Serogroup W-135 Meningococcal Disease Among Travelers
Returning From Saudi Arabia --- United States, 2000
On April 9, 2000, CDC was notified by national public health agencies in
several European countries of cases of serogroup W-135 meningococcal disease
among pilgrims returning from the Hajj in Mecca and their close contacts. As of April 20,
2000, the New York City Department of Health had reported three cases of serogroup
W-135 meningococcal disease in the United States.
One patient was a returning pilgrim who had been vaccinated with
the meningococcal quadrivalent polysaccharide vaccine, and one was a
household contact of a returning pilgrim. The third patient did not participate in the Hajj and
had no household or other close contacts who had traveled to Mecca; however, 5
days before illness onset the patient may have interacted with returning pilgrims or
their families. The three patients had no identified shared contacts or associations.
Two patients had isolation of serogroup W-135 Neisseria
meningitidis from the blood; in the third patient, the pathogen was isolated from joint fluid. Serogroup classification
of the first two isolates has been confirmed as W-135 at CDC; both isolates
were subserotype P1.5,2 by PorA gene sequencing. Multilocus enzyme
electrophoresis typing results are pending. These are the only cases identified among the
11,000 pilgrims reported to have traveled from the United States to Saudi Arabia for
this year's Hajj, which concluded on March 17. No deaths from W-135
meningococcal disease have been reported among pilgrims returning to the United States.
Reported by: A Fine, MD, M Layton, MD, New York City Dept of Health; A Hakim,
Maimonides Medical Center, New York City. P Smith, MD, New York State Dept of Health. Div of Applied
Public Health Training, Epidemiology Program Office; Meningitis and Special Pathogens Br, Div
of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; and EIS officers, CDC.
Editorial Note:
As of April 20, 2000, 40 cases of serogroup W-135
meningococcal disease among Hajj pilgrims or their close contacts have been reported to the
World Health Organization by national health authorities in the United Kingdom, France,
the Netherlands, and Oman (1). In addition, 199 cases of meningococcal disease
were reported from Saudi Arabia, including 30 of serogroup W-135 and 55 of serogroup
A.
This is the largest recorded outbreak of serogroup W-135 meningococcal disease.
In the United States, W-135 accounts for 3%--4% of meningococcal disease
(2) and previously has not been associated with an outbreak. Meningococcal disease
most commonly is manifested as bacteremia or meningitis but can present as
septic arthritis or pneumonia.
Prompted by a serogroup A meningococcal disease outbreak associated with
the 1987 Hajj (3,4), Saudi Arabia began to require meningococcal vaccine for all
entering pilgrims; however, the vaccine formulation varies by country. Most U.S.
pilgrims probably received the quadrivalent polysaccharide vaccine covering serogroups A,
C, Y, and W-135, because it is the only meningococcal vaccine distributed in the
United States. Meningococcal serogroup A and C polysaccharide vaccines have
clinical efficacies of 85%--100% (5). Vaccination with W-135 polysaccharide
induces bactericidal antibody, although clinical protection has not been
documented. Nevertheless, cases among U.S. pilgrims could occur from polysaccharide
vaccine failure or from having been vaccinated in countries using a bivalent A and C
vaccine. Because the polysaccharide vaccine does not prevent or eliminate carriage,
close contacts of returning pilgrims may be at risk.
Health departments and health-care providers should be aware of
possible meningococcal disease among persons who recently traveled to Saudi Arabia or
their household contacts who may not have traveled. Surveillance by local and state
health departments should be enhanced for cases of meningococcal disease in persons
who may have had contact with returning pilgrims or their families, or for any case
of serogroup W-135 meningococcal disease. Health departments in areas
with substantial numbers of returning pilgrims should consider disseminating
information on the signs and symptoms of meningococcal disease, particularly among
returning pilgrims and their household contacts.
If possible cases are identified, health-care providers should contact the local
or state health department and CDC's Meningitis and Special Pathogens Branch,
Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases,
telephone (404) 639-3158. Any isolates should be saved and sent to CDC for further analysis.
Rosenstein NE, Perkins BA, Stephens DS, et al. The changing epidemiology
of meningococcal disease in the United States, 1992--1996. J Infect Dis 1999;180:1894--901.
Moore PS, Harrison LH, Teizak EE, Ajello GW, Broome CV. Group A meningococcal
carriage in travelers returning from Saudi Arabia. JAMA 1988;260:2686--9.
CDC. Meningococcal disease among travelers returning from Saudi Arabia.
MMWR 1987;36:559.
CDC. Control and prevention of serogroup C meningococcal disease: evaluation
and management of suspected outbreaks: recommendations of the Advisory Committee
on Immunization Practices (ACIP). MMWR 1997;46(no. RR-5):13--21.
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