Case 2
Terry has a fever …
This case illustrates the health system response to a
case of invasive meningococcal disease. Notifiable diseases within
Learning Objectives
·
Recognise the requirements for
notification of communicable diseases in
·
Understand the roles and
functions of the public health unit
·
Understand
the use of vaccination and chemoprophylaxis as infection control measures
·
Respond appropriately to the
concerns of the community about a notifiable disease
Terry’s Clinical Summary
Past Medical
History:
Nil
Past
Surgical History:
Nil
Allergies:
Nil
Meds:
Nil
Social
History:
High school student
Lives with parents and younger
sister
Case Notes:
At the end of a busy Friday at the surgery, Terry, a 16 yr old male,
presents to me with a history of fever and headache. He felt fine this morning,
but his symptoms developed this afternoon and he had to come home early from
school. His mother states that there is “flu” in the house and at the school.
On examination, Terry’s temperature is 38º C and I notice a fine rash on his
trunk. I decide that he has a viral illness and prescribe paracetamol, rest and
fluids.
Febrile illness in
general practice:
Febrile illnesses early
in their course are a common presentation in general practice. The most common
cause is self-limiting viral infections of the respiratory tract. However, more
serious infections will often present similarly. Parents therefore need to be
informed about the nature of febrile illnesses, so that they are able to
respond appropriately to febrile illnesses where there child continues to
deteriorate, fails to improve, or does not respond to supportive treatment.
A normal body temperature is 36 to 37.3 degrees Celsius (measured orally). Causes of elevated body temperature include infections, malignancy, cerebral pathology (haemorrhage, trauma etc.), drug reactions (e.g. salicylates, antihistamines, cephalosporins) and metabolic disorders (e.g. gout). Fevers due to infection can be as high as 41.1 degrees Celsius. Common symptoms associated with fever include headaches, sweats, chills and rigors.
Issues to Consider:
a) What advice would you routinely
give parents about when a febrile illness requires further intervention?
Case Notes:
Terry’s condition deteriorates during the evening, with severe headache
and drowsiness and a more marked rash. His parents rush him to the emergency
department where a lumbar puncture is performed and reveals cloudy
cerebrospinal fluid. Further analysis in the laboratory shows gram-negative
diplococci in the CSF. He is diagnosed with meningococcal meningitis.
Meningococcal
disease:
The Gram-negative diplococcus Neisseria
meningitidis is the causative organism. Although 13 serogroups have been
identified, >90 percent of disease in
Meningococcal disease is transmitted
by contact with secretions from the nose and throat of infected persons. It can
be carried asymptomatically by 5 to 30 percent of the community.
Meningococcal infections may present
as meningitis alone, septicaemia alone, or both.
Meningococcal septicaemia is
characterised by fever, vomiting, headache, myalgia, abdominal pain, petechial
(small red spots due to the escape of blood) or purpuric (larger purple-brown
skin marks due to bleeding into the tissues) rash, tachycardia, hypotension and
initially normal level of consciousness, followed rapidly by further hypotension
and shock and sometimes leading to overwhelming sepsis and death.
Meningococcal meningitis is
characterised by a sudden onset with fever, intense headache, neck stiffness,
nausea or vomiting, sometimes progressing to delirium or coma.
The incubation period is 2 to 10
days, but more commonly 3 to 4 days.
The infectious period probably begins
before the onset of symptoms, but is difficult to determine.
For practical purposes, a contact is
defined as significant exposure to a case in the 7 days before onset.
Cases themselves are not efficient transmitters of
disease however for
practical purposes a case can be regarded as non-infectious after 24 hours of
treatment with appropriate antimicrobial therapy.
Notifiable diseases
in
The list of notifiable diseases in
The list of common notifiable diseases that clinicians should
notify on clinical suspicion include:
-
Suspected
food or waterborne illness in 2 or more related cases
-
Gastroenteritis
in an institution
-
Measles
-
Meningococcal
disease
-
Hepatitis A
The above diseases should be notified immediately by
telephone.
Why notify these diseases?
Early information on the occurrence of notifiable diseases,
human pathogenic organisms and contaminants is essential to ensure the health
and safety of the community.
Medical practitioners, hospitals and laboratories examining
patients or samples play a vital role in providing a range of information which
can be used to determine the dynamics of particular agents or infections, and
in particular to identify threats to the health of the community.
This information, combined with information available from
interstate and overseas, forms the basis for public health interventions that
are designed to ensure the control and prevention of the spread of disease.
The role of the Public
and Environmental Health Service is in collating health information, developing
health intelligence and coordinating some public health interventions, in
consultation with local government and others as relevant. As indicated by the
diagram above, the purpose of notification is to trigger public health
interventions to improve the health of the Tasmanian community.
Notification
about the detection of an infectious disease, human pathogen or contaminant in
food, water and the environment, is necessary to build up a picture of the
agent that may threaten public health. This then enables the Director of Public
Health to assess the situation, and constitutes the basis for appropriate
public health action.
As with notifiable diseases, knowledge about the
presence of human pathogenic organisms and contaminants in public water
supplies, for example, enables the Director to assess the situation, and
constitutes the basis for appropriate public health action.
Table - Notifiable Diseases in
|
DISEASE NAME |
PERSON
OR ORGANISATION REQUIRED TO NOTIFY |
||
|
|
Laboratory |
Hospital |
Medical
Practitioner |
|
|
|
|
|
|
Anthrax |
Yes ( |
Yes On Clinical
Suspicion ( |
Yes On Clinical
Suspicion ( |
|
Arbovirus – |
Yes |
|
|
|
Arbovirus – |
Yes |
|
|
|
Arbovirus – Dengue |
Yes |
|
|
|
Arbovirus – Japanese encephalitis |
Yes |
|
|
|
Arbovirus – |
Yes |
|
|
|
Arbovirus – Kunjin virus |
Yes |
|
|
|
Arbovirus Other (details to be specified) |
Yes |
|
|
|
Botulism |
Yes ( |
Yes On Clinical
Suspicion ( |
|
|
Brucellosis |
Yes |
|
|
|
Campylobacteriosis |
Yes |
|
|
|
Chancroid© |
Yes |
|
|
|
Chlamydia trachomatis genital infection© |
Yes |
|
|
|
Cholera |
Yes ( |
Yes On Clinical
Suspicion ( |
Yes On Clinical
Suspicion ( |
|
Creutzfeldt – Jakob Disease (all variants) |
Yes |
Yes On Clinical Suspicion |
Yes On Clinical Suspicion |
|
Cryptosporidiosis |
Yes |
|
|
|
Diphtheria |
Yes ( |
Yes On Clinical
Suspicion ( |
Yes On Clinical
Suspicion ( |
|
Donovanosis© |
Yes |
|
|
|
Gastroenteritis in an institution (residential, educational or child
care facility) |
|
Yes On Clinical
Suspicion ( |
Yes On Clinical
Suspicion ( |
|
Giardia infection |
Yes |
|
|
|
Gonococcal infection© |
Yes |
|
|
|
Haemolytic uraemic syndrome (HUS) |
|
Yes Per Clinical Case Definition ( |
|
|
Haemophilus influenzae type b infection (invasive only) |
Yes ( |
Yes On Clinical
Suspicion ( |
|
|
Hepatitis A |
Yes ( |
|
|
|
Hepatitis B (acute case) |
Yes |
|
|
|
Hepatitis B (carrier) |
Yes |
|
|
|
Hepatitis C |
Yes |
|
|
|
Hepatitis D |
Yes |
|
|
|
Hepatitis E |
Yes |
|
|
|
Hepatitis Other (details to be specified ) |
Yes |
|
|
|
HIV infection© |
Yes |
|
|
|
Diagnosis of an AIDS defining illness© (as per ANCA
case definition 1994) |
|
Yes (as per ANCA case
definition) |
Yes (as per ANCA case definition) |
|
Yes |
|
|
|
|
Influenza infection |
Yes |
|
|
|
Lead [Demonstration of blood
level in excess of 15 mg/dL/ (0.72 mmol/L) in any
person not known to be occupationally exposed to lead. |
Yes |
|
|
|
Legionellosis |
Yes ( |
Yes On Clinical
Suspicion ( |
|
|
Leprosy |
Yes |
Yes On Clinical Suspicion |
Yes On Clinical Suspicion |
|
Leptospirosis |
Yes |
|
|
|
Listeriosis |
Yes ( |
|
|
|
Lymphogranuloma venereum© |
Yes |
|
|
|
Lyssavirus [including Australian Bat Lyssavirus and others (details
to be specified)] |
Yes ( |
Yes On Clinical
Suspicion ( |
|
|
Malaria |
Yes |
|
|
|
Measles |
Yes ( |
Yes On Clinical
Suspicion ( |
Yes On Clinical
Suspicion ( |
|
Meningococcal infection |
Yes ( |
Yes On Clinical
Suspicion ( |
Yes On Clinical
Suspicion ( |
|
Mumps |
Yes |
Yes On Clinical Suspicion |
Yes On Clinical Suspicion |
|
Mycobacterial infection |
Yes |
|
|
|
Ornithosis (psittacosis) |
Yes |
|
|
|
Paratyphoidosis |
Yes ( |
|
|
|
Pertussis |
Yes ( |
Yes On Clinical
Suspicion ( |
Yes On Clinical
Suspicion ( |
|
Plague |
Yes ( |
Yes On Clinical Suspicion ( |
|
|
Pneumococcal infection (invasive disease)
|
Yes |
|
|
|
Poliomyelitis |
Yes On Clinical
Suspicion ( |
|
|
|
Q Fever |
Yes |
|
|
|
Rabies |
Yes ( |
Yes On Clinical
Suspicion ( |
|
|
Rickettsial infection [including |
Yes |
|
|
|
Rubella (including congenital rubella) |
Yes |
Yes (congenital rubella on
Clinical Suspicion) |
Yes (congenital rubella on
Clinical Suspicion) |
|
Salmonellosis |
Yes |
|
|
|
Severe Acute Respiratory Syndrome (SARS) |
Yes ( |
Yes On Clinical
Suspicion ( |
|
|
Shiga toxin producing E.coli
(both VTEC and STEC) |
Yes ( |
Yes On Clinical
Suspicion ( |
|
|
Shigellosis |
Yes |
|
|
|
Smallpox |
Yes ( |
Yes On Clinical
Suspicion ( |
Yes On Clinical
Suspicion ( |
|
Suspected cases of food or
water borne illness |
|
Yes On Clinical
Suspicion ( |
Yes On Clinical
Suspicion ( |
|
Syphilis (including congenital syphilis) © |
Yes |
Yes On Clinical Suspicion |
Yes On Clinical Suspicion |
|
Taeniasis |
Yes |
|
|
|
Tetanus |
|
Yes On Clinical Suspicion |
|
|
Tuberculosis |
Yes |
|
|
|
Tularaemia |
Yes ( |
Yes On Clinical
Suspicion ( |
Yes On Clinical
Suspicion ( |
|
Typhoid |
Yes ( |
Yes On Clinical
Suspicion ( |
|
|
Typhus |
Yes ( |
Yes On Clinical
Suspicion ( |
|
|
Vancomycin resistant enterococci (VRE) |
Yes |
|
|
|
Vibrio infection |
Yes |
|
|
|
Viral haemorrhagic fever |
Yes ( |
Yes On Clinical
Suspicion ( |
|
|
Yellow fever |
Yes ( |
Yes On Clinical
Suspicion ( |
|
|
Yersinia infection |
Yes |
|
|
Issues to Consider:
Which notifiable diseases do you need to pick up the telephone and ring the public health unit urgently about? Why? Further information about this topic is provided in the Tasmanian Notifiable Diseases Guidelines.
Case Notes:
The rest of the family is very worried about catching the bug. Also, a couple of the parents in Terry’s class have rung up the family to see what was happening and find out if their kids were at risk of catching the bug. Terry’s mum rings you up to ask for advice about protecting the family and what she should tell the other parents.
The Public Health Unit response to sporadic cases of
meningococcal disease:
Investigation:
The Public Health Unit will ascertain if there have been
other cases in the school /institution /work and determine the serogroup, if
possible.
Restriction:
Cases should be excluded from school/institution/work until antibiotics
(usually 2 days of rifampicin, or a single parenteral dose of ciprofloxacin or
ceftriaxone) are completed.
Treatment:
Immediate empirical treatment by GPs of clinically suspected
meningococcal meningitis or septicaemia has been shown to reduce case fatality
rate and adverse outcomes. The
antibiotic of first choice is IV ceftriaxone or cefotaxime, but neither are
currently available as Doctors Bag Drugs.
GPs may administer benzylpenicillin, preferably by IVI, but IMI is quite
acceptable if choosing the IV route would lead to delays in treatment.
At the time parenteral antibiotics are given, blood cultures
should be taken if possible, but treatment should not be delayed in order to
obtain blood cultures. Diagnosis may
still be made in some cases using antigen detection and/or gram stain and
culture of biopsied skin lesions. Supportive
evidence may be obtained by growth of N.
meningitidis from nasopharyngeal swabs.
Amoxycillin or ampicillin are third choice antibiotics, but
if all the above are contraindicated chloramphenicol may be used.
Nasopharyngeal
carriage
The Public Health Unit will ensure the case receives
clearance antibiotics. The usual antibiotic regime to eliminate nasopharyngeal
carriage by cases is rifampicin. For
adults the dose is 600 mg orally 12 hourly for 2 days; for children over one
month of age the dose is 10mg/kg orally 12 hourly for 2 days (maximum
600mg/day); and for children under one month of age the dose is 5mg/kg orally
12 hourly for 2 days. The case and household contacts should be
given clearance antibiotics simultaneously.
If at least one parenteral dose of ceftriaxone or
ciprofloxacin has been given, rifampicin is not needed to eliminate
nasopharyngeal carriage.
Rifampicin is contraindicated in
pregnancy and liver disease. Rifampicin
interacts with a number of drugs including anticoagulants, anticonvulsants and
the oral contraceptives. Ciprofloxacin may also be used as 500mg
single oral dose but is not prescribed for children under 12 years of age, or
less than 40 kg body weight or to pregnant women. Ceftriaxone is an alternative
and may be used in pregnancy. The dose
is 5mg/kg to a maximum of 250mg as a single IM injection in adults, reduced to
125 mg for children under 15 years of age.
Do not use in infants below six weeks of age.
Counselling:
The case should be advised of the nature of the infection and
its mode of transmission. Explain the side effects of rifampicin:
·
orange discolouration of soft contact lenses,
tears and urine
·
gastrointestinal
disturbance, dizziness, drowsiness, headache
·
interaction
with anticoagulants/anticonvulsants/oral contraceptives.
Contacts will be
identified and managed by the Public Health Unit. The following is provided for
your information:
Definition:
Household contacts of the case are defined as persons who
have had contact during the 7 days preceding disease onset with > 4 hours of
close personal contact. This includes
friends of a child where there has regularly been at least one hour of close
contact a day (or equivalent).
Other contacts include:
1.
Individuals
exposed to oral secretions (such as mouth-kissing, shared food, drinks,
cigarettes or similar) during the 7 days preceding disease onset.
2.
Sexual
partners of the case in the 7 days preceding disease onset.
3.
Health
Workers who have performed or attempted mouth-to-mouth resuscitation or
otherwise come into direct contact with nasopharyngeal secretions during a
procedure such as intubation. Health
workers are rarely at risk.
4.
Staff and
children in a day-care centre, preschool class or play group that the patient
attends. Contacts may be limited to
staff and children who only use a particular room or attend during a particular
time with the case (“cohort” effect) for a period of > 4 hours.
5.
School
contacts of the case as defined in 1 and 2.
If there are two or more cases in one class, all class members and
teachers are classified as contacts.
6.
High school,
college, university or workplace contacts as defined in 1 and 2.
7.
Dormitory or
school camp contacts - all who slept in the same room, dormitory or tent as the
case.
8.
Car, train or
plane passengers who have shared a closed space with the case for more than 4
hours.
It is important to provide advice (written if possible) on
the signs and symptoms of the disease to ensure early presentation to a doctor.
Management:
Management of contacts centres around providing antibiotic
clearance as soon as possible and within 7 days of the diagnosis of the initial
case.
Rifampicin: For adults
the dose is 600 mg orally 12 hourly for 2 days; for children over one month of
age the dose is 10mg/kg orally 12 hourly for 2 days (maximum 600mg/day); and
for children under one month of age the dose is 5mg/kg orally 12 hourly for 2
days.
All household contacts should be given prophylaxis simultaneously.
Australians who intend travelling rough (i.e. hitchhiking,
backpacking, living in shared rural accommodation) in areas of the world where
epidemics of Group A or C disease are frequent (eg.
Persons over the age of 2 years with inherited defects of
properdin or complement, or functional or anatomical asplenia should also be
vaccinated with polysaccharide vaccine. They should also receive conjugate
vaccine.
Refer to the Australian Meningococcal Disease Guidelines for
current recommendations regarding investigation and management of invasive
meningococcal disease and for recommendations regarding meningococcal
vaccination.
Issues
to Consider:
a) What should you tell Terry’s parents?
b) What should you tell the other parents? Should you talk to the school?
c) What assistance might you request from the Public Health Unit?
d) In what circumstances would there be a role for immunisation with meningococcal vaccine? (You may wish to refer to the Australian Meningococcal Disease Guidelines or the Australian Immunisation Handbook to answer this question)
Epilogue:
Terry recovers without incident and there are no further cases of meningococcal disease amongst Terry’s schoolmates. Terry’s parents are grateful to you for all your help and support throughout their ordeal. You feel more confident about how to manage meningococcal disease should cases arise in your practice in the future.
This case illustrates the health system
response to a case of invasive meningococcal disease. As a result of completing
this case you should now be confident to work with the Public Health Unit in
managing invasive meningococcal disease, be more aware of the role of the Public Health
Unit in communicable diseases prevention, and have a better understanding of the systems surrounding
notifiable diseases within
References and Further
American Public Health Association. Control of Communicable Diseases Manual. 18th Edition. 2005.
Australian Government Department of Health and Ageing. Australian Immunisation Handbook. 8th Edition. 2004.
Tasmanian Department of Health and Human Services. Notifiable Diseases Manual. 2003.