Diagnosis, management, and causes of meningitis in the Gaza Strip: an analysis of guidelines, field assessment, and microbiological study

Abstract Background Reported rates of bacterial and viral (aseptic) meningitis are much higher in the Gaza Strip than in the West Bank. In the Gaza Strip the capacity for microbiological diagnostic testing is limited. The aim of the study was to assess clinical laboratory diagnosis and management of meningitis in the Gaza Strip and to identify the microbiological causes of meningitis. Methods The assessment followed general guidelines of WHO and the US Centers for Disease Control and Prevention, using a preparatory questionnaire sent to all microbiological laboratories in the Gaza Strip. A joint assessment was conducted in May, 2014. Guidelines and procedures for microbiological services, surveillance systems, and clinical procedures for diagnosing and treating clinical meningitis were assessed. On-site field visits were done at four hospitals, including clinical wards and laboratories, and at the Gaza Ministry of Health central laboratory. Cerebrospinal fluid samples from 123 patients with clinical meningitis were consecutively collected from the Ministry of Health central laboratory from November, 2013 to June, 2014. Samples were sent in three batches (January, May, and June 2014) for microbiological analysis at the Norwegian Institute of Public Health. Findings The assessment showed a lack of antibiotic policy and regulation of prescription in the Gaza Strip. Hospital meningitis guidelines did not follow international guidelines. All patients with suspected clinical meningitis were treated with antibiotics even when a viral cause was suspected, and often before hospital admission. Laboratories had dedicated staff and high productivity, but lacked sufficient space, equipment, and reagents, and some standard operating procedures. No molecular methods were available for bacterial and viral detection. Of 123 cerebrospinal fluid samples tested for bacteria, serogroup B Neisseria meningitidis was detected in eight and Streptococcus pneumoniae in one. Of 102 samples available for virus testing, enteroviruses were detected in 63, one of which was also positive for serogroup B N meningitidis . Interpretation National guidelines and policies to promote prudent use of antibiotics in the health services are needed. Clinical guidelines for classifying and treating patients with suspected meningitis should be revised with stakeholders. A reference laboratory with defined tasks should be established. Up-to-date laboratory diagnosis of viral meningitis is urgently needed. Laboratory protocols should be improved and equipment upgraded. Spring-summer meningitis outbreaks seem to be dominated by enteroviruses. In our assessment serogroup B N meningitidis was the main cause of bacterial meningitis. Use of meningococcal vaccine should be considered. Funding The study was funded by in kind contributions from the organisations involved. The Palestinian National Institute of Public Health is a project managed by WHO and funded by the Norwegian Ministry of Foreign Affairs.