SITUATIONAL REPORT 4th Edition Cluster of Meningococcal Disease in Foya District, Lofa County Liberia. 27th January 2018 1. New Updates No new case or death reported on 27 January 2018 which is five days since the last case was reported. A total of 9 cases including 4 deaths have been reported as of 23 January 2018 with case fatality rate of 44.4% Two (02) cases are currently undergoing treatment at the isolation unit, Foya Borma Hospital o The 12 years old patient in the treatment unit has lost her eye vision (cornea scare) but clinically stable o One case is discharged home today Awareness was created today at the Foya market place on the prevention and control of meningitis A total 853 contacts and non contacts have received chemoprophylaxis of ciprofloxacin (237 contacts, 82 HCW, 534 non- contact residents of affected communities) 36.7% (87/237) contacts have completed their 10days follow up today 33.3% (3/9) are females while 66.7% (6/9) are males 44.4% (4/9) are children under 10years while 33.3% (3/9) above 10-20 years and the remaining 22.2% (2/9) are adults above 30years Ebola (RT-PCR), Lassa Fever (RT-PCR), yellow fever (serology-igm) and typhoid (WIDAL) have been ruled out in specimens collected from cases 3, 4 and 5. 2. Background of Event On 13 January 2018, at 2:20pm, the Lofa County Health Team notified the national level of a cluster of illness and death of unknown etiology from Kelimabendu town, Foya district, involving 5 cases with 4 deaths. Community residents initially alerted the Foya district health team about two cases, a 6-year-old female (deceased) and a 14-year-old male, on 13 January 2018. The 6-year old female (case 3) had symptom onset on 10 January 2018 and died two days later (12 January 2018) as a death on arrival at Foya Boma hospital, after presenting with signs and symptoms of general body weakness, fixed gaze, and joint pain. 1
Another member of the same household, a 14-year old male (case 4), developed symptoms on 11 January 2018. Case 4 was initially taken to a church on the Sierra Leonean border and later transferred to the isolation unit at Foya Borma Hospital on 13 January 2018 by the district rapid response team was treated and discharged. He presented with signs and symptoms of fever, joint pain, headache, vomiting, and general body weakness. Viral hemorrhagic fever (VHF) was initially suspected. On the morning of 19 th January 2018, the CHT was notified that one of the contacts became symptomatic and died in the early morning hours. The case (case 5), a 12 year old male (case 5), from a different household and cousin to cases 2, 3 and 4; developed fever and headache on 17 th January 2018, and was treated at home with paracetamol and oral artemisnin-based therapy combination (antimalarial). Symptoms worsened on 18 th January 2018 and he was taken to Isaac Gbermah Health unit where he presented with general body weakness and body rigidity. He died on 19 th January 2018, after being treated for complicated malaria with parenteral artemether, paracetamol, and IV ampicillin. A safe and dignified burial was conducted on 20 th January 2018 by the Environmental Health Team. After an oral swab and cardiac puncture was performed to obtain samples for testing. On 21 January 2018, two new cases developed symptoms: both cases were on the contact list. The first case (case 6), an 85-year-old male, with onset of symptoms on 19 January and is currently in admission: more information on this case will be shared by tomorrow. The other case (case 7), a 12-year-old female, with onset of symptoms on 20 January 2018, including fever, headache, general body pains, pain in the throat and on observation, she was delirious, crying, with a stiff neck and photophobic. She is reported to having stayed in the same household with case 6. She was transferred to the isolation unit where she is undergoing treatment with IV ceftriaxone, IV dexamethasone and IM diclofenac. Retrospective investigation identified three deceased members of the same household as cases 4 and 5, since 5 November 2017. The first case (case 0), a 29-year-old male, was an Ebola survivor and had symptom onset on 1 November 2017. He presented with headache, joint pain, general body weakness, and bleeding into the eyes. He reportedly sought herbal medication from Sierra Leone. He died on 5 th November 2017 and was buried on 6 November 2017 in the community by community members. This case is dropped from line list as it is not linked to the cluster. The second case and case 1 for current cluster, is a 45-year old male farmer and water pump maintenance area focal person, developed signs and symptoms on 25 December 2017. His past medical history includes operated inguinal hernia. He presented with inguinal scrotal swelling, sore-throat, general body weakness. By 1 January 2018, case 2 s symptoms had 2
worsened, and he was taken to Kolahun hospital, presenting with general body weakness, severe abdominal pain, vomiting and watery stools. He died approximately 40 minutes upon arrival at Kolahun hospital and was buried in the community on 2 January 2018 by community members. Four community members bathed his body and are on the contact list for close observation The case 2, a 3-year old male and son of the case 1, developed signs and symptoms on 5 January 2018. This case did not seek care at any health facility and died on 6 January 2018 in the community after presenting with symptoms of general body weakness, excessive crying, and refusal to eat. The case was buried in the community by the residents of the area. The majority of the children (3/9) affect have died within 48hrs In total, there are 9 cases including 4 deaths reported. The case fatality rate is 44.4 %. Six of the cases are males and three are females. Cases range from 3 to 85 years old. 3. Public Health Response a. Coordination: The Lofa County Health Team is taking the lead and coordinating response to this event. County Incidence Management System (IMS) has been activated and meets daily to review progress of implementation of response activities. The District rapid response team led by District Health Officer (DHO) is leading the investigation and response situation with technical and logistical support by WHO field staff. At the national level, the National Public Health Institute of Liberia (NPHIL) is providing technical and operational support to the county with support from WHO and US Center for Disease Control and Prevention. Information sharing with local health officials in neighboring communities in Sierra Leone and Guinea is ongoing. a. Epidemiology and Surveillance: Enhanced surveillance for suspected cases is ongoing. About 300 community members have been orientated on simplified case definition (syndromic) for meningococcal disease. Community health volunteers (gchvs) have also been mobilized to conduct active case search and contact tracing in affected communities. A total of 239 contacts are being followed daily. As a result of active surveillance, 4 probable cases were detected from 21 22 January 2018 and early treatment initiated to prevent fatality. NPHIL/MoH has deployed two national epidemiologists to support field investigation and response. WHO has also a national level medical epidemiologist to support the county. Lofa working case definition: Health care facility case definition: any person coming from or visiting Lofa county and presenting with two or more of the following symptoms: headache, vomiting, 3
general body weaknesses, confusion, and fever, and among children, persisting crying, refusal to eat, fixed gaze, rigid body from December 23, 2017. Community case definition: Any person coming from or visiting Lofa county, who is not feeling well from December 23, 2017. b. Laboratory: Neisseria meningitides serogroup W has been identified in specimens collected from 2 of the 3 cases from whom specimens were tested: case 3 (oral swab) and case 5 (oral swab and cardiac fluid), by RT-PCR. Ebola (RT-PCR), Lassa Fever (RT-PCR), yellow fever (serology-igm) and typhoid (WIDAL) have been ruled out in all three cases. Specimens have been collected from another four probable cases and are enroute to the National Reference Laboratory (NRL) for confirmatory testing. All laboratory testing has been conducted in-country at the National Reference Laboratory. c. Case Management: A total of 5 cases have been admitted at the Foya Borma Isolation Unit for treatment. Out of this number, two have treated and discharged and three are still undergoing treatment. Ceftriaxone as well as ciprofloxacin for prophylaxis (ceftriaxone for prophylaxis among pregnant women) have been supplied to the county to support case management and provide prophylaxis to contacts accordingly. A total of 213 (89%) of the contacts identified have been provided chemoprophylaxis. Twenty-eight (28) healthcare workers are undergoing training in case management protocol for meningococcal disease which started on 23 January 2018. d. Safe and Dignified Burial: Two of the cases (cases 3 and 5) were buried under supervision of the county environmental health team to ensure safe and dignified burial. All other previous deceased case-patients were buried by community members. These community members are on the contact list and are under observation. In the affected communities, residents have been notified to report all community deaths to the health facilities for investigation and safe burial. e. Risk Communication and Social Mobilization: Community awareness is ongoing with local leaders and community development health committees in lead. Mass public awareness have been conducted via the local radio station in Foya district. 4. Situational Context A total of 3 communities are currently affected suggesting further transmission of the disease from the first town, Kelimabendu Town, to five nearby towns. The proximity of these towns to neighboring Guinea and Sierra Leone has cross border implications given the porous border points along the area. This area was also among those that were affected by the 2014-2016 Ebola outbreak. 4
Table 1: Menigitis contact tracing, Foya District, Lofa County, 2018 Community Populati on # of contacts # of cases Contact that graduated Contact not seen Contact under follow-up Foya Bomah 17769 25 0 0 0 25 Kelima Bendu 517 82 4 82 0 0 Kolahun 16529 5 0 5 0 0 Laypalloe 687 44 1 0 0 44 Ndandu 206 5 0 0 0 5 Dopa 85 77 4 0 0 77 Total 137 9 87 0 151 Table 2: Distribution of contacts by cases and assigned gchvs Name of case Contacts Listed gchv J N 5 2 J J 0 0 T J N 108 11 J N 7 2 K S 0 0 J N 8 2 S C 105 11 Y N 8 2 Total 241 30 Liberia is not part of the meningitis belt, but it neighbors two meningitis belt countries, Guinea and Côte d Ivoire. However, the recent cluster of cases of meningococcal septicemia reported from Sinoe County (south eastern Liberia) in April 2017 emphasized the need for strengthening surveillance and response. Meningitis surveillance in Liberia is conducted through an Integrated Disease Surveillance and Response (IDSR) system which detects 14 epidemic-prone diseases and conditions (IDSR Guidelines). Probable Risk factor The outbreak is driven by the following risk factors: Attending and participating in burial of deaths in the community of the disease 5
Living in the same house hold with the cases Challenges Inadequate operational and logistical support Sparse population of the affected communities thus making contact tracing difficult Uncontrolled cross border movements at informal border points Next Steps Continue active case search as well as contact tracing in affected areas Provision of chemoprophylaxis to the remaining contacts Prompt case management of symptomatic contacts at Foya Borma Hospital Psychosocial support to the bereaved families Additional response team will be deployed if required Enhance community awareness and engagement in all affected Communities Continue sharing situation updates with neighboring districts in Guinea and Sierra Leone Figure 1. Timeline of events of meningococcal disease outbreak, Foya District, Lofa County, Liberia, 23 December 2017 23 January 2018 6
Figure 2. Transmission chain of cluster of cases of meningococcal disease outbreak, Foya District, Lofa County, Liberia, 23 December 2017 23 January 2018 Figure 3. Geographical distribution of cases of meningococcal disease, Foya District, Lofa County, Liberia, 23 7
Figure 3. Geographical distribution of cases of meningoccocal disease, Foya District, Lofa County, Liberia, 23 December 2017 23 January 2018 8
Table 1. Attack rate of cases of meningococcal disease by affected communities, Foya District, Lofa County, Liberia, 23 December 2017 23 January 2018 Community Population Number of cases Attack rate (per 1,000 population) Kelimabendu Town 517 4 8 Dopa Town 85 4 47 Lapoloe Town 689 1 1 Total Affected Towns 1291 9 7 9