Neisseria Meningitides Colonization among residents of Makkah and Madinah before Hajj season, 1422 H (2002)

Saudi Arabia has experienced recurrent occurrence of meningococcal meningitis (MCM) cases related to hajj, this was mainly in the two Holy cities (Makkah & Madinah), but occasionally extended to other cities within Saudi Arabia and abroad. This study aimed to determine the carriage rate of meningococci among the two Holy cities' residents before Hajj and identify their serotypes so as to establish the role of the local population in disease transmission. Further, it was meant to evaluate the effectiveness of Ciprofloxacin in eradicating colonization of meningococci.

An observational study was conducted using a cross sectional approach to identify carriers. The populations of the two Holy Cities were divided into two main categories: a high risk population comprised of those who come in direct and close contact with the pilgrims and share the experience of a crowded work space, this included workers at the Holy Mosques (Haram) and adjacent commercial area. The low risk population was comprised of ordinary citizens living in the two Holy Cities (Makkah and Madinah). The total estimated sample size of 1400 persons from each city was equally divided between the high risk and low risk populations. The number for the high risk population was further subdivided equally between those working inside the Holy Mosque and those working in commercial sites adjacent to the mosque.

The low risk populations were selected randomly from individuals registered at Primary Health Care Centers (PHCC). Fifty individuals from both the male and female sections of the PHCCs were selected using a systematic random sampling method. These individuals were then referred to the assigned clinic for interview and obtaining the nasopharyngeal swab. With regards to the high risk population, lists of those working in Hamm were provided by the Department of Holy Mosque Affairs, and 350 names were selected using a systematic random selection method; another 350 individuals were selected from workers at commercial sites adjacent to each Mosque. After training the participating nurses and health care workers, data was collected using a standardized questionnaire, ensuring appropriate collection and transportation of swabs.

Participants who were found to be culture positive for Neisseria meningitides in the oro-pharyngeal swab were given a single 500 mg oral dose of Ciprofloxacin in an attempt to eradicate colonization. After 48 hours of chemoprophylactic ingestion, another nasopharyngeal swab was taken to evaluate its efficacy. Also, another nasopharyngeal swab was taken from those who remained culture positive after 48 hours, 5 days from the time of Ciprofloxacin ingestion.

During the period Jan 17th to Feb 11th 2002 (03-28/11/1422 H) 2797 individuals were included in the study. 49.9% from Makkah and 51.1% from Madinah. The mean age of participants from Makkah was 32.6 years (SD 13.1) and from Madinah 31.0 years (SD 12.9). Males represented the majority of participants both in Makkah and Madinah (71.8% and 73.8% respectively). Saudi nationals among the participants in Makkah were less than in Madinah (45.4% and 56.3% respectively). Participants belonged to 23 nationalities other than Saudis, the highest were Bangladeshis and Pakistanis, representing 11% and 10% respectively. 31.2% of Makkah and 32.5% of Madinah participants were only able to read and write.

Those working at commercial sites adjacent to Holy Mosque showed the highest frequency of having a valid vaccination (78.3% for Makkah and 72.4% for Madinah). Although participants from PHCCs in Makkah showed the lowest level of vaccination (65.8%) compared to other locations in Makkah, it was still higher than those in Madinah other than commercial site location. The majority of participants in Makkah and Madinah knew the type of vaccination received (54.6% and 71.7% respectively). The Bivalent vaccine was much higher in Makkah (34.6%) as compared to Madinah (17.3%). Those who mentioned receiving a Quadrivalent vaccine were slightly lower among participants in Makkah (10.8%) than Madinah (11.1%).

A few of the participants (13.2%) reported using antibiotics within the four weeks prior to the interview. The majority (84.3%) reported that the antibiotic had been prescribed by physician. The reasons for taking the antibiotics varied, but the majority (58.1%) had received them as treatment of different upper respiratory complaints.

Among 2797 nasopharyngeal swabs taken from Makkah and Madinah, 86 (3%) were culture positive for different types of Meningococci. Of these positive cultures, 49 were identified among Makkah participants and 37 among Madinah participants. Of the 49 culture positive samples of Makkah participants, only 16 (32%) demonstrated N. meningitides; 9 were serotype W135 , 3 serotype B, 3 other serotypes (Z, Y, D), and 1 ungroupable. Of the 37 culture positive samples of Madinah participants, only 2 (5%) demonstrated N. meningitides serotype W 135.

Among 1395 participants from Makkah, 16 (1.1%) were identified positive for different N. meningitides serotypes, compared to only 2 (0.1%) among 1402 participants from Madinah. As given in table 1, although there is a statistically significantly higher number of N. meningitides carriers in Makkah compared to Madinah, but there was no significant difference on the basis of site of recruitment of subjects; their age, gender, nationality, vaccination status, antibiotic use and bedroom area.

All the 18 N. meningitis positive participants who received a single dose of ciprofloxacin were found culture negative on swabs collected 48 hours later, thus the efficacy of the single dose of Ciprofloxacin (500mg) was 100%.

Saudi Arabia has frequently been affected by meningococcal epidemics. It has witnessed major outbreaks of MCD in 1987, 1988, 1992, 2000 and 2001.[1-3] This study has demonstrated that MCM is not endemic neither in Makkah or Madinah and the pilgrims coming for hajj might be the source of infection for the outbreaks associated with Hajj, locally or internationally.

The difference in carriage rate between Makkah and Madinah populations revealed an increased risk among the Maldvali population to acquire meningococcal meningitis infection. This higher carriage rate in Makkah may be explained by the fact that the majority of the religious visitors travel primarily to Makkah, which is much more crowded with hajjis than Madinah. especially in and around Al-Haram.

The overall vaccination coverage with Meningococcal vaccine was significantly lower than reported in many studies conducted during the past few years. Higher vaccination coverage rates have been reported in previous studies held in 1413 H (85.9%)[4], 1416 H (98.5%)[5], and 1997 (87.1%)[6], however, these studies had only targeted pilgrims, who are required to have a valid vaccination prior to arrival in Saudi Arabia. Study results are slightly higher than that of a study conducted in the Riyadh population in year 2002, that demonstrated a vaccination coverage of 51% (unpublished). [7] The low vaccination coverage rates observed in this study. however arc hardly acceptable, especially with vaccination campaigns held every year in these two Holy Cities. It is recommended that the vaccination campaign along with health education should be started early before arrival of religious visitors.

As the single dose of 500 mg of Ciprofloxacin was found to be 100% effective in eradicating colonization. Regular use of a single dose of ciprofloxacin is recommended for hajjis on their arrival to Saudi Arabia, especially those coming from endemic areas of MCM. Ciprofloxacin is also indicated for returning domestic pilgrims, to reduce the risk of transmission to close contacts. International Health Missions should be advised to administer ciprofloxacin to their pilgrims at the time of return to their home countries to reduce the risk of transmission in their countries.