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 Introduc on
8 | Epidemiological situa on of meningi s 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 situa on of meningi s in Africa Meningi s bacteriologic trends 2003-2015 -3
MenAfriVac Introduc on
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 situa on of meningi s 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 introduc on 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. 2016 in Mauritania, Togo, Guinea, DRC – Continue to introduce ES and its implementation in Kenya, and Uganda l regional standardization of management tools, database and application l Improvement of the coordination of surveillance activities in all the countries l Finalized WHO the updated SOPs ES and CBS, Lab to support
surveillance19 |
Way forward -2 l Enhancement of the lumbar puncture practice l Increase of financial, human trained and material (IT++) resources in all the countries l Organization of the risk assessment in 2016: Burundi, Eritrea, Rwanda, and Tanzania; l Regular annual meningitis workshop
20 | Thank you for your kind
Semaine/Week 05 Meningitis Weekly B ulletin Inter country Support Team - West Africa 2016
Bulletin Hebdomadaire de retro-information sur la méningite cérébrospinale Weekly feedback bulletin on cerebrospinal meningitis attention 01 to 07 February 2016
I. SITUATION EPIDEMIOLOGIQUE DE LA SEMAINE 05 / EPIDEMIOLOGICAL SITUATION OF WEEK 05
Table 1 : Situation épidémiologique / Epidemiological Situation
Pays Cas Dècès Létalité (%) District en Alerte District en Epidémie Complétude (%) Country Cases Deaths Lethality (%) District in Alert District in Epidemic Completeness (%) BeninP ------Burkina FasoT 103 13 12.6 2 0 100.0 CamerounP ------Centrafrique 8 6 75.0 0 0 40.0 Côte d'IvoireP 18 5 27.8 1 0 97.6 EthiopiaP 33 1 3.0 3 1 100.0 GhanaP 212 10 4.7 8 8 99.5 GuineaP 2 0 0.0 0 0 100.0 GambiaT 0 0 0.0 0 0 100.0 Kenya ------MaliT 13 0 0.0 0 0 95.5 MauritaniaP 0 0 0.0 0 0 100.0 NigerT 49 4 8.2 2 0 100.0 NigeriaP 14 0 0.0 0 0 100.0 RD Congo** 210 16 7.6 - - 21.0 SenegalP 11 0 0.0 0 0 100.0 South Sudan 4 1 25.0 0 0 100.0 SudanT ------TchadT 7 3 42.9 1 0 94.8 TogoP 99 6 6.1 1 2 97.5 Uganda ------Total 783 65 8.3 18 11 71.4
P = Pays partiellement vacciné avec le MenAfriVac/ Country partially vaccinated with MenAfriVac T= Pays entièrement vacciné avec le MenAfriVac / Country entirely vaccinated with MenAfriVac ** La vaste majorité du territoire de la République démocratique du Congo se situe en dehors de la ceinture africaine de la méningite. Par conséquent, les seuils d’alerte et d’épidémie ne sont pas applicables /The majority of the Democratic Republic of the Congo territory is situated outside the African meningitis belt. Thus the alert and epidemic thresholds are not applicable
Nous contacter / Contact us: Inter country Support Team - West Africa / Equipe d’Appui Inter-Pays pour Afrique de l’Ouest Pays sous Surveillance 03 BP 7019 Ouagadougou 03, Burkina Faso Renforcée de la Méningite Tel: (226) 25-30-65-65, Fax: (226) 25-33-25-41 E.mail: [email protected] or [email protected] or [email protected] Countries under Enhanced Site web/Web site: http://www.meningvax.org/epidemic-updates.php Surveillance of Meningitis http://www.who.int/csr/disease/meningococcal/epidemiological/en/ Nota bene: Les données publiées dans ce bulletin sont des informations hebdomadaires. Elles sont susceptibles d’évoluer après complétude et vérification./The data published in this bulletin are weekly informations. They are susceptible to change after completeness and verification.
| 21
Definition case of meningitis l Suspected case ; Any person with sudden onset of fever (>38.5 C rectal or 38.0 C axillary) and neck stiffness or other meningeal signs, including bulging fontanelle in infants l Probable case ; Any suspected case with macroscopic aspect of cerebrospinal fluid (CSF) turbid, cloudy or purulent; or with a CSF leukocyte count >10 cells/mm3 or with bacteria identified by Gram stain in CSF .
In infants: CSF leucocyte count >100 cells/mm3; or CSF leucocyte count 10–100 cells/mm3 and either an elevated protein (>100 mg/dl) or decreased glucose (<40 mg/dl) level. l Confirmed case : Any suspected or probable case that is laboratory confirmed by culturing or identifying (i.e. polymerase chain reaction, immunochromatographic dipstick or latex agglutination) a bacterial pathogen (Neisseria meningitidis*, Streptococcus pneumoniae, Haemophilus influenzae type b) in the CSF or blood. *If N. meningitidis is confirmed, the serogroup should be identified to guide vaccine decisions.
22 | Epidemiological thresholds
Population Intervention 30 000–100 000 Under 30 000 Alert threshold • 3 suspected cases / 100 000 • 2 suspected cases in one week - Inform authorities inhabitants / week - Strengthen surveillance Or - Investigate (Minimum of 2 cases in one An increased incidence compared - Confirm (including week) • laboratory) to previous non-epidemic years - Prepare for eventual (previously 5) response (previously 2)
Epidemic threshold • 10 suspected cases / • 5 suspected cases in one week - Mass vaccination within 4 100 000 inhabitants / week Or weeks of crossing the (previously 10 if at risk, otherwise epidemic threshold • Doubling of the number of cases in Distribute treatment to health 15) - a three-week period centres - Treat according to epidemic (previously 5) protocol - Inform the public
23 | Performance indicators of surveillance
Performance Indicators ES CBS Per cent (%) of districts that have reported weekly meningitis cases and deaths on time. 80% 90% Investigation-Field: Per cent (%) of alert or epidemic districts which have been investigated and 80% 80% documented within the 48 hours after reaching the alert or epidemic threshold. TI transportation: Per cent (%) of districts in alert or epidemic phase that have sent at least 10 TI 80% 90% bottles to the national reference after reaching the alert threshold Laboratory - Confirmation: Per cent (%) of epidemic districts that have confirmed the serogroup of 80% 80% at least 10 suspected meningitis cases within 7 days of surpassing the alert or epidemic threshold. Feedback-Lab: Per cent (%) of alert and epidemic districts that have received results from the <20% <20% samples sent to the national reference laboratory within 7 days of receiving the TI bottles by the laboratory. Negative specimen: Per cent (%) of culture-negative samples among samples received per week <20% <20% by the reference laboratory. Reporting to WHO: Per cent (%) of countries which have reported on time weekly data 80% 80% (surveillance and laboratory results) to WHO Contaminated specimen: Per cent (%) of contaminated samples among samples received per 80% 80% week by the reference laboratory Feedback: Per cent (%) of weekly meningitis bulletins produced by WHO (and sent to countries, 80% 80% WHO/AFRO/HQ and partners).
24 |