Congo Meningitis– In early July 2021, an alert of a suspected outbreak was raised to the Health Division of Tshopo Province in the north-eastern region of the Democratic Republic of the Congo (DRC). The initial alert followed an increase in deaths among people presenting with symptoms including fever, headache, and stiff neck, and some with bloody diarrhea. Samples of blood and stool were collected and tested for Ebola virus disease, shigellosis and salmonellosis. These tested negative on 19 August by the National Institute for Biomedical Research (INRB) lab in Kinshasa.
Meningitis was suspected and as of 16 September, a total of 37 samples of cerebrospinal fluid (CSF) were sent from the University Clinics Laboratory of Kisangani to INRB lab in Kinshasa. Of these, seven were sent to the Pasteur Institute in Paris on 1 September from Kinshasa, and were confirmed to be Neisseria meningitidis by reverse transcriptase polymerase chain reaction (RT-PCR) on 6 September. Additional testing (serotyping) was conducted on these samples from 6 to 13 September, which were identified as Serogroup W by Pasteur Institute Lab in Paris . The remaining 30 samples are planned to be sent to Pasteur Institute, Paris.
Antibiotic susceptibility testing showed that this strain of meningococcus was susceptible to Ceftriaxone. Preliminary retrospective investigations suggested that the outbreak started in early June in two mining areas in Banalia Health Zone in the north of Kisangani, the capital of Tshopo Province. This outbreak is currently active and cases continue to be reported.
As of 18 September 2021, a total of 608 suspected including 12 confirmed cases of meningitis, and 161 deaths (case fatality ratio of 26%), have been reported in the Banalia health zone. Among these cases, 68% (416/608) are aged 15 years or older. Additionally, 16 out of the 20 health areas of the Banalia health zone have notified at least one suspected case of meningitis.
Public health response
The national health authorities, in coordination with WHO, are providing support in responding to this event. The response measures include the following:
1、The local committee for the management of health emergencies is conducting regular meetings to coordinate response activities at the provincial level as well as in the Banalia health zone;
2、A reactive vaccination campaign against meningitis, with vaccine containing meningococcal W antigen, is being planned;
Continuation of in-depth investigations at community level to determine the epidemiological links;
3、Active search for contacts and suspected cases in the mining quarries and in the community;
Strengthening of community-based surveillance;
4、Organized mobile clinics to support case management, sample collection and Infection Prevention and Control (IPC) measures in the affected areas;
5、Supplying additional 5000 doses of Ceftriaxone by the International Coordination Group (ICG) to reinforce the antibiotic stock ;
6、Implementing risk communication activities.
WHO risk assessment
Since 2015, the Democratic Republic of the Congo has reported a high number of suspected cases of meningitis. Parts of the country lie within the African meningitis belt , where bacterial meningitis is endemic and also experiences epidemics, with 6000 to 10,000 suspected cases reported annually. However, only a very small proportion (0-2%) of cases are laboratory confirmed each year.
From 1 January to 1 August 2021, the DRC reported a cumulative total of 3,842 suspected cases including 189 deaths, representing a case-fatality ratio of 5%.
In Tshopo Province, which is in the African meningitis belt, the last meningitis epidemic was reported in November 2009, with 214 cases and 18 deaths (case-fatality ratio of 8%). In May 2016, the province organised a preventive vaccination campaign against meningitis A during which almost 1.7 million people aged between 1 and 29 years were vaccinated. Since then, passive surveillance has been implemented in the province as part of integrated disease surveillance.
Meningococcal meningitis is associated with a high case-fatality ratio (up to 50% when left untreated) and a high incidence (over 10%) of severe sequelae. The current event has already affected 608 people , with 161 deaths. The number of cases and deaths is expected to increase given the infectiousness and lethality of bacterial meningitis.
Logistical challenges, in addition to accessing and communicating with many areas within the health zone, further prevents implementation of an adequate response.
Additionally, the country is responding to the COVID-19 pandemic which is impacting the health systems and disease surveillance capacities; and the existence of other ongoing epidemics in the country is limiting resources for the response to the meningitis outbreak.
At the national level, there is a high risk of the disease spreading to other health zones and to the city of Kisangani, the capital of Tschopo province, due to the movement of people between the affected area and other parts of the country.
At the regional level, the risk is assessed to be moderate due to the cross-border movements between the populations of the Central African Republic and the Tshopo province, and more than 100 mining sites in Banalia where people from neighbouring provinces and the Central African Republic travel for work. Although cross-border measures against COVID-19 may limit the travel and also enhance detection of symptomatic cases.
The risk at global level is assessed to be low.
It is necessary to strengthen the country’s capacity and provide necessary means for diagnosis in order to respond to the current epidemic in an effective manner. Adequate logistics, proper training of health care workers on case identification and notification, and conducting risk communications in the affected health areas to heighten community awareness on measures to prevent transmission of meningitis, what symptoms should be monitored, and when to seek care, as well as strengthening community surveillance and lab capacity are critical in order to organize the response.
Additionally, the country should prepare and conduct a rapid meningitis W vaccination campaign for at-risk populations.
Authorities should strengthen clinical management with ceftriaxone, provide psychosocial care for patients and families, and monitor patients affected by sequelae during and after the disease.WHO advises against any restrictions on travel or trade with the Democratic Republic of the Congo based on the information available on the current outbreak.