Public health management of Invasive Meningococcal Disease

Abstract

Introduction: Invasive Meningococcal Disease (IMD) is a rare, but life-threatening, complication of infection with Neisseria meningitidis (N. meningitidis) bacteria. The most common clinical presentations of IMD are sepsis and meningitis, and even with rapid treatment survivors often suffer serious long-term sequelae. Public health management of IMD is focussed on limiting transmission within a population, thus reducing the risk of outbreak development. National and international guidelines have been developed to facilitate activities by staff in public health departments to identify and respond to IMD cases as they occur. There is limited understanding on how public health management of IMD has developed over time or differs between jurisdictions. The aims of this research study were to: 1. Assess national and international guidelines for the public health management of IMD, with a focus on their recommendations for identification and management of close contacts; and 2. Gain insight into changes across time in the public health management of IMD outbreaks through identifying and describing similarities and differences in responses according to outbreak characteristics and setting. Methods: English language guidelines from national and international public health agencies were assessed using a modified version of the Appraisal of Guidelines, Research and Evaluation (AGREE II) Instrument. Each guideline was scored in four key domains – stakeholder involvement, applicability, clarity of presentation, and rigour of development. The wording used in recommendations for identification and management of IMD close contacts was also compared. To address the second aim, a systematic review was conducted to assess any changes over time in public health responses to IMD outbreaks. Pubmed and Embase were searched for studies that described IMD outbreaks and their associated response. Outbreaks were grouped by N. meningitidis serogroup, location and time; and assessed by size, duration, setting and public health management strategies. Results: Public health guidelines with higher scores using AGREE II had clear, concise recommendations, were well supported by the available evidence, and included information on the risks and benefits of each recommendation. Guidelines that scored poorly showed no clear link between evidence and recommendations, were not explicit in their guidance, or did not detail potential barriers or facilitators to implementation of guidelines. Recommendations for contact management were largely consistent across the included guidelines, with some variation in recommendations for vaccination. The operational definition of a close contact varied between countries – from household and household-like contacts alone to household, household-like, sexual, child-care, co-passengers and healthcare contacts. Outbreak management has evolved over time, with reporting on earlier outbreaks informing responses to subsequent outbreaks. However, the detail included in reports on outbreaks was inconsistent, with many studies missing key contextual information regarding time, person, or place. Discussion: Clear, consistent guidance is necessary to facilitate effective public health management of IMD. Guideline development should prioritise consistency between jurisdictions in recommendations for the public health management of IMD cases and their contacts. Better reporting of IMD outbreaks and their response may also support the development of more consistent public health guidance.