Health Alert Network (HAN) – 00508 | Meningococcal Disease Cases Linked to Travel to the Kingdom of Saudi Arabia … – CDC Emergency Preparedness

Distributed via the CDC Health Alert Network May 20 2024, 10:30 AM ET CDCHAN-00508

Summary The Centers for Disease Control and Prevention (CDC) is issuing this Health Alert Network (HAN) Health Advisory to alert healthcare providers to cases of meningococcal disease linked to Umrah travel to the Kingdom of Saudi Arabia (KSA). Umrah is an Islamic pilgrimage to Mecca, Kingdom of Saudi Arabia, that can be performed any time in the year; the Hajj is an annual Islamic pilgrimage this year taking place June 1419, 2024. Since April 2024, 12 cases of meningococcal disease linked to KSA travel for Umrah have been reported to national public health agencies in the United States (5 cases), France (4 cases), and the United Kingdom (3 cases). Two cases were in children aged 18 years, four cases were in adults aged 1844 years, four cases were in adults aged 4564 years, and two cases were in adults aged 65 years or older. Ten cases were in patients who traveled to KSA, and two were in patients who had close contact with travelers to KSA. Ten cases were caused by Neisseria meningitidis serogroup W (NmW), one U.S. case was caused by serogroup C (NmC), and the serogroup is unknown for one U.S. case. Of nine patients with known vaccination status, all were unvaccinated. The isolates from the one U.S. NmC case and two NmW cases (one U.S., one France) were resistant to ciprofloxacin; based on whole-genome sequencing, the remaining eight NmW isolates were all sensitive to penicillin and ciprofloxacin.

In the United States, quadrivalent meningococcal (MenACWY) conjugate vaccination is routinely recommended for adolescents, and also recommended for travelers to countries where meningococcal disease is hyperendemic or epidemic, including a booster dose of MenACWY if the last dose was administered 35 or more years previously (depending on the age at most recent dose received). In addition, all Hajj and Umrah pilgrims aged one year and older are required by KSA to receive quadrivalent meningococcal vaccine. Healthcare providers should work with their patients considering travel to perform Hajj or Umrah to ensure that those aged one year or older have received a MenACWY conjugate vaccine within the last 5 years administered at least 10 days prior to arrival in KSA. Healthcare providers should also maintain increased suspicion for meningococcal disease in anyone presenting with symptoms of meningococcal disease after recent travel to KSA for Hajj or Umrah pilgrimage. U.S. health departments and healthcare providers should preferentially consider using rifampin, ceftriaxone, or azithromycin instead of ciprofloxacin for chemoprophylaxis of close contacts of meningococcal disease cases associated with travel to KSA.

Background Meningococcal disease, caused by the bacterium Neisseria meningitidis, is a rare but severe illness with a case-fatality rate of 1015%, even with appropriate antibiotic treatment. Meningococcal disease often presents as meningitis with symptoms that may include fever, headache, stiff neck, nausea, vomiting, photophobia, or altered mental status. Meningococcal disease may also present as a meningococcal bloodstream infection with symptoms that may include fever, chills, fatigue, vomiting, cold hands and feet, severe aches and pains, rapid breathing, diarrhea, or, in later stages, a petechial or dark purple rash (purpura fulminans). While initial symptoms of meningococcal disease can at first be nonspecific, they worsen rapidly and can become life-threatening within hours. Survivors may experience long-term effects such as deafness or amputations of the extremities. Immediate antibiotic treatment for meningococcal disease is critical. Blood and cerebrospinal fluid (CSF) cultures are indicated for patients with suspected meningococcal disease. Healthcare providers should not wait for diagnostic testing or receipt of laboratory results before initiating treatment for suspected cases of meningococcal disease.

Meningococcal disease outbreaks have occurred previously in conjunction with mass gatherings including the Hajj pilgrimage. The most recent global outbreak of meningococcal disease associated with travel to KSA for Hajj was in 20002001 and was primarily caused by NmW. Since 2002, KSA has required that all travelers aged one year or older performing Hajj or Umrah provide documentation of either a) a MenACWY polysaccharide vaccine (MPSV4 is no longer available in the United States) within the last 3 years administered at least 10 days prior to arrival or b) a MenACWY conjugate vaccine within the last 5 years administered at least 10 days prior to arrival. This requirement aligns with ACIP recommendations for revaccination of U.S. travelers to endemic areas who received their last dose 35 or more years previously (depending on the age at most recent dose received). Nevertheless, meningococcal vaccination coverage among Umrah travelers is known to be incomplete.

Close contacts of people with meningococcal disease should receive antibiotic chemoprophylaxis as soon as possible after exposure, regardless of immunization status, ideally less than 24 hours after the index patient is identified. Ciprofloxacin, rifampin, and ceftriaxone are the first-line antibiotics recommended for use as chemoprophylaxis. However, ciprofloxacin-resistant strains of N. meningitidis have been emerging in the United States and globally. CDC recently released implementation guidance for the preferential use of other recommended prophylaxis antibiotics in areas with multiple cases caused by ciprofloxacin-resistant strains. Health departments should discontinue using ciprofloxacin as prophylaxis for close contacts when, in a catchment area during a rolling 12-month period, both a) 2 invasive meningococcal disease cases caused by ciprofloxacin-resistant strains have been reported, and b) cases caused by ciprofloxacin-resistant strains account for 20% of all reported invasive meningococcal disease cases. Though a catchment area is defined as a single contiguous area that contains all counties reporting ciprofloxacin-resistant cases, in this circumstance, it is more appropriate to determine the catchment population based on travel history rather than geographic location at the time of diagnosis. Among the 11 global cases associated with travel to KSA that have antimicrobial sensitivity results available, 3 cases (27%) were caused by ciprofloxacin-resistant strains. Rifampin, ceftriaxone, or azithromycin should be preferentially considered instead of ciprofloxacin as prophylaxis for close contacts in the United States of meningococcal disease cases associated with travel to KSA.

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Health Alert Network (HAN) - 00508 | Meningococcal Disease Cases Linked to Travel to the Kingdom of Saudi Arabia ... - CDC Emergency Preparedness