Umrah- and travel-associated meningococcal disease due to multiple serogroup W ST-11 sub-strains pre-Hajj 2024

Collectively, the Hajj and Umrah pilgrimages draw >30 million pilgrims to the Kingdom of Saudi Arabia (KSA) each year. Before Hajj 2024 (14 to 19 June), the meningococcal serogroup W ST-11 complex (W:cc11) Hajj-strain sublineage caused multiple international cases of invasive meningococcal disease (IMD) associated with travel to the Middle East and Asia. Here we identify and characterise the strains responsible.

All Hajj strain sublineage genomes on PubMLST.org underwent core genome MLST comparisons (PubMLST.org).

Isolates from 30 cases, across seven countries, formed five phylogenetic clusters within two distinct strains. Travel histories included KSA, other Middle Eastern countries, India, Mauritius, Kenya via Turkey, and no known associated travel. The prevalent strain, representing four clusters, had no African, and limited Middle Eastern, representation. The geo-temporal distribution of available genomes indicated Eastern Europe as a possible source.

The rapid expansion of Umrah/travel-related W:cc11 IMD cases in early 2024 was due to multiple strains/sublineages. Despite the involvement of non-KSA travel-destinations, the coincidence of cases with the busy month of Ramadan, and the abrupt cessation during Hajj (when vaccine compliance is maximal), suggest that Umrah was a key driver and highlight the need to reinforce mandatory vaccination whilst maintaining global vigilance.