“Strengths in unity”: A Real Time Evaluation of an MSF Collaborative Approach to a Meningitis Outbreak in Niger 2016

Evaluation and Lessons Learned
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This evaluation was commissioned by MSF OCB with the agreement and support of OCBA, OCP and OCG. The initial intention had been to undertake a post evaluation of the collective MSF response to a large Meningitis C epidemic in Niger in 2015. However, a number of factors combined to make the execution of a real time evaluation of MSF meningitis activities in Niger in 2016 more realistic. 2015 saw the first large scale Meningitis C outbreak in Africa since 1979. It was caused by a unique strain of Neisseria Meningitidis C. There had been a worldwide shortage of C containing vaccines in 2015 and this was expected to continue into 2016. As a result in 2015 little reactive vaccination had been carried out in the Nigerien population making them potentially vulnerable to meningitis in 2016 given that they had little conferred immunity.

The findings are based on two field visits to Niger, analysis of relevant documents (reports, records, emails), interviews with a cross section of key people involved in the meningitis response in 2015 and 2016 and participant observation of ongoing events in real time.

To use a more cohesive, collaborative approach was the ambition for 2016 from the different OCs and this was informally agreed at the end of 2015. Basically the 8 regions of Niger were divided between the four operational centres and it was agreed there would be collaboration and communication related to epidemiological data and laboratory activities.

In addition, there would be one spokesperson who would represent MSF to all external actors – mainly the government and UN bodies. This position passed between three of the four HOM informally depending on their workload and other commitments.

Whilst geographical division made practical sense, there was a marked difference in the extent to which the different areas were affected and hence the different OCs were involved in meningitis activities. The comparatively low level of meningitis related activities this year hardly challenged the combined resources of the four MSF operational centres – for example OCP had minimal input as there were few cases in their regions of responsibility and the other sections all had manageable workloads.

The most obvious failing in regards to collaboration was the non sharing of EPREP stock amounts and vaccination cold chain capacity. Even treatment kits although similar, were not standardised across the sections. If regional backup support had been necessary (as was the case in 2015) standardisation is important to avoid confusion and a clear idea of available resources greatly assists emergency response.

Practically, the concept of an MSF meningitis committee was a good one and worked well, bringing all OCs together on a regular basis with Epicentre and allowing some level of discussion and collaboration. The absence of staff directly involved in managing the meningitis outbreak, e.g. emergency coordinators, potentially had the effect of reducing the immediacy and medical relevance of a number of the meetings. A recommendation to add case management to the agenda that initially mainly focused on epidemiology and vaccination strategies was implemented between the first and the second field visit. The meningitis committee could have perhaps started earlier and been used as a forum during the preparatory phase to better harmonise the MSF approaches to the meningitis outbreak.

Epicentre was playing a significant role in coordinating and incorporating the epidemiological and laboratory data from MSF and public institutions and produced a weekly epidemiological bulletin.

The introduction of an inter-sectionally agreed line-list for medical data is a very positive achievement for MSF, meaning that this much larger set of data coming from all sections can be analysed. Unfortunately for this outbreak the approved line list arrived after data had already started to be collected by the different sections meaning it had to be re-entered into the new line list creating more work.

Laboratory results – that should help guide epidemic management – were still being shared very late with partners and MSF never formally received any results of the Pastorex tests undertaken in the regions even though MSF supplied the test kits. Ministry of Health systems set up to manage the transportation of CSF samples to the national reference laboratory were not respected by government employees and despite MSF offering to help this did not really improve.

Vaccination activities were generally informed by epidemiological data and the time limit for effective vaccination was generally respected MSF supported campaigns. Lack of reliable population data given at central level and the Ministry of Health decision to limit the security stock and waste factor combined to 10% meant that in most cases population figures were underestimated and the vaccine stock was not enough. Due to redefined and more sensitive alert and epidemic thresholds proposed by WHO in 2014 (but officially available in 2015) epidemic “pockets” were identified at sub district level and vaccinated in an attempt to contain the number of cases.