Public Health Dispatch: Update: Assessment of Risk for
Meningococcal Disease Associated With the Hajj 2001
During late March and early April 2000, four cases of meningococcal
disease caused by Neisseria meningitidis serogroup W-135 were identified among
U.S. pilgrims returning from the Hajj in Saudi Arabia, their close contacts, and
communities (1). These cases occurred as part of a larger epidemic in which approximately
400 cases caused by a similar and unusual strain were identified worldwide
(2). The Hajj, an annual pilgrimage to the major holy places of Islam, is attended by
approximately two million persons from approximately 140 countries, including an estimated
15,000 from the United States.
After an outbreak of serogroup A meningococcal disease in 1987 associated
with the Hajj, CDC recommended that U.S. pilgrims receive the quadrivalent
meningococcal polysaccharide vaccine (3). This vaccine provides protection against disease
caused by serogroups A, C, Y, and W-135; however, the vaccine may not affect
asymptomatic pharyngeal carriage or a person's ability to transmit disease. To assess the risk
for meningococcal disease in 2001 among U.S. pilgrims, CDC conducted a study
of pharyngeal carriage of N. meningitidis in departing pilgrims traveling to Saudi
Arabia and of passengers returning from Saudi Arabia after the Hajj 1--2 weeks later.
After informed consent was obtained, pilgrims departing from John F.
Kennedy International Airport (JFK), New York, on seven consecutive direct flights to
Saudi Arabia during February 16--27, 2001, were asked to complete a questionnaire
and provide an oropharyngeal swab for culture. During March 9--16, all
disembarking passengers (i.e., pilgrims and nonpilgrims) on five consecutive direct flights from
Saudi Arabia to JFK were similarly approached; 451 pilgrims were enrolled in the
departing portion of the study and 869 passengers, including 727 pilgrims, were enrolled in
the returning portion. Of the 27 N. meningitidis
isolates recovered from1320 passengers, 17 (63%) were nongroupable (i.e., a typically nonpathogenic strain); seven (26%)
were serogroup W-135. Returning pilgrims were more likely to be carriers than
departing pilgrims (2.6% versus 0.9%; p=0.04). None of the departing pilgrims carried
serogroup W-135; however, six (0.8%) returning pilgrims were serogroup W-135
carriers (p=0.06). Among returning passengers, carriage of serogroup W-135 was
similar among pilgrims and nonpilgrims (0.8% versus 0.9%; p=0.98).
Many returning passengers reported upper respiratory symptoms; 63%
reported cough, 58% had sore throat, and 24% had fever during the 2 weeks before their
return. Antibiotic use was reported by 396 (49%) of 811 returning passengers and
was associated with decreased (although not significantly [2.1% versus 4.2%; p=0.09])
N. meningitidis carriage. The cause of this illness is not known; severe illness
requiring hospitalization was not reported.
Because of the low rate of N.
meningitidis serogroup W-135 carriage,
antimicrobial chemoprophylaxis for all pilgrims returning to the United States is not
recommended. Although overall carriage was low, the high proportion of serogroup W-135
carriage suggests continuing transmission in Saudi Arabia. Evidence of this
transmission, combined with reports of cases of invasive disease among pilgrims returning to
the United Kingdom who received only bivalent vaccine against serogroup A and
C, suggests that U.S. pilgrims should continue to receive quadrivalent
meningococcal polysaccharide vaccine before travel to the Hajj.
Reported by: Div of Applied Public Health Training, Epidemiology Program
Office; Meningitis and Special Pathogens Br, Div of Bacterial and Mycotic Diseases;
Surveillance and Epidemiology Br, Div of Quarantine, National Center for Infectious Diseases; and
EIS officers, CDC.
Popovic T, Sacchi CT, Reeves MW, et al.
N. meningitidis serogroup W135 isolates
associated with the ET37 complex [Letter]. Emerg Infect Dis 2000;6:428--9.
Moore PS, Harrison LH, Telzak EE, et al. Group A meningococcal carriage in
travelers returning from Saudi Arabia. JAMA 1988;260:2686--9.
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