Reply to “A refugee patient with meningococcal meningitis type B.”

We want to thank Ozkaya-Parlakay et al.¹ for their insightful commentary. Their report sheds light on a pertinent and compelling additional at-risk population: refugees.^1-4 Global forced displacement has reached unprecedented levels, with 65.6 million people displaced worldwide in 2016.³ This surge in refugees requires significant public health efforts to a) quickly recognize and treat individuals b) prevent infectious diseases outbreaks for example through vaccination programs and c) improve surveillance (including molecular characterization of isolates) in order to better understand the epidemiology in refugee populations and the potential impact on surrounding communities. Refugees and internally displaced persons are at significant increased risk of communicable diseases,⁴ including epidemics of meningococcal disease,^2,5-7 due to multiple factors including overcrowding, malnutrition, co-morbidities and a limited access to basic health care services.²

The refugee boy in the case reported by Ozkaya-Parlakay et al. was diagnosed with serogroup B meningococcal disease. While it is not stated if other cases of meningococcal disease occurred, determining the utility of vaccines is important in this kind of setting. Meningococcal outbreaks in refugee populations have been managed with mass vaccination.⁷ As noted by Ozkaya-Parlakay et al., two serogroup B directed OMV vaccines are now approved for use in multiple countries, but the availability and implementation of these and the protein-polysaccharide conjugate vaccines for serogroups A, C, Y and W (which provide both individual and herd protection) varies widely by country and region. Improving the global implementation of new meningococcal vaccines, the rapid availability of these vaccines for response to meningococcal outbreaks and the access to routine vaccinations in the setting of a humanitarian crisis are of utmost importance in the control of meningococcal and other infectious diseases.

Populations in flux also can change the typical epidemiology of meningococcal disease in a specific region. Recently, 4 cases of serogroup X meningococcal disease were reported in African migrants living in refugee camps in Italy.⁵ Serogroup X disease, for which no direct vaccine is yet available, has occurred as outbreaks in countries in the African meningitis belt, with high rates of morbidity and mortality. Sporadic cases have been reported in Europe, but so far remain rare. Enhanced surveillance and isolate characterization is crucial for early detection of changes in meningococcal epidemiology in order to facilitate earlier diagnosis, treatment, chemoprophylaxis and potential vaccine control of meningococcal disease in refugee populations. For example, there is the possibility that the non-capsule based serogroup B vaccines could be used to control serogroup X.⁸ Changing epidemiology not only affects refugee populations, but new virulent N. meningitidis may be introduced into populations in the host country, who may lack immunity to these meningococcal disease serogroups or clonal complexes.

Public health, treatment and prevention efforts such as vaccinations in the setting of humanitarian crises are challenging to implement due to the limited availability of vaccines and antibiotics, shortage of healthcare workers, challenging case management, and compromise of the cold chain, but the problem as reflected by the increasing refugee numbers does require new strategies for health care of refugees.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.