Since the first cases of meningococcal meningitis A were confirmed in two districts of the West Nile region of northern Uganda in early January, Médecins Sans Frontières (MSF) has been working closely with the Ugandan Ministry of Health (MoH) and the World Health Organization (WHO) to reduce mortality, minimize the spread of the epidemic, and strengthen the epidemiological-surveillance system. Vaccination campaigns started on February 2.
Meningitis outbreaks have been recorded throughout the region with cases in the Democratic Republic of Congo and southern Sudan where MSF is also assessing the situation. Epidemics of bacterial meningitis are most likely to occur in sub-Saharan Africa in an area known as the "meningitis belt" that spans across the African continent from Ethiopia to Senegal.
"If treatment is not available and vaccination campaigns are not launched, bacterial meningitis epidemics can spread fast and cause hundreds of deaths," said Renaud Leray, Head of Mission for MSF in Uganda.
Two weeks after the epidemic threshold of 10 cases per 100,000 per week was reached in Koboko and Arua districts in mid January, an MSF emergency team of 19 international staff and more than 40 national staff members were operating from Arua town. The epidemic threshold was lowered from the standard level of 15 cases per 100,000 people per week because this region has not been affected by a meningitis epidemic in more than 10 years.
Reducing mortality through quality case management
As of February 11, health authorities recorded 1,474 cases and 44 deaths in Koboko and Arua districts. MSF is supporting case management in 25 health structures in Arua and Koboko districts.
"The case fatality rate is currently relatively low - between 2.4 percent and 5.6 percent - depending on the areas," said Dr. Chantal Umutoni, Medical Coordinator for MSF in Uganda. "But we need to continue monitoring the situation closely."
MSF has already supplied more than 1,600 doses of oily chloramphenicol, the most effective antibiotic treatment, to the health structures where the organization is monitoring cases. A single injection is sufficient in most cases and effective within 24 hours. As a second-line treatment and for pregnant women and children aged between two months and one year, MSF uses ceftriaxone.
Targeting the most affected areas to contain the epidemic
Starting on February 2, MSF, MoH and the WHO worked together to conduct a series of vaccination campaigns targeting a total of 450,000 people. MSF teams contributed to the provision of vaccines, medical supplies and logistical and financial support. Since the vaccination campaign was launched, more than 191,000 people were vaccinated under MSF supervision in 70 different sites in Arua and Koboko districts. The MoH has also vaccinated an additional 260,000 people in Arua and Koboko districts.
"Containing a meningitis epidemic requires not only vaccines and syringes. You need to have a reliable epidemiological-surveillance system, quality case management and a strong strategy for the vaccination campaign," said Leray. "You need to start vaccinating where the attack rate is highest and simultaneously treat all the severe cases. Then you can extend the vaccination to all locations where the alert threshold has been reached."
An additional order of vaccines is being placed with the International Coordinating Group (ICG) on Vaccine Provision for Epidemic Meningitis Control to complete the vaccination campaign.
Maintaining the "cold chain"
Mass vaccinations campaigns require sizeable logistical means. In order to preserve the efficacy of the meningitis vaccine, doses must be kept between two and eight degrees Celsius from reception until delivery at the vaccination site. MSF has set up a "cold-chain" system with the MoH, with a base in Arua town, which is fully equipped with 14 freezers and fridges producing almost 450 kg of ice every day.
Roughly half of the 4,500 icepacks are dispatched every day in 30 large cold boxes. These large cold boxes, designed to maintain the temperature for three days, function as a decentralized supply cold chain base for each vaccination site. Smaller vaccines carriers are the final link between the decentralized base and the vaccination site. Each can carry up to 500 doses of vaccine and require four ice packs.
Efficient supply management is also essential given that the target population changes with the spreading of the epidemic. As in other emergencies, MSF relies on prepackaged kits to respond quickly to epidemics or other emergencies. Each meningitis kit contains all of the medical supplies required to vaccinate 10,000 persons. The logistical team is also in charge of setting up crowd control and waste management systems at each site.