Disease Outbreak Alerts: Archive By Date
Disease Outbreak Alerts: Archives by date
Outbreak of meningococcal disease in Olievenhoutbosch, Gauteng Province
An outbreak of meningococcal disease is ongoing in the community of Olievenhoutbosch, Gauteng Province. As of 14 November 2011, 12 cases have been linked to this outbreak, which was first confined to two crèches, but now may be spreading in the wider community. All specimens/isolates tested to date have been identified as Neisseria meningitidis serogroup W135, and are fully susceptible to the recommended chemoprophylaxis antimicrobials (ciprofloxacin, ceftriaxone or rifampicin).
All healthcare facilities and laboratories in Gauteng Province are urged to be on high alert for meningococcal disease (including meningococcal meningitis and meningococcal sepsis). Healthcare workers should maintain a high index of suspicion, and should a suspected case be identified, take for the following actions:
1. Notify: Immediately notify the Department of Health (DoH) by telephone of all suspected cases. Do not wait for laboratory confirmation before notifying. This should be followed by a written notification (GW17/5 form). The contact details for the respective municipal DoH offices are as follows:
2. Confirm the diagnosis: Collect appropriate specimens (blood and/or CSF) for laboratory investigations. Request microscopy, culture and susceptibility (MC&S) and latex agglutination for suspected meningococcal disease. Laboratories have also been placed on high alert, and may refer specimens and isolates to the NICD-NHLS for confirmation and serogrouping when indicated.
3. Additional investigations: Ask the patient (or an accompanying close family member/friend) about any links to the Olievenhoutbosch community, and share this information with the DoH. This may include, e.g. living/residing in the community, attending school/day- care/crèche in the community, receiving a visitor from the community, etc.
4. Ensure correct patient treatment and infection control: Meningococcal disease may progress rapidly to death if the correct treatment is not initiated in a timely manner. Consult the“Guidelines for the Management, Prevention and Control of Meningococcal Disease in South Africa”
5. Post exposure chemoprophylaxis (PEP) to close contacts: Close contacts (i.e. those who have had prolonged close contact with respiratory secretions of the case, e.g. close household contacts) must receive an appropriate course of PEP. Transient close contracts (including healthcare/ambulance/emergency staff) only require PEP if they have been directly exposed to large droplets or secretions from the respiratory tract. Consult the guidelines for specifics on contact classifications and chemoprophylaxis choices.
Outbreak of meningococcal disease at a crèche
The DoH has led a number of public health interventions to prevent secondary cases. This included, firstly, the identification and provision of post-exposure prophylaxis (PEP) to close household contacts of cases. Secondly, two rounds of PEP (single dose ciprofloxacin on 14 September and 30 September) were administered to all crèche attendees (children and staff). However, after each round of intervention, secondary cases continued to be identified. Ongoing transmission during this time was possibly due to repeated reintroduction of the pathogen by asymptomatic carrier(s) following each round of PEP, potentially by a contact of one of the crèche attendees. PEP coverage was a problem due to the informal nature of the crèche, and the mobile nature of the crèche’s population and the surrounding community. While PEP with ciprofloxacin is highly effective and the strain implicated in this outbreak is fully sensitive, it does not prevent disease in all exposed persons. On 19October, a third round of PEP (single dose of ceftriaxone) was extended to all attendees of the two crèches with identified cases, as well as all family members living in the same household as attendees of the crèches. The polysaccharide quadrivalent vaccine (which provides protection against serogroups A,C,Y and W135) was simultaneously administered to the same group, for adults and children aged over 18 months.
Subsequent to this, as of 25 October, no additional laboratory-confirmed cases have been identified. However, the situation continues to be monitored closely, and during this period active surveillance for, and rapid notification of, clinically suspected cases of meningococcal disease is key to enable a rapid public health response. For more information on the outbreak, access the October 2011 issue of the NICD-NHLS Communicable Diseases Communiqué.
Winter and spring seasons are when we typically identify an increase in cases of meningococcal disease. If you suspect that someone may have meningococcal disease, they should immediately seek medical attention. Meningococcal disease may present as meningitis or septicaemia and can worsen rapidly. Symptoms of meningococcal disease in adults and children may include: sudden onset of a high fever, severe headache, eyes sensitive to bright lights, vomiting or nausea, neck stiffness, painful joins, fitting, a skin rash or purple bruises anywhere on the body, and/or drowsiness or confusion. Symptoms are harder to identify in babies, but may include: fever, high pitched moaning or whimpering, blank starring, inactivity, hard to wake up, breathing fast/difficulty breathing, poor feeding, neck retraction with arching of the back, pale and blotchy skin, and/or ‘pin prick’ rash/marks or purple bruises anywhere on the body. Note that not everyone gets all these symptoms. Additional information about meningococcal disease can be accessed at the following external websites:
Centers for Disease Control and Prevention, USA: www.cdc.gov/meningitis/index.html
Meningitis Research Foundation:
World Health Organisation:
Healthcare workers are reminded that they should maintain a high index of suspicion for meningococcal disease which may present with non-specific early signs and symptoms. Disease typically has a rapid progression and should be managed as a medical emergency in order to reduce morbidity and mortality. The appropriate antibiotic treatment is life saving, and should be given on the basis of clinical suspicion and does not require prior laboratory-confirmation. All cases of suspected meningococcal disease (meningitis and sepsis) should be notified telephonically to the Department of Health.
Outbreak Of Newly Emerged, Highly Antibiotic Resistant Bacteria In Hospitalised Patients In Gauteng Province
A cluster of patients with colonisation and/or infection with highly-resistant bacteria producing the enzyme NDM-1 were recently identified in a Gauteng Province hospital. Most of the patients had underlying conditions that would place them at greater risk of acquiring these organisms and had been hospitalised for an extended period. Two of the patients have died; both had advanced disease due to underlying chronic illness and it is likely that these co-morbidities played a major role in their demise.
NDM-1 is an enzyme that makes bacteria resistant to a broad range of beta-lactam antibiotics. These include the antibiotics of the carbepenem group, which are a mainstay of the treatment of antibiotic-resistant bacterial infections and are usually reserved for severe infections. The beta-lactam group of antibiotics includes such well-known antibiotics as the penicillins and cephalosporins.
Many bacteria have been shown to produce this NDM-1 enzyme, including strains of Gram-negative gut bacteria (the Enterobacteriaceae, for example Klebsiellapneumoniaeand Escherichia coli), as well as other bacteria such as Pseudomonasand Acinetobacterspecies. When these bacteria express the gene for NDM-1, treatment is difficult because the bacteria may be susceptible to only very few antibiotics, for example the polymixin antibiotic colistin, and tigecycline. The former is a very old antibiotic that is not used frequently and the latter is a relatively new antibiotic related to tetracycline. Both of these are available in South Africa.
The enzyme was named for New Delhi, India, where the bacteria were first identified in 2009, but the exact origin is not known. NDM-1 bacteria have been identified in a number of other countries to date, typically in hospitalised patients. Currently there are very few reported cases worldwide but it is important that they are promptly identified so that the correct treatment can be given. Specific molecular laboratory tests are required to identify these strains, and these tests are available in some laboratories in South Africa.
The National Institute for Communicable Diseases, a division of the National Health Laboratory Service, is setting up a monitoring programme for the public sector as well as a referral diagnostic service. A number of laboratories in the private sector have the capacity for diagnosis, and were responsible for the diagnosis in the current cluster of patients. Not all patients who harbour these bacteria are ill, but some have systemic infections and do require definitive antibiotic treatment.
In response to the outbreak, additional infection control measures to reduce spread of these organisms within the hospital have been instituted. A monitoring programme for patients has been set up to detect any new infections or colonisation, as well as provide specific antibiotic management for systemic infections as required. Infection control measures and prudent antibiotic usage are overall critical factors in reducing the ongoing emergence of antibiotic resistance worldwide.
Issued by the National Institute for Communicable Diseases, a division of the National Health Laboratory Service