A Tale of Two Countries: Controlling Meningitis in the United States and Benin

Pratima Raghunathan knows first-hand what it's like to be called to an investigation at a moment's notice. While working on a case control study on Buruli ulcer in Ghana, and surveying the aftermath of meningitis in Benin, Africa, Raghunathan took a short break from her work in June 2001.

"I was out all day at a wedding in New York, and when I returned to my parents' home there was a message on the machine from my supervisor, Nancy Rosenstein, asking me to call her," Raghunathan recalls.

"It was late and I was hesitant to call Dr. Rosenstein back, but I did. She explained that two 15-year-old high school students had died from meningococcal disease, both serogroup C, within three days of one another near Alliance, Ohio. A third case had just been hospitalized with suspected meningococcal disease, and the state was requesting CDC assistance," says Raghunathan.

Raghunathan learned that the first two cases attended West Branch High School, and the third attended nearby Marlington High School, which triggered an alert because of their closeness in time and space.

The response: launch a massive vaccination campaign.

"Clusters are rare – there are approximately 10 clusters per year in the United States – so any one particular state may not have recent experience in responding to these situations," Raghunathan says. "CDC has developed guidelines to help state and local health departments decide what measures to take to control these outbreaks. My role was to assist them in applying these guidelines, including how to select the target group for vaccination." With the local and state health departments in charge of the vaccination campaign, Raghunathan's job shifted to educating the public about meningitis.

"There was tremendous concern and anxiety expressed by many community members who did not have very much information about meningitis," Raghunathan says. "CDC worked closely with the state and local health departments to inform the public about the disease. Our team established a hotline, conducted media briefings twice daily, and talked to key groups like doctors and school officials. We think this strategy helped calm the community's fears." By the time of the Ohio outbreak, Raghunathan had already gained expertise in controlling meningitis epidemics overseas. She had just returned from Benin, West Africa, where she worked with the Benin Ministry of Health to control the spread of meningitis which had already struck thousands of people.

There are differences between Raghunathan's investigation of meningitis in Ohio and the disease in Benin.

Raghunathan explains that in Benin, the vaccine supply is very limited, even though the region anticipates outbreaks every year. This was not the case in Ohio where there was enough vaccine for everyone.

"In Benin alone, there were approximately 600,000 doses of vaccine but more than two million people were at risk," explains Raghunathan. "We drove to affected regions with Ministry of Health officials to decide which districts would be vaccinated based on surveillance data. It was sobering to realize that our choices would have an impact on so many people."

In the end, 350 people died in Benin and 9,000 were afflicted. In some districts, the epidemic touched one of every hundred people. Throughout Africa, 36,000 people became ill from meningitis and 3,600 died.

"Given the enormous suffering caused by meningococcal disease, we want to move beyond outbreak control to prevention," Raghunathan says. "We're optimistic about new vaccines already being used in England and Canada promise to have a great impact on the disease. The Gates Foundation has just donated $70 million towards the development of similar improved vaccines for Africa. Companies are working on vaccine formulations appropriate for use in the United States and we expect them in the next three to five years."

The northern region of sub-Saharan Africa is referred to as the meningitis belt because it experiences a meningitis outbreak every year, usually during the dry season, and every eight to 12 years is faced with a large-scale epidemic.

Raghunathan is hoping to spend her second year as an EIS officer studying the aftermath of meningitis in Africa in order to better prepare the region for future outbreaks. At the same time, she will keep her bags packed for the next phone call asking her to get on the next plane to wherever she is needed. Her plans after EIS? To continue her career in public health at CDC.