Any child with the above mentioned signs or symptoms should be seen by a trained doctor for assessment and treatment. Parents and health workers in developing countries need to be equally aware of the alerting signs so that children are cared for at the earliest. A study in Ghana showed that children with meningitis attended the hospital four days, on average, after the onset of illness (26).

A definitive diagnosis of meningitis is made on analysis of CSF; a lumbar puncture is therefore performed unless it is contraindicated. The colour and consistency of the CSF can give some clues: in viral meningitis CSF is clear like tap water, in cases due to H. influenzae CSF is like rice water, in bacterial meningitis the CSF may be cloudy and thick. The gold standard of laboratory methods for a positive diagnosis is shown in Slide 4.

In about 25% of cases however, CSF analysis may not be conclusive in differentiating viral from bacterial meningitis (this happens in early phase of viral meningitis when CSF contains a predominance of polymorphonuclear leukocytes, mixed formulae are found in meningitis due to non-pyogenic bacteria, and antibiotic administration prior to lumbar puncture also causes confusion); for all these atypical cases many complementary tests and approaches have been developed such as the estimation of blood and/or CSF C Reactive Protein, CSF lactic acid, CSF TNF alpha, CSF IL-2, IL-6 and IL-8, CSF ferritin level, plasma procalcitonin, CSF nitrate and nitrite (4-19).
Another approach consists in optimising the interpretation of simple clinical and biological data with the use of scores or graphics, (27-31). The development of all these methods is a proof of how difficult it may be to diagnose meningitis.

The situation in developing countries is much more difficult as patients are seen late, with focal signs, seizures and other complications. Laboratories when they exist are often very poorly equipped. Clinical skills and knowledge of local epidemiology are of great help, to confirm the diagnosis the basics are shown in Slide 5.

Yes. A number of effective antibiotics are available for treatment of bacterial meningitis; the choice of the first line therapy depends upon local epidemiology, for example the rate of S. pneumoniae resistance. Third generation cephalosporins are drugs of choice whenever possible. Each country has its own policy based on national expert recommendations.

Meningococcal infection must be suspected in any child presenting with a non-blanching rash, purpura or petechiae or ecchymosis measuring > or = 3 mm, associated with infectious signs; such child should immediately receive broad spectrum antibiotics before being directed to hospital without any consideration of hemodynamic status (Blood pressure, etc). Recommended antibiotics for this immediate treatment are shown in Slide 6.

In addition to antibiotics, supportive treatment is often necessary. Adjuvant therapy by anti-inflammatories remains controversial. Antibiotics induce bacterial lysis with liberation of proinflammatory mediators into the subarachnoid space leading to cerebral oedema, raised intracranial pressure and sequelae. Animal studies proved a certain benefit and led research workers to recommend the use of steroids in the treatment of bacterial meningitis. Although the first trials took place twenty years ago, there is still no consensus for steroids utilization in routine clinical practice for several reasons:

• there are no clear-cut recommendations for N. meningitidis infections,
• S. pneumoniae serotypes are becoming increasingly resistant to usual antibiotics, steroids may interfere with drug penetration into the CSF and delay its sterilisation.
• the only proven benefit appears to be reduction of hearing loss in H. influenzae type b meningitis.

When steroid treatment is indicated, dexamethasone is preferably administered just before or simultaneously with the antibiotic (dose 0.15 mg/kg six hourly for two to four days) (35-37).

Newborn babies are commonly treated for 14 to 21 days depending on the causative organism (14 days for cases due to group B Streptococcus and 21 days for cases due to E. coli, Listeria monocytogenes, Klebsiella pneumoniae). Older infants and children are commonly treated as follow: H. influenzae (7 days), N. meningitidis (5 to 7 days), S. pneumoniae (10 to 14 days).

Meningitis-causing bacteria are spread through the exchange of respiratory and throat secretions (coughing, kissing) and via close or prolonged contact with a patient. However, panic should be avoided and it should always be remembered that the common cold and flu are much more contagious! By close contacts we must consider people in same household, day care centre, same classroom, or anyone in intimate contact with the patient (boyfriend or girlfriend); those being at risk of acquiring infection, should receive prophylaxis in case of meningitis by N. meningitidis. As for H. influenzae type b infection, no antibiotic prophylaxis is needed if all close contacts aged 4 years or less are immunised against Hib.

Neurodevelopmental sequelae do occur in up to 20% of children recovering from bacterial meningitis. The most severely affected are infants aged less than six months and those presenting with prolonged seizures, coma or focal neurological signs on admission. Children with very low CSF glucose at the initial lumbar puncture commonly develop sequelae (1-3, 37).

(a) In Newborn Babies:

Early complications are: ventriculitis, brain abscesses, ventricular dilatation, cerebral infarction usually leading to porencephalic cyst 2 to 3 weeks later.

Late complications are: hydrocephalus, porencephalic cysts, mental retardation, seizures, focal motor deficiency (hemiplegia, hemiparesis, monoparesis) and hearing loss.

(b) Older infants and Children:

Complications in older infants and children are shown in Slide 7.

It should therefore be remembered that all children having presented bacterial meningitis should undergo audiologic assessment and be followed-up in developmental clinic for many years.

The answer is surprisingly no today! In fact cases of meningitis in newborn babies and other infections at this age are not yet preventable as the origin is often maternal and also because the newborn immune system is very immature, protective immunity taking several weeks to develop. In years to come it may be possible to prevent infections in mothers (S. agalactiae, E. coli) and therefore save babies.

In older children however progress has been achieved with H. influenzae type b vaccine which has reduced the rate of meningitis due this pathogen by 90% in developed countries.
As for pneumococcal infections, there exists a polysaccharide vaccine which is not used routinely but is recommended for children aged 2 years and older with specific pathologies (asplenia after surgery or secondary to Sickle cell disease, chronic cardiac or pulmonary disease for example). Research is progressing on the development of a conjugate vaccine that could be used in infants under 2 years of age who have high rates of pneumococcal infections (otitis media, pneumonia, meningitis).

Meningococcal infections are due to N. meningitidis serogroups B and C in developed countries and A in most developing countries. A quadravalent polysaccharide vaccine for serogroups A, C, Y and W-135 is available in the United States for routine use among high risk groups (persons with terminal complement components deficiencies, those with asplenia and travellers to hyperendemic zones). The introduction of a serogroup C meningocccal conjugate vaccine in the United Kingdom has reduced the incidence of meningitis caused by this pathogen by up to 95% in vaccinated groups.

The situation in developing countries where these infections have highest mortality and morbidity rates remains difficult: children still die of H. Influenzae meningitis for which prevention exists but is costly, children with Sickle Cell disease need to be vaccinated against S. Pneumoniae but this is not possible for the same economic reasons. How do we react when the World Health Organization reports that in 1996 152,813 cases of meningococcal meningitis occurred in 10 African countries causing 15,783 deaths while a vaccine exists in the United States? There is urgency for a shift in health economic policies so that a large majority of children around the world benefit from all medical advances achieved.