Until 2002, this occurred almost annually after the Hajj. However,

potentially risks may still occur, as illustrated by a 2009 case of an individual aged 43 years who contracted a fluoroquinolone-resistant strain of Neisseria meningitidis serogroup A.12 The patient developed symptoms within 24 hours of returning to Italy after traveling to Delhi and Chennai in India, with a stopover of a few hours in Frankfurt, Germany. Although the patient had no known contact with anyone in India Bcl-2 inhibitor with previous or current meningococcal disease, testing revealed the strain was the same that had caused epidemics in the area in 2005 to 2006. Fortunately, no known secondary cases have been reported in Italy.12 During epidemics of meningococcal disease in sub-Saharan Africa, the so-called African meningitis belt that stretches from Senegal to Ethiopia, as many as 1,000 per 100,000 population may be affected.25 Recently, the epidemic-susceptible

area has been expanded to Guinea-Bissau, Guinea, the Galunisertib mouse Ivory Coast, Togo, the Central African Republic, and Eritrea.8 Countries around the Rift Valley and Great Lakes regions are also now considered to be at risk (Figure 3).26,27 The risk of meningococcal disease in the population in this area is particularly elevated during the dry season between December and June because of dust winds and background upper respiratory tract infections. However, due to the dynamics of climate variability, risk exists somewhat all year. Population displacements, such as when nomads and farmers congregate in traditional market areas, and overcrowded living conditions can increase the risk of transmission and contribute to epidemics of disease.28 According to the World Health Organization (WHO), in the 2009 epidemic season, 78,416 suspected cases of meningococcal disease, including 4,053 deaths, were reported in 14 African countries implementing enhanced surveillance techniques.28 This represents Fossariinae the largest number of cases and

deaths since the previous large meningococcal disease epidemic in this region in 1996 to 1997, during which >25,000 people died.25 However, to our knowledge, there has not been a single case published about a traveler having been affected in the African meningitis belt. At the least, to some extent, this may be due to the fact that, following essentially congruent vaccination recommendations, a fair proportion of high-risk travelers may have been protected appropriately. This may also be, in part, because active surveillance is limited in Africa, Latin America, and Asia,25 which may result in an underestimation of burden. Finally, an important proportion of travelers has a different behavior and far more social distancing as compared to the local population. During the annual Hajj pilgrimage, >2 million Muslims from across the globe travel to Mecca and Medina.