Health ministers from countries of the African meningitis belt today committed themselves to introduce a highly promising candidate meningitis vaccine. The vaccine is designed to prevent periodic epidemics of the deadly disease in these countries.

Meeting at the 58th session of the WHO Regional Committee for Africa, held in Yaoundé from 1 to 5 September, the ministers adopted the Yaoundé Declaration, committing themselves to several actions. They agreed to prepare comprehensive meningitis control plans, including the introduction of the new vaccine once available; to implement meningitis control strategies; to undertake joint action vis-à-vis the threat; to improve information exchange for epidemic response; and to contribute financially to epidemic control activities.

"Several hundred million people are at risk of meningitis in 25 African countries. Many generations have suffered," said Professor Avocksouma Djona, Minister of Public Health, Chad. "On behalf of all affected countries in Africa, today we are collectively committing ourselves to put an end to devastating outbreaks of this disease. We will ensure that this effective new vaccine is made available to populations throughout the Meningitis belt," he said.

Affordable for Africa

"The new vaccine is the result of a deliberate effort to get ahead of these epidemics, at a price affordable in Africa. With this vaccine, countries can move away from a reactive response to emergencies towards elimination of the epidemic threat," said WHO Director-General, Dr Margaret Chan. She added that WHO will provide technical support for introduction of the vaccine.

The candidate vaccine has several advantages. Priced at just US$ 0.40 per dose, the vaccine produces in both adults and toddlers a higher immune response than the currently available vaccines. In addition, the new vaccine confers long-term protection and induces immunity in certain non-vaccinated persons who live in proximity of those who are immunized, leading to broad community protection.

The meningitis prevention and control strategy that these countries will implement entails introducing the new meningococcal A conjugate vaccine to immunize - between 2009 and 2015 - a population of approximately 250 million people aged 1 to 29 years and 23 million infants living in 25 African countries. It also requires ensuring that adequate quantities of the currently available meningococcal polysaccharide vaccines are available for epidemic response. The latter initiative is important for two reasons: first, to ensure a smooth transition from current epidemic response strategies to a preventive approach and, second, to respond to the threat of non-group A meningococcus meningitis outbreaks (group C or W135).

The meningitis prevention and control strategy was reviewed and endorsed by WHO's Strategic Advisory Group of Experts on Immunization in April 2008 and by the GAVI Alliance Board in June 2008.

'Money well spent'

"Vaccination with the new meningitis vaccine is money well spent. Our initial investment of US$ 55 million towards a meningitis stockpile will greatly help stave off additional outbreaks of this disease," said Dr Julian Lob-Leyvt, Executive Secretary of the GAVI Alliance. The GAVI Alliance is a public-private partnership of major stakeholders in immunization including WHO, UNICEF, the World Bank, developing country and donor governments, research and technical agencies in the vaccine industry, civil society and the Bill & Melinda Gates Foundation.

The new product, conjugate meningococcal A vaccine ("MenAfriVac"), was developed through the Meningitis Vaccine Project, a product development partnership between WHO and the Program for Appropriate Technology in Health (PATH), a non-governmental organization. The project was set up in 2001 with core funding from the Bill & Melinda Gates Foundation.

"A single case of meningitis can drive a family into a spiral of poverty from which they may never recover. By committing to introducing MenAfriVac in meningitis belt countries, African governments will play a pivotal role in eliminating epidemics that have plagued the continent for more than a century, and they will help reduce poverty," said Dr F. Marc LaForce, Director of the Meningitis Vaccine Project.

Children specially at risk

"Meningitis outbreaks have devastated communities in the poorest countries of Africa for many years. Children, in particular, are at risk. Now, with the new vaccine that is promising to be effective longer, there is a good chance that we can finally get a grip on the disease and protect all children and parents from this life-threatening disease," said Esther Guluma, Regional Director, UNICEF Regional Office for West and Central Africa.

"This is a major development in the prevention and control of cerebro-spinal meningitis in the Sahel countries that will reduce the risk of epidemics currently killing thousands of people in the meningitis belt," said Dr Luis Gomes Sambo, Director of the WHO Regional Office for Africa.

The new vaccine is expected to be introduced starting 2009-10 in Burkina Faso and will be phased into an additional 24 countries between 2010 and 2015, with GAVI support. GAVI funding will also go towards ensuring sufficient stocks of the current vaccines are available for epidemic response during the introduction of MenAfriVac.

Strain behind deadly outbreaks

The candidate conjugate meningococcal A vaccine protects against infection by group A Neisseria meningitidis (meningococcus), the strain mainly responsible for deadly outbreaks in 25 "meningitis belt" countries. Some 430 million people, living in the area stretching east to west across the continent from Senegal to Ethiopia are at risk of this bacterial disease. Even with antibiotic treatment, at least 10% of patients die and up to 20% have serious permanent health problems as a result of the disease.

A phase I clinical trial in adults aged 18 to 35 years was successfully completed in India. Phase II clinical trials of the candidate vaccine have been completed in The Gambia and Mali and showed almost 20 times higher antibody levels in one to two year olds, compared to the existing polysaccharide vaccine. (Follow-up of this trial is ongoing.) Phase II/III clinical trials have been successfully completed in two to 29 year olds in The Gambia, Mali and Senegal.

The vaccine is safe in testing and is manufactured by an Indian company.

Next steps

The vaccine is expected to be licensed in India in the course of early 2009, and to be submitted for WHO evaluation shortly thereafter. African countries may also register the vaccine during 2009 to allow early introduction.

An additional large phase III trial will be conducted in India and Mali in early 2009. A phase II study in infants began in Ghana in late August with results expected in 2010. The results of these trials may allow to extend indications for use to infants.

WHO 

In response to the inflow of Chadian refugees into Cameroon’s northeastern town of Kousséri earlier this month, 5,523 persons have already been relocated to a newly equipped camp in the village of Maltam, while an estimated 10,000 more are expected to join them in the coming weeks.

“At one point, we had at least 30,000 refugees in the country, but many have returned to Chad,” said Sophie de Caen, United Nations Resident Coordinator for Cameroon. “At present, along with the Cameroonian authorities, we plan to continue providing assistance and protection to an estimated 15,000 refugees, until they feel comfortable enough to return home,” she stated.

The refugees, who started to arrive on 2 February when fighting erupted in the Chadian capital N’Djamena, were initially hosted in two temporary sites in Kousséri, as well as in local schools, churches, and private homes. “We have immediately started equipping a camp in Maltam, 32 km away,” explained Jacques Franquin, Representative of the Office of the United Nations High Commissioner for Refugees (UNHCR) in the country. “The camp will enable us to provide assistance and protection in the best possible way,” he added.

The first refugees arrived in Maltam on 16 February, and more are being offered transport from Kousséri to the camp every day. The camp has already been equipped with 1,060 family tents, two boreholes, and 226 latrines – the latter funded and constructed by the International Federation of Red Cross and Red Crescent Societies (IFRC). All refugees relocated to Maltam have already received essential non-food items (NFIs) from UNHCR, such as plastic sheeting, sleeping mats, blankets, mosquito nets, jerry cans, cooking stoves, soap, and sanitary items.

The transport operation and the equipment of the Maltam camp, as well as the aid and protection provided there, are largely possible thanks to a grant of $4.7 million from the United Nations Central Emergency Response Fund (CERF) to six United Nations entities involved in the operation.

“So far, we have completed five general food distributions, targeting all refugees newly arrived in Maltam,” said Abdoulaye Baldé, acting Representative of the World Food Programme (WFP) in the country. He added that a total of 28 metric tonnes (MT) of food was distributed, due to last until the next distribution planned for 03 March. The WFP is also providing logistic support for the operation, especially in terms of transport and storage of aid supplies.

As the refugees reached Maltam, nutritional screening started under the leadership of the United Nations Children Fund (UNICEF), the Red Cross Movement, and Médecins Sans Frontières (MSF) from several countries. “About 25 cases of moderate malnutrition and nine of severe malnutrition were identified, and we are working to address these,” said Christyne Bahringer, a UNICEF spokesperson in Cameroon. “Following successful completion of vaccinations against measles and poliomyelitis on 17 February in Kousséri, a campaign against meningitis is also due to start this Thursday, in the Maltam camp and its surroundings,” she added.

The UNICEF has also concluded a cooperation agreement with the non-governmental organization (NGO) Action Aid, in order to provide recreational and educational opportunities for children in the Maltam camp.
While the Chadian refugee emergency in Cameroon is now under control, the United Nations remains gravely concerned about the continued humanitarian crisis in eastern Chad. “There are over 250,000 Sudanese refugees and over 180,000 internally displaced persons [IDPs] in eastern Chad, the vast majority of whom are heavily reliant on humanitarian aid for their survival,” said Eliane Duthoit, head of the Office for the Coordination of Humanitarian Affairs (OCHA) in Chad. “Our life-saving operations in eastern Chad have continued despite the recent deterioration in the security situation. We must ensure that they are never interrupted, as the current crisis could otherwise turn into a humanitarian disaster,” she added.

The United Nations has announced today the allocation of $4,720,260 from the donor-supported Central Emergency Response Fund (CERF) to meet the humanitarian needs of Chadian refugees who fled to Cameroon’s north-eastern town of Kousséri earlier this month.

“Thanks to these funds, the United Nations will be able to assist and protect thousands of refugees over the coming weeks,” said John Holmes, United Nations Emergency Relief Coordinator (ERC) and Under-Secretary-General for Humanitarian Affairs.

The allocation includes grants of $1,687,843 to the Office of the United Nations High Commissioner for Refugees (UNHCR), which leads the operation, $1,654,482 for the World Food Programme (WFP), $843,053 for the United Nations Children Fund (UNICEF) for six different projects, $330,630 for the World Health Organization (WHO), and $82,040 for the United Nations Population Fund (UNFPA). In addition, $122,212 has been allocated for the United Nations Department of Safety and Security (UNDSS) to ensure the operation’s safety.

“These grants are vital for funding our humanitarian response,” said Sophie de Caen, United Nations Resident Coordinator in the country. “In many instances, we had diverted funds and stocks from other activities. We will now be able to respond to the emergency in a systematic manner,” she added.

“With the funds granted to UNHCR, we intend to cover assistance for up to 20,000 refugees in Kousséri, and to relocate and register an estimated 15,000 of these refugees to a camp in the village of Maltam,” stated Jacques Franquin, Representative of UNHCR in Cameroon. “The camp, located 32 kilometres from Kousséri, is currently being equipped, and it started receiving the first refugees on 16 February,” he explained.

The UNHCR’s activities covered by the grant include the provision of emergency assistance to all refugees, the transport of refugees to Maltam and their registration, and the establishment of the camp in Maltam, including shelter facilities as well as two boreholes. The funds also enable UNHCR to procure basic non-food items (NFIs) such as plastic sheeting, sleeping mats, blankets, mosquito nets, jerry cans, cooking stoves, soap, and sanitary items.

The WFP will use its grant to procure and deliver food aid to the refugees and to provide essential logistic support such as transport and storage of supplies. The UNICEF’s six projects include immunisations, maternal and neo-natal care, child nutrition, water and sanitation, and child protection, as well as recreational activities to ensure the well-being of refugee children. The WHO will be able to provide health care to the refugees, while UNFPA will carry out activities for reproductive health and against gender-based violence (GBV).

The Chadian refugees, most of them from the capital N’Djamena, started to cross the border into Cameroon on 2 February, when armed fighting erupted in Chad. At least 70 percent of them are women and children. Together with the Government of Cameroon, UNHCR and other United Nations agencies have already responded to the most urgent life-saving needs of all refugees. The International Federation of Red Cross and Red Crescent Societies (IFRC) and non-governmental organizations (NGOs), particularly Médecins Sans Frontières – Switzerland (MSF-CH), have played an important role in the response so far.

Approved by the United Nations General Assembly in December 2005 as a successor to the Central Emergency Revolving Fund, the CERF aims to save lives by providing a more predictable and timely response to humanitarian emergencies. For 2008, 67 United Nations member states, as well as foundations and corporate and individual donors, have already committed nearly $420 million to the CERF. All United Nations agencies as well as the International Organization for Migration (IOM) can access CERF funds within 72 hours of a crisis. This enables them to save lives, especially during the earliest stages of a disaster, by immediately focusing on quick life-saving assistance.

Traffic jams and urban bustle have returned to main towns and cities in the west and centre of Cameroon, belying the violence that just weeks earlier left many people there dead and a general population so scared most did not leave their homes for several days.

Yet human rights groups remain concerned that the government is employing heavy-handed tactics in clamping down on the media and arresting and imprisoning hundreds, possibly thousands, of youth who they say are not receiving due process.

“The arrests [of those accused of taking part in the violence] continues,” human rights advocate Madeleine Afité, of House of Human Rights, told IRIN

The number of arrests is in dispute. A government spokesmen said the total is around 1,500 but Afité said the number is much higher. “Around 2000 people were arrested in Douala alone,” she said.

A lawyer in Yaoundé, Me Francis Djonko, told IRIN that those arrested are not receiving due process. "The accused should have at least three days to prepare their defence but that is not being respected in the cases I have had to defend,” he said, adding some of the accused have already receiving prison sentences of up to three years.

A source close to Cameroon’s President Paul Biya said that some members of the government are suspected of fermenting the violence and may soon by taken into custody. President Biya went on state media on 27 February during the rioting to say that “certain politicians” were seeking to overthrow his government in a coup d’état.

Figures on the number of dead also remain unclear. The government spokesperson Jean-Pierre Biyiti Bi Essam told the French Agency Press (AFP) on Wednesday that only 24 people had been killed but human rights groups say the number is far higher.

“We are still trying to cross-check information but we can already say that a hundred or so people must have died,” Afité said.

International media monitoring groups have accused government of censoring the media and beating and intimidating journalists as well as confiscating their equipment.

The government has also closed down at least three media houses but denies that it is part of a general effort to censor the press. “[The media houses] either carried out certain broadcasts which are insensitive, provocative, or controversial and obviously certain administrative decisions have been taken in order to ensure that these broadcasts do not endanger the stability or social order,” government minister Elvis Ngolle Ngolle told Voice of America.

The riots started in the economic centre Douala in the west of Cameroon on 25 February, and quickly spread to the political capital Yaoundé and other cities as youths protested against rising fuel and food prices and efforts by President Biya to change the constitution so that he could run again in the 2011 elections.

Most of the 45,000 Central African Republic (CAR) refugees living in eastern Cameroon are diseased, malnourished and generally in bad health, non-governmental organisation (NGO) and UN workers say.

Since 2005 the Mbororo pastoralists of western CAR have been fleeing child kidnappings and violent attacks - including throat-slitting - by masked bandits whose identities remain unknown.

The refugees arrive “very weakened, after long days of walking and a lot of stress and they live in very difficult conditions”, Eric Grimaldi of Médecins Sans Frontières (MSF) told IRIN.

Once settled in some 60 villages in eastern Cameroon, their health does not improve significantly. For every 10,000 people, there are between three and seven deaths per day among the refugees. According to MSF, the situation is particularly bad in the village of Ngaoui in Adamaoua Province, home to 5,000 refugees and receiving 100 new refugees a month.

“[The refugees] suffer from malnutrition, typhoid and amoebic diseases,” said a nurse in a missionary hospital in the small eastern town of Letta. “The health of the refugees is really very bad… And they always arrive in a critical state to begin with.”

Rare paralytic disease

According to the UN Children’s Fund (UNICEF), 17.2 percent of refugee children under five are malnourished.

MSF has registered several cases of tuberculosis and about 50 cases of a rare paralytic disease called `konzo’. Known as “the disease of the poor”, it results from exclusive consumption of the bitter manioc plant, which, though inexpensive, is poor in vitamins and nutrients. Manioc also contains salt cyanide, which can be toxic if improperly cooked. The result can be irreversible paralysis of the lower limbs, as well as hearing and sight problems.

“We have met families where several children are now paralysed,” MSF’s Grimaldi said, adding that the Cameroonian authorities do not have the material or human resources to prevent the disease and very few doctors know how to treat it.

Difficult to access nutritional centres

The nutritional situation was “so alarming” according to MSF, that in July the UN Refugee Agency (UNHCR), the World Food Programme (WFP), MSF and another aid agency, CARE, in collaboration with the Cameroonian Public Health Ministry, began monthly food distributions.

Five nutritional centres have also been created, but refugees have settled over such a wide area that “[they] have trouble getting to the centres,” the head of UNHCR in Cameroon, Jacques Franquin, told IRIN. “Plus, it’s hard for a mother to stay at a nutritional centre for a month with one of her children while leaving the others at home.”

The refugees have limited access to healthcare, largely because of the bad roads and ill-equipped health centres.

Refugees lack water

Many refugees are equally confronted by a lack of water.

“It takes us six or seven hours to find water,” said Aladji Abdoulaye Gidjo Gargain, father of a refugee family in Borongo, about 450km northeast of Yaoundé. “When we were in CAR, we didn’t have this problem.”

“The arrival of the refugees created imbalances,” explained UNHCR’s Franquin. “They don’t always have access to the wells of the Cameroonians.” Either they cannot afford to pay or there is not enough to share, he said.

The UNHCR has built 15 new wells, but 10 times more are needed.

“Many water points in the region have already run dry, and the dry season hasn’t even started yet,” MSF’s Grimaldi said.

Traumatised

He added that many refugees were still affected by the attacks and kidnappings that they experienced. “We realised that many children refused to eat because they were traumatised by what they had seen and lived [through].”

Unfortunately, Grimaldi said, no one has taken the time - or has the time for the moment - to treat these psychological problems.