'The epidemic has started' - Responding to a meningitis outbreak in southern Sudan

Bacterial meningitis is spread through the air when people sneeze or cough. While most infected people never develop symptoms, without treatment, the disease can kill up to 50 percent of those who do.
"What is really troubling is that we've probably only identified half of the cases. The rest are invisible, people dying in their villages in the really remote areas because they have no access to healthcare facilities." - Dr. Jean-Paul Delain

What is the current situation with meningitis in Aweil East county?

"The epidemic has started and it is increasing quickly. At the beginning of my first week here, there were 12 cases, and they were all being treated at MSF's hospital in Akuem. By the second week, it exploded, and we now have an epidemic alert. By mid-April there were nearly 40 cases - seven people came in just yesterday. This may not sound like a lot, until you consider that the threshold for a meningitis epidemic is 10 cases per 100,000 people.

"With 165,000 people living in the midlands, we are now at more than 20 cases per 100,000 people - more than double the threshold. The situation is worrying, to the extent that Unicef and the World Health Organization (WHO) have even put an important tetanus and measles vaccination campaign on hold.

"Of course what is really troubling is that we've probably only identified half of the cases. The rest are invisible, people dying in their villages in the really remote areas because they have no access to healthcare facilities."

How is MSF responding to the outbreak?

"First, we treat the people who contract meningitis, which is relatively straightforward. For children over one year of age and adults, one intramuscular injection of the antibiotic oily chloramphenicol or a high dose of ceftriaxone works extremely well. We treat infants and pregnant women with daily injections of the antibiotic ceftriaxone for five days.

"To prevent further cases, we will vaccinate at least 25,000 people. We found clusters of cases in a very narrow strip of the area, and there are three health centers - one here in Akuem, and the others in Malual Bai and Malualkon to the east. We should be able to take care of all of the cases in these centers, but if there are more cases from elsewhere we will expand the vaccination campaign.

"We have some problems, though. It may rain soon, which will give rise to many logistical problems, especially because the roads will become nearly impassable. Also, there is always a concern that there may not be enough vaccines available - because of procurement issues, especially this year with meningitis outbreaks and vaccination campaigns occurring in several countries.

"MSF is involved in vaccinations in eight countries: Ethiopia, Nigeria, Niger, Guinea, Burkina Faso, Chad, Uganda, Kenya. These campaigns were enormous and used a large amount of vaccines for the W135 strain of meningitis. But we have 25,000 doses and will start vaccinating in the midlands section."

How many cases have been identified as the W135 strain?

"There are three known strains of the meningococcal bacteria - A, C, and W135. A and C are equivalent, but W135 is newer and seems to spread more quickly. So far, we have only five confirmed cases of W135, but because of this, we will need to use the trivalent vaccine, one that protects against all three strains.

"If we are in the middle of a W135 outbreak, it could be a catastrophe to only use the bivalent AC vaccine because it offers no cross-protection. It would be as if you never vaccinated people at all. The choice of vaccine depends on identifying the bacteria type in the area and can be a huge challenge in isolated areas in Sudan, given the need for cold chain."

What has been your impression of the general healthcare situation in Aweil East county?

"The most striking thing is the absence of health facilities. Away from Akuem, there are almost zero health services. Because of this, people are walking for days to reach MSF in Akuem. In Rumaker, four hours by car north in the highlands, there was absolutely nothing for 25,000 people.

"This is the first time I have been in a country with such a situation. In Congo, even Ethiopia, there are small health posts all throughout the country, but here, it is a health care desert. Imagine life for 25,000 people without medicines, without medical personnel, without any health care whatsoever.

"This morning on an assessment to Malualkon, we treated a little boy who broke his foot in a bicycle accident. His father stopped us on the road and we took care of him. And when we were in Rumaker, a father brought us a little boy suffering from cerebral malaria.

"Except for us treating him on the spot, there was nothing for him. Both received medical care by pure chance. While these boys did not have anything to do with meningitis, I can't help but think that there are hundreds of children just like them in the surrounding areas who receive nothing at all."