Meningococcal Vaccines

Meningococcal meningitis and septicaemia is globally endemic with periodic epidemics.
Five serotypes (A, B, C, W135, Y) of Neisseria meningitidis' 13 serogroups account for virtually all disease.¹

• In the UK and other European countries, serotypes B and C are responsible for most of the endemic disease.¹ Serotype C's contribution has fallen since the introduction of childhood vaccination against the disease.²
• Serogroup A causes the majority of epidemic meningococcal infection in the African meningitis belt. Serogroup W135 has also been associated with Hajj outbreaks and a large epidemic in Burkina Faso in 2002/3.^1,2 In 2006, a new serotype A strain was responsible for increased meningitis attack rates across the African meningitis belt but also extending down into the Great Lakes area (Burundi, Rwanda and Tanzania).³
• Incidence of meningococcal disease is highest in the under 1s, followed by 1-5 year olds with a second peak of risk occurring in 15-19 year olds (particularly in those living in crowded or closed communities eg barracks, student halls).¹
• Although meningococcal disease occurs more commonly in young children, the mortality rate amongst young adults is actually higher.¹

A conjugate vaccination (Men C) has been adopted in the UK's routine immunisation schedule since November 1999 having demonstrated protective immunity in children under two.¹ Polysaccharide vaccines are less effective at protecting this age group due to their immature response to this source of antigen.⁴ Providing early immunity is important since pre-school children are particularly vulnerable to infection from encapsulated bacteria. In addition to direct immunity, Men C has also been shown to have a significant protective effect on herd immunity.^5,6 Conjugate vaccines are expensive which can preclude their use in developing countries. Currently no widely-effective or safe vaccine exists against serotype B. B-polysaccharide is similar structurally to human neural surface antigens and improving its immunogenicity risks autoantibody induction.²

1. Meningococcal Group C conjugate (Men C) vaccine
2. Meningococcal polysaccharides A, C, W135 and Y vaccine (ACWY Vax®)
3. Quadrivalent meningococcal diphtheria-conjugate vaccine (MCV-4)

Previously to the Men C conjugated vaccine, the only vaccine available against meningococcal disease had been a heat stable polysaccharide vaccine covering serotypes A and C and now W135 and Y. The response to serotype C in unconjugated vaccine in those younger than 18 months is not as good or as long-lasting as in adults and its use in infants aged between 2 months and 2 years is unlicensed.

The MCV-4 vaccine is active against subtypes A, C, W135 and Y also and has been licensed in the States and is recommended there for the routine immunisation of adolescents and other high risk groups.⁷ Safety of the polysaccharide and conjugate vaccines are thought to be similar but with improved antibody response with the conjugate vaccine.^7,6 It is not licensed in the UK presently.

• Childhood immunisation - Men C is now part of the primary course of childhood immunisation with 2 doses at 3 and 4 months of age and the combine Hib and Men C conjugated vaccine at 12 months.⁸ Those aged 5-12 months not previously vaccinated should receive 2 doses a month apart and anyone less than 25 (but over a year) not previously vaccinated should receive a single dose.
• Asplenia or dysfunctional spleen - Men C is recommended.
• Travel immunisation⁹ - the polysaccharide vaccine is recommended for those travelling to high-risk areas, in particular, Sub-Saharan Africa, the Middle East and the Indian subcontinent but consult up-to-date travel information. The risk for meningococcal meningitis is extremely low for tourists but higher for those living or working with local areas in endemic or outbreak areas.² Proof of vaccination is required for those travelling on the Hajj or Umrah pilgrimages to Saudi Arabia. Travellers should receive the polysaccharide vaccine even if they have previously had Men C conjugated vaccine.
• Contacts of infected individuals - follow advice of local Health Protection team. Family members and very close contacts of individuals with Meningococcal A or C disease are usually vaccinated in addition to receiving chemoprophylaxis. Similarly, outbreaks of A or C within closed or semi-closed communities may be controlled by vaccination.
• Laboratory workers handling N.menigiditis should also receive vaccination.

• Acute febrile illness does not preclude vaccination.
• In pregnancy there is no evidence that either vaccine is unsafe but usual advice is to avoid unless mother is at high risk of disease.
• Individuals with a previous hypersensitivity reaction to any component of the vaccine including tetanus toxoid or variant diphtheria toxin should not receive vaccination.

For Men C conjugate vaccine:

• Common:
  • Local reactions include redness and swelling at injection site. They increase with age at vaccination.
  • Systemic reactions include mild fever, irritability, headache. Systemic reactions are in the same order as those associated with other routinely administered vaccines - approximately -4% infants develop redness around injection site, 2-4% develop fever but 50% are said to display irritability in the 24-48 hours following vaccination.
• Serious:
  • Hypersensitivity reactions (including anaphylaxis|), bronchospasm and angioedema) are rare.
  • Symptoms of meningism have been reported rarely but there is no evidence that the vaccine can cause meningitis.
  • Convulsions and purpura had been linked to Men C vaccination¹¹ but post-license safety data shows no causal relationship.¹²

The CSM review of safety data (2000) concluded that the vaccine appeared safe and that the balance of risks to benefits was overwhelmingly favourable.¹¹ All suspected adverse reactions should continue to be reported via the Yellow Card system.

For meningococcal polysaccharide A, C, W135 & Y vaccine:

• Approximately 10% develop local injection-site reactions.
• More generalised fever, headache and fatigue is much rarer with children more likely to be affected.
• Hypersensitivity and anaphylaxis have been reported.

For MCV-4 (not currently available in the UK):

• Cases of Guillain-Barré syndrome have been reported to occur following vaccination. Currently, evidence is insufficient to prove or disprove a causal relationship so research and surveillance continue.¹³

• Store vaccine at 2-8 degrees. Do not freeze vaccine or diluent.¹
• Give injection IM or deep sub cut injection are recommended for MenC, with sub cut route for patients with thrombocytopaenia or haemophilia. Deep sub cut recommended for ACWY Vax®. In infants, the anterolateral aspect of the thigh and a 25G needle are advised. For older children and adults, the anterolateral thigh, upper arm or buttocks and a 23G needle.¹⁰
• Immunisation with AXWY Vax® should be at least 2-3 weeks prior to travel.¹⁰
• Booster intervals - no booster currently recommended for Men C conjugate vaccine as immunity is thought to be long-lasting; for ACWY Vax®, a 5-yearly booster is recommended and every 2-3 years for those under 54.

• Seek urgent medical advice if patient becomes short of breath, swelling of mouth or throat or 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 seek 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.