Two dead in Meningitis outbreak in Kent, southern England.

Two people have died in an outbreak of Meningitis in the city of Canterbury, in Kent, southern England, this week, according to the UK Health Security Agency. Both of those who have died have been described as having been teenage students studying at the University of Kent. A further eighteen cases of the disease have been confirmed, sixteen of whom live in or close to Canterbury, with one patient each in London and Paris, both of whom are known to have visited Canterbury immediately before becoming unwell. A further eleven possible cases are under investigation. 

The location of the University of Kent. Google Maps.

Meningitis is a serious infection of the meninges, the membranes covering the brain and spinal cord. Several different Bacteria can cause Meningitis, however, Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis (sometimes spelled Neisseria meningitis) are the most common, and are transmitted from person to person through droplets of respiratory or throat secretions from infected people.

The average incubation period for Meningococcal Meningitis is 4 days, but can range between 2 and 10 days. The most common symptoms of Meningitis are a stiff neck, high fever, sensitivity to light, confusion, headaches and vomiting. Even with early diagnosis and adequate treatment, 5% to 10% of patients die, typically within 24 to 48 hours after the onset of symptoms. Bacterial Meningitis may result in brain damage, hearing loss or a learning disability in 10% to 20% of survivors. A less common, but even more severe (and often fatal), form of Meningococcal Disease is Meningococcal Septicaemia, which is characterised by a haemorrhagic rash and rapid circulatory collapse.

The Canterbury outbreak has been linked to the B serotype of Neisseria meningitidis, a form of Betaproteobacterium. A serotype is a distinct population within a species of Bacteria or Virus which presents different antigen proteins on the surface of its cells, and therefore requires the body to develop a different antibody response. A total of 12 serotypes of Neisseria meningitides have been identified, six of which (A, B, C, W, X and Y) can cause Meningococcal Meningitis epidemics.

Two serotypes 1a and 1b with antigens 2a and 2b on surface. Corresponding antibodys 3a and 3b with the possibility to bind to the antigens. Anna Bauer/Wikimedia Commons.

In the UK, a vaccine for Neisseria meningitidis serotypes A, C, W, & Y is typically offered to school pupils aged 14-15, while a vaccine for serotype B, which is particularly associated with outbreaks in infants, is offered to babies. However, this latter vaccination was only introduced in 2015, and therefore most people over the age of 15 in the UK are not vaccinated against this strain. The charity Meningitis Now, which campaigns on issues relating to the disease in the UK, as well as offering advise to those affected by or concerned about Meningitis, has been campaigning for a roll-out of the serotype B vaccine to older groups. 

As a response to the current outbreak, the University of Kent has arranged for a vaccination program for students to be set up on its campus, where antibiotics, which can help to fight the disease, are also available. Advice for staff and students at the university can be found here. Other people who are concerned that they may have been exposed should contact their GP (a GP, or General Practitioner, is a family doctor in the UK), or the National Health Service's NHS111 help service.

Students at the University of Kent in Canterbury queuing to get Meningitis B vaccine. PA Media.

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Living Stromatolites from Sheybarah Island, Saudi Arabia.

Fossil Stromatolites form some of the earliest evidence for life on Earth, being present in deposits from the Palaeoproterozoic and Archaean, with the oldest known examples currently dated to about 3.48 billion years ago. However, their importance has declined in the Phanerozoic, forming significant proportion of carbonate reefs only for brief periods following the End Ordovician and End Permian extinctions. Stromatolites still exist today, and understanding formation presents us with the possibility of understanding some of the oldest ecosystems on Earth, although modern forms are generally restricted to extreme environments, such as hypersaline marine settings and alkaline lakes, with living Stromatolites only known from two modern open-marine environments, Shark Bay in Western Australia and in the Exuma Islands of the Bahamas. 

In a paper published in the journal Geology on 15 February 2024, Volker Vahrenkamp and Viswasanthi Chandra of the Physical Sciences and Engineering Division at King Abdullah University of Science and Technology, Elisa Garuglier and Ramona Marasco of the Biological and Environmental Sciences and Engineering Division at King Abdullah University of Science and Technology, Kai Hachmann, also of the Physical Sciences and Engineering Division at King Abdullah University of Science and Technology,  Pankaj Khanna of the Department of Earth Sciences at the Indian Institute of Technology Gandhinagar, Daniele Daffonchio, also of the Biological and Environmental Sciences and Engineering Division at King Abdullah University of Science and Technology, and Alexander Petrovic, again of the Physical Sciences and Engineering Division at King Abdullah University of Science and Technology, and of Carmeuse, describe the discovery of a colony of living Stromatolites in the intertidal zone on Sheybarah Island on the Red Sea coast of Saudi Arabia.

Sheybarah Island forms part of the Al Wajh Carbonate Platform on the northwest coast of Saudi Arabia. The Al Wajh Carbonate Platform is connected to the Arabian mainland, and is enclosed by a 115 km reef-shoal belt. The central part of the platform hosts a lagoon with a maximum depth of 42 m, which is surrounded by 92 islands and patch-reefs. Sheybarah Island is located on the southwest edge of this platform, and has an area of 27 km², with a maximum elevation of 2 m above sealevel. The lagoon-facing rim of the southern slope of the Al Wajh Carbonate Platform is dominated by Mangroves, behind which is a sandy and rocky, then a rocky reef flat facing towards the open sea.

(A) Location of study area in northern Red Sea. (B) Sheybarah Island on the southwest Al Wajh Carbonate Platform. White arrows indicate prevailing wind direction based on annual average wind data over 10 years. (C) Location of Stromatolite field at southwestern extent of Sheybarah Island. Vahrenkamp et al. (2024).

The Red Sea is semi-enclosed, with slow surface-water renewal, creating a low nutrient environment. In the northeast part of the Red Sea, the average surface temperature is typically about 28°C during the summer, falling to about 23°C in winter, and surface salinity can reach 41‰. Prevailing winds come from the north-northwest, with an average windspeed of 4 m per second, although in winter strong southwesterly winds sometimes occur. The prevailing winds bring with them a high load of iron-rich sediment.

The presence of Stromatolites on Sheybarah Island was discovered during a scouting visit made to the island in January 2021. The Stromatolites form a field in the intertidal to shallow subtidal zone, on a flat slope which dips towards the sea, formed from a fossil Coral reef. A core drilled into this reef produced a radiocarbon date of 5264 years before the present, suggesting that it was formed during the Holocene sealevel highstand, between 4000 and 8000 years ago, when sealevels in the area would have been about 2 m higher than today. The surface of this reef is eroded, presumably due to modern wave action lowering the flat upper reef to the modern sealevel. A lithified sand layer beneath the Stromatolites yielded a date of 1640 years before present, which dates obtained from laminations within the Stromatolites ranged from 120 to 325 years before the present. This implies that the onset of Stromatolite growth was no more than 300-400 years ago; it is possible that it was more recent and that sand grains from a now absent upper layer have been incorporated into the Stromatolite structure.

Stromatolite samples being collected from the location. Vahrenkamp et al. (2024).

The tidal range in the area where the Stromatolites are growing is typically 50-60 cm, with a maximum of about 1 m, although occasional storm surges can inundate lower lying parts of the island. Sea temperatures measured at a depth of 5 m varied between 21°C and 31°C over the course of a year, though in the intertidal zone the temperature variation was much higher, between 8°C and 48°C, as very shallow seawater was exposed to highs of day time and lows of night time air temperatures. Salinity measured in March was 42‰; at the same time the water pH was 7.8 and dissolved oxygen was 5.9 mg per litre.

The Stromatolites are found over an area of about 50 000 m³, which could be divided into three zones, upper intertidal or beach-adjacent, mid-intertidal, and shallow subtidal, each of which was dominated by Stromatolites of a different morphotype. Stromatolites in the beach-adjacent zone, referred to as Type 1 Stromatolites, tend to be grey-green to dark brown in colour, and elongated-sinusoidal to rhomboidal in shape, aligned so that their long axis is perpendicular to the predominant wave crest direction. These tend to be less than 15 cm high, 5-50 cm wide, and 10-100 cm long, although they often coalesce into larger structures, which can be as much as 10 m long. The surface of these Stromatolites tends to be pustular in texture, and their interiors fairly well lithified. The Stromatolites of the mid-to-lower intertidal zones, referred to as Type 2 Stromatolites, are flatter, reaching a maximum of about 5 cm  in height, forming irregularly shaped, ovoid to tabular clusters which can cover as much as 100 m³. The base of these Stromatolites is often raised above the platform, on a small column of eroded Holocene Coral. In the lower intertidal to shallow subtidal zones Type 3 Stromatolites are low relief and poorly lithified, and often covered by a thin layer of carbonate sand.

(A) Drone survey image of Stromatolite fields, showing three main morphotypes of Stromatolites and their distributions. (B)–(C) Type 1 Stromatolites in upper intertidal zone, with elongated sinusoidal to rhomboidal morphology, laminated internal structures, and pustular exterior. White arrows show grazing Gastropods during high tide (underwater photo). (D)–(E) Type 2 Stromatolites, consisting of low-relief, irregularly shaped ovoid clusters of Stromatolites in the outer field. (F)–(G) Type 3 Stromatolites, composed of less-defined, low-relief microbial mats covered by a thin coating of carbonate sand. Vahrenkamp et al. (2024).

The internal structure of Type 1 Stromatolites was found to be laminated, with undulating layers of sediment interspersed with layers with clotted fabrics and vugs (cavities lined with mineral crystals), which in the fossil record would be interpreted as Thrombolitic Stromatolites. When sections of this material were cut and washed, dense lithified layers stood out in relief. Grazing organisms such as Gastropods were often trapped in the matrix. Millimetre scale microlitic crusts (microbially derived calcium carbonate crusts) alternated with millimetre scale sediment layers, within which lithification was beginning to break down grain boundaries. These grain layers often showed high levels of microboring, suggesting ongoing micritization even after sediment accretion.  Rim cements contained numerous aragonite needles, while microlitic crusts were predominantly aragonite (85%), with significant proportions of high magnesium calcite (9%) and low magnesium calcite (5%), and small amounts of quartz and clay minerals.

(A) Hand sample of Type 1 Stromatolite demonstrating layered structures. (B) X-ray micro–computed tomography (µCT) X-Z cross-section image of Type 1 Stromatolite exposing denser internal laminations (red). Colour bar represents range of µCT values corresponding to CT density; blue represents a void. (C) Thin-section micrograph illustrating micritic crust at surface of Stromatolite. (D) Millimetre-scale lithified sediment grain layers (yellow arrows) and fused grains (green arrows). (E) Grains infested with microborings near outer rims and fused at grain contacts (green arrows). (F) Acicular needle aragonite cements (AA) formed around the grain (G) rims. Vahrenkamp et al. (2024).

Examined through a scanning electron microscope, filamentous Cyanobacteria appeared to be the most abundant organisms within the structure of the Stromatolites, enveloping sediment grains in single strands of bundles, covered with mucous sheaths made up of excreted biological polymers. These filament and biopolymer masses also contained large numbers of sub-micron sized calcium and magnesium carbonate crystals. Also present were biofilm structures with Bacterial cells, and Navicula-like Diatoms. The upper and lower surfaces of the topmost microbial mat included numerous reticulated filament structures. An investigation into the biodiversity of the mats using 16S rRNA gene metabarcoding found that the most abundant micro-organisms were Proteobacteria, which made up 49% of the total (30% Alphaproteobacteria, 12% Gammaproteobacteria, and 7% Deltaproteobacteria), with Cyanobacteria making up 16% of the total, and Bacteroidetes 11%.

(A)–(E) Representative scanning electron micrographs showing (A) extensively microbored sediment grains (MG) wrapped in cyanobacterial filaments and extracellular polymeric substance (EPS) films (arrows); (B) High magnesium calcite microcrystals (triangles) associated with Cyanobacterial filaments; (C) filamentous structures, possibly bunches and strings of Cyanobacteria (black arrows), and single cells of various shapes (white arrows) surrounded by desiccated EPS; (D) filamentous structures of different dimensions (black arrows), surrounding bored surface of sand grain. A Diatom is also present (white arrow); and (E) reticulated filaments (black arrows) surrounded by copious amounts of EPS (white arrows). (F) Microbial diversity of Sheybarah Island Stromatolites. Vahrenkamp et al. (2024).

The presence of Stromatolites on the intertidal platform of Sheybarah Island appears to be driven by environmental factors. The platform surface here is exposed to frequent wetting and drying cycles, as well as extreme temperature fluctuations, with generally low current conditions, apart from the occasional storm event. Similar conditions are found on the other islands of the Al Wajh Carbonate Platform, making it likely that these to are home to Stromatolite colonies. The conditions here are similar to those found in the Exuma Islands of the Bahamas, where Stromatolites are also found; the much lower profile of the Sheybarah Island Stromatolites (never more than 15 cm high) probably reflect the limited tidal range of the Red Sea.

Growth of the Sheybarah Island Stromatolites appears to be driven by microbial activity, which leads to the accretion and differential lithification of sediment grains. The range of structures observed appears to be driven by a cycle of grain-entrapment followed by sedimentation, similar to that which has been documented in the Bahamas. The microbial community within the Stromatolites appears to be made up of a combination of photoautotrophic organisms (Cyanobacteria), and heterotrophic organisms, including ones capable of reducing sulphates.

The reticulated filaments seen in the Sheybarah Island Stromatolites are a surprising structure. Such filaments have previously been observed in microbial mats from aphotic environments, such as caves. At Sheybarah Island they appear to be ubiquitous in the upper layer of Stromatolites, and have a variety of morphologies, including horizontal ridges supported by vertical columnar structures. The nature and composition of these filaments is unclear, and will be the subject of future research.

Vahrenkamp et al. believe the Sheybarah Island Stromatolites to be the first open marine Stromatolites discovered in the Middle East, providing a new opportunity to study structures sparsely distributed on the modern Earth, but which were an important part of the Earth's earliest ecosystems. To date, the Stromatolites of the Bahamas have been considered the best analogue for the shallow-marine Stromatolites which formed throughout the Proterozoic, making the similar, but not identical, Stromatolites from Sheybarah Island a significant discovery with the potential to greatly enhance our understanding of Proterozoic ecosystems.

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Outbreak of Cholera in the eastern Democratic Republic of Congo.

On 14 December 2022, a Cholera epidemic was officially declared by the Governor of the North Kivu Province, in the Democratic Republic of Congo, following the isolation of Vibrio cholerae among 140 of 247 samples collected from suspected cases in the Nyiragongo Health Zone, according to a press release issued by the World Health Organization on 10 February 2023. As of 4 February 2023, a total of 4386 cholera cases (of which 1009 are laboratory-confirmed) with 16 deaths (a mortality rate of 0.4%) have been reported. Cholera is endemic in the eastern part of the Democratic Republic of the Congo, including Ituri, North Kivu, South Kivu, and Tanganyika provinces, with cases reported through the year. 

A multisectoral community-based response has been implemented, including a Cholera vaccination campaign. However, considering the fragile context in which this outbreak is taking place, ongoing armed conflicts with further displacements, concurrent epidemics, inadequate levels of access to health care, poor drinking water, hygienic and sanitary conditions, and population movements between the affected health zones and neighbouring countries (including Rwanda and Uganda), the World Health Organization assesses the risk posed by this outbreak as high at the national and regional level, and low at the global level.

Cholera is endemic in several provinces in the Democratic Republic of the Congo. However, from mid-November to the end of 2022, there has been an upsurge in the number of reported cholera cases in the health zones of Nyiragongo and Karisimbi, in the province of North Kivu. Since then, cases have shown a declining trend.

Number of Cholera cases (suspected and confirmed) reported in Nyiragongo and Karisimbi health zones. World Health Organization.

In Nyiragongo, the number of new Cholera cases (suspected and confirmed) increased from 51 in week 47 (21-27 November) to 556 cases in week 50 (12-18 December) of the year 2022, and to 683 cases in week 52 (26 December 2022- 1 January 2023). On 14 December 2022, a Cholera epidemic was officially declared by the Governor of North Kivu Province, following isolation of Vibrio cholerae in the stool of 140 cases from Nyiragongo Health Zone at the local laboratory in Goma.

As of 4 February 2023, a total of 4386 cholera cases (1009 laboratory-confirmed) with 16 deaths have been reported, of which 4011 (91.5%) are from Nyiragongo and 375 (8.5%) from Karisimbi. In the Nyiragongo Health Zone, the most affected age group is 5-14 years (30.1%), followed by 1-4 years (29.7%) and 15-29 years (16.6%); children under the age of one represent 8% of cases.

In total, 15 health areas including seven in the Nyiragongo Health Zone (Kanyaruchinya, Kibati, Kiziba, Mudja, Munigi, Ngangi III and Turunga) and eight in Karisimbi Health Zone (Baraka, Bujovu, Kasika, Katoyi, Majengo, Methodiste Mugunga and Muugano Solidarite) are currently affected by the Cholera epidemic.

In the Nyiragongo Health Zone, the Kanyaruchinya Health Area is the most affected, contributing to 73.3% of all suspected Cholera cases reported from Nyiragongo. In Karisimbi Health Zone, the Methodist Health Area is the most affected with 59.4% of all cases, followed by Baraka and Lasika health areas (both contributing to 7.3% of cases from Karisimbi Health Zone).

Cumulative number of Cholera cases (suspected and confirmed) by health area in Niyragongo and Karisimbi health zones, as of 4 February 2023. Nord Kivu Provincial Health Division/World Health Organization.

The cholera outbreak is principally affecting internally displaced populations, with 97% of the cases reported among internally displaced people in the Nyiragongo Health Zone, and 59% of cases among internally displaced people reported from the Methodist Health Area of Karisimbi Health Zone, which houses the Don Bosco Internally Displaced Population Camp. However, the outbreak is also spreading across the surrounding communities with nearly 3% of the cases in the Nyiragongo Health Zone and 41% of the cases in the Karisimbi Health Zone belonging to the host community.

Cholera is an acute enteric infection caused by ingesting the Bacterium Vibrio cholerae a Gram-negative, comma-shaped Gammaproteobacterium, related to other pathogenic Bacteria such as Yersinia pestis (Bubonic Plague), and Esherchia coli (food poisoning), which present in contaminated water or food. It is mainly linked to insufficient access to safe drinking water and inadequate sanitation. Cholera is an extremely virulent disease that can cause severe acute watery diarrhoea resulting in high morbidity and mortality, and can spread rapidly, depending on the frequency of exposure, the exposed population and the setting. Cholera affects both children and adults and can be fatal if untreated.

SEM image of Vibrio cholerae Bacteria. Kim et al. (2000).

The incubation period is between 12 hours and five days after ingestion of contaminated food or water. Most people infected with Vibrio cholerae do not develop any symptoms, although the bacteria are present in their faeces for 1-10 days after infection and are shed back into the environment, potentially infecting other people. The majority of people who develop symptoms have mild or moderate symptoms, while a minority develop acute watery diarrhoea and vomiting with severe dehydration. Cholera is an easily treatable disease. Most people can be treated successfully through prompt administration of oral rehydration solution.

The consequences of a Humanitarian crisis, such as disruption of water and sanitation systems, or the displacement of populations towards inadequate and overcrowded camps, can increase the risk of Cholera transmission, should the Bacteria be present or introduced. A multisectoral approach including a combination of surveillance, water, sanitation and hygiene, social mobilization, treatment, and oral Cholera vaccines is essential to control Cholera outbreaks and to reduce deaths.

Multisectoral coordination has been established at the provincial level, and daily coordination meetings are held in Kaniyaruchinya (Nyiragongo Health Zone). The incident management system was activated at the World Health Organization office. A budgeted preparedness and response plan has been developed and several partners are involved in the response, including the World Health Organization, which supports the Provincial Health Division in the implementation of the health sector response in collaboration with the Ministry of Health and the other partners, such as the United Nations High Commissioner for Refugees, International Organization for Migration, Médecins Sans Frontières, UNICEF, World Food Programme, and Save the Children.

A surveillance and laboratory commission has been set up by the North Kivu Provincial Health Division with the support of the World Health Organization and other partners. Four data managers have been trained and equipped with computers by the World Health Organization. Training on case definition has been provided to healthcare workers and community health workers; investigation teams have also been trained on active case finding. Surveillance activities are ongoing, including active case finding, alert notification and investigation, and contact tracing and follow-up. Data is collected daily from Oral Rehydration Points, Cholera Treatment Units and Cholera Treatment Centers. Samples are regularly collected also from suspected cases registered outside the outbreak area in order to assess the extent of the epidemic. Data is analyzed on a daily basis and shared with partners for operational decision-making. The World Health Organization has also supported the National Biological Research Institute in Goma with sample transportation.

The World Health Organization and partners have supported the establishment of 56 Oral Rehydration Points in Internally Displaced Population sites, four Cholera Treatment Units (Kibati, Kanyarucinya, Kahembe, and Don Bosco) and two Cholera Treatment Centers (Munigi, Kiziba) in the most affected health areas, with a total capacity of 205 beds. The World Health Organization and partners also provided support for the free provision of basic health care in functional health structures in the two affected health zones to ensure the maintenance of essential health services for vulnerable populations.

An Infection Prevention and Control/Water, Hygiene and Sanitation commission has been set up by the North Kivu Provincial Health Division and supported by partners including the World Health Organization and UNICEF. Systematic decontamination of households and public spaces is implemented by trained teams. Training for safe and dignified burials is also carried out. In Internally Displaced Population sites a total of 1706 latrines, 293 showers, 91 hand-washing stations and 62 well sites have been established. Regular supply of water is made through cisterns. Training for healthcare workers and hygiene workers on Infection Prevention and Control practices is also carried out regularly.

Several advocacy meetings have been held with community leaders and political-administrative authorities. Community workers have been trained to raise awareness about cholera, and preventive measures are communicated door-to-door and during public meetings with the affected population.

At the national level, coordination meetings were organized to ensure the preparation of the vaccination campaign against Cholera in the two affected health zones. The World Health Organization provided support to the Ministry of Health for the mobilization from the vaccination International Coordination Group of 364 137 doses of oral cholera vaccines in the two affected health zones. With the support of the Global Alliance for Vaccines and Immunization, after its launch by the Governor of North Kivu Province on 25 January 2023, the Oral Cholera Vaccination campaign in three health zones of North Kivu Provincial Health Division (including in Internally Displaced Population sites) took place between 25-30 January 2023 and immunized 351 207 people aged one year and older out of a target of 364 137, giving a coverage of 96.4%.

Cholera is endemic in parts of Democratic Republic of Congo. In 2022, according to data from the National Integrated Disease Surveillance and Response System, a total of 18 403 suspected cases of cholera, including 302 deaths (a fatality rate of 1.6%), were notified in the Democratic Republic of Congo, in 104 health zones in 19 of the 26 provinces of the country.

However, the current epidemic is showing a rapid upsurge in a fragile context, with high risk environments such as Internally Displaced Population camps. For years, the Democratic Republic of Congo has been experiencing several armed and community conflicts, particularly in the east, putting the country in a state of unprecedented Humanitarian and health crisis.

Due to internal armed clashes, which intensified in 2022, nearly 450 857 new Internally Displaced Persons arrived in North Kivu (which already hosts 1.9 million Internally Displaced people). Of them, 53.4% (240 579) are hosted in the territory of Nyiragongo and particularly 97.7% (235 111) in Internally Displaced Population sites, which are characterized by overcrowding, poor hygiene and sanitation conditions, very limited access to drinking water, latrines and basic health services. In addition, population movements are regularly observed between the affected health zones and the other health zones in the province of North Kivu as well as the rest of the country, where the populations also have limited access to drinking water, good hygiene and sanitation conditions, as well as to health care facilities. Moreover, the current rainy season may favor the spread of the epidemic in other health zones.

With the ongoing armed conflicts, displacements are likely to continue, leading to a worsening of the Humanitarian context and the vulnerabilities of the populations, including the need for basic social services. All this is evolving in a context of a fragile health system; recurrent attacks on hospital infrastructures and reduced availability of services. Other outbreaks are also ongoing (COVID-19, Yellow Fever, Poliomyelitis, Measles, Monkeypox, Meningitis, etc.) and there are extremely limited Human, material and financial resources.

The risk of Cholera spreading to neighboring countries cannot be ruled out. Indeed, there are population movements between the affected health zones and neighboring countries, including Rwanda and Uganda.

The affected health zones border the city of Goma, which has an international airport. Countries in the Great Lakes sub-region (Rwanda, Uganda, Burundi), which are most at risk of Cholera importation from the current epidemic hotspots in North Kivu, have inadequate levels of access to health care, poor drinking water, hygienic and sanitary conditions. A Cholera epidemic is also ongoing in Burundi with 120 suspected cases and 1 death reported as of 7 February 2023. This epidemic affects the city of Bujumbura, which is located on the shores of Lake Tanganyika on the border with South Kivu, with population movements across the border.

The outbreak is occurring against a backdrop of a surge in Cholera outbreaks globally, which has constrained the availability of vaccines, tests, and treatments. Considering the above-described scenario, the World Health Organization assesses the risk posed by this outbreak as high at the national and regional level, and low at the global level.

The World Health Organization advises that a multi-pronged approach is essential to combat Cholera and reduce mortality. The measures used combine surveillance, improvement of water supply, sanitation and hygiene, social mobilization, treatment of the disease and oral Cholera vaccines. Countries affected by Cholera are advised to strengthen disease surveillance and national preparedness to rapidly detect and respond to possible outbreaks.

The World Health Organization recommends improving access to proper and timely case management of Cholera cases, improving access to safe drinking water and sanitation infrastructure, as well as improving infection prevention and control in healthcare facilities. These measures along with the promotion of preventive hygiene practices and food safety in affected communities are the most effective means of controlling Cholera. Effective risk communication and community engagement strategies are needed to encourage behavioral change and the adoption of appropriate preventive measures.

Measures aimed at improving environmental conditions include applying long-term sustainable solutions for water supply, sanitation and hygiene in Cholera-prone areas. In addition to Cholera, these interventions can also prevent a wide range of other water-borne diseases and contribute to achieving goals in education and the fight against poverty and malnutrition. Solutions for water supply, sanitation and hygiene related to cholera are in line with the Sustainable Development Goals.

Rapid access to treatment is essential during a Cholera outbreak. Oral rehydration should be available in communities and not just in larger health centers that can offer intravenous infusions and management at any time. With rapid and appropriate care, the case fatality rate should remain below 1%.

Community mobilization must continue as an integral part of the response and should cover information on the symptoms of Cholera, on the precautions to take to protect against the disease, and the need to promptly seek care when symptoms appear.

The oral Cholera vaccines should be used in conjunction with improvements in water and sanitation to control Cholera outbreaks and for prevention in targeted areas known to be at high risk for Cholera.

The World Health Organization recommends Member States to strengthen and maintain surveillance for Cholera, especially at the community level, for the early detection of suspected cases and to provide adequate treatment and prevent its spread. Early and adequate treatment limits the mortality rate of patients to less than 1%.

The World Health Organization does not recommend any travel or trade restrictions to the Democratic Republic of Congo based on the currently available information.

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Meningitis outbreak in the Zinder Region of Niger claims 18 lives.

Between 1 November 2022 and 27 January 2023, a total of 559 cases of Meningitis (of which 111 have been laboratory confirmed), including 18 deaths (an overall fatality rate of 3.2%), have been reported from Zinder Region, southeast of Niger, according to a press release issued by the World Health Organization on 8 February 2023. This compares to 231 cases reported during the period 1 November 2021 to 31 January 2022. The majority of laboratory-confirmed cases are due to infections by the Bacterium Neisseria meningitidis serogroup C. Reactive vaccination campaigns with the trivalent ACW meningococcal polysaccharide vaccine have been implemented.

Niger is located largely in the African Meningitis Belt with seasonal outbreaks recurring every year. However, the ongoing outbreak shows both an increased number of cases and an increased growth rate compared to the previous seasons. 

The Zinder Region shares an international border with Jigawa State in Nigeria where a Neisseria meningitidis serogroup C outbreak is also ongoing, confirming the risk of international spread. Moreover, the simultaneous occurrence of other epidemics, insecurity and population displacement, all in the context of a protracted humanitarian crisis, are likely to contribute to the spread of the outbreak in other countries of the West African subregion.

The World Health Organization assesses the risk posed by the current Meningitis outbreak in Niger as high at the national level, moderate at the regional level, and low at the global level. Being located in the African meningitis belt, Niger has been affected by repeated Meningitis epidemics resulting in 20 789 cases and 1369 deaths reported since 2015.

Epicurve of cases of Meningitis reported in Niger by month, 1 October 2021 - 27 January 2023. World Health Organization.

Two hundred and twenty eight samples collected from patients showing symptoms consistent with Meningitis, 154 (67.5%) of which have subsequently been analyzed bythe Center for Medical and Health Research in Niamy. Neisseria meningitidis serogroup C was identified in 93.7% of confirmed cases (104 individual cases), followed by Streptococcus pneumoniae (five cases, or 4.5% of the total) and Haemophilus influenzae (two cases or 1.8% of the total). The remaining 43 samples tested negative.

Fifty three percent of all the cases were male, with 96.3% of cases (or 538 individual cases) being under 20, with 202 cases (36.2%) reported in the 10-14 years age group, followed by the 5-9 years age group with 153 cases (27.4%), the 15-19 years age group with 107 cases (19.1%), and the 0-4 years age group with 76 cases (13.6%).

The most affected health district in Zinder Region is Dungass (342 cases, 6 deaths), followed by Matamèye (98 cases, 3 deaths), Mirriah (72 cases, 3 deaths), Magaria (38 cases, 5 deaths), Zinder ville (7 cases, 1 death) and Gouré (2 cases, 0 deaths).

Distribution of reported meningitis cases by health district, Zinder region, Niger, 1 November 2022-27 January 2023. World Health Organization.

Meningitis is a serious infection of the meninges, the membranes covering the brain and spinal cord. Several different Bacteria can cause Meningitis, however, Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis (sometimes spelled Neisseria meningitis) are the most frequent ones, and are transmitted from person to person through droplets of respiratory or throat secretions from infected people.

Neisseria meningitides is a form of Betaproteobacteria. A total of 12 serogroups of Neisseria meningitides have been identified, six of which (A, B, C, W, X and Y) can cause Meningococcal Meningitis epidemics.

The average incubation period is 4 days but can range between 2 and 10 days. The most common symptoms of Meningitis are a stiff neck, high fever, sensitivity to light, confusion, headaches and vomiting. Even with early diagnosis and adequate treatment, 5% to 10% of patients die, typically within 24 to 48 hours after the onset of symptoms. Bacterial Meningitis may result in brain damage, hearing loss or a learning disability in 10% to 20% of survivors. A less common, but even more severe (and often fatal), form of Meningococcal Disease is Meningococcal Septicaemia, which is characterized by a haemorrhagic rash and rapid circulatory collapse.

The highest burden of disease is seen in a region of sub-Saharan Africa, known as the African Meningitis Belt, which is especially recognised to be at high risk of Meningococcal but also Pneumococcal Meningitis epidemics.

iger is located largely in the African Meningitis Belt, where Meningitis epidemics typically follow a seasonal pattern (usually from January to June), with a size that varies from year to year. In 2015, a large Meningitis outbreak attributed to Neisseria meningitidis serogroup C occurred, affecting nearly 10 000 people. In 2009 and 2006, meningitis outbreaks caused by Neisseria meningitidis serogroups A and X, respectively, were also reported. Haemophilus influenzae and Streptococcus pneumoniae are two other important pathogens that contribute significantly to the Bacterial Meningitis burden within Niger.

Licensed vaccines against Meningococcal, Pneumococcal and Haemophilus influenzae diseases have been available for many years. These Bacteria have several different strains (known as serotypes or serogroups) and vaccines are designed to protect against the most harmful strains. Over time, there have been major improvements in strain coverage and vaccine availability, but no universal vaccine against these infections exists.

In the African Meningitis Belt, Meningococcus serogroup A accounted for 80–85% of Meningitis epidemics before the introduction of a meningococcal A conjugate vaccine through mass preventive campaigns (since 2010) and into routine immunization programmes (since 2016). Among vaccinated populations, incidence of serogroup A Meningitis has declined by more than 99%, and no serogroup A case has been confirmed since 2017.

However, cases of Meningitis and outbreaks due to other Meningococcal serogroups, apart from serogroup B, continue to strike.

The ongoing outbreak shows both an increased number of cases and an increased growth rate compared to the previous seasons. Moreover, the Meningitis epidemic season (usually from January to June, marked by high temperatures and dry winds combined with heavy dust, a period known as the harmattan), the mixing of populations, the simultaneous occurrence of other epidemics in the same region (Measles, Diphtheria and COVID-19), insecurity and population displacement, all in the context of a protracted Humanitarian crisis, are likely to contribute to the spread of the outbreak.

The Zinder region borders Jigawa State in Nigeria, where a Neisseria meningitidis serogroup C outbreak is also ongoing, confirming the risk of international spread to other countries of the West African subregion. The World Health Organization assesses the risk posed by the current Meningitis outbreak in Niger as high at the national level, moderate at the regional level, and low at the global level.

Meningococcal Meningitis remains a public health concern with a high case fatality rate and leading to serious long-term complications. 

Preventing Meningitis through vaccination is the most effective way to reduce the burden and impact of the disease by delivering long-lasting protection. The rollout of multivalent meningococcal conjugate vaccines is a public health priority to eliminate Bacterial Meningitis epidemics in the African Meningitis Belt. Introduction into routine immunization programmes and maintaining high coverage will be critical to avoid the resurgence of epidemics. 

Antibiotics for close contacts of Meningococcal cases, when given promptly, decrease the risk of transmission. Outside the African Meningitis Belt, chemoprophylaxis is recommended for close contacts within the household. Within the Meningitis Belt, chemoprophylaxis for close contacts is recommended in non-epidemic situations. Ciprofloxacin is the antibiotic of choice, and ceftriaxone an alternative.

Admission to a hospital or health centre is necessary. Isolation of the patient is not usually advised after 24 hours of treatment. 

Appropriate antibiotic treatment must be started as soon as possible. Ideally, lumbar puncture should be done first as antibiotics can make it more difficult to grow Bacteria from the spinal fluid. However, blood sampling can also help to identify the cause and the priority is to start treatment without delay. A range of antibiotics is used to treat Meningitis, including penicillin, ampicillin, and ceftriaxone. During epidemics of Meningococcal and Pneumococcal Meningitis, ceftriaxone is the drug of choice. 

The response to epidemics consists of appropriate case management, active community-based case-finding and reactive mass vaccination of affected populations. Surveillance, from case detection to investigation and laboratory confirmation is essential to the control of Meningitis. 

Reactive vaccination campaigns have been implemented in Zinder region, and monitoring the spread to new areas is crucial to guide further response activities, including considering further vaccine requests if appropriate. Timeliness of the reactive campaign is critical, ideally within four weeks of crossing the epidemic threshold. 

The World Health Organization does not recommend any restriction on travel and trade to Niger on the basis of the information available on the current event.

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