Meningococcal vaccination

Meningococcal meningitis and septicaemia are globally endemic with periodic epidemics. Meningococci are Gram-negative diplococci. They are divided into antigenically distinct capsular groups according to their polysaccharide capsule. There are currently 12 identified capsular groups, A, B, C, E, H, I, K, L, W, X, Y, and Z, of which groups B, C, W and Y are the most common causes of invasive disease in the UK. Meningococcal vaccines have significantly reduced the incidence of meningococcal disease.¹

See also the article on Meningococcal Disease for further information.

Meningitis immunisation¹

All licensed meningococcal vaccines do not contain live organisms and, therefore, cannot cause infection. The currently available vaccines are:¹

• MenC conjugate vaccine: protects against meningococcal group C. The licensed vaccines are: NeisVac-C® and Menjugate Kit®.

• Hib/MenC conjugate vaccine: protects against Haemophilus influenzae type b/meningococcal group C. The licensed vaccines is Menitorix®.

• MenACWY quadrivalent conjugate vaccine: protects against meningococcal groups A, C, W and Y. The licensed vaccines are: Menveo®, Nimenrix® and MenQuadfi®.

• Multicomponent protein vaccine (MenB): protects against meningococcal group B (may protect against other capsular groups). The licensed vaccines are: Bexsero® and Trumenba®.

Indications¹

Childhood immunisation schedule

See also the Immunisation Schedule (UK) article.

• 8 weeks: one dose 4CMenB vaccine.

• 16 weeks: one dose 4CMenB vaccine.

• One year: (primary MenC, booster Hib, booster 4CMenB}: one dose Hib/MenC conjugate vaccine; one dose 4CMenB vaccine.

• Around 14 years: primary (MenAWY), booster (MenC): one dose MenACWY conjugate vaccine.

Prophylactic paracetamol is advised where 4CMenB is administered to infants concomitantly with other routine vaccinations at 8 and 4 weeks.

Unknown or incomplete vaccination histories

Children coming from developing countries, from areas of conflict, or from hard-to-reach population groups may not have been fully immunised. Where there is no reliable history of previous immunisation, it should be assumed that they are unimmunised and the full UK recommendations should be followed.

• Infants younger than 12 months should receive the first dose of 4CMenB and a second dose of 4CMenB two months later. They should also receive the Hib/MenC dose and 4CMenB booster, ensuring at least a two-month interval between the 4CMenB doses.

• Children aged one year to less than two years who received less than 2 4CMenB doses in the first year of life should receive two additional doses of 4CMenB at least two months apart.

• Children aged one year to less than ten years should receive a single dose of a MenC containing vaccine: combined Hib/MenC vaccine should be used if the child has not had a Hib booster on or after their first birthday.

• Children and young adults aged 10 years to less than 25 years (including students up to their 25th birthday attending university for the first time) may also be eligible for the MenACWY conjugate vaccine. Those in this age group who have never received a MenC-containing vaccine should be offered a single dose of the MenACWY conjugate vaccine. No further vaccination is then required.

Premature infants should have their immunisations at the appropriate chronological age, according to the schedule.

Asplenia, splenic dysfunction or complement disorders (including those on complement inhibitor treatment)

• May be at increased risk of invasive meningococcal infection. Additional vaccinations against meningococcal disease are advised.

• Individuals who are to receive Eculizumab therapy should be vaccinated at least two weeks prior to commencement of therapy.

• Where an opportunity arises, and depending on the individual patient’s circumstances, eligible children and adults who have never received 4CMenB or MenACWY conjugate vaccine should be offered these vaccines.

Reinforcing immunisation for at risk individuals

• Meningococcal ACWY conjugate vaccine: booster doses of MenACWY conjugate vaccine in at-risk individuals are currently not recommended because the need for, and the timing of, boosters has not yet been determined. There are currently very few infections due to these 4 serogroups because of the population protection provided by the teenage MenACWY immunisation programme.

• Meningococcal B vaccine: the need for, and the timing of, a booster dose of 4CMenB vaccine in at-risk individuals has not yet been determined.

Travelling or going to reside abroad

In some areas of the world, the risk of acquiring meningococcal infection, particularly of developing capsular group A disease, is much higher than in the UK. Individuals who are particularly at risk are visitors who live or travel ‘rough’, such as backpackers, and those living or working with local people.

Large epidemics of both capsular group A and W meningococcal infection have occurred in association with Hajj pilgrimages, and proof of vaccination against A, C, W and Y capsular groups is now a visa entry requirement for pilgrims and seasonal workers travelling to Saudi Arabia.

Epidemics, mainly of capsular group A and more recently capsular group W infections, occur unpredictably throughout tropical Africa but particularly in the savannah during the dry season (December to June). Immunisation is recommended for long-stay or high-risk visitors to sub-Saharan Africa, eg those who will be living or working closely with local people, or those who are backpacking.

Outbreaks of meningococcal infection may be reported from other parts of the world. Where such outbreaks are shown to be due to vaccine-preventable capsular groups, vaccination may be recommended for certain travellers to the affected areas.

Country-specific recommendations and information on the global epidemiology of meningococcal disease can be found on the Travax and NaTHNaC websites (see Further Reading below).

MenC conjugate vaccine protects against capsular group C disease only. Those travelling abroad should be immunised with an appropriate quadrivalent (ACWY) vaccine, even if they have previously received the MenC conjugate vaccine.

ACWY schedule:

• Birth to less than one year: first dose of 0.5ml; second dose of 0.5ml one month after the first dose. If an infant has already had two MenC conjugate vaccinations then two MenACWY conjugate vaccines should also be given at least 1 month after the last meningococcal conjugate vaccine.

• From one year of age (including adults): single dose of 0.5ml.

Occupational risk

Any laboratory staff who handle strains of or clinical samples containing Neisseria meningitidis must receive a primary course of meningococcal ACWY conjugate vaccine and 4CMenB vaccine with booster doses of both vaccines every five years.

Management of contacts

Advice must be sought from the local health protection team. Household contacts of cases of meningococcal infection are at increased risk and this risk is highest in the first 7 days following onset in the index case but persists for at least four weeks. Immediate risk can be reduced by the administration of antibiotic prophylaxis to the whole contact group. Ciprofloxacin is recommended.

For confirmed or probable MenC infection, a MenC-containing conjugate vaccine should be offered to all close contacts (of all ages) who were previously not immunised, partially immunised or vaccinated more than one year previously with a MenC conjugate containing vaccine.

For confirmed capsular group A, W or Y infections, vaccination with a MenACWY conjugate vaccine should be offered to all close contacts of any age (2 doses one month apart if aged under one year; one dose in older individuals) who were previously not immunised or vaccinated more than one year previously with MenACWY conjugate vaccine.

Hib/MenC, MenACWY and/or 4CMenB vaccine should also be offered according to the recommended national schedule to any eligible unimmunised index cases. The 4CMenB vaccine is currently not routinely recommended for household contacts of an index case or for contacts in an educational setting.

Meningococcal clusters and outbreaks

Outbreaks of meningococcal infections can occur particularly in closed or semi-closed communities such as schools, military establishments and universities. Advice on the management of such outbreaks should be obtained from the local Health Protection Team.

In a meningococcal cluster or outbreak, meningococcal vaccination with the appropriate meningococcal vaccine should be considered for the same group that would receive antibiotic chemoprophylaxis.

Advice on the use of meningococcal vaccines in outbreaks is available from: UKHSA, Colindale (Tel: 020 8200 6868), Health Protection Scotland (Tel: 0141 300 1100) and the Scottish Haemophilus, Legionella, Meningococcus and Pneumococcus Reference Laboratory (Tel: 0141 201 8659).

Contra-indications¹

Minor acute illness does not preclude vaccination. However, if pyrexial, vaccination may be postponed, in order not to confuse signs or symptoms from the vaccine with a developing illness.

Meningococcal vaccines may be given to pregnant women when clinically indicated. There is no evidence of risk from vaccinating pregnant women or those who are breast-feeding. In cases where meningococcal immunisation has been inadvertently given in pregnancy, there has been no evidence of harm to the foetus.

If any doubt, appropriate advice should be sought from a consultant paediatrician, immunisation co-ordinator or consultant in communicable disease control, rather than withhold immunisation. The vaccines should not be given to those who have had:

• Confirmed anaphylactic reaction to a previous dose of the vaccine, or

• Confirmed anaphylactic reaction to any constituent or excipient of the vaccine.

Adverse reactions¹

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 are commonly seen. In older children and adults, headaches, myalgia and drowsiness may be seen. Neurological reactions such as dizziness, febrile/afebrile seizures, faints, numbness and hypotonia following MenC conjugate vaccination are very rare.

Hib/MenC conjugate

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. Less commonly crying, diarrhoea, vomiting, atopic dermatitis, malaise, and fever over 39.5˚C have been reported.

Quadrivalent (ACWY) conjugate vaccine

• Menveo®: very common or common reported reactions included injection site reactions including pain, erythema, induration, and pruritus. Other very common or common reactions include headache, nausea, rash, and malaise.

• Nimenrix®: very common or common reported reactions included injection site reactions including pain, erythema, and swelling. Other very common or common reactions include irritability, drowsiness, headache, nausea, and loss of appetite.

4CMenB vaccine

• 4CMenB (Bexsero®): the most common local and systemic adverse reactions in adolescents and adults were pain at the injection site, malaise, and headache. In infants and children up to ten years of age, injection site reactions, fever (≥38^oC) and irritability. Diarrhoea and vomiting, eating disorders, sleepiness, unusual crying and rash. In infants and children under two years of age, fever ≥38°C (occasionally ≥39°C) is more common when 4CMenB is given at the same time as routine vaccines than when 4CMenB was given alone. It is therefore recommended that paracetamol should be given prophylactically when 4CMenB is given with the routine vaccines in infants under one year of age.

• MenB-fHbp vaccine (Trumenba®): the most common adverse reactions in those over 10 years of age are headache, diarrhoea, nausea, muscle pain, joint pain, fatigue, chills, and injection site pain, swelling and redness.

Giving the vaccines¹

All meningococcal-containing vaccines are given intramuscularly into the upper arm or anterolateral thigh. This is to reduce the risk of localised reactions, which are more common with subcutaneous injection. However, for people with a bleeding disorder, vaccines should be given by deep subcutaneous injection to reduce the risk of bleeding.

Meningococcal vaccines can be given at the same time as other vaccines such as pneumococcal, measles, mumps and rubella (MMR), diphtheria, tetanus, pertussis, polio and Hib. The vaccines should be given at a separate site, preferably in a separate limb. If given in the same limb, they should be given at least 2.5cm apart. The site at which each vaccine is given should be noted in the clinical record.