Abstract

Background: Meningitis is a disease that affects the central nervous system. It results in inflammation of

the covering (meninges) of the brain. The disease could be caused by viruses or bacteria. Meningitis has a

case fatality of up to 50% if untreated and a noted frequency of about 10% complications. Globally, the

incidence of meningitis is most common in the Sub-Saharan Africa. This is often termed as the “meningitis

belt. Ghana lies within the meningitis belt. The meningitis belt is known for high cases of outbreaks world.

More than 3000 cases of meningitis and 400 deaths were reported in Ghana between 2010 and 2015. In the

first eight (8) epidemiological weeks of 2017, the Nadowli district recorded 51 cases with eight

(8) deaths. We therefore investigated the upsurge to characterize it and institute control measures

to prevent further spread.

Method: We used structured questionnaire to interview health officials and community leaders on

the nature of the situation. We reviewed records at the health facilities and interviewed some of

the case patients on admission in the wards. Data was abstracted on age, sex, signs and symptoms,

date of illness onset, date of admission, date of discharge, treatments given and outcome. We

visited some of the affected case-patients who had been treated and discharged. Data was entered,

cleaned and analyzed using Epi Info version 7. We performed descriptive analysis of the outbreak

data by person, place and time.

Results: A total of 67 suspected meningitis case-patients have been recorded with 10 mortalities.

The case fatality rate is 14.9%. The median age of the suspected cases was 24 years (Interquartile

Range 15 -46years). Males formed 35 (52%) majority of the cases. The upsurge involved people

from 41 villages/communities in the Nadowli District and DBI the adjourning district. The

Nadowli Township recorded the highest number of cases 8(11.9%), Charipong 4(5.97%) cases and

Tangasie, Papu, kpazie, all recording 3(4.48%) cases respectively.

Conclusion: Even though the laboratory had the human resources, they were limited with

materials for further testing. They were able to do gram staining latex agglutination. PCR and

culture and sensitivity couldn’t be carried out. There were no records of samples being sent to

facilities outside the region for further testing. Patients were treated with antibiotics. The

surveillance office should intensify their activities to detect cases early. The laboratory should be

equipped with the necessary to enable testing of suspected cases.

Introduction

Meningitis is a disease that affects the central nervous system. It results in inflammation of the covering

(meninges) of the brain. The disease could be caused by viruses or bacteria. The common signs and

symptoms of the disease include nausea, vomiting, headache, neck stiffness, photophobia, convulsion and

in some extreme cases coma (WHO, 2018). Meningitis has a case fatality of up to 50% if untreated and a

noted frequency of about 10% complications. Some of the complications of meningitis includes hearing

loss, mental retardation and non-functional limbs (WHO, 2018).

Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae are the leading causes of

bacterial meningitis worldwide. It has an incubation period of between 3-7days (Paireau, Chen, Broutin,

Grenfell, & Basta, 2016). Vaccination programmes have been implemented in many countries but there is

still an estimated 1.2 million cases of bacterial meningitis occurring worldwide (Paireau et al., 2016).

Neisseria meningitidis, Haemophilus influenzae type b (Hib), and Streptococcus pneumoniae accounts for

most of all cases of bacterial meningitis and 90% of bacterial meningitis in children (Operating, For, &

Diseases, n.d.). Globally, the incidence of meningitis is most common in the Sub-Saharan Africa. This is

often termed as the “meningitis belt” (WHO 2015). Ghana lies within the meningitis belt. The meningitis

belt is known for high cases of outbreaks world. The Northern, Upper East, Upper West, and the Northern

parts of Brong Ahafo and Volta Regions in Ghana lie within the meningitis belt (WHO 2015).

The organisms that cause meningococcal disease are spread through the exchange of respiratory and throat

secretions, during close or lengthy contact, especially if living in the same household (CDC 2017).

More than 3000 cases of meningitis and 400 deaths were reported in Ghana between 2010 and 2015. Over

95% of Ghana’s meningitis burden is due to Neisseria meningitides (Nm). However, there have been few

reported outbreaks of Streptococcus meningitis in recent times in Ghana(Letsa et al., 2018).

Nature of Problem:

Notwithstanding the many advances and interventions made towards the prevention of bacterial

meningitis, the disease still remains a public health challenge especially among populations living

along the African meningitis belt. The Upper West Region lies completely in this belt.

In the first eight (8) epidemiological weeks of 2017, the Nadowli district recorded 51 cases with

eight (8) deaths. As a district, they have exceeded their epidemic threshold. Cases are reported

from all sub-districts and cut across both sexes and all ages. Despite the efforts of local health

officials in reversing the current trend of the disease, the number of cases continue to increase.

A team of Residence from GFELTP was dispatched to support the Nadowli District Health

Directorate to respond to the current upsurge in the number of cases of meningitis in the district.

The objectives of the investigation are:

1. To determine the extent of the suspected outbreak

2. To identify the source of the outbreak and individuals involved

3. To identify risk factors of the outbreak

4. To implement control and preventive measures

Meeting with officials of the Upper West Regional and Nadowli District Health Directorates

On arrival in the Upper West Region, the investigation team met with the officials of the Upper

West Regional Health Directorate to seek for their consent to carry out the investigation and also

obtain first-hand information on the nature of the situation on the ground and the response

measures put in place.

The Upper West Regional Director of Health Services welcomed the team and offered to assist in

every possible way to make the team’s stay in the region successful. He updated the team on the

current meningitis situation in the region. According to him, since the region lies in the meningitis

belt it was not uncommon to record cases of meningitis and that the meningitis was endemic in the

region since they record cases all year round. What was worrying for him was the current upsurge

in the number cases recorded. And the fact that the current cases been seen are the streptococcus

pneumoniae which is not known to cause epidemics but has a high fatality rate.

The team proceeded to meet the Regional Surveillance Officer who provided the team with the

regional line list of suspected and confirmed meningitis cases.

The team then moved on to the Nadowli District where we met with the District Director of Health

services. The Director welcomed the team and then updated us on the current situation with regards

to meningitis in the district. She admitted that there was a current upsurge in the number of cases

reported and further gave us an outline of the response measures that have been taken by the

district. Some of these response measures included; community sensitization, health educations,

record reviews and case management. We obtained the line list of the cases from the District

Disease Control Officer.

 Methods

Outbreak Setting

We began the investigation on the 22nd March, 2017 at Nadowli, the District capital of the Nadowli

District. Nadowli is one of the 13 administrative districts in the Upper West region. It has a total

population of 61561 representing 8.8% of the total population of the Upper West region.

Data Collection

We used structured questionnaire to interview health officials and community leaders on the nature

of the situation. We reviewed records at the health facilities and interview some of the case patients

on admission in the wards. Data was abstracted on age, sex, signs and symptoms, date of illness

onset, date of admission, date of discharge, treatments given and outcome. We visited some of the

affected case-patients who had been treated and discharged. We defined a case of Meningitis as

“any person in the Nadowli District presenting with any of the following signs; neck stiffness,

bulging fontanelle (infants), convulsions, altered consciousness or other meningeal signs with or

without the sudden onset of fever (>38.5oC, rectal or ≥38oC axillary).

We conducted an active case search in the health facilities, by reviewing Out-patient department,

consulting room, admission and discharge registers as well as patient folders within the facility.

We updated the line list with the new cases identified. We held school community and school

health talks in schools of case patients to educate the students and staff on signs and symptoms of

meningitis and the causes and prevention of the disease.

Laboratory assessment

We assessed the capacity of the Nadowli District Hospital Laboratory with regards to meningitis.

We assessed the human resource capacity - the staff strength and the various category of staff. We

also assessed how the cerebrospinal fluid (CSF) samples are collected, stored, processed, analysed

and transported to the next level for further testing.

Environmental assessment

We conducted a community survey to observe the ventilation of houses, Water Sanitation and

Hygiene (WASH) practices in the community. We also interviewed household members to

determine number of people living in a room.

Surveillance

We assessed the surveillance systems operations on meningitis in the District. We evaluated the

timeliness of detection and reporting of the cases as well as analysis of the data collected.

Local Response Capacity

We assessed the category and number of staff available within the district, the case management

strategies, availability of drug and non-drug consumables, preventive practices and social

mobilization and advocacy. We also assessed the transport and communication strategies.

Debriefing

Daily briefing on the activities carried out was done at stakeholders meeting at the Nadowli District

Health directorate.
Data Analysis

Data was entered, cleaned and analysed using Epi Info version 7. We performed descriptive

analysis of the outbreak data by person, place and time. Univariate analysis was done by expressing

categorical variables as frequencies and relative frequencies. Continuous variables were expressed

with appropriate measures of central tendency and dispersion.

We calculated overall, age and sex specific attack rate. We drew an epidemic curve to show the

pattern of the outbreak.

 Results

Descriptive Statistics

From January, 3rd through to 10th March, 2017, a total of 67 suspected meningitis case-patients

have been recorded with 10 mortalities. The case fatality rate is 14.9%. The median age of the

suspected cases is 24 years (Interquartile Range 15 -46years). Males formed 35 (52%) majority of

the cases. The outbreak involved people from 41 villages/communities in the Nadowli District and

DBI the adjourning district. The Nadowli Township recorded the highest number of cases

8(11.9%), Charipong 4(5.97%) cases and Tangasie, Papu, kpazie, all recording 3(4.48%) cases

respectively.

12 12
Female Cases
10 Male Cases 10

Number of Deaths
Number of Cases

Female Deaths
8 8
Male Deaths
6 6

4 4

2 2

0 0
0 - 4yrs 5 - 14yrs 15 - 24yrs 25 -34yrs 35 -44yrs 45 - 54yrs 55 - 64yrs 65 - 74yrs > 75yrs
Age Groups/Years

Figure 1: Age and sex distribution of Meningitis cases and deaths in Nadowli District, Jan-

March 2017.

Majority of the cases were between ages 5 to 24 years. Males were more than the females in the

most affected age groups.

The index case was a 79 years old male from the Kulpieni village. He started experiencing

symptoms of neck stiffness and difficulty in breathing on the 2nd of January, 2017. He visited the

Kulpieni CHPS on the 3rd of January 2017 and was referred to the Nadowli District Hospital on

the same day. While receiving treatment his CSF sample was taken for laboratory investigation.

He passed on in the evening the same day.

4
Number of Caes

06-Mar-17
01-Jan-17
03-Jan-17
05-Jan-17
07-Jan-17
09-Jan-17
11-Jan-17
13-Jan-17
15-Jan-17
17-Jan-17
19-Jan-17
21-Jan-17
23-Jan-17
25-Jan-17
27-Jan-17
29-Jan-17
31-Jan-17

24-Feb-17

02-Mar-17
04-Mar-17

08-Mar-17
10-Mar-17
02-Feb-17
04-Feb-17
06-Feb-17
08-Feb-17
10-Feb-17
12-Feb-17
14-Feb-17
16-Feb-17
18-Feb-17
20-Feb-17
22-Feb-17

26-Feb-17
28-Feb-17
Date of Onset of suspected Cases

Figure 2. An epi-curve of suspected meningitis cases in Nadowli District, Jan-March, 2017

The date of onset of the index case was 2nd Jan, 2017. The disease was found to have an intermittent

pattern of spread. The peak period of the disease event was seen on epidemiological weeks three,

four and six.

Laboratory Findings

The Nadowli District Hospital laboratory had adequate and competent personnel and infrastructure

to process and test cerebro-spinal fluid (CSF) samples for the presence of absence of the etiological

agents of meningitis by gram staining and latex agglutination. But lacked the capacity to carry
Polymerase Chain Reaction (PCR) which serves as the confirmatory and more sensitive test for

detection of etiological agents of meningitis.

However, they lack laboratory supplies and logistics for conducting standard microbiological tests

on CSF. Except for gram staining which was done, culture and sensitivity could be not done.

Lumber Puncture is done either by the doctor or the anaesthetist in the ward and the CSF sample

collected into a sterile container and stored in the lab at room temperature. It is then transported to

the regional hospital laboratory for pastorex and culture and sensitivity or the zonal Public Health

Laboratory in Tamale for PCR.

The laboratory kept records of only the samples that they had worked on but did not have records

of CSF samples that had been referred to higher laboratories. The Disease Control Officer (DCO)

was responsible for filling the meningitis case based forms and so had all the documentations

associated with the referred samples.

Environmental Findings

Most houses of the case patients we visited had just one small window or none at all. In many

instances the single small window was also covered with a black polyethene bag or closed entirely

with mud. The communities were mostly windy very dusty most likely due to the harmattan and

may be a contributing factor to the spread of the disease. The weather was very dry and dusty and

many people lived in single rooms with small single window which are covered at some place. All

these were contributing factors to the spread of the disease.

Surveillance

We sensitized field officers, Disease Control Officers on the reporting format, case identification,

contact listing and contact tracing. Line lists were updated on daily basis and all new cases

recorded had their contacts listed, traced and monitored.

Local response Capacity.

The District had adequate numbers of Disease Control Officers, Nurses and laboratory Scientists,

however the number of Doctors, Health Education/Health Promotion Officers and anaesthetists

wasn’t adequate. The district had very good numbers and willing community based surveillance

volunteers who always worked closely with the District Health Directorate in case management

and contact tracing.

The District Control Officer and his team had undertaken a pilot study to assess the effect of the

presence or absence of fever as a major symptom of meningitis as most the cases presented without

fever but found to be positive. This will help in the long term to detect and give a high suspicion

index of cases of meningitis.

They had a good case management in place which was greatly hindered by unavailability of drugs.

Most antibiotics used most had to be purchased by the patients’ relatives from Wa, the regional

capital and even sometimes as far as Kumasi.

The district also lacked resources and vehicles mounted with public address system to help in the

community sensitization and mobilization efforts. This greatly hampered community outreaches

and the communication strategy of the district.

Joint Actions performed by the investigation team

 Sensitization of the community on prevention and control, signs and symptoms of

meningitis

 Review of the response measures put in place and formation of sub teams for the outbreak

response

 Active case search in affected communities and all the health facilities in the Nadowli

District.

 Review of patient folders for identification and listing of contacts for follow up

 Sensitization of health workers at the health facilities on meningitis record keeping,

infection prevention and control

Conclusion

The Upper West region is one of the regions situated in the meningitis belt. Periodic vaccination

and preventive measures are focused in the meningitis belt with aim of reducing the occurrence of

meningitis. In the past meningococcal meningitis has been noted to cause most outbreaks in Ghana.

However, the trend is changing. Pneumococcal meningitis is becoming common. Even though the

laboratory had the human resources, they were limited with materials for further testing. They were

able to do gram staining latex agglutination. PCR and culture and sensitivity couldn’t be carried

out. There were no records of samples being sent to facilities outside the region for further testing.

Patients were treated with antibiotics. Because culture and sensitivity wasn’t done, resistance to

antibiotics couldn’t be noticed.

Overcrowding was common in the district. In some instances, as many as 5 were sleeping in a

room. Ventilation was also very poor. Roads were dusty and not tarred. The commonest source of

fuel for cooking is firewood. All the factors could have facilitated the spread of the disease.
 Recommendations

National

• To provide sufficient laboratory logistics to enable testing of meningitis cases to be done

at the district hospital.

• To provide sufficient funds to intensify surveillance activities.

• To provide motorcycles to the district directorate to enable field technicians to access un-

motorable areas in the district for surveillance activities.

 Review drugs (antibiotics) policies to subsidize and make them available in all high-risk

districts in the meningitis belt especially during the meningitis season.

Regional

• To provide sufficient funds for surveillance activities to be intensified especially during

meningitis outbreaks.

• To provide logistics for timely transportation of CSF samples to the Regional Hospital

Laboratory and zonal Public Health Laboratory in Tamale for testing.

 The highly skilled disease control and surveillance officers should be highly motivated for

the active and efficient case management, contact tracing, proper coordination of the

activities of the CHPS compounds and community volunteers.

 Ensure reactive vaccination in all high-risk districts in the region prior to the meningitis

season so as to cover all age groups especially the unvaccinated elderly in the community.

District
• Require a prompt line listing of all suspected meningitis patients from all health facilities

(health centres, clinics, CHPS compounds) in the district to initiate active follow-up on

each referral patient from the community level to the district level.

• To intensify surveillance and community education

 Clinical staff at the triage and the public health division should have high suspicion index

so not to miss any case of meningitis during the season.

 Train more clinicians on lumber puncture for CSF sample collection.

 Collaborate with the local over the counter sellers and educate them on the peak periods

for meningitis so as to advise patients with complaints of fever, neck pains and headaches

to report to the hospital.

 Institute surveillance of meningitis “Stiffness of Neck Police” in all chemical shops in the

district to monitor common complaints of stiffness neck, neck pains, fever, and headaches.

This is enable the district monitor and follow-up on patients meeting the case definition

but do not report to the health facility.

• The Nadowli District Hospital Laboratory should keep a log book of all CSF samples that

may pass through their unit.

GFELTP

The District requested to be considered for Basic GFELTP training programme for districts.
The Medical Superintendents of Nadowli hospital requested for a special training in lumber

puncture for staff.

ACKNOWLEDMENT

We gratefully acknowledge the efforts of the Ghana Field Epidemiology and Laboratory Training

Program for their immense effort and contribution in facilitating this investigation and availing

residents the opportunity to participate in the exercise.

We also acknowledge the help and contribution of the Upper West Regional and Nadowli District

health directorates and management teams for making this investigative exercise easier for

residents in terms of accommodation and other logistics.

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