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Home Eurosurveillance Weekly Release  2007: Volume 12/ Issue 9 Article 2
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Eurosurveillance, Volume 12, Issue 9, 01 March 2007
Articles

Citation style for this article: Kadlubowski M, Wasko I, Klarowicz A, Hryniewicz W. Invasive meningococcal disease at a military base in Warsaw, January 2007. Euro Surveill. 2007;12(9):pii=3147. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3147

Invasive meningococcal disease at a military base in Warsaw, January 2007

M Kadlubowski (kadlubek@cls.edu.pl), I Wasko, A Klarowicz, W Hryniewicz

National Reference Centre for Bacterial Meningitis, National Medicines Institute, Warsaw, Poland

On 5 January 2007, two soldiers from a military base in Warsaw, Poland, presented with symptoms indicating fulminant sepsis. The most striking sign was a quickly spreading petechial rash, covering the whole body within just a few hours. The soldiers were admitted to intensive care units in two different hospitals. Neisseria meningitidis was isolated from blood and cerebrospinal fluid in the case of one patient and from blood only in the case of the other, and sent to the National Reference Centre for Bacterial Meningitis (NRCBM) for further characterisation.

Both patients died of severe meningococcal septicaemia, the first one 13 days after admission, the other 16 days after admission. A further 46 people from the same military base were admitted to hospital for observation, because they had symptoms such as fever, headache and/or malaise. All of them received antibiotic treatment. Two days after admission, blood samples were taken for bacteriological analysis and forwarded to the NRCBM for additional diagnostics.

Altogether, 15 cases (including the two soldiers who died of septicaemia) were laboratory-confirmed for invasive meningococcal disease.

Laboratory investigations
In the NRCBM, the isolates responsible for the two cases of severe septicaemia were identified as N. meningitidis serogroup C indistinguishable in all molecular methods applied. Both were of sequence type ST-11, belonging to hypervirulent and hyperepidemic clonal complex ST-11/ET-37 [1].
The sequence type of the isolates was determined by multilocus sequence typing (MLST). Known hypervirulent and hyperepidemic clones of meningococci isolated in Poland were included in the study for comparison.

Blood samples collected from the 46 other patients from the military base were examined by serological and molecular methods. Serum samples were examined for the presence of group C, W135 meningococcal antigen by latex commercial test and for the presence of meningococcal DNA by PCR, as described by Taha [2]. Blood or serum samples from 11 patients were positive both in the PCR and latex test, a sample from one patient was positive only in the PCR, and another one in latex test only.
In addition, three blood samples could be typed directly by culture-independent MLST. In these three samples, the meningococcal DNA specific for ST-11-ET-37 clone was found.

Control measures
Apart from the 46 patients who were admitted to hospital and received antibiotic treatment, special precautions were put in place within the entire military unit. Chemoprophylaxis with a single dose of ciprofloxacin (500 mg) was given to close contacts of affected soldiers (the whole subunit). The entire personnel of the military base, including the patients admitted to hospital, were vaccinated with meningococcal polysaccharide vaccine, groups A, C. At present there is a shortage of conjugated vaccine against group C meningococci in Poland, so the polysaccharide vaccine was the only option available.

Discussion
This outbreak of invasive meningococcal disease is the largest so far described in Poland, with an attack rate of 3.78% (15 laboratory-confirmed cases per 397 people in the military base, including civilian personnel). The case fatality rate in this outbreak was 13.3% (two deaths per 15 laboratory-confirmed cases). As a result of the rapid implementation of antibacterial treatment, the remaining 13 patients with laboratory-confirmed meningococcaemia did not develop severe sepsis. All of them recovered fully and were discharged from the hospital.

The outbreak described here is the second one among military recruits within a year. The first took place in Skwierzyna, in March 2006, and was caused by the same meningococcal strain of serogroup C, ST-11/ET-37 [3]. In addition, there were two sporadic cases of invasive meningococcal disease in military bases in Wroclaw (November 2006) and Gliwice (December 2006). The former was meningococcal meningitis with a good outcome, and the strain responsible for the disease was not related to any of the hypervirulent clones present in Poland. The latter was a meningococcal septicaemia with fatal outcome, caused by group C, ST-11/ET-37 meningococcus.

In view of the emerging epidemiological situation of invasive meningococcal diseases (IMD) in the Polish army, the introduction of mass vaccination of military recruits against N. meningitidis group C with the use of conjugated vaccine is now being considered.

Present epidemiological situation in Poland
Since 2002, an increase in the number of IMD cases caused by serogroup C meningococci has been observed in Poland. Before 2002, group C was responsible for 11% of laboratory-confirmed cases. In 2002, more than 30% of cases confirmed in the NRCBM were caused by this group [4]. This rising trend has continued and in 2006 IMD cases caused by group C reached 46% of all laboratory-confirmed cases (Table).

Table. Invasive meningococcal disease (IMD) in Poland. The number of cases notified and confirmed in the National Reference Centre for Bacterial Meningitis (NRCBM), the incidence of serogroup C and ST-11/ET-37 clonal complex isolates

Year Number of IMD cases notified* Number of laboratory-confirmed cases (NRCBM) Number of cases due to the serogroup C Number of cases caused by the group C, ST-11/ET-37 clonal complex
1997
142
45
4
0
1998
131
45
5
2
1999
119
57
6
1
2000
101
42
7
1
2001
101
35
3
0
2002
85
35
11
1
2003
66
37
15
2
2004
119
88
31
3
2005
205
135
52
5
2006
223
168
79
20

*Until the end of 2003, only cases of meningococcal meningitis were notified; since 2004, notification includes also meningococcal septicaemia.

This trend was accompanied by the emergence and dissemination of epidemic clones of meningococci in Poland. The first was an epidemic clone of phenotype C:2b:P1.5,2 belonging to clonal complex ST-8/Cluster A4. Although this clone appeared in northwest Poland, at first causing only a small number of sporadic cases, it then spread throughout the country [5]. The other group C epidemic clones in Poland that have emerged over the last years are ST-5133 (clonal complex ST-103), phenotype C:NT:P1.3,6, appearing mainly in southwest Poland, and ST-11 (clonal complex ST-11/ET-37), phenotype C:2a:P1.5,2, first seen in the south. The latter has caused at least three outbreaks in different parts of the country. Two of them occurred in military settings (Skwierzyna, March 2006, and recently in Warsaw, January 2007), and one in a group of young people attending the same discotheque in Silesia region.

The changes in the epidemiological situation of meningococcal infections in Poland described here have resulted in a more comprehensive epidemiological surveillance in the country. Since information about meningococcal septicaemia in military bases received a lot of attention in the media, the sanitary-epidemiological stations have received more notifications of suspected cases of IMD from throughout the country, and the NRCBM has obtained more material for PCR diagnostics.

Although according to the official data the IMD incidence rate in Poland (0.54 per 100.000 in 2004) is about two times lower than the EU average (1.13 per 100.000 in the years 2003-2004) [6], the current situation indicates that this problem deserves more attention, and there is need for better surveillance and diagnostics of IMD.

Acknowledgements
Anna Skoczynska, National Reference Centre for Bacterial Meningitis, National Medicines Institute, Warsaw.
Neisseria Multi Locus Sequence Typing website (http://pubmlst.org/neisseria/) developed by Keith Jolley and Man-Suen Chan, hosted by the University of Oxford.

References:
  1. Neisseria MLST website. http://pubmlst.org/neisseria/
    EU-IBIS, European Union Invasive Bacterial Infections Surveillance. http://www.euibis.org/meningo/meningo_statistics.htm
  2. Taha M-K. Simultaneous approach for nonculture PCR-based identification and serogroup prediction of Neisseria meningitidis. J. Clin. Microbiol. 2000;38(2):855-7.
  3. Grecki M, Bienias M. Outbreak of invasive meningococcal disease among soldiers in Skwierzyna, Poland, March 2006. Euro Surveill 2006;11(7):E060706.4. Available from: http://www.eurosurveillance.org/ew/2006/060706.asp#4
  4. Skoczynska A, Kadlubowski M, Hryniewicz W. Increase in the number of infections caused by strains of Neisseria meningitidis belonging to the serological group C in Poland. (Wzrost liczby wykrywanych w Polsce zakazen wywolywanych przez szczepy Neisseria meningitidis nalezace do grupy serologicznej C), Epimeld 7/B/03, National Institute of Hygiene, Chief Sanitary Inspectorate, 2003 (article in Polish). http://www.pzh.gov.pl/epimeld/2003/M_03_07B.pdf
  5. Skoczynska A, Kadlubowski M, Wasko I, Hryniewicz W. Characterisation of Neisseria meningitidis C:2b:P1.2,5 isolates in Poland. Clin. Microbiol. Infect. 2006;12:1027-30.
  6. EU-IBIS, European Union Invasive Bacterial Infections Surveillance. http://www.euibis.org/index.htm

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