Characteristics of serogroup A Neisseria meningitidis strains isolated in the Central African Republic in February 1992

Primary and opportunistic pathogens associated with meningitis in adults in Bangui, Central African Republic, in relation to human immunodeficiency virus serostatus

OBJECTIVE

To determine the causative organisms and characteristics of patients presenting with meningitis in Bangui in order to provide guidance to physicians for case management.

METHODS

Adults with proven or suspected meningitis were enrolled in this prospective study.

LABORATORY TESTS

Full blood count, blood chemistry, and HIV tests were performed. Cerebrospinal fluid (CSF) was submitted for routine microbiology, chemistry (glucose, protein), and hematology testing. When classical microbiology analyses were negative, a broad-range bacterial polymerase chain reaction (BRBPCR) was used.

RESULTS AND CONCLUSIONS

Of the 276 patients enrolled, 215 (77.9%) were HIV positive. In HIV-positive patients cryptococcal meningitis (CM) was the most common cause of meningitis (39.1%) followed by pyogenic meningitis (PM) (30.7%), mononuclear meningitis (MM) (28.8%), and tuberculous meningitis (TM) (1.4%). In HIV-negative patients, PM was the most common cause (60.7%) followed by MM (37.7%) and CM (1.6%, one case). In-hospital mortality was higher in HIV-positive patients (73/128 = 57%) compared to those HIV negative (3/18 = 16.7%) (p = 0.001). Streptococcus pneumoniae (n = 26) was the most common bacterial diagnosis, mainly in HIV-positive patients (n = 22, 10.2%). Meningococcal meningitis (14 Neisseria meningitidis of group A and one W135) was diagnosed in nine (4.2%) HIV-positive and six (9.8%) HIV-negative patients. Gram-negative rods were isolated from five HIV-positive and two HIV-negative patients, respectively. The bacteria and fungi involved in meningitis did not display high levels of in vitro resistance. Conventional microbiology techniques failed to detect the causative agent in 55 (53.4%) PM cases. Broad-range bacterial PCR detected DNA from S. pneumoniae in three samples, N. meningitidis in two, Escherichia coli in one, Listeria monocytogenes in two and Staphylococcus aureus in one sample. In the CSF of five (three HIV negative and two HIV positive), PCR products were not identified with the oligonucleotide probes specific for the usual species of bacteria found in CSF, or genera commonly considered potential contaminants of clinical samples. Among the MM cases, 77 (90.5%) probable viral meningitis (54 HIV positive and 23 HIV negative) and eight TM (HIV positive) were suspected.

Molecular characteristics and susceptibility to antibiotics of serogroup A Neisseria meningitidis strains isolated in Senegal in 1999

A total of 22 strains of Neisseria meningitidis isolated from cerebrospinal fluid samples of patients in Dakar, Senegal, in the course of an epidemic of meningococcal meningitis in 1999 were studied. All the strains were serogroup A, serotype 21:P1.9 and belonged to clonal subgroup III-1. The strains were resistant to sulphonamide, but were susceptible to ampicillin, ceftriaxone and chloramphenicol, which are used in the treatment of cerebrospinal meningitis in Senegal.

Spread of Neisseria meningitidis group A clone III-I meningitis epidemic into Zambia

The epidemic of Neisseria meningitidis group A clone III-I strain began with the 1987 outbreak in Mecca, Saudi Arabia. Intense epidemics in African countries occurred the following year. Clone III-I was first isolated from Africa in 1988 in Chad, followed by epidemics in Ethiopia (1989), Kenya and Tanzania (1989), and The Central African Republic (1992). We report an epidemic of Neisseria meningitidis group A clone III-I afflicting Zambia during a 2-year period (April 1992-May 1994). This extension of the 'meningitis belt' southwards into Central Africa is cause for concern. Active surveillance for this disease should be carried out by all African countries, even those outside the well described sub-Saharan 'meningitis belt'.

Pulsed-field gel electrophoresis analysis of clonal relationships among Neisseria meningitidis A strains from different outbreaks

Pulsed-field gel electrophoresis was used to analyze the DNA of 67 Neisseria meningitidis A strains from five African outbreaks occurring between 1988 and 1996. Endonuclease Bg/II was used to cut chromosomal DNA, generating 19 analyzable fragments. This technique allowed comparison of clonal relationships between outbreak strains and revealed that the same pulsotype was responsible for the outbreaks. This pulsotype is closely related to strain B54, subgroup III reference strain, Finland, 1975, showing only two fragment differences.

Meningitis outbreaks and vaccination strategy

Three outbreaks of meningitis caused by Neisseria meningitidis serogroup A (subgroup III) are described: Niger (1991), Burundi (1992), and Guinea (1993). These outbreaks showed unusual characteristics: a shorter inter-epidemic interval (Niger), unusual geographical location outside the meningitis belt (Burundi and Guinea), and high age-specific attack rates in all age groups (Burundi and Guinea). Mass immunization campaigns mobilized considerable human and financial means (US $322,000 and 3000 person-days of work for health personnel to immunize 629,000 people in Guinea). The vaccination coverage was over 80% in densely populated areas (Burundi and urban Guinea), but below 50% in less populated areas (24/27 and 26/30 sub-districts in Niger and Guinea, respectively). The preventive fraction (proportion of cases prevented by vaccination) was substantial in Guinea (35% for a vaccine efficacy of 85%) and was higher where the campaign was initiated earlier. An 'alert' threshold indicating the onset of an epidemic of 15/100,000 cases in one week showed good sensitivity (94%), specificity (98%) and positive predictive value (89%) in Burundi, permitting quick decision making outside the meningitis belt. These 3 meningococcal meningitis outbreaks show the need for epidemic emergency preparedness and for vigilance on the whole African continent.

Epidemics of serogroup A Neisseria meningitidis of subgroup III in Africa, 1989-94

A total of 125 strains of Neisseria meningitidis recovered in the course of outbreaks from patients with systemic disease in 11 African countries between 1989 and 1994 were analysed by serogrouping, serotyping and multilocus enzyme electrophoresis. Of the 125 patient strains 115 (92%) belonged to the clone-complex of serogroup A meningococci, designated subgroup III. Among the remaining strains, 4 were also serogroup A, but belonged to the clonal groups I and IV-1 (2 strains each), whilst 6 strains (4 serogroup C and 2 serogroup W135) represented clones of the ET-37 complex. Our results indicated that the second pandemic caused by clones of subgroup III is still spreading in Africa. Towards the West it has reached Niger, Mali, Guinea and The Gambia, and towards the South, the Central African Republic, Uganda, Rwanda, Burundi, Tanzania and Zambia.

Molecular typing of Neisseria meningitidis serogroup A using the polymerase chain reaction and restriction endonuclease pattern analysis

A new molecular typing method for identification and characterization of Neisseria meningitidis is reported. Chromosomal DNA from 20 well-documented meningococcal strains of serogroup A originating from France, Central African Republic, Sudan and Burkina Faso were amplified using the polymerase chain reaction. Primers designed in this study were located in the pilA/pilB locus which has been shown to be conserved in the genus Neisseria. The amplified fragments were subjected to restriction endonuclease analysis using three different enzymes, and the restriction endonuclease patterns obtained were compared. Clonal isolates clustered together in distinct restriction endonuclease patterns which are described in this study and coincided with electrotypes as determined by multi-locus enzyme electrophoresis. This DNA-based typing system for meningococci may be useful for epidemiological studies.

The 1990 meningococcal meningitis epidemic of Sarh (Chad): how useful was an earlier mass vaccination?

A large outbreak of meningococcal meningitis (Serogroup A) occurred in southern Chad in 1990. We describe the epidemic in the town of Sarh, where a mass vaccination against meningococcal meningitis had taken place two years before, in 1988 (estimated coverage: 66%). Early warning that an epidemic was imminent was given at the end of February, following more than 15 recorded cases per 100,000 population on 3 consecutive weeks. This threshold proved to be adequate to predict the outbreak. A total of 721 cases were recorded at Sarh hospital and at a nearby health centre. Direct agglutination tests confirmed that Neisseria meningitis serogroup A was the only causative agent. The overall incidence rate in this population of 80,000 was 0.9%. The highest weekly incidence rate was 186 cases per 100,000 population. The mean age of the patients was 12.6 years and age-specific incidence rates ranged from 0.23% to 1.42%. The male/female sex ratio was 1.36. Overall, the mortality among hospitalized patients was 7.9%. Mortality increased during the epidemic. The major risk factor for dying was the delay until reaching hospital. Only 4 out of 29 interviewed parents said that their child had been vaccinated two years before. Among adult patients this proportion was 12/38 (32%). Because of the small numbers and because of the impossibility to check the vaccination records it was not possible to assess precisely the impact of earlier mass vaccination. However, the previous mass vaccination did not prevent this major epidemic and its impact is likely to have been unimportant.

Characterization of serogroup A Neisseria meningitidis strains by rRNA gene restriction patterns and PCR: correlation with the results of serotyping, subtyping and multilocus enzyme electrophoresis

We studied 35 strains of Neisseria meningitidis serogroup A from different locations (France, Central African Republic, Sudan and Burkina Faso) using both ribotyping and a polymerase chain reaction (PCR). A non-radioactive probe label was used for ribotyping; detection consisted of an immunoenzymatic procedure using a bispecific antibody. The PCR was designed to amplify the 16S-23S rDNA internal transcribed spacer. These techniques were compared with other markers. The strains were identified as belonging to three clones (I, III-1, IV) by multilocus enzyme electrophoresis (MEE) and to three subtypes by serological methods. Ribotyping identified five groups and PCR identified four groups. Ribotyping gave more diversity between strains than either MEE or sero/subtyping, but confirmed the epidemiological data provided by the combination of these two techniques. The PCR provided a simple and convenient one-step procedure for the differentiation of strains of serogroup A.