Thousands of men, women, and children in northern Nigeria have been affected by a meningitis C outbreak, reportedly the largest to hit the country in the past 9 years.

Almost 6 months after the 1st cases were recorded in Zamfara State, Nigeria’s Ministry of Health (MoH) is still struggling to fight this epidemic in 7 states of the country. Medecins Sans Frontieres has supported the health authorities with surveillance and case management in the most-affected areas since February

[2017], when the outbreak was officially declared. However, the slow reaction of the country and a global shortage of vaccines have hampered the response.

On 15 Apr [2017], MSF set up a 200-bed treatment centre in Sokoto Town, followed by a 20-bed facility in Anka, Zamfara. In these locations, MSF’s Nigeria Emergency Response Unit (NERU) works intensively to provide free, high-quality medical care and reduce mortality rates as much as possible.

These teams treat challenging cases in a difficult environment. “A few days ago, a 9-year-old boy was brought in unconsciousness and with severe meningitis,” recalls Caroline Riefthuis, an MSF nurse in Sokoto. “He received treatment for 5 days and recovered, but unfortunately we found out that he had become deaf and blind, some of the side-effects of severe meningitis.”

This little boy is one of 614 patients treated in Sokoto Mutalah Mohamad Hospital since April 2017, when MSF took over the management of the centre from the MoH due to a lack of supplies and qualified staff to run it. In Anka General Hospital, 137 patients were admitted since the beginning of the outbreak. Most are between 5-20 years old.

In addition to the staff working in the treatment centres, 11 MSF surveillance teams visited health facilities to determine the origins of new cases in Sokoto, Zamfara, Yobe, Niger and Kebbi. These visits also allowed MSF to implement additional activities, such as health promotion, to increase community awareness of the signs and symptoms of meningitis and active case finding.

At the end of April [2017], the Nigerian MoH reported 9646 suspected cases of meningitis C, with a total of 839 deaths since late 2016. And on 1 May [2017], MSF was finally able to join a vaccination campaign launched by the health authorities in Sokoto. In the 3 most-affected Local Government Areas (LGAs), 25 MSF teams vaccinated approximately 850 people per day for 7 days to reach a target population of 148 000 people — of a total target of 800 000 — between the ages of 1-20. An additional campaign with a target population of nearly 130 000 people will start later this month [May 2017] in the 4 most-affected LGAs of Yobe State.

Although these vaccination campaigns are a crucial step to stop the spread of the disease, MSF has concerns regarding the late response to the crisis in a country where meningitis epidemics are not rare. “The national early warning system and timely response needs to be strengthened, and the implementation strategy better-defined, to reduce the impact of the outbreak as much as possible,” explains Philip Aruna, MSF Head of Mission in Nigeria.

Even more worrisome is the global shortage of meningitis C vaccine, which contributed to the delayed response and increased mortality rates in Nigeria. “The outbreak is spreading fast, and we are concerned because there are not enough vaccines to cover the affected population,” says Aruna. In Sokoto, for example, 3 million vaccines are required to launch a mass campaign, but only 800 000 were available. This insufficient quantity only allows for a reactive campaign, which requires teams to act fast to prevent the disease from spreading further.

To address these logistical challenges and reduce the mortality rates, MSF insists that treatment centres be decentralised so that all people affected by the disease, even those in remote areas, can access free, quality health care and the right tests to quickly confirm cases and prevent misdiagnosis. It is crucial that adequate prevention measures be put in place to avoid another delayed response when the next meningitis outbreak inevitably occurs.

MSF has worked in Nigeria since 1996, running extensive projects on child health, sexual and reproductive health, lead poisoning, and reconstructive surgery in places like Sokoto, Zamfara, Niger, Port Harcourt, and Jahun. The MSF Emergency Response Unit (NERU) also responds to medical emergencies such as meningitis and measles outbreaks. NERU has been active in the country since 2006.

MSF has provided health care to people displaced by violence as well as host communities in north-eastern Nigeria’s Borno State since mid-2014. MSF currently manages 11 medical facilities in 7 towns in Borno (Maiduguri, Dikwa, Monguno, Gwoza, Pulka, Ngala, and Benisheikh) and regularly provides care in 4 other locations.

Nigeria has been experiencing an outbreak of meningococcal meningitis serogroup C that has spread across the country but is mostly concentrated in states in the upper northwest that fall within the African meningitis belt. This epidemic is different from past ones in that _Neisseria meningitidis_ serogroup A, the previous predominant pathogen, has been replaced by meningococcus serogroup C, likely as a consequence of mass vaccination campaigns using a conjugate meningococcal serogroup A vaccine, the MenAfriVac-A. This vaccine reduced by over 90 per cent the incidence of meningococcal meningitis due to serogroup A.

To prevent replacement by other pathogenic serogroups, a quadrivalent conjugate meningococcal vaccine, such the ACYW vaccine, would be ideal. Conjugate vaccines are preferable, because, unlike the polysaccharide vaccines, conjugate vaccines immunize infants, reduce the carriage of meningococci in the throat and thus its transmission, as well as confer a more sustained immune response, and, therefore, longer-term protection than the polysaccharide vaccines. Serogroup B vaccines are based upon meningococcal B outer membrane vesicle protein antigens, because group B polysaccharide is poorly immunogenic in humans and is a potential auto-antigen.



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