Why have these outbreaks occurred?
For another year running, Niger is facing several outbreaks of meningitis C and measles: two life-threatening and highly contagious diseases. Although both outbreaks can be prevented by vaccines, the problem is different in each case.
For meningitis, there is no cheap and effective vaccine for all serogroups of the disease; and the scarcity of production around the world means that vaccines can only be used reactively when an epidemic is declared. Vaccination against measles, on the other hand, has been included in routine vaccination programmes since 1974, but these programmes are still not reaching enough people to prevent transmission of the disease.
We have seen widespread epidemics of meningitis C in the region in recent years. Has the situation been better this year?
It has been a fairly quiet year in the area known as the African meningitis belt, but there are still major shortages of meningitis vaccines. The International Coordinating Group on Vaccine Provision - the body that manages the vaccines established a minimum stock of five million for serogroup C this year. However we continue to vaccinate only when the epidemic threshold is crossed. Vaccinating as soon as the alert level* is reached, as a preventative measure, would be more effective.
Why is there a shortage of vaccines for meningitis?
There are different types of meningitis - there are serogroups A, B, C, W135, X - and there is no effective vaccine for all of them. For now, the best vaccine we have is tetravalent conjugate, which is currently effective against the four most common serogroups. But this is very expensive. The Serum Institute of India is working on a pentavalent conjugate vaccine (A, C, Y, W-135, X) which, in theory, will be inexpensive, effective and safe, but this will not be available until 2020. Given the prospect of a vaccine capable of covering all needs, the rest of the laboratories are not investing in producing other vaccines in case they don’t sell them all.
How has the response to the meningitis C epidemic been in Niger?
Together with the Ministry of Health, we have vaccinated more than 30,000 people against meningitis C in the Tahoua region. We have also provided further support for patient treatment. We were surprised to find such a high percentage of cases of serogroup X, for which there is no vaccine at present. This is a major concern for the future.
Are there other prevention strategies for meningitis C?
New prevention strategies have been tested, such as the administration of a dose of an antibiotic called Ciprofloxacin. This has been used in Niger and it seems that when it is administered to everyone in a rural area, transmission is considerably reduced. More studies are planned in the future to assess the impact of this strategy in urban areas. It could be another weapon in the fight against new epidemics, especially if they are not big.
And in the case of measles, why doesn’t the routine vaccination schedule stop the outbreaks?
The schedule is very strict in terms of age. In Niger, the national protocol states that children must be vaccinated up to 23-months-old. But the vaccines provided by GAVI, the Global Alliance for Vaccines and Immunisation, are only enough to cover children under 12-months-old.
It should also be taken into account that a significant part of the population in Niger lives in nomadic communities or in areas affected by conflict. This means that they have little access to the vaccination packages offered in health centres. In order to prevent the spread of measles, population protection must reach a minimum of 95% and these coverage rates are difficult to maintain among this population.
How could the coverage rate be improved?
The children's schedule should be more flexible. Campaigns should include children up to five years old and any time the child comes into contact with the health system should be an opportunity to update their vaccination card.
Multi-antigen campaigns should also be carried out to protect the child from as many diseases as possible. We are currently responding to a measles epidemic in Arlit (Agadez). In addition to vaccinating against measles, we are also taking the opportunity to add the pentavalent vaccine** and the pneumococcal vaccine in the same campaign.
Where possible and where vaccines are available, we are including the tetanus vaccine for pregnant women or women of childbearing age. This vaccine requires five doses and most women in contexts such as Niger do not receive all of them. So we are taking this opportunity to provide them and their future newborns with good protection. We should take every opportunity to vaccinate against deadly diseases.
Since the beginning of 2018, MSF together with the Ministry of Health, has vaccinated more than 179,460 people in Niger. This includes 145,843 children between six months and 15-years-old who were vaccinated against measles in nine health areas in the Tahoua and Agadez regions. A further 33,620 people aged between two and 29 years were vaccinated against meningitis C in three health areas in the Tahoua region. At present, the organisation is carrying out a vaccination campaign against measles in Arlit, Agadez, with the aim of vaccinating more than 50,000 children under five-years-old. Of these children, those aged under one year will also receive pentavalent and pneumococcal vaccines.
* The alert and epidemic thresholds are respectively 3 and 10 cases of meningitis per 100,000 inhabitants and per week.
** Diphtheria, pertussis, tetanus, haemophilus influenzae type b and hepatitis B.