Cover Image
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 folderB. People's Democratic Republic of Ethiopia
View the document1. Background
Open this folder and view contents2. Referral and Surveillance Systems
View the document3. Meningitis Epidemic Control Plan
View the document4. 1987-1988 Meningococcal Meningitis Epidemic in Addis Ababa
Open this folder and view contents5. Comments
View the document6. Data Collected

1. Background

The western part of Ethiopia lies in the Lapeysonnie meningitis belt. It has experienced several epidemics. The worst one occurred in 1981 with 38700 cases and 990 deaths. Traditionally, Gondar, Gojjam, Wollo, Wollega, Shoa and Eritrea are the high risk regions. The 1988 epidemic started in Addis Ababa with over 7000 reported cases to the MOH. The 1989 epidemic was unusual since it struck regions located out of the meningitis belt. Moreover, besides this change in the limits of the belt, the epidemic started earlier in November.

(introduction...)

The PDRE health system is decentralized and oriented toward a PHC approach. The MOH estimates that 60 % of the population has access to medical facilities.

2.1. Referral System

There are six levels of health services, from the Community Health Services and Health Stations to the Central Referral Hospital.

Kebele level:

- Community Health Services


- Health Stations

Awaja level:

- Health Centres


- Medium & Rural Hospitals

Region level:

- Regional Hospitals


- Central Referral Hospital

The Community Health Services, are community supported and they have, amongst their tasks, an active role in the control of epidemics.

2.2. Surveillance System

2.2.1. Structures

- The Department of Epidemiology

The Epidemiology Department is one of the 5 main health programme departments (see organigramme in annex 3)

The surveillance of communicable diseases as well as their control are amongst its responsibilities. This department has 9 divisions.

Important for epidemic control and surveillance are the Surveillance Division, the Epidemic Control Team, the Immunoprophylaxis Service and the administrative and logistics service.

The data are collected and compiled in the Surveillance Division.

2.2.2. Systems

- Monthly morbidity report

This system consists of the reporting of 150 diseases. Only cases are reported (and not deaths) by age group and sex. The number of vaccinations during the month are also reported on the same form.

There are two sources of data, the hospitals (88) and the out patient clinics.

It takes more or less three months before the reports reach the central level, and there is an important under-reporting of cases when compared to the weekly reporting system.

The data are compiled in the Surveillance Division and in the Health Statistics Division.

Data are compiled by hand.

- Weekly Notification of communicable diseases

This system covers the six EPI diseases plus meningitis, hepatitis, yellow fever, typhus, typhoid fever and diarrhoeal diseases. The data concern cases and deaths by age group and sex and origin. The delay before the information gets to the surveillance division is also long and estimated at around 3 months.

The reports are sent by all the health institutions to the Surveillance Division and to the Department of Epidemiology.

- Weekly radio - telephone communicable diseases report

There is a weekly radio or telephone communication with the different regions. The information reported is the same as that included in the weekly notification forms.

The communication network covers 25 of the 30 health regions. In each of these regions, only the main city has a telephone or a radio or both. It means that this rapid surveillance system is only effective for the major cities of the country and some regions are kept out entirely.

The data are compiled by hand.

Information on stocks is not reported.

The reporting system for refugee camp is separated, and there is not any formal report from NGOs

If an alarming message is received in the surveillance division, the epidemiology department is immediately informed.

The surveillance system is not very effective as soon as one leaves the regional level. The poor communication, the lacks of training of the health personnel at the peripheral level are the major reasons for this situation. In addition, as mentioned above, the health system covers only 60 % of the population.

There is not any feed-back information sent from the central level, except for PHC activities.

- Other surveillance systems in MOH

In 1987, CDD set-up a separate surveillance system partially sentinel based. There are 30 sentinel posts which are either regional hospitals, or health centres. Each sentinel post reports monthly.

The reporting is irregular and it takes sometimes more than a month before CDD gets the information. The reports are mailed to the central level and data are compiled by hand.

Nutritional surveillance is also a sentinel based system.

3. Meningitis Epidemic Control Plan

- Surveillance:

The surveillance system for meningitis epidemics is rather weak. The lack of communication is responsible for a slow flow of information. The serious underreporting, the misclassifications due to a clinically based diagnosis, the lacks of resources for compilation within the Ministry of Health handicap the monitoring of the situation in the country.

CSM is one of the diseases reported through the weekly radio-telephone system. The weaknesses of the system have been pointed out.

Active and Passive case detection

In case of an epidemic, passive and active surveillance systems should be implemented.

Health workers and “motivated” persons from the community at large will be responsible for the active case detection.

Reporting

Specific forms have been developed for daily reports on cases and deaths stating age, sex and origin. These must be sent every week to the Regional Health Department and to the MOH.

- The Epidemic Control Team (ECT):

This division works in close collaboration with the surveillance unit. The main objectives of the ECT are:

- to provide the regions with technical assistance in case of a suspected or confirmed epidemic
- to send additional drugs if needed
- vaccination
- training on epidemics with the collaboration of NGOs.

When there is suspicion of a CSM epidemic, the Department of Epidemiology is informed and one member of the Epidemic Control Team is sent out to the area where the epidemic has been declared. This person will evaluate the situation and take the necessary laboratory samples to confirm the diagnosis and the risk of epidemic.

- Criteria:

The definition advised for an epidemic is a “many-fold increase in the number of cases compared to the normal endemic rate”, or an attack rate higher than 10/100000 per week.

- Crisis Committee:

If the epidemic or risk is confirmed, an Emergency Committee is called in. These committees exist at the national, regional, and district (Awaja) levels. They are responsible for the evaluation, monitoring and management of the emergency. These committees were established during the 1988-1989 epidemic.

At the central level, the chairman of this committee is the head of the Department of Epidemiology. Besides the different divisions of the Department of Epidemiology, other Ministries (e.g. Education, Agriculture), NGOs, are also represented in these committees according to the type of emergency.

In November 1989, the Department of Epidemiology developed a guideline on prevention and control of meningococcal meningitis epidemic.

Before the 1987 and 1988 epidemics there was no specific action plan nor any specific surveillance procedure for meningitis epidemic control. It was during these epidemics that all the following measures were taken and implemented.

- Guidelines for diagnosis and treatment:

The guideline recommends confirming all suspected cases of meningitis by a lumbar puncture.

Chemoprophylaxis:

Chemoprophylactic treatment of close household contacts is recommended by MOH. Rifampicine (RMP) is used for this prophylaxis.

Treatment of cases:

First therapeutic choice: Crystalline Penicilline
Second therapeutic choice: Chloramphenicol IV

- Serogroup and sensitivity monitoring

There is not any systematic monitoring of sensitivity or serogroup.

The MOH recommends testing of samples from cases not responding to antibiotherapy in order to determine whether sulfadiazin is effective for prophylactic treatment.

- Vaccination

Mass vaccination is not recommended. High risk groups eligible for vaccination are, the day-care centre children, students, prisoners, and close household contacts of an index case.

- Other measures:

- Treatment facilities:

Temporary shelters will be installed. This measure allows treatment of the cases near the place they come from, and encourages an early treatment.

- Health Education:

This consists of, during an epidemic, informing the population about the disease in order to avoid any panic in the community.

- Operational Plan

This following operational plan has been developed during the 1988 epidemic.


Figure

4. 1987-1988 Meningococcal Meningitis Epidemic in Addis Ababa

The first cases of meningococcal meningitis from Addis Ababa were reported in November 1987. In December, 17 cases were reported and an alarming message was sent from the Ethio Swedish Paediatric Hospital to the surveillance division. The number of cases increased, reaching a peak in February (194), and in August 1988, 44 cases were still reported.

No specific measures were undertaken before the end of January 1988.

At that time, the total number of cases reported in AA was 77.

Active case detection in the Kebeles where cases had been reported began at that time.

Vaccination was not recommended. The only measure recommended then was the RMP chemoprophylaxis treatment of cases who were household close contacts.

In February, 194 cases were reported and then realising the lack of effectiveness of these measures, the Epidemiology department took over the management of the epidemic.

An emergency committee formed in the department and drafted the first plan.

This plan for outbreak control consisted of the following measures:

- identification of high risk groups based on information collected from hospital records and start of immunization of these groups.

- conduct active case detection with the cooperation of the community organizations and community health workers

- RMP chemoprophylaxis to the close contacts of cases

- Health education of the community through health units and media

The high risk groups identified for the immunization campaign were all the persons less than 20 years old in schools, prisons, military camps and the health workers having a direct contact with the patients.

The vaccination campaign conducted by 5 teams took three weeks and by mid April, 684834 people had been vaccinated.

The figure below, shows the organigramme of the operational plan for the epidemic control in Addis Ababa.


1987-1988 CSM EPIDEMIC OPERATIONAL ORGANIGRAMME IN ADDIS ABEBA

- Stocks in the Central Medical Store Decembre 1987

- Rifampicine 300 mg.(100 caps.)

141 boxes

- Rifampicine 150 mg. syrup

67 bott.

- Crystalline Penicilline

96 vials

- Chloramphenicol I.V. 1 gm.

1000 vials

- Meningococcal vaccines

36500 doses

- International Assistance

- Requests sent through WHO:

On February 13, the MOH sent telexes of request for 200000 vaccines to the Government of Kenya and Tanzania. On February 15 the same request was sent to Nigeria and to WHO in Brazzaville and Geneva.

TABLE III: Requested and Received Assistance

DATE

DESTINATION

DATE ANSWER

ANSWER

13/2

KENYA

15/2

NO

13/2

TANZANIA

15/2

NO

15/2

WHO GENEVA



15/2

LAGOS

16/2

NO

15/2

WHO BRAZZAVILLE

16/2

MORE INFO



24/2

5000 DOSES



3/3

50000 DOSES



22/4

MORE INFO

20/12

WHO BRAZZAVILLE

20/12

MORE INFO


UNICEF

FEBR.

20000 DOSES

5.1. On 1988 Epidemic

The recognition of the epidemic was very late. It was only during the third month that the epidemiology department took over the coordination and response to the epidemic.

The first measures taken, chemoprophylaxis treatment of close contacts, is not a measure to stop an epidemic. Neither will the vaccination of high risk groups during an epidemic achieve this objective. If due to resource constraints a sufficient amount of vaccines is not available, a mapping of the cases would allow the identification of the areas where cases originate and a mass vaccination campaign in these specific areas might be more successful in stopping an epidemic. This might possibly be done in conjunction with high risk group vaccinations in the other areas.

The requests for international assistance did not include any data on the extent of the epidemic or importance of the needs. This lack of information lead to a delay in the answer.

5.2. On Emergency Contingency Plan for Epidemics

The Department of Epidemiology has developed an elaborate plan for epidemics response with a well-defined operational plan.

- Stengths:

- operational plan with definition and identification of vaccination teams, surveillance teams.

- active case detection during epidemics

- defined procedures for epidemic confirmation

- defined procedure for decentralisation of treatment facilities in temporary shelters near the affected villages

- community involvement in epidemic control measures

- Weaknesses:

- weak surveillance capacities for early detection of epidemic

- use of RMP for prophylaxis treatment

- no approval of the use of Oily Chloramphenicol

- high risk groups targetted vaccination during epidemic

- no formal coordination procedure with NGOs, other international agencies for international assistance requests and for epidemic response

6. Data Collected

The data have been collected in the department of Epidemiology, in the Surveillance division and in the department of Statistics.

Information on this 1987-1988 epidemic has been gathered through interviews with the heads of these departments and of the Epidemic Control teams, from CDD division, and from the Addis Ababa Regional Health Directorate.

The collection of data on the first epidemic year (1987-1988), met the same problems as in Khartoum i.e. little information on 1988 and a lot of material on the 1989 epidemic.

The Ethiopian Calendar differs than the Gregorian Calendar and the use of Amharic in many documents brought two additional problems.

1. Data collected:

- N° of cases & deaths in AA/age/sex/month from Dec. 1987 - Aug. 1988

- Total N° cases/Kefitegna + age - sex in AA 1987-1988

- N° cases & deaths/region + sex & age dist.: Sept 88 - Aug. 89

- cases/origin/age/sex/outcome/hosp. per day in AA dec 1987-Apr. 88

- cases-deaths/month in AA 88-89

- cases/month/region 88-87-86-85-84

- cases per year 80 to 90

- vaccines & drugs distributed/region sept. 88 - feb 89

- csm vaccines received on Feb. 89 + donor

- vaccination for children, CBA & pregnant women in AA in 1989

- csm cases/deaths/region Sept. 89 - May 90

- csm cases/deaths/region + age & sex Sept. 89 - Aug. 90

- pop. distrib./age sex/region (1987)

2. Reports:

- 87-88 CSM epidemic report (April 88)

- 88-89 CSM epidemic in Ethiopia

- P. Moore report (1989)

- 1981 csm epidemic in Ethiopia

- Report on csm Sept. 89-Dec. 89/Sept. 89-Jan. 90. MOH. Department of Epidemiology

- Report on csm Nov. 88-April 89

3. Other Documents:

- Guidelines on the prevention and control of CSM epidemic

- monthly & weekly reporting forms

- Refugee report form

- Population and Housing sensus in AA (1984)

- Health Services Directory 1988

- Maps of Addis Ababa