JEDDAH, 23 July — A consultant microbiologist at King Abdul Aziz Hospital, Al-Zahir, Makkah, achieved a singular honor recently when the weaknesses pointed out by him in following an established procedure in analyzing the chemical components of bacteria causing meningitis were acknowledged and the changes suggested were accepted by the World Health Organization (WHO) and the Center of Diseases Control, Atlanta (CDC) in their manual.
“You’re right, we want to change the procedure in the manual. In fact, all the suggestions should be incorporated in a future version of the manual,” was the sum and substance of a communication to him from the manual publishers recently.
Speaking to Arab News, Dr. Haroon Rashid Diwan, who is the author of “100 Question Series in Microbiology,” said the Kingdomwide mass vaccination campaign against meningococcus, the bacterium that is a common cause of meningitis, has been a resounding success in the control and prevention of the disease in Saudi Arabia. “In fact, countries still facing the problem of controlling meningitis can get good guidance from the Kingdom.” The annual Haj season is usually the time when the Ministry of Health issues an all-important message to all doctors and health authorities urging them to be vigilant for signs of any disease, meningitis in particular.
In fact, meningococcal meningitis occurs globally. The disease is endemic in temperate climates causing a steady number of sporadic cases or small clusters with a seasonal increase in winter and spring. The WHO has taken many steps to prevent meningococcal infection, including the laboratory diagnostic manual. The manual “Laboratory methods for the diagnosis of meningitis caused by Neisseria meningitidis, Streptococcus pneumoniae and Hemophilus influenza” is a joint effort of the WHO and Center of Disease Control and Prevention (CDC), Atlanta. The manual deals with three aspects — observation of organisms in cerebrospinal fluid of patients by staining with the staining method called Gram stain; detection of only the soluble antigenic component of the organism by a method called latex test; and to grow the organisms on culture media for further identification and stereotyping. Tanja Popovic, Gloria Ajello and Richard Facklam, all CDC microbiologists, are the principal authors of the manual, which is reviewed by many other microbiologists around the globe. However, according to Dr. Diwan has apprized the Ministry of Health that the manual still needs clarifications in many places. Also, many aspects need further discussion. “To quote a couple of examples: On page 13, the manual gives its own method stating the first thing to do on receiving the cerebrospinal fluid (CSF) in the laboratory is to centrifuge, that is, the step in which the bacteria are spun down in the bottom of the tube and one gets the above remaining clear portion called supernatant, which is used to carry out the latex test (detecting component of bacteria).
This WHO method is different from the method of the manufacturer of the kit. When the manufacturer of the kit was contacted on this issue, they said they take no responsibility of the results if the company recommended method is not followed and also advised that such results should not go out of labs.”
“Strangely, on page 15 Dr. Diwan’s explanation in using their method is that this manual is targeting the developing countries where only one tube will be used to collect the CSF and therefore one has to use this method. Moreover, by this WHO method the sensitivity of the latex kit is compromised, that is, ability to detect the case of meningitis is reduced.
Dr. Diwan’s explanation in using their method is that this manual is targeting the developing countries where only one tube will be used to collect the CSF and therefore one has to use this method. Moreover, by this WHO method the sensitivity of the latex kit is compromised, that is, ability to detect the case of meningitis is reduced. And it may fail to detect those patients who have taken antibiotics, that is, partially treated and such cases can be missed by the WHO method.
Meningitis is the inflammation of the meninges or covering of the brain and spinal cord and is the result of infection by bacteria. The three important bacteria are Neisseria meningitides, Streptococcus pneumonia and Hemophilius influenza type b. Nisseria meningitides (meningococcus) is the commonest overall cause of pyogenic meningitis worldwide and is the only bacterium capable of generating epidemic outbreaks of meningitis. Meningococci are classified into many stereotypes. Meningococcal disease develops so quickly that a patient could be fighting for life within hours of the onset of symptoms. This is why prompt diagnosis and effective treatment are so crucial. Diagnosis and treatment of the meningococcal disease in the early stage is vital in saving lives and reducing morbidity. Identification of the infecting agent is one of the most important functions of the diagnostic microbiology laboratory because acute meningitis is one of the most serious infections. CSF from a suspected meningitis patient is an emergency specimen that requires immediate processing to determine the etiologic agent.
Although sporadic cases occur throughout the world, epidemics tend to be associated with conditions of overcrowding (if the distance between beds is 1.4 ft, the carrier rate is 10 percent and 28 to 30 percent if the distance is less than nine inches), mobilization and enclosed institutional populations. Such outbreaks tend to be extraordinary disruptive especially because of the fear and fright they induce in the populations.
Haj is one of the situations when over two million pilgrims gather from more than 140 countries in Makkah. Aside from epidemics, at least 1.2 million cases of bacterial meningitis are estimated to occur every year; 135,000 of them are fatal. About 500,000 of these cases and 50,000 of the deaths are due to meningococcus. Meningococcal meningitis is the only form of bacterial meningitis, which causes epidemics. The largest epidemics of meningococcal meningitis are experienced by sub-Saharan African countries within the so-called “meningitis belt,” which extends from Ethiopia in the east to Senegal in the West. Epidemics occur in the dry season in this area. While the highest disease rates are found in young children, during epidemics older children, teenagers and young adults are also affected.