Epidemic meningococcal disease and travel

International Travelers' Sociodemographic, Health, and Travel Characteristics: An Italian Study

BACKGROUND

Approximately the 8% of travelers requires medical care, with the diagnosis of a vaccine-preventable disease. The aim of our study was to analyze the socio-demographic, health and travel characteristics of the Italian international travelers.

METHODS

We conducted a cross sectional study from January 2015 to June 2016, at the Travel Medicine Clinic of Siena, asking the doctor to interview patients who attended the Clinic, recording socio-demographic and travel information, malaria prophylaxis, vaccinations. The data were organized in a database and processed by software Stata®.

RESULTS

We collected 419 questionnaires. Patients chose 71 countries for their travels; the favorite destinations were: India (6.31%), Thailand (6.31%), and Brazil (5.10%). The mean length of stay was 36.17 days. Italians, students, and freelancers tended to stay abroad for a longer time (mean: 36.4 days, 59.87 days and 64.16 days respectively). 33.17% of our sample used drugs for malaria chemoprophylaxis: 71.9% of them used Atovaquone/Proguanil (Malarone®), 26.6% used Mefloquine (Lariam®), 1.5% other drugs. The vaccinations that travelers mostly got in our study were to prevent hepatitis A (n = 264), the typhoid fever (n = 187), the Tetanus + Diphtheria + Pertussis (n = 165), the Yellow fever (n = 118) and the cholera (n = 78). Twenty-eight (6.68%) refused some recommended vaccinations. The vaccines mostly refused were for Typhoid fever (n = 20), hepatitis a (n = 9), and cholera (n = 9).

CONCLUSION

Our results demonstrated that Italian international travelers are at-risk because of their poor vaccinations adherence. This implies that pre-travel counseling is fundamental to increase the knowledge of the risks and the compliance of future travelers.

The Global Meningococcal Initiative: recommendations for reducing the global burden of meningococcal disease

The Global Meningococcal Initiative (GMI) is composed of an international group of scientists, clinicians and public health officials with expertise in meningococcal immunology, epidemiology and prevention. The primary goal of the GMI is the promotion of the global prevention of invasive meningococcal disease through education and research. The GMI members reviewed global meningococcal disease epidemiology, immunization strategies, and research needs. Over the past decade, substantial advances in meningococcal vaccine development have occurred and much has been learned about prevention from countries that have incorporated meningococcal vaccines into their immunization programs. The burden of meningococcal disease is unknown for many parts of the world because of inadequate surveillance, which severely hampers evidence-based immunization policy. As the field of meningococcal vaccine development advances, global surveillance for meningococcal disease needs to be strengthened in many regions of the world. For countries with meningococcal vaccination policies, research on vaccine effectiveness and impact, including indirect effects, is crucial for informing policy decisions. Each country needs to tailor meningococcal vaccination policy according to individual country needs and knowledge of disease burden. Innovative approaches are needed to introduce and sustain meningococcal vaccination programs in resource-poor settings with a high incidence of meningococcal disease.

Meningococcal vaccine in travelers

PURPOSE OF REVIEW

New vaccines to prevent meningococcal disease have been licensed in recent years. It is therefore timely to discuss current vaccine strategies pertinent to international travelers in relation to the changing epidemiology.

RECENT FINDINGS

Serogroup W135 achieved epidemic status in Africa in 2002, and then largely disappeared over a short time period. The year 2006 saw a marked epidemic rise in meningitis attack rates across the meningitis belt in Africa. This rise was mainly due to a new serogroup A strain, indicating that a new meningitis epidemic wave is beginning in Africa. Epidemics are also spreading south of the meningitis belt, including the Greater Lakes Area (Burundi, Rwanda, Republic of Tanzania). The new quadrivalent conjugate meningococcal vaccine is now licensed in North America but not elsewhere. In most other industrialized countries, the serogroup C conjugate vaccine is licensed. Plain polysaccharide quadrivalent vaccines are available almost worldwide.

SUMMARY

Quadrivalent meningococcal vaccination is a visa requirement for Hajj and Umrah pilgrims to Saudi Arabia. Travelers to the meningitis belt during the dry season should be advised to receive meningococcal vaccine that covers all four serogroups. This recommendation should be extended to the Greater Lake Area, because of recent epidemics. Vaccine choices depend on availability.

Special infectious disease risks of expatriates and long-term travelers in tropical countries. Part II: infections other than malaria

A wide range of viral, bacterial, and protozoal diseases pose risk to long-term tropical travelers. Risk varies geographically and with lifestyle. For some infections, risk increases with duration of stay, coming to resemble that of the local population. Risk management strategies include vaccination, chemoprophylaxis, avoidance measures, and screening, where appropriate. Vaccination against hepatitis A and B, typhoid, and rabies is recommended for all long-term travelers to (sub-)tropical areas. Lowering of the vaccination threshold for Japanese encephalitis is suggested. Meningococcal disease is rare in travelers, but vaccination is safe and acceptable. The efficacy of Bacillus Calmette-Guérin (BCG) is uncertain; immunological testing avoids BCG's confounding of tuberculin testing. Diarrhea is common, and self-treatment may be recommended. Sexually transmitted infections including human immunodeficiency virus (HIV) are serious risks; education, screening, and HIV postexposure prophylaxis following involuntary exposure are recommended. Many infections are chronic or asymptomatic, and appropriate screening is recommended on return or after prolonged exposure.

Vaccine-preventable diseases in long-term expatriates

The term "expatriates" refers to professionals and their families who live abroad for several months or years. Owing to potential prolonged exposure, and living conditions that may be closer to those of the local population, they are at higher risk of acquiring infectious diseases that are endemic in their new place of residence. They often have reduced access to medical services, putting them at higher risk of complications and more severe outcomes. Vaccination is probably one of the most effective means of preventing expatriates from acquiring endemic or epidemic diseases. Incapacitation or sickness in the field may cause serious disruption to project activities and impose an extra workload on the local team. It may also result in repatriation, with further extra direct and indirect costs for the organization. Predeparture advice and preparation, to promote risk reduction behavior, coupled with adequate support in the field are key ingredients to ensure effective and successful activities of collaborators. Institutions and organizations sending expatriates to developing countries have a clear responsibility, and it is in their own interests to promote the health of their employees working abroad.

Meningococcal disease in international travel: vaccine strategies

International travel and migration facilitate the rapid intercontinental spread of meningococcal disease. Serogroup A, and to a lesser extent serogroup C, have been responsible for pandemics in the past (mainly in Africa), but in recent years there was an international outbreak due to W135 related to the Hajj pilgrimage. The high carriage rates, persistence and transmissibility, in combination with the high case fatality rate of the Hajj-associated W135 outbreak clone, certainly raise considerable concern about the public health consequences of widespread dissemination of this organism and the potential for future epidemics. Indeed, the now evolving W135 epidemic in Africa mandates that the bivalent meningococcal vaccine should be replaced by the tetravalent meningococcal vaccine, covering A, C, Y and W135 serogroups. The currently available polysaccharide tetravalent meningococcal vaccine, albeit associated with high seroconversion and efficacy rates, has several shortcomings: it is not immunogenic in young children, duration of protective immunity is short, and it has minimal or no effect on nasopharyngeal carriage and therefore transmission of the organism. Immunogenicity of polysaccharide vaccines can be improved by chemical conjugation to a protein carrier, thereby eliciting a T-cell-dependent antibody response. In contrast to polysaccharide vaccines, conjugate vaccines are immunogenic in young infants, induce long-term protection, and reduce nasopharyngeal carriage. The tetravalent conjugate vaccine will be a leap forward in the control of meningococcal epidemics in affected countries. It will also boost the uptake of meningococcal vaccines in travelers, because the duration of protection is longer and it eliminates the problem of immune hyporesponsiveness of serogroup C with repeated dosing. The small risk of travel-associated disease for the general traveler and the unpredictable nature of epidemics make it difficult to provide evidence-based vaccine recommendations. The current recommendation is to vaccinate all Hajj pilgrims, travelers to areas with current outbreaks, travelers to the sub-Saharan meningitis belt, and high-risk individuals (i.e., those with immunodeficiencies).

Meningococcal disease and travel

Meningococcal disease continues to be a worldwide problem. This review examines the impact meningococcal disease has on international travel and vice versa the impact international travel has on the intercontinental spread of meningococci. The risk of meningococcal disease to the endemic population differs from that of travellers. The best documented risk of meningococcal disease among travellers has been in Hajj pilgrims for Mecca and Madina in Saudi Arabia. In response to the recent Hajj associated outbreak of W135 meningococcal disease, quadrivalent meningococcal vaccine (against serogroups A/C/Y/W135) became a visa requirement. In view of increasing worldwide reports of Y and W135 meningococcal disease, there should be a switch in recommendation from the bivalent (against A& C) to the quadrivalent vaccine for all travellers.