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The Meningitis Vaccine Project Closure Conference Addis Ababa, Ethiopia: 22-25 February 2016 Meningitis surveillance in the African meningitis belt Dr André Bita, Clément Lingani, Olivier Ronveaux WHO ISTWA, HQ Outline 1. Background 2. Objectives of meningitis surveillance 3. Epidemiological situation of meningitis in Africa 4. Performance analysis of meningitis surveillance 5. Lessons learned 6. Summary 7. Way forward Annexes :Definition case; Operational thresholds; Performance indicators of surveillance 2 | Epidemic meningitis in Africa: Disease burden Reported cases 200,000 188,345 170,000 140,000 92,347 100,000 88,939 88,199 80,743 80,000 68,089 60,000 40,000 27,3011 20,000 0 Years 3 | Background -1 l Meningitis remains a major public health problem in Africa especially in the 26 countries of the meningitis belt. l The bacterial status changed since the introduction of MenAfriVac in Africa in 2010. Previously, NmA that was predominant. Thus, from 2010 to now, S.Pn, NmW, and NmC are predominant l The 3-pillar strategy to eliminate meningitis in Africa; Surveillance; case management; and vaccination l In order to improve the detection of meningitis case and assess the impact of introduction of MenAfriVac, Enhance surveillance (ES) and case based surveillance (CBS) have been introduced respectively in 2003 and 2010 4 | Background -2 l 2003 - 2015: introduction of ES in 19 countries of meningitis belt l 2010-2015: introduction of CBS; currently 13 countries are experiencing CBS l Initiated in 2010 in BFA, Mali, and Niger l 2014: Improvement of CBS in BFA, Mali, Niger, Togo, and (Ethiopia & Chad are in the process) through the MenAfriNet project conducted by CDC with the partnership of WHO, AMP & MoH countries concerned 5 | Background -3 Main differences between ES & CBS Elements ES CBS Lumbar puncture and CSF analysis for suspected meningitis cases >= 80% >= 90% Case investigation form filled for suspected meningitis cases >=80% 100% epidemiological data followed by lab data Routine reporting, management, and analysis of case-level data. ++ +++ One case = one line: epidemiological and lab data are linked 6 | Objectives of meningitis surveillance Objectives ES CBS Early Detection of outbreaks first priority +++ +++ Describe the epidemiology of meningitis ++ ++ - Incidence trends +++ +++ - Identify circulating serogroups ++ ++ - Monitor antibiotic sensitivity ++ ++ Provide data to estimate disease burden ++ ++ Identify geographical areas and populations at risk +++ +++ Assess control strategies ++ ++ Allow measuring the MenAfriVac conjugate vaccine effectiveness + +++ Estimate the impact of vaccination on the disease + +++ - Impact on outbreak pattern - Impact on serogroup circulation 7 | Epidemiological situation of meningitis in Africa from 2003 to 2016 Meningitis Suspected cases, deaths, and CFR-1 MenAfriVac Introduc1on 8 | Epidemiological situa1on of meningi1s in Africa from 2004 to 2016 (S5)-2 2014 2015 2016 (S1-S5) Country Burkina Faso , DR Congo, Case Death CFR(%) Case Death CFR(%) Case Deaths CFR(%) Niger , Nigeria are the Benin 711 88 12.4 575 64 11.1 53 4 7,5 most affected countries. Burkina Faso 3476 353 10.2 2927 288 10,4 412 42 10.2 Cameroon 1156 60 5.2 1226 62 5.1 44 3 6.8 In 2014, a total of 21.641 Central African cases including 1 . 169 41 24.3 295 33 11.2 28 11 39.3 Republic 903deaths (CFR 8.8%) Chad 235 22 - 227 32 14.1 36 5 13.9 reported from 19 Cote d`Ivoire 196 25 12.8 132 22 16.7 49 17 34.7 countries . Outbreaks in DR Congo 10109 994 9.8 8247 608 7.4 1132 108 34.7 Ethiopia (NmC) Ethiopia 1744 52 3 374 - - 109 2 1.8 In 2015, a total of 27.301 Gambia 214 38 17.8 92 19 25,3 6 1 16.7 cases including Ghana 448 17 3.8 388 40 10.3 483 51 10.6 1.933deaths (CFR 7.1%) Guinea 582 55 9.5 229 22 9.6 11 0 0 reported from 19 Kenya 0 0 3 - - - countries 2 major epidemics (NmC) Mali 327 4 1.2 507 7 1.4 60 1 1.7 in Niger and Nigeria Mauritania 1 0 0 1 0 0,0 0 0 Niger 327 40 12.7 8576 577 6.7 138 8 5.8 In 2016 (S5), a total of Nigeria 1175 81 6.9 2670 130 4.9 39 1 2.6 2.840 cases with 266 Senegal 207 5 2.4 202 7 3.5 34 0 0 deaths (CFR 9.9%) reported from 24 Sudan 111 2 1.8 353 7 2 countries . In 2016, 2 South Sudan 102 12 11.8 45 4 9.8 4 1 25 major epidemics in Togo 351 14 4 235 11 4.7 202 11 5.4 Togo (NmW), Ghana (SPn, Uganda 0 0 0 - - - NmW?), Nigeria (NmC) Total 21641 1903 8.8 27301 1933 7.1 2840 266 9.9 Epidemiological situaon of meningi0s in Africa Meningi0s bacteriologic trends 2003-2015 -3 MenAfriVac Introduc1on Large predominance of NmA before 2010. significant decreasing trend of NmA after the introduction of MenAfriVac, Predominance of S.pn NmW and between 2010 and 2016 Increased circulation of NmC in 2015. major outbreaks in Niger and Nigeria 10 | Epidemiological situaon of meningi0s in Africa from 2009 to 2016-4 Niger, Nigeria, Burkina Faso are the major affected countries that recorder 2016 major outbreaks In 2015, 30 districts were in epidemics (NmC). Niger (13) and Nigeria (8) were the major affected countries In 2016 (S5) 14 districts are in epidemics (S.pn, NmW, NmC). Togo 2015 and Ghana, Nigeria (NmC) are the major affected countries 2009 2009 CBS a[er the introduc1on of MenAfriVac Countries NmA recorded (Lab) 2011 2012 2013 2014 2015 no case recorded no case recorded no case 4 NmA Burkina 4 NmA (unvaccinated) recorded (unvaccinat Faso with 3 imported ed) no case recorded no case recorded no case no case Niger 4 NmA (unvaccinated) recorded recorded 29 NmA no case no case Cameroon - - (unvaccinated) recorded recorded 1 NmA no case no case Chad - - (unvaccinated) recorded recorded 3 NmA unknwon no case no case Nigeria - - status recorded recorded 1 NmA no case no case Senegal - - (unvaccinated) 12 | recorded recorded (imported) 12 Performance analysis of meningitis surveillance -1 Strengths weaknesses l Commitment of partners, public health l Updated SOPs fro CBS and ES in process officials and personals l Database is not standardized in all the countries l Introduction and implementation of ES (19 countries) and CBS (13 countries) l Tools are not standardized in all the countries with the improvement through l Application are not standardized in all the MenAfriNet project countries l Regular feedback through meningitis l Lack coordination of surveillance activities bulletin: (weekly/ monthly basis ) l Lack of lumbar puncture <40% l Early detection of meningitis outbreaks l Lack of resources in the majority of countries l Review of Meningitis guidelines including (human, financial, material) thresholds in Dec 2014 and February l Health personal unstable 2015 13 | Performance analysis of meningitis surveillance -2 30000 25000 20000 15000 10000 5000 0 2016 (S1- 2013 2014 2015 S5) Reported cases 19685 21641 27304 2840 Total samples in 4926 4566 9510 266 Reference Lab % RC & TS (>= 80%) 25% 21% 35% 28% % between reported cases and total samples in % between total samples analysed without reference Lab varies 21% – 35% (Std. >= 80/90%) contaminated samples and negative samples varies 69% – 81% (Std. < 20%) 14 | Performance analysis of meningitis surveillance -3 Strengths weaknesses l Completeness varies between 97 to l Timeliness <80% 99% from 2013 to 2016, l Discrepancy between reported l Organization of annual workshop on suspected cases and CSF cases meningitis: review of epidemiological reported vs CSF sample in reference situation and elaboration of Lab vary between 21% - 35% from preparation and response plans for 2013 to 2016. meningitis (last workshop in Niger Dec, 2015) l Some common Lab issues for countries: l The majority of countries in Lack of reagents, equipment in Lab, meningitis belt are in the process of elaboration and validation of their – Not enough qualified Lab human preparation and response plan for resources meningitis outbreaks 15 | Lessons learned l Financial resources adequate for CBS is necessary before its introduction in integrated surveillance, and ES should continue and should be reinforced l Enhance the coordination of integrated surveillance diseases including meningiris l Necessity of standardization of the management tools, database, and application of integrated surveillance l Standardization, sharing and use of the references documents (SOPs), guidelines 16 | Summary -1 l Meningitis continues to pose a major public health burden in the WHO African Region l Burkina Faso , Niger , Nigeria are the most affected countries. A Large epidemics of meningococcal meningitis was reported from Niger in 2015. In 2016 (S5) Togo and Ghana are the majors affected countries. l Surveillance one of the pillars of the strategies to eliminate meningitis in Africa, the main objective is to detect very early meningitis outbreaks and helps to evaluate the impact of MenAfriVac introduction in Africa l Introduction of ES in 2003 and 29 countries involved. Thus, introduction of CBS in 2010, 13 countries involved and MenAfriNet project in BFA, Mali, Niger, Togo to improve CBS 17 | Summary - 2 l No carriage after vaccination in Burkina Faso (Christiansen & al) and Chad (Daugla & al) l Increase in the proportion of cases due to other Nm (C,W, X, Y) and other bacteria (Spn, Hib) è Surveillance & Lab confirmation +++ l NmA : (no case among persons vaccinated in the 16 countries who conducted campaigns from 2010 to 2015) Sustaining optimal level of meningitis surveillance is crucial and it requires timely notification at all levels for decision-making 18 | Way forward -1 l Implementing/ strengthening meningitis surveillance – Extension of CBS in meningitis belt.
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