BACKGROUND: In northwest Nigeria in 2013 and 2014, two sequential, localized outbreaks of meningitis were caused by a new strain of Neisseria meningitidis serogroup C (NmC). In 2015, an outbreak caused by the same novel NmC strain occurred over a wider geographical area, displaying different characteristics to the previous outbreaks. We describe cases treated by Médecins Sans Frontières (MSF) in the 2015 outbreak. METHODS: From February 10 to June 8, 2015, data on cerebrospinal meningitis (CSM) cases and deaths were recorded on standardized line-lists from case management sites supported by MSF. Cerebrospinal fluid (CSF) samples from suspected cases at the beginning of the outbreak and throughout from suspected cases from new geographical areas were tested using rapid Pastorex® latex agglutination to determine causative serogroup. A subset of CSF samples was also inoculated into Trans-Isolate medium for testing by the WHO Collaborating Centre for Reference and Research on Meningococci, Oslo. Reactive vaccination campaigns with meningococcal ACWY polysaccharide vaccine targeted affected administrative wards. RESULTS: A total of 6394 (65 confirmed and 6329 probable) cases of CSM including 321 deaths (case fatality rate: 5.0%) were recorded. The cumulative attack rate was 282 cases per 100,000 population in the wards affected. The outbreak lasted 17 weeks, affecting 1039 villages in 21 local government areas in three states (Kebbi, Sokoto, Niger). Pastorex® tests were NmC positive for 65 (58%) of 113 CSF samples. Of 31 Trans-Isolate medium samples, 26 (84%) tested positive for NmC (14 through culture and 12 through PCR); all had the same rare PorA type P1.21-15,16 as isolates from the 2013 and 2014 outbreaks. All 14 culture-positive samples yielded isolates of the same genotype (ST-10217 PorA type P1.21-15,16 and FetA type F1-7). More than 222,000 targeted individuals were vaccinated relatively early in the outbreak (administrative coverage estimates 98% and 89% in Kebbi and Sokoto, respectively). CONCLUSIONS: The outbreak was the largest caused by NmC documented in Nigeria. Reactive vaccination in both states may have helped curtail the epidemic. A vaccination campaign against NmC with a long-lasting conjugate vaccine should be considered in the region.

Using data from a qualitative study and a subsequent quantitative survey among 918 male and transgender sex workers (MTSW), we explore the context of multiple risks they face. We show that over one-fifth of MTSW have sex with IDU clients. Combined with high levels of risk behavior and very low levels of risk reduction and knowledge, the extent of sexual networking with men who inject drugs contributes further to the sex workers' health risks. Our findings suggest that isolated interventions with single-risk groups are unlikely to be sufficient to control the spread of the epidemic in Pakistan. We highlight the need for integrated approaches to risk reduction programs among MTSW and IDUs.

We conducted an evaluation of our food handler certification program, PROTON. Research examined changes in knowledge, attitude and behavior of participants as a result of completing the course. Participants completed a pre-test assessing the three variables related to food safety at time of registration. One month following the completion of the program, participants completed an identical post-test. A total of 1,042 pre-tests and 320 post-tests were completed. Scores in the pre-test (6.3/10) and mean score for the post-test (7.6/10) rendered a mean difference of 1.3 (95% confidence interval = 1.1 to 1.6; P < 0.0001) demonstrating an increase in knowledge by participants after taking the course. Significant increases for two attitudinal statements related to cross-contamination and time-temperature abuse scored high levels of participant agreement. PROTON is successful at positively impacting the knowledge, attitude and behavior of participants toward factors important to food safety, and recommendations for program enhancement are identified. PRACTICAL APPLICATIONSFrom a program planning perspective, there are a number of implications from this study. It would be useful to revise the program according to the findings so that further positive changes in knowledge, attitude and behavior can be reached. For example, to enhance positive changes, certain parts of the workshop should have greater emphasis on improving skill building opportunities so that food handlers have the practical skills required to complete various safe food handling tasks when in their place of employment. It would also be important to ensure that the program content includes a variety of learning strategies, based on adult-learning principles, to ensure the content is relevant and acceptable to all participants. Overall, PROTON is an effective food handler education and certification program, and enhancement to the program could increase further positive changes. † Statistically significant change from pre-test to post-test where P < 0.001. ‡ Statistically significant change from pre-test to post-test where P < 0.05. CI, confidence interval.

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