Consensus building and recommendations based on the available epidemiology of meningococcal disease in Gulf Cooperation Council States

Meningococcal disease in the Middle East: A report from the Global Meningococcal Initiative

This review details recent findings from the Global Meningococcal Initiative's (GMI) recent meeting on the surveillance and control strategies for invasive meningococcal disease in the Middle East. The nature of case reporting and notification varies across the region, with many countries using bacterial meningitis as an IMD case definition in lieu of meningitis and septicaemia. This may overlook a significant burden associated with IMD leading to underreporting or misreporting of the disease. Based on these current definitions, IMD reported incidence remains low across the region, with historical outbreaks mainly occurring due to the Hajj and Umrah mass gatherings. The use of case confirmation techniques also varies in Middle Eastern countries. While typical microbiological techniques, such as culture and Gram staining, are widely used for characterisation, polymerase chain reaction (PCR) testing is utilised in a small number of countries. PCR testing may be inaccessible for several reasons including sample transportation, cost, or a lack of laboratory expertise. These barriers, not exclusive to PCR use, may impact surveillance systems more broadly. Another concern throughout the region is potentially widespread ciprofloxacin resistance since its use for chemoprophylaxis remains high in many countries.

Meningococcal disease within the Gulf Cooperation Council Countries

This review reports on the recent epidemiology of invasive meningococcal disease (IMD) within the Gulf Cooperation Council (GCC) Countries (focusing from 2012 onwards), the existing immunization strategies and the potential for IMD resurgence. MenACWY vaccination is now established in infant or adolescent immunization programs in Saudi Arabia, Bahrain, Kuwait, and the United Arab Emirates. At present, GCC Countries do not include MenB immunization. National health surveillance reports indicate a total of 156 IMD cases reported across the GCC Countries between 2012 and 2021; between 30% and 80% of cases were reported in individuals aged ≥15 years. Lack of serogroup data hinders the assessment of vaccine impact and decision-making on additional vaccine introductions (e.g. MenB immunization). Hajj/Umrah pilgrimage and the increasing number of large-scale commercial and social events held in the GCC Countries pose a potential risk for future IMD outbreaks. Immunization policies for such events could be strengthened.

Epidemiological profile of Neisseria meningitidis in Casablanca, Morocco: 2010-2019

Surveillance of invasive meningococcal diseases (IMD) must be carried out regularly and continuously in order to detect the emergence of strains of reduced susceptibility to antibiotics for therapeutic and prophylactic use and the appearance of new invasive clones. Molecular-typing approaches allow reliable traceability and powerful epidemiological analysis. This is an epidemiological study of Neisseria meningitidis causing meningitis in Casablanca, Morocco. The grouping was confirmed by PCR mainly on the isolates from cerebrospinal fluid (CSF). A total of 245 confirmed isolates of N .meningitidis were obtained between 2010 and 2019 of which 93 % are of group B. Overall, 24 % of all the isolates have a reduced susceptibility to penicillin G, but no resistance to penicillin G has been reported. All the isolated strains are susceptible to third-generation cephalosporins (3GCs). Genotyping by multilocus sequence typing (MLST) of a selection of 18 strains showed that the majority of isolates belong to the invasive clonal complex CC 32(9/18) followed by the CC 41/44(3/18).

Molecular Characterization of Invasive Isolates of Neisseria meningitidis in Casablanca, Morocco

Meningococcal epidemiology may change unpredictably, and typing of Neisseria meningitidis isolates is crucial for the surveillance of invasive meningococcal disease (IMD). Few data are available regarding the meningococcal epidemiology in countries of North Africa. We aimed to explore invasive meningococcal isolates from the Casablanca region in Morocco. We used whole-genome sequencing (WGS) to characterize 105 isolates from this region during the period of 2011 to 2016. Our data showed that the majority (n = 100) of the isolates belonged to serogroup B. Genotyping indicated that most of the isolates (n = 62) belonged to sequence type 33 of clonal complex 32. The isolates also showed the same PorA and FetA markers and clustered together on the basis of WGS phylogenetic analysis; they seemed to correspond to an expansion of local isolates in the Casablanca region, as reported for similar isolates in several other countries. These data suggest that serogroup B isolates may predominate in Morocco, which may have an important impact in the design of vaccination strategies.

Vaccinations against respiratory infections in Arabian Gulf countries: Barriers and motivators

AIM

To study the uptake, barriers and motivators of influenza, pneumococcal, meningococcal and pertussis vaccines among members of public in Arabian Gulf countries.

METHODS

A cross-sectional survey among the Gulf Cooperation Council (GCC) countries’ residents. Data collected electronically through a smartphone app. The survey variables aimed to investigate the respondents’ awareness about vaccines against influenza, pneumococcal, meningococcal and pertussis infections. Collected data concerning the respondents’ socio-demographic characteristics, their perception toward vaccine uptake and the factors that motivate or demotivate them from taking influenza vaccine. The data were analysed statistically using the SPSS v.23.0. Differences in the characteristics of users from different countries were quantified through bivariate analysis. Other important variables and controlling factors were studied using logistic regression.

RESULTS

A total of 1812 respondents participated in the study. Their mean age was 27 years, 82% were male and 24% had ≥ 1 chronic diseases. The overall uptake of influenza vaccine was 17% (21% among “at risk” people) and ranged from 15% in Saudi Arabia to 24% in Qatar. Doctor’s advice (23%) and a perception of having low body immunity (21%) were the main cited reasons for being vaccinated, whereas unawareness about the vaccine (43%) was the main barrier. The overall uptake of pneumococcal vaccine in the preceding three years was 22% (25% among “at risk” individuals) and ranged from 0% in Bahrain to 79% in Kuwait. The overall uptake of pertussis vaccine was 16% (31% among “vulnerable” people), and ranged from 7% in Saudi Arabia to 75% in Oman. The overall uptake of meningococcal vaccine was 20% (29% among the “at risk” people) and ranged from 3% in Oman to 50% in Bahrain.

CONCLUSION

The vaccination uptake across GCC countries is suboptimal and varies widely across the countries. Further research is needed to unearth the reasons and formulate action plan.

Meningococcal disease during the Hajj and Umrah mass gatherings

The Hajj and Umrah religious mass gatherings hosted by the Kingdom of Saudi Arabia can facilitate the transmission of infectious diseases. The pilgrimages have been associated with a number of local and international outbreaks of meningococcal disease. These include serogroup A disease outbreaks in 1987 and throughout the 1990s and two international serogroup W135 outbreaks in 2000 and 2001. The implementation of strict preventative measures including mandatory quadrivalent meningococcal vaccination and antibiotic chemoprophylaxis for pilgrims from the African meningitis belt has prevented pilgrimage-associated meningococcal outbreaks since 2001. However, the fluid epidemiology of the disease and the possibility of outbreaks caused by serogroups not covered by the vaccine or emerging hyper-virulent strains, mean that the disease remains a serious public health threat during these events. Continuous surveillance of carriage state and the epidemiology of the disease in the Kingdom and globally and the introduction of preventative measures that provide broad and long-lasting immunity and impact carriage are warranted.

Global epidemiology of capsular group W meningococcal disease (1970-2015): Multifocal emergence and persistence of hypervirulent sequence type (ST)-11 clonal complex

Following an outbreak in Mecca Saudi Arabia in 2000, meningococcal strains expressing capsular group W (W) emerged as a major cause of invasive meningococcal disease (IMD) worldwide. The Saudi Arabian outbreak strain (Hajj clone) belonging to the ST-11 clonal complex (cc11) is similar to W cc11 causing occasional sporadic disease before 2000. Since 2000, W cc11 has caused large meningococcal disease epidemics in the African meningitis belt and endemic disease in South America, Europe and China. Traditional molecular epidemiologic typing suggested that a majority of current W cc11 burden represented global spread of the Hajj clone. However, recent whole genome sequencing (WGS) analyses revealed significant genetic heterogeneity among global W cc11 strains. While continued spread of the Hajj clone occurs in the Middle East, the meningitis belt and South Africa have co-circulation of the Hajj clone and other unrelated W cc11 strains. Notably, South America, the UK, and France share a genetically distinct W cc11 strain. Other W lineages persist in low numbers in Europe, North America and the meningitis belt. In summary, WGS is helping to unravel the complex genomic epidemiology of group W meningococcal strains. Wider application of WGS and strengthening of global IMD surveillance is necessary to monitor the continued evolution of group W lineages.

Prevention of meningococcal disease during the Hajj and Umrah mass gatherings: past and current measures and future prospects

The Kingdom of Saudi Arabia (KSA) has a long history of instituting preventative measures against meningococcal disease (MD). KSA is at risk of outbreaks of MD due to its geographic location, demography, and especially because it hosts the annual Hajj and Umrah mass gatherings. Preventative measures for Hajj and Umrah include vaccination, targeted chemoprophylaxis, health awareness and educational campaigns, as well as an active disease surveillance and response system. Preventative measures have been introduced and updated in accordance with changes in the epidemiology of MD and available preventative tools. The mandatory meningococcal vaccination policy for pilgrims has possibly been the major factor in preventing outbreaks during the pilgrimages. The policy of chemoprophylaxis for all pilgrims arriving from the African meningitis belt has also probably been important in reducing the carriage and transmission of Neisseria meningitidis in KSA and beyond. The preventative measures for Hajj and Umrah are likely to continue to focus on vaccination, but to favour the conjugate vaccine for its extra benefits over the polysaccharide vaccines. Additionally, the surveillance system will continue to be strengthened to ensure early detection and response to cases and outbreaks; ongoing disease awareness campaigns for pilgrims will continue, as will chemoprophylaxis for target groups. Local and worldwide surveillance of the disease and drug-resistant N. meningitidis are crucial in informing future recommendations for vaccination, chemoprophylaxis, and treatment. Preventative measures should be reviewed regularly and updated accordingly, and compliance with these measures should be monitored and enhanced to prevent MD during Hajj and Umrah, as well as local and international outbreaks.

Global incidence of serogroup B invasive meningococcal disease: a systematic review

Use of recently licensed vaccines against Neisseria meningitidis serogroup B (NmB) will depend partly on disease burden estimates. We systematically reviewed NmB incidence and mortality worldwide between January, 2000, and March, 2015, incorporating data from 37 articles and 12 websites. Most countries had a yearly invasive NmB incidence of less than 2 per 100,000 people. Within these relatively low incidence rates (compared with common causes of invasive bacterial diseases), substantial variation was detected between countries, with a notably higher incidence in Australia, Europe, North America, and South America. China and India had reports only of sporadic cases, and except for South Africa, sub-Saharan Africa showed a near absence of disease. In countries with consistently collected data, NmB incidence has tended to decrease, even as the proportion of invasive meningococcal disease cases caused by serogroup B has increased. With few exceptions, case-fatality ratios were fairly consistent, ranging between 3% and 10%. In high-income countries, incidence rates of NmB were relatively low compared with other vaccine-preventable diseases and might be decreasing. High case-fatality ratios, substantial disease-related morbidity, and the threat of outbreaks could nevertheless make NmB an attractive target for preventive and reactive immunisation programmes. The low availability of data from low-income and middle-income countries suggests the need for improved surveillance before vaccination strategies are designed.

Trends and variations in the epidemiology of meningococcal disease in Kuwait 1987-2013

The introduction of Haemophilus influenzae type b (Hib) conjugate vaccine and conjugate pneumococcal vaccine into routine childhood vaccination in Kuwait has resulted in the emergence of Neisseria meningitidis as the leading cause of invasive bacterial infection in children. Currently, a quadrivalent ACYW-135 meningococcal polysaccharide vaccine is administered as part of routine childhood vaccination in Kuwait at the age of 2 years. Conjugate meningococcal vaccines have been shown to be more effective in preventing meningococcal infection in young children. The objective of this study was to describe the epidemiology of meningococcal disease (MD) in Kuwait and evaluate the need for conjugate vaccine in routine childhood immunization. We have reviewed the MD surveillance data from the communicable disease unit, Ministry of Health, Kuwait during the period from 1987 to 2013. The analysis included microbiologically confirmed cases of N. meningitidis in the blood and cerebrospinal fluid. There were 293 cases of confirmed MD during the study period. Two hundred and four cases (70%) were in children ≤ 14 years of age. The mean incidence rate was 0.5/100,000 persons. The dominant serogroups were W-135 and B, accounting for 80 cases (32%) each. Serogroup B accounted for 69/204 (34%) of all cases in children ≤ 14 years and serogroup A accounted for 36/89 40% of all adult cases. There were three outbreaks: 1987 (caused by serogroup A), 1989 (caused by serogroup W-135) and 2002 (caused by serogroup B). The mean case fatality rate was 13.5%. In conclusion, despite childhood routine vaccination with ACYW-135 polysaccharide vaccine, infants and young children remain at high risk for MD, which supports the introduction of conjugate meningococcal vaccine to the routine childhood vaccination schedule.

Hajj: infectious disease surveillance and control

Religious festivals attract a large number of pilgrims from worldwide and are a potential risk for the transmission of infectious diseases between pilgrims, and to the indigenous population. The gathering of a large number of pilgrims could compromise the health system of the host country. The threat to global health security posed by infectious diseases with epidemic potential shows the importance of advanced planning of public health surveillance and response at these religious events. Saudi Arabia has extensive experience of providing health care at mass gatherings acquired through decades of managing millions of pilgrims at the Hajj. In this report, we describe the extensive public health planning, surveillance systems used to monitor public health risks, and health services provided and accessed during Hajj 2012 and Hajj 2013 that together attracted more than 5 million pilgrims from 184 countries. We also describe the recent establishment of the Global Center for Mass Gathering Medicine, a Saudi Government partnership with the WHO Collaborating Centre for Mass Gatherings Medicine, Gulf Co-operation Council states, UK universities, and public health institutions globally.

β-Lactamase production in key gram-negative pathogen isolates from the Arabian Peninsula

SUMMARY Infections due to Gram-negative bacilli (GNB) are a leading cause of morbidity and mortality worldwide. The extent of antibiotic resistance in GNB in countries of the Gulf Cooperation Council (GCC), namely, Saudi Arabia, United Arab Emirates, Kuwait, Qatar, Oman, and Bahrain, has not been previously reviewed. These countries share a high prevalence of extended-spectrum-β-lactamase (ESBL)- and carbapenemase-producing GNB, most of which are associated with nosocomial infections. Well-known and widespread β-lactamases genes (such as those for CTX-M-15, OXA-48, and NDM-1) have found their way into isolates from the GCC states. However, less common and unique enzymes have also been identified. These include PER-7, GES-11, and PME-1. Several potential risk factors unique to the GCC states may have contributed to the emergence and spread of β-lactamases, including the unnecessary use of antibiotics and the large population of migrant workers, particularly from the Indian subcontinent. It is clear that active surveillance of antimicrobial resistance in the GCC states is urgently needed to address regional interventions that can contain the antimicrobial resistance issue.

Immune response, antibody persistence, and safety of a single dose of the quadrivalent meningococcal serogroups A, C, W-135, and Y tetanus toxoid conjugate vaccine in adolescents and adults: results of an open, randomised, controlled study

BACKGROUND

The best strategy to protect individuals against meningococcal disease is to immunize against multiple serogroups. Immunogenicity, antibody persistence, and safety of the EU-licensed meningococcal ACWY-tetanus toxoid conjugate vaccine (MenACWY-TT) were evaluated in healthy participants aged 11-55 years from the Philippines and Saudi Arabia.

METHODS

In this phase IIb, open, controlled study, 500 participants were randomised (3:1) to receive one dose of MenACWY-TT or a licensed meningococcal polysaccharide vaccine (Men-PS). Functional antibody responses against meningococcal serogroups A, C, W-135, and Y were assessed by a serum bactericidal antibody assay using rabbit complement (rSBA) at Month 0, Month 1, Year 1, Year 2, and Year 3. Vaccine response was defined as an rSBA titre ≥32 at Month 1 in participants who were seronegative (rSBA titre <8) pre-vaccination and as at least a four-fold increase in titre in participants who were seropositive pre-vaccination. Solicited symptoms were recorded up to Day 4, safety outcomes up to Month 6, and serious adverse events related to vaccination up to Year 3.

RESULTS

Pre-specified criteria for non-inferiority of MenACWY-TT versus Men-PS were met in terms of rSBA vaccine response and incidence of grade 3 general symptoms. At Month 1, 82.7%-96.3% of MenACWY-TT and 69.7%-91.7% in Men-PS recipients had a vaccine response for each serogroup. At Year 3, ≥99.1% and ≥92.9% of MenACWY-TT recipients retained rSBA titres ≥8 and ≥128, respectively, as compared to ≥86.7% and ≥80.0% in the Men-PS group. Both vaccines had a clinically acceptable safety profile, although injection site redness and swelling were more frequent in MenACWY-TT recipients.

CONCLUSIONS

These results suggest that MenACWY-TT could protect adolescents and adults against meningococcal disease up to three years post-vaccination.

TRIAL REGISTRATION

This study is registered at http://www.clinicaltrials.gov/NCT00356369.

Acquisition of meningococcal serogroup W-135 carriage in Turkish Hajj pilgrims who had received the quadrivalent meningococcal polysaccharide vaccine

Invasive meningococcal disease is a recognized public health problem worldwide, with a dynamic and changeable epidemiology. In Turkey, the second most common pathogenic meningococcal serogroup (after serogroup B) is W-135, including an epidemic in 2005, which has been strongly associated with Hajj pilgrims and their close contacts. In two studies conducted in 2010, we assessed meningococcal carriage in intending Turkish pilgrims to the Hajj when they attended to receive a plain polysaccharide vaccine against serogroups A, C, W-135, and Y and, upon their return, to determine the acquisition of meningococcal carriage by the pilgrims themselves and subsequently their household contacts. Nasopharyngeal swabs were obtained from pilgrims before the Hajj and upon their return. Swabs were then obtained from 39 household contacts of pilgrims who were shown to have acquired carriage during the Hajj. Of the 472 pilgrims before the Hajj, 63 (13%) were positive for meningococcal carriage, of which 52 cases (83%) were serogroup W-135. In the 296 pilgrims tested after the Hajj, 81 (27%) were positive for meningococcal carriage, including 74 (91%) with W-135. In 11 family members of pilgrims who acquired W-135 carriage at the Hajj, 10 (91%) had acquired carriage of serogroup W-135. This study illustrates the acquisition of meningococcal carriage, predominantly of serogroup W-135 by pilgrims attending the Hajj, and the transmission of this carriage to their family members on their return, explaining the source of W-135 meningococcal disease in Turkey.

Meningococcal serogroup Y emergence in Europe: update 2011

Neisseria meningitidis is differentiated into 12 distinct serogroups, of which A, B, C, W-135, X, and Y are medically most important and represent an important health problem in different parts of the world. The epidemiology of N. meningitidis is unpredictable over time and across geographic regions. Recent epidemiological surveillance has indicated an increase of serogroup Y invasive meningococcal disease in some parts of Europe as shown in the epidemiological data for 2010 from various European countries previously published in this journal. ( 1) Here, data is reported indicating that the emergence of serogroup Y continued in 2011 in various regions of Europe. The average age of persons affected by N. meningitidis serogroup Y seems to have decreased in some countries in comparison to the previous decade.

Meningococcal disease in the Middle East and North Africa: an important public health consideration that requires further attention

This paper reviews the epidemiological data describing meningococcal disease in the Middle East and North Africa (MENA). While meningococcal disease remains an important cause of endemic and epidemic disease in many MENA countries, existing published epidemiological data appear limited, fragmented, and collected via disparate methodologies. Children aged 5 years and younger are predominantly affected, though outbreaks of the disease often affect older age groups. Whilst serogroup A remains a main cause of meningococcal disease in the region, cases of serogroup B, W-135, and Y have been increasingly reported over the last two decades in some countries. The Hajj pilgrimage is a key factor influencing outbreaks and transmission, and the use of vaccines has minimized the effects on the home countries of the pilgrims and has decreased global dissemination of disease. Wider use of available polyvalent meningococcal conjugate vaccines may provide broader protection against the range of serogroups causing disease or posing a threat in the region. In addition, strengthening regional surveillance systems and regularly publishing reports with reliable estimates of disease incidence, carriage, disease-related mortality, and sequelae may facilitate the development of appropriate interventions and public health strategies regarding meningococcal disease within the region.

Critical appraisal of a quadrivalent CRM(197) conjugate vaccine against meningococcal serogroups A, C W-135 and Y (Menveo) in the context of treatment and prevention of invasive disease

Worldwide, invasive meningococcal disease affects about 500,000 people annually. Case fatality in developed countries averages 10%, and higher rates are reported in less prosperous regions. According to the World Health Organization, the most important pathogenic serogroups are A, B, C, W-135, X, and Y. Clinical features of invasive meningococcal disease make diagnosis and management difficult. Antibiotic measures are recommended for prophylaxis after exposure and for treatment of invasive meningococcal disease cases; however, resistant strains may be emerging. Vaccines are generally regarded as the best preventative measure for invasive meningococcal disease. Polysaccharide vaccines against serogroups A, C, W-135, and Y using protein conjugation technology have clear advantages over older plain polysaccharide formulations without a protein component. The first quadrivalent meningococcal conjugate vaccine (MenACWY-D) was licensed in the US in 2005. More recently, MenACWY-CRM (Menveo^®) was licensed in Europe, the US, the Middle East, and Latin America. MenACWY-CRM uses cross-reactive material 197, a nontoxic mutant of diphtheria toxin, as the carrier protein. MenACWY-CRM offers robust immunogenicity in all age groups, with a tolerability profile similar to that of a plain polysaccharide vaccine. Given its potential for protecting persons from infancy to old age, MenACWY-CRM offers the opportunity to protect broad populations against invasive meningococcal disease. The most optimal strategy for use of the vaccine has to be assessed country by country on the basis of local epidemiology, individual health care systems, and need.