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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
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
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
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
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
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
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.
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
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
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
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
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
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
Environmental assessment
We conducted a community survey to observe the ventilation of houses, Water Sanitation and
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.
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
We calculated overall, age and sex specific attack rate. We drew an epidemic curve to show the
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
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.
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
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,
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
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
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
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
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
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
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
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
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
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
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
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 motorcycles to the district directorate to enable field technicians to access un-
Review drugs (antibiotics) policies to subsidize and make them available in all high-risk
Regional
meningitis outbreaks.
• To provide logistics for timely transportation of CSF samples to the Regional Hospital
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
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.
Clinical staff at the triage and the public health division should have high suspicion index
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
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
• The Nadowli District Hospital Laboratory should keep a log book of all CSF samples that
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
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
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
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