Meningitis: Across Nigeria, a tour of death

In Jabo, Sokoto state, the Bello family faced double tragedy. One week after they lost a baby, the head of the Bello family was taken ill.  “It started with severe headache, then a stiff neck. We rushed him to hospital. Shortly after, he died,” his widow tells a news outlet.  Cerebrospinal meningitis (CSM) is reported […]

In Jabo, Sokoto state, the Bello family faced double tragedy. One week after they lost a baby, the head of the Bello family was taken ill. 

“It started with severe headache, then a stiff neck. We rushed him to hospital. Shortly after, he died,” his widow tells a news outlet. 

Cerebrospinal meningitis (CSM) is reported to have killed up to 60 people in Jabo in two weeks alone. The loss is devastating, and people go to the graves to pay their respects to the dead. 

In Dakwa community, FCT , the death of Abigail Tumo, 22-and that of a six-year-old-have become a rallying cry to step up vaccination against CSM. Six deaths so far are suspected to have been caused by CSM, though laboratory tests are yet to confirm that. 

Her family took her death in good faith; her father Sunday Tumo, a deputy director with the National Orientation Agency was happy his daughter’s death created awareness for meningitis in the area. 

The current meningitis outbreak is not the first, nor the worst. The worst outbreak on record was in 1996-109,580 cases reported and 11,717 people killed. Another in 2003 saw 4,130 cases and 401 dead. In 2008, more than 9,000 cases were recorded and 562 people died. In 2009, cases reached 9,086 and 562 people died. 

The current outbreak is active in 16-Zamfara, Katsina, Kebbi, Niger, Kano and Sokoto being the worst hit. Ninety-two local government areas have reported at least a case, but 17 of them have crossed epidemic threshold, according to epidemiology updates from the Nigeria Centre for Disease Control (NCDC). 

When the current outbreak started last November in Zamfara, it was seen coming. What health workers didn’t know was what exactly was coming. 

Meningitis outbreaks are regularly in Nigeria and countries in the Meningitis belt across Africa. Meningitis comes from different strains of the Neisseria Meningitidis bacteria. Past outbreaks have been caused by serotype A, which a massive MenAfriVac vaccination campaign helped reduce in past years. 

This outbreak is coming more from a serotype C and reaching epidemic proportion for the first time. NCDC says 83% of cases tested have shown the bacteria to be serotype C. 

By April 5, the cases have risen to 3,959 up from 2,997 announced on April 3, and 438 have been killed-many of them aged between five and 14 years. 

“I think the last time govt stood up to this kind of occasion was during the time of Ebola, and this one has killed more people than Ebola,” says Tumo. 

Meningitis causes the covering of the brain-or meninges-to swell. It begins with an infection by bacteria or virus. 

Meningitis may be carried in the throat, but can overwhelm the body’s defences and spread through the bloodstream to the brain. The reason for this shift is still unclear. 

Up to two in every 100 people carry the microorganism in their throat at any given time, but the rate increases in times of epidemics. 

The most common symptoms of meningitis are stiff neck, high fever, sensitivity to light, confusion, headaches and vomiting, and anyone with the symptoms above is advised to urgently seek care at the nearest health facility. 

Nigeria wasn’t prepared for meningitis C, according to Lawal Bakare, technical advisor for communications at NCDC, which is coordinating a central-command-and-control response to meningitis. Nigeria had no business stocking meningitis C vaccine when the bacteria wasn’t a problem. 

The response now is reactive vaccination for vulnerable populations. The International Coordinating Group (ICG) provided 500,000 doses of meningococcal ACWY vaccine. Zamfara began its mass vaccination on Wednesday, Katsina followed on Thursday. 

The FCT plans to vaccinate 70,000 people-targeting camps for internally displaced people, barracks and special populations, said Rilwan Mohammed, executive secretary of the FCT primary health care development agency. 

“We could not have predicted this level of outbreak. However the way the vaccine system works, especially that the government utilises for free vaccination campaign, the country did not have enough stock of this vaccine,” says Bakare. 

“For us to be able to collect this response quantity which we will use for the reactive vaccination, you need to have demonstrated to the ICG through data that we are really in dire need.” 

Serotype C is not new; it exists in other places. Canada and Australia have it in their immunisation programmes. Its outbreak in Nigeria changes things in the meningitis belt. 

“Dry season is going to go. Another dry season is going to come. Every country within the meningitis belt of Africa needs to prepare effectively for Meningitis serotype C. That means campaign and vaccine,” says Bakare. 

“Serotype A, we cannot say it is totally out because we are still recording portions of it. But we now know we are dealing with more of Cs, and that is a major shift in terms of our response. It is not just a country thing, it is a global phenomenon. People in public health and infectious disease are going to be taken this event very, very serious.” 

Nigeria itself could being preparing for the next CSM season by October, and will “give very important consideration” to a vaccine with a wider spectrum of antigens, the federal health ministry said in a statement. 

In the case of meningitis, it means a vaccine that could act against a wide range of serotypes. 

At least three local governments that have crossed epidemic threshold share borders with Niger Republic-Zurmi in Zamfara, Jibia in Katsina and Gada in Sokoto. 

The NCDC is concerned about risk of international border transmission. According to plans, Nigeria will arrange for cross-border surveillance locally within the country and internationally with the republics of Niger and Benin. 

The surveillance includes active search for cases in affected council areas, investigating rumours of outbreaks, sensitising and training clinicians in selected areas and reviewing meningitis guidelines and laboratory protocol. 

The reactive vaccination response is to target most-affected communities and reduce the risk to communities unaffected. 

Starting with 500,000 doses, another batch of 823,970 doses of meningitis C vaccine is expected to scale up the reach. For now the most crucial is getting sufficient dosage to create “herd immunity”-that’s when a population becomes resistant to a contagious disease after a high proportion of individuals become immune through vaccination. Immunity lasts anywhere up to 10 years. 

Sokoto, with 41 deaths on record, has put up an ICG request for meningitis C vaccine. It plans to vaccinate 700,000 people. 

Sokoto governor Aminu Tambuwal on a condolence visit to Danchadi village and surrounding areas in Bodinga council, said, “Health officials have been deployed to affected areas and have been working round the clock. We urge you to follow their instructions and cooperate with them as we tackle this challenge.”  

In Kano, three people have died out of 36 cases reported across 13 council areas, according to the NCDC epidemiology report. Eleven people have been killed in the outbreak in Kebbi, and 33 in Niger state. 

Katsina’s ICG request was for 500,000 doses. It got 50,000 doses instead for the mass vaccination it started on Thursday, targeting the five council areas where meningitis was first reported-Batsari, Jibia, Batagarawa, Faskari and Funtua. 

Other states with cases of suspected or confirmed meningitis are Nasarawa, Gombe, Taraba, Cross River, Osun, Lagos, Yobe, Jigawa and Plateau. In seven of them and the FCT, no laboratory confirmation has been concluded for meningitis. In six of them, no death has been reported. 

At least 216 people have been killed in the outbreak in Zamfara, the largest among states. The governor Abdulaziz Yari was driven to lament the entire consignment of vaccine was “not enough for Zamfara alone, not to talk of Katsina or Kano.” 

Zamfara got 20,000 doses. But it was the governor’s comments linking meningitis C outbreak to the morality of a people-and loosely with fornication-that sparked the largest controversy yet in this outbreak. 

“Because people refused to stop their nefarious activities, God now decided to send Type C virus, which has no vaccine.” 

The NCDC refused to be drawn into any argument. The health ministry condemned the comments. But the Emir of Kano, HRH Sanusi Lamido Sanusi, call the comments “horrendous and Islamically incorrect.” 

“Some of the examples are horrendous. Two hundred people died of meningitis in a state, the governor was asked and he said it is God’s curse on us for the sin of fornication, which apparently does not happen in America, which is why they don’t have meningitis,” he is reported to have quipped in sarcasm. 

“How have we reduced ourselves, what have we done as a people, that we have placed ourselves in a situation where simple things, a medical issue…you don’t have vaccines, say you don’t have vaccines. 

“These are the kinds of things that we have; and when we talk about a difficult environment, we realise that 90% of that difficulty, we can address, because it is self-inflicted.” 

The Nigerian Medical Association weighed in on Friday to say “leaders should stay with the citizens to understand their plights and avoid unnecessary journeys outside the states they seek to govern.” 

Long-distance journeys and numerous journeys are associated with sexually transmitted diseases, CSM is an infection caused by a bacteria and rampant with overcrowding and tramissible via the air, NMA president Dr Mike Ogirima retorted. 

Even the reactive vaccination strikes a raw chord with the medical community. NMA said given research going back 1975 showing the strains involved in various epidemics, “it is embarrassing that this epidemic has taken us unawares.” 

It condemn delay in immunisation once the infection was already established. 

“This is ineffective based on the epidemiology of the disease,” said Ogirima. 

“For immunisation to be effective, it must have been administered around three months before the period of clinical manifestation due to the latent period.” 

Fifteen weeks into the epidemic, the biggest spike in number of cases occurred in week 10-nearly 450. Authorities believe the cases are tapering off, but they are still searching. 

But it came too late for Bello, Abigail and the six-year-old.