Meningitis immunisation

• A conjugate vaccination - meningococcal group C (MenC) - has been adopted in the UK's routine immunisation schedule since November 1999, having demonstrated protective immunity in children aged under 2.^[1]
• MenC only confers protection against meningococcal C and not the other serogroups.
• Polysaccharide vaccines are less effective at protecting this age group, due to their immature response to this source of antigen.^[3]
• Providing early immunity is important since pre-school children are particularly vulnerable to infection from encapsulated bacteria.
• In addition to direct immunity, MenC has also been shown to have a significant protective effect on herd immunity.^[4][5]
• Conjugate vaccines are expensive which can preclude their use in developing countries.^[6]
• There is a vaccine against serotype B, although it is not available in the UK. B-polysaccharide is similar structurally to human neural surface antigens and improving its immunogenicity risks autoantibody induction.^[2]

Available vaccines

1. Meningococcal group C (MenC) conjugate vaccine. There is also a Haemophilus influenzae type b/meningococcal group C (Hib/MenC) conjugate vaccine.
2. Quadrivalent (ACW135Y) polysaccharide vaccine (ACWY Vax®). This is an older vaccine and is not recommended for children.
3. Quadrivalent (ACW135Y) conjugate vaccine (Menveo®). This is a newer vaccine.^[7]
4. If a quadrivalent vaccine is to be used, then the Department of Health currently recommends the conjugate vaccine be used in preference to the polysaccharide vaccine because it provides better and longer-lasting protection. Children aged under 5 should always be vaccinated with Menveo® when a quadrivalent vaccine is needed. For babies under 1 year of age, two doses one month apart are needed for protection, but older children and adults should receive a single dose.

Indications

• Childhood immunisation (see also separate article Immunisation Schedule UK):
  • Meningococcal group C (MenC) conjugate vaccine is part of the primary course of childhood immunisation with a dose at 3 months of age, the combined Hib and MenC conjugate vaccine given between 12 and 13 months and a booster at around 14 years.
  • The Hib/MenC vaccine can be given at the same time as the pneumococcal conjugate and MMR vaccines, by separate injections.
  • Those aged over 12 months, but under 10 years not previously vaccinated, should receive one dose of either MenC or Hib/MenC if required. Children over 10 years, who have not been previously vaccinated, may receive the booster early.
  • Those aged 10-25 years who have never been vaccinated, should receive a single dose of MenC vaccine. If they have received a booster after age 10, no further doses are required. If they were last vaccinated at less than 10 years, the booster dose should be given.
• Asplenia, splenic dysfunction, immunosuppression or complement deficiency:
  • MenC and MenACW135Y conjugate vaccine are recommended for patients with asplenia, splenic dysfunction, immunosuppression or complement deficiency.^[1]
  • Children aged under 1 year should be vaccinated according to the immunisation schedule. A dose of MenACWY conjugated vaccine should be given at least one month after the Hib/MenC vaccine.
  • Children over 1 year old should be given a Hib/MenC vaccine and the MenACWY conjugated vaccine one month later.
• Travel immunisation:^[8]
  • Large epidemics of meningococcal disease have been linked to the Hajj pilgrimage. Current recommendations are that the quadrivalent ACWY vaccination is a compulsory entry requirement into Saudi Arabia for pilgrims on Hajj and Umrah, and for other travellers in Hajj season. Vaccination is also recommended for travel to sub-Saharan Africa and certain other countries, especially if travellers will be living or working with local people or visiting during an outbreak.^[8]
  • If the person has recently received MenC, an interval of at least two weeks should ideally be allowed before administration of the MenACWY vaccine.
  • The risk for meningococcal meningitis is extremely low for tourists but higher for those living or working within local areas in endemic or outbreak areas.^[2]
• Contacts of infected individuals:
  • Follow the advice of the local Health Protection Team.
  • Previously unimmunised family members and very close contacts of individuals with confirmed meningococcal C disease should be offered MenC conjugate vaccination.
  • Close contacts of any age who were only immunised in infancy and those who completed the recommended immunisation course (including the 12-month booster) more than one year before should be offered an extra dose of MenC conjugate vaccine.
  • Chemoprophylaxis (usually with rifampicin) should also be offered without delay.
  • For confirmed serogroup A, W135 or Y infections, vaccination with a quadrivalent conjugate vaccine (Menveo®) should be offered to all close contacts of any age (two doses one month apart if aged under one year; one dose in older individuals).
• Laboratory workers handling Neisseria meningitidis should also receive vaccination.

Contra-indications

• Acute febrile illness does not preclude vaccination.
• In pregnancy there is no evidence that either vaccine is unsafe but the usual advice is to avoid unless the mother is at high risk of disease.
• The vaccines are safe to give women who are breast-feeding.
• Individuals with a previous hypersensitivity reaction to any component of the vaccine including meningococcal polysaccharide, diphtheria toxoid or the CRM197 carrier protein or tetanus toxoid should not receive vaccination.

Adverse reactions^[1]

For MenC conjugate vaccine:

• Pain, tenderness, swelling or redness at the injection site and mild fevers are common in all age groups.
• In infants and toddlers - crying, irritability, drowsiness, impaired sleep, reduced eating, diarrhoea and vomiting can be common.
• In older children and adults - headaches, myalgia and drowsiness may occur.
• Neurological reactions such as dizziness, febrile/afebrile seizures, faints, numbness and hypotonia following MenC conjugate vaccination are very rare.

For Hib/MenC conjugate vaccine:

• Mild side-effects, such as irritability, loss of appetite, pain, swelling or redness at the site of the injection and slightly raised temperature, commonly occur.
• Crying, diarrhoea, vomiting, atopic dermatitis, malaise and fever over 39.5°C are rare side-effects.

For quadrivalent (ACW135Y) conjugate vaccine:

• Very common or common reported reactions have included injection site reactions including pain, erythema, induration and pruritus.
• Other very common or common reactions may include headache, nausea, rash and malaise.

Giving the vaccines^[1]

• Store vaccine at 2-8°C. Do not freeze vaccine or diluent.
• Giving the injection intramuscularly (IM) in the upper arm or anterolateral thigh is recommended.
• A deep subcutaneous route is advised for patients with thrombocytopenia or haemophilia.
• Immunisation with MenACWY should be at least 2-3 weeks prior to travel.^[9]
• Booster intervals:
  • Children over 1 year of age, who have previously received one, two or three doses of Menveo® as infants, should be given an additional dose of Menveo® if they are travelling to an area that puts them at risk from meningococcal infection.
  • The meningococcal ACWY conjugate vaccine is likely to provide longer-lasting protection than the polysaccharide vaccine. However, the need for, and the timing of, a booster dose of Menveo® has not yet been determined.

Patient advice

• Seek urgent medical advice if the patient becomes short of breath, has swelling of the mouth or throat or has a rash within a few days of immunisation.
• Parents should give a dose of paracetamol or ibuprofen if their child develops a fever post-immunisation, keeping the child cool and seeking medical advice if the fever persists after a second dose.
• Travel immunisation for meningococcal meningitis is not routinely available on the NHS and payment is at the discretion of the practice.