Guidance on the prevention and management of meningococcal meningitis and septicaemia in higher education institutions

Public Health England


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Raising awareness, promoting immunisation and planning ahead

  • Meningococcal disease can develop suddenly, usually as meningitis or septicaemia, and can kill or leave people with life changing disabilities and health problems
  • There has been a rapid increase in one type of meningococcal disease, MenW, in recent years in the UK
  • This recent MenW strain has been particularly virulent and can be difficult to diagnose because it has been associated with symptoms infrequently seen with meningococcal disease, such as severe diarrhoea and vomiting
  • Higher Education students, particularly freshers, are known to be at increased risk of meningococcal disease
  • This rapid rise of MenW disease nationally led to the introduction of a targeted vaccination programme with MenACWY vaccination being offered to all 14–18 year olds and to freshers
  • This vaccine will save lives and it is extremely important that all freshers are aware and have the opportunity to be vaccinated before they arrive at university or as soon as possible after they arrive
  • The uptake of school leavers in 2015 (when this programme began) was disappointing with only 36% of those 18 year olds taking up the offer of this free vaccination in England
  • We know that efforts of Higher Education Institutions in collaboration with their student health partners can and have made a difference when MenACWY vaccine has been offered opportunistically to their freshers
  • It is important that all higher education students are made aware of the common signs and symptoms of this disease, that they know to tell someone if they feel unwell, that they keep an eye on friends they know are unwell and that they seek medical advice immediately if someone has symptoms of concern or whose condition is getting worse
  • There are resources available to help support Higher Education Institutions (HEI) inform their students detailed the full guideline

Definitions

  • Invasive meningococcal disease (IMD) is an acute infectious bacterial disease caused by Neisseria meningitidis. There are 12 capsular groups of Neisseria meningitidis that cause human disease of which groups B, C, W and Y (referred to as MenB, MenC, MenW and MenY respectively) were historically the most common in the UK
  • Since the introduction of the routine MenC vaccination programme, cases of IMD in the UK due to MenC disease have reduced dramatically, with MenB currently accounting for the majority of cases, followed by MenW and MenY. This bacterium is found in the human throat and between 5 and 11% of adults and up to 25% of adolescents carry the bacteria without any signs or symptoms of disease
  • However, in some individuals illness can develop very rapidly after acquiring the bacterium and is fatal in five to ten per cent of cases. Illness is most commonly due to septicaemia (blood poisoning), meningitis (inflammation of the brain lining) or a combination of the two. Other parts of the body e.g. throat, joints, lungs and eye may occasionally be infected. Urgent antibiotic treatment and rapid admission to hospital are needed
  • Vaccination with a Meningococcal ACWY (MenACWY) vaccine for longer term prevention against 4 meningococcal groups (A, C, W and Y) causing IMD is available to all new HEI students (Freshers) up to 25 years of age. This is due to an increase in a highly virulent form of MenW disease in the UK. All new HEI entrants should ideally have been vaccinated with the MenACWY vaccine at least two weeks before starting at their HEI. Students may have been immunised as part of a school based programme or by their GP
  • Immunisation against MenC disease has been in place since 1999 and continues to be offered routinely at 12 months of age (as MenC/Hib vaccine). In early 2013, a new vaccine was licenced in Europe which had been developed specifically to prevent MenB disease (4CMenB, Bexsero®) and this has been part of the infant programme since September 2015. HEI students are not currently routinely offered this vaccine
  • Prophylaxis is preventive treatment. This will usually consist of a single dose of antibiotics (chemoprophylaxis) and is recommended for the group of close (household-type) contacts of a case to reduce the risk to these contacts themselves and, more importantly, to reduce the risk of further cases in that setting by eradicating carriage of the organism in the throats of members of that group who have no symptoms

Case definitions

  • Initial diagnosis of meningococcal disease (meningitis or septicaemia) is often based on clinical signs and symptoms. Laboratory identification and characterisation of the meningococcal bacteria responsible for the infection provides important information to assist the public health response. In the absence of microbiological confirmation, however, the nature and level of response will be decided by the local Health Protection Team and will depend largely on the certainty of clinical diagnosis. The following are the recommended case definitions for public health action
  • Confirmed case: person with a clinical diagnosis of meningococcal meningitis or septicaemia, or other invasive disease (e.g. orbital cellulitis, septic arthritis) which has been confirmed microbiologically by culture or non-culture methods
  • Probable case: person with a clinical diagnosis of meningococcal meningitis or septicaemia or other IMD without microbiological confirmation, where an experienced member of the local Health Protection Team, in consultation with the clinician and microbiologist consider that meningococcal disease is the most likely diagnosis
  • Possible case: person with a clinical diagnosis of meningococcal meningitis or septicaemia or other IMD without microbiological confirmation, where an experienced member of the local Health Protection Team, in consultation with the clinician and public health doctor consider that diagnoses other than meningococcal disease are at least as likely. Cases categorised as possible do not require public health action but may raise awareness and anxiety that requires the prompt dissemination of information to students and staff
  • After a single confirmed or probable case in an HEI the local Health Protection Team (HPT) will be informed. They will liaise with the HEI to ensure that clear information is available to the relevant students and staff. The HPT will also help to ensure that prophylaxis is offered to the close household contacts of that case
  • Household contact is defined as prolonged close contact with the case in a household type setting during the seven days before onset of illness. Examples of such contacts would be those living and/or sleeping in the same household, boy/girlfriends or other intimate contacts, or students sharing a kitchen or bathroom in a hall of residence. It would not include students on the same course, unless they were also a close contact as defined above
  • The local HPT, the HEI and local NHS services (including student health services, where appropriate) should agree responsibility for the following actions (summarised below)

Ongoing health promotion activities

Action Person/organisation responsible*
1   Ensure plan is in place for dealing with cases and outbreaks HEI/HPT/NHS
2 Ensure HEI health services have received a copy of these revised guidelines HEI/HPT/NHS
3 Ensure effective support arrangements for ill students HEI
4 Promote MenACWY vaccination among first year students up to 25 years of age HEI/NHS
5 Encourage students to register with a GP HEI
6 Raise awareness about meningococcal disease each autumn among students, staff, GPs and Accident and Emergency staff HEI/HPT/NHS
7 Distribute leaflets, posters widely in HEIs and general practices HEI/HPT/NHS
* Can be modified to take account of local arrangements and circumstances
HEI=normally Dean of Students or equivalent; HPT=experienced individual nominated within the Local Health Protection Team; NHS=responsible local NHS organisations such as the NHS England Screening and Immunisation Team in England.

Before arrival

  • HEIs should send out information and advice on meningococcal disease (meningitis and septicaemia) in joining packs to students
  • UK first year undergraduates should already have been offered MenACWY vaccine at school, college or by their GP before they leave for their HEI. Students should be advised to check if they have been vaccinated before arrival (a single dose is required), to make arrangements for vaccination before leaving for their HEI where necessary and to have the vaccination at least 2 weeks before arrival at the HEI, if possible, to allow time for immunity to develop prior to their arrival. Multiple prompts to check immunisation status may be helpful, such as when applying for library cards or HEI accommodation. The vaccine is available to new HEI entrants, including international students, if they are a first year entrant and up to 25 years of age. HEIs should, therefore, also send information about meningococcal disease (meningitis and septicaemia) and available vaccinations to international students who may not have been routinely vaccinated
  • At enrolment, HEIs should encourage students to register with a local GP as soon as possible, and to ask for MenACWY vaccine if eligible and not already vaccinated
  • Public information resources targeting eligible teenagers and their students are available at www.gov.uk/government/collections/meningococcal-acwy-menacwy-vaccination-programme. In Scotland resources are available at www.immunisationscotland.org.uk and in Northern Ireland at www.publichealth.hscni.net (ordered via 0300 555 0119)
  • They can also be ordered in hard copy from the DH/ PHE Publications Orderline, or devolved administration equivalent. Additionally the meningitis charities can supply free information (see appendix in the full guideline). HEIs are encouraged to distribute these leaflets widely with any correspondence to first-time university entrants. Further information on the programme can be found on NHS Choices and HEIs are asked to support related social media campaigns

Raising awareness among students

  • At the start of the academic year, all new students should be encouraged to:
    • acquaint themselves with the common symptoms and signs of meningococcal disease
    • register with a local general practice and inform warden at hall of residence (if applicable) of GP’s name
    • look out for each other’s welfare
    • inform someone (a friend or hall warden) if they are feeling ill, so that they can be regularly monitored and prompt medical attention sought if their condition deteriorates; and
    • check that they have had MenACWY vaccination if eligible (see section 3 of full guideline); but be aware that this vaccine does not protect against all meningococcal strains or against other organisms that can also cause meningitis or septicaemia
  • The following are suggested methods for raising awareness:
    • distribute leaflets and symptom cards to all new students on arrival (see appendix in full guideline)
    • incorporate into HEI checklists of what to do before arrival
    • display posters and leaflets throughout the university and in all halls of residence (see appendix in full guideline)
    • incorporate information on meningococcal disease in handbooks for new students, including the national meningitis charities helpline telephone numbers
    • use social media, mass texting or emailing where possible to provide information
    • make leaflets and symptom cards available through general practices and the university health centre
    • involve the Students’ Union in awareness raising campaigns
    • use the student newspaper and student-led media to highlight the message
    • use the computer network through the use of log on messages and information on Internet or Intranet web pages
    • use electronic prompts to check immunisation status whilst undertaking other routine student actions, such as applying for a library card or accommodation
    • arrange displays at the 'Freshers’ Fair'; and
    • consider working with the meningitis charities (see full guideline) or consider other channels already communicating with students

Raising awareness among staff

  • The following are suggested methods for raising awareness:
    • use contact with staff and social media to highlight the issue of meningococcal disease from time to time and particularly at the start of the academic year
    • contact Heads of Departments and Deans at the start of the academic year to alert them to their role if an episode of meningococcal disease occurs
    • Public Health management guidelines exist and will be followed but tutors should be aware of their role in helping to defuse anxiety and in providing sound information and
    • arrange training for hall wardens and sub-wardens so that they are aware of the common signs and symptoms of meningococcal disease, the need for students who are unwell to be regularly monitored and for prompt medical attention to be sought if a student’s condition gets worse even if a doctor has previously been consulted

Raising awareness among general practitioners and hospital doctors

  • General practitioners, including deputising services (out of hours), should be reminded by the local HPT or responsible NHS organisations:
    • to maintain a high level of suspicion for meningococcal disease in students (information available from meningitis charities, see appendix in full guideline).
    • of the recommended treatment for a suspected cases of IMD prior to hospital admission based on current recommended clinical guidance and of the need to ensure that they have the appropriate antibiotic in their emergency bag
  • Hospital doctors should be reminded by the local HPT:
    • to maintain a high level of suspicion (especially Accident and Emergency staff) for meningococcal disease in students
    • to ensure that a full range of specimens are collected from patients with suspected meningococcal disease; and
    • to notify the local Health Protection Team immediately of any suspected case

Action in the event of student illness

  • Meningococcal disease is notoriously difficult to diagnose in the early stages. It usually starts with fever, aches and pains, and feeling unwell, just like many infections. There may also be vomiting and/or diarrhoea. At this stage, it is usually very difficult to make an accurate diagnosis. In meningococcal disease, however, the illness can get worse very rapidly. Early admission to hospital is advised if a student’s condition is worsening, especially if another case or cases have recently occurred at the same HEI
  • It is important to keep looking for signs and symptoms that help in making the diagnosis as meningitis and septicaemia can kill in hours. Signs and symptoms are detailed on charity websites (www.meningitis.org/symptoms and www.meningitisnow.org/meningitis-explained/signs-and-symptoms/signs-and-symptoms-children-and-adults) as summarised below

Main signs and symptoms of meningitis and septicaemia

Meningitis Septicaemia
Fever Fever and shivering
Very bad headache Vomiting
Vomiting Severe pains and aches in joints and limbs
Stiff neck Very cold hands and feet
Dislike of bright lights Pale or mottled skin
Rash Rapid breathing
Confusion, delirium Diarrhoea and stomach cramps
Severe sleepiness, losing consciousness Red or purple spots/rash that do not fade under pressure*
Seizures Difficulty walking or standing
Severe sleepiness, losing consciousness
* a rash that doesn’t fade when pressed with a glass due to bleeding under the skin (see www.meningitis.org/symptoms or www.meningitisnow.org/meningitis-explained/signs-and-symptoms/glass-test)
  • Medical help must be summoned as a matter of utmost urgency if there is concern about the health of an ill student. If a doctor is not immediately available call an ambulance using 999 or take the student to the nearest Accident and Emergency department

Action when a single possible, probable or confirmed case occurs

Dealing with a case of possible meningococcal disease

  • Local HPTs will lead and advise on the appropriate course of action. Contacts of a possible case of IMD would not meet the criteria for needing antibiotics. However, if there is concern or alarm among fellow students, it is advisable to issue information to contacts and local HPTs will be able to advise on this and provide templates for communication

Dealing with a case of probable or confirmed meningococcal disease

  • The actions outlined below are recommended

Action for a single confirmed or probable case of meningococcal disease

Action Person/organisation responsible
1   Make a risk assessment to define close contacts (e.g. household and intimate contacts) requiring information and antibiotics and other "non-close” contacts (from household, study and social groups) who may require information HPT
2 Inform and liaise with the HEI doctor or senior nurse (where applicable) HPT
3 Inform and liaise with the Vice-Chancellor’s office, Dean of Students and other relevant HEI staff (Often through student welfare services) To be agreed based on local arrangements
4 Arrange for close contacts to be alerted and to be issued with antibiotic prophylaxis (and offered vaccine where appropriate) HPT
5 Inform and alert the general practitioners of all close contacts who are thus treated HPT
6 Provide public health information and advice to the HEI HPT
7 Inform urgently—same day if possible—students in same hall of residence (where applicable) and consider information requirements of students sharing classes or social activities with the case HEI drafted in liaison with HPT
8 Assess which student group(s) it is appropriate to inform, in other departments and/or halls of residence for example HEI in liaison with HPT
9 Consider arranging a meeting for students in the same hall, teaching group or other defined group HEI in liaison with HPT
10 Consider alerting national meningitis helplines/NHS 111* HEI in liaison with HPT
11 Alert specific HEI practices and others known to serve significant numbers of students and consider alerting GP out of hours HPT
12 Draft a holding reactive press statement HEI/HPT (jointly)
* NHS 24 in Scotland using 111 and NHS Direct Wales using 0845 46 47
HPT=Public Health England Health Protection Team; HEI=normally Dean of Students or equivalent.

Action when more than one case occurs

  • More details on dealing with unrelated cases of meningococcal disease, dealing with a cluster (outbreak) of meningococcal disease, action after a case or cluster can be found in the full guideline

Immediate action for a cluster of meningococcal disease

Action Person/organisation responsible*
1   Activate the outbreak plan and convene an Incident Control Team HPT
2 Consult with regional/national epidemiologists HPT
3 Consider prophylaxis for defined target group Incident Control Team
4 Consider vaccination for defined target group Incident Control Team
5 If agreed, administer preventative antibiotics to the target group HPT/NHS to organise
Local provider to deliver*
6 If agreed, vaccinate the target group HPT/NHS to organise
Local provider to deliver*
7 Issue information immediately (within four hours) to students in the same hall of residence (where relevant) HEI
8 Issue information immediately (within four hours) to students in the same hall of residence (where relevant) HEI
9 Alert local Accident & Emergency departments and acute hospitals (same day) HPT
10 Alert all general practices serving students urgently (same day) by telephone or fax HPT
11 Consider notifying other local HEIs (where applicable) HEI
12 Alert all appropriate local general practices as soon as possible (next working day) e.g. via public health link HPT/NHS
13 Convene meeting with the target group HEI
14 Check for any signs & symptoms in other contacts HPT/HEI
15 Consider setting up a helpline for students, staff and parents, ensuring national charity helplines are available as back up HEI
16 Notify details of the incident to the meningitis charities and NHS 111 HPT
17 Notify other Health Protection Teams via the weekly PHE HPT national teleconference HPT
18 Agree public communication strategy HEI/Health Protection Team/NHS (jointly)
* These may differ depending on local arrangements and commissioning arrangements.
HEI=normally Dean of Students or equivalent; HPT=local Health Protection Team; NHS=local NHS organisations. NHS 24 in Scotland using 111 and NHS Direct Wales using 0845 46 47

References

full guideline from...
www.gov.uk/government/publications/meningitis-and-septicaemia-prevention-and-management-in-higher-education-institutions

Public Health England. Meningitis and septicaemia: prevention and management in higher education institutions. London: Public Health England. November 2016.


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