The recent outbreak of Cerebrospinal meningitis (CSM) in parts of northern Nigeria did not catch the nation's health authorities unawares. Investigations by Good Health Weekly show that preparations were already in place to contain the disease in the nation's "meningitis belt" long before the outbreak.
From hindsight, CSM, an epidemic prone disease mostly caused by a bacterium - Nesseriae meningitis, usually occurs in a cycle of 10-12 years. The last major CSM epidemic in Nigeria occurred in 1996/97 when over 108,568 cases and about 11,231 deaths were recorded.
"We have anticipated the CSM epidemic this year," Minister of Health, Prof. Babatunde Osotimehin noted in a situation report last week. "On 3rd September 2008, we alerted all the States in the meningitis belt to intensify surveillance, preposition drugs and laboratory materials and sensitise the public on preventive measures. Indeed, right from August 2008, the Ministry had prepositioned all the states in the meningitis belt with oily chloramphenicol as well as laboratory reagents and materials for confirmation of cases."
In retrospect, Osotimehin said: "It was on 10 November 2008, when the World Health Organization (WHO) alerted us of a possible serious outbreak of the disease this year and advised us to intensify surveillance, strengthen laboratory network, reactivate EPR Committee, ensure emergency stocks and supplies, strengthen supportive supervision and conduct rapid assessment of laboratories."
The Minister further noted that on 28 January the Presidency alerted the Health Ministry of an outbreak of CSM in Zinder Region of Niger Republic and requested urgent action to be taken to avert outbreak of the disease in Kano, Katsina and Jigawa States.
"By the end of February 2009, 5,323 cases and 333 deaths had been reported from 22 states, with 89 LGAs crossing the epidemic threshold. Precisely between January 15-16, 2009 with the support from WHO, the ministry conducted assessment of the capacity of state public health laboratories to carry out confirmation of CSM."
Following the alert of CSM outbreak in Niger Republic, on 20th January, the Health Minister had alerted the Governors of Jigawa, Kano and Katsina States on the impending emrgency. In his letter, the Health Minister requested the Governors to immediately direct their State Ministries of Health to intensify surveillance and public education on the mode of prevention of the disease. In addition, they were urged to preposition drugs and other consumables and improve laboratory confirmation of cases.
A couple of weeks later on February 4-5, again with the support from WHO, the Ministry carried out advocacy and sensitization visits to Katsina, Jigawa and Kano States for improve surveillance, public education, laboratory support and prepositioning of drugs and other materials for improved case management.
To further strengthen the State capacity to manage the epidemics, a training and sensitization workshop on enhanced CSM preparedness and response was organised for officials of these states.
The activity which was held in Kaduna, had amongst its participants, Commissioners of Health, State Directors of Public Health, State Epidemiologists, State Public Health Lab Focal Persons, one clinician per state and WHO Surveillance Officers, all from the 26 CSM high risk States. At the end of the training, the Commissioners for Health signed commitments on behalf of their States.
Following report of increasing number of cases and deaths, on 17-20 February, the WHO further supported the Federal Ministry of Health to conduct cases detection, verification and confirmation in Bauchi, Gombe, Yobe and Borno States.
This activity was with intensive laboratory back up. Even as all this was going on, respite came on Thursday 19th February, with the arrival of 160,000 doses of trivalent CSM vaccine in the country. The vaccines, donated by UNICEF Headquarters in Geneva, were quickly distributed by the National Primary Healthcare Development Agency (NPHCDA) to the seven most affected States, namely Adamawa, Gombe, Jigawa, Kano, Kaduna, Katsina and Yobe.
For four days (February 25-28, 2009), the Ministry in collaboration with WHO, provided supportive supervision for CSM vaccination campaign in 21 LGAs in the seven States. On the last day of the exercise, 100,000 vials of Ceftriazone out of a total of 1 million vials ordered by the Ministry were received and have been allocated to the 89 LGAs already in epidemic phase, awaiting distribution to the states.
"Our team of laboratory scientists are currently in the field (in 22 states) carrying out further laboratory confirmation of cases with the use of laboratory items (in the form of 69 packs of Pastorex test kits and 7 x 100 Lumber Puncture kits) all donated by the WHO." The next step was to distribute the 100,000 vials of Ceftriazone to the States.
We had a distribution list and proposal ready. There were also 500,000 doses of bivalent CSM vaccine donated by WHO that arrived March 5, 2009 and has been distributed to the states by NPHCDA. This activities are being backed with mass vaccination and supportive supervision from the Ministry.
Even as this report was being put together, another 1.5 million doses of CSM vaccine ordered by the Ministry arrived the country week-end and are being distributed by the NPHCDA for mass vaccination with supportive supervision from the Ministry.
Yet another 110,000 doses of CSM vaccines accessed through ICG by the Ministry/WHO for Katsina State has been obtained to augment the 268,000 and 130,000 doses of CSM vaccines already accessed through ICG by MSF for Jigawa and Katsina States respectively in the States. Mass vaccination has commenced soon after the IPDs.
The way forward in the national response to the outbreak of CSM, as garnered from the Federal Ministry of Health, includes a monthly replenishable epidemic management imprest fund of N2.5 million. This is to be supported with availability of four operational vehicles to be sourced from the government vehicle pool and earmarked specification for epidemic management.
A lump sum N25 million is also expected to be allocated for management of the current epidemic, to take care of logistics support, travel fares for supportive supervision, laboratory field activities, additional advocacy and public enlightenment, as well as drugs and vaccine distribution.
Prior to this, on Thursday February 12th, 2009, the Commissioners of Health of the 26 States considered to be most at risk to CSM in Nigeria, had met in Kaduna for a sensitization and advocacy meeting where they pledeged commitment towards the effective management and control of the disease.
The event, convened at the instance of the Federal Ministry of Health and the CSM coordination partnership under the leadership of the Minister of Health Prof. Babatunde Osotimehin, was chaired by Minister of State for Health, Dr. Aliyu Idi Hong.
It was acknowledged that much lives had either been lost or put in danger as a result of rampaging effect of CSM and bearing in mind their core roles and responsibilities to ensure good quality of life for the people.
The two-day deliberation by technical and programme officers from the Ministries made it clear that much needed to be done in developing and strengthening the CSM (and other diseases) surveillance and notification processes in the States, including the public health and State laboratories for definitive diagnoses of cases.
At that forum, it was agreed that the manpower and health human resources be strengthened using the present CSM outbreak as an entry point to holistic human capital development.
It was immediately decided that the states health mnistries must take urgent steps always to initiate and sustain on case management capacities and capabilities. The Commisioners thereby committed themselves to provide the required leadership to deal with CSM and other Epidemic prone diseases, by ensuring optimal coordination of all activitiesand providing the enabling environment that will ensure active surveillance of CSM and other epidemic prone disease in out states as well as availability of case management commodities such as oily CAF, IV fluids etc.
As part of the drive, all public health and other laboratories in the affected states were pencilled for optimisation to attain definitive CSM case diagnosis while private laboratories are to be co-opted in the surveillance, diagnosis and management scheme.
Henceforth, there is to be supportive supervision to States and LGAs along with maximal dissemination of appropriate information and messages on CSM and other such diseases to the public in the States, all backed by allocation of adequate financial resources to disease prevention and control.