News of the WeekInfectious Disease

Shortage of Meningitis Vaccine Forces Triage in Burkina Faso

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Science  07 Mar 2003:
Vol. 299, Issue 5612, pp. 1499-1501
DOI: 10.1126/science.299.5612.1499a

Despite pleas last fall to prepare for a serious outbreak of bacterial meningitis this winter, public health officials are scrambling to halt a mounting epidemic in Burkina Faso, caused in part by an uncommon and hard-to-fight strain of the Neisseria meningitidis bacterium known as W135. Although some supplies of a new vaccine effective against W135 reached the West African country last week, they are not nearly enough, says William Perea of the World Health Organization (WHO). Public health officials are now forced to ration the limited supply in a way that saves as many lives as possible.

Less well known than AIDS, tuberculosis, and malaria, bacterial meningitis kills and disables thousands of victims in the so-called meningitis belt of Africa each year. Transmitted through airborne droplets, it grabs hold in the winter as dry winds blow south of the Sahara and leave irritated airways vulnerable to infection. In last year's outbreak, 1500 people died and hundreds more were left with brain damage and other permanent disabilities. With 3000 cases already, and more than 400 deaths, this year promises to be even worse, says Perea.

Preventive vaccination is key, as the disease is not easy to treat. Even under ideal conditions in the United States or Europe, with access to advanced antibiotics, one in 10 patients die and up to 15% suffer permanent complications such as deafness, brain damage, or limb amputation.

A relatively cheap vaccine can prevent the most common strains of the bacterium, the A and C strains, but last year's outbreak in Burkina Faso was caused by the W135 strain. At the time, the only vaccine effective against the W135 strain costs between $4 and $40 per dose—far out of reach of people in Burkina Faso and most other African countries.

Limited defense.

Vaccine against Neisseria meningitidis strain W135 is in short supply.

CREDIT: EYE OF SCIENCE/PHOTO RESEARCHERS

Fearing a repeat, WHO and other public experts and nongovernmental organizations urged drug companies to produce a less expensive vaccine in preparation for this year's meningitis season, which typically runs from December to June (Science, 11 October 2002, p. 339). They also asked wealthy countries to contribute $10 million to help buy enough doses to prevent an epidemic. The response from donors was tepid. Norway and Monaco offered small donations, but the Bill and Melinda Gates Foundation made the only significant contribution, says Graciela Diap of Doctors Without Borders, which is helping respond to the crisis. “We were trying to pre-position some vaccine stocks in the field to be prepared for the epidemic,” says Diap, but most donors said to come back once there was a crisis. The limited funding slowed the negotiations, but early this year, drug giant GlaxoSmithKline (GSK) agreed to produce a cheaper variant of its existing vaccine, effective against three strains of the bacterium.

By that time, the first cases of meningitis—caused by both the W135 and the A strains—had been reported in Burkina Faso. After a fast-track approval in Belgium, the first 500,000 doses of GSK's trivalent vaccine were shipped to Burkina Faso last week. The country has requested 1.9 million doses.

WHO experts are now trying to figure out how best to distribute the available doses of vaccine. With limited data, they are trying to assess quickly which strains are prevalent where—the A strain can be treated with a cheaper vaccine—and deliver the precious trivalent vaccine to areas where the W135 strain is most threatening.

The crisis highlights an old debate among meningitis experts. John Robbins of the National Institute of Child Health and Human Development in Bethesda, Maryland, argues that routine vaccination, rather than emergency vaccination during a crisis, could prevent epidemics and could also reduce the cost of the vaccines by providing a guaranteed market. Several countries, including China, have implemented routine strategies and no longer suffer epidemics as they did through the 1970s, he argues.

But WHO officials and other experts assert that the benefits of routine immunization with existing vaccines are not worth the financial and logistical costs. In fact, one study published in January 2000 in The Lancet calculated that an organized response to an outbreak saved approximately the same number of lives as did a preventive vaccination campaign.

As the latest outbreak in Burkina Faso illustrates, however, launching an organized response is easier said than done. Both routine vaccination and the outbreak-response strategy face significant hurdles, notes Mark Miller of the National Institutes of Health Fogarty International Center, but he believes that routine vaccination is worth exploring. “I would think it would be very useful to do a demonstration project” in a region at high risk for outbreaks, he says. “The current strategy deserves a reassessment.”

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