Download Eurosurveillance Weekly, funded by Directorate General Health and

Eurosurveillance Weekly, funded by Directorate General Health and Consumer Protection of the
European Commission, is also available on the world wide web at <http://www.eurosurv.org/>. If you
have any questions, please contact Birte Twisselmann <[email protected]>, +44 (0)20-8200
6868 extension 4417. Neither the European Commission nor any person acting on its behalf is liable
for any use made of the information published here.
Eurosurveillance Weekly: Thursday 19 April 2001. Volume 5, Issue 16
Contents:
1. Neisseria meningitidis W135: 2a: P1.2,5 arising from successive pilgrimages to Mecca
2. Syphilis continues in gay men in Greater Manchester, England
3. Polio eradication: final 1% poses greatest challenge
Neisseria meningitidis W135: 2a: P1.2,5 arising from successive pilgrimages to
Mecca
Editorial note and background
After the haj pilgrimage in March 2000, cases of infection with a particular strain of meningococcus –
W135: 2a: P1.2,5 – occurred in various parts of the world in pilgrims and their contacts. The Geneva
office of the World Health Organization (WHO) undertook surveillance of cases arising out of this
incident, and the European Commission's DG SANCO began a rapid reporting system covering six
countries: France, Germany, Ireland, the Netherlands, Spain, and the United Kingdom (UK).
This year the dates of the haj were 4 to 8 March. Further cases of meningococcal infection with a
strain indistinguishable from last year's have since been reported (see earlier surveillance reports
from the European Union (EU) rapid reporting system (1-5). An update from the EU is provided below.
This episode of persisting meningococcal infection from one strain arising out of successive visits to
the haj is unusual and of interest for several reasons, some of which are discussed below.
1. Pilgrims to Mecca are required to be vaccinated with meningococcal polysaccharide vaccine (6).
Although a quadrivalent vaccine is produced, it is more expensive than the bivalent A and C
vaccine, and less readily available. Moreover, the bivalent vaccine contained the two most
common groups and the haj associated outbreak in 1987 was caused by a group A strain. Hence
few pilgrims used the quadrivalent vaccine.
2. It seems plausible that most pilgrims were immune to groups A and C strains, but not immune to
W135, and that this was why this serogroup of meningococcus caused the outbreaks in 2000 and
2001.
3. It is unclear, however, if the W135 infecting strain evolved from an A or C strain (to which there
was already fairly extensive vaccine induced immunity in the pilgrims) or was endemic in Saudi
Arabia or Mecca, or was brought in by one or more pilgrims. If it was endemic in Mecca, it
certainly wasn't common – the epidemiology of meningococcal infection in Mecca showed that
serogroup A accounted for 89% of 483 cases between 1987 and 1997 (7). Serogroup W135
however, although it accounted for only 6.4% of cases, was almost twice as frequent as
serogroup C (3.3%).
4. Extended international outbreaks of meningococcal infection with a specific identifiable strain are
rarely described. In 2000, cases were diagnosed first in pilgrims, then their household contacts,
then other contacts and those with no known contact. Infection in those with no known contact
with pilgrims or pilgrim contacts suggests that the W135: 2a: P1.2, 5 strain has now established
itself in many countries as part of the endemic range of pathogenic meningococci, unlike the
group A meningococcus which caused the outbreak in 1987; this strain did not appear to persist
in European countries, although a few secondary cases occurred. It is possible that the W135
strain established itself also in Saudi Arabia or Mecca after the haj 2000 outbreak if it was not
already endemic there, because it infected pilgrims again in 2001. The description below of the 3
year old boy from the UK whose parents visited during the Umra and not the haj supports this
hypothesis.
In the update reported below, no cases associated with this year's haj have so far been diagnosed in
Ireland or Spain, the two other countries in the DG SANCO rapid reporting network. The 6 month old
baby in France is probably unconnected. The other three cases from France, both patients from
Germany, and the woman from the Netherlands (provided serology of her strain confirms that it
belongs to the electrophoretic type (ET)-37 complex) are almost certainly part of the extended
international outbreak. Of these six, only three had direct known contact with pilgrims. All the UK
cases so far reported however (except the two with unknown history) were in pilgrims or their
contacts.
Three of the patients reported below – two children and one adult – had septic arthritis, an
uncommon though well described manifestation of meningococcal infection.
Rapid EU reporting system for meningitis W135: update
Seven cases of infection with W135 or compatible strains were reported from France, Germany, and
the Netherlands, and 11 from the United Kingdom (UK) between 24 February 2001 and 30 March
2001.
France
Meningococci of strain W135: NT: P1.6 were isolated from the blood of a baby boy aged 6 months
with no known link to the haj. Multilocus DNA fingerprinting (MLDF) and pulsed field gel
electrophoresis (PFGE) showed that this strain does not belong to ET-37 complex. Serogroup W135:
2a: P1.2,5 was isolated from the blood of an 18 year old man with no link to the haj. MLDF analysis
showed markers of ET-37 complex. Two other cases had direct links to the 2001 haj. Neisseria
meningitidis of serogroup W135: 2a: P1.2,5 was isolated from the blood of a 36 year old woman,
whose mother in law had visited Mecca for the 2001 haj. MLDF analysis showed markers of ET-37
complex. The same serogroup and serosubtype was isolated from the blood and throat of a 76 year
old man with angina and fever, who had been in contact with several pilgrims. The patient recovered.
MLDF and PFGE showed markers of ET-37 complex.
Germany
N. meningitidis W135: 2a: P1.2,5 was isolated from a 6 year old Muslim girl with symptoms of
septicaemia and septic arthritis of the ulna. and from the knee joint of a 57 year old female patient of
German origin, whose symptoms were septicaemia and septic arthritis. Both cases were confirmed as
having no link with the haj.
Netherlands
Meningococcal infection with strain W135: 2a: P1.2,5 was reported in a female patient who went to
Mecca at the end of 1999, but not in 2001. The date of onset was 21 March 2001. The patient’s
vaccination status is unclear. She met her son in law – whose vaccination status is also unclear – at
the airport on his return from the 2001 haj. Detailed serological characteristics of the isolate are not
available yet.
United Kingdom
As of Friday 30 March 2001, 11 patients with N. meningitidis strain W135: 2a: P1.2,5 infection
associated with the haj were reported in the UK (table). Several of the cases have been shown to be
indistinguishable from the strain associated with the 2000 haj (8). Six of the cases were pilgrims, four
were household contacts, and one was a non-household contact. Four cases died.
Cases of confirmed infection with W135: 2a: P1.2,5 associated with the 2001 haj, reported in
the UK between 24 February and 30 March 2001
No.
Week
Onset date
Age
Sex
Outcome
1
2
3
4
5
6
7
9
11
11
11
11
12
12
04/03/2001
14/03/2001
14/03/2001
18/03/2001
18/03/2001
23/03/2001
23/03/2001
35 years
4 years
58 years
48 years
38 years
2 years
36 years
F
F
Died
M
M
M
Died
Survived
Died
Association with haj
Pilgrim
Household contact
Pilgrim
Pilgrim
Pilgrim
Household contact
Other contact of pilgrim
8
9
10
11
12
13
13
13
25/03/2001
30/03/2001
27/03/2001
26/03/2001
73 years
5 months
10 months
1 year
F
F
M
Died
Pilgrim
Household contact
Household contact
Pilgrim
Other non-haj associated cases reported in the UK in the same period include a case of W135:
2a: P1.2,5 meningococcal infection in a 1 year old girl whose parents went to the Umra in Saudi
Arabia in autumn 2000. The same strain was collected from the knee aspirate of a 3 year old boy,
whose parents had visited the haj in 2000.
No further details are currently known for two cases of W135: 2a: P1.2,5 meningococcal infection – a
28 year old patient who subsequently died, whose link with the haj has yet to be confirmed, and a 4
month old child.
References:
1.
2.
3.
4.
5.
6.
7.
8.
Henderson S, Handford S, Ramsay M. Rapid reporting system for meningitis W135: 2a:P1.2, 5 prompted by haj
outbreak. Eurosurveillance Weekly 2000; 4: 001116. (http://www.eurosurv.org/2000/001116.htm)
Henderson S, Handford S, Ramsay M. Rapid reporting system for meningitis W135: 2a:P1.2, 5: update.
Eurosurveillance Weekly 2000; 4: 001214. (http://www.eurosurv.org/2000/001214.htm)
Henderson S, Handford S, Ramsay M. Rapid reporting system for meningitis W135: 2a:P1.2, 5: update.
Eurosurveillance Weekly 2001; 5: 010118. (http://www.eurosurv.org/2001/010118.htm)
Henderson S, Handford S, Ramsay M. Rapid reporting system for meningitis W135: 2a:P1.2, 5: update.
Eurosurveillance Weekly 2001; 5: 010215. (http://www.eurosurv.org/2001/010215.htm)
Henderson S, Handford S, Ramsay M. Rapid reporting system for meningitis W135: 2a:P1.2, 5: update.
Eurosurveillance Weekly 2001; 5: 010314. (http://www.eurosurv.org/2001/010314.html)
World Health Organization. Health conditions for travellers to Saudi Arabia. Wkly Epidemiol Rec 2000; 75: 7-8.
(http://www.who.int/wer/pdf/2000/wer7501.pdf)
El Bushra HE, Hassan NMM, Al Hamdan NA, Al-Jeffri MH, Turkistani AM, Al Jumaily A, et al. Determinants of case
fatality rates of meningococcal disease durting outbreaks in Makkah, Saudi Arabia, 1987-97. Epidemiol Infect 2000;
125: 555-60.
Hahné S, Ramsay M. Meningococcal disease associated with the 2001 haj – update. Eurosurveillance Weekly 2001;
5: 010405. (http://www.eurosurv.org/2001/010405.html)
Editorial note and background by Norman Noah ([email protected]); W135 update provided by
Sarah Handford ([email protected]), Brian Henderson ([email protected]), and Mary
Ramsay ([email protected]); table compiled by Susan Hahné, Public Health Laboratory Service
Communicable Disease Surveillance Centre, London, England.
Syphilis continues in gay men in Greater Manchester, England
Transmission of syphilis in the Greater Manchester outbreak, first recognised in 1999 (1) is
continuing. Since the last update in October 2000 (2), the total number of cases identified has nearly
doubled (from 53 to 104), with the highest number of new cases being diagnosed in January 2001.
Seventy-four per cent of the 51 new cases were diagnosed as either primary or secondary syphilis
and therefore considered infectious (figure). Several cases of early latent (non-infectious) syphilis
have also been diagnosed since October 2000. The outbreak continues to be concentrated in men
who have sex with men, with 87% of new cases describing themselves as being 'exclusively
homosexual.'
The continuing rise in infectious cases suggests that initial interventions to control the outbreak,
including distribution of free condom packs (with enclosed syphilis alert cards), outreach education,
and posters displayed at gay events were not successful in halting transmission. As a result, renewed
efforts at targeted health promotion and screening were initiated on 14 February. One such
intervention included the introduction of a weekly early evening clinic located within the gay village
which provided free syphilis screening on site, and regular peer outreach and counselling by
members of the Lesbian and Gay Foundation. Seventy-six people were approached in bars in the first
three weeks of the scheme and asked to complete a short questionnaire about syphilis awareness.
The data suggest comparatively high awareness of syphilis with poor interest in taking up sexual
health screening. Sixty-eight per cent of respondents were aware of a local increase in syphilis, 85%
were aware that symptoms did not always accompany ongoing infection, and 80% were aware that
syphilis was easily treatable. Nevertheless, only 36% were interested in free screening, and only two
people attended the outreach clinic for testing. Possible reasons for the poor uptake include
ignorance of the outreach clinic’s existence, and low perceived risk of acquiring syphilis. A poster
campaign is continuing and the screening clinic is still available.
Similar outbreaks of syphilis among homosexual men have been reported in other sites in the United
Kingdom and mainland Europe (2,3). Recently, an outbreak of 63 cases of infectious syphilis, 87% of
whom were homosexually active men, was reported in Dublin (4). A large-scale publicity campaign
was launched in January and the number of gay men presenting for sexual health screens at their
local genitourinary medicine clinics has risen noticeably.
As syphilis shares modes of transmission with, and can facilitate the transmission of, HIV infection,
these outbreaks may herald a subsequent rise in the incidence of HIV in the worst affected areas,
particularly among gay and bisexual men. This highlights the importance of evaluating interventions to
improve their effectiveness, maintaining heightened awareness and continuing to develop relevant
and appropriate interventions among those at greatest risk. Enhanced syphilis surveillance is
continuing locally.
References:
1.
2.
3.
4.
CDSC. Increased transmission of syphilis in Manchester. Commun Dis Rep CDR Wkly 2000; 10(10): 89.
CDSC. Increased transmission of syphilis in Brighton and Greater Manchester among men who have sex with men.
Commun Dis Rep CDR Wkly 2000; 10(43): 383,6.
Doherty L, Fenton K, O’Flanagan D, Couturier E. Evidence for increased transmission of syphilis among homosexual
men and heterosexual men and women in Europe. Eurosurveillance Weekly 2000; 4: 001214.
(http://www.eurosurv.org/2000/001214).
NDSC. Update: syphilis outbreak. EPI-INSIGHT 2001; 2 (April): 1.
Reported by Kevin Fenton ([email protected]), Public Health Laboratory Service Communicable
Disease Surveillance Centre, London, England.
Polio eradication: final 1% poses greatest challenge
The eradication of poliomyelitis is 99% complete, according to figures released on 3 April by the
Global Polio Eradication Initiative, which is spearheaded by the World Health Organization (WHO),
Rotary International, the United States Centers for Disease Control and Prevention (CDC), and the
United Nations Children’s Fund (UNICEF) (1).
In 2000, no more than 3500 cases of polio were reported worldwide (although laboratory results for
the year are still being finalised, for weekly updates see <www.polioeradication.org>). This is a 99%
decrease from the 350 000 annual cases estimated in 1988 when the initiative was launched. In just
12 months the number of polio cases has been more than halved, from 7141 in 1999. This reduction
is a result of the World Health Assembly’s call in 1999 to accelerate eradication activities, including
increased rounds of national immunisation days (NIDs) and use of a strategy delivering the vaccine
from house to house, enabling vaccination teams to find and immunise more children.
Last year a record 550 million children under five years were immunised during intensified NIDs in 82
countries. In India, for example, 152 million children were vaccinated in three days, and, in a
synchronised effort, 76 million children were vaccinated in 17 countries across West and Central
Africa.
The campaign for a world certified polio free by 2005 is on track. But the participants in the initiative
warned that the biggest challenges of the programme lie ahead: accessing all children, closing a
funding gap of US$ 400 million, and maintaining political commitment in the face of a disappearing
disease.
The poliovirus now circulates in no more than 20 countries, down from 30 in 1999 and 125 in 1988.
These are mainly in South Asia and sub-Saharan Africa. They are: Afghanistan, Angola, Bangladesh,
Benin, the Central African Republic, Chad, Congo, Côte D’Ivoire, the Democratic Republic of the
Congo, Egypt, Ethiopia, Ghana, India, Nepal, Niger, Nigeria, Pakistan, Sierra Leone, Somalia, and
Sudan. Poliovirus transmission is at very low levels in 11 of these countries.
Given the magnitude of the polio eradication effort, political commitment to achieving the 2005
certification target is required from the highest levels in countries where polio is endemic and those
that are free of the disease. Polio free countries must begin the process of containing all laboratory
stocks of the virus. Until global eradication, no child is safe from polio. To give two examples, in
August 2000 an imported poliovirus from Angola caused a major outbreak on the small West African
island nation of Cape Verde, which had been polio free for years. This outbreak paralysed 44 people
and killed 17. In December, the Pan American Health Organization (PAHO) reported on an outbreak
of poliomyelitis in the Dominican Republic and Haiti, details of which were published in
Eurosurveillance Weekly (2), which caused concern because ‘wild’ poliovirus has not circulated in the
western hemisphere since 1991, and because the virus identified was an unusual derivative of the
Sabin type 1 oral poliovirus vaccine.
Reference:
1.
2.
World Health Organization/Global Polio Eradication Initiative. Polio eradication: final 1% poses greatest challenge.
Press Release WHO/17, 3 April 2001. (http://www.who.int/inf-pr-2001/en/pr2001-17.html)
(http://www.polioeradication.org)
Noah N, Fine P. Polio outbreak in Dominican Republic and Haiti: low coverage with oral polio vaccine may allow
Sabin vaccine-derived virus to circulate. Eurosurveillance Weekly 2000; 4: 001207.
(http://www.eurosurv.org/2000/001207.htm)
Reported by Birte Twisselmann ([email protected]), Eurosurveillance editorial office.