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Status of the Rollout of the Meningococcal Serogroup A applyparastyle “fig//caption/p[1]” parastyle “FigCapt” The Journal of Infectious Diseases SUPPLEMENT ARTICLE Status of the Rollout of the Meningococcal Serogroup A Conjugate Vaccine in African Meningitis Belt Countries in 2018 Ado Bwaka,1 André Bita,1 Clément Lingani,1 Katya Fernandez,2 Antoine Durupt,3 Jason M. Mwenda,4 Richard Mihigo,4 Mamoudou H. Djingarey,5 Olivier Ronveaux,2 and Marie-Pierre Preziosi3 220 1World Health Organization (WHO) Inter-Country Support Team West Africa, Ouagadougou, Burkina Faso; 2WHO Infectious Hazard Management, Geneva, Switzerland; 3WHO Initiative for Vaccine Research, Geneva, Switzerland; 4WHO Regional Office for Africa, Brazzaville, Congo; 5WHO Infectious Hazard Management, Regional Office for Africa, Brazzaville, Congo Background. A novel meningococcal serogroup A conjugate vaccine (MACV [MenAfriVac]) was developed as part of efforts to prevent frequent meningitis outbreaks in the African meningitis belt. The MACV was first used widely and with great success, be- ginning in December 2010, during initial deployment in Burkina Faso, Mali, and Niger. Since then, MACV rollout has continued in other countries in the meningitis belt through mass preventive campaigns and, more recently, introduction into routine childhood immunization programs associated with extended catch-up vaccinations. Methods. We reviewed country reports on MACV campaigns and routine immunization data reported to the World Health Organization (WHO) Regional Office for Africa from 2010 to 2018, as well as country plans for MACV introduction into routine immunization programs. Results. By the end of 2018, 304 894 726 persons in 22 of 26 meningitis belt countries had received MACV through mass pre- ventive campaigns targeting individuals aged 1–29 years. Eight of these countries have introduced MACV into their national routine immunization programs, including 7 with catch-up vaccinations for birth cohorts born after the initial rollout. The Central African Republic introduced MACV into its routine immunization program immediately after the mass 1- to 29-year-old vaccinations in 2017 so no catch-up was needed. Conclusions. From 2010 to 2018, successful rollout of MACV has been recorded in 22 countries through mass preventive cam- paigns followed by introduction into routine immunization programs in 8 of these countries. Efforts continue to complete MACV introduction in the remaining meningitis belt countries to ensure long-term herd protection. Keywords. African meningitis belt; MenAfriVac; meningococcal serogroup A; rollout. Historically, large recurring meningitis epidemics affected an first used widely with great acceptance and success, in December extensive region of sub-Saharan Africa known as the menin- 2010, during mass vaccination campaigns targeting persons aged gitis belt, which comprises whole or part of 26 countries from 1–29 years in Burkina Faso, Mali, and Niger. It was the first time Senegal in the west to Ethiopia in the east. In this geograph- that a new WHO prequalified vaccine was used in the African ical area, outbreaks occur during the dry epidemic season, region with no time lag after completion of clinical trials and li- usually covering the first half of the year. The main pathogen censure and directly through a mass vaccination campaign rather responsible for epidemic bacterial meningitis in this region was than in routine immunization as had been done previously with Neisseria meningitidis serogroup A (NmA). new vaccines. The campaign was conducted in 1 phase in 2010 in Starting in 2010, a novel meningococcal serogroup A conju- Burkina Faso, and in 2 phases in Mali and Niger between 2010 gate vaccine ([MACV] the product is manufactured by a single and 2011. The MACV was then progressively introduced, into the manufacturer and is marketed under the name MenAfriVac) was epidemic-prone areas in other countries of the African meningitis prequalified by the World Health Organization (WHO) for pro- belt, through mass preventive vaccination campaigns. tection against meningitis caused by NmA [1–3]. The MACV was To sustain population-level immunity, WHO recommends that MACV be introduced into the routine childhood immu- Correspondence: A. Bwaka, MD, MPH, World Health Organization, Inter-Country Support nization program no more than 5 years after completion of Team Office for West Africa, 158 Avenue de l’Indépendance, 03 B.P. 7019 Ouagadougou 03, mass preventive campaigns. A single dose should be admin- Burkina Faso ([email protected]). istered to children aged 9–18 months. In addition, routine in- The Journal of Infectious Diseases® 2019;220(S4):S140–7 © The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society troduction should be accompanied by a one-time catch-up of America. This is an Open Access article distributed under the terms of the Creative Commons campaign for birth cohorts born since the mass campaign [4]. Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. The Regional Strategic Plan for Immunization 2014–2020 in the DOI: 10.1093/infdis/jiz336 WHO African Region set a target (1) for all countries within the S140 • JID 2019:220 (Suppl 4) • Bwaka et al meningitis belt to introduce MACV through mass campaigns and evaluation, and social mobilization were convened during and (2) for 15 of these countries to have introduced MACV into the planning and operational phases. their routine immunization schedules by 2020 [5]. This article In the early 2010s, only 2 countries in the meningitis belt describes the status of MACV rollout in the meningitis belt were, at the time, equipped with a National Immunization countries and highlights the challenges that may be associated Technical Advisory Group (NITAG). The NITAGs that were with the delay of the vaccine rollout in some countries. established in additional countries, mostly from 2013 on, have gradually became functional and provided recommendations METHODS relating to MACV rollout in time to inform routine introduc- Country Risk Prioritization tion and catch-up campaigns [7]. The District Prioritization Tool (DPT) [6] is a comprehensive Vaccine Handling and standardized easy-to-use tool that has been developed for The MACV received regulatory approval to be kept outside the meningitis risk assessment in countries of the African men- cold chain for up to 4 days at up to 40°C in a controlled tem- ingitis belt before introduction of MACV. The DPT was used perature chain (CTC). The CTC approach was first used on a to rank countries for purposes of planning for MACV mass large scale in 2014 in a vaccination campaign in 10 health dis- campaigns, as well as for future introduction into routine im- tricts in Togo. A survey carried out in Togo showed that the munization programs. This methodology was developed for use of this approach did not have a negative impact on the vac- sequential country introductions based on epidemic risk and cination coverage, and there were no significant differences in disease burden as well as the ability of countries to conduct vac- coverage in districts with CTC or in districts without CTC [8]. cination campaigns. Using this tool, countries were ranked into The CTC approach was also used in selected districts in Benin, 5 risk categories: Group 1 - countries with high epidemic risk Democratic Republic of the Congo, Côte d’Ivoire, Mauritania, and high disease burden (Burkina Faso, Chad, Ethiopia, Mali, and South Sudan. Niger, Nigeria, and Sudan); Group 2 - countries with high ep- Furthermore, MACV was administered to pregnant and idemic risk but low disease burden (Benin, Cameroon, and lactating women despite the “label caution statement”. This was Ghana); Group 3 - countries with low epidemic risk but high supported by a WHO recommendation based on a risk-benefit disease burden (Democratic Republic of the Congo and South assessment. There were no severe adverse effects following im- Sudan); Group 4 - countries with an intermediate epidemic risk munization reported in this population compared with other and disease burden (Côte d’Ivoire, Guinea, Senegal, Togo, and vaccinated individuals. Furthermore, a formal evaluation, com- Uganda); Group 5 - countries with low epidemic risk and low missioned by WHO, revealed no evidence of any safety con- disease burden (Burundi, Central African Republic, Eritrea, cerns when the vaccine was used in pregnant women. Gambia, Guinea-Bissau, Kenya, Mauritania, Rwanda, and United Republic of Tanzania). Data Collection Resource Mobilization and Coordination We reviewed country reports on MACV campaigns and routine immunization data reported to the WHO Regional Office for Gavi, the Vaccine Alliance, provided support for operational Africa from 2010 to 2018. We also reviewed the country plans and vaccine costs based on the country requests for campaigns for MACV introduction into routine immunization programs. (up to $0.65 per person) and also provided cofinancing to Discussions were undertaken with country stakeholders on the help governments with routine immunization. Governments likelihood of countries adhering to the period of introduction and other partners, such as the WHO, UNICEF, and the as provided in the country plans. International Committee of the Red Cross, provided additional resources for assessment, social mobilization, and transport to RESULTS reach remote areas. The international coordination for MACV rollout was
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