The Deadly Sleeping Menace of Meningitis and What Can be Done

The recent outbreak of Meningitis C in 19 states across Nigeria has already resulted in over 400 deaths in the country. The most affected states are Zamfara, Katsina, Kebbi, Sokoto, and Niger.

This is not the first time such an outbreak from Cerebral Spinal Meningitis (CSM) has occurred. The worst Meningitis outbreak in Nigeria and neighboring countries occurred in 1996 and 1997 with over 25,000 deaths, majorly from the Meningitis A strain.

Common symptoms of CSM include sudden high fever, stiff neck, severe headache that seems different than normal, headache with nausea or vomiting, confusion or difficulty concentrating, seizures, sleepiness or difficulty waking, and sensitivity to light. I recall in 1996 a family of four children brought into the emergency pediatric ward where I worked who had complaints of headaches, high fever, and neck stiffness. Before nightfall, three of the children were dead. Along with other doctors and health staff of the Plateau Hospital in Jos, I worked around the clock to treat patients with CSM. We were able to treat many kids with appropriate antibiotics and intensive care. The lucky ones were those that came to the hospital for treatment early. Many who survived, however, continued to have some sequelae of the disease such as deafness.

While 400 deaths are nowhere near the number of deaths recorded 20 years ago in the sub-region, this is the highest rate of infection and deaths from the Meningitis C strain in Nigeria. It is known that the Meningitis disease pattern has a ten to fifteen-year cycle, what is harder to predict is the strain. The major strain seen in Nigeria in the past has been the Meningitis A strain. That strain, however, has been gradually reducing as a result of the massive preventive campaigns in the Africa Meningitis belt with the MenAfriVac, a vaccine targeting the Meningitis A strain.

Cases of the Meningitis C strain were reported in Nigeria as early as 2013. Then they were reported again in 2014 and 2015. This should have been an early warning for Nigeria. In a meeting of experts in October 2015 at the World Health Organization (WHO), concerns over Meningitis C and the preventive measures that needed to be put in place such as enhanced surveillance, prepositioning for rapid laboratory diagnosis, lumbar puncture kits, and antibiotics were discussed. Vaccination was also discussed. Given the shortage of the vaccines for the Meningitis C strain, it was suggested that rather than the ideal preventive campaign with a polyvalent vaccine effective against the Meningitis C strain, a reactive campaign should be conducted at the onset of an outbreak.

With so much warning and notice it is surprising that Nigeria was still not prepared and over 400 people have already died.

In contrast, Nigeria quickly responded to the Ebola outbreak in 2014. Through coordination at all levels of government, the Ebola disease was prevented from spreading beyond 20 people and out of the 11,000 deaths across Africa, only eight were in Nigeria. The rapid containment in Nigeria has been lauded the world over. With the warning spikes of CSM (type C strain) during the past four years, why hasn’t the response to this outbreak of Meningitis C been as rapid? Especially since the lessons learned from Ebola can enable a swifter and better-coordinated response.

Community members at a health facility in Sokoto where JSI, through the Targeted States High Impact Project, worked to strengthen healthcare delivery. Photo credit: JSI.

Regardless of why, Meningitis C is here, so now what?

There are many lessons to learn from the 1996 Meningitis outbreak. Based on it, the pathway forward from here needs to include a prepared health workforce, surveillance, lab testing and diagnosis, prompt identification and treatment, and vaccination. It also must include engaging with communities and providing them with the right information about prevention and treatment.

Most of all, we need vaccinations. The success from the use of the vaccine formulated for the prevention of Meningitis A in Africa, MenAfriVac, resulted in the reduction of Meningitis A deaths from thousands in 2009 to almost none in 2014. Dr. Marie-Pierre Preziosi from WHO told BBC back in November 2015, “There will be major epidemics in 10 to 15 years, so the call to countries now is, ‘Do not stop your efforts — you need to introduce the vaccine into routine immunisation programmes.”

Nigeria has received an initial 500,000 doses of Meningitis C vaccine and is expecting 823,970 more for a reactive campaign. The Federal Ministry of Health and Agencies, state governments, and partners are working hard to ensure the outbreak is stopped. One urgent step though is for Nigeria to come up with the resources needed to ensure the total amount of vaccines required are purchased, arrive on time, and are distributed to where they are most needed.

Nigeria is due to introduce MenAfriVac vaccine into its routine immunization system in 2017, but what happens the next time a different strain emerges? Further studies are needed to determine the most appropriate vaccine to be introduced in Nigeria.

Ultimately, preparing for outbreaks begins long before the first case and must entail a strong routine immunization system that provides vaccinations to all target groups, regular communication and education of the public, regular upskilling of health workers, strong surveillance, and prepositioning and stockpiling vaccines and appropriate medicines. The Government of Nigeria and partners need to look closely at prioritizing this before the next outbreak.

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