MANAGING MENINGITIS EPIDEMICS IN AFRICA

MANAGING MENINGITIS EPIDEMICS IN AFRICAEHA Team

Outline 1. Objective2. The disease3. Transmission4. Disease burden5. Disease trend- Ethiopia6. Strategies for epidemic control7. Disease incidence8. Determining alert & epidemic threshold9. Pillars 1, 2,310. Post epidemic follow up11. M&E and performance indicators

Objectives

• GeneralTo 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

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.

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

Disease burden- EthiopiaNational Trend of Meningitis Cases and Deaths from 2000-2009: Ethiopia

7018

5037

2170

3165

701 1007 662 612 797

329250

179 187

28 47 11 18 270500

100015002000250030003500400045005000550060006500700075008000850090009500

10000

2000/2001 2001/2002 2002/2003 2003/2004 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009

Years

Numb

er of

Cas

es an

d De

aths

0501001502002503003504004505005506006507007508008509009501000

Cases Deaths

Analysis: WHO - Ethiopia Country Office DPC Cluster UnitData Source: FMOH - EthiopiaDate of Production: March, 2010

Cases= 1465. Deaths = 0. Affected Woredas= 60

Strategy for epidemic control-Africa Region

• Three- pillar strategy for epidemic meningitis control

• Pillar 1: Surveillance• Pillar 2: treatment and care• Pillar 3: vaccination.

Calculating disease incidence & CFR

Attack rate Case fatality Ratio (CFR)

Number of casesdivided by total district population X 100 000

Number of deaths divided by number of cases in the same period X 100

Determining alert and epidemic thresholdsPopulation < 30,000 Population > 30,000

Alert threshold

2 cases in one week OR Greater number of cases than the same period in non-epidemic years

AR = 5 cases/100 000 population /week

Epidemic threshold

5 cases in one week ORdoubling in number of cases over 3-week period. Special situations should be studied on a case-by-case basis (a)

AR = 15/100 000 population/week .In certain conditions indicating higher 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.

Pillar 1:SurveillanceScale up surveillance

• Scale up the disease surveillance system at an early stage before the epidemic to detect the first cases.

• Identify the pathogen as well as the sero-group of the meningococcus (Nm) responsible for the infection, to serve as a trigger to launch a rapid response operation.

• use standard case definitions to recognize early cases. Should be confirmed by laboratory tests.

• Standard reporting mechanisms in place to analyse data, determine the extent and evolution of an outbreak.

Case definitionSuspected case:

• Any person with sudden onset of fever (>38.5 °C rectal or 38.0 °C axillary) and one of the following signs – neck stiffness, flaccid neck, bulging fontanel, convulsion or other meningeal signs.

Probable case: • Any suspected case with macroscopic

aspect of its CSF turbid, lousy or purulent; or with microscopic test showing Gram negative diplococci, Gram positive diplococci, Gram positive bacilli; or with leukocytes count of more than 10 cells/mm3.

Confirmed case: • Isolation or identification of the causal

pathogen (Neisseria meningitidis) from the CSF of a suspected or probable case by culture, PCR or agglutination test.

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.

Pillar 1:surveillancePre-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.

Pillar 1: surveillance- During epidemicAt 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.

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

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.

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.

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.

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

Treatment protocols during meningitis epidemics in Africa - without laboratory confirmation

• OR Oily chloramphenicol single dose as presumptive RxIM routeDose = 100mg/kg (max 3g)2nd dose if no improvement after 24 hrs

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.

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.

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.

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).

Pillar 3-Vaccine considerationsThere 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

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.

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.

Pillar 3: vaccination budgetThe 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.

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.

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

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

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%)

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)

References

Managing meningitis epidemics in AfricaA quick reference guide for health authorities

and health-care workers.November 2010

World Health Organization

THANK YOU