# Presentation: 216414

## Meningococcal Disease and  and Meningococcal Vaccine

**Epidemiology and Prevention of Vaccine-Preventable Diseases**
**National Immunization Program**
**Centers for Disease Control and Prevention**

**Revised January 2007**
**Update April 2007**

## Note to presenters:

**Images of vaccine-preventable diseases are available from the Immunization Action Coalition website at ****http://www.vaccineinformation.org/photos/index.asp**

## Neisseria meningitidis

**Severe acute bacterial infection**
**Cause of meningitis, sepsis, and focal infections**
**Epidemic disease in sub-Saharan Africa**
**Current polysaccharide vaccine licensed in 1978**
**Conjugate vaccine licensed in 2005**

## Neisseria meningitidis

**Aerobic gram-negative bacteria**
**At least 13 serogroups based on characteristics of the polysaccharide capsule**
**Most invasive disease caused by  serogroups A, B, C, Y, and W-135**
**Relative importance of serogroups depends on geographic location and other factors (e.g. age)**

## Meningococcal DiseasePathogenesis

**Organism colonizes nasopharynx**
**In some persons organism invades bloodstream and causes infection at distant site**
**Antecedent URI may be a contributing factor**

## Meningococcal DiseaseClinical Features

**Incubation period 3-4 days (range 2-10 days)**
**Abrupt onset of fever, meningeal symptoms, hypotension, and rash**
**Fatality rate 9%-12%; up to 40% in meningococcemia**

## Neisseria meningitidisClinical Manifestations*

***1992-1996 data**

## Meningococcal Meningitis

**Most common pathologic presentation**
**Result of hematogenous dissemination**
**Clinical findings**
**fever**
**headache **
**stiff neck**

## Meningococcemia

**Bloodstream infection**
**May occur with or without meningitis**
**Clinical findings**
**fever****	****	**
**petechial/purpuric rash**
**hypotension**
**multiorgan failure****	**** **

## Meningococcal DiseaseLaboratory Diagnosis

**Bacterial culture**
**Gram stain**
**Non-culture methods**
**Antigen detection in CSF**
**Serology**

## Neisseria meningitidis Medical Management

**Initial empiric antibiotic treatment after appropriate cultures are obtained**
**Treatment with penicillin alone recommended after confirmation ****of *****N. meningitidis***

## Meningococcal Disease Epidemiology

**Reservoir****	****	****   Human****	****	****	****	****  **
**Transmission****	****   Respiratory droplets**
**Temporal pattern   Peaks in late winter–early ****	****	****	****	****   spring**
** **
**Communicability****	****   Generally limited**
**	****	****	****	****	**

**Notes:**
Limited communicability implied from lack of secondary cases in household settings.  Secondary cases may occur in some situations, such as day care settings.

## Meningococcal Disease— United States, 1972-2005

## Meningococcal Disease, 1998Incidence by Age Group

- Meningococcal Disease, 1998Incidence by Age Group

***Rate per 100,000 population**

**U.S. Rate**

## Rates of Meningococcal Disease* by Age, United States, 1991-2002

*** Serogroups ****A/C/Y/W135**

**U.S. Rate**

## Meningococcal Disease in the United States

**Distribution of cases by serogroup varies by time and age group**
**In 1996-2001:**
**31% serogroup B**
**42% serogroup C**
**21% serogroup Y**
**65% of cases among children <1 year of age due to serogroup B**

## Neisseria meningitidis Risk factors for invasive disease

**Host factors**
**Terminal complement pathway deficiency**
**Asplenia**
**Genetic risk factors**
**Exposure factors**
**Household exposure **
**Demographic and socioeconomic factors and crowding                                        **
**Concurrent upper respiratory tract infection**
**Active and passive smoking**

## 18-23 years old						1.4 / 100,000 
18-23 years oldnot college student				1.4 / 100,000 
Freshmen										1.9 / 100,000 
Freshmen in dorm				5.1 / 100,000

**18-23 years old****not college student****	****	****	****	****1.4 / 100,000**** **
**Freshmen****	****	****	****	****	****	****	****	****	****	****1.9 / 100,000**** **
**Freshmen in dorm****	****	****	****	****5.1 / 100,000**

**Meningococcal Disease Among Young Adults, United States, 1998-1999**

**Bruce et al, *****JAMA***** 2001;286;688-93**

## Meningococcal Outbreaks in the United States

**Outbreaks account for <5% of reported cases**
**Frequency of localized outbreaks has increased since 1991**
**Most recent outbreaks caused by serogroup C**
**Since 1997 outbreaks caused by serogroup Y and B organisms have also been reported **

## Meningococcal Polysaccharide Vaccine (MPSV)

**Menomune****®**** (sanofi pasteur)**
**Quadrivalent polysaccharide vaccine (A, C, Y, W-135)**
**Administered by subcutaneous injection**
**10-dose vial contains thimerosal as a preservative**

## Meningococcal Conjugate Vaccine (MCV)

**Menactra****®**** (sanofi pasteur)**
**Quadrivalent polysaccharide vaccine (A, C, Y, W-135) conjugated to diphtheria toxoid**
**Administered by intramuscular injection**
**Single dose vials do not contain a preservative**

## MPSV Recommendations

**Approved for persons 2 years of age and older**
**Not recommended for routine vaccination of civilians**
**Should be used only for persons at increased risk of *****N. meningiditis***** infection who are 2-10 years or 55 years of age and older, or if MCV is not available**

## Routinely recommended for:
All children at 11-12 years of age
Unvaccinated children at entry to high school (age 15 years)
All college freshmen living in a dormitory
Other persons 11-55 years of age at increased risk of invasive meningococcal disease

**All children at 11-12 years of age**
**Unvaccinated children at entry to high school (age 15 years)**
**All college freshmen living in a dormitory**
**Other persons 11-55 years of age at increased risk of invasive meningococcal disease**

- MCV Recommendations

***MMWR***** 2005; 54(RR-7);1-21 **

**Notes:**
At its February 2005 meeting the Advisory Committee on Immunization Practices voted to recommend routine meningococcal vaccination for several other groups. Meningococcal conjugate vaccine is recommended for all persons at their preadolescent visit, which should occur at ages 11 or 12 years. This is also the time when most children should receive their first TD booster dose. 

In order to produce a more rapid reduction of meningococcal disease among adolescents ACIP also recommended that for the next 2 to 3 years teens about to enter high school also be vaccinated, at about age 15 years. 

College freshmen living in a dormitory should be routinely vaccinated because of their increased risk of invasive disease. 

Other adolescents who wish to reduce their risk for meningococcal disease may elect to receive vaccine. 

MCV is preferred for all these groups. 

## Meningococcal VaccineRecommendations

**Use of MCV is preferred for persons 11-55 years of age for whom meningococcal vaccine is recommended**
**MPSV should be used for persons 2-10 years and >55 years**
**Use of MPSV is an acceptable alternative for persons 11-55 years of age if MCV is not available **

***MMWR***** 2005; 54(RR-7);1-21 **

## Meningococcal VaccineRecommendations

**Recommended for persons at increased risk of meningococcal disease:**
**Microbiologists who are routinely exposed to isolates of *****N. meningitidis***
**Military recruits**
**Persons who travel to and U.S. citizens who reside in countries in which *****N. meningitidis***** is hyperendemic or epidemic**
**terminal complement component deficiency**
**functional or anatomic asplenia **

***MMWR***** 2005; 54(RR-7);1-21 **

## Meningococcal Endemic Areas 2004

**Notes:**
Senegal and Gambia in the west to Ethiopia in the east.

## Meningococcal Vaccine Recommendations

**Both MCV and MPSV recommended for control of outbreaks caused by vaccine-preventable serogroups**
**Outbreak definition:**
**3 or more confirmed or probable primary cases**
**Period **_**<**_**3 months**
**Primary attack rate **_**>**_**10 cases per 100,000 population***

***Population-based rates should be used rather **
** ****than age-specific attack rates**

## Meningococcal Vaccine Revaccination

**Revaccination may be indicated for persons at increased risk for infection***
**Revaccination may be considered 5 years after receipt of the MPSV **
**MCV is recommended for revaccination of persons 11-55 years of age although use of MPSV is acceptable **
**Revaccination after receipt of MCV is not recommended at this time**

***e.g., asplenic persons  and those who reside in areas in which disease is  endemic (does not include college settings)**

## Meningococcal VaccinesAdverse Reactions

**Local reactions          4%-48%    11%-59%**
**   ****for 1-2 days**
**Fever **_**>**_**100****o****F                   3%               5%**
**Systemic reactions    3%-60%     4%-62%**
**  ****(headache, malaise**
**   ****fatigue) **

**MPSV**

**MCV**

## Meningococcal Conjugate Vaccine and Guillain-Barré Syndrome (GBS) 

**19 cases* of GBS among within 6 weeks of MCV**
**The number of cases does not appear to exceed the number expected**
**best current estimate of risk is 0.89 excess cases of GBS per million doses distributed**
**No change in vaccine recommendations at this time**

***CDC unpublished data and *****MMWR***** 2006;55:1120-4**

## Meningococcal Conjugate Vaccine and Guillain-Barré Syndrome (GBS) 

**CDC recommends that persons with a history of GBS not receive MCV**
**Persons with a history of GBS who are at especially high, prolonged risk for meningococcal disease, such as certain microbiologists, might consider vaccination **

********MMWR***** 2006;55:1120-4**

## Meningococcal VaccinesContraindications and Precautions

**Severe allergic reaction to vaccine component or following prior dose of vaccine**
**Moderate or severe acute illness**

## National Immunization ProgramContact Information

**Telephone****	****	****800.CDC.INFO**** **
**Email****	****	****	****nipinfo@cdc.gov**** **
**Website****	****	****www.cdc.gov/nip**