27 Feb 2015
Meningococcal diseaseMeningococcal disease is a rare, but potentially devastating infection in travellers caused by the bacteria Neisseria meningitidis
Meningococcal disease is a rare, but potentially devastating infection in travellers.
It is caused by the bacteria Neisseria meningitidis. The most common forms of meningococcal disease are meningococcal meningitis (infection of the protective lining around the brain) and septicaemia (blood poisoning).
Worldwide meningococcal disease is most prevalent in the ‘meningitis belt’ of sub-Saharan Africa particularly during the dry season. Dry season months in Africa vary. In West Africa, the dry season is usually between December and June.
Meningococcal disease in travellers is primarily a risk for those visiting areas prone to outbreaks (the meningitis belt) or an area where a known outbreak is occurring.
Travellers whose planned activities put them at increased risk could consider vaccination with quadrivalent vaccine protective against A, C, Wand Y serogroups.
All pilgrims travelling to the Kingdom of Saudi Arabia for the Hajj or Umrah are required to show proof of vaccination with quadrivalent vaccine in order to obtain a visa.
Invasive meningococcal disease is a serious disease caused by the Gram-negative bacterium, Neisseria meningitidis. Approximately 10 percent of the general population of the UK are thought to carry N. meningitidis in their nasopharynx (the lining of the nose and throat) with the highest rates of carriage among adolescents and young adults . Carriers are asymptomatic (do not have symptoms), but can develop disease when bacteria invade the bloodstream from the nasopharynx. Invasive disease is a rare but serious outcome usually presenting as septicaemia (blood poisoning) or meningitis (infection of the lining of the brain). According to the World Health Organization (WHO), 5-10 percent of individuals with meningococcal meningitis have a fatal outcome, with up to 20 percent of survivors having long-term complications such as hearing loss and speech impairment .
N. meningitidis is divided into ‘serogroups’ according to the structure of its outer polysaccharide capsule. Thirteen serogroups have been identified but the six major serogroups associated with disease are A, B, C, W, X and Y. The distribution of each serogroup varies geographically and also changes over time . Effective vaccinations are available against meningococcal disease .
In most of the world cases of meningococcal disease occur sporadically or in small clusters with marked seasonal variations. Rates of invasive meningococcal disease in the developed world are low with the incidence in Europe and the USA being less than 1 case per 100,000 population per year [5, 6]. In the UK the incidence of meningococcal disease has declined since the introduction of meningococcal C vaccination in 1999. The incidence of meningococcal disease in the UK in 2011 was 1.66 per 100,000 . Serogroups B and C are the most common cause of disease in Europe, the Americas, Australia and New Zealand. In the UK since 2009 there has been an increase in the number of cases of serogroup W infections .
Worldwide, the highest rates of disease occur in the ‘meningitis belt’ of sub-Saharan Africa (Figure 1). This extends across the dry savannah regions from Senegal in the west, to Ethiopia in the east . The baseline incidence in the meningitis belt varies from 10-20 cases per 100,000 population per year; however during epidemics, rates can rise as high 1000 cases per 100,000 population per year . The largest recorded outbreak of meningococcal disease occurred in Africa in 1996 when over 20,000 deaths were reported to the WHO . Epidemics in the meningitis belt usually occur in the dry season . A combination of factors facilitates this seasonal transmission including: dust winds, increased incidence of upper respiratory tract infections, overcrowding and seasonal population displacement . Dry season months in Africa vary. In West Africa, the dry season is usually between December and June. Serogroup A is the commonest cause of meningococcal disease in the meningitis belt, however outbreaks of serogroups C, W and X have also occurred [8, 11].
Between 1987 and 2001 several outbreaks of meningococcal serogroup W disease have been associated with the Hajj pilgrimage including among pilgrims returning to their home countries . Carriage rates during the Hajj have been reported to be as high as 80% . In 2000, an international outbreak of meningococcal infection due to serogroup W was associated with the Hajj pilgrimage . During the Hajj in 2000 more than 400 cases of meningococcal meningitis cases due toserogroup W135 were reported in pilgrims and theirclose contacts from 16 countries . As a consequence of this pilgrims to the Hajj or Umrah require proof of vaccination with quadrivalent (A, C, W, Y) vaccine in order to obtain a visa for entry to into the Kingdom of Saudi Arabia. General advice for pilgrims to the Hajj or Umrah can be found here.
Current outbreaks of meningococcal disease are recorded in the Outbreak Surveillance Database.
Figure 1: WHO map meningococcal disease areas at high risk, 2014
Source: World Health Organization, 2015
Please check our Country Information pages for individual country vaccine recommendations.
Risk for travellers
Despite being rare in travellers, meningococcal disease may have devastating consequences. Determining whether a case of meningococcal disease is travel-related is difficult. Rather than acquiring infection in another country, a traveller can be colonised with meningococcal bacteria prior to travel and develop symptoms whilst abroad. A link with travel can be inferred when a strain of N. meningitidis rarely seen in the UK is isolated e.g. serogroup A. In England, Wales and Northern Ireland, there is currently no routine reporting of travel-related meningococcal infections. In most UK travellers there is not an increased risk of meningitis .
Meningococcal disease is primarily a risk for those travelling to areas prone to outbreaks (the meningitis belt) or an area where a known outbreak is occurring.
Travellers visiting such locations at increased risk include:
- long stay travellers who have close contact with the local population
- healthcare workers
- those visiting friends and relatives
- those who live or travel ‘rough’ such as backpackers
- individuals with no spleen or a poorly functioning spleen
- individuals with certain immune deficiencies e.g. certain complement deficiencies
|General advice on vaccinations for individuals without a spleen or with a dysfunctional spleen and complement disorders (including those regularly taking complement inhibitors, such as Eculizumab) can be found here.|
Vaccine recommendations for specific countries can be found on our Country Information pages.
The reservoir for N. meningitidis is exclusively human. Carriers of N. meningitidis harbour the bacteria in their nasopharynx. Approximately 10 percent of the population of the UK carry N. meningitidis. Rates of carriage are higher in adolescents and young adults and are also increased in closed populations including military personnel and university students [1, 16, 17]. Transmission between individuals occurs via the respiratory route, from coughing, sneezing, kissing or during close contact with a carrier. In most individuals, infection leads to a period when the organism is carried but does not cause illness, after which most individuals clear the infection. Such carriage may lead to immunity against the specific serogroup concerned .
Invasive meningococcal disease is rare, occurring in only a small number of carriers when bacteria invade the bloodstream from the nasopharynx. Damage to the lining of the nose resulting from smoking and upper respiratory tract infections may facilitate bacterial invasion from the nasopharynx.
Signs and symptoms
The most common clinical presentations of invasive meningococcal disease are meningitis and septicaemia. Meningococcal meningitis usually presents with sudden onset of fever, intense headache, neck stiffness, nausea and vomiting. These symptoms can develop within hours. The person is often irritable and prefers to lie still. Septicaemia usually presents with fever and a non-blanching petechial or purpuric rash. Confusion, shock and coma may ensue. Infants and young children, however, are likely to present with non-specific symptoms and signs. These are serious diseases with high mortality and morbidity, particularly if treatment is delayed.
Less commonly, invasive meningococcal disease may also present in other ways including: pneumonia, arthritis, and pericarditis (heart lining infection) . In rare cases, the infection may present as a chronic form of invasive meningococcal disease, with prolonged, intermittent fevers, rash, joint pains and headaches .
Diagnosis and treatment
Diagnosis of meningococcal disease can be confirmed by isolation of the organism from the blood or cerebrospinal fluid through culture. Antigen detection techniques or polymerase chain reaction (PCR) can also be used. Suspected meningococcal infection is a medical emergency. Treatment with intravenous antibiotics should be commenced as soon as possible. Admission tointensive care for close monitoring and supportive treatment is usually necessary. Medical resources in countries where meningococcal disease is most common may be limited.
Preventing meningococcal disease
Travellers should be advised about disease transmission and activities that may put them at higher risk. (See ‘Risk for travellers’ section above).
Meningococcal vaccinations are administered as part of the routine NHS vaccination schedule. Meningococcal group C vaccination was the first meningococcal vaccination to be added to the schedule in 1999. Both meningococcal group B (Bexero®) and the quadrivalent meningococcal vaccine (protective against serogroups A,C,W and Y) have been offered to children from Autumn 2015 [18, 19]. See NHS vaccination schedule.
A quadrivalent vaccine (protective against serogroups A, C, Wand Y) may be offered to travellers considered at higher risk of meningococcal disease (see ‘Risk for travellers’ section above). All pilgrims travelling to Saudi Arabia for the Hajj or Umrah are required to show proof of vaccination before they can be issued with a visa. Vaccine recommendations for specific countries can be found on the Country Information pages.
Quadrivalent vaccinations include: Conjugate meningococcal quadrivalent ACW135Y vaccines Menveo® and Nimenrix® and polysaccharide meningococcal quadrivalent vaccine: ACWY Vax® (which is no longer manufactured). Conjugate vaccinations are more immunogenic than the older polysaccharide vaccines and provide longer lasting protection. These vaccines are preferred to the polysaccharide vaccines in all situations.
As of February 2017, Menveo® (conjugate MenACWY) has a marketing authorisation for use in children from 2 years of age, adolescents and adults and Nimenrix® (conjugate MenACWY) has a marketing authorisation for individuals from 6 weeks to 12 weeks and from 12 months and older. The use of these vaccines in certain infant age groups is off-license, following Public Health England (PHE), Immunisation against infectious disease, the 'Green book' (see resources).
Nimenrix® is a black triangle medicine. Black triangle medicines are monitored intensively by the UK safety regulators – the Medicines Healthcare products Regulatory Agency (MHRA) and Commission on Human Medicines (CHM) and require all suspected reactions to be reported to the MHRA.
The Summary of Product Characteristics (SmPC) for individual vaccines should be consulted for specific information relating to the product [20-22].
Table 1: Recommendations for the use of quadrivalent meningococcal vaccines for travel from PHE 'Green book' please note the manufacturers information may differ
|Birth to less than one year*||
|From one year of age (including adults)||Single dose of 0.5ml|
* If the infant has already had two MenC vaccinations then two MenACWY conjugate vaccines should also be given .
Known hypersensitivity to any components of the vaccine, or to a previous dose. Vaccination should be delayed in acute febrile illness .
First Published : 27 Feb 2015
Last Updated :  08 Feb 2017
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