In this chapter:
- Key information
- 13.1. Bacteriology
- 13.2. Clinical features
- 13.3. Epidemiology
- 13.4. Vaccines
- 13.5. Recommended immunisation schedule
- 13.6. Contraindications and precautions
- 13.7. Potential responses and AEFIs
- 13.8. Public health measures
- 13.9. Variations from the vaccine data sheets
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Mode of transmission
By respiratory droplets or direct contact with nasopharyngeal secretions from a carrier or case.
2–10 days, commonly 3–4 days.
Period of communicability
Commonly 3–4 days without treatment, range 2–10 days. Antibiotic therapy eradicates N. meningitidis from mucosal surfaces within 24 hours, and the case is no longer considered infectious.
Other available vaccines
Dose, presentation, route
0.5 mL per dose.
Funded vaccine indications
MenACWY-D (Menactra) or MenC (NeisVac-C) for:
Laboratory workers handling bacterial cultures
Health care professionals in very close contact with cases.
MenACWY: effectiveness of 80–85%; effectiveness wanes to 50–60% within 2–5 years after vaccination.
MenC: effectiveness of 83–100%; group C incidence reduce by 90% in post population-wide programmes; persistence of protection may be partially due to herd effects as antibody wanes within 2–3 years.
4CMenB: based on bactericidal antibody levels and circulating meningococcal B strains, protection is estimated as 63–100% in under 2‑year olds, 72–100% in 2–3-year olds and 91–100% in older children and adults. UK data over 3 years post programme implementation observed a 75% reduction in group B cases in infants.
Potential responses to vaccines
MenC and MenACWY: localised pain, irritability, headache and fatigue, mild fever.
4CMenB: increased risk of fever and fever-related events in children <2 years (prophylaxic paracetamol advised). Older age groups: localised pain, nausea, myalgia, malaise, mild fever and headache.
No specific contraindications or precautions, except prior anaphylaxis to vaccine components.
Public health measures
All cases must be notified if clinically suspected.
Parenteral antibiotics should be administered as soon as possible before admission to hospital or in hospital if delays of longer than 30 minutes are likely.
For chemoprophylaxis of contacts see section 13.8.2.
Meningococcal disease is caused by Neisseria meningitidis, a gram-negative bacterium, causing sepsis, meningitis and some less common clinical syndromes. Groups B, W and C are currently the most important types in New Zealand. Increasingly, group W and Y organisms are the cause of bacteraemia and pneumonia in the elderly. Predominant groups differ between countries; group A is an important epidemic strain, particularly in Africa and the Middle East. Meningococci are spread from person to person by respiratory droplets or direct contact with nasopharyngeal secretions from a carrier or case.
Table 13.1 below describes the symptoms and signs of meningococcal disease – individuals may present with some or all of these. Meningococcal septicaemia is more common than meningitis, and presentation varies from a mild non-specific illness to rapid progression with fatal outcome. Symptoms and signs in infants are frequently non-specific. The classical rapidly progressing petechial or purpuric rash may not be present or may initially appear maculopapular. Atypical initial presentations, including gastrointestinal symptoms, septic arthritis and epiglottitis, are more frequently reported with meningococcal W disease, and may contribute to delayed diagnosis and increased case-fatality.[1, 2] Pneumonia is more frequently reported with group Y.
Meningococcal disease covers a spectrum, from persistent fever with or without rash and arthritis to rapidly progressive purpuric rash and shock. Meningitis can occur with and without signs of sepsis. In fulminant cases, coma and death can occur within a few hours despite appropriate treatment.
Because of the potential for rapid progression, antibiotics should be administered (Table 13.2) as soon as possible before hospital admission. Antibiotics given prior to transfer should be clearly noted on information accompanying the patient to hospital.
- Patients allergic to penicillin who do not have a documented history of anaphylaxis to penicillin can be given ceftriaxone.
- Patients with a documented history of anaphylaxis to penicillin and who are suspected of suffering from meningococcal disease should be sent immediately to hospital without pre‑admission antibiotics.
13.3.1. Global burden of disease
Incidence and serotypes
The prevalence of meningococcal groups varies geographically. The highest burden of disease occurs in sub-Saharan Africa, where despite a dramatic fall in Group A disease following introduction of a Group A conjugate vaccine this ‘meningitis belt’, epidemics continue with around 30,000 cases reported annually, now including Group W.
The incidence in Canada, the US and Europe varies substantially from 0.2 to 3 per 100,000 persons per year. Group B has become the predominant capsular group in Europe, Americas and Australia, with incidence typically highest in children aged under 2 years. Group C disease has almost disappeared in countries with universal immunisation programmes, but outbreaks have been observed in men who have sex with men in the US and Europe.
Since 2009 there has been an emerging global incidence of Group W disease, initially in the United Kingdom and South America. Australia has experienced a rapid increase in Group W cases since 2013 with New Zealand also seeing a rapid increase in cases since 2017. Like group C clonal complex ST11 strains, group W ST11 strains have enhanced virulence. Higher rates of carriage of these ST11 strains has been noted within age groups where invasive group W disease is more prevalent (infants and the elderly).
Some parts of the world, particularly in Scandinavia, have reported an increase in group Y disease. In other regions, there is evidence of colonisation, but disease caused by group Y is rare. Patients with group Y strain disease are more likely to develop pneumonia and to be elderly than other strains.[3, 4]
This emergence of group W and Y strains has led to meningococcal C vaccines being replaced by quadrivalent (group A, C, W, Y) meningococcal conjugate vaccines (MenACWY).
The highest incidence of meningococcal disease occurs in children aged under 5 years (especially under 2 years) with a secondary peak in older adolescents (15–19 years).The age distribution for groups W and Y is more likely to include older people that for B and C. A pooled overall case-fatality rate of 8.3 percent (range 4.1–20 percent) is reported internationally, varying by group and age.
Most infection occurs in healthy people, but those with certain rare immune deﬁciencies (terminal components of complement (C5–9) or properdin) or asplenia are at much higher risk, particularly of recurrent meningococcal disease. Individuals with infection caused by groups other than A, B, C, W, Y and untypeable strains or who experience recurrent disease should be investigated.
Close contacts of primary cases of meningococcal infection are at increased risk of developing infection, such as the case’s household, early childhood education services, semi-closed communities, schools, correctional facilities and military recruit camps. Students living in hostel accommodation may also be at higher risk.[8, 9, 10] In health care settings, only those with close exposure to oropharyngeal secretions of patients with meningococcal disease (as may occur during intubation or resuscitation) and microbiology laboratory workers are considered to be at increased risk.
It is not possible to calculate the incubation period for meningococcal disease for sporadic cases. Secondary cases (ie, in contacts of known cases of meningococcal disease) usually occur within four days, but it can be up to 10 days. The infectivity of patients with meningococcal disease is markedly reduced after 24 hours of antibiotic therapy, although treatment with cefotaxime, ceftriaxone, rifampicin or ciproﬂoxacin is necessary to reliably eradicate nasopharyngeal carriage and hence relax infection prevention and control precautions (see section 13.8.2).
In high-income countries in the absence of immunisation, nasopharyngeal carriage of N. meningitidis occurs in approximately 10 percent of the overall population, rising from 2 percent in children aged under 4 years to a peak of 24.5 percent to 32 percent among 15–24-year-olds, then declining with increasing age.[3, 11] In adolescents and young adults, the overall and capsular group carriage vary between regions and age groups. The relationship between risk factors for disease and those associated with carriage is incompletely understood. Carriage prevalence does not predict the disease incidence nor the occurrence or severity of outbreaks, as most of the carried strains are non-encapsulated and do not cause disease. Smoking, passive smoking, household crowding and upper respiratory tract infections increase carriage.
13.3.2. New Zealand epidemiology
Incidence and mortality
In 2019 the notification rate for meningococcal disease was 2.8 cases per 100,000 population, with a total of 139 cases notified (134 laboratory-confirmed; ESR, 8 June 2020). Cases have increased since 2014, but remain significantly lower than the peak annual incidence rate of 16.7 per 100,000 for all ages and 200 per 100,000 in children under 12 months as experienced in 2001 during the meningococcal epidemic from 1991 to 2007. The epidemic was largely due to a single Group B subtype (B:4:P1.7b,4). The annual number of notified cases of meningococcal disease in New Zealand since 1970 is shown in Figure 13.1.
For further details and reports of meningococcal disease in New Zealand refer to the ESR surveillance reports.
Meningococcal disease incidence is about three-fold higher in Pacific people (9.2 per 100,000, 29 cases in 2019) and two-fold higher in Māori (6.1 per 100,000, 47 cases) compared with the total population. Household crowding is an important risk factor for meningococcal disease, independent of ethnicity. In 2019, the highest age-specific disease rates were among those aged under 1 year (52.0 per 100,000, 31 cases) decreasing in ages 1–4 years (8.5 per 100,000, 21 cases). Ten deaths occurred in 2019, giving a case fatality rate of 7.2 percent (ESR, 8 June 2020).
Strain type was determined for 122 of the 134 laboratory-confirmed cases in 2019. Group B strains were the most prevalent, causing 51 percent of the confirmed cases (Figure 13.2). The group B strain (B:4:P1.7b,4) responsible for the epidemic caused 16 percent of all meningococcal disease in 2019 (19 of the 122 typed cases). Cases of meningococcal disease caused by group C strains decreased since 2011 (Figure 13.2), while group W increased from five cases in 2016 to 36 in 2019.
Internationally, meningococcal vaccination programmes were revolutionised by the development of conjugate vaccines, which allow vaccination in younger children and induced herd immunity when used in population-wide programmes due to reduced nasopharyngeal carriage (see section 1.4.3).
The monovalent (C) and quadrivalent (ACWY) conjugate vaccines are conjugated to a protein, either CRM197 (diphtheria toxin-derived), diphtheria toxoid or tetanus toxoid. Previously used, polysaccharide-only vaccines provided three to five years’ protection in adults, but they are generally regarded as inferior to conjugate vaccines and are no longer available or registered in New Zealand. Those travelling to Africa, the Middle East and other areas with wide serogroup prevalence, including group A, require MenACWY vaccine for broad protection. In 2018, a multicomponent meningococcal group B recombinant vaccine (4CMenB) was registered in New Zealand to protect against group B disease.
With the current New Zealand epidemiology, neither MenACWY nor 4CMenB give protection across all prevailing meningococcal groups and both types of vaccine are recommended. The meningococcal vaccines registered and available are summarised in Table 13.3 below.
No meningococcal vaccines are on the routine Schedule but group C conjugate and quadrivalent meningococcal conjugate vaccines are recommended and funded for certain individuals (see section 13.5).
Two meningococcal conjugate vaccines are funded for certain at-risk groups.
- Meningococcal group C conjugate vaccine MenC (NeisVac-C, Pfizer NZ Ltd) contains 10 µg of polysaccharide derived from the group C capsule, conjugated to 10–20 µg of tetanus toxoid. Other components include aluminium hydroxide and sodium chloride.
- Quadrivalent meningococcal conjugate vaccine MenACWY-D (Menactra, Sanofi) contains 4 µg of each polysaccharide derived from the capsules of group A, C, W and Y N. meningitidis strains, each conjugated to diphtheria toxoid. Other components include sodium chloride and sodium phosphate.
Quadrivalent meningococcal conjugate vaccines
A second quadrivalent meningococcal conjugate vaccine MenACWY-T (Nimenrix, Pfizer NZ Ltd) is registered and available in New Zealand for individuals from age 6 weeks. MenACWY-T contains 5 µg of each polysaccharide derived from the capsules of group A, C, W and Y N. meningitidis strains, conjugated to 44 µg of tetanus toxoid carrier protein. Other components and excipients include sodium chloride, trometamol and sucrose.
Another quadrivalent meningococcal vaccine, MenACWY-CRM197 (Menveo, GSK) is licensed from 2 months of age elsewhere, including Australia, Europe, UK and the US, which is conjugated to a diphtheria-toxin derived CRM197 protein (as used in PCV13). It is not available in New Zealand.
Group B meningococcal vaccines
The 4CMenB recombinant vaccine (Bexsero, GSK) is available in New Zealand from age 6 weeks (not funded). Based on bactericidal antibody titres, it is expected to provide protection against more than 75 percent of the circulating group B strains, including the former epidemic strain B:4:P1.7b,4 (NZ 98/254). This vaccine contains four components from the group B meningococci: three recombinant group B surface proteins associated with bacterial adhesion and survival plus detoxified outer membrane vesicles containing antigen used in the MenNZB epidemic vaccine.
A two-component meningococcal group B recombinant vaccine (2CMenB; Trumenba, Pfizer Ltd) is licensed from 10 years of age in the US, Europe and Australia. It is not registered in New Zealand.
In February 2015 the US Advisory Committee on Immunization Practices recommended that individuals aged 10 years or older at increased risk for meningococcal disease should receive a meningococcal B vaccine (either 4CMenB or 2CMenB). In June 2015, this recommendation was extended to include all aged 16–23 years (with a preferred age of 16–18 years), to provide short-term protection against most circulating strains of serogroup B meningococcal disease.
Historic MeNZB vaccine
A strain-specific group B meningococcal vaccine (MeNZB, Chiron/Novartis) containing outer membrane vesicles derived from the epidemic strain B:4:P1.7b,4 (NZ 98/254) was developed for epidemic control in New Zealand and used between 2004 and 2008. The programme ceased in 2008 because of a decline in incidence of group B disease (see previous editions of the Handbook).
Since the immune response to MenNZB was short-lived, previous recipients who wish to be protected against meningococcal B disease will need to be fully immunised with 4CMenB.
13.4.2. Efficacy and effectiveness
Meningococcal conjugate vaccines
Quadrivalent meningococcal conjugate vaccines
Clinical trial data use immunogenicity and bactericidal antibody titres as a proxy for efficacy. Effectiveness of conjugate meningococcal vaccination against laboratory-confirmed disease is difficult to assess due to the low incidence of cases, even during localised epidemics, such that data is limited around the effectiveness of the MenACWY vaccines. With the emergence of group W and Y strains, more countries have implemented mass campaigns and routine immunisation programmes to control outbreaks with MenACWY vaccines and can assess impact through disease incidence and carriage studies.
The overall effectiveness of a single dose of diphtheria conjugate quadrivalent meningococcal vaccine (MenACWY-D, Menactra) given at age 11–12 years was estimated to be 69 percent up to eight years post-vaccination (from 79 percent in year one to 61 percent up to eight years post-vaccination). These findings cannot be extrapolated across all MenACWY vaccines due to differences in immunogenicity.
Following a mass vaccination campaign in children aged 9 months to 4 years in Chile with MenACWY (MenACWY-D or MenACWY-CRM, depending on age), there was a 92.3 percent reduction in group W disease and the case-fatality rate declined from 23 percent in 2012 to 0 percent in 2016 in children aged 1–4 years. However, there was no impact in infants aged under 12 months or adults aged 80 years or older.
The MenACWY-D vaccine was poorly immunogenic in infants aged under 6 months, and it is currently registered in New Zealand for individuals aged 9 months to 55 years.
The MenACWY-T vaccine (Nimenrix) is registered in New Zealand for individuals from aged 6 weeks. Clinical trials showed that the vaccine elicited bactericidal antibodies against all four groups from age 2 months with acceptable reactogenicity and safety profile.
The conjugate quadrivalent meningococcal vaccines are available in New Zealand. There is no published data on effectiveness in older adults.
Meningococcal group C conjugate vaccines
Meningococcal C conjugate vaccines were used successfully in national immunisation and mass vaccination programmes from 1999 in the UK, resulting in almost complete elimination of group C disease. A targeted immunisation campaign during an epidemic in Salvador, Brazil demonstrated MenC vaccination to be 98 percent effective against group C disease in young children.
Data from the UK programme indicated that a booster dose in the second year of life was important for sustained protection following infant vaccination. Protective efﬁcacy against carriage by adolescents of group C one year after the UK immunisation campaign was estimated at 69 percent. Countries that included catch-up vaccinations for older children and adolescents, including the UK and Australia, have observed the greatest impact from meningococcal immunisation campaigns through herd immunity and a reduction in transmission across all age groups. There was a 67 percent reduction in group C disease among unvaccinated children within the target age groups and a reduction of 35 percent of cases in unvaccinated adults older than age 25 years. At the same time there was no evidence of capsular switching or an increase in disease caused by group B strains.
With the emergence of group W and now group Y meningococci, MenC has generally been replaced by MenACWY vaccines on national programmes in infants and adolescents.
Meningococcal group B recombinant vaccine
Three years after initiation of the introduction of 4CMenB to the national immunisation schedule in the UK, a 75 percent reduction in group B disease was reported in the vaccine-eligible age groups compared with a historical cohort. With 88 percent coverage but a low number of cases (25), adjusted vaccine effectiveness for all group B strains was 59.1 percent (95% CI: -31.1–87.2) following two primary doses and one booster dose, with an estimated 277 cases prevented. This research is ongoing.
As has been observed during college outbreaks in the US,[29, 30] in South Australia where 4CMenB is administered in a school-based programme at age 15–18 years, 4CMenB had no effect on disease-causing meningococci carriage suggesting that vaccination of adolescents is unlikely to generate herd immunity. A 4CMenB vaccination campaign used during an isolated outbreak in a region of Québec, Canada outbreak demonstrated direct protection of 79 percent against outbreak strain group B disease and an overall impact of 86 percent in target groups with no herd effects.
The safety and efficacy of 4CMenB in adults above 50 years of age have not been established. There is limited data on its use in patients with chronic medical conditions and immunocompromised by medication or disease, such as HIV infection or hereditary immune system defects.
13.4.3. Transport, storage and handling
Transport according to the National Standards for Vaccine Storage and Transportation for Immunisation Providers 2017 (2nd edition).
Store at +2°C to +8°C. MenACWY-D, MenACWY-T and 4CMenB should be protected from light. Do not freeze.
MenACWY-T (Nimenrix) must be reconstituted with the supplied diluent and used as soon as possible.
Quadrivalent meningococcal conjugate vaccines (MenACWY)
Each MenACWY dose is 0.5 mL, administered by intramuscular injection (see section 2.2.3).
MenACWY-D (Menactra) is registered in New Zealand for individuals aged 9 months to 55 years. For children aged 9–23 months, two doses are given at least three months apart. For individuals aged 2–55 years, one dose is given. See Table 13.5 for schedules for at-risk individuals.
MenACWY-D can be concurrently administered with other vaccines in separate syringes and at separate sites,[33, 34, 35, 36] except for PCV13. MenACWY-D should preferably be administered at least four weeks after PCV13. This is because, when administered concurrently, there is possible blunting of the immune response to some of the pneumococcal serotypes.[37, 38] (see section 13.5.2 for recommendations in regard to high-risk children age under 12 months and section 4.3.3).
MenACWY-T (Nimenrix) is registered in New Zealand for individuals from age 6 weeks. For infants aged under 12 months, two doses are given eight weeks apart, with a booster from age 12 months at least six months after second dose. For adults and children from age 12 months, one dose is given. A booster dose may be indicated in some individuals.
MenACWY-T can be concurrently administered with other vaccines in separate syringes and at separate sites; there is no data on concurrent administration of MenACWY-T and PCV13, however, interference is unlikely.
Meningococcal group C conjugate vaccine (MenC)
Each MenC (NeisVac-C) dose is 0.5 mL, administered by intramuscular injection (see section 2.2.3).
For infants aged under 9 months, two doses are given at least eight weeks apart, with the first dose given not earlier than age 6 weeks. One dose of MenACWY is recommended in the second year of life from age 12 months. See Table 13.5 for schedules for at-risk individuals. MenC can be administered concurrently with other scheduled vaccines, in separate syringes and at separate sites.
In view of the New Zealand epidemiology, a quadrivalent (MenACWY) vaccine would be preferable, to obtain broader meningococcal protection.
Meningococcal group B recombinant vaccine (4CMenB)
Each 4CMenB (Bexsero) dose is 0.5 ml, administered by intramuscular injection (see section 2.2.3).
For infants aged 6 weeks to ≤11 months, two doses are given with a minimum of eight weeks between doses, with a booster given from 12 months at least six months after the second dose.
For children aged 12 months to under 11 years, two doses are given at least eight weeks apart. No booster dose is required. For children and adults aged 11 years to 50 years, two doses are given one month apart. No booster dose is required. (Note: the safety and efficacy in individuals aged over 50 years have not been established.)
4CMenB can be administered concurrently with other scheduled vaccines, in separate syringes and at separate sites.
Note: 4CMenB elicits a robust immune response, sometimes with high fevers in some infants. Routine use of paracetamol with every dose of 4CMenB in children aged under 2 years, whether given alone or with other vaccines, is recommended to reduce the risk of high fever and injection-site pain. Some infants will still develop a fever and/or injection-site pain even though they have received paracetamol doses.
Prophylaxic paracetamol is recommended to be given 30 minutes prior to and six-hourly for up to 48 hours following vaccination for children aged under 2 years. For children and infants aged from 2 months, ibuprofen may be given as an alternative to paracetamol.
13.5.1. Individuals at increased risk
The meningococcal vaccines are recommended (but not funded) for other individuals at risk, as described in Table 13.4.
There are areas of the world where the risk of meningococcal disease is increased. Nevertheless, the risk to travellers to the developing world has been estimated as being less than one in a million per month. Recurrent epidemics of meningococcal disease occur in the sub-Saharan ‘meningitis belt’, from Senegal in the west to Ethiopia in the east, usually during the dry season (December to June). Epidemics are occasionally identiﬁed in other parts of the world, including in Europe and the Americas. Generally, countries outside of Africa experience smaller outbreaks, but case-fatality rates can be high.
The preferred vaccines (MenACWY and/or 4CMenB) for travel would be based on the epidemiology of the country. For website sources for information about meningococcal vaccines for travellers, see the WHO website. Quadrivalent meningococcal vaccine is a requirement for pilgrims to the Hajj.
Before moving into communal living situations
MenACWY-D is recommended and funded from age 13–25 years inclusively for individuals who will be living in communal accommodation within the next three months, or who are in their first year of living in communal accommodation (specifically, boarding school hostels, tertiary education halls of residence, military barracks or prisons) as they are likely to be at higher risk of acquiring meningococcal infection.
A catch-up dose of MenACWY-D is also funded for individuals who are currently living in boarding school hostels, tertiary education halls of residence, military barracks, or prisons, from 1 December 2019 to 30 November 2021.
Recommended and funded
MenC and MenACWY-D are recommended and funded for:
Recommended but not funded
MenACWY-D or MenACWY-T and 4CMenB are recommended, but not funded, for:
MenACWY-T is recommended but not funded for high-risk infants age under 9 months in place of MenC.
4CMenB is recommended but not funded for all the above high-risk groups.
MenACWY and 4CMenB are recommended but not funded for all infants, young children, adolescents and young adults.
- Pneumococcal, Hib, influenza and varicella vaccines are also recommended for individuals pre- or post-splenectomy or with functional asplenia. See section 4.3.4.
- See section 4.3.4 for more information.
- The period of immunosuppression due to steroid or other immunosuppressive therapy must be longer than 28 days.
- Only one dose is funded for close contacts of meningococcal cases.
Age at diagnosis
Recommended vaccine schedule
Infants aged 6 weeks to under 12 months
Children aged 12 months to under 18 years
Adults aged 18 years and older
Give 2 doses 8 weeks apart, then 1 dose every 5 years.a,b
Individuals aged between 13 and 25 years, in certain communal living situationsc
1 dose, no booster required
- Give MenACWY-D at least 4 weeks before or after PCV13[37, 38] (see below).
- MenACWY-D is registered for individuals aged 9 months to 55 years, but there are not expected to be any safety concerns when administered to adults older than 55 years.
- Funded for individuals aged 13–25 years inclusively who either: are entering within three months or who are in their first year of living in boarding school hostels, tertiary education halls of residence, military barracks or prisons; or to 30 November 2021 who are currently living in boarding school hostels, tertiary education halls of residence, military barracks or prisons.
There is a possibility of blunting of some PCV serotype antibody responses when MenACWY-D (Menactra) is given concurrently with the PCV13 series because both vaccines contain diphtheria-derived proteins as conjugates. The clinical significance of this blunting, observed in a clinical trial with PCV7, is unknown and the affected serotypes (4, 6B, 18C) are currently rare in New Zealand. The benefits of achieving broad meningococcal protection as early as possible in immunocompromised infants outweigh the theoretical risk of modest reduction of some pneumococcal antibody levels, so MenACWY-D is recommended at 9 months (see Table 4.4, Table 4.5 and Table 13.5). Note: two doses given at least three months apart are recommended as a primary series; each dose should be given at least four weeks before or after PCV13 to reduce this risk of interference.
In the absence of a universal programme, non-high-risk children and adolescents may be offered meningococcal vaccines, but these are not funded. Table 13.6 suggests the most appropriate ages for this, reflecting the known ages of increased risk. The predominant meningococcal strains in New Zealand in childhood are B, W and C. With the current New Zealand epidemiology, neither MenACWY nor 4CMenB give protection across all prevailing meningococcal groups and both types of vaccine are recommended. For those who are likely to travel, the broadest protection is preferable because of the differing serotype patterns between countries.
- Refer to section 13.4.4 and the vaccine data sheets for the intervals between doses.
- Prophylaxis paracetamol (or ibuprofen) is recommended for this age group, see section 13.7.3.
- MenACWY-D should be administered at least 4 weeks after PCV13 (if used).
- In particular, for individuals aged 13–25 years not eligible to funded vaccine, particularly living in crowded private homes, other hostels or student accommodation, or planning overseas travel.
13.5.3. Pregnancy and breastfeeding
There are no reports of any adverse effects among pregnant women who have been vaccinated during pregnancy. The vaccine may be given to pregnant women if indicated. Meningococcal vaccine may be given to breastfeeding women.
Meningococcal conjugate vaccines, MenC (age under 2 years) and MenACWY-D (from age 9 months) are funded for vaccination or re-vaccination of eligible individuals, as follows. See also section 4.3.
Up to three doses plus booster doses (as appropriate) are funded for individuals:
- pre- or post-splenectomy
- pre- or post-solid organ transplantation
- with functional asplenia
- with complement deficiency (acquired or inherited)
- who are HIV-positive.
Two doses are funded for individuals:
- post-haematopoietic stem cell transplantation
- prior to planned or following immunosuppression for longer than 28 days.
There are no speciﬁc contraindications for meningococcal vaccines, except for anaphylaxis to a previous dose or any component of the vaccine.
13.7.1. Quadrivalent meningococcal conjugate vaccine
Potential adverse reactions after meningococcal conjugate vaccines include localised pain, irritability, headache and fatigue.[22, 39] Fever is reported by 2–5 percent of adolescents who receive MenACWY-D.
The safety of two doses of MenACWY-D was assessed in a phase III trial of infants: dose one was administered at age 9 months and dose two was administered at age 12 months, with or without routine childhood vaccines. The percentage of participants with solicited systemic reactions after MenACWY-D administration alone at age 12 months (60.6 percent) was lower than after the vaccination at age 9 months (68.2 percent), lower than the control groups at age 12 months (75.2–84.1 percent, depending upon the control vaccine) and lower than when MenACWY-D was administered concurrently with the routine childhood vaccines (68.3–73.2 percent).
The safety profile of MenACWY-T (Nimenrix) is very similar to other meningococcal conjugate vaccines.
There is no evidence of an association between meningococcal conjugate vaccines and GBS. An early report in the US of a suspected temporal association between MenACWY-D (Menactra) and GBS was followed by a large retrospective cohort study in the US that found no evidence of an increased risk of GBS following administration of MenACWY-D.[37, 40] If indicated, meningococcal conjugate vaccines may be administered to individuals with a history of GBS.
A Cochrane Review assessed the safety of MenC against group C disease. MenC vaccines were shown to have an excellent safety profile in infants. The events more frequently reported in infants were fever (1–5 percent), irritability (38–67 percent), crying more than expected (1–13 percent), redness at the site of vaccination (6–97 percent), tenderness at the site of vaccination (11–13 percent) and swelling at the site of vaccination (6–42 percent). Anaphylaxis was reported at a rate of one per 500,000 doses distributed.
There is an increased risk of fever and medically attended fever-related events, such as febrile seizures, associated with 4CMenB in some children age under 2 years.[4, 43, 44, 45, 46] These events peaked at six hours post-vaccination and generally subsided by day 3. Prophylaxic paracetamol is recommended 30 minutes prior and six-hourly for up to 48 hours following vaccination for children aged under 2 years. Ibuprofen may be given as an alternative to paracetamol. Some infants will still develop a fever and/or injection-site pain even though they have received paracetamol doses.
In clinical trials, some infants and young children also experienced injection-site tenderness and irritability. Adolescents and adults may experience localised pain, nausea, myalgia, malaise, mild fever and headache.
Invasive meningococcal disease must be notified on suspicion to the local medical officer of health.
The overall rate of secondary cases in untreated adults is around 1 per 300. Adults and children in close contact with primary cases of invasive meningococcal infection are recommended to receive antibiotic prophylaxis, preferably within 24 hours of the initial diagnosis, but prophylaxis is recommended up to 14 days after diagnosis of illness.
Blood or cerebrospinal fluid culture is the main diagnostic method, but blood PCR may be useful if antibiotics are given without prior access to blood culture. It is recommended that in primary care 3–5 mL of blood should be taken in an ethylenediaminetetraacetic acid (EDTA) anticoagulant tube (usually with a purple top) prior to administration of antibiotics unless blood culture is available. This should accompany the patient to hospital.
A contact is anyone who has had unprotected contact with upper respiratory tract or respiratory droplets from the case during the seven days before onset of illness to 24 hours after onset of effective treatment. Contacts at particular risk include:
- those sleeping at least one night in the same household, dormitory, military barrack or student hostel bunkroom (not residents of nursing or residential homes who sleep in separate rooms) as the case, or who have been in a seat adjacent to the case in a plane, bus or train for more than eight hours
- health care workers who have had intensive unprotected contact (not wearing a mask) with a case during intubation, resuscitation or close examination of the oropharynx
- exchange of upper respiratory tract secretions, including intimate kissing
- other contacts as determined by the medical officer of health on a case-by-case basis, such as children and staff attending an early childhood service.
Prophylaxis is not routinely recommended for health care personnel unless there has been intimate contact with oral secretions (eg, performing mouth-to-mouth resuscitation or suctioning of the case before antibiotic therapy has started).
The recommended antibiotics are rifampicin, ceftriaxone or ciprofloxacin, preferably given within 24 hours of initial diagnosis, but prophylaxis is recommended up to 14 days after diagnosis of illness.
The recommended dose of rifampicin is 10 mg/kg (maximum dose 600 mg) every 12 hours for two days. For infants aged under 4 weeks, the recommended dose is 5 mg/kg every 12 hours for two days.
Rifampicin should be avoided for pregnant or lactating women.
A single dose of intramuscular ceftriaxone (125 mg for children aged under 12 years and 250 mg for older children and adults) has been found to have an efﬁcacy equal to that of rifampicin in eradicating the meningococcal group A carrier state. Ceftriaxone is the drug of choice in a pregnant woman because rifampicin is not recommended later in pregnancy. Ceftriaxone may be reconstituted with lignocaine (according to the manufacturer’s instructions) to reduce the pain of injection. A New Zealand study demonstrated that ceftriaxone and rifampicin were equivalent in terms of eliminating nasopharyngeal carriage of N. meningitidis group B.
Do not use in infants under aged under 4 weeks.
Ciproﬂoxacin given as a single oral dose of 500 mg or 750 mg is also effective at eradicating carriage. This is the preferred prophylaxis for women on the oral contraceptive pill and for prophylaxis of large groups.
Ciproﬂoxacin is not generally recommended for pregnant and lactating women or for children aged under 18 years. Consult the manufacturer’s data sheet for appropriate use and dosage of ciprofloxacin in children.
Use of meningococcal vaccines for close contacts
Close contacts of cases of group A, C, W or Y meningococcal disease may be offered the appropriate meningococcal conjugate vaccine (see section 13.5).
In a multi-occupancy residential meningococcal B outbreak an emergency supply of 4CMenB is available for use. See below for the use of the vaccines for the control of outbreaks, as initiated by the local public health service.
13.8.3. Outbreak control
When there is an outbreak of meningococcal disease of a specific vaccine group, an immunisation programme may be recommended and funded for a deﬁned population. The local medical officer of health will determine the necessary action in discussion with the Ministry of Health.
For more details on control measures, refer to the ‘Neisseria meningitidis invasive disease’ chapter of the Communicable Disease Control Manual .
The MenACWY-D data sheet states that the vaccine is indicated for use in individuals aged 9 months to 55 years. The Ministry of Health recommends that this vaccine may be used in adults aged over 55 years.
The data sheet states that MenACWY-D should be given as a single dose for individuals aged 2 years and older. The Ministry of Health recommends that two doses are given to individuals at high risk of meningococcal disease (see Table 13.5 and section 4.3), with booster doses every five years. If the first MenACWY-D dose was given before age 7 years, give a booster after three years then five-yearly.
A history of GBS is listed as a precaution in the MenACWY-D data sheet. However, there is no evidence of an association between meningococcal conjugate vaccines and GBS (see section 13.7.2). The Ministry of Health advises that, if indicated, MenACWY-D may be administered to individuals with a history of GBS.
The MenC data sheet states that the first dose of vaccine is not be given earlier than age 8 weeks. However, the Ministry of Health recommends that MenC may be given from age 6 weeks to infants at high risk of meningococcal disease (see Table 13.4 and Table 13.5).
The 4CMenB data sheet states that the vaccine is indicated from age 2 months or older. However, the Ministry of Health recommends that 4CMenB can be given from age 6 weeks to infants at high risk of meningococcal disease (see Table 13.5).
- Campbell H, Parikh SR, Borrow R, et al. 2016. Presentation with gastrointestinal symptoms and high case fatality associated with group W meningococcal disease (MenW) in teenagers, England, July 2015 to January 2016. Euro Surveillance 21(12).
- Ladhani SN, Beebeejaun K, Lucidarme J, et al. 2015. Increase in endemic Neisseria meningitidis capsular group W sequence type 11 complex associated with severe invasive disease in England and Wales. Clinical Infectious Diseases 60(4): 578–85.
- Cohn A, MacNeil J. 2015. The Changing Epidemiology of Meningococcal Disease. Infectious Disease Clinics of North America 29(4): 667–77.
- Harrison LH, Granoff DM, Pollard AJ. 2018. Meningococcal Capsular Group A, C, W and Y conjugate vaccines. In Plotkin SA, Orenstein W, Offit P, et al (eds) Plotkin’s Vaccines (7th edition). Elsevier: Philadelphia, US.
- Rubilar PS, Barra GN, Gabastou JM, et al. 2018. Increase of Neisseria meningitidis W:cc11 invasive disease in Chile has no correlation with carriage in adolescents. PloS One 13(3): e0193572.
- Wang B, Santoreneos R, Giles L, et al. 2019. Case fatality rates of invasive meningococcal disease by serogroup and age: a systematic review and meta-analysis. Vaccine 37(21): 2768–82.
- Meningococcal Disease Surveillance Group. 1976. Analysis of endemic meningococcal disease by serogroup and evaluation of chemoprophylaxis. Journal of Infectious Diseases 134(2): 201–4.
- Neal KR, Nguyen-Van-Tam JS, Jeffrey N, et al. 2000. Changing carriage rate of Neisseria meningitidis among university students during the first week of term: cross sectional study. BMJ 320(7238): 846–9.
- Bruce MG, Rosenstein NE, Capparella JM, et al. 2001. Risk factors for meningococcal disease in college students. JAMA 286(6): 688–93.
- Nelson SJ, Charlett A, Orr HJ, et al. 2001. Risk factors for meningococcal disease in university halls of residence. Epidemiology and Infection 126(2): 211–7.
- Christensen H, May M, Bowen L, et al. 2010. Meningococcal carriage by age: a systematic review and meta-analysis. Lancet Infectious Diseases 10(12): 853–61.
- Peterson ME, Li Y, Shanks H, et al. 2019. Serogroup-specific meningococcal carriage by age group: a systematic review and meta-analysis. BMJ Open 9(4): e024343.
- Baker M, McNicholas A, Garrett N, et al. 2000. Household crowding a major risk factor for epidemic meningococcal disease in Auckland children. Pediatric Infectious Disease Journal 19(10): 983–90.
- Public Health England. 2019. Immunisation against Meningococcal B Disease for Infants Aged from Two Months: Information for Health Professionals (ed). URL: https://www.gov.uk/government/publications/meningococcal-b-vaccine-information-for-healthcare-professionals (accessed 3 July 2020).
- Public Health England. 2016. Meningococcal. In The Green Book. URL: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/554011/Green_Book_Chapter_22.pdf (accessed 3 July 2020).
- Patton ME, Stephens D, Moore K, et al. 2017. Updated recommendations for use of MenB-FHbp serogroup B meningococcal vaccine – Advisory Committee on Immunization Practices, 2016. MMWR: Morbidity and Mortality Weekly Report 66(19): 509–13.
- MacNeil J, Rubin L, Folaranmi T, et al. 2015. Use of serogroup B meningococcal vaccines in adolescents and young adults: recommendations of the Advisory Committee on Immunization Practices, 2015. Morbidity and Mortality Weekly Report (MMRW) 64(41): 1171–6.
- Folaranmi T, Rubin L, Martin S, et al. 2015. Use of serogroup B meninogococcal vaccines in persons age >10 years at increased risk for serogroup b meningococcal disease: Recommendations of the Advisory Committee on Immunization Practices, 2015. Morbidity and Mortality Weekly Report (MMRW) 64(22): 608–12.
- Cohn AC, MacNeil JR, Harrison LH, et al. 2017. Effectiveness and duration of protection of one dose of a meningococcal conjugate vaccine. Pediatrics 139(2).
- Villena R, Valenzuela MT, Bastias M, et al. 2019. Meningococcal invasive disease by serogroup W and use of ACWY conjugate vaccines as control strategy in Chile. Vaccine 37(46): 6915–21.
- Rennels M, King J, Jr., Ryall R, et al. 2004. Dosage escalation, safety and immunogenicity study of four dosages of a tetravalent meninogococcal polysaccharide diphtheria toxoid conjugate vaccine in infants. Pediatric Infectious Disease Journal 23(5): 429–35.
- Hedari CP, Khinkarly RW, Dbaibo GS. 2014. Meningococcal serogroups A, C, W-135, and Y tetanus toxoid conjugate vaccine: a new conjugate vaccine against invasive meningococcal disease. Infect Drug Resist 7(3 April): 85–99.
- Cardoso CW, Ribeiro GS, Reis MG, et al. 2015. Effectiveness of meningococcal C conjugate vaccine in Salvador, Brazil: a case-control study. PloS One 10(4): e0123734.
- Campbell H, Borrow R, Salisbury D, et al. 2009. Meningococcal C conjugate vaccine: the experience in England and Wales. Vaccine 27(Suppl 2): B20–9.
- Maiden MC, Stuart JM, UK Meningococcal Carriage Group. 2002. Carriage of serogroup C meningococci 1 year after meningococcal C conjugate polysaccharide vaccination. Lancet 359(9320): 1829–31.
- Ramsay ME, Andrews NJ, Trotter CL, et al. 2003. Herd immunity from meningococcal serogroup C conjugate vaccination in England: database analysis. BMJ 326(7385): 365–6.
- Balmer P, Borrow R, Miller E. 2002. Impact of meningococcal C conjugate vaccine in the UK. Journal of Medical Microbiology 51(9): 717–22.
- Ladhani SN, Andrews N, Parikh SR, et al. 2020. Vaccination of infants with meningococcal group B vaccine (4CMenB) in England. New England Journal of Medicine 382(4): 309–17.
- McNamara LA, Thomas JD, MacNeil J, et al. 2017. Meningococcal carriage following a vaccination campaign with MenB-4C and MenB-FHbp in response to a university serogroup B meningococcal disease outbreak – Oregon, 2015–2016. Journal of Infectious Diseases 216(9): 1130–40.
- Soeters HM, Whaley M, Alexander-Scott N, et al. 2017. Meningococcal carriage evaluation in response to a serogroup B meningococcal disease outbreak and mass vaccination campaign at a college – Rhode Island, 2015–2016. Clinical Infectious Diseases 64(8): 1115–22.
- Marshall HS, Lally N, Flood L, et al. 2020. First statewide meningococcal B vaccine program in infants, children and adolescents: evidence for implementation in South Australia. Medical Journal of Australia.
- Deceuninck G, Lefebvre B, Tsang R, et al. 2019. Impact of a mass vaccination campaign against Serogroup B meningococcal disease in the Saguenay-Lac-Saint-Jean region of Quebec four years after its launch. Vaccine 37(31): 4243–5.
- Arguedas A, Soley C, Loaiza C, et al. 2010. Safety and immunogenicity of one dose of MenACWY-CRM, an investigational quadrivalent meningococcal glycoconjugate vaccine, when administered to adolescents concomitantly or sequentially with Tdap and HPV vaccines. Vaccine 28(18): 3171–9.
- Gasparini R, Conversano M, Bona G, et al. 2010. Randomized trial on the safety, tolerability, and immunogenicity of MenACWY-CRM, an investigational quadrivalent meningococcal glycoconjugate vaccine, administered concomitantly with a combined tetanus, reduced diphtheria, and acellular pertussis vaccine in adolescents and young adults. Clinical and Vaccine Immunology 17(4): 537–44.
- Rinderknecht S, Bryant K, Nolan T, et al. 2012. The safety profile of Haemophilus influenzae type b-Neisseria meningitidis serogroups C and Y tetanus toxoid conjugate vaccine (HibMenCY). Human Vaccines & Immunotherapeutics 8(3): 304–11.
- Klein NP, Reisinger KS, Johnston W, et al. 2012. Safety and immunogenicity of a novel quadrivalent meningococcal CRM-conjugate vaccine given concomitantly with routine vaccinations in infants. Pediatric Infectious Disease Journal 31(1): 64–71.
- Centers for Disease Control and Prevention. 2013. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report: Recommendations and Reports 62(2): 1–28. www.cdc.gov/mmwr/pdf/rr/rr6202.pdf (accessed 27 February 2020).
- Pina LM, Bassily E, Machmer A, et al. 2012. Safety and immunogenicity of a quadrivalent meningococcal polysaccharide diphtheria toxoid conjugate vaccine in infants and toddlers: three multicenter phase III studies. Pediatric Infectious Disease Journal 31(11): 1173–83.
- American Academy of Pediatrics. 2018. Meningococcal disease. In Kimberlin D, Brady M, Jackson M, et al (eds) Red Book: 2018 Report of the Committee on Infectious Diseases. Elk Grove Village, IL, 551–61. URL: https://redbook.solutions.aap.org/redbook.aspx (accessed 15 April 2020).
- Velentgas P, Amato AA, Bohn RL, et al. 2012. Risk of Guillain-Barré syndrome after meningococcal conjugate vaccination. Pharmacoepidemiology and Drug Safety 21(12): 1350–8.
- Australian Technical Advisory Group on Immunisation. 2018. Australian Immunisation Handbook (ed). Canberra: Australian Government Department of Health. URL: https://immunisationhandbook.health.gov.au/ (accessed October 2019).
- Conterno LO, Silva Filho CR, Ruggeberg JU, et al. 2006. Conjugate vaccines for preventing meningococcal C meningitis and septicaemia. Cochrane Database Syst Rev (3): CD001834.
- Vesikari T, Esposito S, Prymula R, et al. 2013. Immunogenicity and safety of an investigational multicomponent, recombinant, meningococcal serogroup B vaccine (4CMenB) administered concomitantly with routine infant and child vaccinations: results of two randomised trials. Lancet 381(9869): 825–35.
- Vesikari T, Prymula R, Merrall E, et al. 2015. Meningococcal serogroup B vaccine (4CMenB): Booster dose in previously vaccinated infants and primary vaccination in toddlers and two-year-old children. Vaccine 33(32): 3850–8.
- Harcourt S, Morbey RA, Bates C, et al. 2018. Estimating primary care attendance rates for fever in infants after meningococcal B vaccination in England using national syndromic surveillance data. Vaccine 36(4): 565–71.
- Zafack JG, Bureau A, Skowronski DM, et al. 2019. Adverse events following immunisation with four-component meningococcal serogroup B vaccine (4CMenB): interaction with co‑administration of routine infant vaccines and risk of recurrence in European randomised controlled trials. BMJ Open 9(5): e026953.
- Ministry of Health. 2012. Neisseria meningitidis invasive disease. In Communicable Disease Control Manual. Wellington. URL: http://www.health.govt.nz/publication/communicable-disease-control-manual-2012 (accessed February 2020).
- Simmons G, Jones N, Calder L. 2000. Equivalence of ceftriaxone and rifampicin in eliminating nasopharyngeal carriage of serogroup B Neisseria meningitidis. Journal of Antimicrobial Chemotherapy 45(6): 909–11.
- Schaad UB, abdus Salam M, Aujard Y, et al. 1995. Use of fluoroquinolones in pediatrics: consensus report of an International Society of Chemotherapy commission. Pediatric Infectious Disease Journal 14(1): 1–9.