13. Meningococcal disease

Key information

Mode of transmission

By respiratory droplets or direct contact with nasopharyngeal secretions from a carrier or case.

Incubation period

2–10 days, commonly 3–4 days.

Period of communicability

Commonly 3–4 days without treatment, range 2–10 days. Certain antibiotic therapy eradicates N. meningitidis from mucosal surfaces within 24 hours, and the case is no longer considered infectious.

Funded vaccines

  • Quadrivalent meningococcal conjugate conjugated to diphtheria toxoid (MenACWY-D): Menactra.
  • Meningococcal group C conjugate (MenC): NeisVac-C.
  • Meningococcal B recombinant (4CMenB): Bexsero.

Other available vaccines

  • Quadrivalent meningococcal conjugate conjugated to tetanus toxoid (MenACWY-T): Nimenrix.

Dose, presentation, route

0.5 mL per dose.

Presentation:

  • MenACWY-D: vial
  • MenACWY-T: vial and pre-filled syringe; must be reconstituted before use
  • MenC: pre-filled syringe
  • 4CMenB: pre-filled syringe.

Intramuscular injection.

Funded vaccine indications

MenACWY-D (Menactra), MenC (NeisVac-C) and 4CMenB (Bexsero) for:

  • patients pre- or post-splenectomy or with functional or anatomical asplenia
  • patients with HIV, complement deficiency (acquired, including monoclonal antibody therapy against C5, or inherited)
  • pre- or post-solid organ transplant
  • HSCT (bone marrow transplant) patients
  • patients prior to planned and following immunosuppression
  • close contacts of meningococcal cases (any group)
  • patients with prior meningococcal disease of any group.

MenACWY-D (Menactra) for:

  • adolescents and young adults aged 13–25 years inclusive who will be living or are currently living in a boarding school hostel or university hall of residence, military barracks or prison.

Recommended, unfunded

Laboratory workers handling bacterial cultures

Health care professionals in very close contact with cases.

Vaccine effectiveness

MenACWY: 80–85%; effectiveness wanes to 50–60% within 2–5 years after vaccination.

MenC: effectiveness of 83–100%; antibody wanes within 2–3 years.

4CMenB: 75% reduction in group B cases in infants over 3 years and cross-protection against group W observed; 71% reduction in group B disease in adolescents.

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 antipyretic advised). Older age groups: localised pain, nausea, myalgia, malaise, mild fever and headache.

Contraindications

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.

Post-exposure prophylaxis

For chemoprophylaxis of contacts see section 13.8.2.

13.1. Bacteriology

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.

13.2. Clinical features

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.

 Table 13.1: Symptoms and signs of meningococcal disease

Adolescents and adults

Young infants and children

  • Sepsis syndrome, including poor peripheral perfusion and tachycardia
  • Nausea/vomiting
  • Meningeal signs
  • Rash – petechial/purpuric, but may be maculopapular; rash may not be present early and absent in about one-third of cases
  • Sleepy, difficult to rouse
  • Occasionally in young adults, irrational behaviour
  • Arthralgia, myalgia, leg pain
  • Atypical presentation (particularly group W) may include pneumonia, septic arthritis, myocarditis or diarrhoea

As for adolescents and adults, plus the following:

  • bulging fontanelle
  • tachycardia
  • altered responsiveness
  • irritability and/or floppiness
  • refusing drinks or feeds
  • poor peripheral perfusion
  • atypical presentation may include epiglottis, diarrhoea or septic arthritis

Notify all suspected cases urgently to local medical officer of health, including out-of-hours.

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.

Table 13.2: Recommended antibiotics for suspected cases

Antibiotic

Children <30kg

Children >30kg and
Adults (max dose)

Ceftriaxonea
(first line treatment)

50 mg/kg when given by GP/primary care

100 mg/kg IV (or IM) up to 2g when given in ED

2 g IV (or IM)

Benzylpenicillinb
(second choice)

50 mg/kg IV (or IM)

2.4 g IV (or IM)

  1. Patients allergic to penicillin who do not have a documented history of anaphylaxis to penicillin can be given ceftriaxone.
  2. 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. Epidemiology

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.[3] Group B has become the predominant capsular group in Europe, Americas and Australia, with incidence typically highest in children aged under 2 years.[4] 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).[5]

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).

Risk groups

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.[6]

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,[7] 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.[12] The relationship between risk factors for disease and those associated with carriage is incompletely understood.[3] 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.[3] Smoking, passive smoking, household crowding and upper respiratory tract infections increase carriage.

13.3.2. New Zealand epidemiology

Incidence and mortality

In 2020 the notification rate for meningococcal disease was 0.7 cases per 100,000 population, with a total of 35 cases notified (33 laboratory confirmed; ESR, 9 August 2021). Cases 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:P1.7-2,4). 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.

Figure 13.1: Notified cases of meningococcal disease, 1970–2020

This line graph shows that meningococcal disease was low in the 1970s and reached a high in the late 1990s and early 2000s, and has been under 200 notifications a year since 2006.

Source: ESR

Meningococcal disease incidence is highest in Māori (1.2 per 100,000, 10 cases in 2020) compared with the total population. Household crowding is an important risk factor for meningococcal disease, independent of ethnicity.[13] In 2020, the highest age-specific disease rates were among those aged under 1 year (8.4 per 100,000, 5 cases) decreasing in ages 1–4 years (3.7 per 100,000, 9 cases). Three deaths occurred in 2020, giving a case fatality rate of 8.6 percent (ESR, 9 August 2021).

Strain types

Strain type was determined for 32 of the 33 laboratory-confirmed cases in 2020. Group B strains were the most prevalent, causing 56 percent of the typed cases (Figure 13.2). The group B strain (B:4:P1.7b,4) responsible for the epidemic caused 28 percent of all meningococcal disease in 2020 (9 of the 32 typed cases). Cases of meningococcal disease caused by group C strains decreased since 2013 (Figure 13.2), while group W increased from five cases in 2016 to 36 in 2019. Cases in all groups decreased in 2020, likely in part, due to the public health measures implemented to control the COVID-19 pandemic.

Figure 13.2: Meningococcal disease notifications by group, 2013–2020

This line graph illustrates the points above.

Source: ESR

13.4. Vaccines

13.4.1. Available vaccines

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.

Table 13.3: Meningococcal vaccines registered and available in New Zealand

Name (manufacturer)

Vaccine type

Bexsero
(GSK)
Meningococcal group B four-component recombinant (4CMenB)

Menactra
(Sanofi)

Quadrivalent meningococcal conjugate (MenACWY-D): contains group A, C, W and Y polysaccharides conjugated to diphtheria toxoid

NeisVac-C
(Pfizer NZ Ltd)
Meningococcal group C conjugate (MenC): contains group C polysaccharide conjugated to tetanus toxoid

Nimenrix
(Pfizer NZ Ltd)

Quadrivalent meningococcal conjugate (MenACWY-T): contains group A, C, W and Y polysaccharides conjugated to tetanus toxoid

Funded vaccines

No meningococcal vaccines are on the routine Schedule. See section 13.5 for funded vaccine for special groups.

Three meningococcal vaccines are funded for certain special groups (see section 13.5).

  • 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.
  • Recombinant meningococcal B vaccine, 4CMenB (Bexsero, GSK) contains four components from the group B meningococcus: three recombinant N. meningitidis group B surface proteins associated with bacterial adhesion and survival (Neisseria heparin binding antigen fusion protein, adhesin A protein, and factor H binding protein) plus detoxified outer membrane vesicles containing antigen as used in the MenNZB epidemic vaccine. Other components include aluminium hydroxide, sodium chloride, histidine and sucrose.

Other vaccines

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.

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).[14] 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.[15]

The MenACWY-D vaccine was poorly immunogenic in infants aged under 6 months,[16] 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.[17]

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.[18] 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.[19 ]

A booster dose in the second year of life was indicated in the UK for sustained protection.[20] The greatest impact from meningococcal immunisation campaigns was obtained through herd immunity and a reduction in transmission was observed across all age groups, including in unvaccinated adults, where catch-up programmes in adolescents were implemented.[21 22]

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.[23] 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.[23] This research is ongoing.

Following 4CMenB vaccination of adolescents aged 15-16 years in South Australian schools, there was an overall reduction of 71 percent (95% CI 15-90; p=0.02) in group B meningococcal disease cases aged 16-19 years: five cases in 2017–2018 (predicted 9.9 [95% predicted interval 3.9-17.5]) and one case in 2018–2019 (predicted 10.9 [4.4–19.1]).[24]

As was observed during college outbreaks in the US,[25, 26] in South Australia where 4CMenB is administered in a school-based programme at age 15–18 years, 4CMenB had no effect on disease-causing meningococcal carriage suggesting that vaccination of adolescents is unlikely to generate herd immunity.[27] 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.[28]

Cross-protection against meningococcal group W has been observed following vaccination of infants with 4CMenB in the UK. Among age-cohorts that were fully and partially eligible to 4CMenB, respectively, it was estimated that there were 69 percent (adjusted incidence rate ratio 0.31; 95% CI 0.2-0.67) and 52 percent (0.48; 0.28-0.81) fewer cases of group W disease than predicted in 2018/2019; this included direct and indirect protection over four years. An estimated 98 cases (95% CI 34-201) cases of group W disease were directly prevented in children aged under 5 years.[29] The researchers state that MenACWY conjugate vaccines would still be required for direct and indirect protection against those groups, since the degree of cross-protection is dependent on the expression of vaccine antigens on the meningococcal surface.[29]

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. In a phase 3 clinical trial, children aged 2­–17 years showed good but reduced immunogenicity in those with immunocompromise.[30] Immunogenicity in children with asplenia and splenic dysfunction was similar to healthy children but reduced in children with complement deficiencies.[31]

The safety and efficacy of 4CMenB in adults above 50 years of age have not been established.

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.

Reconstitution

MenACWY-T (Nimenrix) must be reconstituted with the supplied diluent and used as soon as possible.

13.4.4. Dosage and administration

Quadrivalent meningococcal conjugate vaccines (MenACWY)

Each MenACWY dose is 0.5 mL, administered by intramuscular injection (see section 2.2.3).

Menactra (MenACWY-D)

MenACWY-D (Menactra) is registered in New Zealand for individuals aged 9 months to 55 years. See Table 13.5 for schedules for certain special groups.

  • 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.
  • Booster doses may be indicated in some high-risk individuals.

MenACWY-D can be concurrently administered with other vaccines in separate syringes and at separate sites,[32, 33, 34, 35] 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.[36, 37] (see section 13.5.2 for recommendations in regard to high-risk children age under 12 months and section 4.3.3).

Nimenrix (MenACWY-T)

MenACWY-T (Nimenrix) is registered (not funded) in New Zealand for individuals from age 6 weeks.

  • For infants aged under 12 months, two doses are given eight weeks apart, plus a booster from age 12 months at least six months after second dose.
  • Healthy infants aged 6 months to under 12 months, who are not immunocompromised, can be given one dose instead of two primary doses, plus a booster from age 12 months, at least eight weeks later.
  • For adults and children from age 12 months, one dose is given.
  • Booster doses 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). See Table 13.5 for schedules for at-risk individuals.

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.

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 at least six months after the second dose, from age 12 months.
  • For children aged 12 months (for first dose) and adults, two doses are given at least eight weeks apart. (Note: the safety and efficacy in individuals aged over 50 years have not been established, but no safety concerns are expected.)

Generally, the need for booster doses from the age 12 months or older at the time of their first dose has not been established. Booster doses are funded five-yearly for some high-risk individuals (see Table ‎13.5).

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. Recommended immunisation schedule

13.5.1. Individuals at increased risk

Meningococcal vaccines are not on the Schedule but are funded in special circumstances, as described in the shaded section of Table 13.4; Table 13.5 shows the recommended dosing schedules.

See sections 4.3, 4.4 and 4.5 for more information about vaccination of special groups, including recommended immunisation schedules for high-risk individuals with certain medical conditions.

The meningococcal vaccines are recommended (but not funded) for other individuals at risk, as described in non-shaded rows in Table 13.4.

Before travel

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.

Table 13.4: Meningococcal vaccine recommendations
Note: Funded circumstances are in the shaded rows. See the Pharmaceutical Schedule for any changes to the funding decisions.

Recommended and funded

MenC or MenACWY-D and 4CMenB are recommended and funded for:

  • patients pre- or post-splenectomy or with functional or anatomical aspleniaa,b
  • patients with HIV, complement deficiency (acquired, including monoclonal antibody therapy against C5, or inherited)
  • patients who are pre- or post-solid organ transplantb
  • HSCT (bone marrow transplant) patientsb
  • patients prior to planned immunosuppressionb,c
  • patients following immunosuppressionb,c
  • close contacts of meningococcal cases of any groupd
  • individuals who have previously had meningococcal disease of any groupe

    MenACWY-D is recommended and funded for:

  • individuals aged 13–25 years inclusively who are entering within three months or are in their first year of living in boarding school hostels, tertiary education halls of residence, military barracks or prisons.

Recommended but not funded

Priority groups

MenACWY-D or MenACWY-T and 4CMenB are recommended, but not funded, for:

  • individuals are laboratory workers regularly handling meningococcal cultures
  • adolescents and young adults living in communal or overcrowded accommodation not covered by funded vaccine
  • individuals who are travelling to high-risk countries (see the WHO website) or before the Hajj.

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.

Other groups

MenACWY and 4CMenB are recommended but not funded for all infants, young children, adolescents and young adults.

  1. Pneumococcal, Hib, influenza and varicella vaccines are also recommended for individuals pre- or post-splenectomy or with functional asplenia. See section 4.3.4.
  2. See section 4.3.4 for more information.
  3. The period of immunosuppression due to steroid or other immunosuppressive therapy must be longer than 28 days.
  4. For close contacts, given as per the routine dosage schedule (see section 13.4.4).
  5. Regardless of time elapsed since disease.
Table 13.5: Recommended meningococcal vaccine schedule for high-risk individuals (funded)
Note: See the Pharmaceutical Schedule for any changes to funding decisions.

Age at diagnosis

Vaccine
(trade name)

Recommended vaccine schedule

Infants aged 6 weeks to under 12 months

MenC
(NeisVac-C)

and

MenACWY-D
(Menactra)

  • If aged under 9 months, give 2 doses of MenC 8 weeks apart, followed by MenACWY-Da at ages 9 and 13 months. Administer one MenACWY-D booster dose after 3 years, then 5-yearly. (See alternative unfunded MenACWY-T (Nimenrix) option in Table 13.6.)
  • If aged 9–11 months, give 2 doses of MenACWY-Da at least 3 months apart, followed by a booster dose after 3 years, then 5-yearly.
4CMenB (Bexsero)
  • Give 2 doses 8 weeks apart, plus booster given at least 6 months after second dose, from age 12 months and then 5-yearly.

Children aged 12 months to under 18 years

MenACWY-D
(Menactra)

  • If aged 12 months – under 7 years at diagnosis, give 2 doses of MenACWY-Da at least 3 months apart followed by a booster dose after 3 years, then 5‑yearly.
  • If aged 7 years or older give 2 doses of MenACWY-D 8 weeks apart followed by a booster dose 5-yearly.a
4CMenB (Bexsero)
  • From age of 12 months, give 2 doses 8 weeks apart.
  • Booster dose 5-yearly from age 12 months.c

Adults aged 18 years and older

MenACWY-D
(Menactra)

Give 2 doses 8 weeks apart, then 1 dose every 5 years.a,b

4CMenB (Bexsero) Give 2 doses 1 month apart, then booster 5 yearly.c

Individuals aged between 13 and 25 years, in certain communal living situationsd

MenACWY-D

(Menactra)

1 dose, no booster required

  1. Give MenACWY-D at least 4 weeks before or after PCV13[37, 38] (see below).
  2. 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. Likewise, 4CMenB is licenced to age 50 years but no safety concerns are expected when given to adults other than 50 years.
  3. 4CMenB booster funded for individuals pre- and post-splenectomy and for patients with functional or anatomic asplenia, HIV, complement deficiency (acquired or inherited), or pre- or post-solid organ transplant.
  4. 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,[38] 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 rather than waiting until the PCV13 series is completed (see Table 4.5, Table 4.6 and Table 13.5). Note: two doses given at least three months apart are recommended as a primary series; ideally, each dose should be given at least four weeks before or after PCV13 to reduce this risk of interference, but PCV13 and MenACWY-D can be given together or at any interval for pragmatic reasons or if an accelerated schedule is required.

13.5.2. Recommendations for children and adolescents

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.

Table 13.6: Recommended schedule for non-funded meningococcal vaccines in children and adolescents
Note: Vaccine immunity is not long-lasting. The suggested ages of vaccination are not expected to protect individuals through all of childhood but focused on protection during the ages of highest risk. This does not apply to epidemic situations.

Age at time of consultation

Vaccine options
(trade name)

Number of doses

6 weeks to <12 months

4CMenB (Bexsero) 2 dosesa,b plus a booster from age 12 months
MenACWY-T (Nimenrix) 2 dosesa,c plus a booster from age 12 months

12 months to <5 years

4CMenB (Bexsero)

2 dosesa,b

MenACWY-D (Menactra) or
MenACWY-T (Nimenrix)
2 MenACWY-Da,d doses or
1 MenACWY-T

Early adolescence
(12 to <16 years)e

4CMenB (Bexsero)

2 dosesa

MenACWY-D (Menactra) or MenACWY-T (Nimenrix) 1 dose plus a booster at age 16–18 years

Late adolescence
≥16 yearse

4CMenB (Bexsero)

2 dosesa

MenACWY-D (Menactra) or MenACWY-T (Nimenrix) 1 dose, no booster required
  1. Refer to section 13.4.4 for the intervals between doses.
  2. Prophylaxis paracetamol (or ibuprofen as age-appropriate) is recommended for this age group, see section 13.7.3.
  3. Infants aged from 6 months to ≤12 months who are not immunocompromised, can instead be given one dose plus booster from age 12 months at least two months later.
  4. MenACWY-D should be administered at least four weeks after PCV13 (if used).
  5. 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.[36] The vaccine may be given to pregnant women if indicated.[36] Meningococcal vaccine may be given to breastfeeding women.

13.5.4. (Re)vaccination

Meningococcal conjugate vaccines, MenC (age under 2 years), MenACWY-D (from age 9 months) and 4CMenB are funded for vaccination or re-vaccination of eligible individuals, as follows. See also section 4.3.

Meningococcal conjugate vaccines, MenC (age under 2 years) and MenACWY-D (from age 9 months)

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 and following immunosuppression for longer than 28 days.

Recombinant meningococcal B vaccine, 4CMenB

  • Age under 12 months – up to three doses plus booster after age 12 months and every five years (as appropriate)
  • Age from 12 months – up to two doses plus booster every five years (as appropriate)

Funded for individuals:

  • pre- or post-splenectomy
  • pre- or post-solid organ transplantation
  • with functional or anatomic asplenia
  • with complement deficiency (acquired or inherited)
  • who are HIV-positive
  • post-haematopoietic stem cell transplantation
  • prior to planned and following immunosuppression for longer than 28 days.

13.6. Contraindications and precautions

See also section 2.1.3 for pre-vaccination screening guidelines and section 2.1.4 for general contraindications for all vaccines.

There are no specific contraindications for meningococcal vaccines, except for anaphylaxis to a previous dose or any component of the vaccine.

13.7. Potential responses and AEFIs

13.7.1. Quadrivalent meningococcal conjugate vaccine

Potential adverse reactions after meningococcal conjugate vaccines include localised pain, irritability, headache and fatigue.[17, 38] 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.[37] 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.[17]

Guillain–Barré syndrome

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.[36, 39] If indicated, meningococcal conjugate vaccines may be administered to individuals with a history of GBS.[40]

13.7.2. Meningococcal group C conjugate vaccine

A Cochrane Review assessed the safety of MenC against group C disease.[41] 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.[4]

13.7.3. Meningococcal B recombinant vaccine

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, 42, 43, 44, 45] 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.

13.8. Public health measures

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.

13.8.1. Contacts

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.[46] 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).

13.8.2. Chemoprophylaxis for contacts

Recommended antibiotics

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.

Rifampicin

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.

Ceftriaxone

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.[47]

Do not use in infants under aged under 4 weeks.

Ciprofloxacin

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.[46]

Ciprofloxacin is not generally recommended for pregnant and lactating women or for children aged under 18 years.[48] 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 any group (including group A, B, C, W or Y) meningococcal disease may be offered the appropriate meningococcal vaccine (see section ‎13.5).

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 .

13.9. Variations from the vaccine data sheets

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 can be used in adults aged over 55 years.[40]

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.[38]

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.[40]

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).

The data sheet recommends two doses of 4CMenB to be given eight weeks apart between ages 12 and 23 months and not less than one month apart from the age of 2 years. The Ministry of Health recommends two doses of 4CMenB be given at least eight weeks apart for those aged 12 months or older at the time of the first dose.

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