In October 1996, a 15-month-old male child residing in Salt Lake County was reported to the Bureau of Epidemiology, Child Blood Lead Epidemiology and Surveillance (CBLES) Project with a presumptive elevated blood lead test. That test was confirmed a week later with a venous blood lead level of 30.6 µg/dL. The Bureau of Epidemiology, Adult Blood Lead Epidemiology and Surveillance (ABLES) Project also received a report of an elevated blood lead level of 44.7 µg/dL on the father of the child. The reports on the child were forwarded to the Salt Lake City /County Health Department who conducted nursing and environmental surveillance intervention. Salt Lake City/ County Health Department conducted an environmental risk inspection of the home and found that the child lived in an apartment that was built after the discontinuance of the use of lead-based paint. The home was clean and in good repair and maintenance. No lead based paint was found using X-ray fluorescence technology. There were no environmental sources of lead identified. The inspector noticed traces of grease in the carpet and took a wipe sample of the carpet. Those samples were tested and found to have 60 µg of lead per square foot. The bureau conducted occupational and child risk assessment surveys with the father. Neither the father or mother participated in any hobbies or home activities that used lead. However, the father was employed at a radiator repair shop where he used lead and lead solder as part of his work. No precautions were taken at his work to protect him from lead exposure. The father had not received any training concerning the dangers of lead exposure.

The ABLES project was started in 1992 and the CBLES project was started in January 1996. Data obtained by surveillance under the ABLES project indicate that 37% of adults reported to the bureau with blood lead levels > 25 µg/dL have children living at home who are under six years of age. The Centers for Disease Control and Prevention (CDC) recommends that all children under six years of age be tested annually for lead poisoning. That is particularly important if the child lives in an environment where they could be exposed to lead such as homes built before 1972, near environmental lead sources, or have parents or other adults in their home who work in lead related industries.

Updated recommendations for the control and prevention of meningococcal disease were recently published in the Morbidity and Mortality Weekly Report, Recommendations and Reports, February 14, 1997/Vol. 46/ No. RR-5. In this report, the Advisory Committee on Immunization Practices (ACIP) updated the schedule for administering chemoprophylaxis. The following information has been abstracted from the complete report.

Antimicrobial chemoprophylaxis of close contacts of sporadic cases of meningococcal disease is the primary means for prevention of meningococcal disease in the United States (Table 1). Close contacts include a) household members, b) day care center contacts, and c) anyone directly exposed to the patient’s oral secretions (e.g., through kissing, mouth-to-mouth resuscitation, endotracheal intubation or endotracheal tube management). The attack rate for household contacts exposed to patients who have sporadic meningococcal disease has been estimated to be four cases per 1,000 persons exposed, which is 500-800 times greater than for the total population. Because the rate of secondary disease for close contacts is highest during the first few days after onset of disease in the primary patient, antimicrobial chemoprophylaxis should be administered as soon as possible (ideally within 24 hours after the case is identified). Conversely, chemoprophylaxis administered >14 days after onset of illness in the index case-patient is probably of limited or no value. Oropharyngeal or nasopharyngeal cultures are not helpful in determining the need for chemoprophylaxis and may unnecessarily delay institution of this preventive measure.

Rifampin is administered twice daily for 2 days (600 mg every 12 hours for adults, 10 mg/kg of body weight every 12 hours for children > 1 month of age, and 5 mg/kg every 12 hours for infants < 1 month of age). Rifampin is effective in eradicating nasopharyngeal carriage of N. meningitidis. Rifampin is not recommended for pregnant women, because the drug is teratogenic in laboratory animals. Rifampin changes the color of urine to reddish-orange and is excreted in tears and other body fluids; it may cause permanent discoloration of soft contact lenses. Because the reliability of oral contraceptives may be affected by rifampin therapy, consideration should be given to using alternate contraceptive measures while rifampin is being administered.

In addition to rifampin, other antimicrobial agents are effective in reducing nasopharyngeal carriage of N. meningitidis. Ciprofloxacin in various dosage regimens is >90% effective in eradicating nasopharyngeal carriage. A single 500-mg oral dose of ciprofloxacin is a reasonable alternative to the multidose rifampin regimen. Ciprofloxacin levels in nasal secretions far exceed the MIC₉₀ for N. meningitidis following oral dosing. Ciprofloxacin is not generally recommended for persons < 18 years of age or for pregnant and lactating women because the drug causes cartilage damage in immature laboratory animals. However, a recent international consensus report has concluded that ciprofloxacin can be used for chemoprophylaxis of children when no acceptable alternative therapy is available.

When ceftriaxone was administered in a single parenteral dose (an intramuscular dose of 125 mg for children and 250 mg for adults), it was 97%-100% effective in eradicating pharyngeal carriage of N. meningitidis. Thus, ceftriaxone (diluted in 1% lidocaine to reduce local pain after injection) is also a reasonable alternative for chemoprophylaxis.

Systemic antimicrobial therapy of meningococcal disease with agents other than ceftriaxone or other third-generation cephalosporins may not reliably eradicate nasopharyngeal carriage of N. meningitidis. If other agents have been used for treatment, the index patient should receive chemoprophylactic antibiotics for eradication of nasopharyngeal carriage before being discharged from the hospital.

CONCLUSIONS

N. meningitidis is the leading cause of bacterial meningitis in older children and young adults in the United States. The quadrivalent A, C, Y, and W-135 meningococcal vaccine available in the United States is recommended for control of serogroup C meningococcal disease outbreaks and for use among certain high-risk groups, including a) persons who have terminal complement deficiencies, b) persons who have anatomic or functional asplenia, and c) laboratory personnel who routinely are exposed to N. meningitidis in solutions that may be aerosolized. Vaccination also may benefit travelers to countries in which disease is hyperendemic or epidemic. Conjugate serogroup A and C meningococcal vaccines are being developed by using methods similar to those used for H. influenzae type B conjugate vaccines, and the efficacies of several experimental serogroup B meningococcal vaccines have been documented in older children and young adults.

Antimicrobial chemoprophylaxis of close contacts of patients who have sporadic cases of meningococcal disease is the primary means for prevention of meningococcal disease in the United States. Rifampin has been the drug of choice for chemoprophylaxis; however, data from recent studies document that single doses of ciprofloxacin or ceftriaxone are reasonable alternatives to the multidose rifampin regimen for chemoprophylaxis.