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Epidemiology, prevalence and clinical diagnosis of meningitis at Abbassia Fever Hospital, Cairo, 1966–1989
4 TRANSACTIONS OF THE ROYAL SOCIETYOF TROPICALMBDICINE AND HYGIENE (1991) 85,
Epidemiology, prevalence and clinical diagnosis Fever Hospital, Cairo, 19661989 Michael E. Kilpatrick’,
SUPPLEMENT 1, 4-5
of meningitis
Nabil I. Girgis’, Zoheir Farid’ and John E. Sippel’
Unit No. 3, Cairo, Egypt;
‘Mercer
University,
School of Medicine,
Abstract The United States Naval Medical Research Unit No. 3 and the Abbassia Fever Ho&al in Cairo. Egypt have together diagnosed and treated 7809 patients admitted to a meningitis ward since 1966. Aetiological diagnosis was based on clinical evaluation and laboratory studies. Marked increases in annual admissions in 1970-1972, 1980-1982 and 1987-1988 were related to increases in admissions due to meningococcal disease, while in 1977-1981 the increase was due to encephalitis related to Rift Valley fever. Better, rapid diagnostic procedures are needed to enable effective treatment to be given earlier and to reduce mortality rates. Introduction The epidemiology of meningitis is an expensive title which will be defined and compressed by this presentation. The United States Naval Medical Research Unit No. 3 (NAMRU-3) in Cairo, Egypt has had a uniaue relationshiu with the Ministrv of Health’s Abbassia Fever fiospital (AFH) meniigitis ward since 1966. NAMRU-3 and AFH are situated side by side and have together been responsible for the clinical care, laboratory diagnosis and therapy of patients admitted to the meningitis ward, referred to as the NAMRU-3-AFH ward in most previous publications (KILPATRICK et al., 1987; HANGA et al., 1988; GIRGIS et al., 1989a. 1989b). The oatients admiited generally come from the greater C&o area, but can be referred from all parts of Egypt. The population has increased tremendously during this time. The data collected were only from patients admitted, so reflect only admission rates and cannot necessarily be correlated with prevalence or incidence rates. There are no denominator data. From 1966 to the present there have been no changesin Ministry of Health directives to refer patients with signs and symptoms of meningitis to fever hospitals and care at AFH has always been free, so there are no obvious biases in referrals or admission practices during this reported period. Results and Discussion During the time of this study, 7809 patients were admitted to the meningitis ward and entered into the data base used for this analysis. The diagnostic categoriesinto which the meningitis patients were placed were bacterial, tuberculous or viral aetiologies. The clinical impression was first based on duration of illness before presentation. Those patients with illness of over 10 d duration were generally presumed to be tuberculous meningitis, while those with illness of less than 10 d were presumed to be either bacterial or viral. The results of the admission cerebrospinal fluid (CSF) examination
Macon,
at Abbassia
‘US Naval Medical Research Georgia, USA
then confirmed or altered the clinical impression. If the white blood cell count was less than 100 and glucose and protein were essentially normal and the Gram stain was negative, the diagnosis was viral. If the leucocyte count was over 1000, predominantly polymorphonuclear leucocytes, the glucose was low and the protein slightly elevated, the diagnosis was bacterial meningitis. If the white cell count was less than 1000 and predominantly lymphocytes, the glucose was low and the protein high, the diagnosis was tuberculous meningitis. The last confirmation or alteration of diagnosis was based on organism identification by Gram staining, antigen detection or by culture. The bacterial category was divided into aetiological agent isolated or identified (meningococcal, pneumococcal, Haemophilus, or other) or to culture-negative (purulent). Tuberculous meningitis was either culture-positive or culture-negative and viral meningitis was the resultant category. Further details will be given in the presentation on laboratory diagnosis (SIPPEL et al., 1991). The cyclic pattern of increased incidence of meningo
1963; EL AKKAD,
1969). The Desk
&hnission rates.at APH tended tb folldw the &ak rates seen in Sudan, but occurred one to two years later, indicating a northerly spread of increased diseaseprevalence (SIPPEL & GIRGIS, 1987; SALLH et al., 1990). The total annual admissions for meningitis from 1967-1989 (from July of one year through to June of the next), with the annual rates for meningococcal meningitis and purulent meningitis, are shown in Fig. 1. Fig. 2 shows the total annual admission rates and the annual rates for H. injhunzae and S. pneumoniae, and Fig. 3 shows the total annual admission rates and the annual rate for tuberculous meningitis (culturepositive and culture-negative) and encephalitis. The total annual admission peaks in 1970-1972, 19801982 and 1987-1988 were definitely related to increasesin meningococcal disease(the purulent category increases in these years certainly reflect meningococcal disease since the other bacterial aetiologies were consistent from year to year). The peak in the viral category from 1977-1981 coincided with an epidemic of Rift Valley fever occurring in Egypt during that period, with serological evidence of human disease (LAUGHLIN et al., 1978). The infecting agent mortality rates during the years of this study have changed little except for a decrease in meningococcal meningitis. One of the complicating factors for mortality rates is that 70% of patients admitted were in coma at the time of admission, some 20% were drowsy,and 10% or fewer were alert. The mortality rates (Table) for the study period were 8% for meningococcus, 13% for meningococcaemia, 41%
5
H O
000
s ;
4*
: y
200
s 0 87
(50 -
71
73
76
TOTAL KlYIII)ION
77 +
79
81
83
86 *
II. MENlNOlDlTla
07
88
P”R”LENT
Fig. 1. Total cases of meningitis, cases due to N. menit&idi~, and cases of purulent meningitis; Abbassia Fever Hospital, Cairo, 1967-1989.
for Haemophilus injiuenzae, 41% for Streptococcus pneumoniae, 13% for ‘purulent’, 58% for tuherculous culture-positive, and 48% for tuherculous culturenegative. The effect of various antibiotic susceptibility patterns and newer drug therapeutic programmes will he presented in the next paper (SIPPEL et al., 1991). It should again be stressed that these data reflect admissions for meningitis to one hospital. Results cannot he generalized to a country or a region. The critical points are that the AFH continues to admit, diagnose and treat critically ill patients with meningitis. The fact that so many patients are admitted in a comatose state reveals that better, rapid diagnostic methods are needed to enable effective treatment to be given earlier. This is still the challenge of infectious diseases in the third world. Acknowledgements
0 a, -
xa9
7,
,3
76
77
70
81
TOTALA.DYlSSION -8 H. lNFL”ENLlE
83
85
a7
89
We thank MS Elinor Cross, Epidemiology Department, Naval Medical ResearchInstitute (NMRI), for designing the programe to enter the patients’ data for analysis and for her training of personnel on data entry. This work was supported by the Naval Medical Research and Development Command, NMC NCR, Bethesda, Maryland? USA, work unit no. 3M161102BS13.AK-311. The opmons and assertionscontained herein are the private ones of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy, the Department of Defense, or the Government of the United States.
x s. PNEUMONIAE
Fig. 2. Total cases of meningitis, cases due to H. iq?unzae, and cases due to S. pnewnaiue; Abbassia Fever Hospital, Cairo, 1967-1989.
References
El-Akkad, A. M. (1969). Epidemiology of cerebrospinal meningitis in Egypt during the last 50 years. Journal of the Egyptian Public Health Association, 44, 260-280.
Girgis, N. I., Farid, Z. & Kilpatrick, M. E. (1989a). Diagnosis of bacterial meningitis. Lancer, ii, 1039. Girgis, N. I~, Farid, Z., Mikbail, I. A., Farrag, I., Sultan, Y. & Kilpatrick, M. E. (1989b). Dexametbasone treatment for bacterial meningitis in children and adults. Pediatric Infectious Diseases Josmsal, 8, 848-851.
Hanna, L. S., Girgis, N. I., Abu El-Ella? A. H. & Farid, Z. (1988). Ocular complications in meningitis: fifteen years study. Metabolic, Pediatric and Systemic Ophthalmology, 11, 160-162. Kilpatrick, M. E., M&bail, I. A. & Girgis! N. I. (1987). Negative cultures of cerebrospinal fluid in partially treated bacterial meninaitis. TroPical and Geoaraohical - Medicine? 39, 34%349.-
-YEARLY
AOH15910N
+
,a
MENIN(IITIS
-*~ ENCEPH*LITIS
Fig. 3. Total cases of meningitis and cases of tuberculous meningitis and encephalitis; Abbassia Fever Hospital, Cairo, 1967-1989.
Table. Mortality Fever Hospital,
rates from meningitis, Cairo, 1966-1989
Abbassia
Mortality rate (%) N. meningitidis Meuingococcaemia H. infIuenzae SK;ygofiiae Tuberculous Tuberculous Viral
(positive) (negative)
-
Lapeyssonme, L. (1963). Le meningite cerebra-spinale en Afrique. Bulletin of the World Health OrganizatCm, 28, suaolement. l-l ~~ 14. ..~CT~~~~~~~~~, Laughlm, L. W., Girgis, N. I., Meegan, J. M., Strausbaugh, L. J., Yassin, M. W. & Watten, R. H. (1978). Clinical studies on Rift Valley fever, part 2: ophtbalmological and central nervous system complications. Journal of the Egyptian Public Health Association, 53, 183-184. Sallb, M., Sid Abmed, H., Karrar, N., Kamil, I., Osman, K., Palmgran, H., Hofvander, Y. & Olcen, P. (1990). Features of a large epidemic of group A meningocoecal meningitis in Khartoum, Sudan in 1988. ScandiMtin Journal of Infectious Diseases, 22, 161-170. Sippel, J. E. & Girgis, N. I. (1987). Epidemiology of meningococcal disaesein north-eastern Africa. In: Evolution of Meningococcal Disease, Vedros, N. A. (editor). Boca Raton, Florida: CRC Press, pp. l-8. Sippel, J. E., Girgis, N. I., M. E. Kilpatrick & Farid, Z. (1991). Studies on laboratory diagnosis of bacterial meningitis. Transactions of the Royal Society of Tropical Medicine and Hygiene, 85, supplement 1.
Epidemiology, prevalence and clinical diagnosis Fever Hospital, Cairo, 19661989 Michael E. Kilpatrick’,
SUPPLEMENT 1, 4-5
of meningitis
Nabil I. Girgis’, Zoheir Farid’ and John E. Sippel’
Unit No. 3, Cairo, Egypt;
‘Mercer
University,
School of Medicine,
Abstract The United States Naval Medical Research Unit No. 3 and the Abbassia Fever Ho&al in Cairo. Egypt have together diagnosed and treated 7809 patients admitted to a meningitis ward since 1966. Aetiological diagnosis was based on clinical evaluation and laboratory studies. Marked increases in annual admissions in 1970-1972, 1980-1982 and 1987-1988 were related to increases in admissions due to meningococcal disease, while in 1977-1981 the increase was due to encephalitis related to Rift Valley fever. Better, rapid diagnostic procedures are needed to enable effective treatment to be given earlier and to reduce mortality rates. Introduction The epidemiology of meningitis is an expensive title which will be defined and compressed by this presentation. The United States Naval Medical Research Unit No. 3 (NAMRU-3) in Cairo, Egypt has had a uniaue relationshiu with the Ministrv of Health’s Abbassia Fever fiospital (AFH) meniigitis ward since 1966. NAMRU-3 and AFH are situated side by side and have together been responsible for the clinical care, laboratory diagnosis and therapy of patients admitted to the meningitis ward, referred to as the NAMRU-3-AFH ward in most previous publications (KILPATRICK et al., 1987; HANGA et al., 1988; GIRGIS et al., 1989a. 1989b). The oatients admiited generally come from the greater C&o area, but can be referred from all parts of Egypt. The population has increased tremendously during this time. The data collected were only from patients admitted, so reflect only admission rates and cannot necessarily be correlated with prevalence or incidence rates. There are no denominator data. From 1966 to the present there have been no changesin Ministry of Health directives to refer patients with signs and symptoms of meningitis to fever hospitals and care at AFH has always been free, so there are no obvious biases in referrals or admission practices during this reported period. Results and Discussion During the time of this study, 7809 patients were admitted to the meningitis ward and entered into the data base used for this analysis. The diagnostic categoriesinto which the meningitis patients were placed were bacterial, tuberculous or viral aetiologies. The clinical impression was first based on duration of illness before presentation. Those patients with illness of over 10 d duration were generally presumed to be tuberculous meningitis, while those with illness of less than 10 d were presumed to be either bacterial or viral. The results of the admission cerebrospinal fluid (CSF) examination
Macon,
at Abbassia
‘US Naval Medical Research Georgia, USA
then confirmed or altered the clinical impression. If the white blood cell count was less than 100 and glucose and protein were essentially normal and the Gram stain was negative, the diagnosis was viral. If the leucocyte count was over 1000, predominantly polymorphonuclear leucocytes, the glucose was low and the protein slightly elevated, the diagnosis was bacterial meningitis. If the white cell count was less than 1000 and predominantly lymphocytes, the glucose was low and the protein high, the diagnosis was tuberculous meningitis. The last confirmation or alteration of diagnosis was based on organism identification by Gram staining, antigen detection or by culture. The bacterial category was divided into aetiological agent isolated or identified (meningococcal, pneumococcal, Haemophilus, or other) or to culture-negative (purulent). Tuberculous meningitis was either culture-positive or culture-negative and viral meningitis was the resultant category. Further details will be given in the presentation on laboratory diagnosis (SIPPEL et al., 1991). The cyclic pattern of increased incidence of meningo
1963; EL AKKAD,
1969). The Desk
&hnission rates.at APH tended tb folldw the &ak rates seen in Sudan, but occurred one to two years later, indicating a northerly spread of increased diseaseprevalence (SIPPEL & GIRGIS, 1987; SALLH et al., 1990). The total annual admissions for meningitis from 1967-1989 (from July of one year through to June of the next), with the annual rates for meningococcal meningitis and purulent meningitis, are shown in Fig. 1. Fig. 2 shows the total annual admission rates and the annual rates for H. injhunzae and S. pneumoniae, and Fig. 3 shows the total annual admission rates and the annual rate for tuberculous meningitis (culturepositive and culture-negative) and encephalitis. The total annual admission peaks in 1970-1972, 19801982 and 1987-1988 were definitely related to increasesin meningococcal disease(the purulent category increases in these years certainly reflect meningococcal disease since the other bacterial aetiologies were consistent from year to year). The peak in the viral category from 1977-1981 coincided with an epidemic of Rift Valley fever occurring in Egypt during that period, with serological evidence of human disease (LAUGHLIN et al., 1978). The infecting agent mortality rates during the years of this study have changed little except for a decrease in meningococcal meningitis. One of the complicating factors for mortality rates is that 70% of patients admitted were in coma at the time of admission, some 20% were drowsy,and 10% or fewer were alert. The mortality rates (Table) for the study period were 8% for meningococcus, 13% for meningococcaemia, 41%
5
H O
000
s ;
4*
: y
200
s 0 87
(50 -
71
73
76
TOTAL KlYIII)ION
77 +
79
81
83
86 *
II. MENlNOlDlTla
07
88
P”R”LENT
Fig. 1. Total cases of meningitis, cases due to N. menit&idi~, and cases of purulent meningitis; Abbassia Fever Hospital, Cairo, 1967-1989.
for Haemophilus injiuenzae, 41% for Streptococcus pneumoniae, 13% for ‘purulent’, 58% for tuherculous culture-positive, and 48% for tuherculous culturenegative. The effect of various antibiotic susceptibility patterns and newer drug therapeutic programmes will he presented in the next paper (SIPPEL et al., 1991). It should again be stressed that these data reflect admissions for meningitis to one hospital. Results cannot he generalized to a country or a region. The critical points are that the AFH continues to admit, diagnose and treat critically ill patients with meningitis. The fact that so many patients are admitted in a comatose state reveals that better, rapid diagnostic methods are needed to enable effective treatment to be given earlier. This is still the challenge of infectious diseases in the third world. Acknowledgements
0 a, -
xa9
7,
,3
76
77
70
81
TOTALA.DYlSSION -8 H. lNFL”ENLlE
83
85
a7
89
We thank MS Elinor Cross, Epidemiology Department, Naval Medical ResearchInstitute (NMRI), for designing the programe to enter the patients’ data for analysis and for her training of personnel on data entry. This work was supported by the Naval Medical Research and Development Command, NMC NCR, Bethesda, Maryland? USA, work unit no. 3M161102BS13.AK-311. The opmons and assertionscontained herein are the private ones of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy, the Department of Defense, or the Government of the United States.
x s. PNEUMONIAE
Fig. 2. Total cases of meningitis, cases due to H. iq?unzae, and cases due to S. pnewnaiue; Abbassia Fever Hospital, Cairo, 1967-1989.
References
El-Akkad, A. M. (1969). Epidemiology of cerebrospinal meningitis in Egypt during the last 50 years. Journal of the Egyptian Public Health Association, 44, 260-280.
Girgis, N. I., Farid, Z. & Kilpatrick, M. E. (1989a). Diagnosis of bacterial meningitis. Lancer, ii, 1039. Girgis, N. I~, Farid, Z., Mikbail, I. A., Farrag, I., Sultan, Y. & Kilpatrick, M. E. (1989b). Dexametbasone treatment for bacterial meningitis in children and adults. Pediatric Infectious Diseases Josmsal, 8, 848-851.
Hanna, L. S., Girgis, N. I., Abu El-Ella? A. H. & Farid, Z. (1988). Ocular complications in meningitis: fifteen years study. Metabolic, Pediatric and Systemic Ophthalmology, 11, 160-162. Kilpatrick, M. E., M&bail, I. A. & Girgis! N. I. (1987). Negative cultures of cerebrospinal fluid in partially treated bacterial meninaitis. TroPical and Geoaraohical - Medicine? 39, 34%349.-
-YEARLY
AOH15910N
+
,a
MENIN(IITIS
-*~ ENCEPH*LITIS
Fig. 3. Total cases of meningitis and cases of tuberculous meningitis and encephalitis; Abbassia Fever Hospital, Cairo, 1967-1989.
Table. Mortality Fever Hospital,
rates from meningitis, Cairo, 1966-1989
Abbassia
Mortality rate (%) N. meningitidis Meuingococcaemia H. infIuenzae SK;ygofiiae Tuberculous Tuberculous Viral
(positive) (negative)
-
Lapeyssonme, L. (1963). Le meningite cerebra-spinale en Afrique. Bulletin of the World Health OrganizatCm, 28, suaolement. l-l ~~ 14. ..~CT~~~~~~~~~, Laughlm, L. W., Girgis, N. I., Meegan, J. M., Strausbaugh, L. J., Yassin, M. W. & Watten, R. H. (1978). Clinical studies on Rift Valley fever, part 2: ophtbalmological and central nervous system complications. Journal of the Egyptian Public Health Association, 53, 183-184. Sallb, M., Sid Abmed, H., Karrar, N., Kamil, I., Osman, K., Palmgran, H., Hofvander, Y. & Olcen, P. (1990). Features of a large epidemic of group A meningocoecal meningitis in Khartoum, Sudan in 1988. ScandiMtin Journal of Infectious Diseases, 22, 161-170. Sippel, J. E. & Girgis, N. I. (1987). Epidemiology of meningococcal disaesein north-eastern Africa. In: Evolution of Meningococcal Disease, Vedros, N. A. (editor). Boca Raton, Florida: CRC Press, pp. l-8. Sippel, J. E., Girgis, N. I., M. E. Kilpatrick & Farid, Z. (1991). Studies on laboratory diagnosis of bacterial meningitis. Transactions of the Royal Society of Tropical Medicine and Hygiene, 85, supplement 1.