MENINGITIS IN BRAZIL: EPIDEMIOLOGICAL TRENDS AND THE ROLE OF NURSES IN CARE AND PREVENTION – BIBLIOGRAPHICAL REVIEW 

REGISTRO DOI: 10.5281/zenodo.10537127


HORACIO, Hariel Sá Pazianoto1
COIMBRA, Juliano Rodrigues1
SILVA, Douglas  Fernandes1


ABSTRACT 

INTRODUCTION: Meningitis is a worldwide pathology that has a high rate of morbidity  and mortality. It consists of an inflammation that affects the meninges, especially in the  subarachnoid space, cranial and spinal segments. It can manifest itself in two different  forms: the bacterial form, a more serious form that can lead to death in a matter of  hours, and the viral form, which is less severe and the individual recovers more quickly. OBJECTIVE: To analyze the existing literature on nurses’ care for patients affected by  meningitis in Brazil, in addition to epidemiological trends of the disease. METHODOLOGY: Literature review using the main internet databases to select  articles. CONCLUSIONS: Meningitis is a serious public health problem due to its high  morbidity and mortality rate, especially in children. It is necessary to emphasize that  vaccination is extremely effective in controlling and eradicating diseases, not just  individually, but collectively, benefiting the entire community. 

Keywords: Meningitis; Epidemiological Profile; Nurse.

1. INTRODUCTION 

In the years 1971 and 1975, an epidemic known as Meningococcal Disease  began in Brazil, the number of cases was devastating, with a high lethality and with the  highest number of cases in the city of São Paulo due to the local health infrastructure (Focaccia & Negra, 2022). 

The meningitis disease is a widespread worldwide illness with a high morbidity  rate; its physiopathology involves inflammation of the meninges, primarily in the  subarachnoid space, the cranial segment, and the medulla. The disease can manifest  itself in two different forms: bacterial, which is the most serious variant and can lead to  death in a matter of hours, and viral, which has a lower severity and fatality rate, with  faster recovery of the individual (SILVA; MEZAROBBA, 2018).  

Neisseria meningitidis, Streptococcus pneumoniae, Mycobacterium  tuberculosis e Haemophilus influenzae are the main bacteria responsible for the  occurrence of bacterial meningitis, the latter being a variant frequently associated with  infections in children. However, Mycobacterium tuberculosis is the one with the highest  mortality rate, particularly affecting children under the age of five (Dias et al., 2017). 

Meningitis is a pathology that presents symptoms like those of the flu, which  makes its accurate diagnosis difficult. For this reason, it is crucial that the doctor  performs neurological exams and a lumbar puncture to collect cerebrospinal fluid  (CSF). Affected individuals may not be able to touch their chin to their chest due to the  signs and symptoms of the disease, which include headache, fever, malaise, vomiting,  photophobia, petechiae, convulsions and neck stiffness. Consequently, it’s critical to  emphasize that children are more likely to experience this final symptom (Amorim et  al., 2022). 

Due to its high contagion, meningitis is considered a serious public health  problem and, therefore, is classified as a notifiable disease and must be reported 24  hours after diagnosis (Amorim et al., 2022). Epidemiological surveillance is responsible  for controlling reported cases, this data is available in the Notifiable Diseases  Information System (Sistema de Informações de Agravos de Notificação – SINAN)  (PAIM; GREGIO; GARCIA, 2019). Meningitis can affect any age but is most common  in children aged 1-4 due to their immune system not being fully mature. Treatment  consists of antibiotics, and vaccination is the most efficient way to prevent meningitis,  it is essential for their protection (Maimaiti et al., 2022).

The pathology known as meningitis has a high morbidity and mortality and has  a significant impact on global public health. In Brazil, despite the preventive measures  adopted, the disease is still responsible for a high number of cases and deaths,  especially in children (Dias et al., 2017). In this context, it becomes imperative to carry  out studies that could aid in understanding the epidemiology of meningitis and  improving prevention and control strategies. Furthermore, the role of nurses in the  clinical management of meningitis cases is essential to guarantee the quality of care  provided to patients and minimize the risks of complications and sequelae. This article  aimed to analyze the literature on nursing care for meningite patients in Brazil, as well  as epidemiological trends of the disease, with the goal of ensuring practices and  strategies to prevent complications and ensure the safety of treated patients. 

2. EPIDEMIOLOGY IN BRAZIL 

2.1. Analysis of regional prevalence 

It is estimated that out of 1.2 million people contract meningitis, 135 thousand  people die (MAIMAITI et al., 2022a). In Brazil, meningitis is considered a notifiable  disease and must be reported within 24 hours of diagnosis. The Neisseria meningitidis (meningococo) is the main etiological microorganism, with a lethality rate of around  20% in Brazil. Meningitis represents an endemic condition within the Brazilian territory,  exhibiting more pronounced outbreaks during the winter season and sporadic  occurrences in alternative periods throughout the year. In the studies of Rodrigues  Santos (RODRIGUES SANTOS, 2021), between 2010 and 2020, 204.5 thousand  cases of meningitis were reported to Notifiable Diseases Information System (Sistema  de Informações de Agravos de Notificação – SINAN) in Brazil. Children aged 1 to 9  were the most affected age group with around 32.2% of cases, followed by adults aged  20 and 39 with 19.3% of notifications. In total, the country’s rate was 97 cases/100  thousand inhabitants (Amorim et al., 2022). 

2.2. Identification of vulnerable groups 

Amorim et al., (Amorim et al., 2022) pointed out that meningitis mainly affects  males, this is because this population has greater exposure to risk factors, thus  contributing to the transmission of the disease. In addition, studies have shown that  men are more resistant when it comes to seeking medical care.

Maimaiti et al. (Maimaiti et al., 2022) e Rodrigues (Rodrigues, 2015), report that  the disease can affect any age group, being more common in children aged 1-4 years  because their immune system is not completely mature. Furthermore, there are some  risk factors that may be associated with the occurrence of the disease, such as:  malnutrition, immunosuppression and trauma to the central nervous system and some  bacterial infectious processes such as bacteremia (pneumonia, empyema,  osteomyelitis, and endocarditis), sinusitis, otitis media, encephalitis, myelitis and brain  abscess (Dazzi et al., 2014).  

2.3. Socioeconomic inequalities and impact on nurses’ performance

Socioeconomic inequality can have a significant impact on patients with  meningitis. Low-income patients may face difficulties in accessing adequate medical  care, early diagnosis, and effective treatment. In this way, it can lead to serious  complications and even increase the risk of mortality. In addition, socioeconomic  factors such as early mortality rates and limited access to basic healthcare can  increase the risk of infections, including meningitis. Patients with low incomes may  have trouble getting access to quality medical care, which could have a detrimental  effect on their prognosis and course of treatment (LIMA, 2017).  

Therefore, the nursing team is responsible for developing technical and  scientific skills, as well as knowledge, skills, and emotional control, adopting new  strategies for coping with the disease, specialized psychological support and active  listening, always aiming to provide qualified assistance (Dal’bosco et al., 2020). 

The initial approach carried out in cases of meningitis is the sum of the Glasgow  Coma Scale, which scores and adds three neurological parameters: eye opening (4),  verbal response (5) and motor response (6). The maximum score is 15 points and the  minimum, which is compatible with brain death, is 3. To consider intubation criteria, the  sum is considered 8. In this evaluation, pupillary responses are observed, because if  they become mydriatic or anisocoric and /or not responding to light, may be a sign of  poor cerebral perfusion (MACHADO; BORGES, 2015). 

In addition to the neurological assessment, the nurse must assess the patient’s  pain level using the FACES pain scale, as if left untreated, it increases the patient’s  Intracranial Pressure (ICP), causing great suffering (MACHADO; BORGES, 2015).  

The patient’s vital signs must also be checked, such as blood pressure, which  must remain between 120mmHg and 60mmHg; pulse oximetry, which must remain between 90 and 100%; the body temperature which cannot exceed 36.5ºC and the  pulse frequency which must vary between 60 and 100 beats per minute. Therefore, to  obtain thorough monitoring, all this information must be checked hourly by the nursing  team (MACHADO; BORGES, 2015).  

Nurses may face challenges when dealing with patients from different  socioeconomic backgrounds, such as lack of financial resources, limited access to  healthcare services, and lack of knowledge about preventative measures such as  vaccination. Therefore, social inequality can directly affect the role of nurses in caring  for patients with meningitis. They play a crucial role in the education, prevention and  treatment of meningitis, adapting their strategies according to the needs and resources  available to each patient (LIMA, 2017). 

3. ETIOLOGY AND CAUSING AGENTS IN THE BRAZILIAN CONTEXT

As already mentioned, meningitis is a comprehensive global pathology that has  a high morbidity and mortality rate. Its pathophysiological pathology consists of  inflammation that affects the meninges, mainly in the subarachnoid space, cranial and  spinal segments. This disease can manifest itself in two different forms: bacterial,  which is the most serious variant and can lead to death in a matter of hours, and viral,  which has a lower severity and fatality rate, with faster recovery of the individual  (SILVA; MEZAROBBA, 2018). Figure 1 presents epidemiological data on Meningitis in  Brazil between 2010 and 2020 (n=187.508).

Figure 1: Epidemiological data on Meningitis in Brazil (2010-2020) (MORAES; GALDINO; TEIXEIRA,  2022). 

Out of the 187.508 confirmed cases, 54,2% (n=101.558) were observed in the  South and 4,3% in the North (n=8.072), correspondingly indicating the more and less  affected locations in Brazil, followed by the South (19,8% / n=37.195), the North (17,1%  / n=32.009), and the Central-Oeste (4,6% / n=8.674) (MORAES; GALDINO;  TEIXEIRA, 2022). 

Figure 2 presents epidemiological data on Meningitis in Brazil between 2010  and 2020 by Federative Unit.

Figure 2: Epidemiological data on Meningitis in Brazil by Federative Unit (2010-2020) (MORAES;  GALDINO; TEIXEIRA, 2022). 

In Brazil there are 26 federative units, among them, the State with the highest  number of confirmed cases was São Paulo (41% / n=76,317) and the one with the  lowest number was Amapá (0.1% / n=154). Paraná had the second highest number of  notifications (8.4% / n=15,826), followed by Rio Grande do Sul (7% / n=12,879), Rio  de Janeiro (6.4% / n=11,942) , Minas Gerais (5.9% / n=11,213), Pernambuco (5.8% /  n=10,946), Bahia (4.7% / n=8,960), Santa Catarina (4.5% / n=8,490) , Pará (2.3% /  n=4,371), Ceará (2.1% / n=4,080), Goiás (1.7% / n=3,161), Piauí (1.6% / n=3,002),  Espírito Santo (1.1% / n=2,086), Mato Grosso (1.1% / n=2,011), Mato Grosso do Sul  (1% / n=1,781), Amazonas (1.0% / n=1,742), Federal District (1.0% / n=1,721),  Alagoas (0.7% / n=1,317), Rio Grande do Norte (0.6% / n=1,269), Maranhão (0.6% /  n=1,256 ), Rondônia (0.3% / n=699), Paraíba (0.3% / n=694), Tocantins (0.4 / n=681),  Sergipe (0.2% / n=485), Acre (0.1% / n=226) and Roraima (0.1% / n=199) (figure 2)  (MORAES; GALDINO; TEIXEIRA, 2022). 

Viral meningitis in Brazil

Viruses are responsible for most cases of acute meningitis, can be caused by  different families of viruses and are often confused with bacterial meningitis. Among  the viruses responsible for most cases of acute meningitis, enterovirus stands out as  the most common pathogen identified, followed by mumps virus, herpes simplex virus,  arboviruses, chickenpox, measles, rubella, and adenoviruses (Santos et al., 2022). 

Contamination with the meningitis virus occurs through close contact with an  infected person through respiratory droplets when coughing, sneezing, or sharing  personal objects. To this end, as it is a pathology that presents symptoms like those of  the flu, which makes its accurate diagnosis difficult, neurological examinations and a  lumbar puncture are necessary to collect cerebrospinal fluid (CSF) (Amorim et al.,  2022). 

Bacterial meningitis in Brazil 

The main bacteria responsible for the occurrence of meningitis are Neisseria  meningitidis, Streptococcus pneumoniae, Mycobacterium tuberculosis and  Haemophilus influenzae, the latter is frequently associated with infections in children  (Dias et al., 2017). 

On the other hand, Neisseria meningitidis, also known as meningococcus, is  known for presenting the highest mortality rate, especially in children from regions of  low economic and social status. This bacterium is the main cause of septicemia and  meningitis worldwide (Teixeira et al., 2018). 

Patients affected by bacterial meningitis are generally quite symptomatic and  often present less than 24 hours after the onset of symptoms (ROLDI et al., 2022).  Headache, fever, malaise, vomiting, photophobia, petechiae, convulsions and neck  stiffness are the most common clinical features. Therefore, it is important to highlight  that this last symptom is more prevalent in children (Amorim et al., 2022). 

Bacterial meningitis is the most serious form of the disease and can lead to  death quickly. The clinical findings of this disease overlap with other types of meningitis  and therefore require an examination of CSF parameters and imaging tests when  necessary (ROLDI et al., 2022). 

The doctor and the nursing team are primarily responsible for direct care for the  affected person, therefore, despite such monitoring, it is possible for complications of  the disease to occur, especially when its etiology is bacterial, whereas in the case of viral etiology, the Complicated developments are usually associated with  immunodeficient patients. Among the most common complications encountered are  deafness, cognitive or behavioral deficits, motor abnormalities, hydrocephalus and  visual or language disorders (Paim et al., 2019). 

Figure 3: Nisseria meningitidis – Intracellular gram-negative diplococci and leukocytes in the CSF from  a patient with meningococcal meningitis. The arrow denotes diplococci in proximity and within  leukocytes (NADINE; DAVID, 2012).  

o Nurse’s inventions in prevention and identification 

The nurse’s role is to develop awareness policies to broaden society’s view of  the severity of the disease. Primary prevention is the key to more effective control.  Nurses play an important role in promoting care, recognizing, and perceiving various  changes. Therefore, you must have extensive and skilled knowledge for the patient’s  recovery, to ensure quick and responsible care (Silva et al., 2020). 

Professional nurses must always seek knowledge and training, as they are  responsible for making and implementing scientifically based decisions, actions and  care for the patient’s recovery. In addition, he is responsible for planning, coordination  and implementation aimed at preventing this pathology, increasing the patient’s  chances of improvement (Silva et al., 2020).

4. TREATMENT, COMPLICATIONS AND SEQUELARES IN THE NATIONAL  CONTEXT 

Antibiotic therapy and challenges in access to medicines

A quick and careful initial approach to suspected cases of meningitis is very  important for the patient’s improvement. Immediate hospitalization, respiratory  isolation, collection of samples for diagnostic tests and the institution of empirical  antibiotic therapy proportional to clinical suspicion are crucial measures for the  effective treatment of the disease. General support, such as fluid replacement, is  essential for patient care, as well as adjusting antibiotic therapy according to the results  of sensitivity tests are also essential steps in the treatment of meningitis. Notification  to the Municipal Health Department for epidemiological investigation and  implementation of appropriate prevention measures also contributes to controlling the  disease (CARVALHO et al., 2022). 

Treatment of bacterial meningitis with medication varies depending on the  patient’s age. For newborns, the use of ampicillin in combination with ceftriaxone is  indicated. Between 1 and 23 months, ceftriaxone is the medication of choice. For  patients aged between 2 and 50 years, in addition to ampicillin associated with  ceftriaxone, vancomycin can be used together with cefepime, ceftazidime or  meropenem (CARVALHO et al., 2022). 

The use of corticosteroids, such as dexamethasone, has been shown to be  effective in children with H. influenzae, reducing neural damage and hearing loss. The  use for S. pneumoniae is not yet consensual, but it is considered an option due to the  reduction in morbidity and mortality. It should be administered before or simultaneously  with the initial dose of antibiotic (CARVALHO et al., 2022). 

Challenges to accessing medicines may include limited availability of medicines  in certain regions, high treatment costs, lack of adequate infrastructure for storage and  distribution of essential medicines (CARVALHO et al., 2022). 

Available antivirals and their distribution in the country 

In most cases, treatment with antiviral medications is not carried out.  Hospitalization, monitoring of signs of greater severity, careful evaluation and clinical  follow-up are generally necessary.

The conduct is always determined by the medical team, however, in specific  cases, such as Herpes Simplex Virus (HSV), treatments with intravenous acyclovir are  used, where it is used to treat viral infections by inhibiting the replication of the virus. (SANTOS et al., 2022). 

In general, the more serious the infection, the greater the chances of  complications. Neurological damage seen includes hearing and vision loss, problems  with memory, loss of concentration and motor coordination, epilepsy, and cerebral  palsy (CARVALHO et al., 2022).  

5. VACCINATION IN BRAZIL 

Specific vaccination programs 

The preventive form, which is vaccination, the first dose begins at 2 months of  age with the Pentavalent vaccine, which prevents infections caused by Haemophilus  influenzae type B, with a booster dose at 4 and 6 months. The meningococcal  conjugate vaccine is given at 3, 5 and a booster at 12 months, protecting the child  against infections with Neisseria meningitidis serogroup C (SILVA; MEZAROBBA,  2018).  

The World Health Organization (WHO) recommends a meningococcal vaccine in  the expanded immunization program (EPI) to prevent meningitis, especially in  countries with a high disease burden. Vaccination strategies differ between countries  due to diverse meningococcal groups and disease burden, cost-effectiveness,  budgetary impact, and public health priority (Maimaiti et al., 2022). 

Prevention measures must be strictly followed, and epidemiological surveillance  is primarily responsible for ensuring their implementation. Therefore, it is necessary to  control this disease through patient isolation, chemoprophylaxis of contacts, contact  surveillance, immunization, timely identification and control of outbreaks and health  education actions. These control measures aim to reduce the incidence of the disease  and prevent the occurrence of secondary cases (Liphaus et al., 2021). 

Challenges and successes in implementing immunization programs

The National Immunization Program (PNI) was created in 1973 by the state and  municipal health departments. According to the Domingues et al. (DOMINGUES et al.,  2020), authorities, the PNI aims to comply with the principle of decentralization of the 

Unified Health System (SUS), acting in an articulated, hierarchical, and integrated way.  Therefore, constant discussions about standards, goals and results are necessary, as  it enables implementation in all spheres of SUS management. The PNI contributes to reducing regional and social inequalities, guaranteeing access to vaccination for all  Brazilians, in all locations. 

The implementation of meningitis immunization programs in Brazil faced  challenges such as ensuring adequate vaccination coverage, distributing vaccines in  all regions of the country, and raising awareness among the population about the  importance of vaccination. However, according to the authors Gonçalves e Assis  (GONÇALVES E ASSIS, 2022), there have been significant successes, such as the  reduction in cases and deaths from meningitis, the increase in the supply of vaccines  through the National Immunization Program and the inclusion of new vaccines in the  national calendar. 

Currently, there is still hesitation among the population about vaccination.  Therefore, it is the nurse’s role to develop strategies and training for other health  professionals who work in this service. Over the years, the Ministry of Health has  developed several campaigns. The vaccination calendar has become more complex  and complete today, thus requiring extensive knowledge from professionals about  vaccination schedules. The PNI has invested in various training courses to increase the  number of doses of vaccines administered and raise awareness among the population  about their importance. It is important to have qualified professionals who know how  to make good recommendations about the need for vaccination and answer the  population’s doubts. 

The main challenge facing health units is caused by the presence of fake news  on social media, which circulates daily. To obtain accurate information about vaccines  and their effectiveness in preventing diseases, it is crucial to always check the veracity  of the information and seek reliable sources, such as health bodies and scientific  institutions. The Ministry of Health points out that the drop in numbers related to  immunization in the country is mainly due to fake news. 

6. CONCLUSION 

In this work, using scientific literature as a basis, it was observed that meningitis  is a serious public health problem due to its intensity of spread and its high rate of  morbidity and mortality, especially in children. Therefore, it is necessary to highlight the importance of prophylactic methods such as vaccination, which are extremely  effective in controlling and eradicating diseases, not only individually, but collectively,  as they lead to a reduction in the circulation of the disease, benefiting the entire population. In addition, the literature also states that historically the Brazilian population  has confidence in the efficacy and safety of vaccines, however adherence has been  decreasing in recent years, mainly due to the growth of the anti-vaccine movement and  the circulation of erroneous and/or false information without scientific basis that  circulate mainly on social media. There are currently several Federal Government  programs that deal with this topic. These guidelines are implemented through  vaccination campaigns and health education programs, which can be found on the  Ministry of Health portal. Therefore, it can be concluded that despite all these strategies  developed, there are still several barriers that make access and eradication of  meningitis difficult. It is necessary to obtain quality scientific information in an  accessible and clear way to combat denialist movements, so that science is  democratized and available to the entire population. It is worth mentioning that health  professionals must be educators and health promoters, being essential for the  population to be aware of the importance of vaccination. 

7. Acknowledgements 

The authors wish to University Center of the Integrated Faculties of Ourinhos – Unifio, Ourinhos, SP, Brazil.

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1Department of Nursing – University Center of the Integrated Faculties of Ourinhos – Unifio, Ourinhos, SP, Brazil. 

Hariel Sá Pazianoto Horacio (ORCID: 0009-0004-4697-4828) harielpazianoto@gmail.com (Corresponding author) 
Juliano Rodrigues Coimbra (ORCID: 0000-0002-3227-452X) juliano.coimbra@unifio.edu.br  
Douglas Fernandes da Silva (ORCID: 0000-0002-0252-1112) douglas.silva@unifio.edu.br