World Health Organization guidelines proved themselves inadequate during a recent outbreak of meningococcal meningitis in the Democratic Republic of Congo (DRC), reports a team of Belgian and African researchers. Routine mass vaccination against group A and C meningococci should be considered in the country, they suggest. Current guidelines suggest that a vaccination program should begin only after an epidemic has begun.

Limited resources, in terms of the DRC's infectious disease surveillance system and laboratory network, make the WHO guidelines unworkable in the country, suggests Jean-Paul Butzler, professor of microbiology at the Free University of Brussels and president of the International Society for Infectious Diseases, who led the team.

As a result of the latest outbreak in the country, hundreds of people, mostly young females, were infected with serogroup A meningococci in the country's South Kivu province, and 83 died.

Every year, infection with Neisseria meningitides (meningococci) causes between 30,000 and 300,000 deaths worldwide. In Africa, serogroup A meningococci are endemic and cause large epidemics about once every five to ten years.

Most of these epidemics occur in Africa's "meningitis belt," which stretches across the savannah from the Atlantic to the Red Sea, south of the Sahara. But sometimes epidemics sweep outside the belt, and last year one hit the DRC with disastrous results.

Cases began to appear early last August in the province of South Kivu in a region called Katana, about 50 miles north of the province's main town, Bukuvu. The outbreak reached epidemic proportions (15 cases per 100,000 individuals) within two weeks, and brought teams based at the Provincial Public Health Reference Laboratory and the Hospital of Katana and at the University of Brussels in Belgium.

WHO guidelines recommend that emergency vaccination with a meningococcal A and C polysaccharide vaccine should be administered as soon as the epidemic threshold is reached. However, the Katana health zone's stretched resources had not processed the necessary epidemiological and microbiological data in time to alert officials, and a vaccination program was not started until September.

A further delay on the part of neighbouring health zones in South Kivu meant that a province-wide immunization program was not initiated until December, by which point the epidemic was already over.

By November, when the epidemic ended, the outbreak had reached the main town of Bukuvu and the island of Idjwi to the east. The infection was contracted by 674 people, 85% of whom were less than 30 years of age, and 53% of whom were female.

"In the province of South Kivu, our results indicate that surveillance systems and laboratory network are poorly effective, which causes a delay between the beginning of the epidemic and mass vaccination," noted Butzler.

The data underscore the need for an effective surveillance system and laboratory network to control meningococcal disease in sub-Saharan Africa, he added.

Before that can be achieved, says Butzler: "Authorities should consider mass preventive campaigns before the outbreak occurs."