meningitis
DESCRIPTION
TRANSCRIPT
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MANAGING MENINGITIS EPIDEMICS IN AFRICA
MANAGING MENINGITIS EPIDEMICS IN AFRICAEHA Team
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Outline 1. Objective2. The disease3. Transmission4. Disease burden5. Disease trend- Ethiopia6. Strategies for epidemic control7. Disease incidence8. Determining alert & epidemic threshold9. Pillars 1, 2,310. Post epidemic follow up11. M&E and performance indicators
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Objectives
• GeneralTo detect early, confirm and appropriately respond to meningitis epidemics
• Specific– Collect and analyze data on suspect cases– Rapid lab confirmation– Use information for control measures
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The Disease – Meningococcal meningitis • A serious bacterial infection of the meninges caused by
the bacteria Nisseria meningitides .• Commonest sero-groups of – Nm: A, B, C, W135• Bacteria carried in the throat, transmitted from person
to person through respiratory or throat secretions. • The average incubation period is 4 days (2 - 10 days).• Most common symptoms: high grade fever, headache
stiff neck, confusion, sensitivity to light and bulging fontanel in infants.
• Fatal in 50 % of cases if untreated and may cause severe brain damage in 10–20 % of patients who survive.
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Disease Burden
• Epidemic Meningococcal Disease is a major public health challenge
• 90 % of cases reported in the “Meningitis belt” that stretches across - Senegal to Ethiopia with approximately 450 mill people
• About 700,000 cases in a decade with a CFR 10%
• High risk period : December to June
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Disease burden- EthiopiaNational Trend of Meningitis Cases and Deaths from 2000-2009: Ethiopia
7018
5037
2170
3165
701 1007 662 612 797
329250
179 187
28 47 11 18 270500
100015002000250030003500400045005000550060006500700075008000850090009500
10000
2000/2001 2001/2002 2002/2003 2003/2004 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009
Years
Numb
er of
Cas
es an
d De
aths
0501001502002503003504004505005506006507007508008509009501000
Cases Deaths
Analysis: WHO - Ethiopia Country Office DPC Cluster UnitData Source: FMOH - EthiopiaDate of Production: March, 2010
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Cases= 1465. Deaths = 0. Affected Woredas= 60
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Strategy for epidemic control-Africa Region
• Three- pillar strategy for epidemic meningitis control
• Pillar 1: Surveillance• Pillar 2: treatment and care• Pillar 3: vaccination.
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Calculating disease incidence & CFR
Attack rate Case fatality Ratio (CFR)
Number of casesdivided by total district population X 100 000
Number of deaths divided by number of cases in the same period X 100
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Determining alert and epidemic thresholdsPopulation < 30,000 Population > 30,000
Alert threshold
2 cases in one week OR Greater number of cases than the same period in non-epidemic years
AR = 5 cases/100 000 population /week
Epidemic threshold
5 cases in one week ORdoubling in number of cases over 3-week period. Special situations should be studied on a case-by-case basis (a)
AR = 15/100 000 population/week .In certain conditions indicating higher epidemic risk (b )AR = 10/100 000 population/week
(a) For mass gatherings, refugees and displaced persons, 2 confirmed cases in 1 week are enough to warrant vaccination.
(b) No epidemic in previous 3 years or vaccination coverage < 80 % or alert threshold crossed early in season.
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Pillar 1:SurveillanceScale up surveillance
• Scale up the disease surveillance system at an early stage before the epidemic to detect the first cases.
• Identify the pathogen as well as the sero-group of the meningococcus (Nm) responsible for the infection, to serve as a trigger to launch a rapid response operation.
• use standard case definitions to recognize early cases. Should be confirmed by laboratory tests.
• Standard reporting mechanisms in place to analyse data, determine the extent and evolution of an outbreak.
Case definitionSuspected case:
• Any person with sudden onset of fever (>38.5 °C rectal or 38.0 °C axillary) and one of the following signs – neck stiffness, flaccid neck, bulging fontanel, convulsion or other meningeal signs.
Probable case: • Any suspected case with macroscopic
aspect of its CSF turbid, lousy or purulent; or with microscopic test showing Gram negative diplococci, Gram positive diplococci, Gram positive bacilli; or with leukocytes count of more than 10 cells/mm3.
Confirmed case: • Isolation or identification of the causal
pathogen (Neisseria meningitidis) from the CSF of a suspected or probable case by culture, PCR or agglutination test.
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Pillar 1:surveillance cont.
Pre-epidemic : At the district level:• Design, print and distribute standard reporting forms and
standard case definitions (SCD) to all health centres;• Ensure all health centres are aware of SCD;• Identify/appoint and train surveillance officers in all areas
of the district;• Compile surveillance data on a weekly basis of all
suspected cases (as well as zero reporting), analyse trends and monitor any signs of disease activity;
• Pre-position diagnostic reagents and other surveillance material within district and reference laboratories.
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Pillar 1:surveillancePre-epidemic - health centres:• Be aware of and understand the standard
case definitions;• Report on zero cases and be ready to report
on suspected, probable and confirmed cases;• Conduct lumbar punctures on any suspected
case;• Complete a case-base form for all suspected
cases.
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Pillar 1: surveillance- During epidemicAt the district level:• Monitor and analyse surveillance data on daily basis to determine
the daily AR & CFR .• Disaggregate the data to identify disease activity within age groups
and population centres of less than 100 000 people;• As soon as a district has crossed an alert or epidemic threshold, alert
all the health facilities in the area;• Investigate and verify the extent of any outbreaks that have been
identified;• Ensure 10 CSF samples are collected at the start of the epidemic in
order to determine the Nm sero-group responsible and the type of vaccine required;
• Send CSF samples received from H/Cs to reference lab. for analysis at least twice a week ;
• Monitor the disease activity for the duration of the epidemic season.
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Pillar 1: surveillance- During epidemic• In the health centres:
• compile and submit reports on the number of cases and deaths on a daily basis;
• Continue to collect CSF samples on a regular basis throughout the epidemic in order to detect any change in sero-group;
• Package and forward CSF samples to a reference laboratory, conditioning samples in triple packaging for travel
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Pillar 2- treatment and care- pre epidemic
REMEMBER!• Meningitis is a life-threatening emergency – NEVER delay adequate
treatment.• If laboratory results are available, treat according to microbiological
results.
• At the district level:• Plan and implement training courses for health-workers on epidemic
treatment protocols;• Print and distribute national treatment protocols to all health
centres;• Calculate the amount of antibiotics and material that may be needed
during an epidemic, pre-position stocks in high-risk areas and establish smooth lines for distribution throughout the district.
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Pillar 2- treatment and care – during epidemic
During an epidemic• Instruct all health centres to switch to the
epidemic Rx protocol- – single dose chloramphenicol/ ceftriaxone
• Launch a public info campaign- inform communities of availability of free Rx in Govt H/cs
• Monitor supplies of antibiotics and restock H/cs when stock decrease.
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Treatment protocols during meningitis epidemics in Africa - without laboratory confirmation
REMEMBER!• Never give chloramphenicol to:• pregnant or breastfeeding women• infants less than two months old
In children aged 0–23 months• Ceftriaxone 100 mg/kg/day once a day 7 days • (< 2 months) and 5 days (2−23 months)• Transfer if no improvement within 48 hours or coma or
convulsion• Adapt treatment according to patient’s age and most likely
causative pathogen.• If no improvement after 48 hours, refer.
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Treatment protocols during meningitis epidemics in Africa - without laboratory confirmation
In children over 2 years and adults• N. meningitidis should be considered the most
likely pathogen – presumptive treatment is justified.
• Ceftriaxone- single dose as presumptive treatment- IM route .
Dose =100mg/kg; 2nd dose if no improvement after 24 hrs.
If no improvement after 48 hrs, Rx for 5 dys or refer
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Treatment protocols during meningitis epidemics in Africa - without laboratory confirmation
• OR Oily chloramphenicol single dose as presumptive RxIM routeDose = 100mg/kg (max 3g)2nd dose if no improvement after 24 hrs
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Pillar 2- treatment and care- pre epidemic
In the health centres:• Following lumbar puncture, treat every new
patient who is suspected of having meningitis with antibiotics as soon as possible;
• Ensure any child < 2 yrs or any patient with severe symptoms is admitted to H/C for Rx and adjust the Rx as necessary;
• Record details of all patients in the registry.
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Pillar 3: Vaccination• To limit the magnitude of the epidemic, WHO
recommends large-scale vaccination of pop. Groups at risk, with the appropriate vaccine (AC or ACW)
• Vaccination should target Meningococcal sero-group identified being responsible for the outbreak
• Such VC require extensive coordination involving procurement, distribution and logistics, public information and post-vaccination follow-up.
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Pillar 3: Vaccination- epid threshold crossed • If ET exceeded in a district, Nm sero-group identified, essential that a
VC is conducted in both the district affected and any adjacent district reached the alert threshold.
• A micro-plan and budget for each area targeted for mass vaccination must be prepared.
• Sufficient amounts of vaccines be requested from the national stocks, or from the International Coordinating Group (ICG) on Meningitis Vaccine Provision which manages the international emergency stockpile.
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Pillar 3: vaccination
• A public information campaign must be launched to inform all the communities in the target areas of the coming campaign.
• A cold chain to distribute the vaccines to the target areas must be established/strengthen.
• Preparations must be made to manage the waste from the campaigns.
• A system for monitoring adverse events following vaccination will be needed.
• 1. The ICG is composed of representatives from WHO, UNICEF, Médecins sans Frontières (MSF) and the International Federation of the Red Cross and Red Crescent Societies (IFRC).
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Pillar 3-Vaccine considerationsThere are two types of Meningococcal vaccines available:• Polysaccharide vaccines in various combinations against A, C,
W135 and Y.– A and C vaccines developed over 30 years ago. – In reactive vaccination: Bivalent vaccine against A and C,
Trivalent against A, C and W 135, Tetravalent vaccine against A, C, Y and W 135.
• Conjugate vaccines against C and A, C, W135 and Y. Unlike polysaccharide vaccines, conjugate vaccines affect bacterial carriage, and thus transmission. They can create herd immunity. They are new but very costly
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Pillar 3- Preparing a vaccination micro plan
• To access International coordination group (ICG) vaccine stockpile the following are required:
• Provide evidence of a meningococcal disease outbreak.
• Provide laboratory confirmation of the Nm sero-group responsible.
• Develop and provide plan(s) of action for the vaccination campaign(s).
• Provide proof of necessary storage and transportation resources to ensure the safe and effective delivery and maintenance of the vaccines to the area affected.
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Pillar 3- Preparing a vaccination micro plan• A micro-plan must be prepared for every district targeted for a vaccination campaign. • Responsibility of the district health authorities to complete, submit the plan to secure the
necessary vaccines.
• The micro-plan should include:• Names of sub-districts targeted for vaccination;• Total population currently present in the target areas;• Population targeted for vaccination; • Type and quantity of vaccine needed;• Quantity of additional supplies needed – AD syringes, safety boxes, dilution syringes, cotton
wool, gloves;• Number of teams conducting the campaign (each team requires vaccinators, recorders,
crowd controllers and a supervisor);• Number of supervisors – at team, district, provincial and central levels;• Mechanism for training the vaccination teams;• Logistic needs – cold chain equipment, vehicles;• Mechanism for managing waste resulting from the campaign;• Plans for vaccination campaign coverage surveys.
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Pillar 3: vaccination budgetThe budget should include:• Allowances for members of the vaccination
team;• Social mobilization costs (including allowances
for staff);• Costs of logistic equipment;• Costs of waste management.
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Post-epidemic follow up• A meningitis epidemic is declared to be over - attack rate
descends below the alert threshold over 2 consecutive weeks. Once that point has been reached, a number of follow-up activities are needed:
• Continue weekly reporting of both cases and laboratory results to monitor decreasing trends;
• Gather remaining stocks of antibiotics or reposition for use in treatment for other conditions;
• Return any remaining stocks of vaccines to district stockpiles;• Dispose of all waste following vaccination campaigns;• Conduct a vaccination coverage survey;• Revert to the national endemic treatment protocol;
• Evaluate the outbreak response and compile a report on the
outbreak and feedback to stakeholders.
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Monitoring and Supervision• District level
– Health staff are trained on how to perform lumber puncture
– Update staff on case management, thresholds, reporting• Regional level
– Surveillance staff to visit affected districts monthly– Emergency committees to be reactivated– Regular weekly meetings advised
• National surveillance unit– Monitor if any district has reached alert thresholds– Check with lab after every 5 days– Availability of TI bottles– RRT to be designated
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Monitoring and Supervision • National Reference laboratory
– Ensure timely sending of results to the districts– Regular feedback on specimen transportation and
handling – Ensure that transportation of specimen to WHO
collaborating centres complies with the required international standards
• National Technical coordination group– Monitor the epidemic through weekly meetings
implementation of enhanced surveillance of Meningitis– Ensure coordination of inputs from other partners.– Regular updates and end of epidemic report
• WHO, collaborating centres and other partners– DPC on behalf of WR to coordinate the activities– Sub-regional level, WHO, Partners will provide technical
support
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Performance indicators of SOPs
• Reporting: Percent of districts which have reported weekly NM cases and deaths on time (80%)
• Field investigation: % of alert and epidemic districts that have sent at least 10 TI bottles to NTLab (80%)
• Lab investigation: % of alert and epidemic districts that have confirmed sero group from at least 10 TI bottles (80%)
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Performance indicators of SOPs • Feed back-Lab: Percent of alert and epidemic
districts that received results from the lab within10 days of sending TI bottles.
• Specimen handling and lab investigation: % of culture negative samples Per week (<10%)
• Specimen handling and lab investigation: % of contaminated samples per week (< 20%)
• Reporting to AFRO?: % of countries reporting weekly (80%)
• Reporting/Feedback: % of weekly bulletins to countries, WHO/AFRO/HQ and partners (80 % within two weeks)
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References
Managing meningitis epidemics in AfricaA quick reference guide for health authorities
and health-care workers.November 2010
World Health Organization
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THANK YOU