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close this bookCerebrospinal Meningitis Epidemics and Surveillance Systems in the Sudan, Ethiopia and Chad (Centre for Research on the Epidemiology of Disasters, 1990, 40 p.)
close this folderII. COUNTRY REPORTS
close this folderA. REPUBLIC OF THE SUDAN
View the document1. Background
Open this folder and view contents2. Referral and Surveillance Health Systems
View the document3. Meningitis Epidemics Control Plan
View the document4. 1988 Cerebrospinal Meningococcal Meningitis Epidemic in Khartoum
Open this folder and view contents5. Comments
View the document6. Data Collection

1. Background

The Sudan lies on the eastern part of the “Meningitis Belt”. The first meningitis epidemics in the Sudan were described at the end of the last century1. In 1950/1951, the country experienced the worst epidemic with more than 50000 reported cases. The 1988 and 1989 epidemics are responsible for 38805 cases and 2770 deaths. In 1988 only, 32016 cases were reported.

1K. David Patterson. Gerald W. Hartwig. Cerebrospinal Meninngitis in West Africa and Sudan in the Twentieth Century; African Studies Association. Crossroads Press; University of California. L.A. 1984

Epidemics usually start in February, reach a peak in May and end at the onset of the rainy season.

2.1. Referral System

The Sudan has nine regions and the health system in the Sudan is highly decentralized. Each region has one Director of Health Services, under whom there is a Provincial Director of Health in each province (see organigramme in annex 1).

Peripheral level:

- PHC Units, Dressing Stations, Dispensaries


- Health Centres - Rural Hospitals

Provincial level:

- Provincial Hospital

Regional level:

- Regional Hospital

2.2. Surveillance System

Meningitis is a notifiable disease in the Sudan. The reports are issued by the different health units, from the lower (primary health care unit) level to the Provincial General Health Directorate, passing through the different levels of the referral system. The data are then centralized at the Regional level and in the Central Epidemiology unit.

The NGOs do not report on a routine basis to the MOH, neither the data collected in the Refugee camps. This system includes also the report of Yellow Fever and Cholera cases.

a. Structures

- Ministry of Health and Division of Epidemiology:

The Division of Preventive Medicine and nine other divisions are under the authority of the first undersecretary (see organigramme in annex 2). The Preventive Medicine department is composed of 5 different units: the Central Epidemiology Unit, the Sanitation & Environment Unit, Health Education Unit, Malaria Control Programme Unit and Trachoma Unit. The Central Epidemiology Unit is responsible for specific disease surveillance and control, including Meningitis, Yellow Fever and Cholera. It is also the focal point for emergencies.

b. System:

- Frequency:

The notifiable diseases are reported weekly to the higher level in the referral system and to the Epidemiology Unit.

- Regularity and communication means and delays:

The epidemiology unit gets 50 % of the reports.

The delays are variable according to the origin of the report and it can take several months before a report reaches the central level.

The means of communication are poor. The MOH does not have radio or telephone communications with all the provinces. At the lower level the reporting system relies on telegrams, when they exist, and most of the time on the availability of messagers.

There is no specific reporting form.

- Type of information:

- on the cases and deaths: age, sex, origin, vaccination antecedent and outcome.
- on the stocks: not on routine basis
- on the number of immunization performed

- Compilation and Feed-back information:

The data are compiled by hand.

The central epidemiology unit feeds back the Regional and Provincial Directorates.

- Communication to other countries:

There is not any formal communication system with neighbouring countries.

3. Meningitis Epidemics Control Plan

During and after the 1988-1989 CSM epidemics the Epidemiology Unit and MOH have developed specific procedures for meningitis outbreak control. Many of the following measures were implemented during the occurrence of this last epidemic.

- Surveillance:

In the case of an epidemic, daily reports are compiled in the Epidemiology Unit. Data are collected daily by radio, telephone or telegram when possible.

Information on stocks of vaccines and drugs is collected before the high risk season.

- Warning messages:

At the beginning of the high risk period, a warning message is sent to each region reminding them of the risk of encountering cases and case definition. Reception of warning messages is not always certain. One can assume that these messages normally reach the regional levels and sometimes reach the provincial level. The poor communication network does not permit these messages to reach the lower levels.

- Serogroup and Sensitivity monitoring:

At the beginning of the high risk season, samples are taken from different regions and are analysed in the national reference laboratory in Khartoum (National Public Health Laboratory).

- Criteria for an epidemic:

There are not any formal criteria or thresholds which define an epidemic.

- Crisis Committee:

In case of epidemic, a crisis committee meets in the epidemiology unit. This committee meets every day and is responsible for issuing the general policy of control of the epidemic, the assessment of the needs, the mobilisation of the resources, and the coordination of the management of the epidemic.

Crisis committees exist also at the regional level.

- Diagnosis & Treatment protocols:

The diagnosis of CSM cases is mainly based on clinical symptoms. The Epidemiology Unit developed in 1989 a guideline for the treatment of meningitis. This guideline is distributed in case of an epidemic. The recommendations of the MOH are:

* Treatment of cases:

1. Crystalline Penicilline


2. Chloramphenicol


3. Ampicilline


4. Tetracycline


5. Erythromycine



* Prophylaxis of close contacts:

Ampicilline if not vaccinated

- Stocks:

The stocks of vaccines are renewed at the beginning of the high risk season.

On September 1, 1990 there were 125000 doses of CSM vaccines in the Central Medical store.

4. 1988 Cerebrospinal Meningococcal Meningitis Epidemic in Khartoum

At the beginning of 1988, the Sudan experienced a major CSM outbreak with a total number of 32016 reported cases and 2067 reported deaths. The Central and Khartoum regions, followed by Kordofan, Darfur and Eastern Region were the most affected areas. Khartoum is responsible for a third of the total number of cases. The epidemic began in the outskirts of Khartoum and rapidly spread in the three cities of Khartoum, Khartoum North and Omdurman.

MANAGEMENT OF THE EPIDEMIC

The first cases occurred in January 1988 but according to the data available in MOH only one case had been reported by the end of the month. At the beginning of February, the number increased sharply and 23 cases had been reported to the MOH by the end of the second week of the month.

On February 16, the emergency system was alerted and warning messages were sent to the other regions.

After that, data were collected daily and compiled weekly within the central epidemiology unit.

The data underestimated the real number of cases as shown in a survey1 conducted in the 3 major hospitals. According to this survey, a number of 106 cases had occurred on February 16.

1Christophe Paquet; Epide de Mngite Khartoum. Fier-mars 1988 Rapport d'Evaluation; Epicentre Paris

The weekly reported number of cases multiplied by three per week until a peak was reached around the sixth week of the epidemic when 1519 cases had reported in Khartoum region.

- Sensitivity and Serotype

On March 15, all of the 52 samples had been analysed in the central laboratory of Khartoum showing N. meningitidis Group A.

All of them were sensitive to Sulfadiazine, Crystalline Penicilline, Ampicilline and Chloramphenicol.

A survey conducted in May 1988 showed resistance to Sulfadiazine.1

1Report of cerebrospinal Meningitis Survey. Khartoum, Sudan. May 1988. MOH, Department of epidemiology. EMRO, NAMRU - 3

- Treatment

In 1988, the MOH did not distribute any recommended guidelines for the treatment of the cases. The most common drug regimen at the beginning of the epidemic consisted of a combination of Sulfonamides +

Crystalline Peni + ampicilline. Oily Chloramphenicol was not utilised.

Chimioprophylactic treatment of close contacts was not applied.

- General Measures

In the beginning of March, the schools were closed as well as the cinemas and the stadium.

Messages to inform the populations were broadcast on radio and TV and published in the newspapers.

- Immunizations

One million doses were used in Khartoum during the 1987 CSM vaccination campaign. It means that more than one fifth of the population was protected at the beginning of this epidemic.

During this 1988 epidemic, a mass vaccination campaign was organised.

The mass vaccination campaign with A polyvalent A & C meningococcal polysaccharide vaccine started on February 20, 1988 in Khartoum. 80 immunization centres were used:

- 14 mobile teams
- 18 centres equipped with pedojets
- 49 centres using classical syringes or one centre for 625001 persons

1the estimate population in Khartoum including displaced population is 5 millions

This structure relied on the 60 existing EPI centres of the capital city. The activities of the mobile teams were burdened by logistic constraints such as the lack of vehicles (1 vehicle for 14 teams).

The campaign began relatively early but slowly. By the beginning of March, 100.000 immunizations had been performed in Khartoum. During the following days 60 to 80,0000 persons were vaccinated each day.

A total of 3,4 million doses of vaccines had been used in Khartoum by the end of March.

In the areas where the displaced population was settled, the coverage was much lower than in the general population due to the logistic constraints: lack of mobility of the mobile teams and the absence of health infrastructure or EPI centres in these sectors.

All persons over two years old were vaccinated.

The population was informed of the immunization campaigns through the media.

No vaccination cards were distributed to the patients.

Vaccination campaigns were implemented in other regions and by the end of July 1988, 11.6 million doses distributed.

- Stocks of vaccines and drugs

On February 1, 1988 the Central Medical Store had in stock:

CSM Vaccines

862500

doses

Crystalline Penicilline

355200

vials

Ampicilline caps.

4508000

caps

Ampicilline inj.

452140

vials

Ampicilline syrup

94840

bott

Chloramphenicol cap.

149000

caps

Chloramphenicol inj.

19850

vials

Chloramphenicol syrup

28135

bott.

- International Assistance received:

Requests for international assistance were not sent before March 1. The number of reported cases during that week was 229 in Khartoum or almost 10 times more than the number of cases reported during the second week of February. Since the beginning of the epidemic 337 cases had been reported.

TABLE I: Assistance requested:

DATE

DESTINATION

TYPE

AMOUNT

1/3




15/3

MERIEUX

Technical collaboration

21/3

WHO

Antisera for serotype & sensensitivity tests

kg 1,5

22/3

UNICEF

Vaccines

5000000



Crystalline Peni




Chloramphenicol


30/3

MERIEUX

Vaccines

needs: 6 millions

TABLE II: Assistance received:

DATE

ORIGIN

TYPE

AMOUNT (doses)

2/3

EMRO

Vaccines

500000



Rifampicine

1000

11/3

EMRO

Diagnosis mat


15/3

EMRO

Vaccines

187500

15/3

MERIEUX

Vaccines

500000

17/3

Saudi Arabia

Vaccines

500000

February ?

UNICEF

Vaccines

500000

5.1. On 1988 Epidemic

The detection of the epidemic was rapid but the response rather slow. The lack of resources, for example the lack of vehicles for the vaccination campaign, is partially responsible. More than anything else, it is the lack of preparation to respond that hampered the control of the epidemic. For example, forms for daily and weekly reports were developed only after the first month of the epidemic. Neither the amplitude of the outbreak nor the needs had been evaluated accurately. Requests for international assistance came late. There was no standardized treatment protocol. Despite the important number of NGOs in Khartoum, there was not any MOH-NGO coordination.

5.2. On Epidemic Control Plan

This plan developed during the two last epidemics, has several strengths and weaknesses.

- Strengths:

- warning messages at the beginning of high risk season
- sensitivity monitoring at the beginning of high risk season
- assessment of stocks

- Weaknesses:

- weak surveillance and early detection capacities
- no computerized compilation capacities
- Coordination committee does not include all the agencies active in the health sector (NGOs)
- no established procedure for coordination of international assistance request

The surveillance system in the Sudan does not allow an early detection of an epidemic. Moreover the undereporting of cases is important. The poor communication means, the irregularities of reporting are the main constraints. A simple but robust system should be implemented. This implies several improvements:

1° Communication capacities and data collection

a. establishment of reliable channels of communication for information flow
b. improvement of radio communication means: at least one in each region.
c. establishment of a simple case definition including preferably the aspect spinal fluid
d. data collected should consist of age, sex, date, address.

2° Compilation

- computerized capacities at the central level at least

The response capacities would be improved with a better preparedness. The following measures can be suggested:

- committees with adequate expertise at the regional and central level should be identified including representative from NGOs.

- design of procedure for rapid needs assessment

- assessment of resources and design of procedures for resource mobilisation

- assessment of transportation capacities in all the country

The standardized treatment protocol should encourage the use of oily chloramphenicol in case of epidemic.

6. Data Collection

Most of the information has been gathered from the department of epidemiology.

It was difficult to get information and data on the 1988 epidemic. On the contrary, data on the 1989 epidemic were easier to get. This indicates perhaps the better organisation in the MOH during the second year of these epidemic waves. The analysis produced by the Department of Epidemiology on these epidemics concerns the two years 1988 & 1989. A number of daily reports and several weekly reports were lost. It was not possible to find any written record of the different actions taken during that epidemic. Most of the few existing documents are written in Arabic.

Another source of information within the MOH would have been the Department of Statistics. But first, data for 1988 are not yet available and secondly, the data are less reliable than that reported directly to the Department of Epidemiology.

In WHO office, the file on this 1988 epidemic has disappeared.

Finally, more than two years after the event it was not easy to identify witnesses of this epidemic in other organizations.

1. Data collected:

Epidemiologic data on the 1988 epidemic in Omdurman:

- N° of cases - deaths - per town sector per day from March to June 1988
- N° of cases per town sector and per week from 15/3 to 15/5
- N° of cases/hosp/day from 1/3 to may 1988
- N° of vaccinations from 1/3 to may 1988
- Total N° of hospital admissions in Feb. to June 1988 & tot. N° of beds
- gross information (pop. density...) on most affected town sectors

Epidemiologic data on the 1988 epidemic in Khartoum region:

- weekly reports

February
March
April
May
June
July

- Monthly reports N° of cases-deaths/month/town (3) 1988-1989

- N° of vaccines distributed from Jan 1 to May 1988

Epidemiologic data on CSM in the Sudan

- N° cases-deaths per month per region (7) 1980;1982 to 1989.

2. Reports

- CSM Meningitis in Sudan 1988 and 1989 El Sadiq; El Khalifa; D. Robinson.

- Epide de Mngite - Soudan - Fier-Mars 1988. Rapport d'luation - Dr. Christophe Paquet; Epicentre; Paris.

- Report of cerebrospinal Meningitis Survey. Khartoum, Sudan. May 1988. MOH, Department of epidemiology. EMRO, NAMRU - 3

3. Other documents and Maps

- map of Omdurman
- map of Displaced Population in KHT
- 1987 Health Directory