16 May 2019

Nigeria: Meningitis: What We're Doing to Keep Nigeria's Death Toll Low This Year - NCDC Official

interview

Nigeria is currently in the meningitis season. However, since the outbreak, reported cases and deaths this year have been fewer than for previous years (2016-2018).

In this interview with PREMIUM TIMES, Priscilla Ibekwe, a deputy director with the Nigeria Centre for Disease Control (NCDC) and the incidence officer for cerebrospinal meningitis 2018/2019 season, spoke on the current situation and what is being done differently this year. She also talked about the place of vaccines in curtailing the outbreak.

PT: Nigeria is currently in the meningitis season. How have we fared with preparedness, surveillance, and control of the disease this year?

Ibekwe: We have done well in the sense that at the end of the 2017/2018 season, we had what is called the after action review in August 2018, where we reviewed what we had done and drew lessons from it. We reviewed the states and the federal action response in the 2017/2018 CSM season, and based on those lessons we decided we will focus on good practice. The areas and gaps that we identified, we used that to develop what is called the Incident Action Plan for 2018/2019.

As part of our preparedness, as far back as November 8, 2018, the Director-General NCDC, Chikwe Ihekweazu, wrote to all the state commissioners of health, asking them ahead of the season to begin to prepare and support the state teams in terms of training, capacity building and prepositioning, making sure they have the medical consumables that are required of the state. This was one of the first things that we did as part of the preparedness. We made sure that guidelines were downloaded, printed and distributed.

From the NCDC angle, we sent out a standard questionnaire about the CSM season for every state to complete. It is an assessment form in terms of their preparedness. The form addresses all areas such as vaccines, do they have enough vaccines, do they have the drugs, and all that?

As they complete those forms the states know where their gaps are and it helps them to begin to prepare. Not only did they give us those answers, we provided technical assistance and support, advising them on how to address the gaps identified per state for each state based on their response.

We went ahead to look into our stores, to find out, we have already done forecasting and procured medical consumables and commodities that are used during the outbreaks, including lumbar puncture kits, including antibiotics. For the high-risk states, we sent some ahead of time so that they add that to what the state has bought. These are part of the things we did at the national level.

PT: How did you tackle the lack of expertise to quickly detect/diagnose the disease, as this was one of the factors responsible for the slow intervention in 2016/2017 season?

Ibekwe: Before the end of last year; we trained the state doctors on case management; that is recognising a case of meningitis and knowing the treatment to give in the case of both adult and in children. We also trained them on lumbar puncture, being able to take a little fluid from the back, that is the spinal cord area, which is called the cerebrospinal fluid. We need that fluid for diagnosis to be able to know what is growing in there, to find out the type of bacteria or organism that is causing meningitis.

We can see that this year, the collection is better. When they see patients, they can easily diagnose, start-up treatment and also collect the samples (fluid) that are required to help us diagnose. We have seen tremendous improvement in diagnosis in the states.

PT: Comparing this year with the previous two years (2016-2018 season), what do you think we can do to improve on the situation on the ground, knowing full well that this year the cases are on a downward trend?

Ibekwe: You will recall that in 2016/2017, we recorded over 14,000 cases and during that time as part of the response, vaccination had to be done in certain wards. Drawing on those lessons, we found that in 2017/2018, only about 3, 467 patients were reported. We are continuing to improve.

We have been raising awareness and risk communication is part of the preparation that has happened at the national and the state levels. This translates to states airing jingles to educate the communities about the signs and symptoms of meningitis and that they need to report to the health facilities promptly. Secondly, there is awareness communication where people will gather like churches, women's meetings, mosques, markets, and gatherings. With these, the index of suspicion is much higher. Also in the health facilities, a lot more people have been trained and the guidelines on how to treat the patients have been distributed across board.

We have also tried to ensure that at least one hospital in a local government is designated as a treatment centre for CSM. Which means, if a nurse or community health care worker feels that a patient has signs of meningitis, they refer them to that hospital. It is expected that at that hospital, the patients are admitted, investigations are done. We are not waiting for the reports of the investigation, we start up treatments pending what the result of the investigation will say. Our preparedness is a lot better and our response much better, but we will continue to do more.

PT: We know the minister has been complaining that some states are not as responsive as they are meant to be. In term of meningitis this year, what have been the state responses?

Ibekwe: I will say that letter that was written by the DG, NCDC, was kind of a wakeup call to say we want you to begin to prepare. We found out that a lot of states actually started their preparation; of course, money is never enough.

The states are trying the best that they can within the big picture of what they can pay for. But this area has not been neglected and we have always continued to provide support. But we wish that more funding will be directed to this area.

Looking at the numbers this year, as at April 10, 2019, we have had 641 reported cases of suspected meningitis. Of these, only 74 has been confirmed as being positive for bacterial meningitis

It means we are doing something right in the sense that we started early, people know about the signs and symptoms of meningitis and they are going to the hospital. That is what we want to see, we want to continue to reinforce those messages.

PT: There was a mass vaccination campaign in 2016 and 2017, how do you think this impacted on meningitis outbreak this year?

Ibekwe: Certainly you know that vaccines are very effective, they are safe and when you take them you see the results. For example in 2011, the big thing was meningitis type A (Men A), and when that vaccine was given, we hardly have any type "A" meningitis showing up.

Now what we are increasingly seeing is type C, which is 30 per cent. What I am saying here is that vaccinations given worked. Alongside, it is not only about vaccination, it is about people having good hygiene, people washing their hands, meningitis is an airborne disease, therefore, when people are sneezing or coughing, they cover their mouth with a tissue.

And that tissue should be put inside the dustbin and you should wash your hands. And there are other things we can do to help increase our immunity like sleeping well, drinking enough clean water, exercising and eating the right type of food. Making sure we have enough vegetables and fruits and proteins, not necessary meat, could be beans and soya, all these things help to improve our immunity.

During the meningitis season, we encourage people not to be in crowded areas, to make sure that their rooms are well ventilated, it is airy, you open the windows, open the door and as much as possible be in an airy room.

PT: For this year's outbreak, which is the dominant strain we are having and what is the statistics so far?

Ibekwe: As at April 10, we had 641 suspected cases reported and 55 deaths. Not all of them came at a time when we could take samples from them. From the sample we have received, we tested 234 samples, which is just only about a third. Of these, 74 were confirmed for bacterial meningitis.

We isolated two strains causing this issue; we have streptococcus pneumonia responsible for 42 per cent and the Neisseria meningitides serogroup C responsible for about 30 per cent.

All these are vaccine preventable. We are encouraging mothers to ensure that their children have the childhood vaccinations. You cannot walk away from vaccinations. Vaccinations are one of the miracles and wonders in public health that has been very effective and we must take advantage of this.

PT: What percentage of those infected this year are children?

Ibekwe: Over 70 per cent of those reported are between one to 15 years. And males account for 61 per cent of the cases. Why are males more infected? It just happens, and that is a grey area up for medical research.

What is important here, I must stress, is that all age groups can have meningitis. It is an airborne disease. But it is more likely to affect young people or people in the extremes of the age (the younger or the older people).

But we do not want a situation where people will believe they are teenagers or adults, so they cannot have it. It is important for people to know the signs and symptoms of meningitis.

The signs and symptoms of meningitis are very high fever, headache, vomiting, what most people may feel like they have malaria symptoms. However, when that person begins to feel that their neck is stiff and they cannot move their neck, it is something to be concerned about.

Some people have difficulty coping with light, photosensitivity, they cannot cope with normal bright light. When people are beginning to have symptoms of drowsiness, getting confused, those are very bad signs, they have to run quickly to the health facility. It is not a time to go to the chemist, or pharmacist, it is a time to go to the doctor to examine that person and get prompt treatment.

PT: In how many days can all these symptoms manifest?

Ibekwe: All the symptoms can manifest between one and nine days. When somebody comes in contact with someone who has meningitis, about 15 per cent of us carry the meningitis strain in our noses, it may not be hurting them, but at same time, they are carriers and they are passing on the meningitis bacteria.

The important thing is that once you are unwell, have very high fever, headache, neck stiffness, it is not something to try and treat at home. Once you are unwell, you take your paracetamol, you do not feel better, there is all the mentioned symptoms, it is not something to sit down at home about and it is also not something to say is a spiritual thing.

Ok, if it is spiritual, I have to stress this. In one of the communities we went to in Katsina as part of our rapid response team; we found out that they felt it was a spiritual thing. Our focus is this, even if you thought it was a spiritual thing, deal with it in the spiritual way but also go to the hospital. Look at it in two ways.

PT: Which states are currently top in the chart for this year's outbreak?

Ibekwe: We have 19 states in the meningitis belt in Nigeria but the top five states topping the charts in the on-going epidemic are Katsina, as at April 10, we have 222 patients from the state, Zamfara 150 patient, Sokoto 81, Niger 52, Jigawa 26.

But this numbers are still increasing, we are looking at our data again because the state epidemiologist are consistently sending us data and we analyse this data and give them advice on what to do. In Niger State, there are about 43 doctors, clinicians who are undergoing training on how to do Lumbar Procedure (LP) and case management. It is not as if they have never done it before, it is about reinforcing and making sure that doctors are confident and confortable about management of meningitis.

One of the things that have also happened recently is that the United States Centre for Disease Control (US CDC) has also provided some training recently for reference laboratory staff on the CSM desk. We also invited 10 laboratory focal people for the high risk states to come and reinforce their skills. So that they go back and ensure that the work they do they continue to do it well.

PT: What is the World Meningitis Day all about?

Ibekwe: April 24 is the World Meningitis Day. Nigeria is joining the world to celebrate the World Meningitis Day and the theme for this year is life after meningitis. The hashtag is after meningitis. While we are asking people to know about the signs and symptoms of meningitis, the focus of this year is to understand that meningitis is a serious disease and have long term effects which can be for life. We want people to care and give support to survivors. We want Nigeria to be in a situation where there is an integrated package of responsive care that cuts across health, education, social service and work for anybody that has meningitis. Some of the disable people in the society became that way due to meningitis.

PT: With the trend of things this year, how soon should we be expecting the season to be over?

Ibekwe: Usually, you know that when the rain begins, the cases begin to come down. I cannot wait for that to happen because, at the end of the da,y what we need to understand is that it is Nigerians that are getting unwell and that could be your relative or mine.

We want to do the best that we can to bring the number of people affected by the disease to the barest minimum. I want to use this opportunity to raise awareness around the complication of meningitis.

About 15 to 20 per cent of people who have meningitis have complications thereafter. Some of these complications can be as bad as brain damage; some may lose their limbs, eyesight, some learning difficult and deafness or difficulty in hearing.

I want us to know that these 55 patient I talked about who died, their love ones are affected because of the loss of their loved ones, they need psychological support and love. We need to wrap some support round them. For these people who have complications, many of these complications are lifetime; we need to think about comprehensive integrated care for these people. It is not only within the medical sector, we are talking about somebody who has a child who is deaf, and now has to think about psychological support for the parent, dealing with the guilt or anxiety, there is a need to help them through that process.

That is the psychological support I am talking about. And for the child, hearing aids. Beyond hearing aids, there are educational issues for this child, there has to be an integrate level of care across the health sector and the education sector and production. I mean labour and productivity because, these people either as a child or adult over time will need some work.

Meningitis is something we need to bring to the barest minimum and I am very glad that, at least, we can see that in the past three years, the numbers have been going done.

I also want to bring it to your attention that the world is taking this very seriously; the World Health Organisation (WHO) is developing a strategy called defeating meningitis by 2030. It is global strategy that is being developed so that by 2030, in line with the sustainable development goals for health, that the vaccine preventable causes of meningitis can be brought to the barest minimum.

One of the pillars that this document is highlighting is after care and support for survivors of meningitis. And NCDC represented Nigeria to see that the global strategy reflect the situation of developing countries like Nigeria and our peculiarities so that the strategies are the kind that we can implement and get good result.

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