0

2019

Defeating Meningitis by 2030 A global roadmap

DRAFT 26 JUNE 2019

DRAFT 26 June 2019

1

Defeating Meningitis by 2030 – a global roadmap

Meningitis – a call for action

Meningitis, a devastating disease with a high case fatality and serious after-effects remains a major

global public-health challenge(1-4). Cases and outbreaks are a threat in all countries of the world, with

the highest burden in Africa (Figure 1). Meningitis, an inflammation of the membranes that surround

the brain and spinal cord, can be caused by infection with bacteria, viruses, protozoa and fungi. There

were an estimated 300,000 deaths globally from meningitis in 2015(1). Meningitis and meningitis

related sepsis can lead to severe after-effects, such as hearing loss, visual impairment, brain damage

and limb loss, that have a considerable emotional, social and financial impact on individuals, families

and communities(5-7). Epidemics of meningitis present a major challenge for health systems, the

economy and society. Meningitis is a largely vaccine-preventable disease, but progress in defeating

meningitis lags behind other vaccine preventable diseases such as tetanus(8).

Figure 1: Age-standardized incidence of meningitis per 100 000 population by location for both sexes, 2016

Source:(1)

In May 2017, over 50 representatives from governments, global health organizations, public health

bodies, academia, private sector, and civil society called for a global vision to “defeat meningitis by

2030”(9). In September of that year, 200 representatives from the 26 countries of the African

meningitis belt amplified this call and highlighted the need for equitable and sustainable access to

meningitis vaccines(10).

DRAFT 26 June 2019

2

WHO is coordinating the response to this call to action. A Technical Task Force of major technical

partners historically invested in long-term meningitis control, with complementary focus and

expertise, was convened to develop the roadmap. A baseline situation analysis(4) was undertaken

and, in February 2019, experts in meningitis, health and disability met to advance the draft

roadmap(11). The Task Force has further developed the roadmap for wider consultation.

The global roadmap

Scope

This roadmap of the first global strategy on meningitis sets a path to tackle the main causes of acute

bacterial meningitis: Neisseria meningitidis (Nm, meningococcus), Streptococcus pneumoniae (Spn,

pneumococcus), Haemophilus influenzae (Hi) and Streptococcus agalactiae (group B streptococcus, or

GBS). This focus is based on (i) the worldwide burden of disease due to these organisms, which also

cause sepsis and pneumonia, and (ii) the impact that this global strategy could have to diminish the

burden by 2030. Other important causes of meningitis, such as tuberculosis (TB) and Cryptococcus,

are not forgotten, several goals directed at reducing the burden of disease are applicable to all causes

of meningitis, particularly in support, after-care, advocacy and engagement. In addition, the

meningitis roadmap will reinforce and complement other global strategies on infectious diseases and

wider initiatives relating to health systems strengthening, universal health coverage, global health

security, disability rights and disability inclusion (see Connection to Other Global initiatives). A global

fight against meningitis is fully aligned with WHO's new 13th General Programme of Work and

captures the essence of WHO’s three-fold mission: promoting health, keeping the world safe, serving

the vulnerable(12).

Vision

The roadmap vision is global, since meningitis affects all populations worldwide, and ambitious, to

harness the energy of the coalition that is assembling around meningitis.

Roadmap vision

Towards a world free of meningitis

DRAFT 26 June 2019

3

Visionary goals

The visionary goals set out three main aims to reduce the impact of meningitis worldwide by 2030, a

date that aligns with the Sustainable Development Goals (SDGs)(13). Achieving these goals will rely on

strong commitments from countries, partners, and donors to collectively engage in defeating

meningitis.

Visionary goals by 2030

➢ Eliminate bacterial meningitis epidemics ➢ Reduce cases and deaths from vaccine-preventable bacterial meningitis* ➢ Reduce disability and improve quality of life after all causes of meningitis

* Global and regional targets to be agreed.

The serious impairments caused by meningitis feature prominently in this strategy, reflecting a greater

awareness that meningitis has a spectrum of outcomes, not only whether someone lives or dies.

A theory of change (Figure 2) summarizes the overall framework of the roadmap.

Figure 2: Theory of change for global roadmap to defeat meningitis by 2030

Issu

es Meningitis causes 300,000 deaths a year

globally and carries a risk of epidemics, many cases

could be prevented by vaccination

Tools, supplies and facilities for diagnosis and treatment are insufficient

Surveillance systems are not strong enough to

document the numbers, causes and effects of

meningitis

Meningitis and sepsis are a major cause of disability but availability and access

to care are weak

Awareness of meningitis as a global problem is low

among policy makers

Inp

uts

Countries commit to implement plans to

defeat meningitis

Partners commit to providing oversight,

technical expertise and innovative development

Donors commit to supporting the global

plan

Civil society commits to endorsing the roadmap

and raising awareness

Ou

tpu

ts Achieve high vaccine

coverage, develop new vaccines, develop

prevention strategies and epidemic control

Ensure meningitis diagnostic tools available,

health workers trained, quality-assured treatment

Ensure surveillance of meningitis and sequelae

at all levels

Ensure management of sequelae and care for

people affected by meningitis

Ensure meningitis has high global priority with awareness of meningitis

and disability at all levels

Ou

tco

mes Enhanced access to

improved vaccines and effective strategies for

prevention and epidemic control

Improved tools and access to diagnosis and

treatment

Improved monitoring of meningitis epidemiology

through disease

surveillance

Improved access to support and care for people and families

affected by meningitis

Higher awareness through advocacy and

engagement

Imp

act

by 2030

Epidemics of bacterial meningitis are eliminated

Cases and deaths from vaccine-preventable

bacterial meningitis are reduced (by % to be

determined)

Risk of disability is

reduced and quality of life is improved after all

causes of meningitis

DRAFT 26 June 2019

4

Strategic goals

As shown in Figure 2, the three visionary goals (the outcomes) depend on achieving the SGs and

milestones structured/organized in 5 domains of action or pillars (outputs):

Pillar 1: Prevention and epidemic control

Pillar 2: Diagnosis and treatment

Pillar 3: Disease surveillance

Pillar 4: Support and care for people affected by meningitis

Pillar 5: Advocacy and engagement

Each pillar sets out strategic goals, key activities and specific milestones to be achieved in order to

reach these goals. While serving to organise action, it is clear that the five pillars are interconnected:

diagnosis is closely linked to surveillance, surveillance informs prevention and epidemic control,

support and care for patients and families should commence during treatment at the time of

diagnosis, and advocacy and engagement are necessary for the success of every pillar. Maintaining

these links will be essential to success.

Targets for visionary and strategic goals will be set in the monitoring and evaluation framework, and

adapted to regional and local context. The roadmap should be adapted by countries into locally

relevant, evidence-based meningitis action plans with regional guidance/objectives for

implementation.

DRAFT 26 June 2019

5

Pillar 1: Prevention and epidemic control

Achieved through development and enhanced access to affordable vaccines, effective prophylactic measures and targeted control interventions

Enhanced efforts are needed to advocate for immunization. These include (i) encouraging vaccine

introduction, achieving and maintaining sufficient vaccine coverage, especially in lower- and middle-

income countries (LMICs) where the burden of meningitis is greatest, (ii) promoting the development

of vaccines to address the residual disease burden due to GBS, and Hi, Nm and Spn serogroups or

serotypes not covered by existing vaccines, (iii) reinforcing policy and improving strategies to enhance

the impact of vaccination and (iv) ensuring equitable access to affordable vaccines. Polysaccharide-

conjugate vaccines are dramatically reducing the global burden of disease caused by Nm, Spn and Hi

but their global uptake and impact needs to be enhanced. However, not all serogroups are presently

covered by these vaccines. Novel protein-based vaccines against NmB disease are now being used at

public health scale in high income countries (HICs). No vaccine exists for the prevention of GBS disease,

but GBS conjugate vaccine candidates are in development. Several Nm and Spn conjugate vaccine

candidates are also in late stage development including multivalent products with broader

serogroup/type coverage than existing vaccines. In addition, protein vaccine candidates against Nm,

Spn and GBS are in various stages of development. Also, as high usage of antibiotics in the treatment

of suspected meningitis can lead to the development of antimicrobial resistance (AMR), enhanced and

sustained vaccination programmes will have an increasingly important role in strategies for mitigating

the negative impact of AMR.

Chemoprophylaxis is generally used for close contacts of cases of meningococcal meningitis, but needs

further evaluation, particularly in the context of epidemics in the African meningitis belt. Policies for

prevention of GBS transmission from pregnant mothers to children using intravenous antibiotics are

implemented in many HICs but need evaluation before recommending for use in low and middle

income countries (LMICs).

The most important challenges in the control of Nm or Spn meningitis epidemics include weak

laboratory capacity to confirm the epidemic pathogen and lack of timely access to sufficient quantities

of affordable vaccines for outbreak response. For Spn meningitis outbreaks, guidance on response is

needed. And ultimately, evidence-based policy adjustment followed by high uptake of adequate

DRAFT 26 June 2019

6

preventive vaccination strategies using appropriate vaccines would ideally prevent the occurrence of

epidemics.

The aims of this pillar are to (i) introduce new vaccines, achieve and maintain high coverage of current

and new vaccines, against Nm, Spn, Hi and GBS in all countries, as required (ii) develop and

license/WHO prequalify effective and affordable new vaccines targeting Nm, Spn, Hi and GBS (ii)

develop evidence-based policy on vaccination strategies that result in optimal individual protection

and, where feasible, herd protection (iv) develop and implement context-specific strategies to prevent

GBS infection in infants (v) develop and improve strategies for outbreak prevention and response

including vaccination, chemoprophylaxis and risk communication, inclusive of mass gatherings and

humanitarian emergencies.

7

Strategic goals Key activities Landmark goals (milestones)

SG 1: Introduce new vaccines, achieve and maintain high coverage of current and new vaccines, against Nm, Spn, Hi and GBS in all countries as appropriate (see SG18, SG20)

Implement locally appropriate tailored immunization strategies to achieve and maintain high vaccination coverage against Nm, Spn, Hib (and GBS when a vaccine is available) in all countries, reinforcing and complementing existing immunization strategies Ensure proper linkages and synergies with WHO, UNICEF, Gavi and other global or regional initiatives aiming to reduce costs and increase access to vaccines for Lower-Middle Income Countries (LMICs), e.g. the Measles & Rubella Initiative, and the planned WHO Immunization Agenda 2030. Ensure vaccines preventing bacterial meningitis are affordable, accessible and easy to use (e.g. regimen and number of doses, simple vaccination schedule, thermostable, product labelling and packaging) for every country where they are needed

Spn, Hib. By 2025, Spn and Hib conjugate vaccines introduced in all countries with locally relevant strategies, including new vaccine introduction By 2030, >90% vaccine coverage for complete series maintained or achieved in all countries Nm (meningitis belt) By 2021, introduction of preventive vaccination against Nm serogroup A in routine immunization programmes completed in >= 20 meningitis belt countries By 2023, introduction of preventive vaccination against Nm serogroups ACWXY in routine immunization programmes started in >=5 meningitis belt countries; By 2030, preventive vaccination against MenACWXY started in all countries in the meningitis belt as appropriate and with >90% coverage in the groups targeted for vaccination Nm (other countries) By 2025, locally relevant meningococcal disease vaccination strategies introduced in all countries with moderate/high incidence GBS By 2030, GBS vaccine introduced, if available and with Gavi support where needed, in >=10 countries with an established burden of GBS in line with WHO policy

Define regulatory pathways for licensure of GBS vaccines By 2022, regulatory pathways for licensure of GBS vaccines

defined, based on consultations with National Regulatory

Authorities and WHO PQT

DRAFT 26 June 2019

8

SG2: Develop and license/WHO prequalify affordable new vaccines targeting Nm, Spn, Hi and GBS

Develop and license/WHO prequalify affordable vaccines: additional multivalent meningococcal conjugate vaccines, additional MenB vaccines, additional pneumococcal, Hi and GBS vaccines

Nm By 2020, WHO TPP for multivalent meningococcal conjugate vaccine published, including thermostability considerations By 2021, WHO Technical Report Series (TRS) for multivalent meningococcal conjugate vaccine published By 2022, at least one affordable multivalent (ACWXY) meningococcal conjugate vaccine licensed and WHO prequalified By 2026, at least one affordable MenB vaccine and sufficient sources of affordable multivalent meningococcal conjugate vaccines to ensure security of supply Spn By 2021, WHO TRS for PCVs updated By 2020, at least one, and by 2025 at least three, additional affordable PCVs, with coverage consistent with emerging data on serotypes causing invasive disease in LMICs, licensed and WHO prequalified By 2026, at least one new Spn vaccine with broader coverage – either higher valency PCV or protein containing vaccine - licensed and WHO prequalified GBS By 2022, regulatory pathways for licensure of GBS vaccines

defined, based on consultations with National Regulatory

Authorities and WHO Prequalification Team

By 2026, at least one affordable vaccine against GBS licensed and WHO prequalified (for maternal immunization during pregnancy to prevent GBS-related stillbirth and invasive GBS disease in infants)

DRAFT 26 June 2019

9

Hia By 2028, at least one vaccine against Hia licensed to address high burden of disease in some communities, e.g. indigenous peoples in N. America and Australia

Improve access to affordable vaccines through provision of support -including tech transfer, to vaccine manufacturers in their efforts to develop, license/WHO prequalify new vaccines and ensure diversification of quality-assured sufficient vaccine production capacity in more countries, including LMICS

By 2030, sufficient sources of affordable Spn and Nm multivalent

conjugate vaccines to ensure security of supply

By 2030, quality-assured sufficient vaccine production capacity

diversified into >=5 LMICs for Hib, Spn and Nm multivalent

conjugate vaccines

SG3: Develop evidence-based policy on vaccination strategies that result in optimal individual protection and, where feasible, herd protection

Evaluate vaccination strategies for use of multivalent meningococcal conjugate vaccines to achieve herd protection

By 2022, modeling research studies on multivalent meningococcal conjugate vaccination strategy completed and results disseminated with open access to support vaccine introduction strategies By 2024, cluster randomized studies and/or carriage studies on multivalent meningococcal conjugate to inform vaccination strategy completed and published

Develop global policy for use of MenB and multivalent meningococcal conjugate vaccines

By 2022, global policy available for use of MenB and multivalent meningococcal conjugate vaccines By 2030, global policy updated as new vaccines and evidence become available

Assess the overall vaccine impact, duration of protection, serotype replacement and indirect effects induced with different pneumococcal conjugate vaccine (PCV) schedules to inform vaccination strategies for use of PCVs in order to maintain immunity in populations and

By 2025, vaccine effects and duration of protection induced with different PCV schedules documented, including feasibility of new dosing schedules and catch-up campaigns

DRAFT 26 June 2019

10

to prevent/control vaccine-preventable pneumococcal disease among unvaccinated individuals (older children, adolescents and adults)

By 2026, global policy on PCV schedules updated and implemented based on these findings

Establish immune correlates of protection (serogroup

/type specific) for Nm, Spn, and GBS

By 2025, studies to establish further immune correlates of

protection in different transmission settings conducted and

published for Nm, Spn and GBS

Quantify the potential benefits of vaccines on

decreasing overall antibiotic use for invasive infections

or for prophylaxis and on reducing antimicrobial

resistance

By 2024, potential benefits of meningitis vaccines quantified on decreasing overall antibiotic use and reducing antimicrobial resistance

SG4: Develop and implement

context-specific strategy to

prevent GBS infection in infants

(see SG7, SG11)

Conduct research to further document transmission

patterns of GBS and risk factors for early/late onset GBS

disease

By 2023, study completed on transmission of GBS and risk factors for early/late onset GBS disease

Develop and implement global strategy on preventing

GBS transmission to infants considering evidence, needs

and feasibility, with consideration for potential impact

on antimicrobial resistance, linking with other sepsis,

maternal and child health initiatives

By 2025, global policy available on GBS prevention in infants

By 2030, recommended prevention policies implemented in

countries where appropriate, unless superseded by a vaccination

programme

SG5: Develop and improve

strategies for outbreak

prevention and response

including vaccination,

chemoprophylaxis and risk

Review and establish WHO definitions for outbreaks of

meningococcal and pneumococcal meningitis, and late

onset GBS disease in all Regions to guide investigation

and control measures

By 2021, WHO definitions updated or established for

meningococcal and pneumococcal meningitis and late onset GBS

disease outbreaks in all Regions

DRAFT 26 June 2019

11

communication, inclusive of

mass gatherings and

humanitarian emergencies

(see SG20)

Develop and update strategies on surveillance,

preparedness and response to meningitis epidemics,

including consideration of mass gathering issues

Update strategies on vaccination during and after humanitarian emergencies for preventing epidemics among refugees and displaced persons

By 2023, guidelines on surveillance, preparedness and response

to meningitis epidemics updated, including updating of reactive

vaccination strategies

Develop strategies to ensure sufficient vaccine stockpile

and gradually transition from polysaccharide to

affordable multivalent meningococcal conjugate

vaccines to respond to outbreaks

By 2021, the ICG stockpile of meningococcal vaccines

appropriately replenished (quantity, composition, timeliness),

building on predictive modeling research, to enable an early

response to outbreaks in the meningitis belt

By 2023, sufficient affordable multivalent meningococcal

conjugate vaccines available globally to respond to outbreaks in

all Regions without ICG intervention, allowing to plan for gradual

phasing out of the meningitis ICG, as well as to address

preventive vaccination needs for mass gatherings

Define strategies to prevent / respond to pneumococcal

meningitis outbreaks

By 2021, WHO strategy for pneumococcal meningitis outbreak prevention and response available, possibly including catch up and/or response vaccination campaigns if appropriate

Conduct research and review policy for use of antibiotic

prophylaxis as a control measure during meningococcal

meningitis outbreaks in the African meningitis belt, with

consideration for potential impact on antimicrobial

resistance

By 2021, additional study completed on the potential risks and

benefits of this strategy of using antibiotic prophylaxis during

meningococcal meningitis outbreaks in the African meningitis belt

By 2022, revised policy (if necessary) published on antibiotic

prophylaxis during meningococcal meningitis outbreaks in the

DRAFT 26 June 2019

12

African meningitis belt, with possibly time-limit considerations (in

consideration and coordination with introduction/ availability of

multivalent Nm conjugate vaccines)

Prepare and implement context-appropriate community

engagement and risk communication messaging on

severity of disease to maximise reach during outbreaks

through traditional and innovative/digital approaches

e.g. radio, newspaper, community outreach, social

media, SMS mass messaging

Monitor secondary communication of messages and

rumours via monitoring and accountability mechanisms

(including social media monitoring)

By 2020, social and communication channels mapping completed

in all high-risk countries

By 2020, guidance for monitoring secondary communication of

messages and community rumours on meningitis outbreaks

available and used globally

By 2021, risk communications with mixed methods of messaging

available and used in meningitis outbreaks globally

13

Pillar 2: Diagnosis and treatment

Achieved through access to appropriate diagnostic tests at all levels of care,

enhanced surveillance and prompt and effective treatment

Laboratory confirmation is well defined for the main bacterial pathogens (culture and real time PCR

being the gold standards), but health workers, especially in LMICs, may not be trained or resourced to

identify cases of meningitis, cerebrospinal fluid (CSF) samples are often not collected, and laboratory

capacity is often weak. There is a lack of quality assured, affordable, high performance rapid diagnostic

tests (RDTs). Antibiotic treatment regimens are well established, but WHO guidelines for treatment of

adults with bacterial meningitis are not currently available and recommended antibiotics are not

always available. A review of adjunctive therapies in LMICs is needed.

The aims of this pillar are (i) to make meningitis diagnostic tools available at the appropriate level of

care to increase confirmation of bacterial meningitis and antimicrobial susceptibility testing (AST), (ii)

to develop and implement a diagnosis, treatment and care policy for maternal/infant GBS,

particularly for use in low-resource settings, (iii) to ensure community health workers can recognize

and refer patients with meningitis, and that peripheral primary care workers can diagnose and

initiate treatment (iv) to provide appropriate quality assured treatment and supportive care for

every patient to reduce sequelae and deaths.

14

Strategic goals Key activities Landmark goals (milestones)

SG6: Make meningitis diagnostic tools available at the appropriate level of care to increase confirmation of bacterial meningitis and antimicrobial susceptibility testing (AST)

Increase use of diagnostic lumbar punctures (LPs) and other specimen sampling by ensuring availability of sterile kits, supporting national policies and training to enable staff other than doctors to do LPs, and increasing community acceptance of LPs

By 2024, CSF and other samples (e.g. blood) as required collected in all countries from >50% of suspected meningitis cases

Evaluate role of blood tests (culture, PCR) as an alternative to CSF

By 2022, studies published on evaluaton of blood testing in the diagnosis of meningitis/sepsis in at least two settings, including the African meningitis belt

Establish innovative (pooled) funding mechanisms to enable development of rapid diagnostic tests

By 2022, funding mechanisms established to enable development of RDTs and deployment into the field at scale

Support research into identification of biomarkers (preferably based on blood or urine) to be used in a point of care (POC) test suitable for use in LMICs, to rapidly detect invasive bacterial vs viral infection

By 2026, quality assured, affordable and accessible, point of care (POC) diagnostic tests developed based on a specific biomarker(s) to rapidly detect invasive bacterial vs viral infection and that are appropriate for use in LMICs By 2030, tests used in 50 LMICs

Develop target product profiles (TPPs) for diagnostic tests that identify the main pathogens of suspected meningitis cases (bacterial, viral, fungal), determine market needs, and develop diagnostic tests according to TPP

By 2026, quality assured and affordable syndromic (multiplex) diagnostic test available to identify and distinguish the main pathogens responsible for meningitis (bacterial, viral, fungal) By 2030, tests used in 50 LMICs

DRAFT 26 June 2019

15

SG7: Develop and implement diagnosis, treatment and care policy for infant GBS, particularly for low-resource settings (see SG4)

Develop affordable POC diagnostic tests, suitable for low resource settings, for (i) maternal GBS carriage (ii) invasive GBS disease in infants

By 2026, a quality assured, affordable and accessible POC diagnostic tests available to identify (i) maternal GBS carriage and (ii) invasive GBS disease

Develop and implement diagnosis, treatment and care policies/strategies for infant GBS, particularly for low resource settings

By 2026, infant GBS diagnosis, treatment and care strategy available for all countries By 2030, recommended strategy implemented in >50% of countries

SG8: Ensure community/peripheral level health workers are trained and provided with suitable resources to enable them to appropriately identify, diagnose, and treat people with meningitis (see SG14, SG15)

Ensure appropriate training and supervision for each level of care on timely identification, diagnosis, referral and treatment of meningitis so that community health workers can recognize and refer, and so that peripheral primary care workers can diagnose and initiate treatment

By 2026, a training and supervision programme on identification, diagnosis, referral and treatment of meningitis patients (including potential sequelae) from peripheral level to hospital level established and integrated into existing training >80% of countries

Ensure a mechanism for timely procurement and distribution of recommended antimicrobials and medical supplies needed for supportive care at country level as part of essential medicine supplies

By 2024, established mechanism for timely antimicrobials and supplies for supportive care integrated into national procurement in >80% of countries

SG9: Provide appropriate quality-assured treatment and supportive care for every patient to reduce sequelae and deaths (see SG3, SG12)

Review the potential benefit of adjunctive therapies for bacterial meningitis e.g. mannitol, steroids in LMICs

By 2024, potential benefit of adjunctive therapies in LMICs evaluated by systematic review

Develop and disseminate comprehensive, regionally adapted, patient management guidance and treatment packages for all ages and causes of meningitis, specifically

By 2025, evidence-based package of treatment and care that addresses all causes of meningitis and tailored to all resource settings made available for all Regions

DRAFT 26 June 2019

16

addressing current gaps (e.g. neonatal meningitis and sepsis, WHO antibiotic treatment guidance for adults and use of adjunctive therapies or other strategies for prevention and management of sequelae) and antimicrobial resistance evidence

17

Pillar 3 Disease Surveillance

Achieved by encompassing all main causes of bacterial meningitis and their

sequelae to guide meningitis control policies and accurately monitor progress

toward goals

Guidelines for national surveillance of meningitis pathogens are not uniformly implemented, and

there are no recommended guidelines for GBS surveillance. In many countries, weak surveillance

systems hamper prompt outbreak detection and response and decisions about vaccine introduction.

Laboratory capacity for diagnostic testing, including molecular characterization, needs strengthening

for effective surveillance. Disease data reporting to the international level and whole genome

sequence (WGS) repositories are needed to strengthen global surveillance. There is very limited

guidance and implementation of surveillance of sequelae in all regions.

The aims of this pillar are to (i) set standards for bacterial meningitis surveillance systems and ensure

that they are in place in each country (ii) develop and implement global guidance, including for low-

resource settings, on surveillance of infant GBS disease (iii) develop and implement a strategy for

surveillance of sequelae from meningitis (iv) improve disease data reporting to the international level

to strengthen regional and global monitoring and estimation of the disease burden.

18

Strategic goals Key activities Landmark goals (milestones)

SG10: Ensure effective bacterial meningitis surveillance systems are in place in each country

Review regional surveillance strategy for main bacterial meningitis pathogens in each region and elaborate guidelines as needed. (SG11 covers GBS surveillance)

By 2021, regional surveillance guidance available in all regions for main bacterial meningitis pathogens

Develop, adopt and implement a minimum package of surveillance for the main bacterial meningitis pathogens at country level, with standards for epidemiology, laboratory capacity (including microbiology and antimicrobial resistance), data management making use of innovative tools

By 2025, minimum package of main bacterial meningitis pathogens surveillance implemented in >80% of countries

Perform global surveillance of emerging resistance patterns of main pathogens, linking with antibiotic resistance networks and control strategies

By 2023, a global mechanism to monitor the antibiotic resistance pattern of main meningitis pathogens is functional

SG11: Develop and implement global guidance, including for low-resource settings, on surveillance of infant GBS disease

Conduct situation analysis on surveillance of infant GBS invasive disease (including stillbirths, pre-term births due to GBS) world-wide

By 2021, situation analysis completed on infant GBS disease surveillance world-wide

Develop regional and international guidelines and tools for surveillance of infant GBS disease, including standardized case definitions and ascertainment methodologies

By 2020, international and regional guidelines for surveillance of infant GBS disease developed for all Regions

Establish surveillance systems for infant GBS (including stillbirths, pre-term births), according to guidelines and as regionally appropriate

By 2024, surveillance of infant GBS implemented in high burden regions, and by 2028 in medium/low burden regions.

DRAFT 26 June 2019

19

SG12: Develop and implement the surveillance of sequelae from meningitis (see SG14, SG15, SG19)

Develop a global strategy for surveillance of sequelae from meningitis and sepsis (routine surveillance, sentinel sites, surveys). Develop tools/SOPs/protocols for surveillance of sequelae and training materials

By 2026, global strategy and tools for surveillance of sequelae developed

Map institutions, and civil society organizations (CSOs)/ Organizations of Persons with Disabilities (including parent and patient groups, self- help groups), providing services to persons with disabilities, engage with them and include them in surveillance networks of sequelae (coordinate activity with SG15)

By 2025, institutions and CSOs, providing services to persons with disabilities mapped and included in surveillance of sequelae

Adapt the global strategy to be region specific and implement surveillance of sequelae at country-level Support training of health-care workers (including staff of audiology, neurology, physiotherapy, orthopaedic and prosthetic departments), teachers, community members, CSO members on the collection of information on sequelae from meningitis and sepsis

By 2030, regionally adapted strategies for meningitis sequelae implemented

Encourage Demographic Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) to collect data on disabilities

By 2022, variables on disabilities will be integrated in the standard DHS and MICS indicator list

DRAFT 26 June 2019

20

SG13: Ensure disease data reporting to the international level to strengthen regional and global monitoring and estimation of the disease burden

Refine and improve estimates of regional and global burden from meningitis due to Nm, Spn, Hi and GBS, including risk and impact of sequelae

By 2022, estimates of global and regional disease burden of main pathogens refined, including risk and impact of sequelae

Establish regional or international mechanism/network for molecular surveillance, of bacterial meningitis pathogens allowing for timely strain identification and sharing of information

By 2025, representative proportion (minimum 10%)) of strains characterized for Nm, Spn, Hi and GBS meningitis pathogens strains characterized in a globally coordinated mechanism in all Regions

In collaboration with the WHO collaborating centres and reference laboratories, establish a global genome library for meningitis pathogens (Nm, Spn, Hi, GBS), and associated clinical and epidemiological data with clear governance and guidelines for access and use of strains

By 2025, global genome library functional for each of the four pathogens

21

Pillar 4: Support and care for people affected by meningitis

Achieved by ensuring that effective systems for identification and management

of sequelae are implemented and that people and families/carers affected by

meningitis can access appropriate support and care services that meet their

needs.

It is estimated that at least one third of people surviving an episode of bacterial meningitis have

enduring after-effects. Impairments caused by meningitis are wide-ranging and often severe.

Common sequelae include seizures, hearing and vision loss, cognitive impairment, neuromotor

disability, memory and behavior changes, as well as scarring and limb amputations after

meningococcal sepsis. Aftercare has a high cost and may not be affordable for families. Policies and

services for assessment of sequelae, treatment, rehabilitation and follow up including in communities

are often absent or insufficient with inequitable access, especially in LMICs. Training on disability and

bereavement for health care professionals and community workers is limited, with inadequate

numbers of trained staff at all levels of care from community to hospital. Given the global burden of

bacterial meningitis, it is essential to build and strengthen health systems to provide the necessary

care and programmatic support for everyone who needs it.

The aims of this pillar are to (i) strengthen early recognition and management of sequelae in health

care and community settings (ii) increase availability and access to appropriate care for people

affected by meningitis including those with sequelae from meningitis and for families/carers of those

who have either recovered or died.

22

Strategic goals Key activities Landmark goals (milestones)

SG14: Strengthen early recognition and management of sequelae after meningitis in health care and community settings (see SG8, SG12)

Conduct primary and secondary research on

epidemiology and impact of sequelae on children

and adults to determine extent of service needs in

different settings

By 2023, studies completed on impact of sequelae and service needs

Develop and implement best practice guidelines for

detection, monitoring and management of

meningitis sequelae before and after discharge

from hospital, at all levels of health care and in

community settings e.g. schools

By 2025, global guidelines for systematic detection, monitoring and management of sequelae after meningitis developed; and by 2028, adapted and implemented in >50% of countries

Promote community-based programmes to (i) identify sequelae and disabilities, based on UN (Washington Group) and WHO instruments, and refer for assessment and appropriate care (ii) to provide care, support and aftercare to individuals, families and communities affected by meningitis e.g. psychosocial support

By 2028, system of community-based identification of sequelae and disabilities, and referral for assessment and care established in >50% of countries By 2028, community based programmes available in >50% of countries to provide routine comprehensive support to those affected by meningitis

DRAFT 26 June 2019

23

SG15: Increase availability and access to appropriate care (i) for people affected by meningitis and (ii) for their families/carers

(see SG12, SG17)

Map out existing services and support systems

available by country for (i) people with disabilities,

including those with meningitis sequelae and (ii) for

families/carers of people affected by meningitis,

identifying barriers to access, availability, and use

(informal and formal) (coordinate activity with

SG12)

By 2023, services and support systems mapped out

for (i) people with disabilities including meningitis

sequelae and (ii) families /carers of people with

meningitis who have recovered or died, in >80% of

countries including barriers to access, availability,

and use

Strengthen partnerships between government and

CSOs, including disabled people organizations and

other networks, so that people with sequalae or

disabilities due to meningitis and their

families/carers have access to quality and effective

services that are in line with international human

rights standards and frameworks

By 2025, guidelines to facilitate access for people

affected by meningitis to services on community-

based rehabilitation (CBR) developed; and by 2028,

in place in >50% of countries

Provide up-to-date relevant information to people and carers affected by meningitis about access to services for managing sequelae through varied channels e.g. media, social media, schools, community-based mechanisms etc

By 2027, up-to-date relevant information provided by media, social media, schools, community-based mechanisms etc to people affected by meningitis on access to services and support

24

Pillar 5: Advocacy and Engagement

To raise public and political awareness of meningitis and around disability, to

improve health-seeking and access to control measures

Advocacy can drive lasting change and makes the case for that change. Advocacy goals for meningitis

include better protection against meningitis, better diagnosis and treatment, and better support and

aftercare for those who have experienced meningitis and their families. Provision of general

information about meningitis to the overall population, at-risk groups and health workers, as well as

specific information for people who have directly been affected by meningitis, their families and

communities, can play an important role in defeating meningitis, but such information is often lacking.

Meningitis poses specific information challenges. Its rapid onset leaves little time to act, increasing

the need for good, targeted information. It is frequently confused with other fever-causing diseases,

such as malaria, increasing the need for health worker resources and training. Disability is a common

feature of life after meningitis, meaning good aftercare information is essential.

Effective information can make people aware of the need to seek help based on awareness of the

signs and symptoms of meningitis and to increase demand from populations for vaccination.

Clinical guidelines are often not available to help ensure that health workers and clinicians are trained

and resourced to respond. Information is generally lacking to help signposting of patients to support

services.

The aims of this pillar are to (i) improve recognition among funders and policymakers at national,

regional and global level that meningitis and the roadmap to defeat meningitis should be prioritized

as a health issue at every level, (ii) increase awareness and sensitization of communities around

disability and the services available to manage disabilities, (iii) ensure awareness among all

populations of meningitis signs, symptoms and consequences so that they seek appropriate

healthcare, (iv) ensure that people and communities are aware of their right to meningitis prevention

and support services, and that they value and demand them, and (v) maintain high vaccine confidence.

25

Strategic goals Key activities Landmark goals (milestones)

SG16: Ensure recognition among funders and

policymakers at national, regional and global level

that meningitis and the roadmap to defeat

meningitis should be prioritized as a health issue

at every level

Raise awareness of meningitis as a health priority

among funders and policy makers through national

and international champions, community

engagement, CSOs, advocacy groups and health

care providers

By 2021, meningitis and related disability included

in all relevant WHO (Global and Regional) and

donors’ strategic and operational plans and

budgets

Build a business case for investment prevention,

surveillance, diagnosis, and treatment of

meningitis, and for prevention and management of

sequelae, targeted for use by policymakers,

decision makers and funders at global, regional and

national levels

By 2020, a business case available and promoted at

global, regional and national level

Countries undertake baseline needs assessment on

meningitis and then create national action plans

that address gaps and are aligned to the global

roadmap

By 2022, >80% of countries have undertaken a

meningitis baseline needs assessment.

By 2024, >80% of countries have a context

appropriate meningitis action plan and monitoring

framework aligned to their national health strategy,

budget and global roadmap through to 2030

Improve global recognition of and activities around

World Meningitis Day (WMD) and other global

health dates (e.g. sepsis, cerebral palsy, disability),

adapt messaging to policy makers as well as the

general public, and raise funding for promoting

activities that support the roadmap

By 2022, WMD and related global health dates

visibly endorsed by global policy makers/funders

and used by >80% of countries to assess/promote

roadmap progress and share learning through

personal stories and best practice around the world

DRAFT 26 June 2019

26

SG17. Ensure awareness and sensitization of

communities around disability and available

services

(see SG15)

Support global and national campaigns on

International Day of Persons with Disabilities to

increase awareness and sensitization of

communities on disability, and to address

significant attitudinal barriers that lead to stigma

and undignified treatment of people with

disabilities

Raise awareness of new systems for data collection

on sequelae/disability and of available support

services

By 2025 awareness raised on International Day of

Persons with Disabilities in >80% of countries to

increase sensitization of communities on disability

and awareness of available services

SG18: Ensure awareness among all populations of

the symptoms, signs and consequences of

meningitis so that they seek appropriate

healthcare

(see SG6, SG8)

Undertake communication programmes and

activities that increase population awareness of the

symptoms, signs and consequences of meningitis

and of the recommended health seeking response,

based on strategies used to promote recognition of

other diseases (HIV, malaria and TB), including

social media, champions, community leaders, and

frontline workers

By 2023, meningitis awareness campaigns

conducted in >80% of countries appropriate to

national burden and integrated with existing health

awareness activities

Study the factors that facilitate or act as barriers to

health seeking behaviours for meningitis and

integrate actions into country plans to address the

issues identified

By 2025, region specific research published into

factors that facilitate or act as barriers to health

seeking behaviours for meningitis.

By 2028, recommended actions included in national

plans in >80% of countries

DRAFT 26 June 2019

27

SG19: Ensure that people and communities are

aware of their right to meningitis prevention and

support services, and that they value and demand

them

(see SG1, SG3, SG16)

Identify, encourage and support civil society

organizations that do or could promote the

interests of those affected by meningitis, including

those with sequelae, and invite involvement in

delivering the goals of the roadmap through their

communities, engagement with national and

regional authorities and international networks of

CSOs

By 2025, citizen representation and input to

national meningitis annual plans in >30% of

countries

Improve community understanding of existing and

new vaccination platforms (e.g. maternal

immunization when available for GBS) by

Knowledge, Attitude and Practice (KAP) studies,

and social anthropological research

By 2025, KAP studies and social anthropological

research conducted and by 2028 (depending on

vaccine availability) GBS maternal vaccination

promoted

SG20: Maintain high vaccine confidence

(see SG1, SG5)

Communicate widely through social media,

community platforms, and media engagement on

the safety and impact data of meningitis vaccines

and leverage the story of MenAfriVac to emphasize

that other causes of meningitis remain but are

potentially addressable with new vaccines

Develop risk and crisis communication plans for

new and existing vaccines in order to address

potential inaccurate communication of adverse

events

By 2023, communication plans promoting vaccine

confidence developed and implemented in >50% of

countries; and by 2026, in > 80% of countries

28

Connection to other global initiatives

The multi-pathogen, multidisciplinary nature of the Defeating Meningitis roadmap provides

opportunities for linkage with other global projects and initiatives, which can drive accelerated

progress towards mutual or complementary goals. The Defeating Meningitis technical task force is

actively working to identify potentially complementary initiatives and will establish and maintain

linkages with these initiatives to ensure alignment of goals and integrated approaches wherever

possible.

Initiatives with potential synergy with the Defeating Meningitis roadmap fall into several categories:

Maintain active collaboration:

• WHO Sepsis programme

• Group B Streptococcus Vaccine Development Technology Roadmap

• Global Antimicrobial Resistance Surveillance System

• WHO Vaccines for AMR project (no website yet)

• WHO Rehabilitation Support Package

• WHO Deafness and Hearing Loss programme

Maintain communication to identify potential future opportunities:

• Global roadmap for advancing development of vaccines against sexually transmitted

infections

Share information to promote visibility of the Defeating Meningitis roadmap or our goals/targets:

• Immunization Agenda 2030 (draft 0, no website yet)

o Successor to the Global Vaccine Action Plan

• WHO Global Observatory on Health Research and Development

• Global Action Plan for Healthy Lives and Wellbeing For All

• IMPRINT – Immunising Pregnant Women and Infants Network

TBD (we are working to contact these groups/initiatives to identify how we can synergize)

• Global Action Plan for Pneumonia and Diarrhoea

• Japanese Encephalitis Prevention and Control programs (WPRO, SEARO)

• Cryptococcal disease component of the WHO HIV programme

• The End TB Strategy

DRAFT 26 June 2019

29

• Pocket Book of Hospital Care for Children (next edition)

• WHO Universal Health Coverage Package

• Global Strategy for Women’s, Children’s, and Adolescents’ Health

• Every Newborn Action Plan

• Africa Health Strategy 2016-30

• WHO Global Strategy on Human Resources for Health

• Convention on the rights of persons with disabilities

• BactiVac Network

Timelines for roadmap development WHO is hosting a web-based public consultation from June to July 2019 and will convene a global

stakeholder consultation in September 2019. At this meeting, 120-150 delegates from around the

world will be invited to give feedback on the roadmap: the priority for this meeting will be to align

with country perspectives and ensure that people affected by meningitis have a voice. Regional

meetings will be held to tailor the strategy to regional issues. The draft roadmap will be submitted to

the WHO Executive Board and the World Health Assembly for review and endorsement in 2020.

Roadmap sections to be developed include:

Implementation

Communication plan

Monitoring and Evaluation framework

Critical path/ risk management

Financing

Business plan/value proposition

DRAFT 26 June 2019

30

Key references

1. Zunt JR, Kassebaum NJ, Blake N, Glennie L, Wright C, Nichols E, et al. Global, regional, and national burden of meningitis, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2018;17(12):1061-82. 2. van de Beek D. Progress and challenges in bacterial meningitis. Lancet. 2012;380(9854):1623-4. 3. McIntyre PB, O'Brien KL, Greenwood B, van de Beek D. Effect of vaccines on bacterial meningitis worldwide. The Lancet. 2012;380(9854):1703-11. 4. WHO. Defeating meningitis by 2030: baseline situation analysis Geneva WHO; 2019 [Available from: https://www.who.int/immunization/research/BSA_20feb2019.pdf?ua=1. 5. Edmond K, Clark A, Korczak VS, Sanderson C, Griffiths UK, Rudan I. Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis. Lancet Infect Dis. 2010;10(5):317-28. 6. Edmond K, Dieye Y, Griffiths UK, Fleming J, Ba O, Diallo N, et al. Prospective cohort study of disabling sequelae and quality of life in children with bacterial meningitis in urban Senegal. Pediatr Infect Dis J. 2010;29(11):1023-9. 7. Kohli-Lynch M, Russell NJ, Seale AC, Dangor Z, Tann CJ, Baker CJ, et al. Neurodevelopmental Impairment in Children After Group B Streptococcal Disease Worldwide: Systematic Review and Meta-analyses. Clin Infect Dis. 2017;65(suppl_2):S190-s9. 8. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1151-210. 9. Park W. A global vision for meningitis by 2030 and how to get there. Wilton Park, UK; 2017. 10. WHO. 14th Annual meeting on surveillance, preparedness, and response to meningitis outbreaks in Africa & 4th Annual MenAfriNet partners’ meeting: Ouagadougou, Burkina Faso - 12 – 15 September 2017 2017 [ 11. Park W. Defeating meningitis by 2030: developing a global roadmap 2019. 12. WHO. Thirteenth general programme of work 2019−2023 2018 [Available from: http://origin.who.int/about/what-we-do/gpw-thirteen-consultation/en/. 13. UN. Sustainable development goals [Available from: https://www.un.org/sustainabledevelopment/sustainable-development-goals/.