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MSF Responds to Outbreaks across Africa's "Meningitis Belt"
April 5, 2007
Doctors Without Borders/Médecins Sans Frontières (MSF) has been quick to respond to meningitis epidemics in several countries in Africa's "meningitis belt." In the four countries–Burkina Faso, Sudan, Uganda and the Democratic Republic of the Congo (DRC)–where the epidemic threshold has been reached MSF's first response was to evaluate the outbreak, identify the strain of meningitis, and treat people infected with the disease. Now in the second stage of treatment and prevention, MSF has also been carrying out mass-vaccination campaigns to prevent the spread of this highly contagious disease.
The outbreak was first recorded in late 2006. Since then 27,650 cases and 1,840 deaths have been reported in the four countries worst affected.
In the last few weeks, teams in Uganda and DRC have successfully assisted in the vaccination of more than 700,000 people and case numbers appear to be dropping. In Burkina Faso, MSF vaccinated 475,000 people in the capital Ouagadougou and plans to vaccinate an additional 500,000 in rural areas of the country. In southern Sudan nearly 491,000 people have been vaccinated by MSF and an additional 290,000 will be vaccinated in the coming weeks. Teams in other countries where outbreaks are feared are on the alert.
Meningitis outbreaks are so common in sub-Saharan Africa that an area stretching from Senegal in the west to Ethiopia in the east is known as the "meningitis belt." After several years of low incidence in the belt, the 2006 epidemic season saw a marked rise in meningitis outbreaks across the region and the WHO considers it highly likely that a new epidemic wave will emerge in the coming years.
Vaccine supply a concern
Between 1995 and 1997 Africa experienced the largest recorded outbreak of epidemic meningitis in history, with over 250,000 cases and 25,000 deaths. Although the current outbreak has not approached these levels, MSF is concerned that the effective management of outbreaks is hampered by problems with the production of vaccines that leads to a limited availability of both meningococcal vaccine and referent treatment. MSF is participating in the research of alternatives in order maintain its ability to respond quickly to outbreaks of meningitis.
MSF is also concerned that in countries such as Burkina Faso, the vaccines needed to control the epidemic are not getting through because no international donors are prepared to fund them. On March 26, MSF called on donors to commit a further 1 million euros to the fight against meningitis. So far the response has been disappointing. Only one donor has agreed to fund more vaccines and MSF is worried that the delays in getting the vaccine to Burkina Faso will cost lives.
With around 15,500 suspected cases and 1,100 deaths recorded since the beginning of February, Burkina Faso has been hardest hit by the current meningitis epidemic.
MSF's response initially focused on the capital, Ouagadougou, where an estimated 1.5 million people were at risk. Working with the Ministry of Health, MSF has treated 1,400 people infected with the disease. In addition a mass vaccination campaign was launched. Over the course of three days, MSF teams vaccinated some 475,000 people in Ouagadougou's Pissy district. The vaccination campaign covered 98% of the target population aged 2-30 years old. In the coming weeks MSF plans to expands its medical activities into rural areas and vaccinate another 500,000 people.
Yet efforts at containing the outbreak in Burkina Faso have been hampered by a lack of funding for the vaccines needed. Although the International Coordinating Group (ICG) on Vaccine Provision for Epidemic Meningitis Control (an organization for the response to epidemics, of which MSF is a member) has approved the release of 3.3 million doses for use by the health authorities in Burkina Faso, so far only 1.6 million have reached the country. Around 1.7 million vaccines have been blocked due to a lack of funding.
On March 26, MSF issued an urgent call to donors to release the funds necessary to get these vaccines to the health authorities of Burkina Faso. A few days ago the African Development Bank announced that it would pay for an additional 600,000 vaccines. But MSF is worried that the delays will cost lives.
"A vaccination campaign has to start very early in the epidemic cycle to be effective," says Francois Giddey, MSF's Head of mission in Burkina Faso, "The delay in getting this vaccine means it's too late for the health authorities to vaccinate some of the rural districts. In the next few weeks, MSF will have to vaccinate areas where the epidemic threshold has only recently been reached and make sure that we have the capacity to treat as many people as possible in the districts that aren't vaccinated."
In addition to the vaccinations, MSF is also registering new cases; training staff to identify and treat meningitis; providing necessary materials; and managing the most severe cases. In Bahr el Ghazal, 255 patients with severe meningitis have been hospitalized in two structures opened by MSF's emergency team. In the areas where MSF has set up epidemiological surveillance, 3,734 cases have been registered so far and there have been 235 deaths. In Juglai, in the Bor area, 278 cases and 21 deaths have been reported.
To make matters worse an outbreak of cholera has also hit some parts of southern Sudan. As of March 25, the World Health Organization (WHO) reported 3,896 cases of cholera and 110 deaths in 6 states. In Juba, the regional capital of southern Sudan, an MSF cholera treatment center that opened at the beginning of March has already admitted more than 1,000 people. In Jonglei state, the MSF treatment unit set up in Pibor has treated 79 patients.
A meningitis epidemic was confirmed in Adi health zone, in the eastern Democratic Republic of Congo (DRC), on January 24 and medical staff immediately started work identifying and treating patients, strengthening epidemiological monitoring and preparing a vaccination campaign. In mid February, a 52-person team started to vaccinate everyone from 2 to 30 years of age. In seven days, they covered 18 health areas and vaccinated 140,000 residents.
What is Meningitis?
Meningococcal meningitis is an infection of the meninges, the membrane that surrounds the brain and spinal cord. It is caused by the bacterium neisseria meningitidis and four strains (A, B, C and W135) cause epidemics. The current epidemic is caused by strain A.
How do you get it?
The bacteria neisseria meningitidis is carried in the nasal passages. Not all persons carrying the bacteria become sick–there are many carriers who are completely well. A patient becomes sick when the bacteria crosses the mucosal barrier and enters the bloodstream.
Meningococcal meningitis is highly contagious and is transmitted through the air on drops of saliva by sneezing or coughing. Living in cramped conditions and sharing eating and drinking utensils can also facilitate the spread of the disease. The incubation period is usually 4 days, but can range from 2 to 10 days.
What are the Symptoms?
The most common symptoms are headaches, vomiting, high fever, a stiff neck and sensitivity to light.
How is it treated?
An epidemic is declared when 15 cases per 100,000 people per week have been detected (10 cases per 100,000 people in special circumstances). During an epidemic doctors rely on clinical diagnosis and treatment consists of a single dose injection of the antibiotic oily chloramphenicol. 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.
Without treatment, 50 to 80 percent of those who develop active meningitis will die. Even with early diagnosis and treatment 5 to 10 percent of patients can die, typically within 24 to 48 hours of the onset of symptoms. As many as one-in-five survivors will suffer from neurological after effects such as brain damage, hearing loss or learning disability.
Is vaccination effective?
As meningitis is highly contagious mass vaccination remains the most effective means of limiting the spread of the disease, but it must be accompanied by enhanced epidemiological surveillance and prompt case management. If the vaccine is to be effective it must be kept at a temperature between two and eight degrees Celsius from production until injection at the vaccination site. A good logistical support system is essential for any vaccination campaign to be successful.
What is the Meningitis Belt?
The meningitis belt is made up of a number of countries stretching from Senegal in west Africa to Ethiopia in the east. In these countries meningitis epidemics occur in the dry season (December to June) roughly every 8-14 years. It is thought that susceptibility to disease increases during the dry season because of dust winds and a higher number of respiratory tract infections due to the cold nights. When the throat's mucous membranes are more irritated, it is easier for the meningococcus to penetrate the body. Roughly 300 million people are at risk in the meningitis belt.