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• W1586861609 abstract "Since 1997, Robbins et al. have cogently argued that routine immunization with group A polysaccharide in sub-Saharan Africa would prevent epidemic and endemic meningitis (1, 2). Others have claimed that this recommendation rests on unproven assumptions and would be difficult to implement within existing immunization frameworks (3, 4). Understandably frustrated because of a lack of response by political agencies plus continued epidemics in Africa, Robbins et al. now repeat the same arguments in more detail. Unfortunately, their article is flawed, because it is highly polemic and contains numerous inappropriate or inaccurately represented citations. For example, routine immunization in northern Benin is inferred to have prevented meningitis epidemics through 1997 (5); however, acceptable levels of routine immunization in northern Benin were not maintainable for more than a few years (5). Contrary to Robbins et al.'s claim for long-lived immunity in vaccinees aged >5 years routine immunization in the mid-1990s did not prevent a major epidemic in northern Benin in 2001 (6). Similarly, the primary citation for the efficacy of two doses of group A polysaccharide in infants does indeed claim that no cases were observed in such infants, but it also states the most only one to two cases would have been expected (7). Such citations do not warrant initiating routine immunization with four doses of group A polysaccharide throughout sub-Saharan Africa. The current practice of implementing mass vaccination once threshold levels of meningococcal disease have been exceeded enables short-term political decisions and possibly can be justified by cost-benefit calculations. It does not prevent epidemics (or endemic disease), however, nor has it been very effective at stopping major epidemics in Africa. Clearly, the ideal situation would be routine vaccination with an effective multi-component vaccine that provides long-lived immunity against meningitis. Such a vaccine does not yet exist, and the arguments below indicate that current efforts to develop a conjugated group A polysaccharide vaccine will not provide the ideal vaccine. History and molecular epidemiology teach that epidemic and endemic meningitis are only poorly predictable (8-11). Since the 1950s, successive waves of meningitis epidemics, each lasting for years, have been caused by subgroups I/II (1950s-70s), IV-1 (1980s), and III (late 1980s to present day). The first and last of these epidemic waves were imported from outside Africa because of the evolution of particularly fit and virulent meningococcal genoclouds (11). During both epidemic and endemic periods, a certain proportion of meningococcal disease also was caused by unrelated bacteria --sometimes of serogroups C, W135, and X (12-14). Only one-third of endemic bacterial meningitis in Africa is caused by meningococci, with the remainder caused by Haemophilus influenzae and Streptococcus pneumoniae. The prospects of finding an economically feasible and effective conjugated vaccine that can protect against all these agents are not good. Furthermore, medical interest in meningococcal meningitis and the motivation for routine vaccination tends to wane during endemic periods, which can be as long as 15-20 years in individual African countries. Vaccines, and particularly conjugated polysaccharide vaccines, are the current paradigm for preventing infectious bacterial diseases in Africa. Yet improved housing, water, hygiene, and nutrition probably are the main factors that resulted in a general reduction in bacterial diseases in Europe and North America during the twentieth century, not vaccines (or antibiotics). Sub-Saharan Africa is lagging in these areas, and its load of general infectious disease remains extremely high. Levels of immunization that have eradicated epidemic infectious diseases, such as poliomyelitis, in Europe and North America still can permit the occurrence of epidemics in sub-Saharan Africa (15). …" @default.
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• W1586861609 date "2003-10-01" @default.
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• W1586861609 title "Successful prevention of meningitis in Africa will need more than a vaccination strategy" @default.
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