Meningitis vaccination in Uganda. Photo © Vanessa Vick

Doctors Without Borders/Médecins Sans Frontières (MSF) has completed a mass meningitis-vaccination campaign in two districts of the West Nile region of Uganda, supervising the vaccination of 291,000 people and assisting with the vaccination of 333,000 more. Epidemiological data suggest that the nine-week-old outbreak is now waning with the number of new meningitis cases declining substantially.

Since the first cases of meningococcal meningitis serotype A were confirmed in Arua and Koboko Districts in the northwest of Uganda in early January, MSF worked closely with the Ugandan Ministry of Health (MoH) and the World Health Organization (WHO) to reduce mortality, minimize the spread of the epidemic, and strengthen the epidemiological-surveillance system.

"Early intervention and rapid response is critical in order to stop the spread of this deadly, but preventable, disease," said Dr. Marie-Helene Soulier, MSF medical coordinator for the vaccination campaign. Persons aged 2-30 (70 percent of the overall population) were targeted for vaccination after data generated at the beginning of the outbreak confirmed that they were the most susceptible to contracting the disease.

Between February 2 and February 22, an MSF emergency team, consisting of more than 75 staff members, supervised the vaccination of a total of 291,000 people in Arua and Koboko districts. MSF also assisted the MoH in the vaccination of an additional 333,000 people by supplying vaccines and medical materials as well as by supporting the "cold-chain" system that is needed to maintain the vaccines within a constant temperature range in order to preserve their efficacy. A total of 624,000 people were vaccinated at 70 sites in Arua and Koboko districts over a period of 3 weeks. The MoH is carrying out vaccinations in other West Nile Districts, including Adjumani, Moyo, and Yumbe.

Children wait in line for meningitis vaccination in Uganda. Photo © Vanessa Vick

"According to MSF protocol, we used teams of one vaccinator and two preparers (people who fill the syringes and keep them cold)," explained Jane Lynch, MSF logistical coordinator. "One vaccinator can vaccinate 1,500 people per day. With two teams per site, and with four at some, you can vaccinate up to 6,000 people in one site per day."

Meningitis outbreaks have also been recorded throughout the region with cases in the Democratic Republic of Congo and southern Sudan MSF has already vaccinated 110,000 people in eastern DRC and 60,000 in southern Sudan and continues to monitor the situation in these countries. Epidemics of bacterial meningitis typically occur in sub-Saharan Africa in an area known as the "meningitis belt" that spans the African continent from Ethiopia to Senegal.

Treating the Sick

In an effort to assist Ugandan health authorities care for people who contracted meningitis, three MSF physicians supported the treatment of patients in 29 regional health centers and hospitals in Arua, Koboko, and Yumbe districts. Since the beginning of the outbreak in early January, a total of 2,802 people have been admitted to health structures for treatment, with 74 people succumbing to the disease so far, resulting in a relatively low case fatality ratio (CFR) of 2.5 percent.

"Our case management strategy has on the whole been very successful," said Molly Sweeney, supervisor of MSF's meningitis-treatment teams. "Local health workers have worked hard with MSF to intervene early enough in the epidemic, saving many lives."

Treatment of meningitis consists of a single dose injection of oily chloramphenicol, an antibiotic. In most cases a single dose leads to full recovery, but a second is sometimes required. For children aged two months to one year and for pregnant and lactating women, treatment consists of one injection daily of ceftriaxone over five days. MSF supplied more than 8,000 doses of oily chloramphenicol and 2,500 doses of ceftriaxone to the health structures where its teams were supporting the treatment of meningitis cases. Throughout the outbreak, MSF continued to monitor the strain of the bacteria by routinely performing lumber punctures on affected patients and sending the cerebro-spinal fluids to reference laboratories for testing.

Maintaining the "cold chain"

Freezers used to maintain the cold chain for vaccines in Arua, Uganda. Photo © Vanessa Vick

Mass vaccinations campaigns require sizeable logistical capacity. In order to preserve the efficacy of the meningitis vaccine, doses must be kept between 2 and 8 degrees Celsius from production until injection at the vaccination site. MSF set up a "cold-chain" system in cooperation with the MoH, with a base in Arua town, which was equipped with 14 freezers and fridges producing almost 450 kg of ice every day. Roughly half of the 4,500 icepacks were dispatched daily to the vaccination sites in 30 large cold boxes. The boxes, designed to maintain the temperature for three days, function as a decentralized supply cold chain base for each vaccination site. Smaller vaccine carriers are the final link between the decentralized base and the vaccination site. Each can carry up to 300 doses of vaccine and require 4 ice packs.