World Meningitis Day 2022: Labs Play an Integral Role in Defeating Meningitis

Despite a pandemic, outbreak response must go on

In June 2021, the World Health Organization (WHO) identified a deadly suspected meningitis outbreak in the Democratic Republic of Congo (DRC). Of those who became ill, more than 6 in 10 died. Unfortunately, due to civil unrest limiting access to affected areas and lack of laboratory testing capacity at regional and national labs, it was difficult for the country to confirm which pathogen was responsible for the outbreak, leading to delays in vaccinating people to protect them from acquiring meningitis.

Laboratory staff from the national level (INRB) and from a provincial lab (Tshopo) with Christine Lascols, CDC Lab Expert & Trainer.

Photo credit: Dr. Berthe Miwanda, INRB

In September 2021, an urgent request came to CDC’s Bacterial Meningitis Lab (BML). Prof. Muyembe, Director of Kinshasa’s “Institut National de Recherche Biomédicale” (INRB), a medical research center, needed support for strengthening PCR lab capacity at INRB. This lab capacity would be critical to responding to the suspected meningitis outbreak that had now grown to 262 cases.

Prior to the COVID-19 pandemic, a CDC lab expert would have been deployed immediately. But how could CDC help when the COVID-19 pandemic brought most non-mission critical travel to a halt? CDC BML staff worked to provide immediate assistance through procurement of lab supplies and PCR reagents, sharing of training materials, and holding a virtual training in September 2021 for laboratory staff in DRC’s INRB. Following the training, CDC BML’s staff assistance continued with weekly check-in sessions between laboratory scientists in Atlanta and in Kinshasa.

Once travel was finally possible, CDC BML staff provided a 3-week in-person training at INRB in Kinshasa in April 2022, to a total of 14 participants from the national and regional laboratories (see photos). CDC BML staff were able to establish a functional molecular laboratory for diagnosing and confirming bacterial meningitis at the national reference laboratory in Kinshasa. INRB is now able to test all cerebrospinal fluid (CSF) specimens received from all regions in the country for meningitis diagnosis. This in-country visit was combined with remote assistance to ensure sustainability of the capacity to continue to perform PCR in the national reference laboratory moving forward.

Over the last five years, CDC BML staff have rapidly responded to a number of meningitis outbreaks occurring in several countries, including Liberia, Ethiopia, and DRC, by providing lab support and technical assistance. The DRC experience showcases how CDC BML staff work with in-country partners to rapidly respond to a meningitis outbreak, even during the COVID-19 pandemic.

Epidemic meningitis, a major cause of mortality in Africa

More than 1.2 million cases of bacterial meningitis are estimated to occur worldwide each year, and without treatment, the case-fatality rate can be up to 70%. Additionally, 1 in 5 survivors may suffer from permanent complications including hearing loss, neurologic disability, or loss of a limb. Thankfully, many types of meningitis are preventable through vaccination, and there is strong momentum in the international health community for combatting this disease.

Applying virtual platforms for laboratory training during the COVID-19 pandemic

Laboratory staff from the national level (INRB) and from a provincial lab (Tshopo) during data analysis group practice sessions.

Photo credit: Christine Lascols, CDC.

For decades, the Bacterial Meningitis Epidemiology (BMET) and Laboratory (BML) teams in CDC’s Meningitis and Vaccine Preventable Diseases Branch (MVPDB) have cultivated domestic and international partnerships, with a focus on meningitis belt countries to strengthen meningitis surveillance, diagnosis, and treatment. It is known that a strong laboratory system in countries at higher risk for meningitis is crucial. CDC’s BML team has worked to strengthen laboratory systems for meningitis surveillance and outbreak response through trainings and technical assistance in the following laboratory areas:

• Specimen handling
• Diagnosis
• Data management and analysis
• Procurement
• Quality control

Rapid and accurate diagnosis is critical for confirming which pathogen is causing bacterial meningitis and conducting surveillance and outbreak investigations in a timely fashion. Quality-controlled laboratory systems are required when it comes to diagnosing bacterial meningitis. To sustain adequate laboratory diagnostic capacity in partner countries, CDC’s BML team has established effective methods for remote technical assistance to ensure rapid laboratory confirmation.

CDC is currently providing laboratory support to 11 meningitis belt countries (Benin, Burkina Faso, Chad, DRC, Ethiopia, Ghana, Guinea, Mali, Niger, Nigeria, and Togo). CDC also supports meningitis surveillance in African countries outside of the meningitis belt, such as Mozambique. All 11 meningitis belt countries have participated in BML-led trainings over the last couple of years to build in-country laboratory capacity for surveillance, diagnostic testing, and outbreak response. Technical support provided by CDC’s BML team—through annual trainings and supervision visits—has resulted in successful in-country activities led by national reference laboratory teams and health officials in the respective countries

During the first year and a half of the COVID-19 pandemic, all but mission-critical travel and laboratory shipping and testing of specimens at CDC were postponed indefinitely, while seasonal epidemics of bacterial meningitis continued to occur in the meningitis belt region. To overcome this challenge, CDC’s BML team implemented innovative strategies to continue to provide trainings to partner countries using virtual platforms and training videos. Four regional trainings were offered to our African partners in 2020–2021:

• Data Management Workshop (5 days; November 2020)
• Triplex PCR Training for Meningitis Pathogens (4 hours, April 2021)
• Laboratory Quality Workshop (6 days; September 2021)
• Quality Assurance Implementation Meeting (2 days; November 2021)

These offerings included a range of 11 to 58 participants from 8 to 15 countries. In 2022, a PCR training video offered in English and French was shared with countries. A new bacteriology animated video series in English and French, covering safety practices, specimen transport, Trans-Isolate (T-I) medium inoculation, and cytology, is being prepared and will soon be available for countries.

2030 is around the corner

In November 2020, WHO approved Defeating Meningitis by 2030: A Global Road Map, a landmark achievement that resulted from a globally coordinated vision to defeat meningitis. This initiative acknowledges the suffering faced by millions of people affected by meningitis around the world. In particular, the meningitis belt, a region of sub-Saharan Africa, is disproportionately affected with hyperendemic meningitis and an elevated risk of recurrent outbreaks. While approval of the road map is in itself a significant achievement, that road map also lays out the substantial work that remains to be done despite significant progress made over the last few decades.

The road map identifies five pillars as the key areas to strengthen:

• Prevention and epidemic control
• Surveillance
• Diagnosis and treatment
• Support and care for those affected by meningitis
• Advocacy and engagement

The MenAfriNet consortium, a partnership between the Bill & Melinda Gates Foundation, GAVI (the Vaccine Alliance), CDC, WHO, Davycas International, and Ministries of Health, has been integrally involved in strengthening prevention and epidemic control, surveillance, and diagnosis and treatment.

Strong collaborative network is the future

CDC’s partnership with countries in the African region supports a critical component of the meningitis road map, but more work is still needed across the five pillars. CDC supports critical meningitis surveillance and data management activities in the region, which allow for a stronger understanding of the evolving epidemiology of meningitis in sub-Saharan Africa. Additionally, the strong collaboration observed between the meningitis belt countries and CDC highlights the potential to synergize efforts through strategic partnerships that can one day lead to defeating meningitis.

Author: Christine Lascols, Microbiologist, CDC BML

Co-Author: Joann Kekeisen-Chen, Epidemiologist, CDC BMET