Meningococcal Meningitis and GIS

Paul W Saunders
Introduction:

Meningococcal meningitis occurs when the bacterium Neisseria meningitidis invades the body
and infects the thin lining surrounding the brain and spinal cord known as the meninges (World
Health Organization 2003). Infection is characterized by two common syndromes,
meningococcal meningitis and septicemia, both of which can lead to morbidity or death (Maiden
and Caugant 2006 p.17). An estimated 10 to 25% of the population can be carriers at any given
time, with carriage rates increasing during epidemics (World health Organization 2003, Pollard
and Nadel 2006 p.486, Volovskaya 1990 p. 202). Humans are the only known carriers of N.
meningitidis, with disease occurring in all countries of the world (Volovskaya 1990 p. 203).

The endemic character of N. meningitidis produces a background rate of disease, which must be
considered during the identification of epidemics (Boisier et al. 2005). Coupled with this is the
occurrence of 13 serogroups or subtypes of N. meningitidis, five of which are known to cause
epidemics, these being A, B, C, Y and W135 (Frosch and Vogel 2006). The spatial and temporal
characteristics of these features and their suspected link to both social and environmental
attributes in a given area allows for the effective use of geographical techniques for surveillance
and control of the disease (Cuevas et al. 2007, Group on Earth Observations 2007).

The Spatial and Temporal Attributes of Meningococcal Meningitis and Associated

Environmental and Social Factors:

The occurrence of meningitis has been associated with overcrowding, poor hygiene, socio-
economic conditions, influenza infection, cohort distribution, mean annual rainfall, airborne dust
and prevailing wind conditions (Cuevas et al. 2007, Boisier et al. 2005, Volovskaya 1990 p. 203,
Cartwright 2006 p.9). Each of these factors has associated with it both spatial and temporal
attributes which allow for their easy incorporation into a geographical information system (GIS)
(Johnson and Johnson 2001). The use of such systems for evaluation of epidemiology
characteristics of a disease, surveillance, delineation and the identification of disease risk is well
documented in the literature (Ali et al. 2003, Johnson and Johnson 2001, Pan American Health
Organization 1996, Foody 2006, Nuckols et al. 2004, Sipe and Dale 2003, Pfeiffer and Hugh-
Jones 2002, Sabesan and Raju 2005).

Meningococcal Meningitis and GIS:

The use of a GIS for meningitis surveillance and control requires the selection of appropriate
indicators. The issue of indictor selection was dealt with by the Pan American Health
Organization (2001) in which they defined an indicator as:

“a construct of public health surveillance that defines a measure of health (i.e. the
occurrence of a disease or other health-related event) or a factor associated with health
(i.e., health status or other risk factor) among a specified population”
Effective use of a GIS, for the surveillance and control of meningitis, involves the identification
of indicators that will allow us to; identify the target population, track available resources and
mobilize the needed intervention. Selected indicators and their interaction with the three areas
listed above will be dealt with in the remainder of this document along with their incorporation
into a GIS designed for the identification and control of meningitis epidemics.

Identifying Populations at Risk or Currently Subjected to an Epidemic:

Due to the interplay between the observed epidemiology and aetiology of meningitis infection,
the identification of populations at risk will involve the assimilation and combination of data
from two distinct areas; disease propagation within the population and the influence of prevailing
environmental conditions.

The Pan American Health Organization (2001) provide a list of criteria for the surveillance,
identification and reporting of meningococcal meningitis cases in a specific areas. It also
introduces data analysis, presentation of results and uses and users of those results. A threshold
of 15 cases per week over two weeks was stated as an indicator of an occurring or impending
epidemic and reflects the criteria used in past epidemics (Haelterman et al. 1996). Basic data on
population density, cohort distribution and prevailing social conditions are all important at this
stage. It is important to correctly identify the geographic location of all cases and provide
locational information for all collected and submitted data. This can be done using retail GPS
units, which were shown by Ali et al. (2003) to be as accurate as more expensive professional
grade models.

This data must then be combined with selected environmental data from all areas of concern.
Data on absolute humidity, dust in the air, rainfall, land cover types and the previous distribution
of epidemics should also be collected for use due to their ability to aid in predicting future
outbreaks (Cuevas et al. 2007, Molesworth et al. 2003). This data may already be available in
digital form or may need to be digitized or obtained through the classification of remotely sensed
data.

Tracking and Distributing Available Resources:

Situating health centers has a major impact on the ability to obtain the data listed in the above
section. GIS is a prime tool for this task due to its ability to evaluate data within its spatial and
temporal context (Sabesan and Raju 2005, Johnson and Johnson 2001). The spatial extent of
data gaps can also be identified. This is especially relevant to the collection of environmental
data and allows for the deployment of limited instrumentation in areas of the most value.

GIS can also aid in the development of the most suitable reporting structure based on the current
spatial distribution of facilities or mobile teams. This can be done through the analysis of
transportation and communication networks and its association with population distribution and
density (Gordon and Womersley 1997, Kumar 2000).
Figure 1 provides an outline of data and communications paths. Links to remote data collection
sites (i.e weather stations, case data, etc.) would have to be added, as required, with a direct or
indirect transfer path to the GIS as the final stage.

Figure 1 Diagram of GIS Information Flow and Communication Routes

Mobilization of Available Resources:

Mobilization of resources for a response to a specific meningitis epidemic will be dictated by the
timely flow of data as outlined above, and the required analysis by the centralized GIS
processing unit. Paramount in the early stages is the mapping of the spatial distribution of the
outbreak and identification of the serogroup responsible (Chadee et al. 2006, World Health
Organization 1998). A pro-active response, based on high-risk areas identified with predictive
models that incorporate associated environmental attributes, by pre-vaccination of the population
is currently not cost effective due to the short span of immunity conferred by current vaccines
(Miller et al. 2006, Haelterman et al. 1996).

With this information, the outbreak extent can be determined, the size and density of the
affected population calculated and the vaccine type required determined. Rapid response teams
can then be deployed as per the guidelines developed by the World health Organization (1998).
In the event that the required number of vaccine units is not available, application can be made to
the World Health Organization for access to their stockpile. Information on this procedure can
be found at http://www.who.int/csr/disease/meningococcal/icg/en/print.html .

Bringing it all Together with GIS:

The World Health Organization (WHO) (1998) meningococcal response guidelines provides a
description of techniques and method to address outbreaks but does not address how this
response is to be managed on a national scale. A GIS has the capability to fulfill this role due to
its ability to store various types of data and their spatial attributes. The design and
implementation of such a system is not simple and straightforward and its effectiveness will
depend on addressing specific issues during its creation.

A primary concern for many health agencies is the huge cost of the required hardware and
software needed for implementation of a GIS (Pan American Health Organization 2001, Sipe and
dale 2003). By centralizing data assimilation, filtering and processing these costs can be
reduced. For dissemination of the results from analysis completed, personnel outside the
headquarters areas can download a standalone viewer, such as ArcExplorer, which forms part of
the ArcGIS family supplied by ESRI (ESRI 2008). The software selected for implementation
will determine standalone viewers. The WHO (1998) guidelines provide reference to other
software programs that are available, some at little or no cost.

Of equal importance to the successful establishment of a GIS is the availability of qualified

personnel (Sipe and dale 2003, Al-Shorbaji 2006). Personnel operating the GIS processing
center would have to be made up of individuals from the GIS, computer science and health
professional fields. Efforts would have to be made to ensure educational institutions are
equipped to train the required personnel and allowance must be made to retain these individuals
once employed.

Communication systems are vital to the efficient operation of the health GIS. Existing landlines
can be used where available but more remote areas will require dependable mobile
communications. Field personnel can be provided with satellite phones (i.e. Iridium phones
http://www.iridium.com/ ) which currently can be used throughout the world. Remote data
collection equipment, such as weather stations, can be automated to submit collected data, on a
daily or weekly basis, through available wireless communication routes (Varshney 2006).
Communication systems must be designed to insure that information flow in both directions is of
equal quality and reliability.

Data availability must be timely and consistent, with quality insured and preserved at all transfer
points. Nationally available data, such as census results, meteorological measurements, WHO
records and various types of publically available remotely sensed data can be obtained. This
would have to be combined, at the local level, with data on localized population density, average
number per household, houses size, immigration and emigration rates, cohort size and social
class (Lawson and Williams 2001 pp. 32-34, Gordon and Womersley 1997). All data must be
transferred and processed on a timely basis, due to the need for quick intervention, if the early
identification of epidemics and subsequent control are to be successful (Gao et al. 2008). Myers
et al. (2000) dealt with the use of early warning systems, and went into detail about the required
components of such a system and outputs that could be generated.

Gao et al. (2008) outlined the use of online GIS for the collection and dissemination of health
related data. The automation of basic geographical statistical models, such as cluster
identification, could allow for real-time classification of high risk areas or those currently
undergoing epidemics. One of the benefits of such a system is the automated incorporation of
data from multiple sources and in multiple formats ( Rolfharme et al. 2006, Sipes 2004, Blanton
et al. 2006). Workflow can also be streamlined through the elimination of the requirement for
entering data into multiple systems (Shui et al. 2006). Software companies, such as Premise
(http://www.premiseusa.com/by-challenge-ed-overcrowding.htm), have brought this capability
down to the health facility level, allowing integration at the emergency department tier. The
development and adoption of international standards by health organizations will provide much
needed improvements in these areas of health data management.

Conclusion:

The creation and establishment of GIS system, as outlined above, will require a variety of steps.
First would be the identification of current resources comprised of available data, software,
hardware and the required expertise. This will allow for the identification of gaps and the
development of a work plan to address those gaps.

Secondly, the assistance of outside expertise could be requested. With the help of organizations,
such as the WHO and other NGO’s, the development of a health GIS for this or any other
country should be possible. It will however require a long-term commitment from all
government organizations and should not be expected to proceed without overcoming some
technical, financial, social or scientific hurdles.

Finally, the development of a monitoring system to provide feedback on the operation of the
system and mechanisms for incorporating recommendations based on that feedback must be
established and maintained.
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