Meningococcemia primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ammu Susheela, M.D. [2]

Primary Prevention

• Current vaccines have polysaccharides of groups A, C, Y, and W-135. No vaccine available presently for group B disease since the polysaccharide is not sufficiently immunogenic to produce a reliable antibody response in humans to be effective.
• There is a vaccine for the bacteria that cause meningococcal disease.
• Available vaccines do not cover all serogroups (“strains”) of Neisseria meningitidis bacteria.
• Meningococcal vaccines are not 100% effective. This means that even if you have been vaccinated, there is still a chance you can develop a meningococcal infection.

Who Needs to be Vaccinated ?

• First-year college student living in a residence hall
• Military recruit
• Damaged spleen or your spleen has been removed
• Terminal complement deficiency
• Microbiologist who is routinely exposed to Neisseria meningitidis (the causal pathogen)
• People traveling or residing in countries in which the disease is common.

Vaccine

There are two kinds of meningococcal vaccine in the U.S.:

• Meningococcal conjugate vaccine (MCV4) is the preferred vaccine for people 55 years of age and younger.
• Meningococcal polysaccharide vaccine (MPSV4) has been available since the 1970s. It is the only meningococcal vaccine licensed for people older than 55.

Meningococcal Polysaccharide Vaccine (MPSV4)

• Both vaccines can prevent 4 types of meningococcal disease, including 2 of the 3 types most common in the United States and a type that causes epidemics in Africa.
• There are other types of meningococcal disease; the vaccines do not protect against these.The first meningococcal polysaccharide vaccine was licensed in the United States in 1974.
• The current quadrivalent A, C, Y, W-135 polysaccharide vaccine (Menomune, sanofi pasteur) was licensed in 1978.
• Each dose consists of 50 mcg of each of the four purified bacterial capsular polysaccharides. The vaccine contains lactose as a stabilizer.
• MPSV4 is administered by subcutaneous injection. The vaccine is available in single-dose and 10-dose vials. Fifty-dose vials are no longer available.
• Diluent for the single-dose vial is sterile water without preservative.
• Diluent for the 10-dose vial is sterile water with thimerosal added as a preservative. After reconstitution the vaccine is a clear colorless liquid.
• No vaccine is available in the United States for serogroup B.

Meningococcal Conjugate Vaccine (MCV4)

• Two meningococcal conjugate vaccines are licensed in the United States.
• Menactra (sanofi pasteur) was licensed in 2005.
• The vaccine contains N. meningiditis serogroups A, C, Y and W-135 capsular polysaccharide antigens conjugated to diphtheria toxoid protein.
• Each 0.5-mL dose of vaccine is formulated in sodium phosphate buffered isotonic sodium chloride solution to contain 4 mcg each of meningococcal A, C, Y, and W-135 polysaccharides conjugated to approximately 48 mcg of diphtheria toxoid protein carrier.
• Menactra is approved for use in persons 9 months through 55 years of age.
• It is administered by intramuscular injection. Menactra is supplied as a liquid in a single-dose vial and does not contain a preservative or an adjuvant.Menveo (Novartis) was licensed in the United States in 2010.
• Menveo consists of two components: 10 µg of lyophilized meningococcal serogroup A capsular polysaccharide conjugated to CRM (MenA) and 5 µg each of capsular polysaccharide of serogroup C, Y, and W135 conjugated to CRM-197 in 0.5 mL of phosphate buffered saline, which is used to reconstitute the lyophilized MenA component before injection.
• Menveo is approved for use in persons 2 through 55 years of age. It is administered by intramuscular injection. It does not contain a preservative or an adjuvant.

Immunogenicity and Vaccine Efficacy

Meningococcal Polysaccharide Vaccine

• The characteristics of MPSV4 are similar to other polysaccharide vaccines (e.g., pneumococcal polysaccharide).
• The vaccine is generally not effective in children younger than 18 months of age.
• The response to the vaccine is typical of a T-cell independent antigen, with an age-dependent response, and poor immunogenicity in children younger than 2 years of age.
• In addition, little boost in antibody titer occurs with repeated doses; the antibody which is produced is relatively low-affinity IgM, and “switching” from IgM to IgG production is poor.
• A protective level of antibody is usually achieved within 7–10 days of vaccination. Among infants and children younger than 5 years of age, the level of antibody against serogroup A and C polysaccharide decreases substantially during the first 3 years following a single dose of vaccine.
• In healthy adults, antibody levels also decrease, but antibodies are detectable as long as 10 years after vaccination.
• Although vaccine-induced protection likely persists in school-aged children and adults for at least 3 years, the efficacy of the group A vaccine in children younger than 5 years of age may decrease markedly within this period.
• In one study, efficacy declined from more than 90% to less than 10% 3 years after vaccination among children who were younger than 4 years of age when vaccinated.
• Efficacy was 67% among children who were older than 4 years of age at vaccination.

Meningococcal Conjugate Vaccine

• The approval of Menactra was based on studies that compared the serologic response to a single dose to the response of persons of similar age who received a single dose of meningococcal polysaccharide vaccine.
• In these studies a similar proportion of recipients achieved at least a fourfold rise in serum bactericidal antibody titer assay following MCV4 as those who received MPSV4.
• The proportion of recipients in each group that achieved a titer of 1:128 (the titer considered to predict protection) was more than 98% in both groups.
• The approval of Menveo was based on a comparison of serum bactericidal antibody responses to immunization with Menveo to those following immunization with Menactra.
• The response to Menveo was found to be non-inferior to the response to Menactra in all age groups that were studied (2 through 55 years).
• When MCV4 vaccine was licensed in 2005 it was believed that a single dose would provide protection for at least 10 years.
• Since that time serologic data have become available that show a significant decline in antibody 3 to 5 years after vaccination, although few cases among vaccinated persons have been reported.
• ACIP believes the serologic data are sufficiently compelling to recommend revaccination for persons at highest risk of meningococcal disease.
• Data indicate that the immune response to a single dose of meningococcal conjugate vaccine is not sufficient in persons with persistent complement component deficiency (e.g., C5--C9, properidin, factor H, or factor D deficiency) or asplenia.
• Persons with these conditions should receive a 2-dose primary series administered 2 months apart.

Meningococcal Polysaccharide Vaccine

• Routine vaccination of civilians with MPSV4 is not recommended. Use of MPSV4 should be limited to persons older than 55 years of age, or when MCV4 is not available.

=Meningococcal Conjugate Vaccine

• Two doses of MCV4 are recommended for adolescents 11 through 18 years of age: the first dose at 11 or 12 years of age, with a booster dose at age 16.
• Adolescents in this age group with HIV infection should get three doses: 2 doses 2 months apart at 11 or 12 years, plus a booster at age 16.
• If the first dose (or series) is given between 13 and 15 years of age, the booster should be given between 16 and 18. If the first dose (or series) is given after the 16th birthday, a booster is not needed.
• Healthy persons who receive their first routine dose of meningococcal conjugate vaccine at or after age 16 years do not need a booster dose.
• Routine vaccination of healthy persons who are not at increased risk for exposure to N. meningitidis is not recommended after age 21 years.
• A booster dose is not recommended for healthy persons 22 years of age or older even if the first dose was administered at 11 through 15 years of age.
• Persons with persistent complement component deficiency, and persons with functional or anatomic asplenia should receive a 2-dose primary series administered 2 months apart and a booster dose every 5 years.
• The minimum interval between MCV4 doses is 8 weeks. Although doses separated by 8 weeks can both be counted as valid it is preferable to use a longer interval between doses, 3 to 5 years if possible.
• MCV4 can be administered at the same visit as other indicated vaccines. All vaccines should be given at separate sites with separate syringes.
• Both MCV4 and MPSV4 are recommended for use in control of meningococcal outbreaks caused by vaccine-preventable serogroups (A, C, Y, and W-135).
• An outbreak is defined by the occurrence of at least three confirmed or probable primary cases of serogroup C meningococcal disease during a period of 3 months or less, with a resulting primary attack rate of 10 or more cases per 100,000 population.

HIV patients

• HIV infection is not currently considered to be an indication for MCV4 vaccination by itself.
• However, some persons with HIV infection should receive MCV4 for other indications, such as adolescents or international travel.
• Persons with HIV infection who are vaccinated with MCV4 should receive 2 doses at least 8 weeks apart. Persons with complement component deficiency, functional or anatomic asplenia or HIV infection who have already received 1 dose of MCV4 should receive a second dose at the earliest opportunity.

Children

• Children 9 through 23 months of age with persistent complement component deficiency, who are traveling to or residents of countries where meningococcal disease is hyperendemic or epidemic, and who are in a defined risk group during a community or institutional meningococcal outbreak should receive a 2-dose series of Menactra brand MCV4, 3 months apart. *Because of their high risk for invasive pneumococcal disease, children with functional or anatomic asplenia should be vaccinated with MCV4 beginning at age 2 years to avoid interference with the immunologic response to the infant series of pneumococcal conjugate vaccine (PCV). The minimum interval between doses is 8 weeks.
• Persons who received the first dose of MCV or MPSV before 7 years of age and remain at increased risk for meningococcal disease should be revaccinated 3 years after the first dose. Persons who received a dose of MCV or MPSV at 7 years of age or older and remain at increased risk for meningococcal disease should be revaccinated 5 years after their previous dose.

Contraindication of Vaccination

• Anyone who has ever had a severe (life-threatening) allergic reaction to a previous dose of MCV4 or MPSV4 vaccine should not get another dose of either vaccine.
• Anyone who has a severe (life threatening) allergy to any vaccine component should not get the vaccine.
• Anyone who is moderately or severely ill at the time the shot is scheduled should probably wait until they recover. Ask your doctor. People with a mild illness can usually get the vaccine.
• Meningococcal vaccines may be given to pregnant women. MCV4 is a fairly new vaccine and has not been studied in pregnant women as much as MPSV4 has. It should be used only if clearly needed. The manufacturers of MCV4 maintain pregnancy registries for women who are vaccinated while pregnant.

Complications

• Allergic reactions

• Hives
• Swelling of face and throat
• Difficulty breathing
• Palpitation
• Dizziness
• Weakness

• Fainting smells
• Seizure-like movements
• Fever

Prophylaxis

• Rifampin 600 mg PO q12h x 4 doses total or alternatively ciprofloxacin 500 mg PO x 1 in patients over 18 who cannot tolerate rifampin.