Meningococcal Meningitis Outbreak During The Hajj

Bacterial Meningococcal Meningitis is a rare and potentially fatal infection if not treated early on2. It is caused by the meningococcus bacterium and affects various individuals-mainly those who are of the ages zero to four and fifteen to twenty-five2. Bacterial Meningococcal Meningitis is a serious bacterial infection of the membranes surrounding the brain and spinal cord called the meninges. It causes the meninges to inflame and trigger symptoms such as headaches, high fevers, stiff neck, confusion, and light sensitivity. For a proper diagnosis, doctor’s will first do a physical examination of their patient to look for any signs of stiffness in the neck or skin rashes that may suggest a bacterial infection1. They then will do further testing by taking blood samples to find bacteria, CT or MRI scans of the patients’ head to find swelling or possible inflammation, and spinal taps to see what is causing the possible Meningitis1. If Meningitis is present and found to be bacterial, immediate antibiotics are administered to the patient1. The doctor may also administer a general antibiotic even prior to figuring out the exact bacteria that caused the patients’ illness and then switch to a drug that targets the specific bacteria that was found. Corticosteroids will be given as well to reduce the inflammation in the meninges1. There are numerous different strains of Meningococcal Meningitis; one being the Neisseria meningitidus serogroup W135. Serogroup W135 has been known to have been correlated with many clinical cases, including epidemic outbreaks such as in Saudi Arabia6.

In April of 2000 in Saudi Arabia during the annual Islamic pilgrimage to the Hajj, two million pilgrims from all around the world came together to celebrate a month of religious rituals5. What was thought to be a wholesome experience for many Islamic individuals, had resulted into an outbreak of the Neisseria meningitidus W135 strain of Meningococcal Meningitis. The disease was reported to have been worldwide not only for the individuals who had attended the Hajj and returned home, but also their close contacts. A majority of the cases although, were reported in Saudi Arabia itself. At the Hajj, millions of individuals are gathered together in one space, tightly pressed and compacted together; making the disease more malleable and pliable when travelling from one individual to another. Neisseria meningitidus W135 only infects humans, there is no animal reservoir, and it lies in the fluid of the spinal cord4. It leaves its host via drainage of mucus through the nasal and oral cavity4. Transmission of the disease is human to human through droplet transmission of respiratory or throat secretions from carriers4. Elongated contact such as kissing, sneezing or coughing on another individual, or living in close residence with a carrier, influences the spread of the disease; as in this case, at a mass gathering, transmission of the disease is easily transmissible person to person due to the fact that the disease enters the human body through the mucous membranes located in the upper respiratory tract4. Meningitis usually only affects individuals who are very young or in their late teens early twenties, but generally can affect any individual who is in close quarters with a carrier. Appreciating this information, it elucidates that after these individuals attended the Hajj, the attack rate of the Neisseria meningitidus W135 was twenty-five cases per every one hundred thousand pilgrims5. Retrospective review identified two-hundred-sixty-four suspected cases of the Neisseria meningitidus W135 strain of Meningococcal Meningitis in those who attended Hajj that year3. Of those, two-hundred-fifty-three were laboratory confirmed with one-hundred-seventy-nine being positive by cerebral spinal fluid or blood culture, and seventy-four being negative by culture but positive by cerebral spinal fluid latex agglutination3. As a result of this outbreak, seventy patients died, providing a case fatality rate of twenty-eight percent3. The disease mainly affected males who were middle-aged and more susceptible and probable to chronic illness than residents3. The last case of Neisseria meningitidus W135 was identified to be on June 5th of the same year.

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During the Saudi Arabian outbreak of Neisseria meningitidus W135, not much was done to control the disease itself, but rather give vaccinations and antibiotics for the individuals who were affected or those who were within the vicinity of affected carriers. Since the outbreak has ended, the World Health Organization has put into place a surveillance procedure from case detection to investigation and leaving laboratory confirmation as one of the only crucial ways to confirm Meningococcal Meningitis in a population and preventing an outbreak from occurring4. The main goals of the World Health Organization are to: detect and confirm outbreaks, observe the incidence patterns-including the distribution and advancement of Meningococcal serogroups-estimate the disease burden, observe how resistant an antibiotic has become, keep an eye on the circulation, distribution, and development of specific Meningococcal strains, and estimate the impact of Meningitis control methods, more specifically preventative vaccination4. There is a current polysaccharide based vaccine for the Neisseria meningitidus W135 strain but it does have some drawbacks6. It does not supply long-lasting protection against the strain, hence the need for eighty percent of the population to constantly get re-vaccinated each time an epidemic occurs6. Logistic demands and costs of the vaccine are very high and it has relatively no effect on colonization or transmission of the disease within the population, resulting in travelers who are returning from an epidemic zone still transmitting the disease to others they come in contact with5. The only other way to prevent this disease from spreading is for an individual to wash their hands to prevent the spread of germs, get constant checkups and vaccinations, practice good hygiene, stay healthy, cover their mouths when coughing and sneezing, and avoiding areas where meningitis is high-risk1.

I believe that the outbreak of Neisseria meningitidus W135 in Saudi Arabia could not have been prevented as much as the World Health Organization would have intervened. Due to the purpose of the event that the multitude of pilgrims were attending, there would have been no way to prevent these individuals from going to such a religiously mandatory gathering. Even if the attendees were told that they needed to get vaccinated for the disease before arriving, vaccine production would have to increase a great amount, making the cost for the vaccine, although it is already quite expensive, all the more costly because it is in such high demand. Also, Neisseria meningitidus W135 is a strain of Meningitis that is constantly drifting into various different subtypes of the original disease, resulting in a vaccine not being all that effective overall3. The World Health Organization is currently trying to eliminate Meningococcal Meningitis as a public health issue, but for many reasons stated previously, it is easier said than done4. Due to Meningococcal Meningitis being such a pliable disease amongst large groups, I feel like it is inevitable that not only this disease, but various other diseases can rise to surface. What the World Health Organization is currently doing after the outbreak seems like the most logical course of action to prevent any infectious disease in a population from causing an epidemic. By trying to estimate the rate of infection within a population and figuring out when the infection is most dominant within the population, allows them to make educated guesses on when to expect the disease to occur next, approximately how many people will be in the country at a given time, and come up with solutions on how to prevent the disease from causing an epidemic. Since Neisseria meningitidus W135 is such an ever-changing strain of Meningitis, they cannot keep administering new and improved antibiotics to two million returning pilgrims because it begins to raise a safety issue, development of resistance, and yet again, more issues with cost5. Before a large-scale program is put into place, investigators need to evaluate the impact and prominence of improved rates of vaccination with the Meningococcal vaccine on the rate of Neisseria meningitidus W135 carriage in the pilgrims5. By doing this, it will allow investigators to observe the results that will occur once an individual is vaccinated and get a better understanding as to why or how this bacterium changes and evolves to come up with a more appropriate vaccination or antibiotic.

Neisseria meningitidus W135 is a very infectious and lethal strain of Meningococcal Meningitis if it is not treated early on. It is easily transmissible from one person to another and is ever developing into different subtypes, making vaccination quite difficult. Attempting to keep this bacterium at bay is not easy and will require more examination overtime to evaluate the rate of evolution that occurs to properly create a vaccine that will be effective long termly. Investigators recommend that in order to prevent oneself from this disease, individuals must avoid contact with people and areas that are at high risk of the infectious disease and practice good hygiene as much as possible. Saudi Arabia’s outbreak was devastating and is still under watch to make sure that the disease does not cause another epidemic. Technology is ever advancing and soon enough, this disease will be eliminated with patience.

References

1. Brennan, D. (2019, October 5). Meningitis: Symptoms, Causes, Transmission, and Treatment. Retrieved October 27, 2019, from https://www.webmd.com/children/understanding-meningitis-basics#2-7.
2. Kiernan, M. (n.d.). Meningococcal Disease. Retrieved October 27, 2019, from https://brainfoundation.org.au/disorders/meningococcal-disease/.
3. Lingappa, J. R., Al-Rabeah, A. M., Hajjeh, R., Mustafa, T., Fatani, A., Al-Bassam, T., … Rosenstein, N. E. (2003, June). Serogroup W-135 meningococcal disease during the Hajj, 2000. Retrieved October 27, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3000138/.
4. Meningococcal meningitis. (2018, February 19). Retrieved October 27, 2019, from https://www.who.int/news-room/fact-sheets/detail/meningococcal-meningitis.
5. Wilder-Smith, Annelies, Goh, Tai, K., Barkham, Timothy, … I., N. (2003, March 15). Hajj-Associated Outbreak Strain of Neisseria meningitidis Serogroup W135: Estimates of the Attack Rate in a Defined Population and the Risk of Invasive Disease Developing in Carriers. Retrieved October 27, 2019, from https://academic.oup.com/cid/article/36/6/679/317945.
6. W135 strain of the disease. (2015, July 24). Retrieved October 27, 2019, from https://www.who.int/csr/disease/meningococcal/w135/en/.
7. 2000 - Meningococcal disease in Saudi Arabia and the Netherlands - Update. (2015, July 23). Retrieved October 27, 2019, from https://www.who.int/csr/don/2000_04_27/en/.