This document discusses strategies for managing meningitis epidemics in Africa. It outlines a 3 pillar approach including surveillance to detect outbreaks, treatment and care of patients, and vaccination campaigns. Key steps are increasing surveillance before epidemics to detect early cases, confirming the bacterial strain to guide treatment and vaccine selection, and conducting reactive vaccination campaigns when epidemic thresholds are crossed in affected areas and surrounding districts. Ongoing monitoring and evaluation is also recommended to track the response.
2. Outline
1. Objective
2. The disease
3. Transmission
4. Disease burden
5. Disease trend- Ethiopia
6. Strategies for epidemic control
7. Disease incidence
8. Determining alert & epidemic threshold
9. Pillars 1, 2,3
10. Post epidemic follow up
11. M&E and performance indicators
3. Objectives
• General
To detect early, confirm and appropriately respond to
meningitis epidemics
• Specific
– Collect and analyze data on suspect cases
– Rapid lab confirmation
– Use information for control measures
4. The Disease – Meningococcal meningitis
• A serious bacterial infection of the meninges caused by
the bacteria Nisseria meningitides .
• Commonest sero-groups of – Nm: A, B, C, W135
• Bacteria carried in the throat, transmitted from person
to person through respiratory or throat secretions.
• The average incubation period is 4 days (2 - 10 days).
• Most common symptoms: high grade fever, headache
stiff neck, confusion, sensitivity to light and bulging
fontanel in infants.
• Fatal in 50 % of cases if untreated and may cause
severe brain damage in 10–20 % of patients who
survive.
5. Disease Burden
• Epidemic Meningococcal Disease is
a major public health challenge
• 90 % of cases reported in the
“Meningitis belt” that stretches
across - Senegal to Ethiopia with
approximately 450 mill people
• About 700,000 cases in a decade
with a CFR 10%
• High risk period : December to June
6. Disease burden- Ethiopia
National Trend of Meningitis Cases and Deaths from 2000-2009: Ethiopia
10000 1000
9500 950
9000 900
8500 850
8000 800
7500 750
7000 7018 700
6500 650
6000 600
5500 550
Number of Cases and
5000 5037 500
Deaths
4500 450
4000 400
3500 329 3165 350
3000 300
2500 250 2170 250
2000 179 187 200
1500 150
1000 701 1007 662 797 100
500 47 612
0 28 11 18 27 50
0
2000/2001 2001/2002 2002/2003 2003/2004 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009
Years
Analysis: WHO - Ethiopia Country Office
DPC Cluster Unit
Data Source: FMOH - Ethiopia
Date of Production: March, 2010 Cases Deaths
9. Strategy for epidemic control-Africa Region
• Three- pillar strategy for
epidemic meningitis control
• Pillar 1: Surveillance
• Pillar 2: treatment and care
• Pillar 3: vaccination.
10. Calculating disease incidence & CFR
Attack rate Case fatality Ratio (CFR)
Number of cases Number of deaths
divided by divided by
total district population number of cases in the same
X 100 000 period
X 100
11. Determining alert and epidemic thresholds
Population < 30,000 Population > 30,000
Alert 2 cases in one week OR AR = 5 cases/100 000
threshold Greater number of cases than the population /week
same period in non-epidemic years
Epidemic 5 cases in one week OR AR = 15/100 000
threshold doubling in number of cases over population/week .
3-week period. In certain conditions
Special situations should be indicating higher
studied on a case-by-case basis (a) epidemic risk (b )
AR = 10/100 000
population/week
(a) For mass gatherings, refugees and displaced persons, 2 confirmed
cases in 1 week are enough to warrant vaccination.
(b) No epidemic in previous 3 years or vaccination coverage < 80 % or
alert threshold crossed early in season.
12. Pillar 1:Surveillance
Scale up surveillance Case definition
• Scale up the disease surveillance Suspected case:
system at an early stage before the • Any person with sudden onset of fever
epidemic to detect the first cases. (>38.5 °C rectal or 38.0 °C axillary) and one
of the following signs – neck stiffness,
• Identify the pathogen as well as the flaccid neck, bulging fontanel, convulsion
sero-group of the meningococcus or other meningeal signs.
(Nm) responsible for the infection, to Probable case:
serve as a trigger to launch a rapid • Any suspected case with macroscopic
response operation. aspect of its CSF turbid, lousy or purulent;
• use standard case definitions to or with microscopic test showing Gram
recognize early cases. Should be negative diplococci, Gram positive
confirmed by laboratory tests. diplococci, Gram positive bacilli; or with
leukocytes count of more than 10
• Standard reporting mechanisms in cells/mm3.
place to analyse data, determine Confirmed case:
the extent and evolution of an • Isolation or identification of the causal
outbreak. pathogen (Neisseria meningitidis) from
the CSF of a suspected or probable case by
culture, PCR or agglutination test.
13. Pillar 1:surveillance cont.
Pre-epidemic : At the district level:
• Design, print and distribute standard reporting forms and
standard case definitions (SCD) to all health centres;
• Ensure all health centres are aware of SCD;
• Identify/appoint and train surveillance officers in all areas
of the district;
• Compile surveillance data on a weekly basis of all
suspected cases (as well as zero reporting), analyse trends
and monitor any signs of disease activity;
• Pre-position diagnostic reagents and other surveillance
material within district and reference laboratories.
14. Pillar 1:surveillance
Pre-epidemic - health centres:
• Be aware of and understand the standard
case definitions;
• Report on zero cases and be ready to report
on suspected, probable and confirmed cases;
• Conduct lumbar punctures on any suspected
case;
• Complete a case-base form for all suspected
cases.
15. Pillar 1: surveillance- During epidemic
At the district level:
• Monitor and analyse surveillance data on daily basis to determine
the daily AR & CFR .
• Disaggregate the data to identify disease activity within age groups
and population centres of less than 100 000 people;
• As soon as a district has crossed an alert or epidemic threshold, alert
all the health facilities in the area;
• Investigate and verify the extent of any outbreaks that have been
identified;
• Ensure 10 CSF samples are collected at the start of the epidemic in
order to determine the Nm sero-group responsible and the type of
vaccine required;
• Send CSF samples received from H/Cs to reference lab. for analysis
at least twice a week ;
• Monitor the disease activity for the duration of the epidemic season.
16. Pillar 1: surveillance- During epidemic
• In the health centres:
• compile and submit reports on the
number of cases and deaths on a daily
basis;
• Continue to collect CSF samples on a
regular basis throughout the epidemic in
order to detect any change in sero-group;
• Package and forward CSF samples to a
reference laboratory, conditioning samples in
triple packaging for travel
17. Pillar 2- treatment and care- pre epidemic
REMEMBER!
• Meningitis is a life-threatening emergency – NEVER delay adequate
treatment.
• If laboratory results are available, treat according to microbiological
results.
• At the district level:
• Plan and implement training courses for health-workers on epidemic
treatment protocols;
• Print and distribute national treatment protocols to all health
centres;
• Calculate the amount of antibiotics and material that may be needed
during an epidemic, pre-position stocks in high-risk areas and
establish smooth lines for distribution throughout the district.
18. Pillar 2- treatment and care – during epidemic
During an epidemic
• Instruct all health centres to switch to the
epidemic Rx protocol-
– single dose chloramphenicol/ ceftriaxone
• Launch a public info campaign- inform
communities of availability of free Rx in Govt H/cs
• Monitor supplies of antibiotics and restock H/cs
when stock decrease.
19. Treatment protocols during meningitis epidemics in Africa - without
laboratory confirmation
REMEMBER!
• Never give chloramphenicol to:
• pregnant or breastfeeding women
• infants less than two months old
In children aged 0–23 months
• Ceftriaxone 100 mg/kg/day once a day 7 days
• (< 2 months) and 5 days (2−23 months)
• Transfer if no improvement within 48 hours or coma or
convulsion
• Adapt treatment according to patient’s age and most likely
causative pathogen.
• If no improvement after 48 hours, refer.
20. Treatment protocols during meningitis epidemics in Africa -
without laboratory confirmation
In children over 2 years and adults
• N. meningitidis should be considered the most
likely pathogen – presumptive treatment is
justified.
• Ceftriaxone-
single dose as presumptive treatment- IM route .
Dose =100mg/kg; 2nd dose if no improvement after
24 hrs.
If no improvement after 48 hrs, Rx for 5 dys or
refer
21. Treatment protocols during meningitis epidemics in Africa -
without laboratory confirmation
• OR Oily chloramphenicol
single dose as presumptive Rx
IM route
Dose = 100mg/kg (max 3g)
2nd dose if no improvement after 24 hrs
22. Pillar 2- treatment and care- pre epidemic
In the health centres:
• Following lumbar puncture, treat every new
patient who is suspected of having meningitis
with antibiotics as soon as possible;
• Ensure any child < 2 yrs or any patient with
severe symptoms is admitted to H/C for Rx
and adjust the Rx as necessary;
• Record details of all patients in the registry.
23. Pillar 3: Vaccination
• To limit the magnitude of the epidemic, WHO
recommends large-scale vaccination of pop. Groups
at risk, with the appropriate vaccine (AC or ACW)
• Vaccination should target Meningococcal sero-
group identified being responsible for the outbreak
• Such VC require extensive coordination involving
procurement, distribution and logistics, public
information and post-vaccination follow-up.
24. Pillar 3: Vaccination- epid threshold crossed
• If ET exceeded in a district, Nm sero-group identified, essential that a
VC is conducted in both the district affected and any adjacent district
reached the alert threshold.
• A micro-plan and budget for each area targeted for mass
vaccination must be prepared.
• Sufficient amounts of vaccines be requested from the national
stocks, or from the International Coordinating Group (ICG) on
Meningitis Vaccine Provision which manages the international
emergency stockpile.
25. Pillar 3: vaccination
• A public information campaign must be launched to inform
all the communities in the target areas of the coming
campaign.
• A cold chain to distribute the vaccines to the target areas
must be established/strengthen.
• Preparations must be made to manage the waste from the
campaigns.
• A system for monitoring adverse events following
vaccination will be needed.
• 1. The ICG is composed of representatives from WHO, UNICEF, Médecins sans
Frontières (MSF) and the International Federation of the Red Cross and Red
Crescent Societies (IFRC).
26. Pillar 3-Vaccine considerations
There are two types of Meningococcal vaccines available:
• Polysaccharide vaccines in various combinations against A, C,
W135 and Y.
– A and C vaccines developed over 30 years ago.
– In reactive vaccination: Bivalent vaccine against A and C,
Trivalent against A, C and W 135, Tetravalent vaccine
against A, C, Y and W 135.
• Conjugate vaccines against C and A, C, W135 and Y. Unlike
polysaccharide vaccines, conjugate vaccines affect bacterial
carriage, and thus transmission. They can create herd
immunity. They are new but very costly
27. Pillar 3- Preparing a vaccination micro plan
• To access International coordination group (ICG)
vaccine stockpile the following are required:
• Provide evidence of a meningococcal disease
outbreak.
• Provide laboratory confirmation of the Nm sero-
group responsible.
• Develop and provide plan(s) of action for the
vaccination campaign(s).
• Provide proof of necessary storage and
transportation resources to ensure the safe and
effective delivery and maintenance of the vaccines to
the area affected.
28. Pillar 3- Preparing a vaccination micro plan
• A micro-plan must be prepared for every district targeted for a vaccination campaign.
• Responsibility of the district health authorities to complete, submit the plan to secure the
necessary vaccines.
• The micro-plan should include:
• Names of sub-districts targeted for vaccination;
• Total population currently present in the target areas;
• Population targeted for vaccination;
• Type and quantity of vaccine needed;
• Quantity of additional supplies needed – AD syringes, safety boxes, dilution syringes, cotton
wool, gloves;
• Number of teams conducting the campaign (each team requires vaccinators, recorders,
crowd controllers and a supervisor);
• Number of supervisors – at team, district, provincial and central levels;
• Mechanism for training the vaccination teams;
• Logistic needs – cold chain equipment, vehicles;
• Mechanism for managing waste resulting from the campaign;
• Plans for vaccination campaign coverage surveys.
29. Pillar 3: vaccination budget
The budget should include:
• Allowances for members of the vaccination
team;
• Social mobilization costs (including allowances
for staff);
• Costs of logistic equipment;
• Costs of waste management.
30. Post-epidemic follow up
• A meningitis epidemic is declared to be over - attack rate
descends below the alert threshold over 2 consecutive weeks.
Once that point has been reached, a number of follow-up
activities are needed:
• Continue weekly reporting of both cases and laboratory
results to monitor decreasing trends;
• Gather remaining stocks of antibiotics or reposition for use in
treatment for other conditions;
• Return any remaining stocks of vaccines to district stockpiles;
• Dispose of all waste following vaccination campaigns;
• Conduct a vaccination coverage survey;
• Revert to the national endemic treatment protocol;
• Evaluate the outbreak response and compile a report on the
outbreak and feedback to stakeholders .
31. Monitoring and Supervision
• District level
– Health staff are trained on how to perform lumber
puncture
– Update staff on case management, thresholds, reporting
• Regional level
– Surveillance staff to visit affected districts monthly
– Emergency committees to be reactivated
– Regular weekly meetings advised
• National surveillance unit
– Monitor if any district has reached alert thresholds
– Check with lab after every 5 days
– Availability of TI bottles
– RRT to be designated
32. Monitoring and Supervision
• National Reference laboratory
– Ensure timely sending of results to the districts
– Regular feedback on specimen transportation and
handling
– Ensure that transportation of specimen to WHO
collaborating centres complies with the required
international standards
• National Technical coordination group
– Monitor the epidemic through weekly meetings
implementation of enhanced surveillance of Meningitis
– Ensure coordination of inputs from other partners.
– Regular updates and end of epidemic report
• WHO, collaborating centres and other partners
– DPC on behalf of WR to coordinate the activities
– Sub-regional level, WHO, Partners will provide technical
support
33. Performance indicators of SOPs
• Reporting: Percent of districts which have reported
weekly NM cases and deaths on time (80%)
• Field investigation: % of alert and epidemic districts
that have sent at least 10 TI bottles to NTLab (80%)
• Lab investigation: % of alert and epidemic districts
that have confirmed sero group from at least 10 TI
bottles (80%)
34. Performance indicators of SOPs
• Feed back-Lab: Percent of alert and epidemic
districts that received results from the lab within10
days of sending TI bottles.
• Specimen handling and lab investigation: % of
culture negative samples Per week (<10%)
• Specimen handling and lab investigation: % of
contaminated samples per week (< 20%)
• Reporting to AFRO?: % of countries reporting weekly
(80%)
• Reporting/Feedback: % of weekly bulletins to
countries, WHO/AFRO/HQ and partners (80 % within
two weeks)
35. References
Managing meningitis epidemics in Africa
A quick reference guide for health authorities
and health-care workers.
November 2010
World Health Organization
