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Meningococcal Disease

Ask the Experts: Diseases & Vaccines

Meningococcal Disease

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Meningococcal Disease
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For People with Risk Factors Contraindications and Precautions
Vaccine Recommendations
It seems that CDC is trying to confuse us by publishing new meningococcal vaccine recommendations every year or two. Where can we find the most current recommendations?
You are correct that there have been multiple recommendations published since the first meningococcal conjugate recommendations in 2005. However, CDC published a compilation of the 2005 and subsequent meningococcal vaccine recommendations in March 2013. This document is available on the MMWR website at www.cdc.gov/mmwr/pdf/rr/rr6202.pdf.
Who is recommended to be vaccinated against meningococcal disease?
Groups for whom the CDC's Advisory Committee on Immunization Practices (ACIP) has recommended routine vaccination against meningococcal disease include
- all adolescents age 11–12 years
- all previously unvaccinated adolescents age 13 through 18 years
- all previously unvaccinated first-year college students age 19 through 21 years who are or will be living in a residence hall
- all people age 2 months and older with anatomic or functional asplenia, or persistent complement component deficiency
- all people age 2 months and older who travel to or reside in countries where meningococcal disease is hyperendemic or epidemic (for example, sub-Saharan Africa or to Mecca, Saudi Arabia, for the annual Hajj)
- any person working as a microbiologist with routine exposure to isolates of N. meningitidis
- military recruits
Can you provide a comprehensive overview of the meningococcal conjugate vaccine recommendations, including those for vaccinating younger children and older adults who have risk factors?
IAC has prepared a table that provides a summary of the ACIP recommendations for use of meningococcal vaccine for people of all ages, and includes recommendations published by ACIP in MMWR in March 2013. The table is available at www.immunize.org/catg.d/p2018.pdf.
The FDA recently approved MCV4-CRM (Menveo, Novartis) for use in children as young as 2 months of age. What is the ACIP recommendation for use of this vaccine?
In August 2013, MCV4-CRM (Menveo, Novartis) was approved by the FDA for children age 2 through 23 months. Previously, the FDA had licensed the use of Menveo in children 2 years of age or older. MCV4-CRM is now approved for people age 2 months through 55 years. It is the first quadrivalent meningococcal conjugate vaccine approved for children younger than age 9 months. For children beginning the vaccination series at age 2 months the schedule is 4 doses at age 2, 4, 6, and 12–15 months. Fewer doses are recommended for children beginning the vaccination series at age 7 months or older (see the Menveo product information for details).
On October 23, 2013, the ACIP voted to recommend the use of Menveo (MCV4-CRM, Novartis) in high-risk children 2 through 23 months of age. Three meningococcal conjugate vaccines are now approved and recommended for certain high-risk children: MenHibrix (Hib-MenCY, GSK) for children 6 weeks through 18 months of age, Menveo for children 2 months and older, and Menactra (MCV4-D, sanofi) for children 9 months and older.
Which previously unvaccinated college students are recommended to receive MCV4 and how many doses should they be given?
Previously unvaccinated first-year college students age 19 through 21 years who are or will be living in a residence hall should receive 1 dose of MCV4. Routine vaccination is not recommended for adults age 22 and older who do not have a risk factor. If an adult patient requests vaccination against meningococcal disease, ACIP states that you can vaccinate them.
Which previously vaccinated college students need a booster dose of MCV4?
A booster dose should be given to first-year college students age 21 years and younger who are or will be living in a residence hall if the previous dose was given before the age of 16 years.
Will the meningococcal vaccine provide protection against all serogroups?
No. The quadrivalent conjugate vaccines and the polysaccharide vaccine contain antigen for serogroups A, C, Y, and W-135. Serogroups C and Y (which are included in the bivalent conjugate vaccine) account for about two-thirds of invasive meningococcal disease in the United States. Serogroups A and W-135 are rare in the United States. Serogroup B, which accounts for about a third of invasive disease, is not included in the vaccine. Work is underway to develop a vaccine for serogroup B.
ACIP recommends that adolescents who receive the first dose of meningococcal conjugate vaccine at age 13 through 15 years receive a one-time booster dose at age 16 through 18 years. Given how hard it is to get teens into a medical office, is it okay to give the doses close together if the opportunity arises or should we try to space it out as far as possible (age 18)?
If the first dose is given at age 13 through 15 years, you can give the booster dose as early as age 16 years, with a minimum interval of 8 weeks from the previous dose. So even if the patient was vaccinated at age 15 years 11 months, you could wait at least 8 weeks and then give the booster at age 16 years 1 month (or later) if you chose to do so.
The ACIP recommendations for meningococcal vaccine published in March 2013 advise using MCV4 in certain adults older than age 55 years. Please provide details of this recommendation.
Previously, ACIP recommended only the quadrivalent meningococcal polysaccharide vaccine (MPSV4; Menomune, sanofi) for use in adults age 56 years and older. The most recent recommendations, published in March 2013, recommend the use of quadrivalent meningococcal conjugate vaccine (MCV4; Menactra, sanofi; Menveo, Novartis) in adults age 56 years and older who (1) were vaccinated previously with MCV4 and now need revaccination or (2) are recommended to receive multiple doses (for example, adults with asplenia or microbiologists working with Neisseria meningitidis). Both MCV4 vaccine products are licensed for use in people through age 55 years, which means that the use of these vaccines in people age 56 and older is off-label but ACIP-recommended. The document is available at www.cdc.gov/mmwr/pdf/rr/rr6202.pdf.
Vaccine Products Back to top
What is the appropriate way to differentiate between the different meningococcal vaccines?
The nomenclature for meningococcal vaccines is based on both the serotypes included in the vaccine as well as the vaccine type (conjugate or polysaccharide). There is only one polysaccharide vaccine (Menomune, sanofi) and it is known as MPSV4 (the 4 denotes the number of serotypes in the vaccine). There are two licensed quadrivalent meningococcal conjugate vaccines (MCV4) –  Menactra (sanofi) which is known as MCV4-D, and Menveo (Novartis), known as MCV4-CRM. Each of these vaccines include the same four serotypes (A, C, W, and Y). A bivalent (serogroups C and Y) conjugate vaccine (MenHibrix [GlaxoSmithKline]) combined with Hib vaccine is licensed for children age 6 weeks through 18 months.
With four licensed meningococcal vaccines, how do I decide which one to use?
Quadrivalent meningococcal conjugate vaccine (MCV4) is the preferred product for people age 55 years and younger and some people older than 55 years. MCV4-D (Menactra, sanofi) is licensed for persons age 9 months through 55 years and MCV4-CRM (Menveo, Novartis) is licensed for persons age 2 months through 55 years. HibMenCY (MenHibrix, GlaxoSmithKline) is approved only for children age 6 weeks through 18 months. These conjugate vaccines are believed to have several advantages over meningococcal polysaccharide vaccine (MPSV4; Menomune, sanofi), such as reduction in bacterial carriage in the nose and throat, longer duration of immunity, and better immunologic memory.
MPSV4 should be used for adults age 56 and older who have not previously received meningococcal vaccine and anticipate requiring a single dose, such as international travelers and persons at risk as a result of a community outbreak of meningococcal disease. MPSV4 can also be used in people age 2 through 55 years who have a contraindication or precaution to MCV4. ACIP recommends off-label use of MCV4 for persons age 56 years and older who were previously vaccinated with MCV4 and require revaccination or for whom multiple doses are anticipated, such as persons with asplenia and microbiologists.
Are the two quadrivalent meningococcal conjugate vaccines (MCV4) interchangeable?
MCV-D (Menactra) is not approved for children younger than 9 months so only MCV4-CRM (Menveo) should be used for children age 2 through 8 months. For persons age 9 months and older the quadrivalent vaccines are interchangeable.
What are the new ACIP recommendations for use of MenHibrix, the combination meningococcal serogroups C and Y and Haemophilus influenzae type b vaccine?
Licensed in June 2012, MenHibrix (HibMenCY, GSK) is a vaccine indicated for active immunization to prevent invasive disease caused by Neisseria meningitidis serogroups C and Y and Haemophilus influenzae type b. This vaccine does not protect against meningococcal serogroups A, B, and W135.
ACIP recommends that infants at increased risk for meningococcal disease be vaccinated with 4 doses of HibMenCY at age 2, 4, 6, and 12 through 15 months. This includes infants with recognized persistent complement pathway deficiency and infants with anatomic or functional asplenia, including sickle cell disease. HibMenCY can be used in infants age 2 through 18 months who live in communities with serogroup C or Y meningococcal disease outbreaks.
IAC has developed a handy reference table that summarizes ACIP's recommendations for meningococcal vaccination of children and adults. It's available at www.immunize.org/catg.d/p2018.pdf.
For People with Risk Factors Back to top
Three meningococcal conjugate vaccines are approved for children younger than 2 years of age. Which children should be vaccinated before their second birthday?
MCV4-CRM (Menveo, Novartis) and HibMenCY (MenHibrix, GlaxoSmithKline) are approved for children as young as age 2 months. MCV4-D (Menactra, sanofi) is approved for children age 9 months and older. ACIP recommends that high-risk children be vaccinated. ACIP defines high-risk children age 2 through 23 months as (1) those with persistent complement component deficiency, (2) those with functional or anatomic asplenia, (3) those traveling to or residing in an area of the world where meningococcal disease is epidemic or (4) are at risk during a community outbreak attributable to a vaccine serogroups.
For children with functional or anatomic asplenia, MCV4-D (Menactra) should not be administered to children until the PCV13 vaccination series is completed. Children who remain at increased risk for meningococcal disease should receive a booster dose 3 years after the primary series.
Which people age 2 years and older are recommended to receive a 2-dose primary series of MCV4?
For people who are age 2 through 55 years, a 2-dose series of MCV4, spaced 2 months apart, is recommended if they have functional or anatomic asplenia, or persistent complement component deficiency, including C3, C5-C9, properdin, factor H, and factor D. In addition, people in this age group who are HIV-positive for whom MCV4 is otherwise recommended (such as an adolescent age 11 through 18 years) should receive a 2-dose series of MCV4, spaced 2 months apart.
Why delay meningococcal vaccination for infants with functional or anatomic asplenia until the pneumococcal conjugate vaccine series is completed?
In addition to being at increased risk for meningococcal disease children with functional or anatomic asplenia are also at increased risk invasive disease caused by Streptococcus pneumoniae. Data show that the MCV4-D vaccine (Menactra, sanofi) may interfere with the immunologic response to PCV13 if these two vaccines are given too close together. So ACIP recommends that MCV4-D not be administered until at least 4 weeks after completion of the age-appropriate PCV13 series. MCV4-CRM (Menveo) and HibMenCY (MenHibrix) do not affect the immune response to pneumococcal vaccine so can be given at any time before or after PCV13.
Can we vaccinate a 2-year-old boy with functional or anatomic asplenia who has not completed a series of PCV13?
If the child is receiving MCV4-D (Menactra) you should first be certain that he is up to date with PCV13 vaccine. At least 4 weeks should elapse after completion of the PCV13 series before giving the MCV4-D. There is no similar space consideration if MCV4-CRM (Menveo) is used; this vaccine may be given simultaneously with PCV13 or at any interval since receipt of PCV13.
Adults who are asplenic need PCV13 and MCV4. Does the recommendation to separate PCV13 and MCV4-D (Menactra) apply to adults as well as children?
Studies that showed possible interference when PCV7 and Menactra were given simultaneously where done in children and not adults. This was then extrapolated to use of PCV13 and Menactra in children. This interference was not noted with Menveo.
At this time, there are no data to support a similar recommendation for adults. However, to be prudent, if MCV4-D is being used, you should consider spacing it 4 weeks after PCV13. Menveo can be administered at any time before, simultaneous with or after PCV13.
I have a pediatric patient who has functional asplenia. I gave her a dose of Menactra (MCV4-D) when she was 3 years old. Do I need to give her a booster at some time?
Because she has functional asplenia, she is due for the second dose of the primary series (assuming 8 weeks have passed since the first primary series dose). Because she has a high risk medical condition she will need periodic booster doses. If she is younger than age 7 years when she receives the second dose of her primary series she should receive her first booster dose 3 years after completing the primary series. She should then receive a booster dose every five years thereafter. If she is age 7 years or older when she receives the second primary dose she should receive her first booster dose 5 years after the completing the primary series and every five years thereafter.
Are people who are HIV-positive in a risk group for meningococcal disease?
HIV infection does not put a person into a risk group that necessitates meningococcal vaccination. However, the updated ACIP recommendations for use of MCV4 vaccines state that people with HIV who are vaccinated should receive a 2-dose primary series administered 2 months apart. Accordingly, the following HIV-positive people should receive 2 initial doses of MCV4 (instead of 1), spaced 2 months apart:
- HIV-positive adolescents age 11 through 18 years who, like other adolescents, are recommended for routine MCV4 vaccination
- HIV-positive people age 2 through 55 years who are at prolonged increased risk for exposure to meningococcal disease (for example, travelers to, or residents of countries, where meningococcal disease is hyperendemic or epidemic and microbiologists who routinely work with Neisseria meningitidis)
- any HIV-positive adult who chooses to be vaccinated.
Booster Doses Back to top
I've heard the updated recommendations for the use of meningococcal conjugate vaccines in adolescents now include a booster dose. Would you please tell me more?
ACIP recommends people age 11 or 12 years be routinely vaccinated with quadrivalent meningococcal conjugate vaccine (MCV4) and receive a booster dose at age 16 years. Adolescents who receive the first dose at age 13 through 15 years should receive a one-time booster dose, preferably at age 16 through 18 years, which are the years before the peak in incidence of meningococcal disease among adolescents occurs. Teens who receive their first dose of meningococcal conjugate vaccine at or after age 16 years do not need a booster dose, as long as they have no risk factors.
Why did ACIP vote to recommend a routine booster dose of MCV4 for adolescents age 16 years and older?
In 2005, ACIP recommended routine MCV4 vaccination for all adolescents at age 11 or 12 years to protect them from meningococcal disease as older teens. The peak age for meningococcal disease is 16 through 21 years. In 2005, ACIP reasoned that higher MCV4 vaccination rates could be achieved if administering the dose was coupled with giving the Td booster dose at the 11 or 12-year-old visit (the Td dose for 11 or 12-year-olds was replaced by Tdap in 2006). Current data now indicate that the protection provided by MCV4 wanes within 5 years following vaccination. For this reason, in 2010, ACIP recommended an MCV4 vaccine booster dose to provide continuing protection during the peak years of vulnerability (see www.cdc.gov/mmwr/pdf/wk/mm6003.pdf).
If someone received meningococcal polysaccharide vaccine (MPSV4) at age 5 years (such as for international travel) and a dose of MCV4 at age 11 or 12 years, will they still need a booster dose of MCV4 vaccine at age 16 years?
Yes. Any meningococcal vaccination given prior to the tenth birthday (either with MCV4 or MPSV4) does NOT count toward routinely recommended doses.
If someone received MPSV4 or MCV4 at age 10 years and another dose at age 11 or 12 years, will they still need a booster dose at age 16 years?
No, as long as the first dose was given at age 10 years or older, the second dose was MCV4 (not MPSV4), there was an interval of at least 8 weeks between the two doses, and they are not in a risk group that necessitates ongoing boosters (for example, due to asplenia). In this scenario, however, the healthcare provider may offer a booster dose if the person is younger than age 22 years and about to enter a college or university setting.
Which people with risk factors should receive subsequent boosters of meningococcal conjugate vaccine (MCV4)?
When the first meningococcal conjugate vaccine (Menactra, sanofi) was licensed in 2005, data were lacking on long-term efficacy and the need for additional vaccination. Since that time, studies indicate that antibody level declines over time. Consequently, ACIP recommended routine boosters of MCV4 for people at highest risk for meningococcal infection in 2009 (see www.cdc.gov/mmwr/pdf/wk/mm5837.pdf). This group includes people (1) with persistent complement component deficiency, (2) with anatomic or functional asplenia, (3) who have frequent prolonged exposure (such as microbiologists routinely working with Neisseria meningitidis, and travelers to or residents of areas with high rates of meningococcal disease [such as the African meningitis belt]). Children at continued high risk who received the first dose of MCV4 before age 7 years should receive the second dose no sooner than 3 years after the first dose. People at continued high risk who received the first dose of meningococcal vaccine at age 7 years or older should receive the second dose no sooner than 5 years after the first dose. MCV4 is licensed through age 55 years, However, ACIP recommends off-label use of MCV4 for adults 56 and older who were vaccinated previously with MCV4 and are recommended for revaccination, or for whom multiple doses are anticipated.
Should people with continued high risk of meningococcal disease receive additional doses of meningococcal vaccine beyond the 3- or 5-year booster described above?
Yes, people should receive additional booster doses (every 5 years) if they continue to be at highest risk for meningococcal infection.
A 19-year-old student who received 1 dose of MCV4 at age 12 years will be attending a community college this fall. Does she need a booster dose of MCV4?
Yes, but only if she will be living in residential housing. Adults age 19 through 21 years who meet these criteria and who received the previous dose of MCV4 before age 16 years, need a booster dose.
What do you do if an adult patient is in a high-risk situation for meningococcal disease (for example travel to sub-Saharan Africa) and doesn't know whether they received MCV4 or MPSV4 (Menomune, sanofi) in the past. Should we vaccinate them?
Yes. The ACIP recommendation is to vaccinate when vaccination is indicated and when you don't have adequate documentation.
Administering Vaccine Back to top
By what route should MCV4 and MPSV4 be administered?
All meningococcal conjugate vaccines should be administered by the intramuscular route. MPSV4 should be given by the subcutaneous route.
We mistakenly gave a patient the diluent for Menveo (Novartis) meningococcal conjugate vaccine without adding it to the powdered vaccine. Since vaccine antigen is present in the diluent as well as in the powder, what should we do now?
Menveo's liquid vaccine component (the diluent) contains the C, Y, and W-135 serogroups, and the lyophilized vaccine component (the freeze-dried powder) contains serogroup A. Because the patient received only the diluent, he or she is not protected against invasive meningococcal disease caused by Neisseria meningitidis serogroup A.
Invasive disease with N. meningitidis serogroup A is very rare in the United States, but is more common in some other countries, particularly the African meningitis belt. If the recipient (of the C-Y-135 "diluent" only) is certain not to travel outside the United States then the dose does not need to be repeated. However, if the recipient plans to travel outside the United States the dose should be repeated with either correctly reconstituted Menveo, or with a dose of Menactra brand MCV4. There is no minimum interval between the incorrect dose and the repeat dose.
Contraindications and Precautions Back to top
I understand that a prior history of Guillain-Barrè syndrome (GBS) is no longer a precaution for giving meningococcal conjugate vaccine. Please tell me more about this.
A history of GBS had previously been a precaution for Menactra (sanofi) brand MCV4 vaccine. Findings from two studies that examined more than 2 million doses of Menactra given since 2005 showed no evidence of an increased risk of GBS. Consequently, ACIP recommended in 2010 to remove the precaution for use of Menactra in people with a history of GBS. This precaution did not apply to Menveo (Novartis) or Menomune (sanofi).
 
This page was reviewed on September 1, 2013
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