Chemoprophylaxis for meninggococcal disease in healthcare workers

Since the successful implementation of Hib vaccine in 1994, Neisseri meningitidis has become the leading infectious cause of death in childhood in the UK. More than 2000 cases of meningococcal disease are reported each year, with a mortality rate of about 10%, rising to 50% in severe cases. In 1999, 104 cases of meningococcal disease were admitted to our paediatric intensive care unit (PICU), of which 100 (98%) were retrieved from various referral hospitals in the region. As part of the retrieval team for the PICU, we are frequently asked for guidance regarding self-prophylaxis by the referring healthcare workers, especially from anaesthetists who have had close involvement with the resuscitation of the patient. In our series, anaesthetists at the referring hospitals performed airway management manoeuvres in 85% of cases, some with frank pulmonary oedema, and therefore potentially exposed to nasopharyngeal secretion and sputum. There is controversy regarding this issue as there is little scientific data on which to assess risk. Nasopharyngeal carriage of meningococci is common (up to 10% of the population may carry a number of meningococcal strains). The disease is spread via droplet transmission through close contact and viable organisms may be found in the nasopharynx of presenting cases even after community administration of penicillin. Only a few cases arise from contact, and a quoted figure of 0.5% of all cases are associated with family contact. There has been one reported case of a French paediatrician contracting severe meningococcal infection one week after having intubated a comatose patient with meningococcal disease. Prophylaxis for healthcare workers has recently been reviewed by Pollard [1], who suggested that the offer of antibiotic prophylaxis should be extended to all healthcare workers who have had direct exposure to nasopharyngeal secretions from a patient with meningococcal infection. This is to reduce colonisation of recipients and their close contacts with virulent strains. This advice concurs with that given in the United States, but goes against UK guidelines, which stipulate that chemoprophylaxis (rifampicin, ciprofloxacin or ceftriaxone) should only be given to those who administered mouth-to-mouth resuscitation to patients with meningococcal disease [2]. Pollard's advice raised concerns in the microbiological community that widespread chemoprophylaxis would have implications regarding the abolition of the recipient's own protective nasopharyngeal flora, leading to the acquisition of pathogenic flora. There were also concerns regarding the emergence of resistance to rifampicin as well as to ciprofloxacin, and its financial implications [3-6]. The issue of vaccination is also contentious. A protein–polysaccharide conjugate vaccine against group C meningococcal disease has recently been introduced in the immunisation schedule in the UK and is expected to decrease cases due to this serogroup. However, there is no effective vaccine for the meningococcus B serogroup, which causes approximately 40% of serious infections, and likely to increase following the introduction of the serogroup C vaccine. Thus, vaccination would not remove the perceived need for chemoprophylaxis. More elementary to the above discussion is the role of preventative measures during the early management of meningococcal cases. Barrier protection in the form of masks and perhaps goggles should be worn when intubating children presenting with the features of meningococcal disease, who have not had 24 h of antibiotic therapy. These basic precautions significantly reduce the risk of disease transmission during resuscitation. In view of this controversy, what is the best practice? Chemoprophylaxis for health workers involved in airway manoeuvres in patients who have frank pulmonary oedema seems logical but is not evidence based. Consultants in communicable disease control have a difficult task of allaying the anxiety of the exposed personnel whilst assessing the risk of disease transmission in each individual case. Clearly there is a need for a review of current UK guidelines and for distribution of information regarding the risk to healthcare workers in these circumstances. Until then, ignorance of the estimated risk will result in controversy and cases such as that of the French paediatrician will continue to alarm those exposed to the disease.

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