Volume 28-05
1 March 2002

[Table of Contents]

THE USE OF THE INTERNET TO INFORM YOUNG INTERNATIONAL TRAVELLERS OF CONTACT WITH A CASE OF MENINGOCOCCAL MENINGITIS

Background

A female, 19 years of age, from the United Kindom (U.K.) was admitted to hospital in Vancouver, British Columbia (B.C.), on 10 July, 2001 with a history of vomiting and drowsiness. A lumbar puncture performed on 11 July, showed intracellular gram-negative diplococci. A presumptive diagnosis of meningococcal meningitis was made and subsequently confirmed by polymerase chain reaction (PCR) on 12 July. It was later identified as sero-group B; therefore it was not preventable by the vaccines that are currently available, and was unrelated to an outbreak which was occurring at that time in Abbottsford, B.C.

Neisseria meningitidis is transmitted by direct contact with saliva and respiratory droplets from the nose and throat of infected persons. Up to 30% of teenagers and 10% of adults carry meningococci in the upper respiratory tract at any point in time⁽¹⁾. Most cases of meningococcal meningitis are sporadic, and occur without a history of contact with a known case.

The primary means for prevention of sporadic meningococcal disease is antimicrobial chemoprophylaxis of close contacts of infected persons to eliminate nasopharyngeal carriage. Close contacts are at 500 to 800 times the risk of the general population of invasive disease⁽²⁾, and include household members or anyone directly exposed to the patients oral secretions (e.g., through kissing; or sharing food, eating utensils, drink cans, water bottles, cigarettes or lipstick).

Chemoprophylaxis should be administered to close contacts with exposure to the case while the case was infectious (i.e., during the 7 days before the onset of symptoms and up to 24 hours following the start of the appropriate antibiotic). Because the rate of secondary infection of close contacts is highest during the first few days after onset of disease in the index patient, chemoprophylaxis should be administered as soon as possible, ideally within 24 hours after identification of the index case⁽³⁾. The risk of a serious outcome can be reduced by informing close contacts about the symptoms and signs of meningococcal disease, so they are more likely to seek medical attention early⁽⁴⁾.

Methods

History obtained from friends of the case, revealed that she had been staying at Hostelling International-Vancouver, Jericho Beach (a 282-bed hostel) during her infectious period. The hostel has dormitory-style sleeping arrangements, shared bathrooms and one shared kitchen with shared utensils. Sharing of cigarettes and drinks was reportedly a frequent occurrence at the hostel. Active and passive smoking have been found to be associated with meningococcal disease and carriage^(1,5). Clusters of meningococcal disease have been reported in university students living in similar circumstances (i.e. the same residence)⁽⁴⁾.

The youth hostel was, therefore, considered a 'household' and chemoprophylaxis was recommended for all staff and residents who stayed at the hostel during the week before the patient was admitted to hospital. Up to 80 new residents stay at the hostel each day, so potentially 750 persons needed to be informed about chemoprophylaxis and signs and symptoms of meningococcal disease.

Rifampin taken twice a day for 2 days is usually recommended for meningococcal disease prophylaxis in B.C. However to ensure compliance in this mobile young population, persons >= 18 years of age, were offered a single dose of ciprofloxacin; which has been shown to be 90% effective in eradicating nasal carriage⁽⁶⁾. Rifampin was offered to those < 18 years of age and intramuscular ceftriaxone was recommended for those who were pregnant.

Posters were developed by Vancouver/Richmond Health Board (VRHB) informing residents about the meningitis case, recommending prophylactic antibiotics and announcing a clinic at the hostel offering antibiotics the next morning. These were e-mailed to the hostel and posted on dormitory doors on the evening of 11 July. The meningococcal disease 'Health File' from the B.C. Ministry of Health web site was printed and photocopied by the hostel for distribution to the residents.

Communicable disease control staff from VRHB offered antibiotics to residents and staff at the Jericho Beach hostel on subsequent occasions, as well as at the Vancouver Downtown hostel, since residents moved between the hostels and shared social activities. On 12 July a press release was developed with the assistance of the B.C. Centre for Disease Control, and sent to media outlets, all B.C. youth hostels, B.C. medical health officers and provincial epidemiologists throughout Canada. Local emergency rooms were notified of clinics over the weekend. News reports aired on radio and television on 12 July and articles appeared in the local and national newspapers the following day.

The greatest challenge was how to notify contacts who had left the hostel and were travelling. The young international traveller may not listen to radio or television, or read newspapers. They may also travel throughout the province, to other provinces or other countries.

E-mail addresses of residents who were no longer at the hostel were obtained, where available, from present residents and contact was made by health board staff or other hostel residents made direct e-mail contact with friends informing them of the situation. Coyotenet provides Internet computers servicing the Canadian Hostelling International, Backpackers and other locations on the west coast of the U.S. Sixty-five terminals in its hostel network were updated to display a health warning on the off-line screen saver. As part of the program all the terminals were changed to log into a default web site displaying the health warning when the kiosks were used.

Results

All 26 staff and three volunteers of the hostel who may have had close contact with the case received chemoprophylaxis. Over 100 hostel residents are known to have received prophylactic antibiotics. However, it is not known how many persons sought medical advice and received antibiotic prophylaxis through private physicians or emergency rooms within B.C., or sought treatment outside B.C.

Several hundred calls regarding meningitis were received by VRHB staff and by staff at the hostel itself. A number of contacts were made via e-mail; one close contact, who had spent considerable time with the case, e-mailed the health board from England 2 days after the case was diagnosed. In the 7 days that it was online, the health warning web page had over 15,000 hits, it is not known how many more people may have seen the screen saver.

No further cases of meningococcal meningitis were identified or reported to VRHB.

Discussion

All opportunities to disseminate information about signs and symptoms of meningococcal disease to contacts should be employed⁽⁷⁾. An outbreak of syphilis was linked to an Internet chat room⁽⁸⁾; however, there was little evidence in the literature that the Internet was used to trace or inform contacts. Collaboration and co-operation between the B.C. Centre for Disease Control, the Health Board, the media and Hostelling International enabled the rapid and widespread dissemination of information. Using the Internet as a vehicle for health message dissemination may allow public health officials to reach young travellers more effectively than traditional media outlets.

Ackowledgements

The authors would like to thank the assistance and co-operation of Hostelling International - Canada - British Columbia Region and the staff of HI-Vancouver Jericho Beach Hostel; Coyotenet; Dr. John Blatherwick and the Vancouver/Richmond Health Board staff.

References

1. Caugant DA, Hoiby EA, Magnus P et al. Asymptomatic carriage of Neisseria meningitidis in a randomly sampled population. J Clin Microbiology 1994;32:323-30.

2. Meningococcal Disease Surveillance Group. Meningococcal disease. Secondary attack rate and chemoprophylaxis in the United States, 1974. JAMA 1976;235:261-65.

3. CDC. Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2000;49(RR07):1-10.

4. Clusters of meningococcal disease in university students. CDR Weekly 1997;7:393, 396.

5. Stanwell-Smith RE, Stuart JM, Hughes AO et al. Smoking, the environment and meningococcal disease: a case control study. Epidemiol Infect 1994;112:315-28.

6. Cuevas LE, Kazembe P, Mughogho GK et al. Eradication of nasopharyngeal carriage of Neisseria meningitidis in children and adults in rural Africa: a comparison of ciprofloxacin and rifampin. J Infect Dis 1995;171:728-31.

7. Prophylaxis for holiday contacts of single cases of meningococcal disease. CDR Weekly 1998;8:307.

8. Klausner JD, Wolf W, Fischer-Ponce L et al. Tracing a syphilis outbreak through cyberspace. JAMA 2000;26:284:447-49.

Source: JA Buxton, MBBS, MHSc; MS Smythe, RN, BSN; JR Salzman, MD, DTM & H, Communicable Disease Control, Vancouver/ Richmond Health Board, Vancouver, British Columbia.

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