Introduction to

meningococcal
meningitis
Managing
infectious hazards

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 Learning objectives

 list the major components of meningitis

outbreak control
 describe the main challenges in
implementing an effective outbreak
response.

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 Meningitis

 an inflammation of the meninges, the

thin lining surrounding the brain and the
spinal cord;
 main focus on bacterial meningitis due
to Neisseria meningitidis
(meningococcus)
 causes large-scale epidemics;
 several Neisseria meningitidis (Nm)
serogroups. Main epidemic ones are:
Nm A, B, C, W , Y and X.

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 Transmission

 Transmission is person to person from

respiratory droplet/throat secretions
during close and prolonged contact with
carrier or sick untreated person.
No animal reservoirs.
 Incubation: 4 days in average (range is
2-10 days).

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 Transmission

 Asymptomatic carriers:
 bacteria in the pharynx (throat)
 unaffected by the disease themselves
 can transmit it to others
 prevalence: 1-10% (endemic
situations), 10-25% (epidemics).
 Bacteria sometimes overwhelms the
body’s defenses allowing infection to
spread through the bloodstream and to
the brain.

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 Signs and symptoms

 Vomiting  High sudden fever

 Headaches,  Bulging fontanel

sensitivity to light (babies)

 Stiff neck (babies opposite: "the rag doll")

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 Signs and symptoms

 seizure, coma
 petechial rash (meningococcal septicemia).
Without treatment, 10-20% of survivors will suffer
sequelae, (neurological issues) most common is
deafness.
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 Epidemiology

 worldwide distribution
 highest burden: African Meningitis Belt
(26 countries)
large-scale epidemics (20-200 thousand
cases/year)
 seasonal (dry season)
 highest incidence of disease: infants and
young adults
 risk factors: mass gatherings,
overcrowding, smoking (household).

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 New vaccine introduced in 2010

Men A conjugate vaccine (MACV)

dramatic reduction of N. meningitidis A epidemics
Nm W, Nm X, Nm C epidemics still occur

2015 Nm C
outbreak in Nigeria MACV introduction
and Niger (>10,000
cases)

2016 Nm W
outbreak
in Ghana, Togo
(>4000 cases)
Suspected cases of meningitis, African belt, 1985-2016

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 Non A epidemics continues

Suspected Meningitis Cases by Week, Niger 2003-2015

2500 NmC

2000
NmA NmA

NmW
CASES

1500

NmX
1000

500

0
2 2 2 2 2 2 2 2 2 2 2 2 2
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1 1 1 1 1
3 4 5 6 7 8 9 0 1 2 3 4 5
YEAR

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 Diagnosis

Confirmation: Lab. capacity

according to
laboratory
the level:

 Lumbar puncture  rapid diagnostic tests: field

(Cerebrospinal fluid sample)  Gram stain: district
 PCR: regional/national
 culture: regional/national.

Note: Neisseria meningitidis serogroup identification

is key to orientate vaccine choice for response
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 Surveillance

 surveillance systems tailored to:

outbreak detection, monitoring disease
trends, and impact of vaccine;
 standard case definitions (as per IDSR*)
 suspected (clinical)
 probable (laboratory, non specific)
 confirmed (laboratory);
 rapid confirmation of pathogen: critical to
determine appropriate treatment and
epidemic response.
* Integrated Disease Surveillance and Response
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 Surveillance

 strengthening diagnostic lab capacity at all levels

 linking of epidemiological and laboratory data
 enhancement of laboratory quality assessment and control (QA/QC)
 role of WHO Coordinating Centers (CCs) in lab capacity enhancement
and monitoring circulation/emergence of epidemic-prone strains.

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 Surveillance: action thresholds

Weekly surveillance - suspected case attack rates

Alert Threshold
 Preparedness/
3 cases / 100,000 / confirmation
week

Epidemic Threshold
10 cases / 100,000 /  Response
week

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 Treatment

 antibiotics available
 prompt treatment crucial to prevent death and complications
(50% case fatality without treatment)
 in N. meningitidis epidemics:
 5 days ceftriaxone recommended
 7 days in infants 0-2 months.
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 Immunization

Conjugate vaccines
Monovalent C, Tetravalent ACYW.
 expensive (more then 25 $US/dose), confer
longer lasting immunity, prevent carriage
and induce herd immunity;
 monovalent A
Affordable (less then 1 $US/dose), used in
mass preventive campaigns and in routine
infant immunization, starting in 2016. Safe
and long lasting.

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 Immunization

 Polysaccharide vaccines:
AC, ACW, ACYW
Affordable (2-6 $US/dose), offers 3
year protection only, and it does not
induce herd immunity.
 used for outbreak response

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 Chemoprophylaxis

 recommended for household contacts of

meningococcal meningitis in non-epidemic situations

 ciprofloxacin antibiotic is recommended, and

ceftriaxone as an alternative
 1 dose to eliminate carriage

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 Outbreak response

 To prevent
case management
the lethality

 To prevent
reactive vaccination
the cases

Note: Speed is of essential for an effective

vaccination response: within 4 weeks of
crossing the epidemic threshold

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 Key concerns

Very limited global vaccine supply:

 global polysaccharide vaccine production
declining
 vaccines a key component of outbreak
response

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 Key concerns

International Coordinating Group (ICG) emergency vaccine

stockpile since 1997
 executive members: IFRC, MSF, UNICEF, WHO (secretariat)
 ensure rapid, equitable access to vaccines in epidemics
 countries facing outbreaks submit request to ICG
 vaccine release based on availability.
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 WHO recommendations

Preparedness for
outbreaks of
N. meningitidis C
 WER 2015 (633-644):
 Surveillance
strengthening;
 5 day treatment policy
to be maintained as
long as possible;
 Prophylaxis research
protocol.
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 WHO recommendations

Pneumococcal meningitis
outbreaks in sub-Saharan
Africa
 WER 2016 (297-304):
 Extend standard
antibiotic treatment up
to 14 days to be
considered.
 More evidence needed
before recommending
reactive vaccination .

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 Out of the African belt

 Stay pragmatic, forget the thresholds:

 characterize as soon as possible
 epi investigation
 lab confirmation.
 Control:
 case management: presumptive
treatment
 chemoprophylaxis
 prevention of nosocomial transmission
 vaccination.

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 Research and development
Photo credit: Institut Pasteur

 Rapid Diagnostic Tests:

point of care, affordable, heat stable,
and designed for field use.
 Development of affordable
multivalent conjugate vaccines
(ACYXW).
 The ability to understand and
forecast occurrence of epidemics and
estimate vaccine supply needs.

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 Resources

 Managing meningitis epidemics in Africa: a quick

reference guide for health authorities and health-care
workers. 2015
http://www.who.int/csr/resources/publications/HSE_GAR_ERI_
2010_4/en/
 2014 revised guidelines for meningitis outbreak
response
http://www.who.int/csr/resources/publications/meningit
is/guidelines2014/en/
 ICG forms and information available at
http://www.who.int/csr/disease/meningococcal/icg/en/

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 Key contacts

 Dr. Olivier Ronveaux

Epidemiology in Vulnerable Settings
Infectious Hazard Management
Health Emergency Programme
WHO
ronveauxo@who.int

Photo credit: WHO/O. Ronveaux

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