Meningococcal epidemiology in Ethiopia after MenAfriVac: A situational analysis of surveillance gaps and national meningococcal vaccine policy.

Abstract Ethiopia introduced the MenAfriVac vaccine to control epidemics of serogroup A meningococcal disease (MenA) between 2013 and 2015. Since the campaign, no MenA epidemics have been reported. However, lacking a follow-up strategy, two critical questions remained unanswered: (1) is protection against MenA waning to a point where epidemics could re-emerge and (2) are non-A serogroups, known to cause outbreaks elsewhere in the meningitis belt, currently circulating in Ethiopia? To inform future policy, this situational analysis draws on historical records, post-2015 surveillance data, MenAfriVac campaign reports, and the current policy landscape to assess meningococcal epidemiology in Ethiopia. Available national data cannot answer either question. Disease notification relies on sentinel surveillance at three hospitals; none located in the epidemic risk western regions and none with a defined catchment population. Cases are rarely laboratory-confirmed, almost never serogrouped, and the resulting data are not reported in a timely manner. Primary carriage and serosurvey studies remain limited, and their methodological heterogeneity including diverse populations, sampling techniques and laboratory assays restricts their generalisability for population-level policy decisions. In the absence of quality primary data, indirect risk estimation based on campaign coverage and regional waning models indicates that population protection dropped from 85% in 2015 to 24% in 2024 and will fall further to 11% by 2030 without intervention. Despite this, the current E-NITAG prioritisation exercise relies on this sparse evidence base, excludes MenAfriVac from the candidate list, and does not incorporate costing or serogroup-coverage data. Addressing the meningococcal evidence gap requires rebuilding national surveillance into a tiered system. Under this structure, primary facilities manage clinical case detection, regional and zonal hospitals perform confirmatory testing, and representative tertiary hospitals conduct serogrouping and genomic characterization with national laboratory support. Until this longitudinal surveillance yields sufficient data for policy decisions, supplementary carriage and seroepidemiological studies remain necessary to assess circulating serogroups and population immunity.