Department of Health surveys regularly ask parents to name the illness they most fear. The answer is always the same: meningitis. The disease is the most common infectious cause of death in young people and the number one killer of children under five. It can claim the life of an apparently healthy child in a matter of hours. With all under-18s now immunised - at least against one strain of the disease - the number of cases in schools is falling. But there's no room for complacency. As those who have worked in affected schools will testify, there are few more traumatic situations than dealing with the grief, fear and panic which accompany an outbreak of meningitis.
What is it?
Defining the disease is straightforward: it's the inflammation of the meninges, the linings which surround the brain and spinal cord. But it's a far from straightforward condition. There are two basic types: one is caused by viruses, the other by bacteria. Viral meningitis is more common, but less harmful. Usually triggered by Coxsakie enteroviruses - found in faeces or sewage-contaminated water - its effects are similar to a nasty bout of flu. Bacterial meningitis is much rarer, with around 2,500 cases in the UK each year. But this is the form of meningitis which makes the news.
Meningococcal disease It gets even more complicated. Dozens of different types of bacteria can cause meningitis. The most prevalent, especially among children of school age, are meningococcal bacteria, of which there are five different strains: A, B, C, W135 and Y. The most common strains in the UK are B and C, although, in other parts of the world, A is widespread. Meningococcal bacteria are quite common. Everyone carries them at some time at the back of their throat or in their nose. But in rare cases the bacteria overwhelm the body's defences. They enter the bloodstream and pass to the brain, and this causes meningitis. It's still not clear why this can suddenly happen when millions of people carry the bacteria with no ill effect. "We know more about meningitis than we did, and we're learning all the time," says Professor Robert Booy of the Royal London Hospital. "But it's still quite mysterious."
What about the rash?
The rash, which many people think of as the classic symptom of meningitis, indicates septicaemia. It's possible to have meningitis without septicaemia, or vice versa, but in most cases they occur together.
Septicaemia happens when the meningococcal bacteria multiply in the bloodstream, releasing toxins which damage blood vessels. Blood seeps through the walls of the damaged vessels, becoming visible beneath the skin - first as tiny red pinpricks, then as blotchy patches similar to bruising.
If it goes unchecked, gangrene sets in and vital organs collapse. It's estimated that in more than 90 per cent of "meningitis" fatalities, the actual cause of death is septicaemia.
Meningitis is highly contagious, isn't it ?
No. The bacteria are fragile and can't survive outside the body for any length of time. They can be passed on through saliva - by coughing, sneezing, kissing or sharing drinks - but spreading the bacteria isn't the same as spreading meningitis. Between 10 and 25 per cent of us carry meningitis bacteria, but in most cases our body's defences can cope. So even if you come into close, prolonged contact with a sufferer, you're unlikely to develop the disease. Most incidents are isolated cases where only one person is affected; it's the rare "cluster" outbreaks which make the news.
So why are people so afraid?
Because meningitis can kill with alarming speed. In some cases there may be just two hours between the first signs of illness and death. And although fewer than one in 10 people who contract meningitis will die, there is a grimmer fatality rate of 25 per cent when septicaemia sets in. Survivors face the possibility of permanent disability: meningitis can cause deafness or brain injury, while septicaemia sufferers may need to have damaged limbs amputated.
What are the symptoms?
For meningitis: high temperature, vomiting, stiff neck, severe headache, aversion to bright lights and drowsiness. For septicaemia: fever, muscle pains, cold feet, diarrhoea, and a rash which doesn't fade when a glass is pressed against it. (As a septicaemic rash may fade in its early stages, check at regular intervals.) The symptoms for viral and bacterial meningitis are similar, although less severe for viral. In mild cases, patients may not even feel ill enough to see their GP.
But it's rare for all these symptoms to be present in any one case, and there's no set order in which they appear. Making a diagnosis is difficult because many of the symptoms can easily be mistaken for a severe case of flu. "Teachers shouldn't feel under pressure," says Bev Hart of the Meningitis Trust. "The only thing you can do is trust your instincts."
Don't be tempted to wait for the rash to appear to confirm your suspicions; it's usually the last symptom to show and it doesn't appear in every case.
If you suspect meningitis then call a doctor or ambulance immediately.
Early diagnosis makes a full recovery far more likely. And while you may always think you should have spotted the signs sooner, don't be too hard on yourself; even medics don't always recognise the symptoms (an accurate diagnosis requires a blood test and a lumbar puncture). "I took my son to the doctor, who treated him for an ear infection," says one Northamptonshire mother. "The next day he collapsed and I took him to hospital, where he was treated for sinusitis. It was only the day after when the rash appeared that they put two and two together, despite the fact that a girl from his school had died from meningitis a few weeks earlier."
Who is most at risk?
Anyone, of any age, can get meningitis. "It's Russian roulette," says Julia Warren of the Meningitis Research Foundation. Young people, however, are particularly susceptible. Children under five are most at risk, with 13 to 19-year-olds the next vulnerable group, so secondary schools need to be vigilant. This is especially true in boarding schools where close social contact carries on outside the classroom. As with other diseases, winter is the riskiest time. The highest incidence of bacterial meningitis occurs between November and January.
Toddlers are vulnerable because their immune systems are not fully developed, but it remains a mystery why secondary school pupils and university students should be susceptible. "We're still researching that question," says Professor Booy. "It could be the emotional stress of teenage life and a greater exposure to smoky atmospheres. Then there's the high level of social interaction among young people, in particular the frequent exchange of oral secretion. Or snogging."
Does vaccination work?
Yes. Some short-term vaccines are available, but there is a new effective long-term vaccine against meningococcus C, the strain which most commonly affects teenagers and causes cluster outbreaks. Early evidence suggests that the pound;240 million MenC vaccination programme has cut the incidence in under-18s by 75 per cent, effectively saving 50 lives a year.
All children who arrive in school should already have been vaccinated. But it's worth checking records - especially of pupils from overseas - and urging children who have missed out to visit their GP. The immunisation programme for under-18s, launched in 1999 after the incidence of meningococcal disease in the UK more than doubled over three years, is currently being extended to under-25s. Adverse reactions are common.
Vaccination can result in a headache, rash or dizziness, lasting a few hours. However, fears that the vaccine may have been responsible for isolated fatalities seem to be unfounded.
What do I do if there's a case of meningitis in school?
Phone a doctor or call an ambulance immediately, and notify the child's parents. After that, you'll find that the medical side of things is out of your control. The first impact at school will be "contact tracking". A public health doctor will visit to try to work out who has had intimate contact with the meningitis sufferer. He or she may then prescribe prophylactic antibiotics. If it's the first case in school then normally only close friends and immediate family will be offered drugs. But if it's the second or third, antibiotics will be given to a class or year group or, very rarely, the whole school. (Sometimes staff get overlooked; you may need to ask.) Consent forms are needed, but it's not usually a problem getting parents to agree. You're far more likely to have problems with parents whose children aren't being offered treatment. The powerful antibiotics will kill "friendly" bacteria as well as the ones that can cause meningitis, so be prepared for a surge of absences in the following weeks as everyone's immune system recovers. Even after antibiotics have been prescribed, it's important to remain vigilant. Symptoms may not appear until seven or eight days after exposure to the bacteria, and while the antibiotics kill bacteria in the nose and throat, if the infection is already in the bloodstream, then they may not be effective.
Dealing with parents The fear of meningitis is nearly always out of proportion to the actual risk. If your school - or even a neighbouring school - experiences an isolated incident, there will be widespread concern. If there's a second case you'll be fighting ignorance, fear and panic. "Meningitis is every parent's worst nightmare," says Julia Warren. Some schools affected by meningitis report more than a third of pupils being kept at home. There are even accounts of parents refusing to let their children leave the house, believing that the bacteria are in the air, while one head recalls an angry mother demanding the evacuation, fumigation and swabbing of the entire school.
The health authorities will write to all parents with information about the illness and its symptoms. But the school still has a major role to play in ensuring that parents are fully informed. Be prepared for the phones to start ringing. It's tempting to take refuge behind an answering machine, but remember that what parents are seeking is reassurance - and that means personal contact. When there was an outbreak of meningitis at Ton Pentre infants' school in the Rhondda Valley, headteacher Elaine Barnett called an open meeting for parents. "That was the key to the handling of the whole issue," she explains. "Parents felt fully involved and fully informed; they had the chance to be heard. It became a community problem, not an individual problem, and there was no hysteria. I didn't tell them they should send their children to school rather than keep them at home; I said that it was up to them."
Dealing with pupils Again, information is the key. Children will have lots of questions, so make sure staff are well informed. Pupils in the same class or year group as someone diagnosed with meningitis are likely to feel frightened, guilty and confused. If someone has died, then those feelings will be magnified and compounded by grief. Staff will probably be feeling similar emotions, making it a traumatic time for everyone. It will be easier if you have counselling procedures already in place, but be prepared for behavioural problems in the coming weeks, as complex emotions work themselves out. Fear can also result in a kind of hypochondria - especially in teenagers - and there may be some false alarms. But take every complaint of feeling unwell seriously. Finally, take full advantage of the support offered by the health authorities and the meningitis charities (see resources). Pupils will be reassured if what teachers are saying is reinforced by experts from outside the school.
Dealing with the media Meningitis is easy to sensationalise. You won't want to encourage headlines such as "Killer in the classroom" and "Deadly brain bug hits school", but accept that you will have to deal openly with the media. If you don't, then it will look as if you have something to hide. Be ready to counter any claims that the school did not react quickly enough. If you send a child home with symptoms which could be early signs of meningitis, then always recommend they contact their GP. It's sound advice and should forestall any accusations of negligence.
The media will probably be on the doorstep sooner than you expect, so have the facts close at hand and ensure that the information you release is consistent with that provided by the health officials. Establish an "outbreak control team" that includes a senior member of staff, a senior health official, and the person responsible for communicating with the media. A daily meeting can review the best action to take, decide on the next steps, and determine exactly what information should be released to parents and the press.
Can schools help prevent meningitis ?
There's little anyone can do to prevent meningitis, other than vaccinating against MenC. There's evidence that good general hygiene - regular hand-washing, not sharing drinks, and so on - can lessen the risk, simply by cutting down on bacteria and viruses. But the most important thing is to ensure that staff and pupils know the basic facts about the disease and what symptoms they should be looking out for. It isn't enough to pin up a poster and hope that everyone reads it.
In secondary schools the curriculum offers opportunities to look at meningitis as a PSHE subject, or as part of science or even media studies.
For primary teachers, it can be more difficult to know at what age you should raise the issue.
It's important not to be alarmist; you don't want young children thinking they've got meningitis every time they have a headache. The best approach is to urge classmates to look out for each other. Meningitis is almost always diagnosed by another person; the sufferer is usually too distressed and confused to diagnose him or herself.
History of meningitis In the 1700s, meningitis was lumped together with several other illnesses vaguely identified as "brain fever". In the early 1800s, bacterial meningitis was recognised as a condition in its own right, but without antibiotics it was almost always fatal. Although antibiotic treatments were developed in the early 20th century, meningitis epidemics broke out during both world wars. Between 1939 and 1945 there were more than 11,000 cases annually in the UK, possibly because immune systems were lowered, or because the bacteria spread easily in cramped air raid shelters. The biggest meningitis epidemic in history was as recent as 1996, in the so-called "meningitis belt" of sub-Saharan Africa. There were 111,000 cases and nearly 13,000 deaths.
Today, different strains of meningitis dominate in different areas of the world. Type A, which has been virtually eradicated in Britain, kills thousands in Africa and India. A handful of outbreaks occur in the UK each year, when tourists bring more than souvenirs back from their holidays.
Will we ever eradicate it?
The next big step forward will be the development of a vaccine for meningococcal B. Millions of pounds have been committed to research programmes around the world, but without success. "It will happen," says Julia Warren. "But if the breakthrough came tomorrow it would still be 10 years before a vaccine was ready for public use." And by then we may be facing new strains of the disease. "Germs are very clever; they're constantly evolving," says Professor Booy. "It's likely to be an ongoing battle."