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The meningitis outbreak
returns to Niger: Concern, efforts, challenges and recommendations .
Abstract
Meningitis, a disease that commonly manifests in African meningitis
belt, continues to be a public health problem as it is a fatal disease
that leave survivors with long-term effects. Most cases of meningitis
are due to bacterial and viral infection, although parasites, fungus,
cancer, drugs, and immune disorders can rarely cause meningitis. Stiff
neck, high temperature, light sensitivity, disorientation, headaches,
and vomiting are the most typical symptoms of meningitis. Niger being in
African meningitis belt, has been impacted by many meningitis outbreaks.
Since 2015, a total of 20 789 cases and 1369 fatalities (CFR 6.6%) have
been documented in Niger. In contrast to earlier seasons, the current
outbreak of meningitis in Niger exhibits both an increase in the number
of cases and a rise in the growth rate. A total of 559 instances of
meningitis, including 18 fatalities (overall CFR 3.2%), were reported
in the Zinder Region, southeast of Niger, from 1 November 2022 to 27
January 2023, compared to 231 cases reported from 1 November 2021 to 31
January 2022. In the current outbreak, the Neisseria meningitidis
serogroup C (NmC) is responsible for the majority of laboratory
confirmed cases (104/111; 93.7%). To organize the response to the
pandemic, a global team from the WHO and other partners, including MSF
and UNICEF, has been sent out in Niger. Even though there are many
challenges in battle against meningitis in Niger, immunization,
antibiotics administration and strong disease surveillance are
recommended techniques to cope with the current meningitis outbreak in
Niger.
Keywords: meningitis, outbreak, Niger, African meningitis belt,
vaccination.
Introduction
Meningitis, a fatal disease that leaves survivors with serious long-term
effects, continues to be a serious global public health problem
[1]–[3]. There are threats from cases and outbreaks in many
nations around the world. The condition, which is inflammation of the
membranes surrounding the brain and spinal cord, is primarily caused by
bacterial and viral infection. Meningitis can also be the result of
parasitic and fungal infections, and cryptococcal meningitis is more
prevalent in HIV positive individuals. Non-infectious causes such as
specific drugs, cancer, and autoimmune disorders can also cause
meningitis [1].
Bacterial meningitis has significant long-term repercussions and a high
case fatality rate, and is caused by several kinds of bacteria. These
bacteria include Streptococcus pneumoniae, Haemophilus influenzae,
Neisseria meningitidis, and Streptococcus agalactiae (group B
streptococcus). Although it occurs less commonly, other bacteria such as
nontyphoidal salmonella, Listeria monocytogenes, Streptococcus suis, and
pathogens such as Staphylococcus aureus or S. epidermidis can also cause
meningitis [1], [4].
In the African meningitis belt, which Lapeyssonnie first described in
1963, meningococcal meningitis is a major threat [5]. Meningitis
seasonal hyperendemicity and recurrent large-scale outbreaks are known
features of the African meningitis belt, which spans sub-Saharan Africa
from Senegal to Ethiopia [6]. The epidemic begins early in the dry
season and ends quickly with the arrival of the rains, but may recur in
the next dry season. Meningitis epidemics mostly last between two and
three years in any given nation. In addition to being difficult to
forecast, the recurrence of these epidemics is poorly understood.
Meningococcal disease outbreaks are currently controlled by early
diagnosis of the disease using the epidemic threshold of ten to fifteen
cases per 100,000 people per week, followed by widespread administration
of polysaccharide vaccines [7].
Meningitis epidemics were primarily caused by serogroup A Neisseria
meningitidis (NmA) until the development and administration of
meningococcal serogroup A conjugate vaccine (MenAfriVac) in the
meningitis belt starting in 2010, however since then, no NmA epidemics
have happened. Serogroups W (NmW) and X (NmX) have, however, frequently
caused epidemics since 2000, sometimes with local incidence rates which
can be compared to NmA outbreaks. The causes of epidemics are still
speculative, but their identification would improve epidemic prediction
and aid in the development of control measures such as immunization
[8].
The incubation period of the causative agents mostly lasts 4 days on
average, however, it can last anywhere between 2 and 10 days [4].
Stiff neck, high temperature,
light sensitivity, disorientation, headaches, and vomiting are the most
typical symptoms of meningitis [9]. Even with prompt diagnosis and
appropriate care, 5% to 10% of individuals pass away, usually 24 to 48
hours after their symptoms first appear. 10% to 20% of survivors of
bacterial meningitis may experience brain damage, hearing loss, or
learning disability. Meningococcal septicaemia, which is characterized
by a hemorrhagic rash and rapid circulatory collapse, is a less common
but much more severe and frequently fatal variety of the disease
[10].
Epidemiology and outbreak of meningitis in Niger
Niger has been impacted by many meningitis outbreaks due to its location
in the African meningitis belt, resulting in
20 789 cases and 1369 fatalities
(CFR 6.6%) documented since 2015.
A total of 559 instances (111
laboratory confirmed cases) of meningitis, including 18 fatalities
(overall CFR 3.2%), have been reported in the Zinder Region, southeast
of Niger, from 1 November 2022 to 27 January 2023, compared to 231 cases
reported from 1 November 2021 to 31 January 2022.
Neisseria meningitidis serogroup
C (NmC) is responsible for the majority of laboratory-confirmed cases
(104/111; 93.7%) [10].
Meningitis epidemics occur seasonally in Niger every year due to its
location mostly within the African meningitis belt.
In contrast to earlier seasons,
the current outbreak exhibits both an increase in the number of cases
and an increase in the growth rate. The risk of an international spread
is confirmed by the fact that Jigawa State in Nigeria, where a NmC
outbreak is also ongoing, and Zinder Region share a border
internationally. Furthermore, the concurrent incidence of other
epidemics, insecurity, and population relocation, all within the
framework of a prolonged humanitarian crisis, are likely to aid in the
spread of the outbreak to other subregional nations in West Africa
[10].
Efforts to conquer meningitis in Niger
In the Zinder area, a technical committee has been formed
to organize the response to the
pandemic. To help in response, a global team from the WHO and other
partners, including MSF and UNICEF, has been sent out. Case
investigations are part of the surveillance system operations that have
been strengthened in the Zinder region, particularly in the Dungass
health district. Laboratories are still collecting samples and
confirming results of probable meningitis cases. Acquisition of
antibiotic ceftriaxone, isolation of patients, deployment of health
workers for case management, dissemination of case management
guidelines, and free treatment for cases are only a few of the case
management actions that have been strengthened [10].
The International Coordinating Group (ICG) on Vaccine Provision approved
and delivered a request for 608 960 doses of the trivalent ACW
polysaccharide vaccine on December 31, 2022, and January 9, 2023, in two
batches of roughly 300 000 doses each. The Global Alliance for Vaccines
and Immunization (GAVI) and WHO have supported the Ministry of Health in
implementing reactive vaccination campaigns with the trivalent ACW
meningococcal polysaccharide vaccine in the health districts of Dungass,
Gouré, Mirriah, and Matamèye, targeting the age range of 2 to 29 years.
Overall, a 99.8% immunization rate was achieved. In close collaboration
with administrators and community leaders in affected districts, risk
communication and community engagement activities are ongoing, providing
health advice and infection, prevention, and control recommendations
through community radios and other channels, including door-to-door
education on the necessity of seeking immediate medical attention if
symptoms occur in order to promptly begin treatment [10].
Challenges to fight meningitis in Niger as well as in African
meningitis belt
Challenges in conquering meningitis in African meningitis belt is found
in prevention, epidemic control, diagnosis, treatment, and disease
surveillance. First, multivalent conjugate vaccines are inconsistently
used, rarely available, and expensive, and some serogroups are not
covered by existing vaccines. Because not all strains are protected by
new MenB protein vaccines, herd immunity may not be achieved [1].
Furthermore, the lack of resources, such as laboratories, equipment, and
qualified employees, as well as the availability of drugs and money, are
significant impediments in low-and middle-income countries (LMICs),
especially in the African meningitis belt [11].
Meningococcal illness manifests as sporadic cases or outbreaks and is
dynamic and highly unpredictable [12]. Although a higher percentage
of laboratory confirmation in cases during and between epidemics can
help to assess the spread and threat of new clones, vaccines are
difficult to obtain due to the unpredictable nature of epidemics and the
pathogens involved, as well as the long cycle of the vaccine production
and the short shelf life of vaccines [1].
In many nations, ceftriaxone, a highly efficient antibiotic, is the
standard course of therapy for meningitis [13]. The availability of
ceftriaxone in the African meningitis belt is limited, which may result
in less-than-ideal treatment plans. Lack of access to care causes delays
in treatment initiation, which in turn causes subpar results. Empiric
treatments are frequently used due to limited microbiological
capabilities and a lack of accessible and affordable diagnostics for
diagnosis. Furthermore, in LMICs, healthcare community workers (HCW) may
not be aware of the value of screening for acute problems, such as
seizures and symptoms of elevated intracranial pressure, as well as
sequelae, particularly if there are no approved treatments [1].
Meningococcal disease must be controlled through surveillance, with
outbreak detection, incidence monitoring, disease burden estimation,
analyses of antibiotic resistance, evaluations of control strategy, and
serogroup and strain distribution assessments serving as the main
drivers of surveillance networks [14], [15]. Surprisingly, there
are still large gap in meningitis disease surveillance in terms of
policies and financial support. Several regions do not prioritize
surveillance, hence there is no national guidance for its
implementation, and most low-income countries still rely on external
financial support to conduct surveillance [1].
Recommendations
The most efficient strategy to reduce the severity and effects of
meningitis is to prevent it through immunization, which provides
long-lasting protection [16]. A public health priority is the
distribution of multivalent conjugate meningococcal vaccines to prevent
bacterial meningitis epidemics throughout the African meningitis belt.
To prevent the return of epidemics, routine immunization programs and
maintaining high vaccination coverage are essential.
When promptly administered, antibiotics reduce the risk of transmission
to those in close proximity to meningococcal cases [17]. The right
antibiotics must be administered as soon as possible. It is best to
perform a lumbar puncture first since antibiotics may make it more
difficult for germs to grow in spinal fluid. Blood sampling, however,
can also be useful in determining the reason, and the priority is to
begin treatment early. Meningitis is treated with a variety of
medications, such as penicillin, ampicillin, and ceftriaxone.
Ceftriaxone is the recommended medication for meningococcal and
pneumococcal meningitis epidemics. Chemoprophylaxis is advised for close
household connections outside the meningitis belt in Africa, and
chemoprophylaxis for close contacts in the meningitis belt is advised in
non-epidemic circumstances [10], [18].
Appropriate case management, proactive community case finding, and
reactive mass immunization of affected populations constitute the
response to the epidemic. Meningitis must be controlled through
surveillance, from case identification to inquiry and laboratory
confirmation [10]. Niger is recommended to strengthen meningitis
disease surveillance policies and techniques in order to be able to
respond effectively to the disease outbreak.
Conclusion
Due to its high fatality rate and the potential for severe long-term
consequences, meningococcal meningitis continues to be a public health
concern, especially in the African meningitis belt. The current
meningitis outbreak in Niger is of a great concern. Rapid measures
including mass immunization, screening, drug administration and disease
surveillance are recommended to be implemented by Niger government and
other countries which are particularly in African meningitis belt.
Nations, international organizations, vaccine industries, epidemiology
experts and NGOs are called to work together to eradicate meningitis in
Niger and other countries in African meningitis belt.