Increase Vaccination against Meningococcal Meningitis to areas Outside the Meningitis Belt: Lessons From A Cluster Of Meningitis In Bunyangabu–A Policy Brief

Summary

Meningococcal meningitis occurs globally but the highest burden is in the Meningitis belt of Sub-Saharan Africa. Some parts of Northern and Western Uganda are found in the meningitis belt. The disease is transmitted from person to person through infected air droplets. Infants and young children are particularly at risk, especially in crowded areas. The disease is preventable through vaccination. In Uganda, there was mass vaccination of children and young adults in the regions covered by the meningitis belt in January 2017. However, in November 2017, there were 2 clusters of meningitis in Bunyangabu district, with 3 deaths of children. In one case-patient, meningococcal meningitis was confirmed. Bunyangabu district does not lie in the meningitis belt. This means that meningococcal meningitis can spread and cause morbidity and mortality in areas that lie outside the meningitis belt. Therefore vaccination of all children in Uganda against meningococcal meningitis would go a long way in averting illness and deaths

Introduction

Meningococcal meningitis occurs worldwide but the highest burden of the disease is in the meningitis belt of sub-Saharan Africa, stretching from Senegal to Ethiopia. The meningitis belt refers to those regions in Sub Saharan Africa that are susceptible to outbreaks of meningococcal meningitis partly because of the physical environment that is conducive for the proliferation of the bacteria. Some parts of Uganda are found in this belt; that is the Northern and a small portion of the Western parts. Meningococcal meningitis can occur as sporadic cases, small clusters as well as enormous epidemics. Overcrowding is a particular risk factor for this infection. It mainly affects infants, preschoolers and the young adults. Meningococcal meningitis is caused by bacteria, Neisseria meningitides. Transmission is from person to person through infect- ed air droplets, saliva or respiratory secretions. The bacteria attack the meninges – the thin lining surrounding the brain and spinal cord. The symptoms typically consist of: sudden onset of headache, fever, stiff neck, convulsions, sensitivity to light and vomiting.

More than 10% of the affected persons develop severe complications such as brain damage, blindness and hearing impairment even when treated. Failure to get treatment results into deaths of up to 50% of those that develop symptoms. Diagnosis of meningococcal meningitis is made on clinical and laboratory examination. Cerebrospinal fluid (CSF) got from a lumbar puncture of a patient with meningococcal meningitis is examined for evidence of meningococcal bacteria. (1). The disease is preventable through vaccination and therefore maintaining high vaccination coverage can go a long way towards elimination of meningococcal epidemics in Africa.

Uganda has a comprehensive immunization program that has achieved reasonable routine immunization coverage of infants. According to the 2016 Uganda Health Demographic Survey (2), 55% of children aged 12-23 months received all basic vaccinations. However, the meningococcal vaccine is not among the vaccines offered in the routine immunization and so is not accounted for in these statistics. In the past, because Northern Uganda and a few parts of Western Uganda lie in the meningitis belt, there was a preventive immunization campaign focusing on the greater Northern Uganda and parts of western Uganda between 19 and 24 January 2017. While this is applaudable, environmental changes such as longer dry seasons, low humidity and dusty conditions may allow for the meningitis belt to extend to areas where it previously did not exist.

On 13^th November 2017, the Uganda Ministry of Health through the Public Health Emergency Operations Centre was notified of an unknown illness with two sudden deaths in Bunyangabu District. The case-patients presented with fever, convulsions, loss of consciousness, neck stiffness and headache which were consistent with meningitis.

Approaches and Results

We defined a suspected case as onset of fever and neck stiffness and any of the following: convulsions, loss of consciousness, headache, vomiting, and nausea in a resident of Kabonero or Kateebwa sub-counties, Bunyangabu District from 1-30 September, 2017. A confirmed case was a suspected case with laboratory confirmation of meningitis. We conducted active community case finding in affected sub-counties & reviewed medical records at drug shops and clinics where case-patients had been admit- ted during our data collection. We also conducted an environmental assessment in the communities where the case-patients dwelt and schools & churches that the case-patients attended.

We identified a total of 5 case-patients with a mean age of 4 years. The first case-patient was on 30^th September 2017 and the other on 18^th Oct0ber 2017. Case-patients peaked on 28^th October 2017 and declined to 0 thereafter. Three of the 5 case-patients died, giving a case fatality rate of 60%. The average time from development of symptoms to death was 2 days. There were two clusters of cases in two sub-counties. One cluster in Kabonero sub-county had 3 cases from and the other in Kateebwa sub- county had 2 cases. All case-patients that died originated from Kabonero sub-county and all were closely related. The two from Kateebwa sub- county that survived were siblings.

There was no established epidemiological link between the two clusters because the children from the respective clusters had not attended the same school, health facility, or social gathering. The parents to these children had not similarly interacted. All case-patients presented with neck stiffness and fever while 80% presented with vomiting and 60% had convulsions and loss of consciousness. Only one case patient had a lumbar puncture and CSF analysis done. Neisseria meningitidis was isolated. However, the strain causing the out-break was not identified and the samples had been destroyed at the time of the outbreak investigation. All the patients were treated from the neighboring Kabarole District. There was sensitization of health workers in the affected and surrounding districts on the possible outbreak of meningitis and the need to have enhanced surveillance so as to identify more cases. Immediate family members of the cases were offered a dose of intravenous ceftriaxone as chemical prophylaxis.

Context And Importance Of The Problem

Although Bunyangabu District does not lie in the meningitis belt, we found a confirmed case of meningococcal meningitis. There was minimal district preparedness in handling these clusters of infections and this catastrophe can occur in any other district of Uganda that is not in the meningitis belt. This experience shows that the other districts may similarly be inadequately prepared to handle meningococcal meningitis clusters or outbreaks.

Critique Of Policy Options

Currently, the Uganda National Expanded Program on Immunization (UNEPI) has no policy on meningococcal meningitis immunization. However, according to PATH, an international organization that generates data for introduction of new vaccines, the MenAfriVac® vaccine is expected to have been given to all the eligible population in the meningitis belt and therefore protect almost the entire population of the belt (3). If this is done, it will be a step in the right direction inaverting deaths and disability due to meningococcal meningitis. However, it is important to know that a cluster of cases has been found outside the belt. This implies that there is another population at risk that should be considered when during vaccination drives.

Policy Alternatives

The alternative is to introduce vaccination against Neisseria meningitidis in the routine vaccination of infants. In the investigation we carried out in Bunyangabu District, all the affected were children and it is envisaged that had these been vaccinated, the deaths and morbidity would have been averted. In addition, other districts that do not lie in the meningitis belt should be supported so that there is timely identification of case-patients and hence mitigation of outbreak spread.

Policy Recommendations

It is recommended that the vaccination of the children against meningococcal meningitis is carried out in a phased manner in Uganda. Initially, in the regions within the meningitis belt, and then in the districts surrounding the regions that are in the meningitis belt since there is a risk of spread by travel and congregation of people from the belt to neighbouring districts for trade and cultural ceremonies. The vaccination there after can be spread to cover the entire country. However, all districts’ surveillance systems should be supported so that outbreaks are recognized early and averted.

Implications And Recommendations

There is evidence that Uganda’s immunization program has achieved tremendous success in reducing morbidity and mortality due to immunizable diseases. For example, since introduction of Hib vaccine in 2002, the number of meningitis cases due to Haemophilus Influenza type b (Hib) declined by 95% at sentinel sites for Hib surveillance (4). This underscores the impact vaccination would have on averting morbidity and mortality due to meningococcal meningitis.

References

1.WHO – Meningococcal meningitis Fact sheet Accessed at http:// www.who.int/mediacentre/factsheets/fs141/en/ on 4^th January 2018

2.Uganda Health Demographic Survey, accessed at https://

dhsprogram.com/pubs/pdf/PR80/PR80.pdf

on 4^th January 2018

3.PATH: Map of Africa’s meningitis belt, Accessed at https://www.path.org/menafrivac/meningitis-belt.php on 5th Jan 2018

4.UNEPI Multi Year Plan 2012-2016 . Accessed at http://www.nationalplanningcycles.org/sites/default/files/country_docs/ Uganda/uganda_epi_cmyp_2012-2016_update_2013.pdf