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From the Centers for Disease Control and Prevention
May 24/31, 2000

Serogroup W-135 Meningococcal Disease Among Travelers Returning From Saudi Arabia—United States, 2000

JAMA. 2000;283(20):2647. doi:10.1001/jama.283.20.2647

MMWR. 2000;49:345-346.

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.

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 disease2 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.

World Health Organization, Meningococcal disease in France, United Kingdom, Oman, Saudi Arabia, Netherlands. Available at http://www.who.int/emc/outbreak_news/n2000/<?ddi urlbreak?>April/21a%20apr2000.html. Accessed April 25, 2000.
Rosenstein  NEPerkins  BAStephens  DS  et al.  The changing epidemiology of meningococcal disease in the United States, 1992-1996.  J Infect Dis. 1999;1801894- 901Article
Moore  PSHarrison  LHTeizak  EEAjello  GWBroome  CV Group A meningococcal carriage in travelers returning from Saudi Arabia.  JAMA. 1988;2602686- 9Article
CDC, Meningococcal disease among travelers returning from Saudi Arabia.  MMWR. 1987;36559
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