From Clifton Road to Africa

About the authors:
Fabien Diomandé, MD, MSc, medical epidemiologist, is stationed in Burkina Faso to work with the WHO Africa Bureau and local health authorities and Ryan Novak, PhD, epidemiologist, is based in Atlanta and supports meningitis activities in Africa.

In Africa, more than 90 percent of meningitis cases during epidemics are caused by Neisseria meningitidis serogroup A, which mostly attacks infants, children, and young adults. Without antibiotic treatment, up to 80 percent of infected individuals can die. The bacteria spread during the dry season from November through June. Meningitis is feared across Africa and contributes to poverty that impacts quality of life and has both short and long-term human and financial costs. 

Epidemics of meningococcal A meningitis have swept across sub-Saharan Africa for a century putting the lives of approximately 450 million people at risk in the “meningitis belt,” a stretch of 26 countries from Gambia to Eritrea. As recently as 2009, more than 88,000 people were stricken by meningitis during one such epidemic.  In this region of the world one in ten people who gets the disease will die, typically within a day or two of falling sick.  Caring for someone sick from this disease can consume as much as a third of a family’s disposable income.  Survivors are at risk of serious disabilities like hearing loss, developmental delays, seizures, paralysis, or infection requiring amputation of one’s limbs.   This significant burden of disease has resulted in the people of sub-Saharan Africa eagerly anticipating a solution to the hundred year epidemic scourge. 

In 2010 that solution came in the form of a new vaccine developed specifically for Africa, and the statistics started to change.  Burkina Faso was the first country to conduct a nationwide mass vaccination campaign with this new vaccine.  Over the course of ten days we witnessed hundreds of health workers armed with vaccines and supplies mobilize throughout Burkina Faso, and more than ten million women, men and children between the ages  of 1 to 29 years turn up and endure long-lines to receive the lifesaving MenAfriVac® vaccine.  Subsequent campaigns were soon conducted in the neighboring countries of Mali and Niger with similar success.  At a cost of less than $1 per dose, this affordable vaccine is widely available, helping to save thousands of lives and improve health status across sub-Saharan Africa.  Just two years after the MenAfriVac® campaigns were launched in Burkina Faso, seven additional countries have held vaccination campaigns. Last December, in a town in northern Nigeria, the 100 millionth person was vaccinated against meningitis A—to date there has been no evidence of vaccine failure.  It has taken a little over a decade for the vision of a vaccine to prevent meningitis epidemics in Africa to become a reality.  

CDC’s long history of involvement in meningococcal disease epidemiology and prevention in Africa includes vaccine development and evaluation, surveillance, outbreak preparedness and response, risk factor studies, carriage studies, development and standardization of diagnostic and vaccine assays, and bacteriologic and molecular characterization of meningococcal isolates.  CDC is proud to partner with the Meningitis Vaccine Project (MVP), which is a partnership between PATH and the World Health Organization.  With a mission to eliminate meningitis as a public health problem in sub-Saharan Africa, MVP led the development of MenAfriVac®.  It was the commitment of these organizations, many other global partners and in-country leadership and local health officials across the continent of Africa, that brought this affordable meningococcal A conjugate vaccine through clinical development to public health availability.  But our work is far from done.  

Because this vaccine had never been used on a large public health scale, evaluation is critical.  We have partnered with several countries to support expanded vaccine impact evaluation following campaign rollouts, including adverse events monitoring, surveillance and laboratory confirmation, surveys to estimate vaccine coverage, and special studies to determine the impact on transmission, herd immunity, and molecular epidemiology.  So far, in countries where impact studies have been completed, the vaccine and the vaccination programs have exceeded expectations—very high vaccine coverage and no evidence of vaccine failure, no serious adverse events associated with MenAfriVac®, steep decline in risk of meningitis broadly, substantial reduction in serogroup A carriage, and elimination of serogroup A epidemics. 

CDC is engaged in capacity building with the Ministry of Health in Burkina Faso.  Similar collaborations are underway in Niger, Mali, Ghana, Nigeria, and Ethiopia.  Countries are assessed to determine the part of the disease surveillance system with the greatest need and technology such as EpiInfo database and real-time PCR laboratory diagnostic methods are transferred to the country to improve case detection, data management, and confirmation of patient diagnosis. Our activities have successfully helped health officials sustainably improve meningitis surveillance, and the benefits of this enhanced capacity have spilled over to other important vaccine-preventable diseases such as pneumococcal disease, measles, and yellow fever. 

Because the coverage achieved in mass vaccination campaigns varies from country to country, there may be the appearance of differing vaccine effectiveness.  We have learned that local health officials will need support from a host of global partners to introduce and evaluate the vaccine’s effectiveness, as well as to develop resource allocation strategies and policies that govern how MenAfriVac® can be integrated into routine childhood immunizations. Much more science and policy work will be required for full-scale implementation of MenAfriVac®.  Full and successful implementation of national vaccination programs such as this one is a critical step to achieving the United Nations Millennium Development Goal 4 that focuses on reducing child morbidity and mortality.