Meningitis Contact
Doctor Information
Josephine Raymond 8 years old
No past medical history, no routine medications.
Consultation today is with her father (Mark Raymond)
No past medical history, no routine medications.
Consultation today is with her father (Mark Raymond)
Patient Information
Mark Raymond 42 on behalf of Josephine Raymond 8
Opening line: we have heard that one of Josephine's classmates has been taken into hospital with possible meningitis. I’ve done some reading which mentioned rifampicin as a prophylactic antibiotic that can be given to close contacts to stop them from getting meningitis. I have come here today to get this antibiotic from you for my daughter. So if I can just get the antibiotics then I can be on my way. Thanks.
Revealed readily: one of Josephine's class mates Brenda, that she sits next to in class, has not been at school for the last few days. You've heard from the other parents that Brenda has been taken into hospital with meningitis. You’ve not heard anything official yet.
Josephine is not very good friends with Brenda despite sitting next to her, so you don't know Brenda's parents very well, so you are unsure how Brenda is doing, but hope that she is doing well.
Josephine has not had any symptoms nor signs of meningitis if the doctor asks. She has been perfectly well in herself. She has had all of her vaccinations, and has not had any problems up until now. You have read up online about meningitis, and are aware of all of the symptoms, and what to look out for, but you are obviously concerned as you have read that it can be fatal.
Josephine was born on time, no complications, has had no major health problems in the past, and doest take any routine medications at the moment.
You work as a lawyer, and are very busy, so don't want to spend a lot of time at the GPs, as you have a mountain of paperwork to get back to.
Ideas: You have googled meningitis, and have found that close contacts need to have antibiotics, something called rifampicin came up during your search.
Concerns: That your daughter may get meningitis without it, you think the risk is high that she will catch it without the antibiotics
Expectations: You want the antibiotics today, if the doctor mentions that nothing can be done unless a diagnosis fro Brenda is known, then you will want the Dr to confirm Brenda’s diagnosis, as below.
If the doctor is unwilling to give medication and cites, that they cant give anything unless the other child has confirmed meningitis, then you will demand that information form the GP, you will demand he looks in the other child's notes, or ring the hospital to find out - as the health of his and other children are at stake here!
If the doctor explains that the risk is of contracting meningitis this way is very low, also the antibiotics in question have their risks, and if they explain that this is all handled by a specialist agency - Public Health England - if a diagnosis of meningitis is made and they feel contacts need antibiotics, they will let the school / GPs know. If also informed that they do not routinely offer any antibiotics / vaccines for contacts at school, due to the transmission rates being so low: Then you will be happy to wait to hear from them.
Opening line: we have heard that one of Josephine's classmates has been taken into hospital with possible meningitis. I’ve done some reading which mentioned rifampicin as a prophylactic antibiotic that can be given to close contacts to stop them from getting meningitis. I have come here today to get this antibiotic from you for my daughter. So if I can just get the antibiotics then I can be on my way. Thanks.
Revealed readily: one of Josephine's class mates Brenda, that she sits next to in class, has not been at school for the last few days. You've heard from the other parents that Brenda has been taken into hospital with meningitis. You’ve not heard anything official yet.
Josephine is not very good friends with Brenda despite sitting next to her, so you don't know Brenda's parents very well, so you are unsure how Brenda is doing, but hope that she is doing well.
Josephine has not had any symptoms nor signs of meningitis if the doctor asks. She has been perfectly well in herself. She has had all of her vaccinations, and has not had any problems up until now. You have read up online about meningitis, and are aware of all of the symptoms, and what to look out for, but you are obviously concerned as you have read that it can be fatal.
Josephine was born on time, no complications, has had no major health problems in the past, and doest take any routine medications at the moment.
You work as a lawyer, and are very busy, so don't want to spend a lot of time at the GPs, as you have a mountain of paperwork to get back to.
Ideas: You have googled meningitis, and have found that close contacts need to have antibiotics, something called rifampicin came up during your search.
Concerns: That your daughter may get meningitis without it, you think the risk is high that she will catch it without the antibiotics
Expectations: You want the antibiotics today, if the doctor mentions that nothing can be done unless a diagnosis fro Brenda is known, then you will want the Dr to confirm Brenda’s diagnosis, as below.
If the doctor is unwilling to give medication and cites, that they cant give anything unless the other child has confirmed meningitis, then you will demand that information form the GP, you will demand he looks in the other child's notes, or ring the hospital to find out - as the health of his and other children are at stake here!
If the doctor explains that the risk is of contracting meningitis this way is very low, also the antibiotics in question have their risks, and if they explain that this is all handled by a specialist agency - Public Health England - if a diagnosis of meningitis is made and they feel contacts need antibiotics, they will let the school / GPs know. If also informed that they do not routinely offer any antibiotics / vaccines for contacts at school, due to the transmission rates being so low: Then you will be happy to wait to hear from them.
Examination Findings
Not applicable in this scenario
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination - able to assess for possibility of meningitis Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Enquires about health of Brenda (Josephine's friend) Enquires about vaccination history, and previous medical history) |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them Fails to enquire about Brenda's progress in hospital, nor the vaccination / personal history of Josephine |
Clinical Management Skills
|
POSITIVE INDICATORS
Explains the risk coherently, and discusses probability of meningitis given proximity in classroom. Develops a management plan that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Manages risk effectively, safety netting appropriately - including outlining the signs and symptoms of meninigits that the parents should look out for. |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Offers to confirm Brenda's diagnosis, and inform Josephine's parents. Offers antibiotic therapy. Follow-up arrangements are absent or disjointed |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Shows empathy for difficult situation parents must be in, and shows empathy for Brenda. |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient |
Management
Management
This is a challenging case, as there are elements of uncertainty, ethical dilemmas and complex medical / public health problems. This case focuses around a few key elements:1) ensuring the safety of the child, 2) managing the (patients) fathers expectations, 3) confidentiality. Let’s start with number 1 - the safety of the child.
Meningitis & public health
As you may already know, meningitis is a notifiable disease in the UK. Once notified, there are clear guidelines in place by Public Health England, that define what the local area teams should do in response to a diagnosis. This document is very detailed, and if you feel like a good read, then click this link here to download a PDF version.
For those who are not interested in reading the whole document, here are some of the key elements. Firstly public health must assess whether or not this is a case of meningitis that requires their input, this is done according to the criteria below (taken form the above document)
Case requiring public health action:
This is a challenging case, as there are elements of uncertainty, ethical dilemmas and complex medical / public health problems. This case focuses around a few key elements:1) ensuring the safety of the child, 2) managing the (patients) fathers expectations, 3) confidentiality. Let’s start with number 1 - the safety of the child.
Meningitis & public health
As you may already know, meningitis is a notifiable disease in the UK. Once notified, there are clear guidelines in place by Public Health England, that define what the local area teams should do in response to a diagnosis. This document is very detailed, and if you feel like a good read, then click this link here to download a PDF version.
For those who are not interested in reading the whole document, here are some of the key elements. Firstly public health must assess whether or not this is a case of meningitis that requires their input, this is done according to the criteria below (taken form the above document)
Case requiring public health action:
Confirmed case
Clinical diagnosis of meningitis, septicaemia or other invasive disease (e.g. orbital cellulitis,
septic arthritis)*
AND at least one of:
• Neisseria meningitidis isolated from normally sterile site
• Gram negative diplococci in normally sterile site
• Meningococcal DNA in normally sterile site
• Meningococcal antigen in blood, CSF or urine.
Probable case
Clinical diagnosis of meningitis or septicaemia or other invasive disease where the CCDC/ CPH (consultant in communicable disease control), in consultation with the physician and microbiologist, considers that meningococcal infection is the most likely diagnosis.
Cases not requiring public health action:
Possible case
Clinical diagnosis of meningitis or septicaemia or other invasive disease where the CCDC/ CPH, in consultation with the clinician and microbiologist, considers that diagnoses other than meningococcal disease are at least as likely. This category includes cases who may have been treated with antibiotics but whose probable diagnosis is viral meningitis.In such cases, prophylaxis for contacts is not indicated, but giving out information about meningococcal disease may be helpful.
In summary: if a case is confirmed or probable, then the public health get involved, if it is merely possible, then they do not. If public health do get involved, then the following is an outline on who they would consider giving chemoprophylaxis to.
Prophylaxis indicated
Chemoprophylaxis should be offered to close contacts of cases, irrespective of vaccination status, that require public health action in the following categories:
(a) Those who have had prolonged close contact with the case in a household type setting during the seven days before onset of illness. Examples of such contacts would be those living and/or sleeping in the same household, pupils in the same dormitory, boy/girlfriends, or university students sharing a kitchen in a hall of residence.
(b) Those who have had transient close contact with a case only if they have been directly exposed to large particle droplets/secretions from the respiratory tract of a case around the time of admission to hospital
Prophylaxis NOT indicated (unless already identified as close contacts) for
• Staff and children attending same nursery or crèche
• Students/pupils in same school/class/tutor group
• Work or school colleagues
• Friends
• Residents of nursing/residential homes
• Kissing on cheek or mouth (intimate kissing would normally bring the contact into the close prolonged contact category)
• Food or drink sharing or similar low level of salivary contact
• Attending the same social function
• Travelling in next seat on same plane, train, bus, or car
In this particular CSA case, it’s likely that Josephine would not qualify for prophylactic chemotherapy.
Please note that rifampicin is no longer considered first line chemoprophylaxis any more, current recommendations suggest ciprofloxacin instead for all age groups and in pregnancy.
Dosage of ciprofloxacin:
Dealing with the parents expectations
Josephine’s parents are likely to be concerned / worried / scared about their daughter contracting meningitis, so are naturally going to want to do anything they can to prevent this.
To help placate the parents, explaining the risks may help. Here are the raw statistics taken from the above PDF document that you could use to help convey the risk;
The risk of transmission of meningitis from one child to another during pre-school, primary school or secondary school is 1/1 500, 1/18 000, 1/33 000 respectively.
Dealing with confidentiality
Josephine’s dad is naturally concerned, so he may ask during the consultation for you to find out what’s happening to Brenda and report back. This is obviously a breach of confidentiality, and ill advised. Re-iterating to the parent, that Public Health England will do this automatically, if they felt it necessary is enough in this case to help calm down the dad, and would assure most parents, that there is someone in charge of monitoring this and reporting back to the school / GP if they had any concerns.
Finally it’s important to discuss with Josephine’s parents about the signs and symptoms of meningitis, so that they feel empowered to monitor Josephine, and to obviously bring her back to you / 999 urgently if they have any concerns.
Please note that rifampicin is no longer considered first line chemoprophylaxis any more, current recommendations suggest ciprofloxacin instead for all age groups and in pregnancy.
Dosage of ciprofloxacin:
- Adults and children over 12 years 500 mg stat
- Children aged 5–12 years 250 mg stat
- Children under 5yrs 30mg/kg up to maximum of 125 mg stat
Dealing with the parents expectations
Josephine’s parents are likely to be concerned / worried / scared about their daughter contracting meningitis, so are naturally going to want to do anything they can to prevent this.
To help placate the parents, explaining the risks may help. Here are the raw statistics taken from the above PDF document that you could use to help convey the risk;
The risk of transmission of meningitis from one child to another during pre-school, primary school or secondary school is 1/1 500, 1/18 000, 1/33 000 respectively.
Dealing with confidentiality
Josephine’s dad is naturally concerned, so he may ask during the consultation for you to find out what’s happening to Brenda and report back. This is obviously a breach of confidentiality, and ill advised. Re-iterating to the parent, that Public Health England will do this automatically, if they felt it necessary is enough in this case to help calm down the dad, and would assure most parents, that there is someone in charge of monitoring this and reporting back to the school / GP if they had any concerns.
Finally it’s important to discuss with Josephine’s parents about the signs and symptoms of meningitis, so that they feel empowered to monitor Josephine, and to obviously bring her back to you / 999 urgently if they have any concerns.