Meningococcal Disease

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Meningococcal disease is an acute, severe illness caused by the 

bacterium Neisseria meningitidis. A leading cause of bacterial 

meningitis and sepsis in the United States, N. meningitidis

can also cause pneumonia and focal disease, such as septic 

arthritis. As of August 2020, five meningococcal vaccines are 

licensed and available in the United States: three quadrivalent 

(serogroups A, C, W, and Y) conjugate meningococcal vaccines 

and two recombinant serogroup B vaccines.

Neisseria meningitidis

N. meningitidis, or meningococcus, is an aerobic, gram-negative

bacterium, closely related to N. gonorrhoeae and to several

typically nonpathogenic Neisseria species, such as N. lactamica.

The outer membrane of N. meningitidis is surrounded by a 

polysaccharide capsule that is important for pathogenicity 

because it helps the bacterium resist phagocytosis and 

complement-mediated lysis. The outer membrane proteins and 

the capsular polysaccharide make up the main surface antigens 

of the organism.

Meningococci are classified into serogroups based on the 

structure of the polysaccharide capsule. Twelve antigenically 

and chemically distinct polysaccharide capsules have been 

described and the polysaccharide capsule determines the 

serogroup labeling. Almost all reported cases of invasive disease 

worldwide are caused by one of six serogroups: A, B, C, W, X, and 

Y. The relative importance of each serogroup depends on factors

such as geographic location and patient age. Some strains are

nongroupable and do not express capsule; these strains are

most commonly associated with asymptomatic nasopharyngeal

carriage rather than invasive disease.

Pathogenesis

Meningococci are transmitted person-to-person by respiratory 

droplets or secretions from persons with asymptomatic 

colonization or meningococcal disease. The bacteria attach 

to and multiply in the mucosal cells of the nasopharynx and 

oropharynx and, in a small proportion (much less than 1%) of 

persons, penetrate the mucosal cells and enter the bloodstream. 

The bacteria can then spread through the blood to cause 

systemic disease and cross the blood-brain barrier into the 

cerebrospinal fluid (CSF) to cause meningitis. 

Sarah Mbaeyi, MD; Jonathan Duffy, MD, MPH; Lucy A. McNamara, PhD

Meningococcal Disease

● A leading cause of bacterial

meningitis and sepsis in U.S.

● As of August 2020, five

meningococcal vaccines

licensed in U.S.

Neisseria meningitidis

● Aerobic, gram-negative

bacterium

● Outer membrane surrounded

by polysaccharide capsule

important for pathogenicity

● 12 antigenically and chemically

distinct polysaccharide capsules

that determine serogroup

labeling have been described

● Almost all invasive disease

caused by serogroups A, B, C,

W, X, and, Y

● Relative importance of

serogroups depends on factors

such as geographic location

and age

Meningococcal Disease 

Pathogenesis

● Bacteria attach to and multiply

in nasopharynx

and oropharynx

● In <1% of persons, bacteria

enter bloodstream

■ Can cause systemic disease

and meningitis

Aug 2021 https://wwwdcdc.gov/vaccines/pubs/pinkbook/mening.html
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Meningococcal Disease

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Clinical Features

The incubation period of meningococcal disease is typically 

3 to 4 days, with a range of 1 to 10 days. Meningitis is the most 

common presentation of invasive meningococcal disease and 

is found in about 50% of cases in the United States. Symptoms 

are similar to those seen in other forms of bacterial meningitis, 

and typically include sudden onset of fever, headache, and stiff 

neck, often accompanied by other symptoms, such as nausea, 

vomiting, photophobia (eye sensitivity to light), and altered 

mental status. Meningococci can be isolated from the blood in 

up to 75% of persons with meningitis.

Meningococcal septicemia (bloodstream infection or 

meningococcemia) occurs without meningitis in about 

30% of invasive meningococcal infections. This condition 

is characterized by abrupt onset of fever; chills; cold hands 

and feet; severe aches or pain in the muscles, joints, chest, 

or abdomen; vomiting; diarrhea; and a petechial or purpuric 

rash often associated with hypotension, shock, acute adrenal 

hemorrhage, and multiorgan failure. An additional 15% of U.S. 

cases present with bacteremic pneumonia; this is the most 

common presentation in adults over 65 years of age. Other 

syndromes involving isolation of meningococci from normally 

sterile body sites, such as septic arthritis, can also occur. 

Meningococci also occasionally cause noninvasive infections 

such as conjunctivitis or urethritis. Noninvasive illness due to 

meningococci is not nationally notifiable and the incidence is 

unclear. Throughout this chapter, risk factors and demographics 

described apply only to invasive, reportable meningococcal 

disease cases and the term meningococcal disease refers 

to invasive meningococcal disease. The overall case-fatality 

ratio of meningococcal disease is 10% to 15%, even with 

appropriate antibiotic therapy, and can be higher in persons 

with meningococcemia. As many as 20% of survivors have 

permanent sequelae, such as hearing loss, neurologic damage, 

or loss of a limb.

In the United States, incidence of meningococcal disease is 

highest among infants younger than age 1 year, followed 

by children age 1 through 4 years. A second peak of disease 

incidence is found in young adults 17 through 21 years of age. 

Incidence increases again in adults older than 85 years of age.

Risk factors for the development of meningococcal disease 

include persistent complement component deficiencies 

(including use of a complement component inhibitor, 

eculizumab [Soliris®] or ravulizumab-cwvz [Ultomiris]), 

functional or anatomic asplenia, HIV infection, travel to 

or residence in a country where meningococcal disease is 

hyperendemic or epidemic, and exposure during an outbreak 

of meningococcal disease. Microbiologists who routinely 

work with isolates of N. meningitidis are also at risk. In 

Meningococcal Disease 

Clinical Features

● Incubation period 3 to 4 days 

(range, 1 to 10 days)

● Meningitis is the most common 

presentation of invasive disease 

(~50% of U.S. cases)

■ Sudden onset of fever, 

headache, stiff neck, nausea, 

vomiting, photophobia, 

altered mental status 

● Meningococcal septicemia 

(30% of cases)

■ Abrupt onset of fever, chills, 

cold hands and feet, severe 

aches or pain, vomiting, 

diarrhea, rash

● Bacteremic pneumonia 

(15% of cases)

● Meningococci occasionally 

cause noninvasive infections

● Risk factors for invasive disease

■ Persistent complement 

component deficiencies

■ Functional or anatomic 

asplenia

■ HIV infection

■ Travel to or residence in a 

country where disease is 

hyperendemic or epidemic

■ Exposure during an outbreak

■ Microbiologists who routinely 

work with isolates of N. 

meningitidis

■ Household crowding

■ Smoking

■ Antecedent viral upper 

respiratory infection
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14

addition, household crowding, active and passive smoking, 

and antecedent viral upper respiratory infection have been 

associated with meningococcal disease transmission. 

Laboratory Testing

Meningococcal disease is diagnosed by culture of N. 

meningitidis from a normally sterile site (e.g., blood, CSF) or 

purpuric lesions. Meningococcal disease may also be diagnosed 

through detection of N. meningitidis-specific nucleic acid in a 

specimen obtained from a normally sterile site using a validated 

polymerase chain reaction (PCR) assay. Although culture 

remains the gold standard for diagnosis of meningococcal 

disease, PCR is useful for detection of N. meningitidis from 

clinical samples, particularly when a patient was treated with 

antibiotics prior to specimen collection. Identification of gramnegative diplococci identified in a sterile site specimen strongly 

suggests N. meningitidis but is not confirmatory. 

Once the diagnosis of meningococcal disease has been 

confirmed, the serogroup should be identified through slide 

agglutination or real-time PCR. Laboratories that cannot 

perform serogrouping should transfer the isolate or specimen 

to a reference laboratory, such as their state public health 

laboratory. Several new commercial multiplex PCR assays 

capable of simultaneously testing a single specimen for an 

array of pathogens have become available (e.g., FilmArray® 

Blood Culture Identification Panel and FilmArray® Meningitis/

Encephalitis Panel by PCR from ARUP Laboratories). While these 

assays can rapidly identify N. meningitidis species, most do 

not determine serogroup. Thus, laboratories should continue 

to perform simultaneous culture and use validated, specific, 

real-time PCR assays capable of detecting and differentiating 

meningococcal serogroups. Otherwise, additional steps need 

to be taken, including performing a reflex culture or, at a 

minimum, retaining a clinical specimen for further testing at a 

public health laboratory.

Molecular typing using whole genome sequencing (WGS) can 

provide useful epidemiologic information, particularly if an 

outbreak of meningococcal disease is suspected. 

Serologic testing (e.g., enzyme immunoassay) for antibodies to 

meningococcal antigens is not validated for clinical use in the 

United States. Serologic testing should not be used to establish 

the diagnosis of meningococcal disease or to determine 

whether a patient should receive a meningococcal vaccination.
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Medical Management

Empiric therapy with broad-spectrum antibiotics (including a 

third-generation cephalosporin) should be started promptly 

when meningococcal disease is suspected, ideally after 

appropriate cultures are obtained. 

Once N. meningitidis infection has been confirmed, treatment 

may be continued with penicillin, ampicillin, cefotaxime, or 

ceftriaxone. However, because there have been recent reports 

of penicillin-resistant, β-lactamase-producing N. meningitidis

serogroup Y cases in the United States, healthcare providers 

should ascertain susceptibility of meningococcal isolates to 

penicillin before using penicillin or ampicillin for treatment.

Antimicrobial Chemoprophylaxis

In the United States, the primary means for prevention 

of sporadic meningococcal disease is antimicrobial 

chemoprophylaxis of close contacts of infected persons. 

Close contacts include household members, childcare center 

contacts, and anyone directly exposed to the patient’s oral 

secretions (e.g., through kissing, mouth-to-mouth resuscitation, 

endotracheal intubation, or endotracheal tube management) 

during the 7 days before symptom onset. Healthcare personnel 

should receive chemoprophylaxis if they were managing an 

airway or were exposed to respiratory secretions of a patient 

with meningococcal disease.

For travelers, antimicrobial chemoprophylaxis should be 

considered for any passenger who had direct contact with 

respiratory secretions from an index patient or for anyone 

seated directly next to an index patient on a prolonged flight 

(i.e., one lasting more than 8 hours), or within one seat in any 

direction on a flight of any duration if the index patient was 

coughing or vomiting on the flight. Any case of meningococcal 

disease in a person who has recently traveled should be 

reported to the local quarantine station to determine whether 

an air travel contact investigation is indicated.

Chemoprophylaxis is not recommended for close contacts 

of patients with evidence of N. meningitidis only in nonsterile 

sites (e.g., oropharyngeal, endotracheal, conjunctival). Reports 

of secondary cases after close contact with persons with 

noninvasive pneumonia or conjunctivitis are rare; there is 

no evidence of substantive excess risk. Furthermore, there 

is no indication to treat persons who are asymptomatic 

nasopharyngeal carriers.

Because the rate of secondary disease for close contacts is 

highest immediately after onset of disease in the index patient, 

antimicrobial chemoprophylaxis should be administered as 

soon as possible, ideally less than 24 hours after identification of 

the index patient. Conversely, chemoprophylaxis administered 

Antimicrobial Chemoprophylaxis

● Primary means for prevention 

of sporadic meningococcal 

disease

● Close contacts of infected 

persons: Household members, 

childcare center contacts, 

anyone directly exposed to 

patient’s oral secretions during 

the 7 days before symptom 

onset

● Administer as soon as possible, 

ideally less than 24 hours after 

identification of index patient
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14

more than 14 days after onset of illness in the index patient 

is probably of limited or no value. Oropharyngeal or 

nasopharyngeal cultures are not helpful in determining the 

need for chemoprophylaxis and might unnecessarily delay 

institution of this preventive measure.

Rifampin, ciprofloxacin, and ceftriaxone are 90% to 95% 

effective in reducing nasopharyngeal carriage of 

N. meningitidis and are all acceptable antimicrobial agents for 

chemoprophylaxis. Because there have been recent reports of 

ciprofloxacin-resistant, β-lactamase-producing 

N. meningitidis serogroup Y cases in the United States, 

clinicians and public health staff should consider obtaining 

antimicrobial susceptibility testing of meningococcal isolates 

to inform prophylaxis decisions if their state has reported 

a case of meningococcal disease caused by ciprofloxacinresistant strains within the past 2 years. Clinicians should 

report suspected chemoprophylaxis failures to their public 

health departments. Systemic antimicrobial therapy for 

meningococcal disease with agents other than ceftriaxone 

or other third-generation cephalosporins might not reliably 

eradicate nasopharyngeal carriage of N. meningitidis. If other 

agents have been used for treatment, the patient should 

receive chemoprophylactic antibiotics for eradication of 

nasopharyngeal carriage before being discharged from 

the hospital. 

Epidemiology

Occurrence

Meningococcal disease occurs worldwide. Incidence rates vary 

by serogroup and geography.

Reservoir

Humans are the only natural reservoir of meningococcus. 

At any given time, about 10% of adolescents and adults are 

asymptomatic nasopharyngeal carriers of N. meningitidis. Many 

of these carried strains are nongroupable (not encapsulated) 

and unlikely to cause disease in most people. 

Transmission

Primary mode is by respiratory droplet spread or by direct 

contact with respiratory secretions.

Temporal Pattern

Meningococcal disease occurs throughout the year; however, 

the incidence is highest in the late winter and early spring.

Meningococcal Disease 

Epidemiology

● Reservoir

■ Human 

● Transmission

■ Respiratory droplets or 

direct contact with 

respiratory secretions

● Temporal pattern

■ Peaks in late winter and 

early spring

● Communicability

■ Generally limited
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Communicability

The communicability of N. meningitidis is generally limited. In 

studies of households in which a case of meningococcal disease 

has occurred, only 3% to 4% of households had secondary 

cases. Most households had only one secondary case. Estimates 

of the risk of secondary transmission are generally 2–4 cases per 

1,000 household members at risk. However, this risk is 500 to 

800 times greater than in the general population.

Secular Trends in the United States

Incidence of meningococcal disease in the United States 

has declined annually following a peak in the late 1990s. 

In 2018, 329 total cases were reported in the United States, 

representing an incidence of 0.10 per 100,000 population. 

Serogroups B and C are the major causes of meningococcal 

disease in the United States, each being responsible for 

approximately 25% to 40% of cases; serogroups W and Y, along 

with nongroupable meningococci, are each responsible for 

another 5% to 15%. The proportion of cases caused by each 

serogroup varies by age group. Approximately 60% of disease 

among children and young adults under 24 years of age is 

caused by serogroup B. In particular, among individuals 18 to 

24 years of age, college students have more than three times 

the risk of serogroup B meningococcal disease as similarly 

aged people not attending college. Meanwhile, serogroups 

C, W, or Y cause about 60% of all cases of meningococcal 

disease among persons 24 years of age and older. 

In the United States, meningococcal outbreaks account for 

about 5% of reported cases (i.e., 95% of cases are sporadic). 

An outbreak is defined as 2–3 outbreak-associated cases 

(e.g., cases of the same serogroup unless found to be 

genetically unrelated by molecular typing methods) in an 

organization (e.g., school, college, correctional facility) during 

a three-month period, or multiple outbreak-associated cases 

with an incidence of meningococcal disease that is above the 

expected incidence in a community during a three-month 

period. During 2010 through 2018, multiple serogroup 

B outbreaks among university students and serogroup C 

outbreaks among men who have sex with men were reported. 

Other communities and organizations, including populations 

experiencing homelessness and correctional facilities, also 

experienced outbreaks during this time.

Meningococcal Disease Secular 

Trends in the United States

● In 2018, 329 total cases 

reported (0.10 per 100,000 

population)

● Serogroups B and C major 

causes of meningococcal 

disease

● Proportion of cases caused by 

each serogroup varies by age 

group

● Outbreaks account for 5% of 

reported cases
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Meningococcal Vaccines 

Characteristics

Meningococcal Polysaccharide Vaccine 

As of 2017, meningococcal polysaccharide vaccine (Menomune) 

is no longer available in the United States. 

Quadrivalent Meningococcal Conjugate (Serogroups 

A, C, W, Y) Vaccines 

Three quadrivalent meningococcal conjugate vaccines are 

licensed for use in the United States: MenACWY-D (Menactra), 

MenACWY-CRM (Menveo), and MenACWY-TT (MenQuadfi). 

The combination Hib and bivalent meningococcal conjugate 

vaccine, Hib-MenCY (MenHibrix), is no longer available in the 

United States. 

Menactra is approved for use in persons age 9 months 

through 55 years, Menveo is approved for use in persons 

age 2 months through 55 years, and MenQuadfi is approved 

for use in persons age 2 years or older. Menveo is prepared 

using media containing yeast extracts. Quadrivalent 

meningococcal conjugate vaccines are administered by 

intramuscular injection and do not contain an adjuvant, 

antibiotic, or preservative, although formaldehyde is added 

during the manufacturing process. 

Serogroup B Meningococcal Vaccines 

Two recombinant serogroup B meningococcal (MenB) 

vaccines are licensed for use in the United States: MenB-FHbp 

(Trumenba) and MenB-4C (Bexsero). 

Trumenba and Bexsero are approved for use in persons age 

10 through 25 years and are administered by intramuscular 

injection. Each dose of Trumenba and Bexsero contain 

aluminum as an adjuvant. Bexsero contains kanamycin as an 

antibiotic. Neither Trumenba nor Bexsero contain a preservative. 

The tip caps of prefilled syringes of Bexsero contain latex.

Vaccination Schedule And Use

Meningococcal Conjugate Vaccines

The Advisory Committee on Immunization Practices (ACIP) 

recommends routine vaccination with MenACWY vaccine 

for all adolescents at age 11 through 18 years, with the first 

dose at age 11 or 12 years and a booster dose at age 16 years. 

For adolescents who receive the first dose at age 13 through 

15 years, a one-time booster dose should be administered, 

preferably at age 16 through 18 years. Healthy persons who 

receive their first routine dose of MenACWY vaccine at or after 

age 16 years do not need a booster dose unless they become at 

Meningococcal Vaccines

● Quadrivalent Meningococcal 

Conjugate Vaccines

■ MenACWY-D (Menactra)

■ MenACWY-CRM (Menevo)

■ MenACWY-TT (MenQuadfi)

● Serogroup B Meningococcal 

Vaccines

■ MenB-FHbp (Trumenba)

■ MenB-4C (Bexsero)

Meningococcal Vaccine 

Characteristics

● Quadrivalent Meningococcal 

Conjugate Vaccines

■ Administered by 

intramuscular injection

■ Do not contain an adjuvant, 

antibiotic, or preservative

● Serogroup B Meningococcal 

Vaccines

■ Administered by 

intramuscular injection

■ Contain aluminum as an 

adjuvant

■ MenB-4C (Bexsero) contains 

kanamycin as an antibiotic 

and its prefilled syringes 

contain latex
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increased risk for meningococcal disease. Routine vaccination of 

healthy persons who are not at increased risk for meningococcal 

disease is not recommended after age 21 years. 

ACIP also recommends vaccination for persons age 2 months 

or older at increased risk for meningococcal disease due to 

serogroups A, C, W, or Y. This recommendation includes:

• Persons with persistent complement component 

deficiencies, including persons taking eculizumab or 

ravulizumab-cwvz 

• Persons who have functional or anatomic asplenia, 

including sickle cell disease 

• Persons with HIV infection 

• Microbiologists who are routinely exposed to isolates of 

N. meningitidis 

• Persons identified by public health officials to be at 

increased risk during a meningococcal disease outbreak 

due to serogroup A, C, W, or Y 

• Persons who travel to or reside in countries where 

meningococcal disease is endemic or hyperendemic, 

including the “meningitis belt” of sub-Saharan Africa or 

the Kingdom of Saudi Arabia during the annual Hajj and 

Umrah pilgrimages 

Infants and children who received Hib-MenCY and are traveling 

to areas with high endemic rates of meningococcal disease are 

not protected against serogroups A and W and should receive 

age-appropriate MenACWY vaccine. 

MenQuadfi, but not Menactra or Menveo, is licensed for use 

in adults age 56 years or older. However, any of these vaccines 

can be used to vaccinate people in this age group who are 

recommended to receive quadrivalent meningococcal vaccine 

because of increased risk for meningococcal disease. 

In children at increased risk for meningococcal disease, 

Menactra should be given either before or at the same time 

as DTaP to avoid interference with the immune response to 

meningococcal vaccine. In addition, because of the high risk 

for invasive pneumococcal disease, children with functional or 

anatomic asplenia or HIV infection should not be vaccinated 

with Menactra before age 2 years to avoid interference with 

the immune response to pneumococcal conjugate vaccine 

(PCV13). If Menactra is used in persons of any age with asplenia 

or HIV, it should not be administered until at least 4 weeks after 

completion of all PCV13 doses. There are no similar constraints 

on Menveo or MenQuadfi administration. Booster vaccination 

is recommended for persons who remain at increased risk of 

meningococcal disease. If the most recent dose was received 

at younger than 7 years, a booster dose should be given after 

Meningococcal 

Vaccination Schedule

● Quadrivalent Meningococcal 

Conjugate Vaccines

■ 1 dose at age 11 or 12 years

■ Booster dose at age 16 years

■ Healthy persons who receive 

first dose at or after age 

16 years do not need a 

booster dose unless they 

become at increased risk for 

meningococcal disease

■ Schedule for persons 

at increased risk for 

meningococcal disease varies 

by risk group and age (see 

tables)

● Serogroup B Meningococcal 

Vaccines

■ Recommended for persons 

age 10 years or older who are 

at increased risk of serogroup 

B meningococcal disease (see 

tables)

–2-dose series of Bexsero at 

0 and 1 month or

–3-dose series of Trumenba 

at 0, 1–2, and 6 months

■ Shared clinical decision 

making for adolescents age 

16 through 23 years
Meningococcal Disease

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14

3 years. If the most recent dose was received at age 7 years 

or older, a booster dose should be administered after 5 years 

and every 5 years thereafter as long as the person remains at 

increased risk for meningococcal disease.

Menactra, Menveo, or MenQuadfi can be administered at the 

same visit as other indicated vaccines with one exception. 

In persons with anatomic or functional asplenia and/or HIV 

infection, Menactra and pneumococcal conjugate vaccine 

(PCV13) should not be administered simultaneously.

If the liquid C-W-Y component of Menveo is administered alone 

(without using it to reconstitute the lyophilized A component), 

revaccination may not be needed. Serogroup A disease is rare in 

the United States, so revaccination is not necessary if the person 

does not plan to travel outside the United States. However, the 

person should be revaccinated with a properly reconstituted 

dose of Menveo, or a dose of Menactra or MenQuadfi if they are 

traveling internationally, especially if traveling to Africa. There 

is no minimum interval between the incomplete dose given in 

error and the repeat dose. 

Serogroup B Meningococcal Vaccines

ACIP recommends MenB vaccine for persons 10 years of age or 

older who are at increased risk of serogroup B meningococcal 

disease. This recommendation includes persons with persistent 

complement component deficiencies, including persons taking 

eculizumab or ravulizumab; persons who have anatomic or 

functional asplenia, including sickle cell disease; microbiologists 

who are routinely exposed to isolates of N. meningitidis; or 

anyone identified by public health officials to be at increased 

risk because of a serogroup B meningococcal disease outbreak. 

In persons at increased risk for serogroup B meningococcal 

disease, ACIP recommends either a 2-dose series of Bexsero at 

0 and 1 month (or longer), or a 3-dose series of Trumenba at 

0, 1 to 2, and 6 months. See the tables on pages 241-242 for 

details on ACIP MenB vaccine recommendations for persons 

at increased risk for meningococcal disease. If the second 

dose of Bexsero or Trumenba dose is given earlier than the 

recommended interval, then the dose should be repeated at 

least 4 weeks after the last dose. However, if the second dose of 

Trumenba is administered at an interval of 6 months or more, a 

third dose does not need to be administered. If the third dose 

of Trumenba is administered earlier than 4 months after the 

second dose, the dose should be repeated at least 4 months 

after the last dose. 

ACIP also recommends adolescents age 16 through 23 years 

receive MenB vaccine for short-term protection against most 

strains of serogroup B meningococcal disease based on shared 

clinical decision-making. The preferred age for vaccination is 16 

through 18 years. In healthy adolescents, either a 2-dose series 

of Bexsero at 0 and 1 month (or longer) or a 2-dose series of 
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Meningococcal Disease

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Trumenba at 0 and 6 months may be used. If the second dose 

of Bexsero is given earlier than the recommended interval, the 

dose should be repeated at least 4 weeks after the last dose. 

If the second dose of Trumenba is administered earlier than 6 

months after the first dose, a third dose should be administered 

at least 4 months after the second dose.

Persons who have completed a MenB primary series and 

who become or remain at increased risk for meningococcal 

disease are recommended to receive booster vaccination. For 

persons 10 years of age or older with complement deficiency, 

complement inhibitor use, asplenia, or who are microbiologists 

routinely exposed to isolates, ACIP recommends a booster 

dose one year following completion of a MenB primary series 

followed by booster doses every 2 to 3 years thereafter, for as 

long as increased risk remains. For persons 10 years of age or 

older determined by public health officials to be at increased 

risk during a serogroup B outbreak, ACIP recommends a 

one-time booster dose if it has been at least one year since 

completion of the primary series. (A booster interval of at 

least six months may be considered by public health officials 

depending on the specific outbreak, vaccination strategy, and 

projected duration of elevated risk). Serogroup B meningococcal 

vaccine may be administered simultaneously or at any interval 

with other live or inactivated vaccines, including meningococcal 

conjugate vaccines.

Trumenba and Bexsero are not interchangeable. The same 

serogroup B meningococcal vaccine brand must be used 

for all doses of the series. If doses of both brands have been 
Meningococcal Disease

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14

administered to the same patient, the provider should ensure that the patient receives a complete series of either 

brand and ignore any doses of the other brand. The next dose of the selected brand should be given no sooner 

than the recommended interval after the previous dose of the same brand AND at least 4 weeks after the last (or 

only) dose of the other brand.

ACIP meningococcal vaccine recommendations for persons at increased risk for meningococcal disease 

(age 2 through 23 months)

Age Risk Group MenACWY 

primary series

MenACWY 

booster dose

MenB vaccine 

recommendation*

MenB booster 

dose*

2–23 months

• Asplenia

• HIV infection

Menactra: 

Not recommended

MenQuadfi: 

Not recommended

Menveo:

• 1st dose at 8 weeks: 

4-dose series at 2, 4, 6, 

and 12 months

• 1st dose at 7–23 

months: 2 doses at 

least 12 weeks apart, 

with 2nd dose at age 1 

year or older

Recommended 

for individuals at 

continued risk.†

No

recommendation

No 

recommendation

• Complement 

deficiency 

• Outbreak

• Travel 

MenQuadfi: Not 

recommended

Menactra:

• 9–23 months: 2 doses 

at least 12 weeks apart

or 

Menveo:

• 1st dose at 8 weeks: 

4-dose series at 2, 4, 6, 

and 12 months

• 1st dose at 7–23 

months: 2 doses at 

least 12 weeks apart, 

with 2nd dose at age 1 

year or older

Recommended 

for individuals at 

continued risk.†

No

recommendation

No

recommendation

*Note that MenB-FHbp and MenB-4C are not interchangeable; the same vaccine should be used for all doses, including booster doses.

†

Revaccination with meningococcal conjugate vaccine is recommended after 3 years for children who received their last dose at <7 

years of age. Revaccination is recommended after 5 years for people who received their last dose at ≥7 years of age, and every 5 years 

thereafter for people at continued risk.
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Meningococcal Disease

 14

ACIP meningococcal vaccine recommendations for persons at increased risk for meningococcal disease 

(age 2 through 9 years)

Age Risk Group MenACWY 

primary series

MenACWY 

booster dose

MenB vaccine 

recommendation*

MenB booster 

dose*

2–9 years

• Asplenia†

• HIV infection†

• Complement 

deficiency

2 doses at least 

8 weeks apart

Recommended 

for individuals at 

continued risk.§

No

recommendation

No

recommendation

• Outbreak

• Travel 

1 dose Recommended 

for individuals at 

continued risk.§

No

recommendation

No

recommendation

*Note that MenB-FHbp and MenB-4C are not interchangeable; the same vaccine should be used for all doses, including booster doses.

†

Menactra must be administered at least 4 weeks after completion of PCV13 series.

§

Revaccination with meningococcal conjugate vaccine is recommended after 3 years for children who received their last dose at 

<7 years of age. Revaccination is recommended after 5 years for people who received their last dose at ≥7 years of age, and every 5 years 

thereafter for people at continued risk.

ACIP meningococcal vaccine recommendations for persons at increased risk for meningococcal disease 

(age 10 years or older)

Age Risk Group MenACWY 

primary series

MenACWY 

booster dose

MenB vaccine 

recommendation* MenB booster dose*

≥10 years

• Asplenia†

• Complement 

deficiency

2 doses at least 

8 weeks apart

Recommended 

for individuals at 

continued risk.§

Trumenba: 3-dose 

series at 0, 1–2, and 

6 months or

Bexsero: 2-dose 

series at least 1 

month apart

For individuals who remain at 

increased risk of serogroup B 

disease, a single dose of MenB 

vaccine is recommended 1 year 

after completion of the 

primary vaccination series and 

every 2-3 years thereafter

HIV infection† 2 doses at least 

8 weeks apart

Recommended 

for individuals at 

continued risk.§

No

recommendation

No

recommendation

Microbiologist 1 dose Recommended 

for individuals at 

continued risk.§

Trumenba: 3-dose 

series at 0, 1–2, and 

6 months or

Bexsero: 2-dose 

series at least 1 

month apart 

For individuals who remain at 

increased risk of serogroup B 

disease, a single dose of MenB 

vaccine is recommended 1 year 

after completion of the primary 

vaccination series and every 

2-3 years thereafter

Outbreak 1 dose Recommended 

for individuals at 

continued risk.§

Trumenba: 3-dose 

series at 0, 1–2, and 

6 months or

Bexsero: 2-dose 

series at least 1 

month apart

For individuals who were 

previously vaccinated and 

identified as being at increased 

risk during an outbreak, a 

single dose of MenB vaccine is 

recommended if it has been ≥1 

year since MenB primary series 

completion (≥6 month interval 

might also be considered by 

public health professionals).

Travel 1 dose Recommended 

for individuals at 

continued risk.§

No

recommendation

No

recommendation

*Note that MenB-FHbp and MenB-4C are not interchangeable; the same vaccine should be used for all doses, including booster doses.

†

Menactra must be administered at least 4 weeks after completion of PCV13 series.

§

Revaccination with meningococcal conjugate vaccine is recommended after 3 years for children who received their last dose at <7 

years of age. Revaccination is recommended after 5 years for people who received their last dose at ≥7 years of age, and every 5 years 

thereafter for people at continued risk.
Meningococcal Disease

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14

Immunogenicity and Vaccine Effectiveness

Meningococcal Conjugate Vaccines

In clinical trials, the immunogenicity of MenACWY vaccines 

was assessed as seroconversion rates, defined as achieving a 

seroresponse at a predefined serum bactericidal antibody level 

for each serogroup, or the proportion of participants with a 

fourfold or greater increase in bactericidal antibody to each 

serogroup. An evaluation of MenACWY-D effectiveness (VE) in 

U.S. adolescents demonstrated that the overall effectiveness 

is 69% (51 to 80%). Effectiveness was 77% (57 to 88%) for 

serogroup C and 51% (1 to 76%) for serogroup Y. Effectiveness 

waned over time; VE was 79% (49 to 91%) within 1 year of 

vaccination, 69% (44 to 83%) 1 to 2 years after vaccination, 

and 61% (25 to 79%) 3 to 8 years after vaccination. These 

results, along with antibody persistence data showing waning 

immunity 3 to 5 years following a single dose, informed the 

ACIP recommendation for a booster dose in adolescents at age 

16 years following a primary dose at age 11 or 12 years. 

Serogroup B Meningococcal Vaccines

For both Trumenba and Bexsero, antibody responses were 

measured by serum bactericidal activity using human 

complement against selected meningococcal serogroup B 

strains. Immunogenicity was assessed as the proportion of 

subjects who achieved a fourfold or greater increase in serum 

bactericidal activity using human complement (hSBA) titer for 

each of the serogroup B strains tested, and the proportion of 

subjects who achieved a titer greater than or equal to the lower 

limit of quantification of the assay for all strains (composite 

response).

In a multicenter study conducted among adolescents age 11 

to 17 years in the United States, 81% of subjects who received 

Trumenba and concomitant quadrivalent HPV vaccine (4vHPV) 

had a composite response, and 84% of subjects who received 

Trumenba with saline had a composite response. 

In a randomized, controlled trial in the United Kingdom among 

college students age 18 to 24 years, 88% of recipients of both 

doses of Bexsero had a composite response at one month 

following the second dose. At 11 months after the second dose, 

66% of recipients had a composite response. In a randomized, 

controlled trial in Australia and Canada among adolescents age 

11 to 17 years, 63% of recipients had a composite response one 

month after the second dose.

Meningococcal Vaccine Efficacy

● Quadrivalent Meningococcal 

Conjugate Vaccines

■ 69% effective in U.S. 

adolescents

■ Effectiveness wanes over time

● Serogroup B Meningococcal 

Vaccines

■ Multicenter study 

demonstrated 84% of 

adolescents receiving 

Trumenba with saline had 

composite response

■ In a randomized, controlled 

trial 88% of college students 

receiving 2 doses of Bexsero 

had a composite response 

after 1 month; 66% at 11 

months
220

Meningococcal Disease

 14

Contraindications and Precautions 

to Vaccination

As with other vaccines, a history of a severe allergic reaction 

(anaphylaxis) to a vaccine component or following a prior 

dose is a contraindication to further doses. Moderate or severe 

acute illness (with or without fever) in a patient is considered a 

precaution to vaccination, although persons with minor illness 

may be vaccinated. 

Vaccination with MenACWY vaccine is contraindicated 

for persons who have had a severe allergic reaction (e.g., 

anaphylaxis) after any the following:

• A previous dose of Menactra, Menveo, or MenQuadfi

• Any component of Menactra, Menveo, or 

MenQuadfi vaccines

• Any other meningococcal, diphtheria toxoid-, tetanus 

toxoid-, or CRM197-containing vaccine.

After reviewing safety studies, ACIP voted in 2010 to remove 

a history of Guillain-Barré syndrome (GBS) as a precaution for 

vaccination with any MenACWY vaccine including Menactra. 

However, a history of GBS continues to be listed as a precaution 

in the package insert for Menactra. 

For both Bexsero and Trumenba, severe allergic reaction (e.g., 

anaphylaxis) after a previous dose or to any vaccine component 

is a contraindication for vaccination. Latex sensitivity is listed as 

a precaution for Bexsero because the tip caps of the prefilled 

syringes contain natural rubber latex. Menveo is prepared using 

media containing yeast extracts. 

Vaccination during Pregnancy

To date, no randomized clinical trials have been conducted to 

evaluate use of MenACWY or MenB vaccines in pregnant or 

lactating women. MenACWY vaccines are recommended for 

lactating women if otherwise indicated. ACIP recommends 

that Bexsero or Trumenba vaccination of pregnant women 

should be deferred unless the woman is at increased risk and, 

after consultation with her health care provider, the benefits of 

vaccination are considered to outweigh the potential risks. 

Vaccine Safety

Meningococcal Conjugate Vaccines

In clinical trials of Menactra, the most common injection-site 

reactions were pain (31% to 69%) and erythema (3% to 43%). 

The most common systemic reactions in infants and children 

were irritability and drowsiness; in adolescents and adults the 

most common were myalgia, headache, and fatigue. Most 

symptoms were mild-to-moderate and resolved within three 

Meningococcal Vaccines 

Contraindications and Precaution

● Contraindication

■ Severe allergic reaction 

to vaccine component or 

following prior dose

■ Severe allergic reaction after 

any of the following*:

–A previous dose of Menactra, 

Menveo, or MenQuadfi

–Any component of 

Menactra, Menveo, or 

MenQuadfi vaccines

–Any other meningococcal, 

diphtheria toxoid-, tetanus 

toxoid-, or CRM197-containing 

vaccine

● Precaution

■ Moderate or severe 

acute illness

■ Latex sensitivity (Bexsero only)

*Contraindication for MenACWY vaccines

Meningococcal Vaccine Safety

● Quadrivalent Meningococcal 

Conjugate Vaccines

■ Injection site pain, erythema

■ Irritability, drowsiness, 

myalgia, headache, fatigue, 

sleepiness, malaise

● Serogroup B Meningococcal 

Vaccines

■ Injection site pain, induration, 

erythema, swelling

■ Headache, fatigue, 

myalgia, arthralgia
Meningococcal Disease

221

14

days. The Vaccine Adverse Event Reporting System (VAERS) 

received 13,075 reports for Menactra from 2005 through June 

2016, during which time over 70 million Menactra doses were 

distributed. The most commonly reported adverse events were 

injection site erythema, fever, and headache. Reported adverse 

events were consistent with the findings from pre-licensure 

studies, and no new safety concerns were identified. A cohort 

study in which 1.4 million doses of Menactra were administered 

found that Menactra vaccination was associated with a small 

risk of syncope and medically-attended fever but identified no 

new safety concerns.

In clinical trials of Menveo, the most common injection-site 

reactions were pain (8% to 54%) and erythema (12% to 

39%). The most common systemic reactions in infants and 

toddlers were irritability and sleepiness. The most common in 

children were irritability, myalgia, headache, and sleepiness. 

In adolescents and adults, myalgia, headache, and fatigue 

were the most common. Most symptoms were mild-tomoderate and resolved within three days. VAERS received 

2,614 reports for Menveo from 2010 through 2015, during 

which time 8.2 million Menveo doses were distributed. The 

most commonly reported adverse events were consistent with 

the findings from pre-licensure studies, and no new safety 

concerns were identified. In a postlicensure cohort study in 

which approximately 49,000 individuals aged 11 to 21 years 

received Menveo, an increased risk of Bell’s palsy during the 

84 days following vaccination was observed when Menveo 

was administered simultaneously with other vaccines but not 

when Menveo was administered alone. However, this finding 

was based on only eight patients, several of whom had other 

conditions or infections that might precede Bell’s palsy. The 

importance of this finding is uncertain. 

In clinical trials of MenQuadfi, the most common injection-site 

reaction after the primary dose in all age groups was pain (26% 

to 45%). The most common systemic reactions were myalgia, 

headache, and malaise. Solicited adverse reactions following 

a booster dose in adolescents and adults were comparable to 

those observed following primary vaccination. MenQuadfi was 

not yet in use at the time of this publication and postlicensure 

vaccine safety evaluations will be performed.

Serogroup B Meningococcal Vaccines

In clinical trials of Trumenba, the most common local reactions 

were injection site pain (72% to 93%), induration (21% to 37%), 

and erythema (10% to 24%). The most common systemic 

reactions were headache (27% to 67%), fatigue (30% to 66%), 

myalgia (21% to 40%), and arthralgia (11% to 33%). Most 

symptoms were mild-to-moderate and resolved within five days. 

VAERS received 1,719 reports for Trumenba from 2014 through 

June 2018. The most commonly reported adverse events were 

fever, headache, and injection site pain. Reported adverse 
222

Meningococcal Disease

 14

events were consistent with the findings from pre-licensure 

studies, and no new safety concerns were identified. Adverse 

events following Trumenba were also evaluated during a mass 

vaccination campaign on a university campus in which over 

10,000 doses were administered; rates of injection site pain, 

fatigue, myalgia, fevers, and chills were similar to those reported 

during clinical trials. 

In clinical trials of Bexsero, the most common local reactions 

were injection site pain (82% to 98%), erythema (35% to 68%), 

swelling (26% to 47%), and induration (10% to 48%). The most 

common systemic reactions were headache (21% to 65%), 

fatigue (18% to 73%), myalgia (17% to 75%), and arthralgia 

(8% to 42%). VAERS received 1,470 reports for Bexsero from 

2015 through June 2018. The most commonly reported adverse 

events were injection site pain, fever, and headache; transient 

decreased mobility of the arm where Bexsero was injected was 

also disproportionately reported. Otherwise, reported adverse 

events were consistent with the findings from pre-licensure 

studies, and no new safety concerns were identified. Adverse 

events following Bexsero were also evaluated during several 

mass vaccination campaigns in the United States and Canada. 

The most commonly reported adverse events were consistent 

with findings based on clinical trial data (e.g., fever, injection 

site pain, arm pain), and 0.88 syncopal events per 1,000 persons 

were observed in the U.S. evaluation. 

Vaccine Storage and Handling

MMenACWY (Menactra, Menveo and MenQuadfi) and MenB 

(Bexsero and Trumenba) should be maintained at refrigerator 

temperature between 2°C and 8°C (36°F and 46°F). Whenever 

possible, the lyophilized and liquid components of Menveo 

should be stored together. 

The MenA (lyophilized) component of Menveo should only be 

reconstituted using the liquid C-W-Y component of Menveo. 

No other vaccine or diluent can be used for this purpose. The 

reconstituted vaccine should be used immediately but may be 

held at or below 25°C (77°F) for up to 8 hours. 

Manufacturer package inserts contain additional information. 

For complete information on storage and handling best 

practices and recommendations, please refer to CDC’s Vaccine 

Storage and Handling Toolkit, https://www.cdc.gov/vaccines/hcp/

admin/storage/toolkit/storage-handling-toolkit.pdf. 
Meningococcal Disease

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14

Surveillance and Reporting of 

Meningococcal Disease

Meningococcal disease is a reportable condition in all 

states. Healthcare personnel should immediately report any 

case of invasive meningococcal disease to local and state 

health departments. This is essential so that antimicrobial 

chemoprophylaxis can be rapidly administered to close 

contacts of the case. For guidance for state and local health 

department staff who are involved in surveillance activities for 

vaccine-preventable diseases, please consult the Manual for the 

Surveillance of Vaccine-Preventable Diseases, https://www.cdc.

gov/vaccines/pubs/surv-manual/chapters.html. 

Acknowledgements

The editors wish to acknowledge Jennifer Hamborsky, 

Susan Hariri, and Andrew Kroger for their contributions to 

this chapter.

NOTES
224

Meningococcal Disease

 14

Selected References

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Management of Suspected Outbreaks of Meningococcal 

Disease. Version 2.0. 2019. 

https://www.cdc.gov/meningococcal/downloads/

meningococcal-outbreak-guidance.pdf. 

Accessed September 1, 2020.

CDC. Meningococcal Disease – Surveillance. 

https://www.cdc.gov/meningococcal/surveillance/index.html. 

Accessed September 13, 2020.

CDC. Meningococcal Vaccination: Recommendations of the 

Advisory Committee on Immunization Practices, United States, 

2020. MMWR 2020;69(9):1–41. 

CDC. Recommendations for Use of Meningococcal Conjugtae 

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Immunization Practices, 2016. MMWR Morb Mortal Wkly Rep 

2016;65(43):1189-94.

CDC. Updated Recommendations for Use of MenB-FHbp 

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on Immunization Practices, 2016. MMWR Morb Mortal Wkly Rep

2017;66(19):509-13.

CDC. Use of Serogroup B Meningococcal Vaccines in 

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CDC. Use of Serogroup B Meningococcal Vaccines in 

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Harrison L, Granoff D, Pollard A. Meningococcal Capsular Group 

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Granoff D, Pollard A, Harrison L. Meningococcal Capsular 

Group B Vaccines. In: Plotkin SA, Orenstein WA, Offit PA, eds. 

Plotkin’s Vaccines. 7th ed. Elsevier; 2018:644–62.

McNamara L, Blain. Meningococcal Disease. In: Roush S, Baldy L, 

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NOTES