?J., Green,?J., Smith-Collins,?A., & Chinthapalli,?R. (2013). Managing children with raised intracranial pressure: part one (introduction and meningitis). Nursing Children and Young People, 25(10), 31-36. doi:10.7748/ncyp2013.12.25.10.31.e214Sepsis Alliance. (2017, December 13). Sepsis and meningitis. Retrieved from . (2012). Meningococcal b disease: assessment and management. Nursing Standard, 26(26), 50-55. doi:10.7748/ns.26.26.50.s54World Health Organization. (2018, February 19). Meningococcal meningitis. Retrieved from ................
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