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While the H1N1 flu dominates headlines, a far nastier blight has erupted in Africa, killing thousands. Here’s the story of one of the world’s most neglected diseases.
It’s a deadly scourge, caused by bacteria that attack the fluid surrounding the brain and spinal cord. Occasionally, a few of America’s young get sick, catching the infection from sneezing, coughing or kissing. Annually, about 300 in the U.S. die from it.
It’s a different story in Africa, where every eight to 10 years or so, a killer epidemic sweeps through the meningitis belt, territory running from Ethiopia in the east to Senegal in the West.
Meningitis is not Africa’s biggest killer, but it is one of the most frightening. In a typical outbreak, the disease kills about 10 percent of its victims and leaves about a quarter of its survivors deaf or mentally retarded. It’s quick and brutal: a child can be fine one day and dead the next.
“Bacterial meningitis is probably the most devastating infectious disease that people get in Africa. We are talking about wards filled with people with life-threatening illness,” said Orin Levine, PhD, an associate professor at the Johns Hopkins Bloomberg School of Public Health and the executive director of The Pneumococcal Vaccines Accelerated Development Program and Introduction Plan. “A lot of people are surprised to hear this. It’s acute and it kills or disables up to 50 percent of the kids that get it in Africa. There are long-term economic consequences which for impoverished families make matters worse.”
The trick is getting life-saving medicine to sick people and disease-preventing vaccines to healthy people immediately. Somehow it never goes smoothly.
“Time is of the essence,” said Madeleine Thomson PhD who chairs the Africa Regional Program at The International Research Institute of Climate and Society, Columbia University. “In the U.S., you have fantastic services and kids still die. The fact is that when it happens [in Africa], you may be in a village and you have to walk eight hours to the nearest clinic that may not even have the treatment. We have to develop better forecasting systems to predict the risk of epidemics developing and get the vaccines out. Once the epidemic starts, you’re too late.”
This year’s epidemic hit particularly hard, the most virulent since 1996 when about 250,000 people got sick and 25,000 people died. From February to May 2009, meningitis infected upwards of 50,000 people living in the belt and killed more than 2,600 of them. But these statistics underestimate the true toll. They do not take into account the people who die before getting to a medical center. In response to this year’s virulent strain, the World Health Organization upped its meningitis surveillance in 13 countries: Benin, Burkina Faso, Cameroon, the Central African Republic, Chad, Côte d'Ivoire, the Democratic Republic of the Congo, Ethiopia, Ghana, Mali, Niger, Nigeria and Togo.
An evolving problem
Meningitis is not one microbe, but the name given to any of a number of germs that invade the fluid surrounding the brain and spinal cord. The invasion sparks a fever and stiff neck that, without treatment, can kill or lead to lifelong complications. Before the 1990s, most epidemics were triggered by a bacteria called Haemophilis influenza type B (Hib)—not to be confused with the influenza virus. A widespread vaccination program has dramatically reduced Hib infection. These days, the bacteria Neisseria meningitides (also called meningococcal meningitis) causes most of the epidemics. Streptococcus pneumonia, another kind of bacteria, sparks the most lethal attacks.
Mass vaccination in the U.S. dramatically reduced the number of meningitis cases. There are now three kinds of vaccines, aimed at three different kinds of bacteria. The meningococcal vaccine prevents the type of meningitis that occurs among college students and the military. Dr. Warren Andiman, a professor of pediatrics and public health at Yale University, said the rare cases of bacterial meningitis in the U.S. are typically among children whose parents refused the vaccination. That’s what happened in Minnesota in 2008 when five children got sick, including a 7-year-old who died.
Outbreaks in Africa tend to start suddenly in the unbearable dry, hot winter months and end just as abruptly late spring when the rain begins. No one knows why. Nor do they know precisely why these bacteria tend to live peacefully in the throats of most people but wreak havoc in the bodies of others. Theories abound. Some scientists have a hunch that the gusts of hot, dusty air corrodes the lining of the throat facilitating the germs’ journey into the central nervous system. Dr. Michael Cappello, a professor of pediatrics and microbial pathogenesis at Yale University, calls Africa’s meningitis belt the “perfect storm” — a toxic combination that probably has something to do with poverty, climate, and genetics.
The solution is all about preparation and organization — a colossal challenge in poor countries with little or no health infrastructure. To make matters worse, in between outbreaks meningitis falls off the radar screen of African governments, overseas health organizations, and the media. The other big killers — malaria, HIV, and tuberculosis — capture the limelight. According to Thomson, meningitis is among the list of neglected African diseases. “Actually [meningitis] is neglected among the neglected diseases.”
But Thomson and others of her ilk are on a mission to change all of that. She is on the steering committee of MERIT, the Meningitis Environmental Risk Information Technologies, which aims to develop a better system to forecast these killer epidemics, and to support the development of more permanent solutions.
At the same time, the Meningitis Vaccine Project (a partnership of the World Health Organization and the Program for Appropriate Technology in Health (PATH), with funding from the Bill and Melinda Gates Foundation) is working on a vaccine touted to be long-lasting, safe, and cheap—only 50 cents a shot. Preliminary studies suggest the vaccine works by revving up the immune system. On top of that, environmental information could “help better target these new vaccines,” Thomson says.
The old vaccine only provides immunity for about two to three years, meaning that every time an epidemic hit, millions of potential victims needed to be vaccinated all over again. What’s more, it was useless in children younger than two, who are often targets of the disease.
If the ongoing studies prove the new vaccine to be safe, and if it really works, public health workers plan to distribute some 40 million doses of the new vaccine in early 2010 to people in the hardest hit regions—Burkina Faso, Mali, and Niger. The ultimate goal is to blanket the entire belt with the preventive shot. But that is still years away.
Levine says meningitis is easily preventable if the vaccines are adequately distributed — meaning, administered within the next five years to ten years throughout the meningitis belt to everyone from nine months to 30 years old. That’s about 400 million people.
No doubt there will be obstacles. No vaccine is perfect. The new vaccine—while seemingly potent—only works against meningococcal meningitis Type A. That’s the most common strain, but other strains do attack. If it had been available for this year’s epidemic, it may have prevented disease in Nigeria, but not Chad, which was hit with a different strain, W135.
Despite the limitations, Africans are clamoring for the vaccine. Yet if side effects emerge, that could be enough to frighten entire villages and destroy the trust they have in the foreign health workers. Already health officials are working with community and religious leaders to strengthen ties with the locals.
Levine says, “I don’t want to make it sound like delivering vaccines across the Sahara is a cup of tea, but I think we have the tools and the funding and the political will. We can mobilize a vast army of people to deliver vaccines to those who need it. When we put that combination together, bacterial meningitis will be a thing of the past.”
That is, if all goes according to plan; if the vaccine works; if the financial support continues; and if the shots are distributed to the millions of people at risk. The rainy season is about to start and the numbers of people with new infections are beginning to dwindle. Let’s hope momentum for prevention doesn’t dwindle as well.