MENINGOCOCCAL MENINGOCOCCAL MENINGITIS (MCM) MENINGITIS (MCM) AT DELHI & INDIAAT DELHI & INDIA

Dr. A. K. AVASARALA MBBS, M.D.PROFESSOR & HEADDEPT OF COMMUNITY MEDICINE & EPIDEMIOLOGYPRATHIMA INSTITUTE OF MEDICAL SCIENCES, KARIMNAGAR, A.P.INDIA: +91505417avasarala@yahoo.com

PART - IPART - I

MCM PROBLEM AT MCM PROBLEM AT DELHIDELHI

AND REST OF INDIAAND REST OF INDIA

PROMPTPROMPT THIS JUST IN TIME (JIT) LECTURE IS THIS JUST IN TIME (JIT) LECTURE IS

DEVELOPED AS DELHI IS SUFFERING DEVELOPED AS DELHI IS SUFFERING FROM 405 CASES AND 48 DEATHS DUE TO FROM 405 CASES AND 48 DEATHS DUE TO MCM. (AS ON JUNE 14MCM. (AS ON JUNE 14THTH 2005) 2005)

MCM IS NOT NEW FOR DELHI. SINCE 1966, MCM IS NOT NEW FOR DELHI. SINCE 1966, DELHI IS FACING THE BRUNT OF DELHI IS FACING THE BRUNT OF REPEATED EPIDEMICS OF MCM.REPEATED EPIDEMICS OF MCM.

WHY? IS DELHI BECOMING A HOME WHY? IS DELHI BECOMING A HOME TOWN FOR MCM? TOWN FOR MCM?

THIS AROUSED INTEREST IN ME TO THIS AROUSED INTEREST IN ME TO DEVELOP THIS JIT LECTURE.DEVELOP THIS JIT LECTURE.

LEARNING OBJECTIVESLEARNING OBJECTIVES

LEARNER SHOULD KNOW THE ENTIRE LEARNER SHOULD KNOW THE ENTIRE NATURAL HISTORY OF THE DISEASE NATURAL HISTORY OF THE DISEASE

LEARNER SHOULD UNDERSTAND MCM LEARNER SHOULD UNDERSTAND MCM PROBLEM IN DELHI AND IN REST OF PROBLEM IN DELHI AND IN REST OF INDIAINDIA

HE SHOULD LEARN THE STRATEGIES TO HE SHOULD LEARN THE STRATEGIES TO

CONTROL MCMCONTROL MCM

HE SHOULD BE ABLE TO ANALYZE AND HE SHOULD BE ABLE TO ANALYZE AND DISCUSS THE SITUATIONDISCUSS THE SITUATION

PERFORMANCE PERFORMANCE OBJECTIVESOBJECTIVES

LEARNER CAN APPLY THIS LEARNER CAN APPLY THIS KNOWLEDGE AND CONTROL KNOWLEDGE AND CONTROL STRATEGIES TO OTHER INFECTIOUS STRATEGIES TO OTHER INFECTIOUS DISEASES OF SAME BEHAVIOUR.DISEASES OF SAME BEHAVIOUR.

MCM PROBLEMMCM PROBLEMAT DELHI SINCE 1966AT DELHI SINCE 1966

YEARYEAR CASESCASES DEATHSDEATHS CFR%CFR%19661966 616616 129129 20.920.919831983 12041204 414414 34.234.219841984 17311731 569569 32.932.919851985 61336133 799799 191919861986 38013801 587587 15.415.419871987 30673067 617617 20.120.119881988 26302630 501501 1919

14-6-200514-6-2005 405405 4848 11.911.9

DELHI EPIDEMICSDELHI EPIDEMICS

0

1000

2000

3000

4000

5000

6000

7000

1966 1983 1984 1985 1986 1987 1988 14-6-2005

Years

CASES

DEATHS

CFR%

DELHI 1966 FEATURESDELHI 1966 FEATURES TOTAL CASES 616, MOSTLY MALE INFANTSTOTAL CASES 616, MOSTLY MALE INFANTS ADMITTED IN 5 MAJOR HOSPITALS IN DELHIADMITTED IN 5 MAJOR HOSPITALS IN DELHI SEROGROUP NOT DETERMINEDSEROGROUP NOT DETERMINED INCREASE IN PROPORTION OF INCREASE IN PROPORTION OF

LABORATORY CONFIRMED CASES FROM LABORATORY CONFIRMED CASES FROM 4.8% IN JANUARY4.8% IN JANUARY 10.6% IN FEB10.6% IN FEB 44.9% IN MAY44.9% IN MAY

DELHI 1985 FEATURESDELHI 1985 FEATURES

LARGE EPIDEMIC AFTER 20 LARGE EPIDEMIC AFTER 20 YEARS GAP ,YEARS GAP ,

TOTAL CASES 6133TOTAL CASES 6133 DEATHS 799DEATHS 799 CASE FATALITY RATE 13%CASE FATALITY RATE 13%

PRESENT EPIDEMIC AT DELHIPRESENT EPIDEMIC AT DELHI

48 (10.9%)48 (10.9%)405405 Total as on 14-6-05 Total as on 14-6-05

48483737From 30-5-05 to 8-6-05From 30-5-05 to 8-6-05

37375555JUST 12 DAYS (18-05-2005 JUST 12 DAYS (18-05-2005 TO 30-5-2005)TO 30-5-2005)

26261010JUST 2 DAYSJUST 2 DAYS1616TH TH TO 18 TO 18 TH TH MAY 2005MAY 2005

26 (8.6%)26 (8.6%)116116ONE WEEKONE WEEK9-5-2005 9-5-2005 TO TO 16-5-200516-5-2005

15 15 18718742 42 DAYS DAYS 29-3-2005 29-3-2005 TO TO 9-5-20059-5-2005

DEATHS (cumulative DEATHS (cumulative total & CASE total & CASE FATALITY RATE)FATALITY RATE)CASESCASESDURATIONDURATION

DELHI EPIDEMIC 2005DELHI EPIDEMIC 2005Cases Deaths

Cases

050

100150200250300350400450

Dates

Cases

Cases

Deaths

0102030405060

Dates

Deaths

Deaths

AGE & SEX DISTRIBUTION OF AGE & SEX DISTRIBUTION OF CASES & DEATHSCASES & DEATHS

MORE CASES (44%) AND MORE DEATHS MORE CASES (44%) AND MORE DEATHS (62%) IN 15-29 YEARS GROUP(62%) IN 15-29 YEARS GROUP

AGE GROUP <5 YEARS +6%AGE GROUP <5 YEARS +6% AGE GROUP 5-14 =32%AGE GROUP 5-14 =32% AGE GROUP 15-19=44%AGE GROUP 15-19=44% AGE GROUP 30-44=10%AGE GROUP 30-44=10% AGE GROUP 45+ =6%AGE GROUP 45+ =6%SEX PREDILICTION =M:F= 74%: 26% SEX PREDILICTION =M:F= 74%: 26% CASES SEX DISTRIBUTION -M:F=74:26CASES SEX DISTRIBUTION -M:F=74:26

SERO GROUP TYPINGSERO GROUP TYPING

PRESENT EPIDEMIC IS DUE TO PRESENT EPIDEMIC IS DUE TO SEROTYPE ” A”SEROTYPE ” A” MENINGOCOCCIMENINGOCOCCI

PLACE DISTRIBUTIONPLACE DISTRIBUTION

PLACES AFFECTED ARE MOSTLY PLACES AFFECTED ARE MOSTLY OVERCROWDED:OVERCROWDED:

CITY, CITY, SHAHDARA NORTH, SHAHDARA NORTH, SADAR PAHAR GANJ,SADAR PAHAR GANJ, SHAHDARA SOUTH, SHAHDARA SOUTH, CIVIL LINES, CIVIL LINES, CENTRAL DELHICENTRAL DELHI

ACTION PLANACTION PLAN SECRETARY LEVEL (HEALTH) MEETINGSECRETARY LEVEL (HEALTH) MEETING DIRECTOR GENERAL HEALTH SERVICES DIRECTOR GENERAL HEALTH SERVICES

TECHNICAL INCHARGE AND DAILY TECHNICAL INCHARGE AND DAILY MONITORINGMONITORING

WHO TECHNICAL ASSISTANCEWHO TECHNICAL ASSISTANCE COORDINATION & EXPERTS COMMITEECOORDINATION & EXPERTS COMMITEE PUBLIC EDUCATION PUBLIC EDUCATION SURVEILLANCESURVEILLANCE RISK COMMUNICATIONRISK COMMUNICATION MEDIA BRIEFSMEDIA BRIEFS

CONTROL MEASURES TAKENCONTROL MEASURES TAKEN DIAGNOSIS AND TREATMENT OF ALL CASESDIAGNOSIS AND TREATMENT OF ALL CASES CONTACT TRACING OF ALL CLINICALLY CONTACT TRACING OF ALL CLINICALLY

SUSPECT CASESSUSPECT CASES CHEMO PROPHYLAXIS FOR 305 HOUSE-CHEMO PROPHYLAXIS FOR 305 HOUSE-

HOLDSHOLDS 12000 VACCINATIONS OF QUADRIVALENT 12000 VACCINATIONS OF QUADRIVALENT

MENINGO COCCAL VACCINEMENINGO COCCAL VACCINE 35 CSF SAMPLES TESTED +VE FOR TYPE”A’ 35 CSF SAMPLES TESTED +VE FOR TYPE”A’

MENINGOCOCCIMENINGOCOCCI RISK COMMUNICATION RISK COMMUNICATION

INITIAL LETHARGY IN FIRST INITIAL LETHARGY IN FIRST 42 DAYS OF EPIDEMIC 2005 42 DAYS OF EPIDEMIC 2005

FROM MARCH 29-3-2005 TO 9-5-2005, (42 FROM MARCH 29-3-2005 TO 9-5-2005, (42 DAYS) 187 CASES ARE ALLOWED TO DAYS) 187 CASES ARE ALLOWED TO ACCUMULATE. WHY? ( on ACCUMULATE. WHY? ( on average almost 4-5 cases per day)average almost 4-5 cases per day)

IS IT DUE TO DELAYED INITIATION OF ACTIONIS IT DUE TO DELAYED INITIATION OF ACTION?? IS IT DUE TO DELAYED NOTIFICATION?IS IT DUE TO DELAYED NOTIFICATION? IS IT DUE TO DELAYED CASE FINDING?IS IT DUE TO DELAYED CASE FINDING? OR REDUNNDANCY OT THE PART OF HEALTH OR REDUNNDANCY OT THE PART OF HEALTH

AUTHORITIES AS MCM EPIDEMICS ARE COMMON TO AUTHORITIES AS MCM EPIDEMICS ARE COMMON TO DELHIDELHI

THREE FOLD DAILY THREE FOLD DAILY INCREASE 2005INCREASE 2005

NEXT WEEK ANOTHER 116 NEXT WEEK ANOTHER 116 CASES (16 CASES/DAY) CLEARLY CASES (16 CASES/DAY) CLEARLY INDICATES THAT ACTION INDICATES THAT ACTION INITIATED IS NOT ADEQUATE OR INITIATED IS NOT ADEQUATE OR PROPER. PROPER.

IS THE STRATEGY WRONG OR IS IS THE STRATEGY WRONG OR IS IT DUE TO INSUFFICIENT OR IT DUE TO INSUFFICIENT OR INEFFICIENT APPLICATION OF INEFFICIENT APPLICATION OF CONTROL MEASURES.CONTROL MEASURES.

REST OF INDIAREST OF INDIA

OTHER INDIAN STATES OTHER INDIAN STATES AFFECTED IN 1985AFFECTED IN 1985

HARYANA (FARIDABAD, GURGAON, ROTHAK)HARYANA (FARIDABAD, GURGAON, ROTHAK) UTTAR PRADESH UTTAR PRADESH

(GHAZIABAD, AGRA, MATHURA, ALIGARH, (GHAZIABAD, AGRA, MATHURA, ALIGARH, MUZAFFARNAGAR, BULANDSHAHAR, MEERUT)MUZAFFARNAGAR, BULANDSHAHAR, MEERUT)

RAJASTHAN (BHARATPUR, JAIPUR, BIKANEER)RAJASTHAN (BHARATPUR, JAIPUR, BIKANEER) SIKKIM (GANGTOK) SIKKIM (GANGTOK) GUJARATGUJARAT JAMMU&KASHMIRJAMMU&KASHMIR WEST BENGAL(CALCUTTA)WEST BENGAL(CALCUTTA) KERALAKERALA ORISSAORISSA

OTHER INDIAN STATES OTHER INDIAN STATES AFFECTED IN 1989AFFECTED IN 1989

MADHYA PRADESHMADHYA PRADESH ORISSAORISSA ANDHRA PRADESH ANDHRA PRADESH

1989 MADHYA PRADESH FEATURES1989 MADHYA PRADESH FEATURES TOTAL CASES =249 (AS ON 20-3-1989) DEATHS = 67 MENINGO COCCUS TYPE “A” OUTBREAK IN DISTRICTS OF SAGAR, DAMOH, CHATTARPUR,

MANDSAUR, UJJAIN, SATNA, SHAHJAHANPUR, INDORE

1989 ORISSA FEATURES1989 ORISSA FEATURES CASES = 2951 DEATHS = 344 DISTRICTS AFFECTED: KALAHANDI, KOHLAPUR,

PHULBANI

1989 ANDHRA PRADESH 1989 ANDHRA PRADESH FEATURESFEATURES

TOTAL CASES = 475TOTAL CASES = 475 TOTAL DEATHS = 108TOTAL DEATHS = 108 MENIGOCOCCAL TYPE “A” EPIDEMIC MENIGOCOCCAL TYPE “A” EPIDEMIC

DISTRICTS OF VISAKHAPATNAM, DISTRICTS OF VISAKHAPATNAM, VIJAYANAGARAM, SRIKAKULAMVIJAYANAGARAM, SRIKAKULAM

1989 PERSONAL EXPERIENCE - 11989 PERSONAL EXPERIENCE - 1

WE HAVE VISITTED A RESIDENTIAL WE HAVE VISITTED A RESIDENTIAL SCHOOL AT PACHIPENTA, SCHOOL AT PACHIPENTA, VIZIANAGARAM DISTRICT TO SEE VIZIANAGARAM DISTRICT TO SEE FOUR BOYS BEDRIDEN WITH FEVER, FOUR BOYS BEDRIDEN WITH FEVER, HEADACHE, NECK STIFFNESS AND HEADACHE, NECK STIFFNESS AND TYPICAL PETICHIAL RASH SKIN TYPICAL PETICHIAL RASH SKIN RASHESRASHES 42 BOYS ARE LIVING IN THAT 42 BOYS ARE LIVING IN THAT OVERCROWDED HALLOVERCROWDED HALL

PERSONAL EXPERIENCE - 2PERSONAL EXPERIENCE - 2 ON INVESTIGATION, WE DIAGNOSED ON INVESTIGATION, WE DIAGNOSED

IT AS MCM AND FOUND THAT TWO IT AS MCM AND FOUND THAT TWO CASES PER YEAR HAVE OCCURRED CASES PER YEAR HAVE OCCURRED IN THE PAST TWO YEARS REVEALING IN THE PAST TWO YEARS REVEALING ITS USUAL SPORADIC INITIATIONITS USUAL SPORADIC INITIATION

1989 EPIDEMIC INVOLVED 1989 EPIDEMIC INVOLVED NEIGHBOURING DISTRICTS OF NEIGHBOURING DISTRICTS OF VISAKHAPATNAM, AND VISAKHAPATNAM, AND SRIKAKULAM RESULTING IN 475 SRIKAKULAM RESULTING IN 475 CASES AND 108 DEATHSCASES AND 108 DEATHS