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Nearing elimination of meningitis A from the African "meningitis belt" using meningococcal A conjugate vaccine.

Meningococcal meningitis is a serious infection accounting for deaths and disability among thousands of young people every year. (1) Multiple incidences of severe epidemics of meningococcal meningitis have been reported in Nigeria in 1996 (109,580 cases) and in Niger in 2009. (2,3) Even though cases of meningococcal meningitis have been reported across the world, a large number of recurring epidemics have primarily been reported in the 26 nations of the sub-Saharan Africa region, also known as the "meningitis belt". (1,4)

In order to control the outbreaks of meningococcal meningitis, three types of vaccines have been used, namely polysaccharide vaccines (bivalent, trivalent, tetravalent), vaccine against NmB, and conjugate vaccines against group C. (1) However, due to the various limitations (viz. useful only after the onset of an epidemic, no protection for infants, no impact on disease transmission, offering only short-term protection, etc.) associated with the previous vaccines, the World Health Organization in collaboration with other international stakeholders has approved the administration of meningococcal A conjugate vaccine (MACV), which can be used for infants also in the sub-Saharan Africa region. (4,5) The previous vaccines are still in use in other parts of the world depending on the type of meningococcal strain isolated in each specific region. (1)

Acknowledging the high case load, higher incidence rate and/or case fatality rate, the enormous burden on individuals, families, society, and healthcare systems, in an attempt to counter the disease successfully, MACV was launched initially in Burkina Faso in the year 2010, and was subsequently introduced in the other nations from the meningitis belt. (6,7) Until the end of June 2015, almost 220 million persons in the age-group of 1-29 years have received MACV in 15 nations of the African belt. (1)

The results of the introduction of MACV have been hugely successful; a drastic reduction in the number of suspected cases of Neisseria meningitidis A infection, and associated deaths have been reported since then. (2,4) In fact, before the introduction of MACV in 2010, group A meningococci accounted for almost 80% of all cases in the meningitis belt, while in 2014, only 11,900 suspected cases and less than 1,150 deaths have been reported, which are the lowest estimates since the year 2004. (1) Further, in the year 2013, only 4 laboratory-confirmed cases of meningitis A were reported in the region, and it has been anticipated that owing to the high coverage of MACV in the age-group of 1-29 years, the epidemics of subtype-A meningococci will be soon eliminated from the entire meningitis belt. (4,6)

The MACV has been even successful in interrupting the chain of transmission, providing long-term protection, and was subsequently cleared for administration worldwide in the early part of 2015. (5,8) In addition, an almost one-fourth reduction in the proportion of cases of children infected with tetanus has also been observed as the MACV tends to boost the protective immune response against tetanus. (4,5) However, even now, some of the nations from the meningitis belt have not completely expanded the administration of MACV across all settings. (1)

Further, it is very important to understand that all the accomplished gains will be neutralized unless the affected nations maintain a high level of vaccine coverage by integrating the MACV into the routine childhood immunization schedule. (4,9) At the same time, a gradual increase in the number of meningitis cases due to other serogroups of Neisseria meningitidis and due to Streptococcus pneumoniae has been observed in the African meningitis belt in the 2013 epidemic season.4 This calls for a modification in the existing outbreak response strategy, to ensure prompt detection of cases and outbreaks through enhanced surveillance, appropriate case management through administration of antibiotics, early immunization of populations with subtype-specific vaccines, and administration of MACV on a massive scale. (1,4,5,9,10)

To conclude, the introduction of the meningococcal A conjugate vaccine has cleared the way for the elimination of meningitis-A from the entire meningitis belt. However, for sustaining the achieved gains and expanding the benefits to other regions of the world, the vaccine has to be integrated in the routine immunization schedule.

Authors' contributions statement: SS wrote the manuscript. PS performed the literature review. JR supervised the overall process and epidemiologic interpretation of the information. All authors revised and approved the final version of the manuscript.

Conflicts of interest: All authors--none to declare.


(1.) World Health Organization. Meningococcal meningitis--Fact sheet No. 141; 2015. Accessed on: 19 November 2015. Available at: factsheets/fs141/en/

(2.) Mohammed I, Nasidi A, Alkali AS, et al. A severe epidemic of meningococcal meningitis in Nigeria, 1996. Trans R Soc Trop Med Hyg 2000;94:265-70. [CrossRef] [PubMed]

(3.) Collard JM, Maman Z, Abani A, et al. Microbiological and epidemiological investigation of the Neisseria meningitidis serogroup A epidemic in Niger in 2009: last wave before the introduction of the serogroup A meningococcal conjugate vaccine? Epidemiol Infect 2011;139:1656-60. [CrossRef] [PubMed]

(4.) World Health Organization. Meningococcal disease control in countries of the African meningitis belt, 2014. Wkly Epidemiol Rec 2015;90:123-31. [PubMed]

(5.) World Health Organization. WHO grants approval for safe, effective meningitis A vaccine for infants; 2015. Accessed on: 8 November 2015. Available at: http: //

(6.) World Health Organization. Affordable and effective vaccine brings Africa close to elimination of meningitis A; 2015. Accessed on: 19 November 2015. Available at:

(7.) Gamougam K, Daugla DM, Toralta J, et al. Continuing effectiveness of serogroup A meningococcal conjugate vaccine, Chad, 2013. Emerg Infect Dis 2015;21:115-8. [CrossRef] [PubMed] [FullText]

(8.) Collard JM, Issaka B, Zaneidou M, et al. Epidemiological changes in meningococcal meningitis in Niger from 2008 to 2011 and the impact of vaccination. BMC Infect Dis 2013;13:576. [CrossRef] [PubMed] [FullText]

(9.) Carod Artal FJ. Meningococcal meningitis: vaccination outbreak response and epidemiological changes in the African meningitis belt. Int Health 2015;7:226-7. [CrossRef] [PubMed]

(10.) MenAfriCar consortium. The diversity of meningococcal carriage across the African meningitis belt and the impact of vaccination with a group A meningococcal conjugate vaccine. J Infect Dis 2015;212:1298-307. [CrossRef] [PubMed] [FullText]

doi: 10.11599/germs.2016.1091

Saurabh RamBihariLal Shrivastava [1], *, Prateek Saurabh Shrivastava [2], Jegadeesh Ramasamy [3]

Received: 19 November 2015; revised 10 January 2016; accepted: 18 February 2016.

[1] MD Community Medicine, Assistant Professor, Department of Community Medicine, Shri Sathya Sai Medical College & Research Institute, Kancheepuram, India; [2] MD Community Medicine, Assistant Professor, Department of Community Medicine, Shri Sathya Sai Medical College & Research Institute, Kancheepuram, India; [3] MD Community Medicine, Professor & Head, Department of Community Medicine, Shri Sathya Sai Medical College & Research Institute, Kancheepuram, India.

* Corresponding author: Saurabh RamBihariLal Shrivastava, MD Community Medicine, Assistant Professor, 3rd floor, Department of Community Medicine, Shri Sathya Sai Medical College & Research Institute, Ammapettai village, Thiruporur--Guduvancherry Main Road, Sembakkam Post, Kancheepuram, Tamil Nadu, 603108, India.
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Title Annotation:Correspondence
Author:Shrivastava, Saurabh RamBihariLal; Shrivastava, Prateek Saurabh; Ramasamy, Jegadeesh
Date:Jun 1, 2016
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