MANAGING MENINGITIS EPIDEMICS IN AFRICAMANAGING MENINGITIS EPIDEMICS IN AFRICA EHA Team
Outline1. 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• 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
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- 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 550Number 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
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 & CFRAttack rate Case fatality Ratio (CFR)Number of cases Number of deathsdivided by divided bytotal district population number of cases in the sameX 100 000 period X 100
Determining alert and epidemic thresholds Population < 30,000 Population > 30,000Alert 2 cases in one week OR AR = 5 cases/100 000threshold Greater number of cases than the population /week same period in non-epidemic yearsEpidemic 5 cases in one week OR AR = 15/100 000threshold 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 % oralert threshold crossed early in season.
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.
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 epidemicREMEMBER!• 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 epidemicDuring 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 confirmationREMEMBER!• Never give chloramphenicol to:• pregnant or breastfeeding women• infants less than two months oldIn 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 confirmationIn 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 Rx IM route Dose = 100mg/kg (max 3g) 2nd dose if no improvement after 24 hrs
Pillar 2- treatment and care- pre epidemicIn 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)
ReferencesManaging meningitis epidemics in AfricaA quick reference guide for health authorities and health-care workers.November 2010World Health Organization