Decision reference number: ECHO/-WF/BUD/2004/02000
1 - Rationale, needs and target population:
1.1. - Rationale:
Between January and April 2003 the World Health Organization (WHO) reported 6,062 cases of meningitis (634 deaths) in Africa, most of them in Burkina Faso, 168 suspected cases of yellow fever (14 deaths), mainly in West Africa and 3,995 cases of cholera (61 death) (note: this figure may have increased significantly after the recent epidemic in Liberia). The threat involved with epidemics is that their transmission increases the number of cases and the lethality (mortality specific to a given disease), hence the number of deaths. Early and effective action is required to reduce the morbidity and mortality related to an outbreak. Local reaction by national authorities tends to be insufficient as budgets prioritise existing disease to the detriment of potential epidemics.
In recent years, ECHO has been supporting emergency projects in response to outbreaks of communicable diseases in West Africa. Some lessons learned are that, on most occasions, it is very difficult to determine a specific date that would trigger emergency procedures, such as a Primary Emergency Decision. ECHO's previous experiences in the region show that a certain level of expenditure can be foreseen ahead of the epidemic season, thus justifying the preparation of a humanitarian aid decision in favour of populations affected by epidemics in West Africa. Funds requested under this decision will help specialised organisations to assess outbreaks, treat affected people and prevent further spreading of the epidemic.
Meningitis is endemic in West Africa. Every year there is a surge of cases in West Africa during the first five months. In some years, the surge reaches epidemic proportions, as reflected in the WHO tables annexed. During the period 1996-1997, 278,966 cases were reported with 21,830 deaths in West African countries. According to the Centre for Disease Control (CDC), epidemics of meningitis in Africa have an incidence of up to 2% of the population with an estimated 10%-15% of cases being fatal. Around 10%-15% of patients that recover suffer permanent hearing loss, mental retardation or other serious consequences. According to the same authoritative source the following trends can be expected: "devastating epidemics will continue to occur in countries throughout the African meningitis belt and cause the emergence of epidemics due to a new serogroup in Africa".
The age group most affected by meningococcal meningitis are children and adolescents, which in this region represent the majority of the population. The most affected area is the savannah region that lies between the Sahara desert and the coastal forest-lands. The so-called 'meningitis belt' runs from Senegal to Sudan. The most affected countries are Burkina-Faso, Mali, Tchad, Niger and Nigeria, but outbreaks can occur in any other country of the region. The highest risk is from January to May, which corresponds to the dry season.
Universal prevention to avoid outbreaks of meningitis is not a realistic option as the immunisation provided by the vaccine lasts for a short period (2 to 3 years). Therefore, there has to be a response to each epidemic in order to limit its spread and to mitigate morbidity and mortality. A new strain, Neisseria meningitidis W135, is responsible for the latest epidemics in West Africa. The traditional vaccine A/C is unable to stop the spread of the disease. A new A/C/W135 vaccine is now available but, according to WHO, in insufficient quantities.
Epidemics of yellow fever are increasing in West Africa. Only Africa and South America are affected by yellow fever. Outbreaks became rare in Africa between 1950 and 1990, possibly due to the large immunisation coverage reached in the sixties. Since the 90s, outbreaks of yellow fever are on the increase. The extreme lethality of this hemorrhagic fever justifies a prompt and firm reaction to outbreaks in order to avoid major health threats.
Areas most affected by yellow fever are the humid savannah regions of West and Central Africa during the rainy season. Cases occur between latitude 15° North and 10° South. There are no clear-cut gender or age group limitations. Outbreaks occur occasionally in urban areas in Africa and, to a lesser extent, in jungle regions. During an epidemic 30% of an urban population can be affected whilst case mortality rates can reach 50%.
Vaccination is highly effective for the prevention and the control of epidemic as the protection provided by this protein vaccine is high, fast and is believed to last for more than 35 years. Theoretically yellow fever immunisation is slowly being integrated into many West African countries' Extended Programmes of Immunisation, but this is hampered by the high cost of the vaccine. Increased coverage would reduce the current upward morbidity trend, although the required coverage will probably not be attained during the next decade.
Cholera manifests itself as acute watery diarrhoea frequently accompanied by vomiting, circulatory collapse and shock. Between 25 and 50% of cholera cases are fatal, if untreated. Appropriate treatment leads to mortalities below 1-2%. Cholera epidemics are a sign of poverty and lack of basic sanitation facilities.
Cholera appears worldwide and is very common in West Africa, where it was introduced in 1970. Recurrent outbreaks of cholera in the region are compounded by large population movements prompted by conflict and insufficient sanitation facilities e.g. the outbreak in Monrovia from June to August during fighting in the capital.
There is no geographical, gender or age limitation for cholera in West Africa. Cholera lethality in Africa is the highest in the world (estimated at 5%).
Measles is a common disease that produces higher lethality among displaced populations, in particular when the immunisation coverage has decreased (usually the case in war-affected areas).
Measles is common among young children but it is even more severe when it appears among adolescents or adults. In tropical areas outbreaks of measles usually take place during the dry season. The case fatality rate is 3-5% in developing countries but can reach 30% under certain conditions (e.g. malnutrition, displacement, dense concentrations of people, etc).
Outbreaks of other communicable diseases such as viral hemorrhagic fevers (e.g. Lassa Fever, Ebola...) or Shigellosis may also appear in West Africa, requiring immediate action.