While the world was bedeviled with a novel virus (SARS Cov 2) which attacks mainly the respiratory system to cause corona virus disease 2019 (Covid-19), another disease also mainly spread via contact with respiratory secretions of an infected person was arming itself in the upper west region of Ghana. Fear and panic gripped the global village and all resources were geared at fighting the novel Covid-19 disease while people were dying from an endemic meningitis in the upper west region of Ghana.
1.0 Overview of Meningitis
According to the World Health Organisation (WHO), meningitis is mainly inflammation of the meninges, that is, the coverings of the brain and spinal cord, and thus a disease of the central nervous system. Meningitis is common in areas of the African continent that forms part of the 'meningitis belt'. The five Northern regions of Ghana as well as the northern part of the then Volta and Brong Ahafo regions happen to fall within the meningitis belt of Africa. The incidence of meningitis is particularly on the surge within the months of December to June.
Meningitis is commonly spread among close contacts, people who live in overcrowded areas, immunosuppressed individuals, people at extremes of ages (<5 &>60 years) and those with chronic illnesses and comorbidities. It is transmitted via respiratory secretions of infected persons. Largely, bacteria such as Neisseria meningitides, Streptococcus pneumoniae, H. influenzae are the causative agents of bacterial meningitis, but there could be viral, parasitic, fungal and even autoimmune causes as well.
Common signs and symptoms of meningitis include severe headache, neck stiffness, fever and altered mental state. Others may be photophobia, nausea/vomiting, sleepiness and bulging of the fontanelles in babies.
Diagnosis is usually confirmed with lumbar puncture where cerebrospinal fluid is collected and examined. CT-scan of the brain and meninges is usually indicated. Other supportive investigations may include full blood count, serum electrolyte analysis and glucose tests.
Although persons with meningitis can be cured completely when the causative agent is tackled, especially with bacterial meningitis where Ceftriaxone is the drug of choice. Some patients are left with residual effects of the disease. In view of this, death can easily be avoided in meningitis if treatment is instituted early enough.
2.0 Overview Corona virus disease 2019 (Covid-19)
Unlike meningitis, scientists are still working around the clock to establish facts about covid-19 and the characteristics of the offending virus. There are however some working postulations about it. Covid-19 is a viral respiratory disease believed to be mainly transmitted via aerosols and through introduction of virus unto mucous membranes via infected hands and other media. Some studies also suggest the infection may be airborne. The coronavirus is suggested to have a zoonotic origin and can be transmitted from an infected person to other persons, roughly 2-4 other people. Pets may also play an important role in the transmission of the disease.
This novel virus was first identified in Wuhan, China to be causing an atypical form of pneumonia and has since spread to most parts of the world due to the fluidity of the human populace. The disease was declared a pandemic by the world health organization (WHO) in March, 2020.
The virus enters the upper respiratory tract, establishes itself in the lungs and causes pneumonia-like symptoms such as fever, cough, headache and shortness of breath. In some cases, constitutional symptoms such as nausea/vomiting, a feeling of general malaise, anorexia (loss of appetite) and some gastrointestinal symptoms such as diarrhea may ensue. Studies also suggest there is an inflammatory phase of the disease which eventually leads to lung fibrosis. Recent reports following postmortem of Covid-19 patients suggest the viral proteins attack the heme component of hemoglobin which is responsible for oxygen transport to generate energy. The attack on the heme group dissociate iron to form deoxyhemaglobin rendering it incapable of transporting oxygen. The poor circulation of oxygen results in shortness in breath, fatigue, fever, headache etc.
Currently tests available for diagnosis of Covid-19 are real time reverse transcriptase polymerase chain reaction (rRT-PCR) assays of respiratory samples obtained from nasopharyngeal and oropharyngeal swabs. Other samples that could be used are obtained from bronchoalveolar lavage, serum and possibly sputum.
The treatment of Covid-19 is mainly supportive as there is no WHO approved protocol for treatment. Many countries including Ghana have employed the use of hydroxychloroquine-azithromycin combination together with analgesics and other supportive measures such as oxygen therapy. Some already existing antiviral agents such as remdesir, ritonavir, rintatolimvir are in various stages of clinical trials in the treatment of coronavirus. Corticosteroids and interleukins are also under investigations for their effectiveness. We are hopeful that soon enough vaccines will also be developed in this regard. In view of this, prevention of the infection through regular hand washing with soap under running water, use of alcohol-based sanitizers, staying away from populated locations and use of adequate personal protective equipment is key and cannot be overemphasized.
Even though the case fatality rate at the moment worldwide is 6.8% and 0.5% in Ghana, it is expected to increase tremendously if the burden of the disease overwhelms our health care facilities. This is especially true in Ghana where we cannot boast of more than 200 ventilators and have already overcrowded health institutions.
3.0 Covid-19 and Meningitis in the Upper West Region, Ghana
In Ghana, the first two cases of covid-19 were recorded on March 14, 2020 in the nation’s capital. The total number of cases in Ghana as of May 10th, 2020 stands at 4,263 with a total of 22 deaths. The upper west region of Ghana recorded its first case in March and currently has 20 confirmed cases with 0% case fatality rate.
On the hand, meningitis cases were recorded in January, and on April 29th, 2020, the deputy minister of health Dr. Bernard Okoe Boye reported that the number of meningitis cases in the Upper West region was 273 and the number of deaths stood at 43. Thus, the case fatality rate of meningitis in the Upper West region is 15.8%. In a statement by the minister of health Mr Agyemang Manu, 60% of the tested samples were due to a new strain of N. meningitidis categorized as serotype X, which is not included in the tetravalent vaccine developed for serotype meningitis (serotype A, W, C and Y). Although, there is no vaccine for the new strain (serotype X), it is treatable with antibiotics.
Comparing the case fatality of rate of Meningitis and Covid-19 in the Upper West region clearly demonstrates that the case fatality rate of meningitis was higher. This is even higher than the national case fatality rate of Covid-19. Although this is alarming, previous mass vaccination might have accounted for the overall decline on the number of meningitis cases from 2,632 in 2016, 1,118 in 2017, 987 in 2018 and presently over 400 cases have been recorded nationally.
It is unclear whether the preventive measures instituted by the Ministry of Health against Covid- 19 such as the use of facemasks, social distancing and staying at home has also contributed to the low spread of meningitis. Future works should study the impact of preventive measures of a disease on another.
Also, the response of Ministry of Health and the availability of treatment for meningitis has helped in bringing the cases and death under control.
Currently, both Covid-19 and meningitis are being managed in the Upper West region. The situation of Upper West should be a lesson to the world in formulating flexible/fluid health policies that can effectively manage dual or multiple epidemics.
Regional and international organisations such as WHO, CDC, ECOWAS, AU etc should collaborate in developing flexible health policies that can resolve or manage multiple epidemics likely to confront us in future. We must not forget the contribution of animals and the environment to disease transmission; therefore, the one health concept should be crucial in policy formulation and fight against infectious diseases.