Global & Disaster Medicine

Archive for the ‘Meningitis’ Category

Liberia: Meningococcal septicemia after attending a funeral

 

WHO

Meningococcal septicaemia associated with attending a funeral – Liberia

Disease outbreak news
6 July 2017

This is an update to the Disease Outbreak News “Unexplained cluster of deaths – Liberia” published on 5 May 2017 and update published on 10 May 2017.

On 25 April 2017, the Ministry of Health (MoH) of Liberia notified WHO and partners of a cluster of sudden deaths of unknown aetiology in Sinoe County. The event started on 23 April 2017, when an 11-year-old female had been admitted to hospital presenting with diarrhoea, vomiting, and mental confusion after attending the funeral of a religious leader on 22 April 2017. The child died within one hour of admission.

Between 23 April and 7 May, a total of 31 cases including 13 deaths, and one case with neurological sequelae of an unknown disease associated with attending a funeral were reported from three counties (Sinoe, Grand Bassa, and Montserrado). The majority of cases did not present with fever, but did present with abdominal pain, diarrhoea, vomiting, and mental confusion. Some patients presented with purpura and/ or petechiae. Most of the cases were related to each other either socially, through family or school. All but two cases attended the funeral, who were subsequently identified as contacts of the index case.

On 8 May 2017, MoH informed partners and the public that specimens taken from patients tested positive for Neisseria meningitidis serotype C at the United States Centers for Disease Control and Prevention (CDC). The outbreak was therefore classified as a meningococcal disease outbreak. A total of 14 cases out of 31 cases were later confirmed with presence of Neisseria meningitidis C by PCR in clinical specimens conducted at the National Reference Laboratory in Liberia or clinically diagnosed due to the presence of purpura fulminans. Laboratory results were further confirmed by the National Institute for Communicable Diseases (NICD) and the National Institute of Occupational Health (NIOH) in Johannesburg, South Africa, in addition to serological results of three cases that were tested at Institute Pasteur in France. The temporal characteristics of this outbreak are unusual raising the hypothesis of the presence of a co-factor.

Additionally, on 8 May 2017, the MoH informed partners and the public that toxicological investigations conducted by CDC on urine samples from three cases did not suggest that intoxication was the cause of the outbreak. The samples were tested for pesticide metabolites and toxic metals.

On 20 June 2017, the MoH was notified that results of toxicological investigations carried out at the Center for Analytical Chemistry in Vienna, Austria, on food samples, water and a soft drink that were consumed during the funeral, were not suggestive of intoxication. The samples were tested for more than 600 fungal and bacterial toxins and these were either not detected or were within regulatory limits.

Public health response

The MoH supported by the WHO, CDC, Africa Field Epidemiology Network (AFENET), and other partners started on-site investigations one day after the alert. No disease was identified at the start of the outbreak and Ebola virus disease (EVD) was ruled out within 24 hours of the alert.

The National Public Health Institute of Liberia was activated to lead the response. WHO, CDC, UNICEF, and MSF reinforced the field response, and international coordination and information sharing was supported though the Global Outbreak Alert and Response Network (GOARN). The following response activities were implemented:

  • Most of the cases from Sinoe were managed in the local hospital in Greenville, the capital of Sinoe County and received treatment as per EVD protocol.
  • Infection, prevention, and control measures were implemented in the local hospital.
  • Active case searching was conducted and identified attendees of the funeral and close contacts of the cases were followed up for 21 days.
  • Autopsies were conducted on two patients.
  • Approximately 70 specimens (58 clinical specimens and 12 food samples) were collected for laboratory testing and sent to the national reference laboratory in Margibi County, the United States, France, South Africa, and Austria.
  • Chemoprophylaxis was distributed to all attendees, contacts of the cases, health workers, and burial personnel.
  • A meningitis C vaccination strategy was discussed but not implemented due to the lack of secondary transmission.
  • Social mobilization was implemented with the support of UNICEF.

WHO risk assessment

In the absence of clear understanding of the epidemiology of this outbreak , the risk of recurrence cannot be excluded. However, based on current understanding of the epidemiology of meningococcal disease, the risk is considered low.

The efficient and timely implementation of the response to this event is a result of the expertise developed in Liberia following the large outbreak of EVD in 2014. This led to the quick identification of the event, testing and ruling out EVD as the cause of the outbreak, identification of contacts and their follow-up and the collaboration of the country with partners to perform laboratory testing of human and environmental specimens, which led to the identification of the cause of the disease.

WHO advice

WHO does not recommend any restriction on travel and trade to Liberia on the basis of the information available on the current event.

WHO recommends the inclusion of meningococcal septicemia in routine surveillance in Liberia as an epidemic prone disease together with meningitis due to Neisseria meningitidis.


Thousands of men, women, and children in northern Nigeria have been affected by a meningitis C outbreak, reportedly the largest to hit the country in the past nine years.

MSF

“…..MSF set up a 200-bed treatment centre in Sokoto Town, followed by a 20-bed facility in Anka, Zamfara. In these locations, MSF’s Nigeria Emergency Response Unit (NERU) works intensively to provide free, high-quality medical care and reduce mortality rates as much as possible.

These teams treat challenging cases in a difficult environment.

“A few days ago a nine-year-old boy was brought in unconsciousness and with severe meningitis,” recalls Caroline Riefthuis, an MSF nurse in Sokoto. “He received treatment for five days and recovered, but unfortunately we found out that he had become deaf and blind— complications of severe meningitis.”

This little boy is one of 614 patients treated in Sokoto Mutalah Mohamad Hospital since April, when MSF took over the management of the centre from the MoH due to a lack of supplies and qualified staff to run it. In Anka General Hospital, 137 patients were admitted since the beginning of the outbreak. Most are between five and 20 years old….”

 


WHO: Liberia’s health ministry states that samples from four people who died as part of an unexplained illness cluster tested positive for Neisseria meningitidis serotype C.

WHO

Update on unexplained cluster of deaths – Liberia


10 May 2017

On 25 April 2017, the Ministry of Health of Liberia notified WHO and partners of a cluster of sudden deaths of unknown aetiology in Sinoe County. The event began on 23 April 2017 when an 11-year-old child was admitted to hospital presenting with diarrhoea, vomiting and mental confusion after attending a funeral on 22 April 2017.

As of 9 May 2017, a total of 31 cases including 13 deaths have been reported.

The Ministry of Health of Liberia (MOH) responded quickly to the cluster using the emergency management and laboratory infrastructure it developed during the Ebola outbreak alongside WHO, and other public health partners. The Liberian MOH sent blood, urine, and plasma samples to the US Centers for Disease Control and Prevention (CDC) for testing of infectious diseases and environmental toxins.

On 8 May, WHO was informed by Liberia’s MOH that samples from four of the deceased patients had tested positive for meningitis C (Neisseria menigitidis). Although these most recent reports point to meningitis as the probable cause of illness and death in these patients, the investigation is still ongoing to determine if this bacteria is responsible for other reported illnesses in this cluster.

While awaiting full toxicology reports, the Liberian MOH is exploring whether vaccination against meningitis is an appropriate course of action. WHO supports the ongoing epidemiological and laboratory investigations to identify the etiological agent of this cluster of cases to guide additional control measures.

Since it was notified of the cluster of sudden deaths, WHO has worked closely with Liberian Ministry of Health and other partners in areas of overall coordination, surveillance, contact tracing, case management, social mobilization, community engagement, laboratory investigation, and infection prevention and control.


Liberia’s Mystery Disease: Seven specimens from the deceased tested positive for Neisseria meningitis

Daily Mail

Image result for neisseria meningitidis

 

 


Nigeria: Trying to contain an outbreak of meningitis C

WHO

13 April 2017

A vaccination campaign is underway in Nigeria to contain an outbreak of meningitis C, a strain of meningitis which first emerged in the country in 2013. Since the beginning of this year, the country has reported 4637 suspected cases and 489 deaths across five states.

Nigeria

WHO/A. Clements-Hunt

The International Coordinating Group (ICG) on Vaccine Provision, which coordinates the provision of emergency vaccine supplies during outbreak emergencies, has sent 500 000 doses of meningitis C-containing vaccine to Nigeria to combat the epidemic. The vaccines, funded by Gavi, the Vaccine Alliance, have been administered in Zamfara and Katsina states, which are the worst affected by the outbreak. An additional 820 000 doses of a meningitis C conjugate vaccine – a donation from the UK government to the World Health Organization (WHO) – is being sent to the country.

In the last week, the ICG, which is managed by the International Federation of Red Cross and Red Crescent Societies (IFRC), Médecins sans Frontières (MSF), the United Nations Children’s Fund (UNICEF), and WHO, has also sent 341 000 doses of the Gavi-supported meningitis C-containing vaccine to Niger, where there are over 1300 suspected cases of the disease in districts that border with Nigeria and in the Niamey region of the country.

Meningococcal meningitis is a bacterial form of meningitis, a serious infection of the thin lining that surrounds the brain and spinal cord and can cause severe brain damage. Meningococcal meningitis is fatal in 50% of cases if untreated. Though cases of meningitis occur throughout the world, large, recurring epidemics affect an extensive region of sub-Saharan Africa known as the “meningitis belt” which includes 26 countries from Senegal in the west to Ethiopia in the east.

There are several different types of meningococcal meningitis (A, C, W, etc.) that can cause epidemics. Substantial progress has been made in recent years in protecting Africa from disease due to one of the main epidemic types, through the successful introduction of the Men A conjugate vaccine (MACV) against meningitis A. Since MACV was introduced in 2010, more than 260 million people have been vaccinated across 19 countries. This has resulted in a reduction of the number of meningitis cases by more than 57%. Much work, however, remains to be done to protect the region from meningitis C outbreaks and other types of the disease.

In addition to the use of vaccinations to prevent the transmission of meningitis, 20 000 vials of antibiotics have been sent by the ICG to treat people who have the disease in Nigeria. “Vaccination can drastically reduce the magnitude of the epidemic,” says Dr Sylvie Briand, Director of Infectious Hazard Management for WHO. “But in addition, it is essential to strengthen the care of all those affected by the infection and to ensure those people living in hard-to-reach areas can get treatment.”

The Nigeria Centre for Disease Control, with support from WHO, US CDC, UNICEF and other partners, is leading and coordinating the response to the ongoing outbreak, including intensified surveillance, capacity building for case management and risk communication. WHO’s Country Office in Nigeria, including a number of field offices, have been supporting the government since the outbreak began. An additional team of WHO of meningitis experts has arrived in Nigeria to provide additional epidemic response. “In addition to improving the care of the sick, we are focusing on ensuring accurate information about the spread of the outbreak is available as quickly as possible to help us make the most effective use of vaccines,” says Dr Wondimagegnehu Alemu, WHO Representative to Nigeria.

The emergence of meningitis C in Africa

Since 2013, there have been outbreaks of meningitis C in Nigeria, initially limited to a few areas in Kebbi and Sokoto states in 2013 and 2014. In 2015, however, there were more than 2500 cases of the disease across 3 states in Nigeria as well as 8500 cases in Niger.

Concerns about vaccine supply

Most vaccines currently being used for meningitis C outbreaks in Africa are polysaccharide vaccines, which are in short supply as they are being phased out in other parts of the world. The more effective and long-lasting conjugate vaccines, however, are not readily accessible for outbreak response in the region. The ICG global emergency stockpile currently has approximately 1.2 million doses of meningitis C-containing vaccines left.

“The very limited supply of vaccines to control outbreaks of meningitis C can affect our ability to control these epidemics,” says Dr Olivier Ronveaux, WHO meningitis expert. “In the long term, the accelerated development of affordable and effective conjugate vaccines to cover all epidemic types of meningitis is a high priority for WHO and partners.”

Nigeria and meningitis A

In the past, Nigeria has suffered large-scale outbreaks of meningitis A. In 2009, such an outbreak in the country caused over 55 000 cases with close to 2500 deaths. Niger was also affected, with 13 000 cases and 550 deaths. However, preventive mass vaccination campaigns supported by Gavi and partners, using the safe and effective MACV in Niger (2010-11) and Nigeria (2011-14) have provided high and long-term protection against the bacteria. Since 2010, less than 20 cases of meningitis A have been reported from all vaccinated areas in the region. WHO recommends the continued roll-out of the Men A conjugate vaccine campaigns along with its introduction into routine immunization to prevent a major recurrence of devastating meningitis A epidemics.


Nigeria: As of 19 March 2017, a total of 1407 suspected cases of meningitis and 211 deaths (case fatality rate: 15%) have been reported from 40 local government areas (LGAs) in five states of Nigeria since December 2016.

WHO

Disease outbreak news
24 March 2017

As of 19 March 2017 (epidemiological week 11), a total of 1407 suspected cases of meningitis and 211 deaths (case fatality rate: 15%) have been reported from 40 local government areas (LGAs) in five states of Nigeria since December 2016. Zamfara, Katsina and Sokoto account for 89% of these cases. Twenty-six LGAs from all five states reported 361 cases in epidemiological week 11 alone. Twenty-two wards in 15 LGAs have crossed the epidemic threshold. Three of these LGAs share borders with Niger. NmC is the predominant serotype in this outbreak.

The most affected age group is 5 to 14 year olds and they are responsible for about half of reported cases. Both sexes are almost equally affected.

Public health response

WHO and partners including National Primary health Care Development Authority, UNICEF, Nigeria Field Epidemiology and Laboratory training Program, eHealth Africa, Médecins Sans Frontières, Rotary International, and Nigeria Centers for Disease Control and Prevention are providing support to this outbreak.

The following measures are being implemented:

  • Nigeria Centers for Disease Control and Prevention, with support from the WHO, is taking the overall lead in coordinating the response at the national level.
  • Daily coordination meetings are being held at the state and LGA levels.
  • The rapid response teams are conducting active case finding, performing lumbar puncture of suspect cases and training local staff on case management.
  • Case management is being carried out at the public health centres at the LGA level.
  • 19 600 persons were vaccinated with the meningococcal ACWY vaccine in Gora ward in Zamfara state.
  • 500 000 doses of meningococcal AC PS vaccines and injection supplies was approved by the International Coordination Group (ICG) for utilization in Zamfara State which are planned to arrive on 27 March 2017.
  • Katsina state is preparing an ICG request for submission.

WHO risk assessment

The successful roll-out of MenA conjugate vaccine has resulted to the decreasing trend of meningitis A, however, other meningococcal serogroups are still causing epidemics. The most recent outbreak that has been reported was in Togo due to Neisseria meningitidis serogroup W (see Disease Outbreak News as published by WHO on 23 February 2017).

WHO advice

The outbreak response consists of appropriate case management with reactive mass vaccination of populations. Promptness of the reactive campaign is essential, ideally within four weeks of crossing the epidemic threshold.

WHO does not recommend any travel or trade restriction to Nigeria based on the current information available on this outbreak.


Togo: Since 1 January 2017, 201 suspected cases of meningitis with 17 deaths were reported by 19 health districts.

WHO

Meningococcal disease – Togo

Disease outbreak news
23 February 2017

Since 1 January 2017, 201 suspected cases of meningitis with 17 deaths were reported by 19 health districts. In week 2, the district of Akebou which is part of the Plateau Region issued an alert after four cases of meningitis were reported. In week 4, the epidemic threshold was reached with nine cases and an attack rate of 12.4 per 100 000 inhabitants. From 2 January to 12 February 2017, 48 suspected meningitis cases with three deaths were reported (case fatality rate of 6.3%). Of these, 14 specimens were confirmed as Neisseria meningitidis serogroup W by PCR.

The Plateau Region, together with the other three regions in the country benefited from the mass vaccination campaign with MenAfriVac in December 2014.

Togo is part of the African meningitis belt and documents cases and deaths due to meningitis every year. In 2016, the country recorded an epidemic in the northern part caused by Neisseria meningitidis serogroup W. A total of 1975 cases and 127 deaths were reported in 2016.

Public health response

In response to the outbreak, the following measures are being implemented:

  • 56 000 doses of meningitis vaccines have been requested from the International Coordinating Group (ICG) for the planned vaccination campaign.
  • WHO Field Mission was deployed in the field to strengthen outbreak management.
  • Strengthening of meningitis surveillance at the district level.
  • Training of clinicians at the district level on case management.
  • Conducting cross-border meetings with Ghana and Benin.

WHO risk assessment

The largest burden of meningococcal disease occurs in the African meningitis belt. Although the successful roll-out of MenA conjugate vaccine has resulted in the decreasing trend of meningitis A, other meningococcal serogroups are shown to have caused epidemics. This report of the Neisseria meningitidis W outbreak in Togo calls for a close monitoring of the changing epidemiology of meningococcal disease. There is a need to ensure that global stocks of vaccines are available, laboratory and epidemiologic surveillance systems are strengthened and outbreak response strategies in the countries are on hand.

WHO advice

The epidemic response consists of prompt, appropriate case management involving reactive mass vaccination of populations, and strengthening of meningitis surveillance.

 


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