(Based on the discussion followed by approval of the draft prepared at the meeting of IAP Delhi Branch held at Kalawati Saran Children Hospital on 15th May, 05)

At present Delhi is undergoing an outbreak of Group A Meningococcal infection with clustering in the following areas:

City Zone...............................24 (2)
Sadar Paharganj.....................31 (3)
Civil Lines..............................19
Shahdara North......................31 (3)
Shahdara South.....................25

Delhi had similar outbreak of Meningococcal A infection before 17 years. Infection continued to linger on for 4 to 5 years.
Meningococcal Infections in early stages can be confused with any common febrile illness without any particular localizing feature and at this point of time a high index of suspicion should be maintained especially for people residing in the above areas.

For the sake of uniformity, standard case definitions of Meningococcal Meningitis are:
Suspected case of acute meningitis

• Sudden onset of fever (>38.50C axillary), WITH
  
• Stiff neck
  
• In patients under one year of age, a suspected case of meningitis occurs when fever is accompanied by bulging fontanelle.
  
  

Probable case of bacterial meningitis

• Suspected case of acute meningitis as defined above, WITH
  
• Turbid CSF
  
  

Probable case of meningococcal meningitis

• Suspected case of either acute bacterial meningitis as defined above, WITH
  
• Gram stain showing Gram-negative diplococcus, OR
  
• Ongoing epidemic, OR
  
• Petechial or purpural rash
  
  

Confirmed case of meningococcal meningitis

• Suspected or probable case as defined above, WITH EITHER
  
• Positive CSF antigen detection for N.meningitides and/or Gram –ve diplococcus on smear OR
  
• Positive culture of CSF or blood with identification of N.meningitides
  
  

For Meningococcemia, the case definitions are
Probable: Sudden onset of fever (>38.50C rectal or 38.00C axillary) with or without shock, and one of the following

• Petechial or purpural rash
  
• Gram stain showing Gram negative diplococcus
  
  

Confirmed: Probable Case and Demonstration of N.meningitides or antigen in blood and / or CSF

The referring doctor should administer IV/IM Ceftriaxone in probable case of Meningococcal infection before referring to a higher center.

Chemoprophylaxis: The purpose of chemoprophylaxis is to prevent secondary infections. It should be administered to close contacts of cases i.e. household contacts, contacts in the same class room as well as subjects who have been in contact with oral fluids either by kissing or sharing same utensils and beverages. The risk of secondary cases among close contacts is very high during the first few days and chemoprophylaxis should be administered as soon as possible preferably within 24 hours of diagnosis of the case. Mass chemoprophylaxis is not to be used for prevention of the disease.

Drug	Age Group	Dose
Ciprofloxacin	- Children > 6 years - Adults	- 20mg/Kg single dose - Tablet 500 mg single dose
Rifampicin	- Children< 1month - Children >1month - Adults	- 5mg/Kg twice a day for two days - 10mg/Kg twice a day for two days - 600mg single dose
Ceftriaxone	- Younger than 15 years - Older than 15 years & adults	- 125mg single dose Intramuscular - 250 mg single dose intramuscular

Safe and Effective vaccination is available. Vaccine when administered is protective after about 15 to 20 days for the individual above 2 years of age. However at present it is not recommended for mass immunization. IAP is closely monitoring the situation for any revised guidelines. The vaccine is recommended for high risk groups like all health care workers and individuals who are in contact or likely to be in contact with a patient of meningococcal disease. (Staying in or visiting New Delhi). The vaccine should be offered to all those who desire to get vaccinated after one to one discussion on chances of contracting the disease and the benefits of the vaccine. For individual protection vaccine can be also offered to individuals likely to visit Delhi as discussed above.

Meningococcal - A infection Outbreak In Delhi.Pediatric Oncall [serial online] 2005 [cited 2005 July 1];2. Available from:
http://www.pediatriconcall.com/fordoctor/Medical_original_articles/Meningococcal_infection.asp