Guidelines

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Meningococcal Meningitis in Africa The MERIT
initiative
Eric Bertherat
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Current WHO Strategy in the 'Meningitis Belt' in
Africa
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The Meningitis Belt a region presenting
distinct epidemiological features

• Hyper incidence
• 10-150 per 100,000 in non-epidemic yrs
• 250-1000 per 100,000 in epidemic yrs
• (Europe-USA 1-3 per 100,000)
• Seasonal increase
• Large epidemics during the dry season

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The Meningitis Belt, a combination of risk
factors climatic, socio-demographic, immunologic
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Epidemiological curveWeekly number of suspected
meningitis cases in Burkina Faso, Mali, Niger
(1996 to 2008)
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The situation today in 2009 Currently
experiencing meningitis outbreaks Nigeria,
Niger, Chad Cumulative number of cases in Nigeria
so far in 2009 40,000
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Causes of meningitis epidemics still poorly
understood..

• Introduction of new epidemic strains
• 1996-1997 epidemic associated to spread of Nm A
  of the ST-5 complex
• Accumulation of susceptible cohorts
• Environmental factors
• Low absolute humidity
• Land cover
• Atmospheric dust
• .and millions of doses of vaccine injected

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However there does appear to be a relation
between seasonal climatic factors to meningitis
epidemics

• Cases start increasing at beginning of the dry
  season (January)
• Sharp decrease with the beginning of rains,
  May-June

Grenwood et al, Trans Roy Trop Med 1987
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Public health perspectiveMeningitis outbreak
control strategy

• Current outbreak control strategy is based on
  reactive vaccination campaigns
• Because of limited vaccine supplies
• Not efficient to implement preventive campaign
  because of characteristics of the current vaccine
  
• Relies on efficient surveillance and timely
  reporting and intervention which is not always
  possible
• Vaccination campaigns are consequently
  implemented relatively late
• Challenge can we use environmental/climatic data
  to forecast outbreaks to move towards a more
  preventive strategy and improve effectiveness of
  immunisation campaigns?

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From a public health view

• Knowledge of the natural history of the disease
• What can we expect from the research community
  (environment, socio-demography, mathematical
  analysis..) ?
• How much this added knowledge can improve the
  control strategy (reactive response / preventive
  vaccination) ?

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The MERIT Initiative Meningitis Environmental
Risk Information Technologies
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MERIT ProjectMeningitis Environmental Risk
Information Technologies

• Collaborative group formed in 2007 to help
  facilitate collaboration between the public
  health, epidemiological and environmental
  communities
• Aims
• To improve the application of climate and
  environmental information to help reduce the
  burden of meningococcal meningitis epidemics in
  Africa
• To enhance national and regional surveillance
  capabilities
• To strengthen decision making and public health
  policy development (capacity building included)

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MERIT partners include..

• World Health Organization
• World Meteorological Organization
• Group on Earth Observations
• Health and Climate Foundation
• International Federation of the Red Cross and Red
  Crescent Societies
• Columbia University - International Research
  Institute for Climate and Society, Mailman School
  of Public Health, CIESIN
• Lancaster University
• Liverpool School of Tropical Medicine
• Barcelona SuperComputing Centre
• Climate and Health Working Group, Ethiopia
• CERMES - Centre de Recherche Médicale et
  Sanitaire, Niger
• ACMAD African Centre of Meteorological
  Application for Development
• Navrongo Health Research Centre, Ghana
• UCAR
• Meningitis Vaccine Project

First meeting Geneva, October 2008 Second
meeting Addis Abeba, December 2009
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MERIT ProjectUnderstanding the environmental
risk factors
Mailman School of Public Health, Columbia
University CERMES
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MERIT ProjectUnderstanding the environmental
risk factors
International Research Institute for Climate and
Society (IRI), Columbia University
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MERIT ProjectUnderstanding the environmental
risk factors
International Research Institute for Climate and
Society (IRI), Columbia University
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MERIT ProjectUnderstanding the environmental
risk factors
International Research Institute for Climate and
Society (IRI), Columbia University
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MERIT ProjectUnderstanding the environmental
risk factors
WMO Sand and Dust Storm Warning Advisory and
Assessment System, Barcelona SuperComputing Centre
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MERIT ProjectUnderstanding the environmental
risk factors
Spatial and Temporal Analyses of Meningococcal
Meningitis in Niger Cluster and Wavelet
Analyses WHO, Fogarty International Centre NIH
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MERIT ProjectStrengthening prevention and
response strategies
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Ethiopian MERIT initiative

• Led by the Climate and Health Working Group in
  Ethiopia
• Partnership to facilitate the use of
  environmental information for public health
  decision making
• Partners include Federal Ministry of Health,
  National Meteorology Agency, Anti Malaria
  Association, UNEP, UNICEF, WHO, Ethiopian Public
  Health Association, Center for National Health
  Development in Ethiopia, Ethiopian Health and
  Nutrition Research Institute, School of Public
  Health, Christian Relief and Development
  Association
• MERIT-Ethiopia has four key areas of focus
• Socio-economic impact of the disease including
  disease burden, mortality and mortality
• Determinants and risk factors of meningitis
  epidemic outbreaks
• Education and Training
• Surveillance of the disease

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Niger MERIT initiative

• Aim to develop an operational decision-support
  tool to support a preventive vaccination
  strategy, based on
• Expert opinion
• Risk assessment, bringing together environmental,
  socio-economic, epidemiological and biological
  factors
• Empirical modelling
• 4 modelling studies were reported at the
  international MERIT meeting in December 2008
• Different methodologies implemented for different
  goals and timelines

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Where is MERIT now

• MERIT community established and collaborative
  partnerships producing effective outcomes
• Process elaborated for modelling studies based on
• Expert opinion
• Risk assessment
• Empirical modelling
• With different methodologies for different goals
  and timelines
• Aim is to develop decision-support tools for
  testing in country, while developing in-country
  capacity to integrate environmental information
  with the meningitis outbreak control strategies
• MERIT projects in Ethiopia and Niger, with
  further projects under development in West Africa
• Next international MERIT meeting, Niger 2009