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Published Date: 2010-02-25 16:00:03
Subject: PRO/EDR> Meningitis, meningococcal - Africa: WHO meningitis region
Archive Number: 20100225.0627

MENINGITIS, MENINGOCOCCAL - AFRICA: WHO MENINGITIS REGION
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A ProMED-mail post
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ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

[1] Meningitis belt
[2] Ghana (Upper West)
[3] Burkina Faso

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[1] Meningitis belt
Date: Tue 22 Feb 2010
Source: Thomson Reuters Foundation AlertNet, UN-OCHA IRIN (Integrated
Regional Information Networks) [edited]
<http://www.alertnet.org/thenews/newsdesk/IRIN/c712b3308558e42473603e4bf274f193.htm>

A meningitis epidemic has struck earlier than usual and is spreading across
sub-Saharan Africa's "meningitis belt" from Senegal to Ethiopia, according
to health ministries in the region. The disease occurs during the dry
season, with most cases reported in mid-April.

As of 7 Feb [2010], health ministries in high-risk countries reported 2298
cases, with a 13 per cent fatality rate. Burkina Faso has reported the
highest number of cases, but Togo has experienced the highest fatality
rate, where 25 of 108 infected people died [23 percent fatality rate]. The
World Health Organization (WHO) described the situation as "alarming."

Mamoudou Harouna Djingarey, a WHO epidemiologist and meningitis expert,
told IRIN it was still not clear why infections were spreading earlier than
expected. "This [timing] is a sign of a major epidemic risk if no action is
taken," he warned. Extensive meningitis outbreaks tended to occur every 8
to 10 years, he said, but were now occurring about every 4 years. In the
2009 meningitis season, 14 African countries reported a total of 78 416
suspected cases, including 4053 deaths, the largest number of infections
since the 1996 epidemic.

Studies are being carried out to determine whether climatic and
environmental factors might be influencing the extent of the current
epidemic. Djingarey told IRIN that infections had also been reported
further south than usual, including in Uganda, Kenya, and Democratic
Republic of Congo.

Burkina Faso: on 17 Feb 2010 the Health Ministry in Burkina Faso reported
1251 meningitis cases, with a 15.4 per cent fatality rate. This time last
year [2009] there were 25 per cent less infections, but a similar
percentage of deaths. The disease has reached epidemic proportions in Pama
in the east, Titao in the north, Sapouy in the centre west, and Batie in
the south east, defined by WHO as areas where at least 10 out of 100 000
people are infected. 3 other districts with half as many reported
infections are on alert, according to Burkina Faso's Ministry of Health.

Vaccinations have been carried out in Pama and Titao, and more are
scheduled to take place in the centre west on 20 Feb 2010. "If we can react
quickly the numbers will drop," Health Ministry epidemiologist Jean Ludovic
Kambou told IRIN.

WHO recommends vaccinating everyone aged from 2 to 29 years and living in
an epidemic zone, as well as people in neighbouring areas that are on
"alert". If the country does not have enough vaccine, it can request
no-cost or minimal-cost vaccines from a meningitis vaccine stock managed by
WHO. Alejandro Costa, a WHO vaccine scientist, told IRIN no countries have
requested vaccines as of 19 Feb 2010.

Costa told IRIN 100 000 doses of vaccine from the stockpile had been sent
to Chad, which did not have vaccines on hand but was facing an epidemic in
the southern regions of Mandoul and Logone Orientale [see ProMED-mail post
Meningitis - Chad: (LR,MA) RFI 20100223.0600]. Chad's Ministry of Health
said 42 000 people in the southern town of Doba needed vaccination.

On 19 Feb 2010 the government reported 507 meningitis infections that have
led to 56 deaths, an 11 per cent fatality rate.

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[ProMED-mail posted a report of an outbreak of meningitis in Chad last year
(2009) that involved _Neisseria meningitidis_ serogroups A and W135 (see
Meningitis, meningococcal - Chad (02) 20090424.1544); meningitis due to
these serogroups is potentially vaccine-preventable. In a recent
ProMED-mail post, the news release did not specify the microbial etiology
of the current meningitis outbreak in Chad or the serogroup specificity of
the meningococcal vaccine that is being used (see Meningitis - Chad:
(LR,MA) RFI 20100223.0600). The news release above also fails to identify
which serogroups are involved in the current outbreaks in Burkina Faso or
Chad or the serogroup specificities of the meningococcal vaccines that are
being used.

Maps of the African bacterial meningitis belt can be found at
<http://wwwnc.cdc.gov/travel/images/380.ashx> and
<http://upload.wikimedia.org/wikipedia/commons/9/96/Meningitis-Epedemics-World-Map.png>.
- Mod.ML]

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[2] Ghana (Upper West)
Date: Tue 23 Feb 2010
Source: Ghana News Agency (GNA) [edited]
<http://www.ghananewsagency.org/s_health/r_12822/>

Dr Alexis Nang-beifubah, regional director of health services, told GNA
[Ghana News Agency] on Tuesday [23 Feb 2010] that 17 people have died from
an outbreak of a new strain of cerebrospinal meningitis in the Upper West
Region since January 2010. He said 15 out of the 96 cases reported have
been confirmed to be [_Neisseria] meningitidis_ [serogroup] W135, which is
being seen for the 1st [time] in Ghana.

Jirapa District has recorded 53 cases of the disease with 8 deaths; Wa
Municipality, 17 cases with 5 deaths; Nadowli District 14 cases with 4
deaths while Lawra and Wa East Districts have registered 11 cases and a
case, respectively, with no deaths.

Dr Nang-beifubah, who updated the GNA on the disease situation in an
interview, said the W135 type is common in neighbouring Burkina Faso and
different from the _Neisseria [meningitidis]_ type, [serogroup] "A," which
is known in the Region. He said the health directorate had no vaccines for
the W135 type [?] A, which was emerging in the area for the first time. Dr
Nang-beifubah said 8 cases were initially reported in Jirapa but the number
rose to 13 the following week.

The Health Directorate has mobilized personnel, vaccines and other
logistics to the Districts to vaccinate the people against type A, while
monitoring the trend in all the 9 districts of the Region. Dr Nang-beifubah
said the situation was under control as all Epidemic Management Committees
in the Districts had been reactivated to help to strengthen local
surveillance on the disease. He said Sissala West; Sissala East; Wa West
and Lambussie/Karni Districts have not yet recorded cases of the disease.
He advised people in the Region to avoid overcrowding and to sleep in
ventilated rooms, as well as drink sufficient water and fluids.

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[Although the news release above says that the meningococcal serogroup
involved in the Ghana meningitis outbreak is W135, for which no specific
vaccine is currently available in Ghana, they are, nevertheless,
vaccinating the population at risk with meningococcal serogroup A vaccine,
which, of course, will be ineffective for preventing infection due to
serogroup W135. - Mod.ML

Maps showing the regions and districts of Ghana can be seen at
<http://en.wikipedia.org/wiki/Ghana#Regions_and_districts>. The
HealthMap/ProMED-mail interactive map of the country is available at
<http://healthmap.org/r/0182>. - Sr.Tech.Ed.MJ]

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[3] Burkina Faso
Date: Fri 19 Feb 2010
Source: AllAfrica, Sidwaya Quotidien report [in French, trans.
Sr.Tech.Ed.MJ, edited]
<http://fr.allafrica.com/stories/201002190145.html>

Since the beginning of the year [2010], meningitis has already killed over
100 people. The Ministry of Health provided an update and announced new
measures.

Meningitis is still present, with its grisly statistics: 4 health districts
are experiencing an epidemic and 193 people of the 1252 suspected cases
reported from 1 Jan to 14 Feb 2010 have died, according to data from the
National Committee on the Management of Epidemics, which met Wednesday [17
Feb 2010] evening with minister Seydou Bouda. The victims include people
who have been vaccinated. 7 health districts have reached the alert
threshold for meningitis. Among them 4 are facing an epidemic situation.

Of note are the health districts of Titao with an attack rate of 20.2 per
1000 inhabitants, Pama (13.3 per 1000), Batie (11.5 per 1000), and Sapouy
(11 per 1000). The health districts of Kongoussi, Nanoro, and Leo have
crossed the alert threshold. The causative agent of this epidemic is
meningococcus serogroup A.

The Ministry of Health claims to have already taken action to contain the
epidemic. Vaccination campaigns have been effective in some localities. "We
have already begun reactive vaccination campaigns in the health districts
of Pama and Titao," said the director of control of the disease, Sylvester
R Tiendrebeogo. [The Ministry] is also making available drugs and
consumables in the 13 health regions, university hospitals, and regional
hospitals, at no cost, as well as disseminating awareness messages in the
local languages.

In the presence of certain technical and financial partners, the minister
asked the regional directors of health and executives involved in the
management of epidemics to examine "what went wrong" in order to control
the disease in the future, especially since the situation has slightly
worsened this year [2010] as compared to the same period in 2009. For 948
deaths, the fatality rate of meningitis was 14.56 per cent from the 1st to
the 6th week [29 Dec 2009 - 11 Feb 2010] of 2009, against 15.43 per cent
this year [28 Dec 2009-14 Feb 2010]. Minister Seydou Bouda considers these
numbers "still too high" for the expectations and everyone should share
responsibility and include in their plans the epidemics and in particular
meningitis epidemics. Technicians should seek to reduce as much as possible
the processing of samples and to remove all obstacles to the prompt access
to vaccines in areas of need as well as review the chain of coordination of
reactive control.

The current system is such that persons in a district facing an epidemic
must travel to Ouagadougou to obtain the necessary vaccines. In addition
there are formalities that at certain levels must be fulfilled during a
working day, the vehicles are not necessarily available in the provinces,
and neither are the financial resources to pay the persons in charge of
vaccination. Some have proposed that the alert team at the central level
work day and night, transport the vaccines to epidemic areas, and at the
same time deal with the formalities.

The idea to place a sufficient amount of vaccine in the districts is not
currently feasible. The existing amount of vaccines will allow for a
"dusting" in small quantities and unable to cope with a large-scale
vaccination where necessary. In other words, it will be difficult to
collect these vaccines once they have been distributed across 63 districts,
if there is an emergency in a given region. Earlier this season, the
Ministry of Health had about 850 000 doses of vaccine in stock. To date,
"there is a stock of about 730 000 (728 370) doses," says Dr Tiendrebeogo.
A new order has been placed," he said.

The quality of the meningococcal vaccine is not in question at the moment.
The new concern for this "epidemic season" of meningitis is that people who
were vaccinated in 2009 still contracted the disease. This is the case in
Titao in the Nord Region. "People vaccinated in 2009 as well as those who
weren't have contracted the disease," says a report of the epidemiological
surveillance service. The report states that of 54 patients, more than half
(51.9 per cent) reported having been vaccinated.

For the director of disease control, it is possible that the bodies of
vaccinated people were debilitated by other reasons, which would prevent
the development of the necessary immunity to counteract the infection. He
added, "We are in a context where there is malnutrition, which might
explain why persons vaccinated do not develop satisfactory immunity.

He emphasized that the vaccine available against serogroup A meningococcus
has a success rate of 95 per cent. In his view, the effectiveness of the
vaccine "may arise" as a question of scientific rigor. But he wants the
Burkinabe to understand that people can miss a vaccination campaign given
the population movements, and that they may still contract the disease upon
returning to an already vaccinated area.

For her part, Professor Ramata Ouedraogo, microbiologist, said that the
current vaccine against meningococcus A does not protect from other types
of meningitis and pointed out that "people can acquire another type of
meningitis next year even when they say they have been vaccinated." Health
authorities have given priority to meningococcus A, which according to
experts is responsible for almost all outbreaks in the country.
Nonetheless, treatment for other types of meningitis is also available.
Thus, 20 000 doses of [ACW135Y vaccine against 4 strains of meningococcus]
are ready. For financial reasons, the government lacks sufficient doses of
vaccines against all strains of the bacterium.

The technicians commented on the case of Titao. Of a total of 62 reported
cases, 42 cases (68 per cent) were in people from villages neighboring
Mali, and others directly from Malian villages.

Minister Seydou Bouda issued an order for everyone to be vaccinated, no
matter how transient, or whether they come from neighboring Mali. "Anyone
who comes to you must be vaccinated in order to break the chain of the
epidemic," he said.

The Committee on the Management of Epidemics has recommended the
organization of a cross-border meeting with health authorities in Mali and
that samples of cerebrospinal fluid continue to be taken for monitoring the
bacteria.

WHO, in partnership with the European Union, is considering the possibility
of a vaccination campaign at a regional level (Economic Community Of West
African States - ECOWAS). "We are in the process of discussing the issue,"
says Henriette Nikiema, representing the EU on this occasion. UNICEF has
pledged some 63 million francs CFA [approx. USD 130 000] to facilitate the
acquisition of doses of vaccine, but also to strengthen the capacity of
laboratory technicians, the laboratory technical platform, and the
transport of samples.

Though not the most deadly, meningitis is the disease most feared by the
people of Burkina Faso, by the authorities, and even by the technical
partners. Despite monitoring and response systems repeatedly corrected, the
disease always manages to strike. The new announced conjugate vaccine
provides great hope.

[byline: Aime Mouor Kambire]

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[There are at least 13 serogroups of _Neisseria meningitidis_ based on the
antigenic specificity of their capsular polysaccharides; disease is most
commonly due to serogroups A, B, C, Y, and W135. All serogroup
polysaccharides but B are immunogenic in humans.

There are several different types of meningococcal vaccines that use
meningococcal polysaccharides as the immunogen: the vaccines may contain
one or more of the polysaccharide serogroups alone or conjugated to
protein. Meningococcal vaccines will only protect against meningitis due to
the meningococcal polysaccharide serogroups that the vaccine contains.
Polysaccharide vaccines, which have been available for more than 30 years,
exist for serogroups A, C, Y, and W-135 in various combinations (such as, a
bivalent AC, trivalent ACW-135, and a tetravalent ACYW-135 polysaccharide
vaccine). There is a monovalent protein conjugate vaccine against serogroup
C and a tetravalent against serogroups A, C, Y, and W-135.

Although children as young as 3 months of age may have an immunologic
response to the serogroup A antigen contained in the meningococcal
polysaccharide vaccines, response to the other serogroup antigens is poor
in children younger than 2 years of age. These vaccines also only provide
protection for up to 3 years. In contrast, the meningococcal conjugate
vaccines induce a T-cell-dependent response, resulting in an improved
immune response in infants, provide long-lasting immunity, and prevent
nasopharyngeal carriage of _N. meningitidis_, thus reducing transmission of
this microorganism person-to-person
(<http://www.nfid.org/pdf/publications/meningococcalepid.pdf>).

A preventive strategy based on conjugate vaccines could have a
significantly larger and more enduring impact on attempts to control the
yearly recurrences of this disease that causes considerable morbidity and
mortality, especially among children
(<http://www.jidc.org/index.php/journal/article/view/19745499/102>).

All these vaccines have been proven safe and effective with infrequent and
mild side effects. For both the meningococcal conjugate and the
polysaccharide vaccines, approximately 7-10 days are required following
vaccination for development of protective levels of anti-meningococcal
antibodies.

To control an outbreak, WHO recommends mass vaccination with the
appropriate vaccine, depending on availability, in every involved district
in an attempt to induce herd immunity (whereby transmission is blocked when
a critical percentage of the population have been vaccinated
(<http://www.who.int/mediacentre/factsheets/fs141/en/>).

The news release above says that health authorities believe that
meningococcus serogroup A, which has been responsible for almost all
outbreaks in the Burkina Faso, is also responsible for the current
outbreak, but that people who were vaccinated in 2009, presumably with
meningococcal serogroup A vaccine, still contracted the disease, presumably
due to serogroup A meningococci. They discount loss of vaccine potency.
However, both the polysaccharide and the conjugate vaccines require proper
refrigeration; improper storage or handling of vaccines may result in loss
of vaccine potency and reduced immune response in vaccinees. Also, they
will not prevent meningococcal infection caused by meningococcal serogroups
not represented in the vaccines and will not prevent meningitis caused by
other pathogens, such as _Streptococcus pneumoniae_, a pathogen also known
to cause outbreaks in the African "meningitis" region (see ProMED-mail post
Meningitis, pneumococcal - Africa: WHO meningitis region 20100213.0507). -
Mod.ML

The HealthMap/ProMED-mail interactive map of Burkina Faso is available at
<http://healthmap.org/r/0188>. The departments mentioned can be located via
the maps at <http://en.wikipedia.org/wiki/Communes_of_Burkina_Faso>. -
Sr.Tech.Ed.MJ]

See Also