Rapid Field Response to a Cluster of Illnesses and Deaths - Sinoe County, Liberia, April-May, 2017

Public health management of invasive meningococcal disease outbreaks: worldwide 1973-2018, a systematic review

BACKGROUND

Infectious disease outbreaks are an ongoing public health concern, requiring extensive resources to prevent and manage. Invasive Meningococcal Disease (IMD) is a severe outcome of infection with Neisseria meningitidis bacteria, which can be carried and transmitted asymptomatically. IMD is not completely vaccine-preventable, presenting an ongoing risk of outbreak development. This review provides a retrospective assessment of public health management of IMD outbreaks.

METHODS

A systematic search was performed in PubMed and EMBASE. English-language studies reporting on IMD outbreaks and associated public health response were considered eligible. Reporting on key characteristics including outbreak size, duration, location, and public health response were assessed against Strengthening the Reporting of Observational studies in Epidemiology guidelines. A summary of lessons learned and author recommendations for each article were also discussed.

RESULTS

39 eligible studies were identified, describing 35 outbreaks in seven regions. Responses to outbreaks were mostly reactive, involving whole communities over prioritising those at highest risk of transmission. Recent responses identified a need for more proactive and targeted controls. Reporting was inconsistent, with key characteristics such as outbreak size, duration, or response absent or incompletely described.

CONCLUSION

There is a need for clear, comprehensive reporting on IMD outbreaks and their public health response to inform policy and practice for subsequent outbreaks of IMD and other infectious diseases.

Ready to respond: adapting rapid response team training in Papua New Guinea during the COVID-19 pandemic

Problem

Rapid response teams (RRTs) are critical for effective responses to acute public health events. While validated training packages and guidance on rolling out training for RRTs are available, they lack country-specific adaptations. Documentation is limited on RRT programming experiences in various contexts.

Context

In Papua New Guinea, there remain gaps in implementing standardized, rapid mobilization of multidisciplinary RRTs at the national, provincial and district levels to investigate public health alerts.

Action

The human resources needed to respond to the coronavirus disease (COVID-19) pandemic forced a review of the RRT training programme and its delivery. The training model was contextualized and adapted for implementation using a staged approach, with the initiation training phase designed to ensure RRT readiness to deploy immediately in response to COVID-19 and other public health events.

Lessons learned

Selecting appropriate trainees and using a phased training approach, incorporating after-training reviews, and between-phase support from the national programme team were found to be important for programme design in Papua New Guinea. Using participatory training methods based on principles of adult learning, in which trainees draw on their own experiences, was integral to building confidence among team members in conducting outbreak investigations.

Discussion

The RRT training experience in Papua New Guinea has highlighted the importance of codeveloping and delivering a context-specific training programme to meet a country's unique needs. A staged training approach that builds on knowledge and skills over time, used together with ongoing follow-up and support in the provinces, has been critical in operationalizing ready-to-respond RRTs.

Mass gatherings: a review of the scope for meningococcal vaccination in the Indian context

The risk of meningococcal transmission is increased with crowding and prolonged close proximity between people. There have been numerous invasive meningococcal disease (IMD) outbreaks associated with mass gatherings and other overcrowded situations, including cramped accommodation, such as student and military housing, and refugee camps. In these conditions, IMD outbreaks predominantly affect adolescents and young adults. In this narrative review, we examine the situation in India, where the burden of IMD-related complications is significant but the reported background incidence of IMD is low. However, active surveillance for meningococcal disease is suboptimal and laboratory confirmation of meningococcal strain is near absent, especially in non-outbreak periods. IMD risk factors are prevalent, including frequent mass gatherings and overcrowding combined with a demographically young population. Since overcrowded situations are generally unavoidable, the way forward relies on preventive measures. More widespread meningococcal vaccination and strengthened disease surveillance are likely to be key to this approach.

Stakeholder Perspective of Handling the Deceased during the Nipah Virus Outbreak in Kerala, South India, 2018

In any outbreak situation, a poor stakeholder response can impede the outbreak control and can have high economic and social cost. We conducted a qualitative study to understand stakeholder response in handling of the Nipah deceased persons during the outbreak of Nipah in Kerala, 2018. To understand the responses and to generate knowledge from the data, we used grounded theory approach for the study and conducted in-depth interviews and focus group discussion. Mixed public response and swift state response emerged as the main themes in our study. Under the "mixed public response," three categories emerged, including anxiety and fear, conflicting religious beliefs, and humanitarian concern. Under the "swift state response," the categories emerged were critical resources and robust guidance. A collective effort involving the administration, local and religious groups, and a culturally acceptable scientific protocol proved to be good examples of gaining social acceptance. Kerala puts forth a model of efficient community engagement and communication to gain public support and acceptance in a fatal disease outbreak.

Incidence and Prevention of Invasive Meningococcal Disease in Global Mass Gathering Events

INTRODUCTION

Mass gathering events involve close contact among large numbers of people in a specific location at the same time, an environment conducive to transmission of respiratory tract illnesses including invasive meningococcal disease (IMD). This report describes IMD incidence at mass gatherings over the past 10 years and discusses strategies to prevent IMD at such events.

METHODS

A PubMed search was conducted in December 2018 using a search string intended to identify articles describing IMD at mass gatherings, including religious pilgrimages, sports events, jamborees, and refugee camps. The search was limited to articles in English published from 2008 to 2018. Articles were included if they described IMD incidence at a mass gathering event.

RESULTS

A total of 127 articles were retrieved, of which 7 reported on IMD incidence at mass gatherings in the past 10 years. Specifically, in Saudi Arabia between 2002 and 2011, IMD occurred in 16 Hajj pilgrims and 1 Umrah pilgrim; serotypes involved were not reported. At a youth sports festival in Spain in 2008, 1 case of serogroup B IMD was reported among 1500 attendees. At the 2015 World Scout Jamboree in Japan, an outbreak of serogroup W IMD was identified in five scouts and one parent. At a refugee camp in Turkey, one case of serogroup B IMD was reported in a Syrian girl; four cases of serogroup X IMD occurred in an Italian refugee camp among refugees from Africa and Bangladesh. In 2017, a funeral in Liberia resulted in 13 identified cases of serogroup C IMD. Requiring meningococcal vaccination for mass gathering attendees and vaccinating refugees might have prevented these IMD cases.

CONCLUSIONS

Mass gathering events increase IMD risk among attendees and their close contacts. Vaccines preventing IMD caused by serogroups ACWY and B are available and should be recommended for mass gathering attendees.

FUNDING

Pfizer.

Rapid response to meningococcal disease cluster in Foya district, Lofa County, Liberia January to February 2018

Introduction

Early detection of disease outbreaks is paramount to averting associated morbidity and mortality. In January 2018, nine cases including four deaths associated with meningococcal disease were reported in three communities of Foya district, Lofa County, Liberia. Due to the porous borders between Lofa County and communities in neighboring Sierra Leone and Guinea, the possibility of epidemic spread of meningococcal disease could not be underestimated.

Methods

The county incidence management system (IMS) was activated that coordinated the response activities. Daily meetings were conducted to review response activities progress and challenges. The district rapid response team (DRRT) was the frontline responders. The case based investigation form; case line list and contacts list were used for data collection. A data base was established and analysed daily for action. Tablets Ciprofloxacin were given for chemoprophylaxis.

Results

Sixty-seven percent (67%) of the cases were males and also 67% of the affected age range was 3 to 14 years and attending primary school. The attack rate was 7/1,000 population and case fatality rate was 44.4 % with majority of the deaths occurring within 24-48 hours of symptoms onset. Three of the cases tested positive for Neisseria Meningitidis sero-type W while six cases were Epi-linked. None of the cases had recent meningococcal vaccination and no health-worker infections were registered.

Conclusion

This cluster of cases of meningococcal disease during the meningitis season in a country that is not traditionally part of the meningitis belt emphasized the need for strengthening surveillance, preparedness and response capacity to meningitis.

Risk communication during disease outbreak response in post-Ebola Liberia: experiences in Sinoe and Grand Kru counties

Introduction

Lessons learned from the Ebola virus disease (EVD) outbreak enabled Liberia to develop a health plan for strengthening public health capacity against potential public health threats. risk communication is one of the core pillars that provide life-saving information and knowledge for the public to take preventive and proactive actions against public health threats. These were applied in response to the post-ebola meningococcal septicemia and meningitis outbreaks in Sinoe and Grand Kru counties. This paper documents risk communication experiences in these post-ebola outbreaks in Liberia.

Methods

Risk Communication and health promotion strategies were deployed in developing response plans and promptly disseminating key messages to affected communities to mitigate the risks. Other strategies included engagement of community leaders, partnership with the media and dissemination of messages through the community radios, active monitoring community risk perceptions and compliance, rumor management, mobile stage and interpersonal communication (IPC) during the Meningococcal disease outbreaks in Sinoe and Grand Kru counties.

Results

In Sinoe, about 36,891 households or families in 10 health districts were reached through IPC and dialogue. Circulating rumors such as “Ebola” was the cause of deaths was timely and promptly mitigated. There was increased trust and adherence to health advice including prompt reporting of sick people to the nearest health facility in the two counties.

Conclusion

Risk communication and health promotion encouraged community support and involvement in any response to public threats and events. No doubt, risk communication and health promotion play an important role in preparedness and response to public health emergencies.

Outbreak of Neisseria meningitidis serogroup C outside the meningitis belt-Liberia, 2017: an epidemiological and laboratory investigation

BACKGROUND

On April 25, 2017, a cluster of unexplained illnesses and deaths associated with a funeral was reported in Sinoe County, Liberia. Molecular testing identified Neisseria meningitidis serogroup C (NmC) in specimens from patients. We describe the epidemiological investigation of this cluster and metagenomic characterisation of the outbreak strain.

METHODS

We collected epidemiological data from the field investigation and medical records review. Confirmed, probable, and suspected cases were defined on the basis of molecular testing and signs or symptoms of meningococcal disease. Metagenomic sequences from patient specimens were compared with 141 meningococcal isolate genomes to determine strain lineage.

FINDINGS

28 meningococcal disease cases were identified, with dates of symptom onset from April 21 to April 30, 2017: 13 confirmed, three probable, and 12 suspected. 13 patients died. Six (21%) patients reported fever and 23 (82%) reported gastrointestinal symptoms. The attack rate for confirmed and probable cases among funeral attendees was 10%. Metagenomic sequences from six patient specimens were similar to a sequence type (ST) 10217 (clonal complex [CC] 10217) isolate genome from Niger, 2015. Multilocus sequencing identified five of seven alleles from one specimen that matched ST-9367, which is represented in the PubMLST database by one carriage isolate from Burkina Faso, in 2011, and belongs to CC10217.

INTERPRETATION

This outbreak featured high attack and case fatality rates. Clinical presentation was broadly consistent with previous meningococcal disease outbreaks, but predominance of gastrointestinal symptoms was unusual compared with previous African meningitis epidemics. The outbreak strain was genetically similar to NmC CC10217, which caused meningococcal disease outbreaks in Niger and Nigeria. CC10217 had previously been identified only in the African meningitis belt.

FUNDING

US Global Health Security.