An overview of bacterial meningitis epidemics in Africa from 1928 to 2018 with a focus on epidemics "outside-the-belt"

Determining the bacterial and viral meningitis trend in Iraq from 2007 till 2023 using joinpoint regression

Background

Acute meningitis is a disease with case fatality and disability rate that is dependent on the causative agent.

Objective

Determine the meningitis trend in Iraq from 2007 to 2023 using a joinpoint regression at national and sub-national levels and describe the epidemiology.

Methods

Joinpoint regression model was used on surveillance data from Jan 2007 until May 2023, to calculate annual and average annual percent changes to determine the trend. Meningitis total count was modelled by year of reporting and province using the log transformation and Poisson variance. Best-fit model was chosen based on the weighted BIC criteria as the final point.

Results

Bacterial meningitis was higher than viral meningitis from 2007 to 2018, then viral meningitis started to exceed till 2023. Meningococcal meningitis was lower than other bacterial and viral meningitis from 2007 to 2023. Most meningitis cases across the years were lower than 15 years, at almost 80 %, while 20 %-40 % were lower than one year. Across all years, 55 % of the cases were males; apart from 2019, 70 % were females.

Conclusion

In Iraq, viral meningitis has been the predominant type since 2018. Most meningitis patients were lower than 15-year-old males. The meningitis trend in Iraq was stable from 2007 till 2023.

An isothermal CRISPR- based lateral flow assay for detection of Neisseria meningitidis

BACKGROUND

Neisseria meningitidis can cause life-threatening meningococcal meningitis and meningococcemia. Old standard microbiological results from CSF/blood cultures are time consuming. This study aimed to combine the sensitivity of loop-mediated isothermal nucleic acid amplification (LAMP) with the specificity of CRISPR/Cas12a cleavage to demonstrate a reliable diagnostic assay for rapid detection of N. meningitidis.

METHODS

A total of n = 139 samples were collected from patients with suspected meningococcal disease and were used for evaluation. The extracted DNA was subjected to qualitative real-time PCR, targeting capsular transporter gene (ctrA) of N. meningitidis. LAMP-specific primer pairs, also targeting the ctrA, were designed and the LAMP products were subjected to CRISPR/Cas12 cleavage reaction. the readout was on a lateral flow strip. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of LAMP-CRISPR/Cas was compared with real-time PCR assays. The limit of detection (LOD) was established with serial dilutions of the target N. meningitidis DNA and calculated by Probit regression analysis.

RESULTS

Six LAMP assay-specific primers were developed targeting the ctrA gene of N. meningitidis, which is conserved in all meningococcal serogroups. The LAMP primers did not amplify DNA from other bacterial DNA tested, showing 100% specificity. The use of 0.4 M betaine increased the sensitivity and stability of the reaction. LAMP-CRISPR/Cas detected meningococcal serogroups (B, C, W). The assay showed no cross-reactivity and was specific for N. meningitidis. The LOD was 74 (95% CI: 47-311) N. meningitidis copies. The LAMP-CRISPR/Cas performed well compared to the gold standard. In the 139 samples from suspected patients, the sensitivity and specificity of the test were 91% and 99% respectively.

CONCLUSION

This developed and optimized method can complement for the available gold standard for the timely diagnosis of meningococcal meningitis and meningococcemia.

Determinants of mortality among pediatric patients admitted to Wolaita Sodo University Comprehensive Specialized Hospital with acute bacterial meningitis, Southern Ethiopia: an unmatched case-control study

BACKGROUND

People of all ages suffer from acute bacterial meningitis, but children are the most vulnerable, accounting for over 50% of all cases and deaths in children under the age of five. It is the leading cause of morbidity, mortality, and long-term suffering worldwide. Children are at great risk of disease and mortality due to a lack of specific immunity associated with their young age. As a result, determinants of death were found among pediatric patients treated with acute bacterial meningitis at Wolaita Sodo University Comprehensive Specialized Hospital in Southern Ethiopia.

METHODS

A facility-based unmatched case-control study was conducted on pediatric patients admitted with acute bacterial meningitis at Wolaita Sodo University Comprehensive Specialized Hospital from July 1, 2019, to June 30, 2022. A total of 355 (71 cases and 284 controls) pediatric medical charts were used for data extraction using a preestablished checklist. Data were checked for completeness and consistency, entered into Epi-Data version 4.6 software, and transported to SPSS version 25 for analysis. Multivariable logistic regression analysis was performed to identify the independent determinants of acute bacterial meningitis mortality at a P value of < 0.05 along with a 95% confidence interval (CI).

RESULTS

Age between 2 months and 5 years (adjusted odds ratio (AOR) = 3.19, 95% CI = 1.15-8.88), admission in the summer season (AOR = 0.27, 95% CI = 0.15-0.49), and family size greater than or equal to six (AOR = 3.13, 95% CI = 1.76-5.56), initial antibiotic change (AOR = 10.81, 95% CI = 2.10-55.7), clinical features at presentation such as loss of consciousness (AOR = 16.90, 95% CI = 4.70-60.4), abnormal body movements (seizures) (AOR = 6.51, 95% CI = 1.82-23.4), increased intracranial pressure (AOR = 3.63, 95% CI = 1.78-7.4), malnutrition (AOR = 2.98, 95% CI = 1.34-6.59) and presence of more than one comorbidity (AOR = 3.03, 95% CI = 1.03-9.03) were found to be determinants of acute bacterial meningitis mortality.

CONCLUSIONS

In summary, children aged 2 months to 5 years from large families ( > = 6) with a history of initial antibiotic change, malnutrition, more than one comorbidity, and worse clinical characteristics were related to greater death due to acute bacterial mortality in this study.

Predictors for Uptake of Vaccines Offered during the Second Year of Life: Second Dose of Measles-Containing Vaccine and Meningococcal Serogroup A-Containing Vaccine, Ghana, 2020

BACKGROUND

Understanding the drivers of coverage for vaccines offered in the second year of life (2YL) is a critical focus area for Ghana's life course approach to vaccination. This study characterizes the predictors of vaccine receipt for 2YL vaccines-meningococcal serogroup A conjugate vaccine (MACV) and the second dose of measles-containing vaccine (MCV2)-in Ghana.

METHODS

1522 children aged 18-35 months were randomly sampled through household surveys in the Greater Accra Region (GAR), Northern Region (NR), and Volta Region (VR). The association between predictors and vaccination status was modeled using logistic regression with backwards elimination procedures. Predictors included child, caregiver, and household characteristics.

RESULTS

Coverage was high for infant vaccines (>85%) but lower for 2YL vaccines (ranging from 60.2% for MACV in GAR to 82.8% for MCV2 in VR). Predictors of vaccination status varied by region. Generally, older, first-born children, those living in rural settlements and those who received their recommended infant vaccines by their first birthday were the most likely to have received 2YL vaccines. Uptake was higher among those with older mothers and children whose caregivers were aware of the vaccination schedule.

CONCLUSIONS

Improving infant immunization uptake through increased community awareness and targeted strategies, such as parental reminders about vaccination visits, may improve 2YL vaccination coverage.

Trends in invasive bacterial diseases during the first 2 years of the COVID-19 pandemic: analyses of prospective surveillance data from 30 countries and territories in the IRIS Consortium

BACKGROUND

The Invasive Respiratory Infection Surveillance (IRIS) Consortium was established to assess the impact of the COVID-19 pandemic on invasive diseases caused by Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, and Streptococcus agalactiae. We aimed to analyse the incidence and distribution of these diseases during the first 2 years of the COVID-19 pandemic compared to the 2 years preceding the pandemic.

METHODS

For this prospective analysis, laboratories in 30 countries and territories representing five continents submitted surveillance data from Jan 1, 2018, to Jan 2, 2022, to private projects within databases in PubMLST. The impact of COVID-19 containment measures on the overall number of cases was analysed, and changes in disease distributions by patient age and serotype or group were examined. Interrupted time-series analyses were done to quantify the impact of pandemic response measures and their relaxation on disease rates, and autoregressive integrated moving average models were used to estimate effect sizes and forecast counterfactual trends by hemisphere.

FINDINGS

Overall, 116 841 cases were analysed: 76 481 in 2018-19, before the pandemic, and 40 360 in 2020-21, during the pandemic. During the pandemic there was a significant reduction in the risk of disease caused by S pneumoniae (risk ratio 0·47; 95% CI 0·40-0·55), H influenzae (0·51; 0·40-0·66) and N meningitidis (0·26; 0·21-0·31), while no significant changes were observed for S agalactiae (1·02; 0·75-1·40), which is not transmitted via the respiratory route. No major changes in the distribution of cases were observed when stratified by patient age or serotype or group. An estimated 36 289 (95% prediction interval 17 145-55 434) cases of invasive bacterial disease were averted during the first 2 years of the pandemic among IRIS-participating countries and territories.

INTERPRETATION

COVID-19 containment measures were associated with a sustained decrease in the incidence of invasive disease caused by S pneumoniae, H influenzae, and N meningitidis during the first 2 years of the pandemic, but cases began to increase in some countries towards the end of 2021 as pandemic restrictions were lifted. These IRIS data provide a better understanding of microbial transmission, will inform vaccine development and implementation, and can contribute to health-care service planning and provision of policies.

FUNDING

Wellcome Trust, NIHR Oxford Biomedical Research Centre, Spanish Ministry of Science and Innovation, Korea Disease Control and Prevention Agency, Torsten Söderberg Foundation, Stockholm County Council, Swedish Research Council, German Federal Ministry of Health, Robert Koch Institute, Pfizer, Merck, and the Greek National Public Health Organization.

High-Frequency Changes in Pilin Glycosylation Patterns during Neisseria meningitidis Serogroup a Meningitis Outbreaks in the African Meningitis Belt

In the meningitis belt of sub-Saharan Africa, there are cyclic meningococcal epidemics that coincide with clonal waves of Neisseria meningitidis carriage and invasive disease. In the framework of longitudinal colonization and disease studies in Ghana and Burkina Faso, meningococcal isolates belonging to the closely related hypervirulent A:ST-5, A:ST-7, and A:ST-2859 clones have been collected from 1998 to 2011 during meningococcal outbreaks. A comparative whole-genome sequencing study with 100 of these isolates identified the pilin glycosylation (pgl) locus as one hot spot of recombination. Frequent exchange of pgl genes in N. meningitidis by lateral gene transfer results in differences in the glycosylation patterns of pilin and other cell surface glycoproteins. In this study, we looked at both recombination and phase variation of the pgl genes of these clinical isolates and analyzed the glycan structures resulting from different pgl alleles and their variable expression. Our results indicate that the basal O-linked sugar of the glycans expressed by these isolates is masked by various additional mono- or disaccharide structures whose expression is highly variable due to the phase-variable expression of pgl genes. We also observed a distinct glycoform in two isolates with pgl loci that were modified by recombination. These data suggest that variation in N. meningitidis protein glycosylation could be crucial for bacterial adaptation to evade herd immunity in semi-immune populations. Investigating pilin glycosylation in N. meningitidis can shed light on the mechanisms by which this pathogen evades the host immune response, and may help identify potential targets for novel therapies and vaccines.

The meningitis outbreak returns to Niger: Concern, efforts, challenges, and recommendations

Meningitis, a disease that commonly manifests in African meningitis belt, continues to be a public health problem as it is a fatal disease that leave survivors with long-term effects. Most cases of meningitis are due to bacterial and viral infection, although parasites, fungus, cancer, drugs, and immune disorders can rarely cause meningitis. Stiff neck, high temperature, light sensitivity, disorientation, headaches, and vomiting are the most typical symptoms of meningitis. Niger, being in African meningitis belt, has been affected by many meningitis outbreaks. Since 2015, a total of 20,789 cases and 1369 fatalities (CFR 6.6%) have been documented in Niger. In contrast to earlier seasons, the current outbreak of meningitis in Niger exhibits both an increase in the number of cases and a rise in the growth rate. A total of 559 cases of meningitis, including 18 fatalities (overall CFR 3.2%), were reported in the Zinder Region, southeast of Niger, from 1 November 2022 to 27 January 2023, compared to 231 cases reported from 1 November 2021 to 31 January 2022. In the current outbreak, the Neisseria meningitidis serogroup C (NmC) is responsible for the majority of laboratory confirmed cases (104/111; 93.7%). To organize the response to the outbreak, a global team of WHO and other partners, including MSF and UNICEF, has been sent to Niger. Even though there are many challenges in battle against meningitis in Niger, immunization, antibiotics administration and strong disease surveillance are recommended techniques to cope with the current meningitis outbreak in Niger.

Viral, Bacterial, Metabolic, and Autoimmune Causes of Severe Acute Encephalopathy in Sub-Saharan Africa: A Multicenter Cohort Study

OBJECTIVES

To assess whether viral, bacterial, metabolic, and autoimmune diseases are missed by conventional diagnostics among children with severe acute encephalopathy in sub-Saharan Africa.

STUDY DESIGN

One hundred thirty-four children (6 months to 18 years) presenting with nontraumatic coma or convulsive status epilepticus to 1 of 4 medical referral centers in Uganda, Malawi, and Rwanda were enrolled between 2015 and 2016. Locally available diagnostic tests could be supplemented in 117 patients by viral, bacterial, and 16s quantitative polymerase chain reaction testing, metagenomics, untargeted metabolomics, and autoimmune immunohistochemistry screening.

RESULTS

Fourteen (12%) cases of viral encephalopathies, 8 (7%) cases of bacterial central nervous system (CNS) infections, and 4 (4%) cases of inherited metabolic disorders (IMDs) were newly identified by additional diagnostic testing as the most likely cause of encephalopathy. No confirmed cases of autoimmune encephalitis were found. Patients for whom additional diagnostic testing aided causal evaluation (aOR 3.59, 90% CI 1.57-8.36), patients with a viral CNS infection (aOR 7.91, 90% CI 2.49-30.07), and patients with an IMD (aOR 9.10, 90% CI 1.37-110.45) were at increased risk for poor outcome of disease.

CONCLUSIONS

Viral and bacterial CNS infections and IMDs are prevalent causes of severe acute encephalopathy in children in Uganda, Malawi, and Rwanda that are missed by conventional diagnostics and are associated with poor outcome of disease. Improved diagnostic capacity may increase diagnostic yield and might improve outcome of disease.

A mathematical interpretation for outbreaks of bacterial meningitis under the effect of time-dependent transmission parameters

We consider a SIR-type compartmental model divided into two age classes to explain the seasonal exacerbations of bacterial meningitis, especially among children outside of the meningitis belt. We describe the seasonal forcing through time-dependent transmission parameters that may represent the outbreak of the meningitis cases after the annual pilgrimage period (Hajj) or uncontrolled inflows of irregular immigrants. We present and analyse a mathematical model with time-dependent transmission. We consider not only periodic functions in the analysis but also general non-periodic transmission processes. We show that the long-time average values of transmission functions can be used as a stability marker of the equilibrium. Furthermore, we interpret the basic reproduction number in case of time-dependent transmission functions. Numerical simulations support and help visualize the theoretical results.

Diagnostic accuracy of rapid antigen tests in cerebrospinal fluid for pneumococcal meningitis: a systematic review and meta-analysis

BACKGROUND

Streptococcus pneumoniae is a leading cause of bacterial meningitis worldwide. Conventional microbiological assays take several days and require the use of various drugs for empirical treatment. Rapid antigen tests in cerebrospinal fluid (CSF) may be useful to triage pneumococcal meningitis immediately.

OBJECTIVES

To elucidate whether rapid antigen tests in CSF are useful in the triage of pneumococcal meningitis.

METHODS

Data sourcesCochrane CENTRAL, MEDLINE, EMBASE, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov databases were searched. Study eligibility criteriaAll types of cohort studies except multiple-group studies, where the sensitivity and specificity of rapid antigen tests in CSF compared with CSF culture can be extracted. ParticipantsPatients with suspected meningitis. TestsRapid antigen tests in CSF. Reference standardsOne or more of the following: blood culture, CSF culture, and polymerase chain reaction in CSF. Assessment of risk of biasThe methodological quality of the included studies was assessed using QUADAS-2. Methods of data synthesisWe used a random-effects bivariate model for the meta-analysis. We conducted a subgroup analysis by dividing studies into types of antigen tests, adults and children, low-income and high-income countries, and with or without exposure to antibiotics before lumbar puncture.

RESULTS

Forty-four studies involving 14 791 participants were included. Most studies had a moderate-to-low methodological quality. Summary sensitivity and specificity were 99.5% (95% confidence interval (CI), 92.4-100%) and 98.2% (95% CI, 96.9-98.9%), respectively. Positive predictive values and negative predictive values at the median prevalence (4.2%) in the included studies were 70.8% (95% CI, 56.6-79.9%) and 100% (95% CI, 99.7-100%), respectively. The diagnostic accuracy was consistent across the various subgroups, except for slightly reduced sensitivity in high-income countries.

CONCLUSIONS

Rapid antigen tests in CSF would be useful in triaging pneumococcal meningitis. Further studies are warranted to investigate the clinical benefit of ruling out pneumococcal meningitis based on the results of rapid antigen tests.

Socioepidemiological macro-determinants associated with the cumulative incidence of bacterial meningitis: A focus on the African Meningitis Belt

Background

Bacterial meningitis (BM) is a public health challenge as it is associated with high lethality and neurological sequelae. Worldwide, most cases are registered in the African Meningitis Belt (AMB). The role of particular socioepidemiological features is essential for understanding disease dynamics and optimizing policy-making.

Objective

To identify socioepidemiological macro-determinants that contribute to explaining the differences in BM incidence between AMB and the rest of Africa.

Methods

Country-level ecologic study based on the cumulative incidence estimates of the Global Burden of Disease study and reports of the MenAfriNet Consortium. Data about relevant socioepidemiological features were extracted from international sources. Multivariate regression models were implemented to define variables associated with the classification of African countries within the AMB and the incidence of BM worldwide.

Results

Cumulative incidences at the AMB sub-regions were 111.93 (west), 87.23 (central), 65.10 (east), and 42.47 (north) per 100,000 population. A pattern of common origin with continuous exposition and seasonality of cases was observed. Socio-epidemiological determinants contributing to differentiating the AMB from the rest of Africa were household occupancy (OR 3.17 CI 95% 1.09-9.22, p = 0.034) and malaria incidence (OR 1.01 CI 95% 1.00-1.02, p = 0.016). BM cumulative incidence worldwide was additionally associated with temperature and gross national income per capita.

Conclusion

Socioeconomic and climate conditions are macro-determinants associated with BM cumulative incidence. Multilevel designs are required to confirm these findings.

A phase 3, randomized, controlled, open-label study to evaluate the persistence up to 5 years of 1 or 2 doses of meningococcal conjugate vaccine MenACWY-TT given with or without 13-valent pneumococcal conjugate vaccine in 12-14-month-old children

BACKGROUND

Immunogenicity and safety up to 5 years after administration of 1 or 2 doses of quadrivalent meningococcal serogroup A, C, W, and Y tetanus toxoid conjugate vaccine (MenACWY-TT) given alone or with 13-valent pneumococcal conjugate vaccine (PCV13) in children was investigated.

METHODS

This phase 3 study randomized healthy 12-24-month-olds to MenACWY-TT at Month 0 (ACWY1d), MenACWY-TT at Months 0 and 2 (ACWY2d), MenACWY-TT and PCV13 at Month 0 (Co-Ad), or PCV13 at Month 0 and MenACWY-TT at Month 2 (PCV13/ACWY). Immune responses 1, 3, and 5 years after primary vaccination were evaluated with serum bactericidal activity using rabbit complement (rSBA) titers ≥ 1:8 and geometric mean titers (GMTs). Evaluation of serious adverse events up to 5 years after primary vaccination are reported.

RESULTS

Of the 802 children randomized in the study, 619 completed the study through Year 5. Immune responses after vaccination declined over time but were higher 5 years after vaccination compared with levels before vaccination. At Year 5, the percentages of children with rSBA titers ≥ 1:8 across all serogroups were 20.5 %-58.6 %, 28.4 %-65.8 %, 23.9 %-52.8 %, and 19.4 %-55.8 % in the ACWY1d, ACWY2d, Co-Ad, and PCV13/ACWY groups, respectively. Comparable antibody persistence at Year 5 was observed for participants receiving 1 or 2 doses of MenACWY-TT, although GMTs were elevated in those who received 2 versus 1 dose. The percentage of children with protective antibody titers at Year 5 was similar in participants who received PCV13 and MenACWY-TT compared with that observed for participants who only received 1 or 2 MenACWY-TT doses. No new safety concerns were identified during the study period.

CONCLUSION

Antibody responses persisted in the majority of children up to 5 years after primary vaccination with MenACWY-TT administered in a 1- or 2-dose regimen with or without PCV13, with no new safety concerns identified.

CLINICALTRIALS

gov Identifier NCT01939158; EudraCT number 2013-001083-28.

Association of Diabetes with Meningitis Infection Risks: A Systematic Review and Meta-Analysis

Background

The Global Burden of Disease Study in 2016 estimated that the global incident cases of meningitis have increased by 320,000 between 1990 and 2016. Current evidence suggests that diabetes may be a prime risk factor for meningitis among individuals, including older adults. However, findings of prior studies on this topic remain inconsistent, making a general conclusion relatively difficult. This study aimed to quantitatively synthesize the literature on the risk of meningitis associated with diabetes and compare the risk across different global regions.

Method

Literature search and study design protocol followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was conducted in PubMed, Web of Science, African Journal Online, and Google Scholar using relevant MESH terms. A random effect model was used to pull effect sizes.

Results

Initial search yielded 772 papers but 756 studies were excluded due to duplicity and not meeting inclusion criteria. In all, 16 papers involving 16847 cases were used. The pulled effect size (ES) of the association between diabetes and meningitis was 2.240 (OR = 2.240, 95% CI = 1.716-2.924). Regional-base analysis showed that diabetes increased the risk of developing meningitis in Europe (OR = 1.737, 95% CI = 1.299-2.323), Asia (OR = 2.192, 95% CI = 1.233-3.898), and North America (OR = 2.819, 95% CI = 1.159-6.855). These associations remained significant in the study design and etiological classe-based subgroup analyses. However, we surprisingly found no studies in Africa or South America.

Conclusion

Diabetes is a risk factor for developing meningitis. Given that no research on this topic came from Africa and South America, our findings should be contextually interpreted. We, however, encourage studies on diabetes-meningitis linkages from all parts of the world, particularly in Africa and South America, to confirm the findings of the present study.

Aetiology and diagnostics of paediatric hydrocephalus across Africa: a systematic review and meta-analysis

BACKGROUND

We aimed to identify the aetiological distribution and the diagnostic methods for paediatric hydrocephalus across Africa, for which there is currently scarce evidence.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE (Ovid), the Cochrane Database of Systematic Reviews (Wiley), Embase (Ovid), Global Health (Ovid), Maternity & Infant Care (Ovid), Scopus, African Index Medicus (Global Index Medicus, WHO) and Africa-Wide Information (EBSCO) from inception to Nov 29, 2021. We included studies from any African country reporting on the distribution of hydrocephalus aetiology in children aged 18 years and younger, with no language restrictions. Hydrocephalus was defined as radiological evidence of ventriculomegaly or associated clinical symptoms and signs of the disorder, or surgical treatment for hydrocephalus. Exclusion criteria were studies only reporting on one specific subgroup or one specific cause of hydrocephalus. We also excluded conference and meetings abstracts, grey literature, editorials, commentaries, historical reviews, systematic reviews, case reports and clinical guidelines, as well as studies on non-humans, fetuses, or post-mortem reports. The proportions of postinfectious hydrocephalus, non-postinfectious hydrocephalus, and hydrocephalus related to spinal dysraphism were calculated using a random-effects model. Additionally, we included a category for unclear cases. Diagnostic methods were described qualitatively. To assess methodological study quality, we applied critical appraisal checklists provided by the Joanna Briggs Institute. The study was registered in Prospero (CRD42020219038).

FINDINGS

Our search yielded 3783 results, of which 1880 (49·7%) were duplicates and were removed. The remaining 1903 abstracts were screened and 122 (6·4%) full articles were sought for retrieval; of these, we included 38 studies from 18 African countries that studied a total of 6565 children. The pooled proportion of postinfectious hydrocephalus was 28% (95% CI 22-36), non-postinfectious hydrocephalus was 21% (95% CI 13-30), and of spinal dysraphism was 16% (95% CI 12-20), with substantial heterogeneity. The pooled proportion of hydrocephalus of unclear aetiology was 20% (95% CI 13-28).

INTERPRETATION

Our findings suggest that postinfectious hydrocephalus is the single most common cause of paediatric hydrocephalus in Africa. For targeted investments to be optimal, there is a need for consensus regarding the aetiological classification of hydrocephalus and improved access to diagnostic services.

FUNDING

Rikshospitalet, Oslo University Hospital, Oslo, Norway.

Diagnosis of Pediatric Stroke in Resource Limited Settings

Global awareness of stroke as a significant cause of neurologic sequelae and death in children has increased over the years as more data in this field becomes available. However, most published literature on pediatric stroke have limited geographic representation. Data on childhood stroke from developing countries remains limited. Thus, this paper reviewed geographic/ethnic differences in pediatric stroke risk factors highlighting those reported in low- and middle-income countries, and proposes a childhood arterial ischemic stroke diagnostic algorithm for resource limited settings. Stroke risk factors include cardiac disorders, infectious diseases, cerebral arteriopathies, hematologic disorders, inflammatory diseases, thrombophilia and genetic conditions. Infection of the central nervous system particularly tuberculous meningitis, is a leading cause of pediatric arterial ischemic stroke in developing countries. Stroke should be considered in children with acute focal neurologic deficit especially in the presence of aforementioned risk factors. Cranial magnetic resonance imaging with angiography is the neuroimaging modality of choice but if unavailable, cranial computed tomography with angiography may be performed as an alternative. If both are not available, transcranial doppler together with neurologic exam may be used to screen children for arterial ischemic stroke. Etiological diagnosis follows with the aid of appropriate laboratory tests that are available in each level of care. International collaborative research on stroke risk factors that are prevalent in low and middle income countries will provide information for drafting of stroke care guidelines that are universal yet inclusive taking into consideration regional differences in available resources with the goal of reducing global stroke burden.

Spatial epidemiology of bacterial meningitis in the Upper West Region of Ghana: Analysis of disease surveillance data 2018-2020

Background

The use of a Geographic Information System in identifying meningitis hotspots in the Upper West Region (UWR) remains underutilized, making spatial targeting of meningitis hotspots difficult. We therefore utilized surveillance data enabled with GIS technology to target meningitis outbreaks in the UWR.

Methods

Secondary data analysis was conducted in the study. The dynamics of bacterial meningitis in space and time were studied using epidemiological data from 2018 to 2020. Spot map and choropleths were used to depict the distribution of cases in the region. Moran's I statistics were used to assess spatial autocorrelation. Getis-Ord Gi*(d) and Anselin Local Moran's statistics were used to identify hotspots and spatial outliers within the study area. A Geographic Weighted Regression model was also used to examine how socio bio-climatic conditions influence the spread of meningitis.

Results

There were 1176 cases of bacterial meningitis, 118 deaths, and 1058 survivors between 2018 and 2020. Nandom municipality had the highest Attack Rate (AR) at 492/100,000 persons, followed by Nadowli-Kaleo district at 314/100,000 persons. Jirapa had the highest case fatality rate (CFR) at 17%. The spatio-temporal analysis showed spatial diffusion of meningitis prevalence from the western half of the UWR to the east with a significant number of hotpots and cluster outliers.

Conclusion

Bacterial meningitis does not occur at random. Populations (10.9%) under sub-districts identified as hotspots are exceptionally at higher risk of outbreaks. Targeted interventions should be directed towards clustered hotspots, focusing on zones with low prevalence fenced off by high prevalence zones.

Evaluation of integrated disease surveillance and response (IDSR) and early warning and response network (EWARN) in South Sudan 2021

Introduction

South Sudan has been implementing the Integrated Disease Surveillance and Response (IDSR) strategy since 2006, along with Early Warning and Alert Response and Network (EWARN). The IDSR/EWARN stakeholders commissioned an independent evaluation to establish performance at national, state, county, health facility, and community levels in the first half of 2021.

Methods

the evaluation was conducted between June and September 2021 (during the COVID-19 pandemic) and was based on the World Health Organization (WHO) protocols for monitoring and evaluating communicable disease surveillance and response systems and the guidelines for evaluating EWARN.

Results

integrated disease surveillance and response/early warning and alert response and network indicator data showed improving timeliness and completeness from the beginning of 2021 to week 16 and then a slight depression of timeliness by week 32, while completeness remained high. Event-based surveillance was active at the beginning of 2021 and in week 32. However, there was inadequate sample collection to investigate acute watery diarrhea, bloody diarrhea, and acute jaundice syndrome alerts. Respondents in all cadres had substantial experience working in IDSR/EWARN. All respondents performed the various IDSR/EWARN tasks and duties as expected, but needed more resources and training.

Conclusion

while IDSR/EWARN is performing relatively well, confirmation of priority diseases by the laboratories needs to be strengthened. Health facilities need more regular supervision from the higher levels. Community health workers need more training on IDSR/EWARN. The whole IDSR/EWARN system needs more resources, particularly for communication and transport and to confirm priority diseases. Staff at all levels requested more training in IDSR/EWARN.