Chapter 3 Infectious Diseases Related to Travel
Jessica R. MacNeil, Sarah A. Meyer
Neisseria meningitidis is a gram-negative diplococcus. Meningococci are classified into serogroups on the basis of the composition of the capsular polysaccharide. The 6 major meningococcal serogroups associated with disease are A, B, C, W, X, and Y.
Person-to-person transmission occurs by close contact with respiratory secretions or saliva.
N. meningitidis is found worldwide, but the highest incidence is in the “meningitis belt” of sub-Saharan Africa (Map 3-11). Meningococcal disease is hyperendemic in this region, and periodic epidemics during the dry season (December–June) reach up to 1,000 cases per 100,000 population. By contrast, rates of disease in the United States, Europe, Australia, and South America range from 0.3 to 3 cases per 100,000 population per year. 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 are also found. At any time, 5%–10% of the population may be carriers of N. meningitidis.
Outside the meningitis belt, infants have the highest rates of disease. In meningitis belt countries, high attack rates are seen up to 30 years of age. Risk for travelers is highest in people visiting meningitis belt countries who have prolonged contact with local populations during an epidemic. The Hajj pilgrimage to Saudi Arabia has also been associated with outbreaks of meningococcal disease in returning pilgrims and their contacts.
Meningococcal disease generally occurs 1–10 days after exposure and 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 often involves 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 in this age group.
Map 3-11. Areas with frequent epidemics of meningococcal meningitis
Early diagnosis and treatment are critical. A lumbar puncture should be done to examine the cerebrospinal fluid (CSF) and perform a Gram stain. If possible, the lumbar puncture should be done before starting antibiotic therapy to ensure that bacteria, if present, can be cultured from CSF. Diagnosis is generally made by isolating N. meningitidis from blood or CSF through culture, 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, and empirically prior to the diagnostic test results. Several antibiotic choices are available, including third-generation cephalosporins.
Indications for Use
The Advisory Committee on Immunization Practices (ACIP) recommends vaccination against meningococcal disease for people aged 11–18 years, people with certain underlying medical conditions, and for 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 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.
Four meningococcal vaccines are licensed in the United States: 3 polysaccharide–protein conjugate vaccines and 1 polysaccharide vaccine. The quadrivalent (serogroups A, C, W, and Y) conjugate vaccines are Menactra (MenACWY-D, Sanofi Pasteur) and Menveo (MenACWY-CRM, Novartis). A bivalent (serogroups C and Y) conjugate vaccine MenHibrix (HibMenCY-TT, GSK) is also licensed. MPSV4 is the only licensed meningococcal vaccine for adults aged ≥56 years and is immunogenic in older adults. Currently no licensed vaccine is available in the United States to prevent serogroup B meningococcal disease, although serogroup B vaccines have recently been licensed in Europe, Australia, and Canada. A monovalent serogroup A vaccine (MenAfriVac, Serum Institute of India) has progressively been introduced into meningitis belt countries since 2010. This vaccine is not licensed outside the meningitis belt and is not available outside national and subnational immunization campaigns in meningitis belt countries. Approximately 7–10 days are required after vaccination for development of protective antibody levels. Refer to Table 3-13 for more information about available meningococcal vaccines.
CDC recommends routine administration of a quadrivalent meningococcal conjugate vaccine MenACWY for all people aged 11–18 years. A single dose of vaccine should be administered at age 11 or 12 years, and a booster dose should be administered at age 16 years. Routine immunization is not recommended for other age groups in the United States, with the exception of people at increased risk for meningococcal disease. Those at increased risk for meningococcal disease include people who have a persistent complement component deficiency (C3, C5-9, properdin, factor D, or factor H), people who have functional or anatomic asplenia, or travelers to or residents of countries where meningococcal disease is hyperendemic or epidemic. Vaccine, product, number of doses, and booster dose recommendations are based on age and risk factor and are described in detail for each risk group in the 2013 ACIP Meningococcal Disease Recommendations (www.cdc.gov/mmwr/preview/mmwrhtml/rr6202a1.htm).
Immunization for Travelers
Travelers who visit or reside in countries where meningococcal disease is hyperendemic or epidemic, including the meningitis belt of sub-Saharan Africa during the dry season (December–June), should receive vaccination with a quadrivalent meningococcal vaccine, either MenACWY vaccine (people aged 2 months through 55 years and meningococcal vaccine non-naïve people aged ≥56 years) or MPSV4 (meningococcal vaccine-naïve people aged ≥56 years) before travel. Infants and children who received Hib-MenCY-TT are not protected against serogroups A and W and should receive a quadrivalent vaccine before travel if traveling to areas with high endemic rates of meningococcal disease.
In children initiating vaccination at 2 months of age, MenACWY-CRM should be administered as a 4-dose series at 2, 4, 6, and 12 months of age. In children initiating vaccination at 7–9 months through 23 months of age, MenACWY-CRM or MenACWY-D should be administered as a 2-dose series. Children aged 7–23 months can receive the second dose as early as 8 weeks after the first dose before travel. For people aged 2–55 years, 1 dose of a MenACWY vaccine is recommended. For people aged ≥56 years who have never received meningococcal vaccine, MPSV4 is recommended. However, for people aged ≥56 years who were previously vaccinated with MenACWY or for whom multiple doses are anticipated, MenACWY is preferred, although it is not licensed for this age group.
Travelers aged ≥2 years to the Kingdom of Saudi Arabia for Umrah or Hajj are required by the Saudi government to provide documentation of quadrivalent vaccine receipt in the 3 years before the date of travel. Travelers aged 3 months through 2 years are required to show documentation of 2 doses of a meningococcal vaccine against serogroup A.
International travelers at risk for meningococcal disease who were previously vaccinated with a quadrivalent vaccine should receive a booster dose: for children who received their last dose at <7 years of age, an additional dose of MenACWY should be administered 3 years after the last dose. For people who received their last dose at ≥7 years of age, a booster dose should be administered 5 years after the last dose.
Vaccine Safety and Adverse Reactions
Low-grade fevers and local reactions, such as injection site pain, arm swelling, and pain that limits movement of the injected arm, are side effects seen after both conjugate and polysaccharide meningococcal vaccines but occur more commonly after conjugate vaccine. Symptoms are generally mild to moderate and resolve within 48–72 hours. Severe adverse events, such as high fever, chills, joint pain, rash, or seizures are rare (<5% of vaccinees) with either type of vaccine.
Although no clinical trials of meningococcal vaccines have been conducted in pregnant or lactating women, postlicensure safety data have not identified any serious safety concerns to the mother or fetus. Pregnancy or lactation should not preclude vaccination with MenACWY or MPSV4 if indicated.
Precautions and Contraindications
People with moderate or severe acute illness should defer vaccination until their condition improves. Vaccination is contraindicated for people who have a severe allergic reaction to any component of the vaccines. All meningococcal vaccines are inactivated and may be given to immunosuppressed people.
In the United States and most industrialized countries, antibiotic chemoprophylaxis is recommended for close contacts of a patient with invasive meningococcal disease to prevent secondary cases. Chemoprophylaxis ideally should be initiated within 24 hours after the index patient is identified; prophylaxis given >2 weeks after exposure has little value. Antibiotic regimens for prophylaxis include rifampin, ciprofloxacin, and ceftriaxone. Ceftriaxone is recommended for pregnant women.
CDC website: www.cdc.gov/meningitis/bacterial.html
Table 3-13. Vaccines to prevent meningococcal disease
|VACCINE||TRADE NAME (MANU-
|Meningococcal polysaccharide diphtheria toxoid conjugate vaccine (MenACWY-D)1||Menactra (Sanofi Pasteur)||
0, 3 mo
|If at continued risk2|
|Meningococcal oligosaccharide diphtheria CRM197 conjugate vaccine (MenACWY-CRM)1||Menveo (Novartis)||
0, 2, 4, 10–13 mo
0, 3 mo (2nd dose administered in 2nd year of life)
|If at continued risk2|
|Meningococcal and Haemophilus influenzae type B polysaccharide tetanus toxoid conjugated vaccine3||MenHibrix (GSK)||6 wk–18 mo||0.5 mL||IM||0, 2, 4, 10–13 mo||If at continued risk2|
|Meningococcal polysaccharide vaccine (MPSV4)||Menomune (Sanofi Pasteur)||≥2 y||0.5 mL||SC||1 dose||If at continued risk4|
Abbreviations: IM, intramuscular; SC, subcutaneous.
1In an infant is receiving the vaccine before travel, 2 doses may be administered as early as 8 weeks apart.
2Revaccination with meningococcal conjugate vaccine (MenACWY-D or MenACWY-CRM) is recommended after 3 years for children who were previously vaccinated at ages 9 months through 6 years. Revaccination with meningococcal conjugate vaccine is recommended after 5 years for people who were previously vaccinated at ages 7–55 years, and every 5 years thereafter for people who are at continued risk.
3Infants and children who received HibMenCY-TT and are traveling to areas with high endemic rates of meningococcal disease such as the African meningitis belt are not protected against serogroups A and W and should receive a quadrivalent meningococcal vaccine before travel.
4Revaccination with meningococcal polysaccharide vaccine is recommended for adults aged >55 years who remain at increased risk 5 years after the last dose.
- American Academy of Pediatrics. Meningococcal infections. In: Pickering LK, editor. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012. p. 500–9.
- 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. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2013;62(2):1–28.
- Greenwood B. Manson Lecture. Meningococcal meningitis in Africa. Trans R Soc Trop Med Hyg. 1999 Jul–Aug;93(4):341–53.
- Halperin SA, Bettinger JA, Greenwood B, Harrison LH, Jelfs J, Ladhani SN, et al. The changing and dynamic epidemiology of meningococcal disease. Vaccine. 2012 May 30;30 Suppl 2: B26–36.
- 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.
- Page created: July 10, 2015
- Page last updated: July 10, 2015
- Page last reviewed: July 10, 2015
- Content source: