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Issue 1522
Issue 1,522: October 20, 2020

Ask the Experts: IAC Answers Questions about Meningococcal Disease and the Vaccines That Prevent It 

As an additional service to IAC Express readers, we periodically publish special editions such as this one, providing you with new and updated Ask the Experts questions and answers from IAC experts. This issue includes Q&As about meningococcal disease and the use of MenB and MenACWY vaccines based on updated ACIP recommendations published by CDC in September 2020.

You can find all of these questions and answers, plus more than a thousand others about vaccines and vaccine administration, on our Ask the Experts gateway page at www.immunize.org/askexperts.
 
IAC's team of experts includes Kelly L. Moore, MD, MPH (team lead); Carolyn Bridges, MD, FACP; William Atkinson, MD, MPH; and Deborah Wexler, MD.

Meningococcal Disease and Vaccination
Meningococcal B Vaccination
Meningococcal A, C, W, and Y Vaccination

Meningococcal Disease and Vaccination


Q: How common is meningococcal disease?

A: The incidence of meningococcal disease has declined steadily in the U.S. since a peak of reported disease in the late 1990s. Even before routine use of a meningococcal conjugate vaccine (MenACWY) in adolescents was recommended in 2005, the overall annual incidence of meningococcal disease had decreased 64%, from 1.1 cases per 100,000 population in 1996 to 0.4 cases per 100,000 population in 2005. In 2018, the rate of meningococcal disease in the U.S. reached a historic low of 0.1 cases per 100,000 population. Incidence of disease caused by serogroup B, a serogroup not included in the routinely recommended MenACWY vaccine, also has declined for reasons that are not known.
 
During 2015-2018, an estimated 360 cases of meningococcal disease occurred annually in the United States, representing an average annual incidence of 0.11 cases per 100,000 population. Of those with known serogroup in 2018 (N=302), 39% were serogroup B and 51% were serogroups C, Y, or W-135. The incidence of disease is highest in infants under 1 year, children age 1 year, and adolescents age 16–20 years.

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Q: What groups are at increased risk for meningococcal disease?

A: In addition to risk based on age, non-specific risk factors for serogroups A, C, W and Y include having a previous viral infection, living in a crowded household, having an underlying chronic illness, and being exposed to cigarette smoke (either directly or second-hand).
 
The following groups are at increased risk for all meningococcal serogroups:

  • People with persistent (genetic) complement component deficiencies (a type of immune system disorder)
  • People who use complement inhibitors such as eculizumab (Soliris, Alexion Pharmaceuticals) and ravulizumab (Ultomiris, Alexion Pharmaceuticals) for treatment of atypical hemolytic uremic syndrome or paroxysmal nocturnal hemoglobinuria
  • People with anatomic or functional asplenia
  • Microbiologists routinely exposed to meningococcal isolates in a laboratory
  • People at increased risk during an outbreak of meningococcal disease
  • Military recruits
  • College students

Certain groups are at increased risk of serogroups A, C, W and Y, but not serogroup B:

  • People living with HIV
  • Men who have sex with men (MSM)
  • Travelers to countries where meningococcal disease is endemic or hyperendemic, such as the meningitis belt of sub-Saharan Africa

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Q: Where can I find the most current meningococcal vaccine recommendations?

A: The most current comprehensive recommendations from the Advisory Committee on Immunization Practices (ACIP) for meningococcal vaccines is available on the MMWR website at www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6909a1-H.pdf. This document replaces all previously published reports and policy notes.

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Q: What meningococcal vaccines are available in the United States?

A: The vaccines for meningococcal serogroups A, C, W, and Y (MenACWY; Menactra, Sanofi Pasteur; Menveo, GlaxoSmithKline [GSK]; MenQuadfi, Sanofi Pasteur) contain meningococcal conjugate in which the surface polysaccharide is chemically bonded ("conjugated") to a protein to produce a robust immune response to the polysaccharide. Although each of the 3 MenACWY vaccine products uses a different protein conjugate, the products are considered interchangeable; the same vaccine product is recommended, but not required, for all doses.
 
A discontinued meningococcal polysaccharide vaccine (MPSV4, Menomune, Sanofi Pasteur) was available in the United States until all doses expired in September 2017. It was not interchangeable with MenACWY conjugate vaccines.
 
Since late 2014, vaccines have become available that offer protection from meningococcal serogroup B disease (MenB; Bexsero, GSK; Trumenba, Pfizer). These vaccines are composed of proteins found on the surface of the bacteria. These vaccine products are not interchangeable; the same vaccine product is required for all doses.
 
MenACWY vaccines provide no protection against serogroup B disease, and meningococcal serogroup B vaccines (MenB) provide no protection against serogroup A, C, W, or Y disease. For protection against all 5 serogroups of meningococcus, it is necessary to receive both MenACWY and MenB.
 


*May be given to adults at increased risk older than the FDA-approved upper age limit (see ACIP recommendations, Table 11, page 41, www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6909a1-H.pdf)
**Projected to be available for use in the U.S. during 2021

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Q:  Can MenACWY and MenB vaccines be given at the same visit?

A: Yes. MenACWY and MenB vaccines can be given at the same visit or at any time before or after the other.

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Q: I have a patient with paroxysmal nocturnal hemoglobinuria who is being treated with Soliris (eculizumab). Should he receive meningococcal vaccine?

A: Eculizumab (Soliris) and the related long-acting compound, ravulizumab (Ultomiris) bind to C5 and inhibit the terminal complement pathway. People with persistent complement component deficiency due to an immune system disorder or use of a complement inhibitor are at increased risk for meningococcal disease even if fully vaccinated. This patient should be given a series of MenACWY vaccine, MenACWY (2 doses separated by at least 8 weeks) and a 2- or 3-dose series (depending on brand) of MenB vaccine. The patient should receive regular booster doses of MenACWY and MenB as long as he remains at risk: a booster dose of MenACWY every 5 years and a booster dose of MenB one year after completion of the primary series, followed by a booster dose of MenB every 2–3 years thereafter.
 
Because patients treated with complement inhibitors can develop invasive meningococcal disease despite vaccination, clinicians using Soliris or Ultomiris also may consider antimicrobial prophylaxis for the duration of complement inhibitor therapy.

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Meningococcal B Vaccination


Q: Can you provide a comprehensive overview of the MenB recommendations?

A: IAC has prepared a document that provides a summary of the ACIP recommendations for use of MenB. The document is available at www.immunize.org/catg.d/p2035.pdf.

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Q: Who is recommended to be vaccinated against meningococcal B disease?

A: MenB is routinely recommended for these groups:

  • People age 10 years and older who have functional or anatomic asplenia (including sickle cell disease)
  • People age 10 years and older who have persistent complement component deficiency (an immune system disorder) or who take a complement inhibitor such as eculizumab (Soliris, Alexion Pharmaceuticals) or ravulizumab (Ultomiris, Alexion Pharmaceuticals)
  • People age 10 years and older who are exposed during an outbreak caused by serogroup B
  • Microbiologists who work with meningococcal isolates in a laboratory

For adolescents and young adults not otherwise at increased risk for meningococcal B disease, ACIP recommends that a MenB series may be administered to people 16 through 23 years of age (preferred age 16 through 18 years) on the basis of shared clinical decision-making. The shared clinical decision-making recommendation allows the clinician and patient to decide together based upon the risks and benefits of vaccination for the individual patient.

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Q: What kind of information about MenB vaccine should be considered with a patient when conducting shared clinical decision-making?

A: To assist with the shared clinical decision-making around the option to vaccinate against meningococcal serogroup B disease and the timing of vaccination, CDC has provided some specific considerations about the disease and the vaccine that the patient and provider may weigh:

  • Serious nature of invasive meningococcal serogroup B infection, with a high risk of death and permanent complications
  • Low level of serogroup B disease in the United States, with an average of 34 cases each year among people age 16 through 23 years between 2015 and 2018
  • Increased risk among college students, especially those who are freshmen, attending a 4-year university, living in on-campus housing, or participating in sorority and fraternity life
  • Protection of MenB vaccine against most strains of meningococcal serogroup B bacteria
  • Estimated relatively short duration of MenB vaccine protection, with antibody levels waning within 1–2 years of completing the primary series
  • Evidence to date suggests no impact of MenB vaccine on meningococcal B carriage (may protect an individual from invasive disease but is unlikely to impact transmission of the bacteria to others)

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Q: Which groups should receive a booster dose of MenB?

A: ACIP recommends booster doses of MenB vaccines for people at increased risk of MenB disease. Booster doses should be administered to people in the following groups as long as increased risk remains:

  • People with functional or anatomic asplenia, including sickle cell disease
  • People with persistent complement component deficiency (an immune system disorder)
  • People who take a complement inhibitor (eculizumab [Soliris] or ravulizumab [Ultomiris])
  • Microbiologists who routinely work with meningococcal isolates
  • Previously vaccinated people who are at risk during a meningococcal B disease outbreak

Because protective antibody levels produced by the primary series begin to wane within 1–2 years, the first booster dose is recommended one year after completion of the primary series, with subsequent booster doses every 2–3 years as long as increased risk remains. Previously vaccinated people identified by public health as being at risk during a meningococcal B outbreak should receive a booster dose if it has been at least one year since completion of their primary series, though depending upon the specific circumstances, public health may recommend a booster dose as little as 6 months after completion of the primary series.

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Q: I know the primary series of MenB vaccine should use the same brand for all doses. Does that also apply to booster doses?

A: Yes. MenB vaccines work differently and receiving mismatched MenB doses might result in inadequate protection. For this reason, documentation of the brand of vaccine in immunization is especially important. If a patient at high risk requires a booster dose and the brand of the primary series doses cannot be determined or is unavailable, then CDC recommends restarting the primary series with the available brand.
 
The first booster dose is recommended one year following completion of the primary series with subsequent booster doses every 2–3 years thereafter, as long as risk remains.

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Q: Public health authorities have declared a meningococcal serogroup B disease outbreak at my university and we are now vaccinating all students on campus. Some students report having had a primary series of MenB vaccine, but do not have documentation of which brand was used. What should we do?

A: During an outbreak of meningococcal B disease, swift protection of those at risk is prioritized and CDC subject matter experts do not recommend delaying vaccination in order to locate records. Student health services with documentation of MenB vaccination (including brand) of incoming students, either in a state immunization registry or in student health records, will be able to respond most efficiently to an outbreak.
 
Students whose primary series of MenB vaccine was completed at least 1 year before the outbreak (or as little as 6 months before the outbreak, if recommended by public health) should receive a single booster dose of the same brand of MenB vaccine. If the same brand is unavailable, they should restart the primary series with the available brand. If the brand of the primary series is unknown, administer a dose of the available product and counsel the recipient to request records of the primary series: if the primary series brand is different, then in order to ensure optimal protection, the recipient should be given a booster dose of the primary series product or complete a primary series with the available product after a minimum interval of 4 weeks.

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Meningococcal A, C, W, and Y Vaccination


Q: Can you provide a comprehensive overview of the MenACWY recommendations, including those for vaccinating younger children and older adults who have risk factors?

A: IAC has prepared a document that provides a summary of the ACIP recommendations for use of MenACWY for people of all ages. The document is available at www.immunize.org/catg.d/p2018.pdf.

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Q: Who is recommended to be vaccinated against meningococcal ACWY disease?

A: MenACWY is recommended for these groups:
Routine vaccination of all children and teens, age 11 through 18 years: a single dose at age 11 or 12 years with a booster dose at age 16 years
 
Routine vaccination of people age 2 months or older at increased risk for meningococcal disease (the primary dosing schedule and booster dose interval varies by age and indication):

  • People with functional or anatomic asplenia
  • People who have persistent complement component deficiency (an immune system disorder) or who take a complement inhibitor (eculizumab [Soliris] or ravulizumab [Ultomiris])
  • People who have HIV infection
  • People who are at risk during an outbreak caused by a vaccine serogroup
  • People age 2 months and older who reside in or travel to certain countries in sub-Saharan Africa as well as to other countries for which meningococcal vaccine is recommended (e.g., travel to Mecca, Saudi Arabia, for the annual Hajj)
  • Microbiologists who work with meningococcus bacterial isolates in a laboratory
  • First-year college students living in residence halls who are unvaccinated or undervaccinated; these students should receive a dose if they have not had a dose since turning 16 or if it has been more than 5 years since their previous dose

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Q: Which people with risk factors should receive booster doses beyond the routinely recommended adolescent doses of MenACWY?

A: ACIP recommends routine booster doses of MenACWY for people two months old or older at ongoing high risk for meningococcal infection (see www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6909a1-H.pdf, Table 3). This group includes people (1) with persistent complement component deficiency (an immune system disorder) or who take a complement inhibitor (eculizumab [Soliris] or ravulizumab [Ultomiris]), (2) with anatomic or functional asplenia, (3) with HIV infection, (4) who have higher risk of exposure (including microbiologists who handle Neisseria meningitidis isolates and travelers to or residents of areas with epidemic or hyperendemic meningococcal disease [such as the meningitis belt of sub-Saharan Africa]).
 
Children at continued high risk who received the last dose of the primary series of MenACWY before age 7 years should receive the next dose 3 years after the most recent dose, then every 5 years as long as risk remains. People at continued high risk who received the last dose of the primary series at age 7 years or older should receive the next dose 5 years after the most recent dose then every 5 years as long as risk remains. Two of the 3 MenACWY brands are licensed through age 55 years; however, if MenQuadfi (MenACWY-TT, licensed for use at age 2 years and older) is unavailable for an adult age 56 years or older, you may use the available MenACWY product.

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Q: Are the three MenACWY vaccines interchangeable?

A: Menactra (MenACWY-D) is not approved for children younger than 9 months so only Menveo (MenACWY-CRM) should be used for children age 2 through 8 months. MenQuadfi (MenACWY-TT) is not approved for children younger than age 2 years. From age 2 years and up the vaccines are interchangeable.

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Q: Adults who are asplenic need PCV13 and MenACWY. Does the recommendation to separate PCV13 and Menactra (MenACWY-D) apply to adults as well as children?

A: Yes. If Menactra (MenACWY-D) is being used, you should space it 4 weeks after PCV13. With both asplenic children and asplenic adults, if less than four weeks separate Menactra and PCV13 (in either order), the dose of PCV13 should be repeated four weeks after whichever vaccine was administered second.
 
Menveo (MenACWY-CRM) and MenQuadfi (MenACWY-TT) can be administered at any time before, simultaneous with, or after PCV13.

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Q: Does the recommendation for separation of DTaP and Menactra (MenACWY-D) also apply to children with functional or anatomic asplenia?

A: Yes. The recommendation about spacing of DTaP and Menactra (MenACWY-D) applies to all children younger than 7 years with a high-risk condition for meningococcal disease, including travelers. Menactra may be used earlier than 6 months after DTaP if it is the only available option and vaccination is necessary due to travel to an area with epidemic or hyperendemic meningococcal disease. Menveo (MenACWY-CRM) and MenQuadfi (MenACWY-TT) may be given at any time before or after DTaP.

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Q: If a child with a high-risk condition receives MenACWY at age 9 years (and a second primary dose 8 weeks later), should they receive a booster dose at age 14 years (5 years after the primary series), or should they receive a dose at age 16 years as recommended in the routine schedule?

A: The MenACWY booster dose should be given at 14 years (5 years after the primary series) and every 5 years thereafter. The every 5-year booster dose schedule for people with high-risk conditions takes precedence over the routine adolescent schedule.

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Suggest a question for "Ask the Experts"

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About IAC Express
The Immunization Action Coalition welcomes redistribution of this issue of IAC Express or selected articles. When you do so, please add a note that the Immunization Action Coalition is the source of the material and provide a link to this issue.

IAC Express is supported in part by Grant No. 6NH23IP922550 from the National Center for Immunization and Respiratory Diseases, CDC. Its contents are solely the responsibility of IAC and do not necessarily represent the official views of CDC.

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