The Epidemiology of Invasive Meningococcal Disease in the Kingdom of Saudi Arabia: A Narrative Review with Updated Analysis

Abstract

Reducing invasive meningococcal disease (IMD) through MenACWY immunization is a critical healthcare strategy in the Kingdom of Saudi Arabia (KSA). Robust IMD surveillance is essential to help assess the need for additional immunization initiatives in target populations. This is particularly important in KSA, where mass gatherings accompanying Hajj/Umrah pilgrimages have been associated with IMD outbreaks within the local KSA population, and subsequent intercontinental spread via returning pilgrims. This narrative review of the published literature describes the changing epidemiology of IMD in KSA to provide a perspective on the impact of current immunization strategies and potential gaps. As recent published surveillance data are lacking, we also evaluated publicly reported data from the KSA Ministry of Health (MoH) for 2012-2019 to inform more recent IMD trends. Between 1995 and 2011, national surveillance data indicate that 1103 IMD cases were reported in KSA: 60% in 2000-2001, involving two (mainly MenW) outbreaks involving KSA citizens/residents and pilgrims focused in Mecca and Medina. Across 2002-2011, 184 cases of IMD were reported, with a higher proportion occurring in KSA citizens/residents, and with less focus within pilgrimage centers than apparent in previous years. Our analysis of MoH data found that, between 2012 and 2019, 44 IMD cases were reported, all in KSA citizens/residents, and chiefly in children or infants. No pilgrimage-associated outbreaks have occurred since 2001. Serogroup data were available for 62.5% of all cases for 2002-2011; MenW (40.0%), MenA (35.7%), and MenB (16.5%). Serogroup data for 2012-2019 remain incompletely reported, and the existing surveillance system could be improved, as some element of underestimation/underreporting of IMD may exist. While existing MenACWY immunization strategies for KSA citizens/residents and visiting pilgrims have been successful in reducing IMD due to specific serogroups, disease due to MenB remains a potential risk, and additional immunization strategies should be considered.

Keywords: Bacterial meningitis; Epidemiology; Hajj; Kingdom of Saudi Arabia; Mass gathering; Meningococcal disease; Neisseria meningitidis; Outbreaks; Surveillance.

Fig. 1

IMD in KSA (1995–2011). Case numbers and prevalence of N. meningitidis serogroups in KSA across 3 different periods; 1995–1999, 2000/2001 (which includes outbreaks associated with Hajj), and 2002–2011. a All reported IMD cases. b Serogroup cases. c Serogroup distribution by age strata (1995–2011). Adapted from previously reported data [40]. IMD invasive meningococcal disease; KSA Kingdom of Saudi Arabia

Fig. 2

Meningitis in KSA (2012–2019). a Annual number of meningitis cases by type (meningococcal, pneumococcal, H. influenzae, and ‘other’. b Age distribution of all meningitis cases (2012–2019). c Number of vaccine-preventable meningitis cases. d Incidence of meningococcal, pneumococcal, and H. influenzae meningitis. e Age distribution of IMD cases. Data represent those cases reported by the Ministry of Health [41]. IMD invasive meningococcal disease; KSA Kingdom of Saudi Arabia; VPD vaccine-preventable disease

Fig. 3

Regional distribution of IMD cases in KSA (2012–2019). Data represent those cases reported by the Ministry of Health [41]. IMD invasive meningococcal disease; KSA Kingdom of Saudi Arabia