Current situation in the meningitis belt, impact of MenAfriVac, countries that have introduced or committed to introducing it into routine schedules, catch up campaigns, controlling outbreaks and the challenge of maintaining vaccine stockpiles, use of conjugate and polysaccharide vaccines https://www.meningitis.org/mrf-conference-2017

1. MRF ConferenceMRF Conference
14-1514-15November 2017November 2017
Meningitis Control in Africa
Dr Ado BwakaDr Ado Bwaka
WHOWHO
Inter country Support Team - West AfricaInter country Support Team - West Africa

2. Outline
1. Current Epidemiological situation of meningitis in Africa
2. Strategies to eliminate meningitis epidemics
3. MenAfriVac achievements 2010–2017
4. MenAfriVac introduction in routine : challenges
5. Controlling meningitis outbreaks and challenges
6. Conclusion

3. Meningitis burden remains high in the region
MenAfriVac introduction
2010-2017
Meningitis suspected cases and deaths in Africa, 2004-2017

4. Bacteriological profile of meningitis in Africa 2003-2017
Predominance of
non NmA after 2010:
Nm C, W, X, and Sp.
In 2017:
NmC (35%) major
epidemics since 2015
(Nigeria, Niger(
S.pneumoniae (27%(
Mixed epidemics in
Ghana since 2016
(Sp. & NmC(
NmX (13%)
increasing since 2016
NmW (10%(
major epidemics
since 2016 (Togo &
Ghana(
Predominance of
non NmA after 2010:
Nm C, W, X, and Sp.
In 2017:
NmC (35%) major
epidemics since 2015
(Nigeria, Niger(
S.pneumoniae (27%(
Mixed epidemics in
Ghana since 2016
(Sp. & NmC(
NmX (13%)
increasing since 2016
NmW (10%(
major epidemics
since 2016 (Togo &
Ghana(
MenAfriVac first introduction

5. • Ensure long-term protection against NmA disease
A regional effort, a two-fold strategy
1. Mass vaccination campaigns (herd protection)
2. Routine immunization (long-term sustainability)
• Enhance outbreak response and control
• Enhance surveillance and strengthen laboratory capacity
• Promote development & use of affordable multivalent conjugate vaccines
Strategies to eliminate meningitis epidemics

6. MenAfriVac achievements
Mass campaigns & Routine immunization 2010–2017
> 280 million persons vaccinated in 21 countries
1-dose campaigns targeting 1 to 29 year-olds
 3 million children vaccinated
 Nationwide introduction in 7 countries, underway in an additional 6
countries

7. MenAfriVac® introduction in routine : challenges
• Nationwide vs. high risk areas
• Public perceptions of inequity could arise with regard to different vaccination
programmes in different parts of the country
• Complexity of implementing different vaccination programmes in the same country
• Multiple injections at one visit: MCV1 and YF at 9 months
• Vaccination beyond 12 months of age, changing norms and behaviors:
Mothers; Communities; Health workers
• Health workers training

8. Huge MenAfriVac impact on carriage and disease
Kristiansen et al. (2011, 2012) Burkina Faso
Elimination of NmA carriage in vaccinated & unvaccinated population up to two years after mass
vaccination, when comparing pre- and post-vaccination carriage prevalence
Clin Infect Dis. 2013 Feb 1;56:354-363.
BMC Infect Dis. 2014 Dec 4;14:663.
Daugla et al. (2012, 2013) in Chad
94% reduction in incidence of meningitis in vaccinated vs. unvaccinated districts (suspected cases)
98% decrease in NmA carriage prevalence 4-6 months after mass vaccination vs. pre-vaccination
Lancet. 2013 Jan 4; 383: 40–47.
Emerg Infect Dis. 2015 Jan;21:115-8.
Trotter et al. (2010-2015) in 9 countries (Benin, Burkina Faso, Chad, Côte d’Ivoire, Ghana, Mali, Niger, Nigeria, and Togo)
58% decline in incidence of meningitis (suspected cases)
>99% decline in incidence of NmA meningitis (confirmed cases)
60% decline in risk of epidemics
Lancet. 2017 Aug; 17, 867–872.

9. Sustained vaccine impact on NmA carriage
2009 – 2012 ... 2016 - 2017
Kristiansen PA et al. Clin Infect Dis 2013, BMC Infect Dis 2014
2009 2010 2011 2012 2013 2014 2015 2016 2017
7 years after mass vaccination campaigns
•No Nm A
•No ST-7 or ST-2859 with a non-A capsule
•Predominance of non-groupable Nm (ST-192)
•Presence of invasive epidemic strains C (ST-10217) et W
(ST-11)
Kristiansen PA et al. Preliminary results
MenAfriVac mass campaigns MenAfriVac catch up campaign - routine introduction

10. Vaccine effect on disease, on meningococcal carriage and
transmission
94% reduction
in meningitis incidence
98% difference in NmA carriage
prevalence
Daugla et al, Lancet 2014

11. Vaccine impact on disease
and risk of epidemics, 2005-2015
>99% decline in NmA
IRR=2.0 (95%CI 0.92, 4.38)
for other Nm
58% decline in meningitis
60% decline in risk of epidemics
in fully vaccinated population
Analysis of surveillance data from 9 countries:
Benin, Burkina Faso, Chad, Côte d’Ivoire, Ghana, Mali, Niger, Nigeria, Togo

12. However, NmA is still in circulation
Confirmed cases of NmA after MenAfrivac campaigns, 2011-
2016 NmA detected:
-2015: in 3 countries
-2016: in 5 countries
-2017: in 2 countries (Guinea, Nigeria)
Only one documented case of vaccine
failure (NmA in a vaccinated case)
in Burkina Faso
Introduction into routine is a priority

13. Meningitis epidemics in Africa 2016-17
Figure A : Meningitis epidemic season 2016 w 1-26 Figure B : Meningitis epidemic season 2017 w 1-26
W
C
S.p
W C
Sp
Countries Suspected cases Deaths
Nigeria 14,518 1,166 (CFR = 8%)
Niger 3,303 197 (CFR = 6%)
Togo 515 35 (CFR = 6.6 %)
Cameroon 25 9 (CFR = 36%)
Ghana 817 75 (CFR = 9.2%)
Chad 205 (CFR = 9.3%)
Countries Suspected cases Deaths
Nigeria 600 29 (CFR = 5.2 %)
Niger 1540 114 (CFR = 7.4 %)
Togo 1834 118 (CFR = 6.4 %)
Ghana 2406 222 (CFR = 9.2%)
Chad 114 21 (CFR = 14.6 %)
CW
S.p
X

14. 14
An emerging threat: NmC
Total Cases 14,518
Total Deaths 1,166
Case Fatality Ratio 8%
Samples tested 1006 (7%)
Confirmed cases 474 (47%)
NmC 80%

15. 15
Delays in response: surveillance (analysis and reporting) and laboratory confirmation
EOC Activated
Graph courtesy of Dr. Chikwe Ihekweazu, National Coordinator NCDC

16. Challenges in surveillance and laboratory confirmation
Data quality
Laboratory confirmation capacity
Rapid Test developments
Picture courtesy of

17. Controlling Meningitis outbreaks and challenges
• Planning and resource mobilization
• Annual planning and review meeting on surveillance, preparedness and response and
MenAfriNet partners meeting
• Encourage resource mobilization to implement epidemic preparedness and response
action plan to meningitis epidemics
• Coordination and partnership
• Reinforce technical support during epidemic season in countries
• Regional monitoring of meningitis surveillance
• Support the functioning of national rapid response committees
• Fostering national and international partnership for surveillance and response to
meningitis outbreaks

18. Emergency vaccination response: challenges
 Lack of vaccine
• In 2017: 4,208,505 doses of
vaccines requested by countries
versus 2,877,490 released
 Delays in accessing the international
vaccine stockpile (ICG)
• Late request by countries
• Surveillance data not supportive
• Average shipment : 10 days
 Falsified vaccines (Niger, Cameroon)
Delays in response
2
4 4
9
12
17
20
10 9
7
0 0 0 0 1
2
0 0 1 0
0
5
10
15
20
25
S1 S2 S3 S4 S5 S6 S7 S8 S9 S10
Reactive vaccination
Epi curve, Akebou district, Togo

19. Getting more vaccine!
 Recognized usefulness of
national contingency stockpiles
 close monitoring (quality and
quantities)
 ICG equity principle should be
maintained
 Balance (ideal stock size) to be
carefully maintained
 Procurement strategy (WHO,
GAVI, UNICEF SD) - 5 years
tender 2017-2021 for 25
million doses (5 million doses
per year)
 Promote development and use
of affordable multivalent
conjugates

20. Conclusion
• Unpredictability of meningitis
epidemics. Re-emergence of non-A
meningococcal diseases (C-W-X)
after the introduction of
MenAfriVac
• Need for efficient surveillance
• Laboratory confirmation is key and
should be strengthened
• Resource mobilization for vaccine
stockpile and lab materials for
prompt and adequate response to
• Continue MenAfriVac introduction
for elimination of Meningococcal
meningitis A through campaigns
and routine immunization
• Regional plan for eliminating all
epidemics – 2030 horizon

21. Merci - Thank you