Meningococci of Serogroup X Clonal Complex 181 in Refugee Camps, Italy

Four cases of infection with serogroup X meningococci (MenX) (1 in 2015 and 3 in 2016) occurred in migrants living in refugee camps or reception centers in Italy. All MenX isolates were identified as clonal complex 181. Our report suggests that serogroup X represents an emerging health threat for persons arriving from African countries.

Moreover, serogroup X invasive isolates from other European countries reported and available in the PubMLST database (http://pubmlst.org/neisseria/) showed high heterogeneity among themselves and with the MenX isolates of the African meningitis belt. Because of the lack of a specific herd immunity against this serogroup in Europe, non-African MenX isolates may be associated with increased host susceptibility (4).
Recently, the Italian Reference Laboratory for Invasive Meningococcal Disease (IMD) surveillance of the Istituto Superiore di Sanità, Rome, Italy, received samples from 4 unlinked case-patients with serogroup X IMD that occurred among migrants living in refugee camps or reception centers. The first case was reported in 2015 in a 15-year-old girl from Eritrea (ID2683) who had arrived in a refugee camp in Lombardy, Italy, 3 days before onset of disease, which manifested as septicemia. The other 3 cases were reported in 2016, two in Lombardy (in a 20-year-old man from Mali, ID2820, and a 31-year-old man from Niger, ID2849) and another in a Tuscany camp (in a 24-year-man from Bangladesh, ID2805). These cases were characterized by meningitis with fever >40°C and loss of consciousness. All patients were treated with ceftriaxone and survived. Chemoprophylaxis with rifampin or ciprofloxacin was administered to all persons directly exposed to the index casepatients. The man from Bangladesh lived in a camp with other Africa refugees for several months before disease onset, but symptoms developed in the other 3 patients shortly after their arrival in Italy.
As described by Agnememel et al. (8), MenX isolates from Africa were genetically related: they belonged to CC181and formed a single main lineage. Our genome analyses confirmed the presence of MenX strains with similar characteristics to those already described. In particular, these isolates harbored lpt3 allele 45, previously described as a high virulence marker in the mouse model (8).
The probability of a migrant developing an infectious disease, such as IMD, after arriving in the country of destination may depend on a series of factors, such as the prevalence and incidence of the infectious diseases in the country of origin, the specific characteristics of the infectious diseases (incubation period), the number of contacts that the migrant had during the journey, and the duration of the journey. These factors should be taken into account when assessing the risk of developing specific infectious diseases, such as IMD. Our report suggests that MenX represents an emerging health threat for persons arriving in Italy from Africa. Early diagnosis, treatment, and prophylaxis should be ensured to protect vulnerable populations, including migrants, refugees, and the host community.  A cute febrile illness in the New World tropics has a broad differential diagnosis largely dependent on locale and seasonal outbreaks. In Central America, most febrile illnesses have historically been attributed to dengue or malaria. However, recent evidence from Panama suggests varied differential diagnoses, including hantavirus, chikungunya virus, and Zika virus infection (1,2). In 2009, a dengue outbreak was reported in Panama City, Panama. The Gorgas Memorial Institute in Panama City tested dengue-negative samples from this outbreak for alphaviruses, flaviviruses, and phleboviruses and detected Punta Toro virus species complex (PTVs) in some samples. PTV (genus Phlebovirus, family Bunyaviridae), a member of the sand fly fever group, was initially described in humans in 1966 after being isolated from a soldier in Panama who had fever, headache, myalgia, and leukopenia (3). The phylogenetics of PTV have been thoroughly characterized (4-6), but our search of the literature did not reveal reports of other PTV cases in humans.
The signs and symptoms of sand fly-associated phlebovirus infection vary, but most infections cause a mild febrile illness characterized by retroorbital headache, weakness, back pain, and leukopenia. However, infection with 2 other phleboviruses, mosquitoborne Rift Valley fever virus and tick-associated severe fever with thrombocytopenia syndrome virus, causes severe disease. Little is known regarding the signs, symptoms, and clinical course of PTV infection in humans.
During the 2009 investigation, the Gorgas Memorial Institute analyzed 4,852 samples from persons in Panama with suspected acute dengue; 1,667 (34.4%) of the samples were dengue-negative. We further analyzed 201 of these samples for phlebovirus (online Technical Appendix Table 1, https://wwwnc.cdc.gov/EID/article/23/5/16-1925-Techapp1.pdf). In brief, we extracted viral RNA from the samples and evaluated it by using Phlebovirus genus-specific reverse transcription PCR (RT-PCR) based on the