Combating meningitis in sub-Saharan Africa and what the future holds

In late February global vaccine experts and officials from across Africa gathered in Addis Ababa, Ethiopia, to celebrate one of the region’s biggest public health achievements: virtually obliterating meningitis A off the continent. For a century meningococcal meningitis has swept across 26 countries in sub-Saharan Africa, killing and disabling people and placing huge burdens on families and health care systems. While vaccines were previously available, they were marred by myriad issues: they could only be used once an epidemic had started; they didn’t protect young children or infants; and they only provided short-term protection. Cue in MenAfriVac. Following the devastating 1996 epidemic — which resulted in more than 250,000 meningitis A cases and over 25,000 deaths — African leaders called for the development of a vaccine that would wipe out the disease. As a result, public health officials across the continent, along with the World Health Organization and PATH, formed the Meningitis Vaccine Project. This partnership — along with the Serum Institute of India — designed, developed and produced MenAfriVac, the first vaccine for use specifically in Africa, with African leaders at the table. Introduced in Burkina Faso in 2010, 16 of the 26 countries of the African meningitis belt that stretches from Senegal in the west to Ethiopia in the east, have since conducted mass vaccination campaigns. In the past five years, more than 235 million people have been immunized. As a result, cases of the disease, which can cause severe brain damage or kill within hours, have gone from 250,000 in 1996 to 80 cases in 2015 among countries that have not yet conducted mass immunization programs and those unvaccinated. In the countries that have used the vaccine, the disease has been virtually wiped out. But while it is widely acknowledged that vaccines are the most cost-effective public health intervention, one in five African children still lack access to basic life-saving vaccines. So why was the meningitis A campaign so successful? And how can its success encourage other vaccination efforts on the continent? Lessons learned Experts say the success of the project was testament to the potential role public-private partnerships play in developing vaccines and the fact it was driven by the very people affected by the disease. Another major factor was that from the outset, African leaders had a target price for the vaccine — no more than 50 cents a dose would be spent. “Talk about a public health success,” Kate Elder, a vaccines policy adviser at Médecins Sans Frontières, told Devex. “The reason it was so successful was because a target price was set, so it meant the vaccine wasn’t driven by profit.” Professor Samba Sow, director general of the center for vaccine development at the Ministry of Health in Mali, said communicating with the community was vital for the successful rollout of the vaccine, particularly given the multiple dialects and low literacy rates across the country. “Vaccines start and end with communities,” he said. “The key is to continuously inform the community.” Rodrigue Barry, an advocacy officer at the WHO who worked on the MVP, said there were various issues to overcome, including negative rumours and locals’ perception of the vaccine. He said that in Benin and Chad people questioned the efficacy of the vaccine while there were also issues in reaching male adolescents. This was overcome, he said, by working with sports clubs and universities. “Everything we imagined to try, we did,” he said. “Now we must acknowledge that soon the vaccine will transition into less funded routine immunization programs. With that, there needs to be a shift towards community engagement. Communities can take on a lot of weight if we trust them.” Dr. Chris Elias, president of the global development program at the Bill & Melinda Gates Foundation, said the success of the project meant that it had become a template for designing creative partnerships in the future. “The meningitis A project taught the importance of listening to the health leaders in the region — the whole partnership was a responsible call by African leaders,” adding that the project demonstrated the potential success of utilizing different partnerships across borders. “We have to begin with the end mark and [with this project] we had the end in mind,” he said. The future of MenAfriVac While progress to eradicate meningitis A in sub-Saharan Africa has been heralded as a remarkable public health achievement, there is still much more work to do be done. Now that the campaign has ended, it’s time for governments to step up and integrate MenAfriVac into routine childhood immunization programs. In an interview with Devex, Steve Davis, president of PATH, said despite the encouraging news, now was not the time for complacency. “If we don’t keep the momentum going, if we don’t get the vaccine into national immunization campaigns, there will be new outbreaks,” he said. Davis said there are myriad challenges not only in the countries that need to continue vaccinating their populations, but also in the 10 countries that are yet to conduct campaigns. Central African Republic, Guinea Bissau, South Sudan, Democratic Republic of the Congo and Uganda are ready to rollout the vaccine this year and the other remaining five countries including Rwanda and Burundi are expected to do so by 2017, he said. In addition, eight countries have applied for funding to include the vaccine in their national childhood immunization programs, starting this year. Davis said the major challenge now that countries are expected to pay for the vaccine is how they will handle competing priorities and keep meningitis A vaccinations high on the political agenda. “We can’t be a victim of our own success, we can’t be too comfortable,” he said. “Now that many African countries are middle-income countries and not eligible for Gavi support, what is the role of the global community?” Countries with a gross national income equal or below the threshold of $1,580 are eligible to apply for new vaccine or cash-based program support from Gavi, the Vaccine Alliance. There are currently 54 “Gavi-eligible” countries. In addition to the transition of the vaccine into routine immunization programs, there are also concerns about supply insecurity, political instability and outbreaks of other disease-causing strains of meningitis such as serogroups C, W and X, which also cause epidemic outbreaks in the meningitis belt countries. Barry said it was difficult to promote a vaccine against one strain of meningitis, particularly when locals didn’t distinguish between the strains, leading them to question the efficacy of the vaccine when a different strain appeared in their community. “We need to keep working on the science to develop a multistrain model that’s affordable,” Davis said. In that respect, clinical trials on a pentavalent meningitis vaccine targeting five strains will begin later this year. For the time being though Dr. Matshidiso Rebecca Moeti, WHO regional director for Africa, wants the region to step up its fight not only against meningitis A, but other vaccine-preventable diseases. “We are not where the region needs to be,” she said in a press conference. “Despite progress, persistent challenges remain. Countries need to make more an effort to pay for vaccines and we need to further encourage leaders to act — to understand the importance of vaccination.” To read additional content on global health, go to Focus On: Global Health in partnership with Johnson & Johnson.