MERIT Strategic Review Meeting

Transcription

1 Meningitis Environmental Risk Information Technologies MERIT Strategic Review Meeting Synthesis Report Hôtel Chavannes de Bogis, near Geneva, Switzerland November 10 11,

2 MERIT Strategic Review Meeting Synthesis Report Cite this report: MERIT Strategic Review Meeting: Synthesis Report. Nov Health and Climate Foundation, Geneva, Switzerland, 33 pp. Available from: 1

3 Acknowledgements Steering committee Steering Committee members from the World Health Organization (WHO), the World Meteorological Organization (WMO), the Health and Climate Foundation (HCF), the International Research Institute for Climate and Society (IRI)/Earth Institute at Columbia University, the Group on Earth Observations (GEO) and the Anti Malaria Association (AMA) organized and attended the meeting: Emily FIRTH, WHO, Geneva, Switzerland Stéphane HUGONNET, WHO, Geneva, Switzerland (chair of MERIT) Michel JANCLOES, HCF, Geneva, Switzerland Abere MIHRETIE, AMA, Addis Ababa, Ethiopia Slobodan Nickovic, WMO, Geneva, Switzerland Masami ONODA, GEO Secretariat, Geneva, Switzerland (unavailable for the meeting) Madeleine Thomson, IRI/Columbia University, New York, USA Expert advisory group Wayne ELLIOT, WMO, Geneva, Switzerland Judith MUELLER, Ecole des Hautes Etudes en Santé Publique, Paris/Rennes, France Marie Pierre PREZIOSI, WHO, Geneva, Switzerland Samba SOW, Center for Vaccine Development, Bamako, Mali James STUART, London School for Hygiene and Tropical Medicine, London, UK Meeting participants Lydiane AGIER, University of Lancaster, Lancaster, UK Eric BERTHERAT, WHO, Geneva, Switzerland Hélène BROUTIN, MIVEGEC, CNRS/IRD/Montpellier University, Montpellier, France Laurence CIBRELUS, WHO, Geneva, Switzerland Kara DURSKI, WHO, Geneva, Switzerland Abraham HODGSON, Noguchi Memorial Institute for Medical Research, Accra, Ghana Rajul PANDYA, National Center for Atmospheric Research, University of Colorado, Boulder, USA William PEREA, WHO, Geneva, Switzerland Carlos PEREZ GARCIA, NASA GISS/Columbia University, New York, USA Michelle STANTON, University of Lancaster, Lancaster, UK Michael WILLIAMS, GEO Secretariat, Geneva, Switzerland Rapporteuring Laurence CIBRELUS, WHO (and report writing) Emily FIRTH, WHO Michelle STANTON, University of Lancaster 2

4 Contents Acronyms...4 Executive Summary...5 Introduction...6 Meeting objectives and expected outcomes...6 MERIT external advisory group...7 Summary of presentations and discussions...8 Session 1: Overview of MERIT and the meningitis response strategy... 8 Session 2: Overview of MERIT projects, achievements and country activities...13 Session 3: Group work: reviewing and shaping the future of MERIT...18 Report and recommendations from the MERIT external advisory group...23 Appendix...26 Appendix 1: Outcomes of previous MERIT technical meetings...26 Appendix 2: Meeting agenda...29 Appendix 3: Profiles of the members of the MERIT external advisory group...31 Appendix 4: Contact information

5 Acronyms ACMAD AEFI AMA CHWG CIPH EHESP EMGM GEO HCF ICG IRI MAMEMA Men A MenAfriCar MenAfriVac MERIT MoH MVP NCAR Nm UCAR WHO WMO African Center of Meteorological Application for Development Adverse Effects Following Immunization Anti Malaria Association Climate and Health Working Group Climate Information for Public Health Ecole des Hautes Etudes de Santé Publique European Meningococcal Disease Society Group on Earth Observations Health and Climate Foundation International Coordinating Group on Vaccine Provision for Epidemic Meningitis Control International Research Institute for Climate and Society Multi disciplinary Approach for Modeling and Epidemiology of Meningitis in Africa Neisseria Meningitidis serogroup A African Meningococcal Carriage Consortium Meningococcal A conjugate vaccine Meningitis Environmental Risk Information Technologies Ministry of Health Meningitis Vaccine Project The National Center for Atmospheric Research Neisseria Meningitidis University Corporation for Atmospheric Research World Health Organization World Meteorological Organization 4

6 Executive Summary Background The Meningitis Environmental Risk Information Technologies MERIT project is a collaborative initiative of international organizations, research institutes and members of the environmental, public health and epidemiological communities. Established in 2007, MERIT aims to help reduce the burden of epidemic meningococcal meningitis across Africa s Meningitis Belt by (i) improving the risk assessment and management of the disease, and (ii) informing both the reactive and preventive meningitis vaccination strategies. Strategic review and external group of advisors A large part of the work to date focused on short term forecasting of meningitis risk to improve outbreak response. However, the recent large scale introduction of the meningitis conjugate A vaccine is expected to dramatically change the epidemiology of the meningitis in Africa, and hence, the surveillance and control strategies for the disease. The MERIT framework needs to adjust accordingly. On November 10 and 11, 2011, a sample of the MERIT partners most actively involved in the initiative to date and members from the MERIT steering committee conducted a fiveyear strategic review of the initiative to ensure its ongoing relevance alongside the evolving public health needs. Additionally, a group of external advisers representing the areas of meningitis control, environmental information and policy makers provided feedback and recommendations on the structure and role of MERIT in contributing to the meningitis control strategy in Africa. Outcomes Participants to the meeting made a critical appraisal of the progress, relevance and contribution of current research to inform public health needs. They clarified the expected contribution of MERIT towards setting priorities for research agendas and translating new knowledge into public health actions. The need to explore countries expectations of MERIT was also highlighted. The external advisors acknowledged the high commitment and quality of the multidisciplinary teams involved in MERIT, who are eager to streamline research efforts and make them relevant to decision making. Preliminary research results are very promising, but these outputs are to be translated into operational activities and tangible public health impacts are yet to come. Further, the lack of financial sustainability and autonomy for the initiative impedes the coordination, development, completion and translation of demanddriven research projects, which to date are mostly conducted by groups from the international community. The lack of specific funding also prevents MERIT from sponsoring or commissioning in country activities conducted by local teams, who yet would be the primary beneficiaries of such efforts. Finally, access to meningitis surveillance data is difficult, but this situation should improve once in country Ministries and research teams are involved more deeply in the initiative and better understand its potential. 5

7 Introduction Created in 2007 and chaired by the World Health Organization, the MERIT initiative is a collaborative effort of international institutions, research institutes and individuals from the environmental, public health and social sciences communities. It provides a framework that facilitates multi disciplinary collaboration to help reduce the burden of meningococcal meningitis in the African Meningitis Belt through (i) the development of enhanced decisionsupport tools and (ii) the improvement of meningitis surveillance, prevention and control strategies. Since the launch of the initiative, four international technical meetings have been held in Geneva (2007), Addis Ababa (2008, 2010) and Niamey (2009), bringing together around 50 institutions from more than ten countries in Africa, Europe and America. A large part of the work to date focused on short term forecasting to better inform and improve the meningitis outbreak response strategy. However, the recent introduction of the meningitis conjugate A vaccine is expected to dramatically change the epidemiology of meningitis in the Belt as well as the surveillance and control strategies, and the MERIT framework will need to adjust accordingly. More information on the activities conducted under the umbrella of MERIT to date can be found in Appendix 1: Outcomes of previous MERIT technical meetings. Meeting objectives and expected outcomes The 5 th MERIT meeting was held in Geneva on November 10 and 11, 2011, with a distinctive angle in terms of focus, goals and format. The meeting consisted of a five year strategic review of the initiative to assess and ensure its ongoing relevance alongside the evolving public health needs. The meeting aimed to identify the means for accelerating the production and use of MERIT results to support the meningitis control strategy while further contributing to the broader development of climate health interactions. More specifically, the objectives and expected outcomes of the meeting were as follows: Meeting objectives 1. Review completed and ongoing research activities under the MERIT framework. 2. Identify priority research areas as relevant to the evolving public health situation and needs. 3. Assess the sectoral and institutional representation in the MERIT community. 4. Determine how existing and future research can most effectively be translated into public health actions. 5. Explore country expectations of MERIT. 6

8 Expected outcomes 1. Critically appraise the progress, relevance and contribution of current research and results to inform public health needs. 2. Clarify the contribution of MERIT towards improving the public health strategy, including a well defined set of priorities and research agendas. Spanning two days, the meeting was considerably smaller in size than in previous years. In addition to members of the MERIT steering committee, the strategic review meeting brought together about ten MERIT partners, who were most actively involved in the initiative to date, to share their experiences, research outcomes and future plans in relation to the MERIT framework. The schedule of the 5th MERIT meeting is available in Appendix 2: Meeting Agenda. A group of external advisers representing the areas of meningitis control, environmental information and policy makers provided critical feedback on the role of MERIT in contributing to the meningitis control strategy in Africa. MERIT external advisory group Five experts in global health operations or research focused on meningitis, as well as in climate sciences and resource mobilization served as external advisors to the steering committee of MERIT. Together, they reviewed the achievements of the initiative to date and identified the strengths and weaknesses of the initiative. They discussed the importance for MERIT to continue, along with new ways, means and directions the initiative could explore and implement to achieve its goals in a changing epidemiological landscape. The advisory group also considered how MERIT could facilitate the collection of and access to environmental, epidemiological and microbiological data needed for research on MERIT topics. The full profile of the members of the MERIT advisory group is available in Appendix 3: Profiles of the MERIT Advisory Group Members. 7

9 Summary of presentations and discussions Session 1: Overview of MERIT and the meningitis response strategy Chair: Rajul Pandya, UCAR Opening remarks and meeting objectives Stéphane Hugonnet, WHO, Chair of MERIT Steering Committee The MERIT initiative was created in 2007 to improve the application of climate and environmental information to strengthen decision making and public health policy development. After four years of activities, three technical meetings were held, several activities initiated by a range of partners, but this had very little (if any) impact on meningitis surveillance and control strategies. As the Nm A conjugate vaccine is widely introduced, rapid changes in the epidemiology of meningitis are expected, along with new policy needs that could be informed by MERIT. These elements combined prompted the MERIT steering committee to undergo a strategic review, that focuses on two main topics: (i) the translation of research outputs into operational strategies: what did we learn and how can this be utilized; and (ii) a roadmap for upcoming MERIT activities, in particular regarding how MERIT can contribute to public health and align with rapidly changing epidemiology and needs. More specifically, the following questions were raised: How can new knowledge be integrated into the outbreak response strategy? Can the outbreak response strategy and decision algorithm be improved? Are there information gaps and how can new information and research be obtained? Can MERIT help to support the preventive vaccination strategy? Can MERIT support the evaluation of the impact of the meningitis A conjugate vaccine? Can MERIT bring an added value to the ongoing carriage studies? How can the integration of research into public health actions be facilitated? How can research activities be better aligned with each other and with public health needs? What is the public health demand for specific research? And over what period of time? Is there a need for MERIT to continue? Is there potential for using the MERIT approach in a multi disease context? Who / and which disciplines should be represented in MERIT? How could the current MERIT approach be improved or modified? What is the research agenda and roadmap? 8

10 Overview of current epidemic response strategy and research needs Stéphane Hugonnet, WHO There are four core components to the WHO meningitis control strategy: surveillance, outbreak response, preventive immunization and vaccine development, advocacy and partnership. Surveillance and response through reactive immunization: Control measures are efficient only if implemented quickly after the epidemic incidence threshold has been crossed, and the reactive vaccination has very little effect if implemented after the epidemic peaks. Evidence indeed suggests that the timing of the vaccine has a far greater influence than the vaccination coverage reached. Decisions must therefore be taken quickly and appropriately as, at the district level, the average epidemic duration is short (approx. 8 weeks). Once the epidemic threshold has been exceeded, a vaccine request is made to International Coordinating Group (ICG) 1 on Vaccine Provision for Epidemic Meningitis Control. If the request is approved, the aim is to get the vaccine to the country (capital city) within 10 days. Ideally, each country would maintain a stockpile of the vaccine (which has a shelf life of approximately 2 years) but there hasn t been the incentive to do this.. To date, the decision to vaccinate relies on surveillance data, as they are the only available in routine. However in an ideal situation other criteria would be used in order to attempt to vaccinate before thresholds were exceeded and this is one the aims of MERIT. Preventive immunization with the Nm A conjugate vaccine: Preliminary results obtained from the 3 countries where the conjugate A vaccine has been introduced to date were presented. Burkina Faso was immunized entirely by the end of Before 2010, approximately 10% of suspected cases were tested for confirmation of the disease (recommended level). During the season, approximately 90% of suspected cases were tested. Of these, 4 cases of Nm A were confirmed, with 2 of these cases coming from outside of Burkina Faso, and none of the 4 had been previously vaccinated. In Mali, where a third of the population has been vaccinated, there were no confirmed cases, whereas in Niger in which a third of the population has been vaccinated as well there were 4 confirmed cases. It is yet to determine if this is attributable to the conjugate vaccine, or whether no epidemics were going to occur that year, regardless of the preventive immunization. Responding to meningitis outbreaks and being able to detect the potential re emergence of Nm A is a significant surveillance challenge in the countries who have received the conjugate A vaccine. The potential emergence of other serogroups is also to be carefully looked at and it is unlikely that climate/environmental information can be used to inform this phenomenon. Research needs: The direction of the MERIT paradigm should be changed, such that we start with the practical elements and translate this into research questions rather than starting 1 For more information, see: 9

11 with research and translating it into practice. There also is a critical need for enhancing surveillance, quality of data and having a comprehensive dataset. With respect to the reactive strategy in non conjugate A countries, research should focus on the following key questions: 1. What other risk factors can be included in the decision tree? 2. What factors trigger the end of an epidemic? 3. Can we make regional level predictions to inform vaccination production? With respect to the introduction of the conjugate vaccine, MERIT could be further used to: 1. Guide the introduction of the conjugate A vaccine, particularly at the fringes of the Meningitis Belt 2. Assess the impact of the conjugate A vaccine 3. Determine what changes are going to happen to the Belt in the next 5 10 years MERIT situational analysis Madeleine Thomson, IRI The MERIT initiative was launched in 2007 as a multi sectoral partnership to provide a platform for enabling health specialists (public health specialists, epidemiologists, immunologists, microbiologists, demographers, etc.) and climate and environment specialists to work together to help reduce the burden of meningococcal meningitis epidemics in Africa. The effort was designed to create new knowledge that can be used to improve the reactive and preventive vaccination strategies for the disease. During the past few years, five meningitis areas in which climate can play a role were identified: (i) Mechanisms, (ii) Spatial and seasonal risk, i.e., where and when epidemic occur in an average year, (iii) Subseasonal and interannual changes in risk, (iv) Long term trends in risk, and (v) Assessment of the impact of interventions. Although some preliminary attempts have been successful, one setback in the MERIT project has been the challenge of trying to put the problem before the research, as the problem is difficult to define, and has evolved over time. For instance, at the start of MERIT there were hints that climate plays a role in the year to year variability of the disease. Our beliefs in the mechanisms of the disease have changed over time and it still not clear whether the transmission of the bacteria, and the transition from carriage to infection, is influenced by climate. No mechanisms research group have been clearly identified, hence no progress has been made in this area. Further, to ensure the research outputs impact policy and practice and that, in other words, evidence is turned into practice, it is important to agree on the nature of evidence and to define means to disseminate and access to knowledge. Additionally, data sharing policies remain largely unresolved and impede the development of new projects. Although MERIT succeeded in creating a multi disciplinary network of professionals, in 2010, the climate and epidemiological joint experiment undertaken in 10

12 Following the season also highlighted the difficulties for each community to understand the concepts, expectations, capacities and limitations of the other. An additional problem identified is that MERIT has no core funding or large grants. To date, most of the resources indirectly used for MERIT come on a voluntary basis from northern research teams, in Europe or the USA. The mutli faceted nature of the initiative and its clear expected operational contribution has probably complicated the identification of right donors and funding pipelines. Overview of climate sensitive disease agenda in Africa Abere Mihretie, AMA In this presentation, the Climate and Health in Africa: Ten Years On held in Ethiopia in April was used as an entry point to provide an overview of the climate sensitive disease agenda in Africa. It also reminded the participants of opportunities that could arise from the use of climate and environmental information to improve sustainable management of climate sensitive diseases, such as meningitis. Overall, the dialogue between the health and climate communities is progressing, but the two communities need to better understand the tools, methods and capacities of each other. This could be facilitated by cross trainings between the health and climate communities, building on the lessons learned from previous experiences, in Madagascar for instance. In countries, such efforts could contribute to helping Ministers across different sectors to collaborate. This may also facilitate the coordination of various initiatives that are being led in the field of climate and public health. The challenges around the time line of the climate sensitive diseases research agenda were also addressed. In particular, it was reminded that the operational needs change over time, pressing researchers, who need time to understand the users and to contextualize the science, to adapt to the changes within a time frame much shorter than usually in research. This emphasized the importance of a strategic longer term view that would maximize existing grant funded projects and efforts, and facilitate the transfer knowledge to the operations. The lack of specific funding was also discussed. Update on the introduction of the meningitis conjugate A vaccine and carriage study Marie Pierre Preziosi, MVP/ WHO By the end of 2011, the meningococcal A conjugate vaccine MenAfriVac, developed through the Meningitis Vaccine Project 3 (MVP) and produced at low cost by the Serum Institute of India, will reach 3 new countries, protecting an additional 21 million people in selected regions of Cameroon, Chad, and Nigeria. This year, Mali and Niger will also complete the last phase of their introduction plan, immunizing more than 13 million people aged 1 29 years with a single dose of vaccine. With Burkina Faso fully immunized since 2 More information from: 3 See for more information 11

13 2010, more than 55 million individuals will be protected against meningitis A by the end of In 2012, Sudan, Ghana, Benin and Senegal are expected to launch (and complete for the latest 3) the introduction of the Nm A conjugate vaccine. In total, by 2016, 26 countries are expected to be protected against epidemics of Nm A. The two pronged introduction approach for MenAfriVac implies that the ongoing phased mass immunization campaigns are followed by the integration of the vaccine into routine childhood vaccination programs. Ongoing efforts and studies include: licensure for infants, immune persistence and carriage studies, and surveillance of adverse effects following immunization (AEFI). Update on the African Meningococcal Carriage Consortium: MenAfriCar James Stuart, MenAfriCar/LSHTM Implemented with local partners in 7 Meningitis Belt countries (Senegal, Mali, Ghana, Niger, Nigeria, Chad and Ethiopia), the MenAfriCar 4 project aims to (i) define the pattern of meningococcal carriage across the meningitis belt (including age, seasonality) as well as the rates of acquisition and loss of carriage, and of (ii) measure the impact of the conjugate vaccine against Nm A, on carriage. Results available to date come from swabs and blood samples taken in the 7 countries (predominantly Mali and Niger). Carriage is approximately 4%. The age group 5 14 exhibits a peak in carriage (all serogroups considered), with the age distribution being approximately the same across all 7 countries. Serogroup A was only found in Chad, with a prevalence of 0.35% (n=7; 1%of total samples), while W 135 was predominant (15%), followed by serogroup Y (5%) and X (2%). 77% of the Nm samples were of unknown serogroup and preliminary results from Niger suggest that a large proportion are capsule null (82%). The original plan was to do post vaccination studies in Mali and Niger, but as no serogroup A cases were detected in these countries this is no longer possible, and the postvaccination survey will be conducted in Chad. Antibody testing analysis continues. Households are being followed up to assess the duration of carriage, but generally in African countries carriage is relatively short. Preliminary results from regression models controlling for age group and country, and allowing for potential household clustering suggest that smoking and cow dung cooking fuel might be risk factors for carriage. Relationships between carriage and climate are also being explored. Carriage data, meteorological and dust data with specific on site collection (at 3 carriage sites) and long term immunization data are being combined. Activities include: (i) exploring two seasons of pre vaccination data followed by two three post vaccination data, (ii) comparing countries with similar climatic factors, pre and post vaccination introduction. It will also be important to characterize the seasons when the disease was not strong and explore their potential links to to periods of high non capsulated bacteria. 4 See for more information 12

14 Climate and environmental information for MERIT decision making Slobodan Nickovic, WMO This presentation described the areas of research at WMO that could be relevant to MERIT, such as (but not limited to) sand and dust warning system, mineralogy and prediction of dust mineral composition, as well as monthly and seasonal outlook and prediction through regional climate modeling. Although the research agenda already exists at WMO, it could be tailored to answer some of the questions raised by MERIT particularly with respect to mechanisms studies that would explore potential linkages between iron in dust and the transmission of meningitis, or to modeling dust at surface level. The 3 5 day forecasts computed by the Sand and Dust Storm Warning Advisory and Assessment System (SDS WAS) are available on the WMO portal 5. Different groups do dust modeling in the countries, producing regional information that can be downscaled as needed. However, the dust (and atmospheric) forecast lead time of less than 10 days is probably too short to support public health decision making. Recent efforts also explore the opportunity to stimulating iron rich minerals in dust modeling. Further, there are several circulation patterns for dust, but correlation, re analysis and adaptation of scale could eventually lead to monthly or daily forecast of dust. Session 2: Overview of MERIT projects, achievements and country activities Chair: James Stuart, MenAfriCar/LSHTM The MAMEMA mini group Hélène Broutin, MIVEGEC IRD/CNRS/Montpellier University A working group created as an output of the 4th MERIT technical meeting, the Multidisciplinary Approach for Modeling and Epidemiology of Meningitis in Africa (MAMEMA) project gathers epidemiological modelers, epidemiologists, statisticians and climate scientists who discuss their ongoing activities on meningitis modeling, along with future research collaborative projects. The group, who met for the first time in Montpellier, France, in April 2011, focused on the epidemiological modeling to inform both the reactive and the preventive vaccination strategies. They discussed which hypotheses, parameters and methods should be prioritized, in particular with regards to immunity and genetic variability as examples. After general and epi studies presentations, 4 models were presented, 2 for informing the reactive vaccination and 2 for informing the long term vaccination strategy. The discussions raised the idea of two projects that were suggested to MERIT for consideration as future large research projects: (i) a long term surveillance project for serogroup dynamics and impact of Men A conjugate vaccine, and (ii) a long term carriage study for seasonality, comparison epidemics non epidemics context, carriage/incidence ratio evolution. Four projects were considered feasible in a short time 5 See was.aemet.es/ for more information 13

15 perspective and in the MAMEMA context: (i) health center level surveillance data collection in different countries, (ii) study of the link between carriage and infection (literature review on the evolution of the carriage/infection ratio,), (iii) integration of climate data in the epidemiological models and epidemiological models update, (iv) study of the link between climate/environment and epidemics onsets/size at fine scale. One of the key issues raised in the recent MAMEMA meeting was data sharing, and the need for more communication with the countries about research being undertaken using data from the country. MERIT was suggested as a possible vehicle for a network that would facilitate communication with local ministries and communities, accessing more data and providing feedback to the countries. One must indeed ensure that data works in favor of the local people, and make the point clear that combined data is more valuable that the data held by individual organizations, and that everybody benefits from data exchange. Strengthening the community based approach of MERIT might also ease the access to donors and funds. MAMEMA 2 will take place in Montpellier, France on Apr Short term forecasting of meningitis epidemics Lydiane Agier and Michelle Stanton, University of Lancaster Two approaches have been used to develop a model for forecasting meningitis epidemics on the weekly time scale. The first model predicts the incidence, whereas the second model predicts the epidemic state (below alert threshold, between alert and epidemic threshold, above epidemic threshold). Predictions can be calculated using any arbitrary lead time, but the longer the lead time the less certainty we have in the predictions. Therefore the maximum lead time considered in this analysis was 3 weeks. Both models incorporate a dependence on previous incidence, plus some form of spatial dependence. The models are assessed by whether or not they correctly predict that the epidemic threshold (10 cases per 100,000) has been exceeded. The results are promising, with about 60 70% of epidemics being detected, however additional input from public health experts is needed in order to determine whether these results are operationally useful. Prediction at national and district (seasonal) scales including climate Michelle Stanton, University of Lancaster, and Carlos Perez, IRI Relationships between the seasonality and year to year variability of meningitis outbreaks and climate dynamics in the region have been explored, and attempts to use regional simulations of dust and climate for the meningitis belt are promising but not yet conclusive. This study hypothesizes that accurate predictions of incidence will enable precautionary measures and vaccine supplies to be put in place prior to the start of the season. Twenty years of climate and epidemiological data from Niger were used to investigate potential predictive models. Climate, in particular wind, temperature and dust information can be used to predict meningitis incidence on a seasonal scale at both the national and district level. Early cases (December incidence) can also be used as a predictor. This is potentially a proxy for population susceptibility. The effects of climate and early cases 14

16 operate at different spatial scales. Models can be evaluated in two ways namely with respect to whether the exact magnitude of cases can be predicted, or whether we correctly predict whether a particular (arbitrary) threshold will be crossed. Input from public health communities is needed to truly assess the usefulness of the models, although results so far indicate that climate and early case information increases the chance of correctly detecting that a particular threshold has been exceeded in comparison to a baseline model. UCAR / Navrongo Project Rajul Pandya, UCAR High humidity is related to the end of meningitis epidemics, and can be predicted quite well. The use of humidity to predict the start of an epidemic was investigated, and a paper relating to this has been submitted. In this analysis a generalized additive model (GAM) was fitted to epidemiological data from Navrongo (in Northern Ghana) over the 2008 and 2009 season. Using relative humidity lagged by 2 weeks, and other possible risk factors such as the amount of carbon monoxide in the atmosphere as a proxy for burning and other climate variables it was possible to correctly predict 29% of future epidemics. It was also possible to predict whether or not there would be future cases with a 40% accuracy. As relative humidity can be forecasted quite accurately up to 2 weeks in advance, this gives a 4 week lead time with respect to the start of an epidemic. Fourteen different forecasts for relative humidity were used in order to get a measure of forecasting uncertainty. Interestingly, there was less uncertainty at predicting the end of the season in comparison to predicting the beginning of the season. Further, humidity is a necessary but not conclusive condition/indicator of cases, it is therefore probably more relevant to consider this factor at the end of the season rather than during. Discussions raised by the presentation indicated that the public health perception is that the earlier the season starts, the larger the outbreak and that this would deserve to be further investigated. It was also reminded that the Harmattan wind ends around January, but cases can peak after this. Community surveys were also conducted by UCAR and partners. These surveys indicated that knowledge of meningitis was widespread in Navrongo. There were also indications that household ventilation was an important meningitis risk factor. Further, it is hypothesized that wealthy people are more at risk as they are more likely to migrate seasonally and are more likely to not be included in vaccination campaigns. UCAR and partners have been developing a decision support system, Africa Initiative which was demonstrated in the session. This system is based on the use of GAM to predict the end of the season using relative humidity forecasts. By including epidemiological data in these models, a greater accuracy can be obtained, which could be used as an incentive for communities to add their data to the system. The team also looked at simulating weather from , so they may be able to have some idea of the extent of the Meningitis Belt in the future. 15

17 Overview of the MERIT Nigeria project 6 A.S. Abubakar and Mansur Matazu, Fedral University of Technology, Minna, Nigeria The MERIT Nigeria project was developed in Katsina state, in the Northern part of Nigeria, where climatic conditions are considered highly favorable to meningitis transmission. It arose from a collaborative effort by the Millennium Development Goals (MDGs) state focal office and Ministry of Health, Environment, Research institutes and State Donor representatives from national and international institutions (WHO, UNICEF, UNFPA,MSF, etc). This structure also facilitated raising funds. The project aims to advance the understanding of the environmental, social and economic impacts and determinants of meningitis, education programs and strengthen the disease surveillance system in the state. To date, a series of stakeholders meetings briefings were held in the state, the MDGs grant of $120,000 should be ready by January 2012, the committee awaits executive approval from the Government, and research and technical partnerships are being formalized in order to implement the action plan designed by the group. While the project representatives were unable to attend the meeting in person, this presentation was provided for all participants. District prioritization tool and choice of countries for Men A vaccine introduction Laurence Cibrelus, WHO The Nm A conjugate vaccine is to be first introduced in the most at risk countries and progressively rolled out to the rest of the Belt. At country level, the assessment of epidemic risk relies on (i) the frequency and magnitude of meningitis epidemics reported since 1970, and (ii) the country's proportion of the total number of cases notified during the same period, as a proxy for the case burden. However, because of the limited amount of vaccines available per country yearly, priority also needs to be set among the districts/regions of the countries at risk. Developed by WHO HQ (headquarters) and IST West (Inter country Support Team for West Africa, WHO Regional Office for Africa), the District Prioritization Tool (DPT) enables setting priorities for the introduction of the Nm A conjugate vaccine through the characterization and choice of high priority areas and the calculation of the size of the target population for the campaigns. The DPT is a standard, transparent and evidence based tool that provides a solid ground for discussion and decision making among national policy makers, using country's readily available information, and taking into account their epidemiological situation, capacity to organize a mass campaign, and the vaccine supply situation. Existing in English and French, the DPT has been successfully implemented in 3 countries to date (Nigeria, Chad and Cameroon), and future plans include the implementation of DPT in Sudan, Ethiopia and across the rest of the Meningitis Belt whenever priority setting is needed. The methodology of DPT can also be replicated and adapted for risk assessment of 6 This presentation could not be given during the meeting. 16

18 other diseases, and for post assessment follow up using the district profiles for meningitis automatically computed by the tool. 17

19 Session 3: Group work: reviewing and shaping the future of MERIT Chair: Wayne Elliott, WMO Introduction to working group sessions and overview of expected results Participants to the meeting, including the external advisors, were divided into two equally sized groups, with mixed profiles in each of them (e.g., public health experts and climate scientists). Group 1 was asked to explore different means for current research activities and results to be effectively translated into public health actions and decisions. In particular, members from the group discussed the following topics: (i) How can new knowledge be integrated into the outbreak response strategy and help support the preventive vaccination strategy? (ii) Can the response strategy and decision algorithm be improved? (iii) If and how research activities could be better aligned with each other and public health needs? (iv) Are there information gaps and is how can new information and research be obtained?. Group 2 aimed to define a MERIT roadmap which will help clarify the added value and direction for MERIT moving forward. The following questions were used to lead the discussions: (i) What is the public health demand for specific research? And over what period of time? (ii) How could the current MERIT approach be improved or modified? (iii) How can the integration of research into public health actions be facilitated? (iv) What, if any, future investments are needed? (v) Who / and which disciplines should be represented in MERIT? (vi) Is there potential for using the MERIT approach in a multi disease context?. Feedback from working groups and plenary discussion Working group 1: Integrating new knowledge into meningitis control strategy Members of the group discussed the process that would need to occur for the research that had been undertaken to be translated into action. The prediction models developed so far are promising but they need to be tested further before they can be used as decisionsupport tools. As an initial step to translate current research outputs into practice, the group suggested undertaking a pilot project to see if MERIT partners are able to address the questions raised earlier in the meeting: (i) Can we increase the lead time for the vaccination strategy?, (ii) Can we predict the end of the season?, and (iii) What is the risk of an epidemic on the seasonal scale?. The approaches used so far would be tested and validated this epidemic year ( ) to determine if they are feasible both in terms of how well they perform, and whether the data needed to run the models can be obtained in real time. The models need to run and their outputs monitored in as many countries as possible, and include countries where MenAfriVac has been introduced as well as countries where no preventive immunization campaigns against Nm A have been conducted yet. In country 18

20 partners must be involved in this validation process and this should not be too difficult as it is not planned to change the decision making process at this time. To enable developing and training the models, it is also important that enough historical epidemiological data is available. It was estimated that, other than Mali, Burkina Faso and Niger, the majority of other countries will have approximately 5 years of historical surveillance data. Finally, careful thoughts must be given on how the outputs of the model can best be presented, in a way that is easily interpretable (e.g. should we use a risk traffic light system?) and is tailored to the users needs. Working more closely with the countries will also facilitate identifying and matching their needs. Working group 2: Setting up a road map for MERIT Members from Group 2 discussed a potential road map for MERIT that would build on what they identified as key elements of the initiative: (i) high level commitment from professional of different communities, (ii) risk taking environment, investing in project lying at the crossroads of different disciplines, (iii) research excellence and (iv) the good potential to be useful and user relevant. The group also addressed the multi disease potential of MERIT. Although such an approach might be considered in other fora and is relevant from a country perspective, for the time being it was deemed important to preserve the clarity of the initiative and its focus on meningitis. However, integrating new disciplines to the meningitis oriented projects conducted under the umbrella of MERIT would be a significant step forward in terms of efficiency and comprehensiveness of the initiative. The group thought that social scientists, communicators and African based partners of different fields (epidemiology, immunology, microbiology, and climate sciences) would enrich the systemic approach of the initiative and facilitate the dissemination of the outcomes based on their relevance. Discussions on the future investments that members of the group suggested for MERIT spanned over 4 areas, ranging from management to specific research. First, MERIT would gain greatly, the group suggested, if leadership and management were stronger and if advocacy activities were streamlined. Second, the importance of progressing with the climate component of the risk of meningitis and of translating this new knowledge into practice was also highlighted; and the group suggested doing so via the integration of MERIT activities into existing (and sustainably funded) projects such as MenAfriCar or MVP. Third, and in the mean time, MERIT could support parallel research to enhance knowledge, in particular on mechanisms. Fourth, the group strongly recognized that improved funding options would bring enhanced functioning and achievements to the initiative. Finally, with respect to the introduction of the Nm A conjugate vaccine, the group suggested that multi disciplinary MERIT projects could focus on vaccine impact assessment (e.g., 19

21 removing the effect of climate on meningitis incidence), on carriage studies (for instance as well by removing the climate related component of the results) and on better understanding the changes of the Meningitis Belt, in particular at its fringes. Panel discussion: advisory group recommendations on MERIT and future direction Chair: Michel Jancloes, HCF Plenary discussions insisted on the need to increase the awareness of MERIT in target international and national organizations, linking back to the working group suggestions that advocacy should be strengthened and relationships with in country partners deepened. The importance of separating the science from the operational aspects during MERIT meetings was highlighted. This could take the form of an annual scientific meeting that would showcase research developments, and of a smaller, more focused, meeting that could be used to discuss potential public health actions. Regarding the translation of research into action, it was suggested that some of the activities could be integrated into relevant public health settings such as, for instance, the European Meningococcal Disease Society (EMGM) 7. Linking the MERIT meetings to other congresses might also facilitate attendance, as participants would not need to seek additional funds to be involved. And, more generally, channeling fund raising activities through existing initiatives, such as the Climate for Development in Africa Program (ClimDev Africa) 8 or the Global Framework for Climate Services 9 would undoubtedly help MERIT. Participants to the meeting proposed that the steering committee of MERIT reviews its functioning and membership, with the overall objective of strengthening its leadership role. Along the same line, discussions suggested that the initiative would benefit from regular feedback provided by a group of external advisors, which could take the form of a board. Finally, the importance of filling the social sciences gap in MERIT was also discussed. These discussions are linked to the report by the external advisory group, available in full in the next chapter of this document. 7 See: emgm.eu, for more information 8 More information from : 9 For more information, see: ltation/en/index.html 20

22 Summary of discussions and MERIT roadmap Stéphane Hugonnet, WHO, and Madeleine Thomson, IRI The importance for the MERIT initiative to continue is unquestionable, but significant improvements in structure and functioning are needed to ensure its relevance. For purposes of clarity, MERIT shall remain focused on meningococcal meningitis in Africa, but also encourage a diversity of approach. However, none of the activities could be conducted without strong management and financial stability, made possible and sustained by solid advocacy. Linking these significant fund raising and advocacy efforts to existing, wellfunctioning and well known public health and/or climate projects might facilitate the task of MERIT. Projects such as (but not limited to) MenAfriCar, MVP or ClimDev could advocate for MERIT to climate donors (including these specializing in climate change adaptation and from the private sector). MERIT could also be integrated to some multi disease initiatives activities conducted at country level or at a broader scale, for instance through the Global Framework for Climate Services. With respects to the research agenda of MERIT and its prospects to translate research outputs into operational tools, the six following priority areas and associated strategies were identified: 1. Mechanisms: Continue and develop this effort in parallel including mineral component in models and see if this improves predictability 2. Spatial Risk: DPT Tool incorporate model information for areas on the edge of the belt. Spatial scales confront local observations to regional models. 3. Seasonal risk: Climate Suitability Tool using humidity thresholds available as an operational tool. 4. Sub seasonal and year to year changes in risk: Focus epidemic prediction activities on the edge of the Meningitis Belt for Nm A; and rethink and rebuild models compatible with the transmission dynamics of non A meningitis. Test the three models (weekly, seasonal, district/national incidence/end of season) in communities both vaccinated and non vaccinated with MenAfriVac. 5. Trends in risk: look at changes in risk over the next 5 10 years based on environment, population and changes in the epidemiology due to vaccine strategies etc. 6. Assessment of the impact of interventions: at the regional scale and at the local scale in association with MenAfriCar These activities shall be conducted with as closely as possible to country teams, who shall be brought in to MERIT (e.g., from Nigeria, Ghana etc.). Finally, the MERIT steering committee shall undertake a number of activities that will move the outputs of this strategic review forward. They include (i) making policy decisions 21

23 related to the meeting recommendations, (ii) redefining its functions, membership criteria and composition, (iii) clarifying the responsibilities, task sharing and composition of the secretariat, (iv) writing up a plan of work and responsibilities, (v) developing a business plan that may include the organization of a donor meeting, (vi) planning the next steering committee meeting and the next MERIT meeting(s). Two roads diverged in a wood, and I I took the one less travelled by, And that has made all the difference. Robert Frost, from The Road Not Taken, in Mountain Interval,

24 Report and recommendations from the MERIT external advisory group The following paragraphs present the questions asked by the steering committee of MERIT to external advisory group, as well as the associated comments and recommendations made by the experts. In each of the paragraphs, key words have been bolded for clarity purposes. Assessment of MERIT strengths and weaknesses The following items were identified as strengths of MERIT: MERIT is a dynamic initiative whose members have a high level of commitment, flexibility and openness to suggestions. It brings different disciplines together (climate research and public health), and addresses real public health problems. The results of research to date suggest that MERIT has made research more relevant. The models presented at the meeting aim at the prediction of epidemic force and of the end of epidemics; both points are important in the decision making around reactive vaccination. MERIT is a good example of defined user group. The global framework for climate service is being designed to work into user communities. This is a potentially a good environment with which to engage to keep relevance. The following items were identified as weaknesses of MERIT: There are as yet few research partnerships with countries of the Meningitis Belt. There is a risk to the sustainability of the initiative from a lack of specific funding, both for the coordination tasks and for work on specific research and translation. Visibility is higher in the international climate science and meningitis public health communities but less so in the countries of the African meningitis belt. Researchers have limited funding and limited access to appropriate surveillance data. As yet, there are no tangible impacts on public health operations Is there a need for MERIT to continue? Yes. The advisory group was unanimous that MERIT should continue, provided that some adjustments are made. 23