Two dead in Meningitis outbreak in Kent, southern England.

Two people have died in an outbreak of Meningitis in the city of Canterbury, in Kent, southern England, this week, according to the UK Health Security Agency. Both of those who have died have been described as having been teenage students studying at the University of Kent. A further eighteen cases of the disease have been confirmed, sixteen of whom live in or close to Canterbury, with one patient each in London and Paris, both of whom are known to have visited Canterbury immediately before becoming unwell. A further eleven possible cases are under investigation. 

The location of the University of Kent. Google Maps.

Meningitis is a serious infection of the meninges, the membranes covering the brain and spinal cord. Several different Bacteria can cause Meningitis, however, Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis (sometimes spelled Neisseria meningitis) are the most common, and are transmitted from person to person through droplets of respiratory or throat secretions from infected people.

The average incubation period for Meningococcal Meningitis is 4 days, but can range between 2 and 10 days. The most common symptoms of Meningitis are a stiff neck, high fever, sensitivity to light, confusion, headaches and vomiting. Even with early diagnosis and adequate treatment, 5% to 10% of patients die, typically within 24 to 48 hours after the onset of symptoms. Bacterial Meningitis may result in brain damage, hearing loss or a learning disability in 10% to 20% of survivors. A less common, but even more severe (and often fatal), form of Meningococcal Disease is Meningococcal Septicaemia, which is characterised by a haemorrhagic rash and rapid circulatory collapse.

The Canterbury outbreak has been linked to the B serotype of Neisseria meningitidis, a form of Betaproteobacterium. A serotype is a distinct population within a species of Bacteria or Virus which presents different antigen proteins on the surface of its cells, and therefore requires the body to develop a different antibody response. A total of 12 serotypes of Neisseria meningitides have been identified, six of which (A, B, C, W, X and Y) can cause Meningococcal Meningitis epidemics.

Two serotypes 1a and 1b with antigens 2a and 2b on surface. Corresponding antibodys 3a and 3b with the possibility to bind to the antigens. Anna Bauer/Wikimedia Commons.

In the UK, a vaccine for Neisseria meningitidis serotypes A, C, W, & Y is typically offered to school pupils aged 14-15, while a vaccine for serotype B, which is particularly associated with outbreaks in infants, is offered to babies. However, this latter vaccination was only introduced in 2015, and therefore most people over the age of 15 in the UK are not vaccinated against this strain. The charity Meningitis Now, which campaigns on issues relating to the disease in the UK, as well as offering advise to those affected by or concerned about Meningitis, has been campaigning for a roll-out of the serotype B vaccine to older groups. 

As a response to the current outbreak, the University of Kent has arranged for a vaccination program for students to be set up on its campus, where antibiotics, which can help to fight the disease, are also available. Advice for staff and students at the university can be found here. Other people who are concerned that they may have been exposed should contact their GP (a GP, or General Practitioner, is a family doctor in the UK), or the National Health Service's NHS111 help service.

Students at the University of Kent in Canterbury queuing to get Meningitis B vaccine. PA Media.

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Fungal Meningitis infections reported at two Mexican hospitals.

On 11 May 2023, the United States of America Centers for Disease Control and Prevention notified the Mexico General Directorate of Epidemiology of five cases with central nervous system infection in the United States of America, according to a press release issued by the World Health Organization on 1 June 2023.. All five cases were females with a history of undergoing surgical procedures performed under spinal anaesthesia in Mexico. The surgeries were performed in two private clinics, located in the city of Matamoros in Tamaulipas State, on the border with the USA.  Laboratory test results from samples collected from patients in the USA and Mexico were consistent with Meningitis caused by pathogenic Fungi. Fungal Meningitis is rare but can be fatal and requires immediate medical care. 

As of 26 May 2023, the health authorities from Mexico and the USA have reported a total of 20 cases presenting with signs and symptoms compatible with central nervous system infection, including two deaths reported by the United States of America Centers for Disease Control and Prevention. Patients presented to the hospital with symptoms including headache, fever, nausea, vomiting, sensitivity to light, and fainting after receiving surgical procedures in two private clinics in Mexico, between January and April 2023.

The Mexico Epidemiological Diagnosis and Reference Institute has received five samples of cerebrospinal fluid that tested positive for a Fungus, Fusarium solani by real-time polymerase chain reaction. Additionally, according to the health authorities from the USA, the laboratory results from nine suspected cases were consistent with Meningitis, of which two cerebrospinal fluid and two blood samples showed elevated levels of (1,3)-beta-D-glucan, a biomarker for Fungal infection.  Two pan-fungal polymerase chain reaction tests were negative.

Fusarium solani is a common, filamentous Acomycote Fungi, found in soil systems worldwide, but known to occasionally cause opportunistic infections, typically of the eyes. Although distinct from other members of the genus Fusarium, Fusarium solani is now recognised to be a species complex, i.e. a group of closely related and morphologically similar species, which are nonetheless genetically isolated from each other. 

Hyphae of Fusarium solani stained with Prussian blue. Josef Reischig/Wikimedia Commons.

According to the investigation performed, a total of 547 people had these procedures  between January and April 2023 in the concerned two private clinics, of whom 304 (56%) reside in Mexico, 237 (43%) in the United States, and one in Canada.

Several species of Bacteria, Viruses, Fungi, and Parasites can cause Meningitis, an inflammation of the tissues surrounding the brain and spinal cord. Fungal Meningitis can develop after a Fungal infection spread from somewhere else in the body to the central nervous system. It can be fatal and requires immediate medical care.  While rare, medical and surgical procedures can lead to Fungal Meningitis if medical devices or medications are contaminated with Fungi, or if proper infection prevention control practices are not taken. This type of healthcare-associated infection can lead to severe illness or death. Healthcare-associated Fungal Meningitis outbreaks have occurred among patients who received spinal anesthesia.

Fungal Meningitis cases following a medical/surgical procedure are very infrequent and unusual. In 2012, the United States of America Centers for Disease Control and Prevention investigated a multistate outbreak of Fungal Meningitis and other infections among patients who received contaminated preservative-free methylprednisolone acetate steroid injections; 753 cases were reported, including 64 deaths in 20 States in the USA.

The source, vehicle, and the transmission route for the current outbreak remains unknown, although the investigations are ongoing. A Fungal infection is suspected based on preliminary information provided by the health authorities from Mexico and the USA.

Each year, more than a million people from the USA participate in medical tourism. In 2017, more than 1.4 million Americans sought health care in a variety of countries around the world. These medical tourists commonly travel to Mexico, Canada, and countries in Central America, South America, and the Caribbean. At present, there is no evidence to suggest any secondary spread from these cases of health care associated Fungal Meningitis The involved healthcare facilities where the procedures were undertaken have been closed since 13 May. However, there is an ongoing investigation and follow up of people who may have been exposed to Fungal infections. This may lead to additional cases being reported until the follow up of people exposed to such procedure is completed.

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Outbreak of Pneumococcal Meningitis in Togo.

Since mid-December 2022, Togo has been responding to a Meningitis outbreak that has so far resulted in a total of 141 cases and 12 deaths (a fatality rate of 8.5%), with almost half of the cases affecting children and young adults between 10 and 19 years of age. Overall, 22 samples have been confirmed as Streptococcus pneumoniae, according to a press release issued by the World Health Organization on 11 April 2023.

Togo is located in the African Meningitis Belt, with seasonal outbreaks recurring every year. However, the current outbreak is concerning due to different concomitant factors, including the security crisis in the Sahel which causes population movements, and suboptimal surveillance capacity. This is also the country’s first time dealing with a Pneumococcal Meningitis outbreak.

An incident management system has been established to coordinate the outbreak response activities, and the World Health Organzation is supporting the shipment of antibiotics (ceftriaxone) to improve case management.

The World Health Organzation assesses the overall risk posed by this outbreak as high at the national level, moderate at the regional level, and low at the global level.

On 15 February 2023, the Ministry of Health of Togo officially declared a Meningitis outbreak in Oti Sud District, Savanes Region, in the northern part of the country. From 19 December 2022 to 2 April 2023, a total of 141 suspected cases of meningitis with 12 deaths have been reported from Oti Sud District, corresponding to an attack rate of 112 per 100 000 population.

Number of reported meningitis cases and deaths, 19 December 2022 (week 51 of 2022) to 2 April 2023 (week 13 of 2023), Oti Sud District, Savanes Region, Togo. World Health Organization.

A total of 118 cerebrospinal fluid samples were collected from suspected cases, of which 22 were confirmed by polymerase chain reaction and culture for Streptococcus pneumoniae at the national reference laboratory (81 samples were negative and the results for 15 samples are pending).

The most affected age group is 10–19 years (66 cases, or 47% of the total), followed by the over 30-year age group with 20% of cases (28), and the 20-29 year age group with 15% of cases (22). There is no difference in the case distribution by gender, with 71 (53%) cases reported among males.

Togo introduced the 13-valent Pneumococcal Conjugated Vaccine in 2014, which is currently administered in three doses at the first, second and third months of life. The administrative 13-valent Pneumococcal Conjugated Vaccine coverage in the Savanes Region is 100% for the third dose, but the immunization history is not available for the individual cases, and it is not known if the serotype(s) involved are covered by the vaccine. Additionally, the most affected age groups were born before the 13-valent Pneumococcal Conjugated Vaccine introduction in 2014 and could have not received the vaccine.

Meningitis is a devastating disease with a high case fatality rate and serious long-term complications (sequelae). It remains a major global public-health challenge. Many organisms can cause Bacterial Meningitis. Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae type b constitute the majority of all cases of Bacterial Meningitis and 90% of Bacterial Meningitis in children. It is estimated that about one million children die of Pneumococcal Disease every year.

Streptococcus pneumoniae is an Encapsulated Bacterium, and about 90 distinct Pneumococcal serotypes have been identified throughout the world, with a small number of these serotypes being able to cause disease. Pneumococci are transmitted by direct contact with respiratory secretions from patients and healthy carriers. Serious Pneumococcal infections include Pneumonia, Meningitis and Febrile Bacteraemia; Otitis Media, Sinusitis and Bronchitis are more common but less serious manifestations. The incubation period is two to 10 days. Pneumococcal Meningitis has a high case fatality rate (36%–66%) in the African Meningitis Belt, requires longer treatment than Meningococcal Meningitis, and is more frequently associated with severe sequelae.

Diagnosis of Bacterial Meningitis typically requires lumbar puncture. In the absence of lumbar puncture, diagnosis can only be suspected through clinical examination (but not confirmed, except with a positive blood culture). Culture and polymerase chain reaction are confirmatory tests for Bacterial Meningitis. Rapid diagnostic tests can support the diagnosis but are not confirmatory. Identification of serotypes or serogroups and susceptibility to antibiotics are important to define control measures. Molecular typing and whole genome sequencing can identify additional differences between strains and inform public health responses.

A range of antibiotics is used to treat Meningitis, including penicillin, ampicillin, and ceftriaxone. During epidemics of Meningococcal and Pneumococcal Meningitis, ceftriaxone is the drug of choice. Nevertheless, Pneumococcal resistance to antimicrobials is a serious and rapidly increasing problem worldwide.

Togo is part of the African Meningitis Belt and annually records Meningitis cases and deaths. Although the country has experience in the management of Meningococcal Meningitis outbreaks over the past years, the current Streptococcus pneumoniae outbreak is unusual as the country has never managed a Pneumococcal Meningitis outbreak in the past, and national capacity is limited. 

To date, no imported cases have been reported in neighbouring countries. However, several factors are likely to increase the risk of spread, including the country's location in the African Meningitis Belt; the epidemic season, which typically runs from January to June; constraints in the provision of vaccination services, which do not allow for optimal vaccination coverage to protect the population; the fact that the main age groups affected by the outbreak are not protected by the routine vaccination against Streptococcus pneumoniae introduced in Togo in 2014; the security crisis in the Sahel, affecting the Savanes Region, hampering public health interventions and causing population movements; the precarious economic conditions in the country, particularly in the Savanes Region; and the sub-optimal surveillance capacity for early case detection, diagnosis and treatment in the Oti Sud District. Neighbouring countries are also in the African meningitis belt, and the Oti Sud district borders Ghana and Benin, making it possible for the disease to spread to other countries in the region.

Considering the above-described situation, the World Health Organization assesses the overall risk posed by this outbreak as high at the national level, moderate at the regional level, and low at the global level.

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Meningitis outbreak in the Zinder Region of Niger claims 18 lives.

Between 1 November 2022 and 27 January 2023, a total of 559 cases of Meningitis (of which 111 have been laboratory confirmed), including 18 deaths (an overall fatality rate of 3.2%), have been reported from Zinder Region, southeast of Niger, according to a press release issued by the World Health Organization on 8 February 2023. This compares to 231 cases reported during the period 1 November 2021 to 31 January 2022. The majority of laboratory-confirmed cases are due to infections by the Bacterium Neisseria meningitidis serogroup C. Reactive vaccination campaigns with the trivalent ACW meningococcal polysaccharide vaccine have been implemented.

Niger is located largely in the African Meningitis Belt with seasonal outbreaks recurring every year. However, the ongoing outbreak shows both an increased number of cases and an increased growth rate compared to the previous seasons. 

The Zinder Region shares an international border with Jigawa State in Nigeria where a Neisseria meningitidis serogroup C outbreak is also ongoing, confirming the risk of international spread. Moreover, the simultaneous occurrence of other epidemics, insecurity and population displacement, all in the context of a protracted humanitarian crisis, are likely to contribute to the spread of the outbreak in other countries of the West African subregion.

The World Health Organization assesses the risk posed by the current Meningitis outbreak in Niger as high at the national level, moderate at the regional level, and low at the global level. Being located in the African meningitis belt, Niger has been affected by repeated Meningitis epidemics resulting in 20 789 cases and 1369 deaths reported since 2015.

Epicurve of cases of Meningitis reported in Niger by month, 1 October 2021 - 27 January 2023. World Health Organization.

Two hundred and twenty eight samples collected from patients showing symptoms consistent with Meningitis, 154 (67.5%) of which have subsequently been analyzed bythe Center for Medical and Health Research in Niamy. Neisseria meningitidis serogroup C was identified in 93.7% of confirmed cases (104 individual cases), followed by Streptococcus pneumoniae (five cases, or 4.5% of the total) and Haemophilus influenzae (two cases or 1.8% of the total). The remaining 43 samples tested negative.

Fifty three percent of all the cases were male, with 96.3% of cases (or 538 individual cases) being under 20, with 202 cases (36.2%) reported in the 10-14 years age group, followed by the 5-9 years age group with 153 cases (27.4%), the 15-19 years age group with 107 cases (19.1%), and the 0-4 years age group with 76 cases (13.6%).

The most affected health district in Zinder Region is Dungass (342 cases, 6 deaths), followed by Matamèye (98 cases, 3 deaths), Mirriah (72 cases, 3 deaths), Magaria (38 cases, 5 deaths), Zinder ville (7 cases, 1 death) and Gouré (2 cases, 0 deaths).

Distribution of reported meningitis cases by health district, Zinder region, Niger, 1 November 2022-27 January 2023. World Health Organization.

Meningitis is a serious infection of the meninges, the membranes covering the brain and spinal cord. Several different Bacteria can cause Meningitis, however, Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis (sometimes spelled Neisseria meningitis) are the most frequent ones, and are transmitted from person to person through droplets of respiratory or throat secretions from infected people.

Neisseria meningitides is a form of Betaproteobacteria. A total of 12 serogroups of Neisseria meningitides have been identified, six of which (A, B, C, W, X and Y) can cause Meningococcal Meningitis epidemics.

The average incubation period is 4 days but can range between 2 and 10 days. The most common symptoms of Meningitis are a stiff neck, high fever, sensitivity to light, confusion, headaches and vomiting. Even with early diagnosis and adequate treatment, 5% to 10% of patients die, typically within 24 to 48 hours after the onset of symptoms. Bacterial Meningitis may result in brain damage, hearing loss or a learning disability in 10% to 20% of survivors. A less common, but even more severe (and often fatal), form of Meningococcal Disease is Meningococcal Septicaemia, which is characterized by a haemorrhagic rash and rapid circulatory collapse.

The highest burden of disease is seen in a region of sub-Saharan Africa, known as the African Meningitis Belt, which is especially recognised to be at high risk of Meningococcal but also Pneumococcal Meningitis epidemics.

iger is located largely in the African Meningitis Belt, where Meningitis epidemics typically follow a seasonal pattern (usually from January to June), with a size that varies from year to year. In 2015, a large Meningitis outbreak attributed to Neisseria meningitidis serogroup C occurred, affecting nearly 10 000 people. In 2009 and 2006, meningitis outbreaks caused by Neisseria meningitidis serogroups A and X, respectively, were also reported. Haemophilus influenzae and Streptococcus pneumoniae are two other important pathogens that contribute significantly to the Bacterial Meningitis burden within Niger.

Licensed vaccines against Meningococcal, Pneumococcal and Haemophilus influenzae diseases have been available for many years. These Bacteria have several different strains (known as serotypes or serogroups) and vaccines are designed to protect against the most harmful strains. Over time, there have been major improvements in strain coverage and vaccine availability, but no universal vaccine against these infections exists.

In the African Meningitis Belt, Meningococcus serogroup A accounted for 80–85% of Meningitis epidemics before the introduction of a meningococcal A conjugate vaccine through mass preventive campaigns (since 2010) and into routine immunization programmes (since 2016). Among vaccinated populations, incidence of serogroup A Meningitis has declined by more than 99%, and no serogroup A case has been confirmed since 2017.

However, cases of Meningitis and outbreaks due to other Meningococcal serogroups, apart from serogroup B, continue to strike.

The ongoing outbreak shows both an increased number of cases and an increased growth rate compared to the previous seasons. Moreover, the Meningitis epidemic season (usually from January to June, marked by high temperatures and dry winds combined with heavy dust, a period known as the harmattan), the mixing of populations, the simultaneous occurrence of other epidemics in the same region (Measles, Diphtheria and COVID-19), insecurity and population displacement, all in the context of a protracted Humanitarian crisis, are likely to contribute to the spread of the outbreak.

The Zinder region borders Jigawa State in Nigeria, where a Neisseria meningitidis serogroup C outbreak is also ongoing, confirming the risk of international spread to other countries of the West African subregion. The World Health Organization assesses the risk posed by the current Meningitis outbreak in Niger as high at the national level, moderate at the regional level, and low at the global level.

Meningococcal Meningitis remains a public health concern with a high case fatality rate and leading to serious long-term complications. 

Preventing Meningitis through vaccination is the most effective way to reduce the burden and impact of the disease by delivering long-lasting protection. The rollout of multivalent meningococcal conjugate vaccines is a public health priority to eliminate Bacterial Meningitis epidemics in the African Meningitis Belt. Introduction into routine immunization programmes and maintaining high coverage will be critical to avoid the resurgence of epidemics. 

Antibiotics for close contacts of Meningococcal cases, when given promptly, decrease the risk of transmission. Outside the African Meningitis Belt, chemoprophylaxis is recommended for close contacts within the household. Within the Meningitis Belt, chemoprophylaxis for close contacts is recommended in non-epidemic situations. Ciprofloxacin is the antibiotic of choice, and ceftriaxone an alternative.

Admission to a hospital or health centre is necessary. Isolation of the patient is not usually advised after 24 hours of treatment. 

Appropriate antibiotic treatment must be started as soon as possible. Ideally, lumbar puncture should be done first as antibiotics can make it more difficult to grow Bacteria from the spinal fluid. However, blood sampling can also help to identify the cause and the priority is to start treatment without delay. A range of antibiotics is used to treat Meningitis, including penicillin, ampicillin, and ceftriaxone. During epidemics of Meningococcal and Pneumococcal Meningitis, ceftriaxone is the drug of choice. 

The response to epidemics consists of appropriate case management, active community-based case-finding and reactive mass vaccination of affected populations. Surveillance, from case detection to investigation and laboratory confirmation is essential to the control of Meningitis. 

Reactive vaccination campaigns have been implemented in Zinder region, and monitoring the spread to new areas is crucial to guide further response activities, including considering further vaccine requests if appropriate. Timeliness of the reactive campaign is critical, ideally within four weeks of crossing the epidemic threshold. 

The World Health Organization does not recommend any restriction on travel and trade to Niger on the basis of the information available on the current event.

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Five confirmed deaths as Nigerian Meningitis outbreak reaches the Federal Capital Territory.

Five people have been confirmed dead in an outbreak of Cerebrospinal Meningitis in the Federal Capital Territory of Nigeria this week. Four deaths were recorded in the Durami area of Abuja on Tuesday 28 March 2017, and a fifth death in Dakwa (about 30 km to the northwest) the following day. The victims range in ages from 1 to 29 years, and all developed signs of the disease shortly before dying, though only two, one from Durami and one from Dakwa, have been fully autopsied. The disease has already killed about 270 people in an epidemic centred on Zamfara, Sokoto and Niger states this year, leading to concerns that a vaccination scheme, credited with saving many lives in the country and greatly reducing the annual impact of the disease, may be starting to fail as the disease adapts to the program.

A member of a medical team adminisering vaccinations in Borno State, in northeastern Nigeria. A Clemments-Hunt/World Health Organization.

Meningitis, an infection of the covering of the brain and spinal column can be caused by a number of micro-organisms, though in West Africa it is usually caused by the Bacterium Neisseria meningitides, which causes annual outbreaks in during the Dry Season the African Meningitis Belt, which runs from the Senegambia region on the west to Kenya and Ethiopia in the east. Between five and ten percent of those infected with the disease die within 48 hours of the first onset of symptoms, with the very young most at risk.

The countries of the Africa Meningitis Belt. David Simpson/PATH/Gavi.

Neisseria meningitides is a form of  Betaproteobacteria spread by salivary and respiratory fluids (i.e. by coughing and sneezing, sharing eating utensils etc.). About 10% of the population are thought to be carriers of the disease, without apparent ill effect, but causes disease in others, particularly in children and young adults, occurring as an annual epidemic in parts of Asia and Africa. Symptoms of the disease include fever, headaches, confusion, stiffness and septicaemia, this later being extremely dangerous; patient with  meningacoccal septicaemia develop a vivid purple rash, and about 50% of patients with this symptom typically die.

Nigeria suffered a particularly sever outbreak of Meningitis in 2009, when over a thousand people lost their lives, though since then an extensive vaccination program has been carried out, with an emphasis on targeting young children, which was thought to have brought the disease largely under control, with only 33 fatalities were recorded in 2016. This is likely to indicate the presence of a new strain of the Bacteria, which the current vaccine does not provide protection  against.

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