Comparative data on the clinical presentation and

Comparative data on the clinical presentation and outcome in NmC and NmA are scarce. In a brief report from northern Nigeria in 1977, 114 patients with meningococcal infection were studied, of whom 72 patients had NmC infection and 42 patients had NmA infection. All patients who PFTα had bacteraemia had disease caused by NmC infection, and nine of these 14 patients died. Clinical and laboratory findings were similar in patients with meningitis due to NmA and NmC, but arthritis and cutaneous vasculitis were more common in patients with NmC. The overall mortality rate was 22% in patients infected with NmC, and 12% in patients infected with NmA. Notably, the investigators reported similar mortality rates for both diseases when the patients who had bacteraemia were excluded from the analysis. The excess mortality rate in patients infected with NmC would have been missed in the absence of surveillance for bacteraemia. Reports of non-serogroup-A meningococcal disease in the meningitis belt are increasing, consisting of outbreaks caused by NmW, NmC, and serogroup 1 strain of in northern Ghana. This trend clearly shows the need to provide more comprehensive surveillance platforms for invasive meningococcal disease in the meningitis belt, where diagnosis of disease has relied on the recognition of meningeal symptoms and assessment of cerebrospinal fluid alone without consideration for patients with invasive meningococcal disease, who are at high risk of a fatal outcome. Blood cultures are not routinely done and no intensive care units exist. This change in epidemiology of disease warrants an urgent review of the surveillance and management approaches in place for these outbreaks. First, the clinical case definition should be broadened to include patients with septicaemia at clinical presentation without meningeal signs. Second, provision for integrating bacteraemia surveillance should be included in the laboratory investigation, either by blood culture or another suitable method for the detection and identification of bacteria from the blood stream. Third, the recommended threshold for outbreak alerts and epidemics should be revised because outbreaks caused by non-A meningococcal meningitis serogroups have less clear patterns of outbreak, and analysis of the epidemic risk at the subdistrict level could be poorly sensitive. Finally, improved understanding of the dynamics of these outbreaks will be best accomplished by establishing local and regional microbiological diagnostic, year-round surveillance to track disease incidence and provide causal data that will guide preventive strategies, in the short term and long term.
A few months after the 7·8 magnitude earthquake in Nepal on April 25, 2015, and the subsequent strong aftershocks, outbreaks of scrub typhus were reported from various parts of the country, especially from districts affected by the earthquake. These outbreaks were thought to be due to people and rodents (which carry mites with the bacterium the infective microbe in scrub typhus) living in close proximity in temporary shelters after the earthquake. Although typhus in Nepal has been well reported in large studies, the earthquake posed problems in diagnosis and treatment of the outbreaks, primarily because of poor awareness of the disease. Part of this poor awareness of typhus fever relates to the widespread use of the serological Widal test for typhoid, which often presents with clinical features similar to and indistinguishable from typhus. The Widal test, developed in 1896, is a tube or slide agglutination test that is cheap and simple, but has pitfalls. Cross-reactivity between typhoid, typhus, leptospirosis, malaria, and other prevalent organisms with the Widal test leads to a common misdiagnosis of typhoid fever. This fact is particularly relevant in areas where typhoid is endemic (eg, Nepal) and low background concentrations of typhoid antibodies are present in the normal population. Additionally, a single acute sample is usually used for testing, but an appropriate cutoff for a positive result can be difficult to establish, because the threshold varies between areas and between times in given areas.