ORIGINAL

Niger J Paed 2013; 40 (2): 169 –171

Mado SM

Abubakar U

Onazi SO

Epidemic cerebrospinal meningitis

in children at Federal Medical

Centre, Gusau, Zamfara state,

Nigeria

Adeoye GO

DOI:http://dx.doi.org/10.4314/njp.v40i2,12

Accepted: 23rd November 2012

Abstract Epidemic meningococcal

meningitis is a major public health

problem still affecting tropical

countries, particularly in

Sub-Saharan Africa, which lies

within African meningitis belt.

Repeated large scale epidemics of

CSM have been reported in north-

ern Nigeria for the past four

decades. It is one of the important

causes of morbidity and mortality in

these regions. Mortality from the

CSM remains high despite

Objective: To determine the pattern

of epidemic CSM in children at

Federal Medical Centre, Gusau.

Method: The study was a retrospec-

tive one carried out in children aged

six months to 12 years admitted

into Emergency Paediatrics Unit

(EPU) with a diagnosis of CSM

within the period January to May,

2009.

Results: Seventy- seven children

with epidemic CSM were admitted

and managed in EPU from January-

May 2009.

Conclusion: Neisseria meningitidis

serogroup A CSM is becoming the

disease of young infants, and

stresses the need for inclusion of

CSM vaccine in early infancy in

routine immunization policy, in

areas within the meningitis belt in

Sub-Saharan Africa.

(

)

Mado SM

Adeoye GO

Department of Paediatrics,

Ahmadu Bello University Teaching

Hospital, Zaria

Email: sanimado@yahoo.co.uk

Tel: +234703962150

Abubakar U

Department of Paediatrics, Federal

Medical Centre, Bida

Onazi SO

Department of Paediatrics, Federal

Medical Centre,

advances in treatment

modalities. Neisseria meningitidis

serogroup A have been the major

cause of large scale epidemics in

tropical countries, while serogroups

B, C, Y and W-135 are responsible

for most of invasive disease in

America and other developed coun-

tries.

Introduction

Subjects and Methods

Epidemic meningococcal meningitis is a major public

health problem still affecting tropical countries, particu-

larly in sub-Saharan Africa, which lies in the African

The study was a retrospective one carried out in children

aged six months to 12 years admitted into EPU with a

diagnosis of CSM within the study period January to

May 2009. The folders of all the children with the diag-

nosis of CSM were retrieved. The approval of Federal

Medical Centre Gusau Ethical Committee was sought

for and obtained before the commencement of the study.

Criteria for the diagnosis of CSM was adapted from the

WHO practical guidelines for the control of epidemic

1

meningitis belt. Repeated large scale epidemics have

st

been reported in the 21 Century, about 200 years after

the disease was first reported in Geneva, Switzerland. It

is one of the important causes of morbidity and mortal-

ity in these regions. Mortality from the disease remains

high, despite major achievement in the treatment mo-

dalities. It was reported that about 10% of patients who

had the disease will not survive despite effective treat-

4

meningococcal diseases. Lumbar puncture was done on

all patients after obtaining verbal consent from the par-

ents. Cerebrospinal fluid (CSF) was sent for micros-

copy, culture, sensitivity, and LPA. The bio-data, clini-

cal features, results of investigations, and outcome were

extracted and analyzed. Simple statistical tables were

drawn for the frequencies and percentages.

2

ment. Neisseria meningitidis have been separated by

sero-agglutination into nine serogroups A, B, C, D, X,

Y, Z, W-135, and 29 E. Groups B, C, Y, and W-135 are

responsible for most of invasive disease in America and

other developed countries, whereas, group A and occa-

sionally group C account for large scale epidemics in

many other countries particularly in sub-Saharan Af-

3

rica. At Federal Medical CentreGusau, Zamfara State, in

the north-western Nigeria, an epidemic Cerebrospinal

meningitis (CSM) was observed in the year 2009.

Results

Seventy-seven children with epidemic CSM were admit-

st

ted from January 1 , to May 31 2009. Over this period,

1

70

5

64 children were admitted in to EPU giving overall

ples. Also five more patients had non-meningococcal

meningitis during the epidemics ( 3 pneumococcus and

2 Haemophilus influenzae). CSF culture was positive in

only 5 (6.5%) patients with meningococcal meningitis.

The five isolates were sensitive to ceftriaxone, chloram-

phenicol, and ciprofloxacin while resistant to penicillin.

prevalence rate of 13.7% (77 of 564). Fifty (64.9%)

were males and 27 (35.1%) were females with a M:F

ratio of 1.9:1. The ages ranged from six months to 12

years with a mean age (±1 SD) 67.4± 38.8 months.

Infections and age distribution:

Duration of illness prior to presentation and outcomes:

Thirty-seven (48.1%) and 32 (41.6%) were within the

ages of 6-10 and 1-5 years respectively, while 5 (6.5%)

patients were aged less than one year. Three (3.8%) of

the cases are seen in children above 10 years of age.

Fifty-seven (74.0%) patients recovered fully, 8 (10.4%)

died, 6 (7.8%) had neurologic sequelae (visual 2, deaf-

ness 4) and 6 (7.8%) absconded.The age ranges for the

fatal cases (7 months – 10 years)and those with neu-

rologic sequelae (6 months - 10 years) did not differ.

Only two of the eight fatal cases presented to hospital

within 72 hours of onset of illness while six are among

those presenting later. Also, four of the six patients with

neurologic sequelae presented beyond 72 hours after the

onset of illness. The risk of death is higher when the

duration of illness prior to presentation was more than

72 hours (2/48 versus 6/29; Fisher exact p = 0.03). There

is no statistically significant relationship between neu-

rologic sequelae and duration of illness prior to presen-

tation beyond 72 hours (2/48 versus 4/29; Fisher exact p

Clinical features:

The major clinical presentations are those of fever, neck

stiffness, vomiting, convulsions, coma, and skin rash.

Fever was present in all the patients (100%), while neck

stiffness was seen in 74 (96.1%) cases. Vomiting and

convulsions were seen in 38 (49.4%) and 35 (45.5%)

patients respectively. Altered sensorium was present in

2

6 (33.8%), while 12 (15.6%) had skin rash.

Duration of illness prior to presentation to hospital:

=

0.13).

Forty- eight (62.3%) patients presented to hospital

within 72 hours of onset of illness while 29 (37.7%)

presented more than 72 hours after the onset of illness.

Among the 29 patients who presented at more than 72

hours after the onset of symptoms, 11 (14.3%) of them

were seen 7-14 days after onset.

Discussion

Meningococcal meningitis is primarily the disease of

young children, but in epidemic, even young infants

may be affected. In this study, 40 (51.9%) of patients

were aged six years and above while 32 (41.6%) were

between one and five years age; out of which 11

(34.4%) are young infants. Five (6.5%) are below the

age of 1 year. The same pattern of age distribution have

Monthly prevalence:

The monthly prevalence of epidemic CSM is shown in

fig 1. The

highest prevalence was seen in April

23.6%), which was closely followed by that in March

21.6%). The prevalence in January was 3.3% while in

(

5

earlier been reported in Sokoto, in contrast to what

have been reported by Bwala et al in Maiduguri, north-

6

February was 3.9%. The prevalence of cases dropped to

1

0.5% in the month of May.

east, Nigeria. In Maiduguri, children less than 3 years of

age, some of whom were infants constitute the major

group affected. Also Idris Mohammed and co-workers

7

Fig 1: Monthly prevalence of CSM in children.

in Nigeria reported significant numbers of infants af-

fected during the large-scale epidemics of 1996.The

reason for relative involvement of young infants as

against previously observed pattern is not known, but

virulence of clonal sub-groups might be contributory as

suggested by Idris Mohammed and co-workers. Consid-

ering the relative involvement of young infants during

epidemics, the immunization policy may need to be

reviewed in order to incorporate CSM vaccine during

early infancy into the routine National Immunization

Programme of different countries within meningitis belt.

One major set back for the polyvalent vaccines that have

been in use for the past 30 years was poor immunogenic

response in infants and young children, especially in

those below the age of four years.

Laboratory results:

Recently, a new meningococcal A conjugate vaccine

which induces higher and more sustainable immune

response even in young infants was introduced(WHO

facts sheets/No 141) and may soon become widely used

The Latex Particle Agglutination was positive for Neis-

seria meningitidis serogroup A in all of the 77 CSF sam-

1

71

across African meningitis belt.The seasonal pattern of

the disease is similar to what was described by early

The latex test detected all the 77 cases and their specific

serotypewhich would have been missed by CSF culture.

The CSF culture detected only 5 (6.5%) cases. The low

bacteriologic yield on CSF culture has implication in the

sense that reasonable susceptibility testing to antibiotics

can not be achieved which is a major set back for defin-

ing control measures. The ability of the LPA test to

detect specific serotype causing epidemic in a particular

location and time has implication for effective control of

the disease in terms of mass vaccine administration. The

CSF culture isolates were all sensitive to ceftriaxone,

chloramphenicol and ciprofloxacin. All the patients who

survived, responded well to chloramphenicol; only a few

5 (7.9%) of them have their antibiotic changed to

8

,9

workers. The prevalence of the disease rises and

reached its peak in the month of April. The average tem-

perature in Gusau and environs around the middle of

O

April was 41 c in association with low humidity. Late

presentation to the hospital is a common problem in

developing countries and this may favour poor outcome

with resultant high morbidity and mortality. In this

study, the mortality is higher in those patients presenting

to the facility lately at more than 72 hours from the on-

set of the illness. Also, neurologic sequelae was more in

those patients whose delay in presentation is more than

7

2 hours. This stresses the need for public education on

early recognition and prompt treatment. Owing to the

unfavourable outcome and documented evidence of effi-

cacy of intramuscular oily chloramphenicol in meningo-

ceftriaxone. The mortality rate of 10.4% in this stud₅y is

higher than the 3.7% reported by Bwala et al in

Maiduguri, in 1987.

7

coccal disease, it is imperative to advocate the possibili-

ties of use of pre-referral depot chloramphenicol at Pri-

mary Health Centres/or community during epidemics,

which can be safely administered by trained health

workers at community level.The strain of Neisseria

meningitidis responsible for the epidemics in this study

was Neisseria meningitidisserogroup A.

Conflict of interest: None

Funding: None

This was similar to the strain that caused major epidem-

ics of CSM in northern Nigeria (1970, 1975, 1977, 1986

Acknowledgements

and 1996), Chad (1988), and Niger Republic (1991,

We wish to thank the Medical Record staff for

retrieving the folders. Also special thank goes to WHO

Zamfara State office ( for supplying the LPA kits), and

MSF for supplying chloramphenicol and ceftriaxone

that were used on the patients.

4

1

994). Similarly, Neisseria meningitidis serogroup A

1

0

was the cause of an epidemic reported by Moore et al,

in Saudi Arabia in 1987. The utility value of latex

agglutination test in the diagnosis of meningitis was

shown in this study.

References

1

.

Lapeyssonie L. La meningitecere-

brospinale en Afrique. Bulletin of

the WHO 1963; 28 (suppl): 3-114.

Petter B, Mercel Van D. Meningo-

5.

Emele FE, Anyiwo CE. Cerebro-

spinal meningitis in Sokoto Nige-

ria: a bacteriological analysis of

three successive epidemics. J Med

Lab Sci 1994; 4: 34-9.

8. Whittle HC, Fakunle YM, Abdul-

lahi MT, Barry FHO. Clinicalfea-

tures of epidemic meningococcal

meningitis. Nig Med J 1977; 4:

369-73.

9. Whittle HC, Greenwood BM. Men-

ingococcal meningitis in the

Northern Savanna of Africa.

Tropical Doctor 1976; 3: 99-104.

10. Moore PS, Reeves MW, Schwartz

B, Gellin BG, Broome CV.

2

.

coccal infections at the start of the

st

2

1 Century. Advances in Pediat-

6. Bwala SA, Mohammed I, On-

wuchekwa AC, Gashau AA. An

outbreak of Meningococcal Men-

ingitis in Maiduguri, Borno State,

Nigeria: I. Cinical Aspects. Nig

Med Pract 1989; 18 (2): 31-3.

7. Mohammed I, Nasidi A, Alkali AS

et al. A severe epidemic of menin-

gococcal meningitis in Nigeria,

rics 2005; 52: 129-61.

3

4

.

Saez-Llorens X, McKrackenJr,

GH. Bacterial meningitis in chil-

dren. Lancet 2003; 2: 315-18.

World Health Organization (1995).

Control of epidemic meningococ-

cal diseases. WHO Practical guide-

lines. Lyons Foundation Merieux.

Intercontinental spread of an epi-

demic group A Neisseria

men-

ingitidis strain. Lancet 1989; 2:

260-3.

1

996. Trans R Soc Trop Med Hyg

2

000; 94: 1-6.