Chapter 3Infectious Diseases Related To Travel
Amanda Cohn, Michael L. Jackson
The infectious agent is a gram-negative diplococci, Neisseria meningitidis. Meningococci are classified into serogroups on the basis of the composition of the capsular polysaccharide. The 5 major meningococcal serogroups associated with disease are A, B, C, Y, and W-135.
MODE OF TRANSMISSION
Person-to-person transmission occurs by close contact with respiratory secretions or saliva.
N. meningitidis is found worldwide. At any time, 5%–10% of the population may be carriers of N. meningitidis. Invasive disease is rare in nonepidemic areas, occurring at a rate of 0.5–10 cases per 100,000 population per year, but can occur at a rate of up to 1,000 cases per 100,000 population per year in epidemic regions.
The incidence of meningococcal disease is highest in the “meningitis belt” of sub-Saharan Africa (Map 3-13). The incidence of meningococcal disease is several times higher in the meningitis belt than in the United States, with periodic epidemics during the dry season (December–June). During nonepidemic periods, the rate of meningococcal disease is roughly 5–10 cases per 100,000 population per year. During epidemics, the rate can be as high as 1,000 cases per 100,000 population. Although most common in the African meningitis belt, meningococcal outbreaks can occur anywhere in the world. Serogroup A predominates in the meningitis belt, although serogroups C, X, and W-135 are also found.
Young children have the highest risk for meningococcal disease, but 60% of cases occur in adolescents and adults. Risk is highest in travelers who have prolonged contact with local populations in the meningitis belt during an epidemic. The Hajj pilgrimage to Saudi Arabia has been associated with outbreaks of meningococcal disease in returning pilgrims and their contacts.
Meningococcal disease generally occurs 1–14 days after exposure. Meningococcal disease presents as meningitis in ≥50% of cases. Meningococcal meningitis is characterized by sudden onset of headache, fever, and stiffness of the neck, sometimes accompanied by nausea, vomiting, photophobia, or altered mental status. Up to 20% of people with meningococcal disease present with meningococcal sepsis, known as meningococcemia. Meningococcemia is characterized by an abrupt onset of fever and a petechial or purpuric rash. The rash may progress to purpura fulminans. Meningococcemia may often involve hypotension, acute adrenal hemorrhage, and multiorgan failure. Among infants and children aged <2 years, meningococcal disease may have nonspecific symptoms. Neck stiffness, usually seen in people with meningitis, may be absent.
Early diagnosis and treatment are critical. If possible, a lumbar puncture should be done before starting antibiotic therapy to ensure that bacteria, if any, can be cultured from cerebrospinal fluid (CSF). Diagnosis is generally made by isolating N. meningitidis from blood or CSF, by detecting meningococcal antigen in CSF by latex agglutination, or by evidence of N. meningitidis DNA by PCR.
The signs and symptoms of meningococcal meningitis are similar to those of other causes of bacterial meningitis, such as Haemophilus influenzae and Streptococcus pneumoniae. The causative organism should be identified so that the correct antibiotics can be used for treatment and prophylaxis.
Meningococcal disease is potentially fatal and should always be viewed as a medical emergency. Antibiotic treatment must be started early in the course of the disease. Several antibiotic choices are available, including ceftriaxone, chloramphenicol, cefotaxime, and benzylpenicillin.
PREVENTIVE MEASURES FOR TRAVELERS
Indications for Use
The Advisory Committee for Immunization Practices (ACIP) recommends vaccination against meningococcal disease to people who travel to or reside in countries where N. meningitidis is hyperendemic or epidemic, particularly if contact with the local population will be prolonged. Hyperendemic regions include the meningitis belt of Africa (see Map 3-13) during the dry season (December–June). Advisories for travelers to other countries are issued when epidemics of meningococcal disease caused by vaccine-preventable serogroups are recognized (see the CDC Travelers’ Health website at www.cdc.gov/travel). Note that proof of receipt of quadrivalent vaccination against meningococcal disease is required for people traveling to Mecca during the annual Hajj and Umrah pilgrimages.
Two quadrivalent meningococcal polysaccharide–protein conjugate vaccines (MenACWY) (Menactra, Menveo) are licensed for use in the United States and are differentiated by their protein conjugate. A one-dose primary series of MenACWY-D (Menactra) is licensed for people aged 2–55 years; a two-dose primary series of MenACWY-D is licensed for children aged 9–23 months. MenACWY-Crm (Menveo) is licensed for people aged 2–55 years. Quadrivalent meningococcal polysaccharide vaccine (MPVS4) (Menomune) is licensed for use among people aged ≥2 years. These vaccines protect against meningococcal disease caused by serogroups A, C, Y, and W-135. Approximately 7–10 days are required after vaccination for development of protective antibody levels.
MenACWY-D is the only meningococcal vaccine licensed for children aged 9–23 months. Using either one of the MenACWY vaccines is preferred for people aged 2–55 years; MPSV4 should be used for people >55 years. In the United States, there is no licensed vaccine for people <9 months.
CDC recommends routine vaccination of people with MenACWY at age 11 or 12 years, with a booster dose at age 16 years. For adolescents who receive the first dose at age 13–15 years, a one-time booster dose should be administered, preferably at age 16–18 years. People who receive their first dose of MenACWY at or after age 16 years do not need a booster dose, unless they remain at continued risk for meningococcal disease.
Travelers who were vaccinated previously and are living in or returning to Africa's meningitis belt may need to be revaccinated. ACIP recommends that children previously vaccinated with MenACWY or MPVS4 at ages 9 months through 6 years who remain at an increased risk for meningococcal disease should receive an additional dose of MenACWY 3 years after their previous meningococcal vaccine and every 5 years thereafter, if at continued risk. Likewise, individuals who were previously vaccinated with MenACWY or MPVS4 at ages 7–55 years and who remain at an increased risk for meningococcal disease should receive an additional dose of MenACWY 5 years after their previous dose and every 5 years thereafter, if at continued risk. Travelers aged >55 years should be vaccinated or revaccinated with MPSV4 if it has been >5 years since their last meningococcal vaccine. Travelers to the Hajj must show proof of vaccination in the previous 3 years. Previously unvaccinated travelers who have a history of complement component deficiency (C3, properdin, factor D, or late component), functional or anatomic asplenia, or HIV should receive a two-dose primary series of meningococcal conjugate vaccine, 2 months apart (if aged <56 years) or a single dose of meningococcal polysaccharaide vaccine (if aged ≥56 years), prior to travel if possible.
(Updated January 25, 2012)
Vaccine Safety and Adverse Reactions
For MPSV4, the incidence of local reactions (such as pain and redness at the injection site) has ranged from 4% to 56% across studies. Severe reactions are rare, with an incidence of <0.1 per 100,000 vaccinees. In comparison trials, the incidence of severe reactions after MenACWY was similar to the incidence after MPSV4 vaccination; however, local reactions (including pain that limited movement of the arm of injection) were more common after MenACWY.
Precautions and Contraindications
People with moderate or severe acute illness should defer vaccination until their condition improves. MenACWY and MPSV4 are contraindicated for people who have severe allergic reaction to any component of the vaccines. People with dry natural rubber latex allergy should not receive Menactra. MPSV4 is an acceptable alternative for protection against meningococcal disease. Both MenACWY and MPSV4 are inactivated vaccines and may be given to immunosuppressed people.
In the United States and most industrialized countries, antibiotic chemoprophylaxis among close contacts of a patient with invasive meningococcal disease is recommended to prevent secondary cases. Antibiotic regimens for prophylaxis include rifampin, ciprofloxacin, and ceftriaxone. Ceftriaxone is recommended for pregnant women.
- American Academy of Pediatrics. Meningococcal infections. In: Pickering LK, editor. Red Book: 2003 Report of the Committee on Infectious Disease. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003. p. 430–6.
- Bilukha OO, Rosenstein N. Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005 May 27;54(RR-7):1–21.
- CDC. Recommendation of the Advisory Committee on Immunization Practices [ACIP] for use of quadrivalent meningococcal conjugate vaccine [MenACWY-D] among children aged 9 through 23 months at increased risk for invasive meningococcal disease. MMWR 2011: 60(40);1391–2.
- CDC. Updated recommendation from the Advisory Committee on Immunization Practices (ACIP) for revaccination of persons at prolonged increased risk for meningococcal disease. MMWR Morb Mortal Wkly Rep. 2009 Sep 25;58(37):1042–3.
- CDC. Updated recommendations for use of meningococcal conjugate vaccines—Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep. 2011 Jan 28;60(3):72–6.
- Greenwood B. Manson Lecture. Meningococcal meningitis in Africa. Trans R Soc Trop Med Hyg. 1999 Jul–Aug;93(4):341–53.
- Koch S, Steffen R. Meningococcal disease in travelers: vaccination recommendations. J Travel Med. 1994 Mar 1;1(1):4–7.
- Raghunathan PL, Bernhardt SA, Rosenstein NE. Opportunities for control of meningococcal disease in the United States. Annu Rev Med. 2004;55:333–53.
- Rosenstein NE, Perkins BA, Stephens DS, Popovic T, Hughes JM. Meningococcal disease. N Engl J Med. 2001 May 3;344(18):1378–88.
- Stephens DS, Greenwood B, Brandtzaeg P. Epidemic meningitis, meningococcaemia, and Neisseria meningitidis. Lancet. 2007 Jun 30;369(9580):2196–210.
- Wilder-Smith A. Meningococcal disease: risk for international travellers and vaccine strategies. Travel Med Infect Dis. 2008 Jul;6(4):182–6.
- Travel Notices
- Find a Clinic
- Disease Directory
- Information Centers
- Traveler Information Center
- Common Travel Health Topics
- Adventure Travel
- Bug Bites
- Business Travel
- Counterfeit Drugs
- Cruise Ship Travel
- Cold Climates
- Deep Vein Thrombosis
- Food and Water
- Health Care Abroad
- High Altitudes
- Hot Climates
- Humanitarian Aid Workers
- Jet Lag
- Last-Minute Travel
- Long-Term Travel
- Mass Gatherings
- Medical Tourism
- Mental Health
- Motion Sickness
- Natural Disasters
- Pregnant Travelers
- Road Safety
- Senior Citizens
- Sex Tourism
- Sick After Travel
- Study Abroad
- Sun Exposure
- Swimming and Diving
- Travelers' Diarrhea
- Travelers with Chronic Illnesses
- Travelers with Weakened Immune Systems
- Traveling with a Disability
- Traveling with Your Pet
- Visiting Friends or Relatives
- Water Disinfection
- Traveler Survival Guide
- CDC-TV Videos
- Common Travel Health Topics
- Clinician Information Center
- Travel Industry Information Center
- Traveler Information Center
- Yellow Book
- RSS Feeds
Before you travel make sure you speak with your doctor.