NIGERIA - RECENT OUTBREAKS OF MEASLES AND MENINGITIS

UNCLAS SECTION 01 OF 03 ABUJA 000861

SIPDIS

CDC FOR DIRECTORS EMERGENCY OPERATION CENTER

E.O. 12958: N/A
TAGS: TBIO EAID DEOC SOCI PGOV NI
SUBJECT: NIGERIA - RECENT OUTBREAKS OF MEASLES AND MENINGITIS


1. Summary. From January to April 2008 reports indicate there have
been 20,549 suspected cases of measles (5,798 confirmed) with
sixty-four recorded deaths. This is compared to the 6,400 suspected
cases for all of 2007. About eighty percent of the confirmed cases
for this year are in children under 5, with an estimated 92% of
those unvaccinated. Despite the reported high vaccination rates for
measles, the data is often unreliable. As of April 19, there have
been 4,500 reported cases of cerebrospinal meningitis (CSM),with
351 deaths. The last CSM epidemic in Nigeria was in 1996-1997 when
over 200,000 cases were reported with a 10% death rate. The recent
outbreaks have been primarily in northern Nigeria and are expected
to increase with a major outbreak expected within the next 1-2
years. It is important that the Government of Nigeria (GON) adopt a
comprehensive strategy for reducing measles mortality and containing
CSM to halt their spread. However, there still exists poor
political will on immunization for major diseases and high level
discussions must continue to highlight the inherent weaknesses in
the GON vaccination programs. End Summary.
.
Measles Primer
--------------
.

2. Measles is an acute, highly communicable viral disease
distinguished by fever, cough, conjunctivitis (pink eye),and coryza
(runny nose). It is transmitted by airborne contact with nasal or
throat secretions of infected persons. A red blotchy rash generally
appears between days 3 to 7 of the illness, beginning on the face,
then generalizing on the remainder of the body and can last up to
one week. The disease is more severe in infants and adults than in
children. The most severe symptoms are likely to occur in
malnourished children. Complications can arise from the replication
of the virus in the body, or from subsequent bacterial infection.
Some complications include diarrhea, encephalitis, and pneumonia.
All persons who have not had the disease or who have not been
successfully immunized against measles are susceptible.
.
The Global Measles Situation
--------------
.

3. Despite the existence of a safe, effective, and inexpensive
measles vaccine for over 40 years, measles is still the leading
vaccine preventable killer of children around the world. Each year
there are about 35 million cases of measles and over 600,000 deaths
globally. Over 50% of all measles deaths occur in Africa. In 2003
the World Health Assembly adopted the target of reducing global
measles deaths by 50% from 875,000 cases worldwide in 1999. It
recommends the WHO/UNICEF comprehensive immunization strategy for
sustainable measles mortality reduction.
.
Measles in Nigeria
--------------
.

4. In the tropics, measles occurs primarily in the dry season. As
evidenced over the last six months in Nigeria, there have been
numerous outbreaks. Measles catch-up vaccination campaigns for all
children less than 15 years were conducted in northern Nigeria in
December 2005 and in southern Nigeria in October 2006.
Administrative measles vaccine coverage from those campaigns was
reported at over 90% in the north, and over 75% in the south.
Despite the reports of high vaccination coverage, the quality of the
data is poor and unreliable. This, combined with poor routine
immunization coverage for children born between 2006 and the
present, has resulted in large numbers of children still
unvaccinated, which is contributing to the outbreak of measles this
year. While the measles burden remains high in Nigeria, it is lower
than that observed prior to the 2005/2006 catch-up campaigns.
.
Recent measles outbreaks in Nigeria
--------------
.

5. Between January and April 2008 there have been over 20,549
suspected cases of measles reported in Nigeria of which 5,798 have
been confirmed. Sixty-four deaths have been recorded. This
compares with approximately 6,400 suspected cases for 2007. About
eighty percent of the confirmed cases for 2008 are in children under

5. Of these, an estimated 92% are reported to be in children
unvaccinated against measles. States in the northern part of the
country such as Kano, Katsina, Kebbi, Kaduna, Jigawa, and Borno are
most heavily affected. More outbreaks are expected during the
measles high season due to the accumulation of susceptible children
as a result of low routine immunization coverage.
.
The Government of Nigeria's (GON) Response
--------------
.

6. In Nigeria, one dose of measles vaccine is recommended for all
children between 9 months and 1 year of age. However, this

ABUJA 00000861 002 OF 003


recommendation is not attainable in the current environment where
lack of political will, inadequate supply and poor distribution of
the vaccine continues to erode the already weak routine immunization
program. In an effort to utilize the polio eradication program to
improve the immunization coverage of other vaccines, the GON
instituted the Immunization Plus Days (IPDs) strategy in 2006. The
IPDs strategy has contributed significantly to reducing the number
of children infected with the wild polio virus. It also provides
the opportunity to offer some routine antigens (such as measles
vaccine). Despite the efforts of IPDs, and due to a very weak
routine immunization delivery system, large numbers of children
continue to miss vaccination, which has contributed to the outbreak
of measles in 2008. In an effort to reach more children with
measles vaccine to prevent outbreaks of this kind in 2009, the GON
is in the planning stages of a national Integrated Measles Campaign,
which will be held in November and December 2008. While the GON has
committed in principle to bearing 50% of the operational costs
associated with the upcoming campaign, sources for the majority of
the funding is unclear and planning has remained largely inadequate
for the enormity of this activity.
.
Cerebrospinal Meningitis (CSM) Primer
--------------
.

7. CSM is an acute bacterial disease which is characterized by
sudden onset of fever, intense headache, nausea, vomiting, neck
stiffness and sensitivity to light. CSM is transmitted through
direct human contact with respiratory droplets from the nose and
throat of infected individuals. The incubation period is usually
within 2 to 10 days. CSM fatality rates can approach 50%, and
approximately 20% of CSM survivors suffer long-term effects
including mental retardation, hearing loss, and loss of limb use.
Several serogroups of meningitis exist and vaccines have been
developed to target specific serogroups. In the event of an
epidemic, children and young adults would likely be
disproportionately affected. Meningococcal polysaccharide vaccine
is usually effective for outbreak control, and specifically
effective for serogroups A and C.
.
The Global CSM Situation
--------------
.

8. Epidemic meningococcal disease remains a major public health
challenge in the African "meningitis belt" which extends from
Senegal to Ethiopia, with a population of 300 million people. The
estimated number of meningitis cases in this region between 1995 and
2005 was approximately 700,000 of whom about 10% died.
.
CSM in Nigeria
--------------
.

9. As of 19 April, there have been 4,500 reported cases of CSM in
Nigeria since the beginning of the year, with 351 deaths.
Sixty-four local government areas (LGAs) in 11 states have been
affected, with 5 LGAs categorized as having crossed the epidemic
threshold. Historically, the African Meningitis Belt experiences a
10-12 year cyclical pattern of CSM epidemics. The last epidemic in
Nigeria was 1996-1997, when more than 200,000 cases of CSM were
reported, and a 10% death rate. Based on historical patterns, it is
possible that Nigeria will experience a major outbreak of CSM within
the next 1-2 years.
.
Recent Outbreaks of CSM and GON Response
--------------
.

10. Nine states are primarily affected with CSM - Bauchi, Gombe,
Jigawa, Katsina, Kebbi, Niger, Sokoto, Yobe and Zamfara. It is
expected that further outbreaks will occur this year. The GON is in
the process of procuring 6 million doses of CSM vaccine for covering
the at-risk population in the affected LGAs; however, the pace is
slow. [Comment: According to the WHO, the funding for this vaccine
should have been available in the first week of May; however the
Ministry of Finance has been known to significantly delay the
release of funds for immunization activities. End Comment]. In
addition, the GON and Development Partners (WHO, UNICEF, USAID,
World Bank, etc.) have developed a proposal for submission to the
International Coordinating Group (ICG) on Vaccine Provision for
Epidemic Meningitis Control, for an additional 800,000 doses of CSM
vaccine. Should the GON funding be released in a timely manner, and
the ICG vaccine be accessed, this quantity of vaccine should be
sufficient to stem further outbreaks and position Nigeria better to
minimize outbreaks for 2009's high CSM transmission season. The
Ministry of Health held a three-day training on enhanced CSM
surveillance for State epidemiologists and laboratory personnel from
22 high risk states between April 15-17, 2008.


11. Comment. Measles immunization activities have the potential to

ABUJA 00000861 003 OF 003


reach many children, but often the opportunity is missed, as
insufficient quantities of measles vaccines are available to meet
the demand. It is important that Nigeria adopts and promotes
comprehensive strategies for measles mortality reduction. These
strategies include improving routine immunization services,
conducting follow-up campaigns as planned for November and December
2008, strengthening case-based surveillance for measles, and
improving case management through vitamin A supplementation,
antibiotics, and symptomatic treatment. For CSM, containing a major
outbreak and managing cases depends on accurate identification of
the disease and laboratory confirmation of the causal organism.
Preventive measures should include vaccinations, reducing
overcrowding in living quarters and workplaces, particularly in
schools and dormitories. Unless these steps take place, CSM will
remain a major public health challenge in Nigeria and the African
"meningitis belt". In general there exists poor political will from
the GON on immunizations. The Ambassador has engaged President
Yar'Adua on the importance of polio eradication and immunization,
and she and the USAID Director followed that up in a ministerial
meeting (see Abuja 815). While the President has indicated
substantial concern and recognition of this problem, to date this
has not translated to increased activity or efficiency of
immunization program implementation or release of resources. High
level discussions should continue to highlight the inherent
weaknesses in the GON immunization programs. End Comment.

SANDERS