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Response Strategies Against Meningitis Epidemics After RESEARCH Response Strategies against Meningitis Epidemics after Elimination of Serogroup A Meningococci, Niger Halima Boubacar Maïnassara, Juliette Paireau, Issa Idi, Jean-Paul Moulia Pelat, Odile Ouwe Missi Oukem-Boyer, Arnaud Fontanet, Judith E. Mueller To inform epidemic response strategies for the African men- in similar proportions (3), and NmA has been identified ingitis belt after a meningococcal serogroup A conjugate only exceptionally (4,5). So far, epidemic control measures vaccine was introduced in 2010, we compared the effective- have consisted of reactive vaccination campaigns in epi- ness and efficiency of meningitis surveillance and vaccine demic districts by using serogroup A/C or A/C/W polysac- response strategies at district and health area levels using charide vaccines combined with adapted treatment proto- various thresholds of weekly incidence rates. We analyzed cols. To detect epidemics, national routine surveillance of reports of suspected cases from 3 regions in Niger during 2002–2012 (154,392 health area weeks), simulating elimina- suspected cases of acute bacterial meningitis has been con- tion of serogroup A meningitis by excluding health area years ducted in all meningitis belt countries according to World with identification of such cases. Effectiveness was highest Health Organization (WHO) guidelines (1), although the for health area surveillance and district vaccination (58–366 recommendation of splitting large districts (>100,000 in- cases; thresholds 7–20 cases/100,000 doses), whereas ef- habitants) into subdistricts is not always followed. Districts ficiency was optimized with health area vaccination (5.6–7.7 notifying weekly incidences of 5 cases/100,000 persons cases/100,000 doses). District-level intervention prevented were considered in alert, and those notifying weekly inci- <6 cases (0.2 cases/100,000 doses). Reducing the delay dences of 15 cases/100,000 persons were considered in epi- between epidemic signal and vaccine protection by 2 weeks demic (6); however, specific conditions enabled declaration doubled efficiency. Subdistrict surveillance and response of an epidemic at a threshold of 10 cases/100,000 persons. might be most appropriate for meningitis epidemic response Since PsA-TT was introduced in 2010, NmA inci- after elimination of serogroup A meningitis. dence has been substantially lower than historical levels, and no replacement by other serogroups has been observed or several decades, epidemic meningitis has been a (7). Consequently, the overall incidence of suspected men- Fmajor health problem in the African meningitis belt. ingitis cases has declined in all vaccinated countries, and Neisseria meningitidis serogroup A (NmA) has been re- established surveillance and vaccination strategies might sponsible for most localized epidemics or epidemic waves, no longer be appropriate. Epidemic detection and response and other meningococcal serogroups occasionally caused remains important because serogroups W and X have epi- epidemics (1,2). After the introduction of an NmA conju- demic potential (1,2,4,8,9). A polysaccharide vaccine is gate vaccine (PsA-TT, MenAfrivac; Serum Institute of In- available against N. meningitidis serogroup W (NmW); dia Ltd., Hadapsar, Pune, India), implemented since 2010 vaccines for serogroup X (NmX) are under development. in mass campaigns focused on persons 1–29 years of age, NmA epidemics might continue to occur, requiring mass no epidemics caused by NmA have occurred in countries vaccination campaigns with PsA-TT. where the vaccine is administered (i.e., vaccinated coun- One approach to adapting epidemic response strate- tries). Seasonal hyperendemicity continues to occur during gies to the changing epidemiology is to lower the weekly the dry season because of meningococci and pneumococci incidence thresholds to <10 cases/100,000 persons, which would increase the risk for an increased number of false Author affiliations: Université Pierre et Marie Curie, Paris alerts in small districts. Another approach is to analyze (H.B. Maïnassara, J. Paireau); Institut Pasteur, Paris, France surveillance data at a finer spatial scale than district level. (H.B. Maïnassara, J. Paireau, A. Fontanet, J.E. Mueller); As in Burkina Faso (2,10) and Niger (11), epidemics of Centre de Recherche Médicale et Sanitaire, Niamey, Niger any serogroup usually are highly localized in few neigh- (H.B. Maïnassara, I. Idi, J.-P.M. Pelat, O.O.M. Oukem-Boyer); boring health centers, whereas most health centers in the Chaire Santé et Développement, Paris (A. Fontanet); Ecole des district in question remain (hyper-)endemic. District-level Hautes Études en Santé Publique, Rennes, France (J.E. Mueller) incidences are therefore diluted and may hide epidemic DOI: http://dx.doi.org/10.3201/eid2108.141361 activity. Consequently, surveillance at the health center 1322 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 8, August 2015 Response Strategies against Meningitis Epidemics level could detect epidemics earlier and enable targeting from health district administrations and compiled them in of reactive vaccination, making the overall strategy more a new database. A health area is a geographic area that en- effective and efficient. Early epidemic detection through compasses all villages served by the same health center, surveillance at the health center level could increase the which is an exclusive association. We assessed the com- effectiveness and efficiency of response strategies, particu- pleteness of this health area database of suspected cases by larly in the anticipated situation of eliminated NmA men- comparing the resulting weekly district case counts with ingitis and overall reduced meningitis incidence. those in the national surveillance reports. On the basis of Therefore, during 2002–2012, we evaluated the ef- the completeness of this health area–level database (online fectiveness and efficiency of surveillance and vaccine re- Technical Appendix), we selected 3 regions—Tahoua, Til- sponse strategies in Niger using various epidemic thresh- labery, and Dosso—for further analysis (Figure 1). Togeth- olds and comparing health area and district intervention. er, these regions had 7,648,150 inhabitants during 2012 Our analysis was based on surveillance data of suspected (48% of Niger’s population), 19 health districts (47%), and and confirmed cases and considered 2 scenarios: the his- 373 health areas (51%). Niger used Haemophilus influen- torical situation before PsA-TT introduction (PsA-TT was zae type b vaccine since 2006 but uses no pneumococcal introduced in Niger in 3 phases: the first in August 2010, vaccine in the widened vaccine program. the second in November 2010, and the third in October Data on confirmed cases came from countrywide sur- 2011) and a simulation of NmA elimination. veillance based on PCR (11). For this surveillance, we re- quested that all cerebrospinal fluid samples from persons Methods with suspected meningitis in the health centers be sent to the Centre de Recherche Médicale et Sanitaire (Niamey, Databases Niger) for testing by multiplex PCR (14). After merging The surveillance data used for this analysis were collected with the study database of suspected cases, we obtained during 2002–2012 in Niger. For national routine surveil- the combined information about suspected and confirmed lance, all health centers in Niger report suspected menin- meningococcal case counts for every health area and week. gitis case counts each week to health district administra- Using these data, we prepared a database simulating tion, where data are aggregated to a district case count the situation after NmA elimination by excluding all health and forwarded to the national level for reporting (online area years with at least 1 NmA case or without any labo- Technical Appendix Figure 1, http://wwwnc.cdc.gov/EID/ ratory information. A health area year corresponded to a article/21/8/14-1316-Techapp1.pdf) (12,13). To analyze health area that appears in the annual reporting file, so that response strategies at the health area level, we retrieved the in our analysis health area years represented all the health original health center counts of suspected meningitis cases areas that appear in annual reporting files during the study Figure 1. Location of the study area, Niger. This area comprises the 379 health areas in 3 regions (Tahoua, Tillabery, and Dosso). Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 8, August 2015 1323 RESEARCH period. Only 1 NmA case was identified in the study region after PsA-TT introduction. To validate the representative- ness of this database for meningitis epidemiology after NmA elimination, we compared the distribution of annual incidences between health areas before and after PsA-TT introduction (Figure 2). To prepare the database simulat- ing the situation after NmA elimination, we took into ac- count the exact week of district vaccination, which was conducted in 3 phases: September 2010, December 2010, and November 2011. The Niger national ethics committee approved this research (no. 014/2012/CCNE). Statistical Analysis The Institut National de la Statistique provided the num- ber of inhabitants in each village according to the 2001 national census. We aggregated the villages’ populations at the health area level and applied a mean annual growth rate of 3.3% (15). We calculated weekly incidence rates Figure 2. Annual incidences of suspected meningitis per (WIR) as the weekly number of cases per 100,000 inhab- 100,000
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