Chapter reviewed and updated in September 2021. A description of changes can be found at Updates to the Communicable Disease Control Manual.
There are still a number of cases of invasive meningococcal disease in New Zealand each year and sometimes community outbreaks. Overall, rates are higher in New Zealand than in countries with national immunisation programmes, and Māori and Pacific communities are disproportionately affected. As with the epidemiology in other temperate climates, there tends to be a seasonal pattern, with more cases seen in winter and spring.
Despite rates dropping significantly between 2003 and 2014 following the immunisation response to the meningococcal B epidemic, rates started to gradually increase from 2015. This increase was initially driven by group B strains, with group W also becoming a main driver from 2017. During the COVID-19 pandemic rates have dropped to their lowest values since the eighties, however, this drop is unlikely to be maintained.
More detailed epidemiological information is available on the Institute of Environmental Science and Research (ESR) surveillance website.
Meningococcal disease is a serious invasive disease with an acute onset. It may start as a mild flu-like illness but rapidly progress to fulminant septicaemia and death. Cases typically experience acute fever, malaise, nausea, myalgia, arthralgia and prostration. A rash occurs in about two-thirds of cases – this may range from ill -defined and macular, to petechial or purpuric. More severe infection leads to shock, disseminated intra-vascular coagulation (DIC), acrocyanosis and multi-organ failure.
Approximately 75 percent of cases with septicaemia have meningitis (typically causing headache, photophobia and neck stiffness). Infants present with less specific features.
Other locations of invasive disease with Neisseria meningitidis are possible though rare, such as orbital cellulitis, septic arthritis, and pericarditis.
Nasopharyngeal carriage of meningococci is relatively common, in roughly 15 percent of the population, and is generally more prevalent in young adults, people who are living in conditions of severe overcrowding (Baker et al 2000), smokers and military recruits.
The events that cause meningococcal disease are poorly understood but include a combination of organism, host and environmental factors (Stephens 1999).
Laboratory definitive evidence for a confirmed case requires at least one of the following:
Although not meeting the definition of a confirmed case, meningococcal infection of the conjunctiva is considered an indication for public health action because of the high immediate risk of invasive disease (refer Health Protection Agency 2011). Other sites may also require public health follow-up on a case-by-case basis, as determined by the local medical officer of health.
2–10 days, commonly 3–4 days.
Transmission is from person to person through droplets or secretions from the upper respiratory tract, from a carrier or case.
The case is no longer considered infectious after completion of 24 hours of appropriate antibiotic therapy with rifampicin, cefotaxime/ceftriaxone or ciprofloxacin.
For the purpose of contact tracing, the time period used to define close contacts is from 7 days prior to case’s illness onset to the time the case has completed 24 hours of the appropriate antibiotic treatment.
Attending medical practitioners or laboratories must immediately notify the local medical officer of health of suspected cases. Notification should not await confirmation.
See Appendix 5: Escalation pathways for more information
Obtain a history of vaccination and possible contacts.
Obtain a history of any antibiotic treatment, to help clarify if there may be partially treated disease.
Ensure laboratory confirmation has been attempted, including strain identification (group and subtype).
Droplet precautions until 24 hours after the start of cefotaxime/ceftriaxone, rifampicin or ciprofloxacin. Close contacts do not require isolation even if they are taking prophylaxis.
Parenteral antibiotics should be administered to all cases as soon as meningococcal disease is suspected before admission to hospital or in hospital if delays and assessment in hospital are likely to be more than 30 minutes.
Antibiotics given prior to transfer should be clearly noted on information accompanying the patient to hospital.
It is important that the case receives an antibiotic that will eliminate throat carriage before discharge from hospital, usually rifampicin, ciprofloxacin or ceftriaxone. Unless one of these has been used in the course of treatment, it should be prescribed for the index case before discharge.
There are currently no specific recommendations for vaccinating cases with meningococcal vaccine, other than the general immunisation recommendations – see ‘Health education’ below and the Immunisation Handbook (Ministry of Health 2017).
| Antibiotic | Children <30kg | Children >30kg and Adults (max dose) |
| Ceftriaxonea (first line treatment) |
50 mg/kg when given by GP/primary care 100 mg/kg IV (or IM) up to 2g when given in ED |
2 g IV (or IM) |
| Benzylpenicillin (second choice) |
50 mg/kg IV (or IM) | 2.4 g IV (or IM) |
The following vaccines are now available and funded for a person who has previously had meningococcal disease:
People who have previously had any group (including group A, B, C, W or Y) meningococcal disease may be offered both meningococcal vaccines as appropriate for their age. For more details, please refer to the Immunisation Handbook.
Advise the case and their caregivers of the nature of the infection and its mode of transmission.
Anyone who has had unprotected contact with upper respiratory tract or respiratory droplets from the case during the 7 days before onset of illness to 24 hours after onset of effective treatment.
Public health follow-up is most important for household contacts and contacts that have had similarly close exposure. Examples of such contacts are:
Note: Unless one of these criteria is met, low-level salivary contact such as kissing on the cheek or mouth or sharing food or drink does not require public health follow-up or treatment (given evidence that it does not increase risk of transmission).
If the case has been treated with an effective antibiotic for at least 24 hours before death, any contact risk is low. If the case has not been treated, then occupational contacts should follow routine infection control practices with additional droplet and contact precautions.
Kissing the body is not considered a risk. Body bags are not necessary, and transport to other countries for burial or cremation does not pose a risk. There is no restriction on embalming.
Laboratory workers who handle high concentrations or large quantities of organisms or are routinely exposed to isolates should be protected with the quadrivalent vaccine.
Nil. Routine throat or nasopharyngeal culture of contacts is not recommended because asymptomatic carriage is common.
Nil.
Antibiotic prophylaxis should be given as soon as possible (ideally within 24 hours) after the diagnosis of the index case. After 24 hours, chemoprophylaxis (and vaccine if appropriate) should still be considered for close contacts; however, there is little value in offering this more than 14 days after the diagnosis of illness (there is a low risk of further cases after this period, see CDC 2005b).
The purpose of antibiotic prophylaxis is to eradicate nasopharyngeal colonisation by meningococci and thus prevent transmission to other susceptible people. Prophylaxis will not treat illness that the person may be incubating, so it is essential that the contacts be advised to seek urgent medical attention if they become unwell.
Ciprofloxacin has been recommended in all age groups in international guidelines (Public Health England 2018, Communicable Diseases Network Australia, 2017, European Centre for Disease Prevention and Control, 2010).
Consult Medsafe data sheets for appropriate use and dosages of ciporofloxacin in children. Treatment in children should only be initiated after careful benefit/risk evaluation and prescribing health practitioners should ensure they are familiar with their responsibilities when prescribing a medicine for ‘off-label’ use.
Resistance to ciprofloxacin is rare but has been described. A meningococcal C outbreak in 2018 in Fiji has shown to be resistant to ciprofloxacin. If such a strain is suspected, ciprofloxacin should not be used for antibiotic prophylaxis.
In instances where large groups of people have been exposed to a case, it is likely that contacts will have returned to a variety of health districts. Any follow-up needs to be coordinated by the appropriate medical officer of health to ensure that districts provide consistent advice and treatment.
The aim of the intervention in such settings is to eradicate carriage of the strain from a population at high risk. The medical officer of health determines necessary action in discussion with the Ministry of Health.
Check for other cases in the community. Do not perform screening cultures because asymptomatic carriage is common.
Clean and disinfect surfaces and materials soiled with respiratory secretions.
Key messages include being aware of signs and symptoms, and the importance of early medical advice and treatment.
Ensure people are aware of the availability of and recommendations for meningococcal vaccines. See the Immunisation Handbook (Ministry of Health 2020) for more details.
Ensure complete case information is entered into EpiSurv.
If a cluster of cases occurs, contact 0800GETMOH - CD option, and outbreak liaison staff at ESR, and complete the Outbreak Report Form.