Meningococcal meningitis and septicaemia are globally endemic with periodic epidemics. There are at least 12 serogroups. B, C, W and Y have historically been the most common in the UK.
- Meningococcal infection most commonly leads to meningitis or septicaemia. It can also cause pneumonia, septic arthritis, myocarditis, endocarditis, pericarditis, conjunctivitis and cervicitis.
- Serogroup C's contribution has fallen dramatically since the introduction of childhood vaccination against the disease.
- Serogroup B is now responsible for 80% of cases in the UK; a new vaccination for this serogroup was licensed in the UK in 2013.
- Serogroup A causes the majority of epidemic meningococcal infection in the 'African meningitis belt'; it is extremely rare in the UK.
- Incidence of meningococcal disease is highest in the those aged under 1, followed by those aged 1-5, with a second peak of risk occurring in those aged 15-19 (particularly if living in crowded or closed communities - eg, barracks and student halls).
- Although meningococcal disease occurs more commonly in young children, the mortality rate amongst young adults is higher.
- Serogroup W has increased in the UK since 2009.In February 2015 the Joint Committee on Vaccination and Immunisation (JCVI) declared the increase to constitute an outbreak, leading to a change in the vaccination programme for adolescents from August 2015.
- A conjugate vaccination - meningococcal group C (MenC) - has been adopted in the UK's routine immunisation schedule since November 1999, having demonstrated protective immunity in children aged under 2.
- MenC only confers protection against meningococcal C and not the other serogroups.
- Providing early immunity is important, since preschool children are particularly vulnerable to infection from encapsulated bacteria. Polysaccharide vaccines are less effective at protecting this age group, due to the immature response of young children to this source of antigen.
- In addition to direct immunity, MenC has also been shown to have a significant protective effect on indirect 'herd' immunity, due to reduced carriage rates.
- Conjugate vaccines are expensive which can preclude their use in developing countries.[7, 8]
- Bexsero®, a multi-component protein-based vaccine against meningococcal group B (MenB), has been introduced into the UK's routine childhood immunisation schedule for all infants born since July 2015.
- The development of a vaccine against MenB has been difficult due to the surface proteins varying between sub-types and by the similarity of the capsule to human cells.It is expected to protect against infection from most (88%) of the MenB strains in the UK.
- MenACWY vaccination programme for young adults 2015:
- From August 2015, an urgent catch-up campaign for the current school year 13 (those aged 17-18) through general practice using a call and recall system. And older first-time university entrants up to the age of 25 years, directly replacing the MenC vaccine as part of the "freshers" programme.
- From September 2015 adding MenACWY vaccine to the routine adolescent schools programme (school year 9 or 10 - those aged 13-15), as a direct replacement for the MenC vaccination.
- From January 2016, a catch-up campaign for 2015/16 year 11 students (those aged 15-16).
All available vaccines are inactivated and therefore cannot cause the disease against which they protect.
- MenC conjugate vaccine. There is also a Haemophilus influenzae type b/MenC (Hib/MenC) conjugate vaccine.
- MenB protein-based vaccine (Bexsero®). This is a newer vaccine and the only vaccine against MenB licensed in the UK.
- Quadrivalent (MenACWY) conjugate vaccines: Menveo® is licensed for use from 2 years of age.Nimenrix® is licensed for use from 12 months of age.[12, 13, 14]For babies under 1 year of age, the Green Book recommends Menveo®, when two doses one month apart are needed for protection. Older children and adults should receive a single dose of either vaccine.
- Quadrivalent (MenACWY) polysaccharide vaccine (ACWY Vax®). This is an older vaccine and is no longer recommended due to its higher risk of hyporesponsiveness and poorer protection.
- Childhood immunisation - see also separate Immunisation Schedule (UK) article:
- Meningococcal group C (MenC) conjugate vaccine is part of the combined Hib and MenC conjugate vaccine given between 12 and 13 months and MenACWY (replacing MenC booster) at around 14 years.
- Men B vaccine is now also part of the primary immunisation programme, given with the infant's first and third routine vaccinations (at 2 months and 4 months of age) and a booster given between 12 and 13 months.
- The Hib/MenC vaccine and the MenB vaccine can be given at the same time as the other childhood immunisations, including pneumococcal conjugate and MMR vaccines, by separate injections.
- Those aged over 12 months but under 10 years and not previously vaccinated, should receive one dose of either MenC or Hib/MenC if required. Children over 10 years, who have not been previously vaccinated, may receive the booster early.
- Those aged 10-25 years who have never been vaccinated, should receive a single dose of MenC vaccine. If they have received a booster after age 10, no further doses are required. If they were last vaccinated at less than 10 years, the booster dose should be given.
- MenB is not routinely indicated for children aged 2 or older and is currently not recommended for vaccination in adolescents.
- Asplenia, splenic dysfunction, immunosuppression or complement deficiency:
- MenC and MenACWY conjugate vaccine are recommended for patients with asplenia, splenic dysfunction, immunosuppression or complement deficiency.
- Children aged under 1 year should be vaccinated according to the immunisation schedule. A dose of MenACWY conjugated vaccine should be given at least one month after the Hib/MenC vaccine.
- Children over 1 year old should be given a Hib/MenC vaccine and the MenACWY conjugated vaccine one month later.
- Travel immunisation:
- Large epidemics of meningococcal disease have been linked to the Hajj pilgrimage. A vaccination with quadrivalent MenACWY within three years is a visa entry requirement into Saudi Arabia for pilgrims on Hajj and Umrah, and for other travellers in Hajj season (vaccination certificate required). Vaccination is also recommended for travel to sub-Saharan Africa and certain other countries, especially if travellers will be living or working with local people or visiting during an outbreak.
- If the person has recently received MenC, an interval of at least two weeks should ideally be allowed before administration of the MenACWY vaccine.
- The risk for meningococcal meningitis is extremely low for tourists but higher for those living or working within local areas in endemic or outbreak areas.
- Contacts of infected individuals:
- Follow the advice of the local Health Protection Team.
- Chemoprophylaxis (usually with ciprofloxacin) should be offered without delay.
- Previously unimmunised family members and very close contacts of individuals with confirmed meningococcal C disease should be offered MenC conjugate vaccination.
- Close contacts of any age who were only immunised in infancy and those who completed the recommended immunisation course (including the 12-month booster) more than one year before should be offered an extra dose of MenC conjugate vaccine.
- For confirmed serogroup A, W or Y infections, vaccination with a quadrivalent conjugate vaccine should be offered to all close contacts of any age.
- MenB vaccine is not currently recommended for contacts of an index case.
- Laboratory workers handling Neisseria meningitidis should also receive vaccination.
- Minor acute illness does not preclude vaccination. However, if pyrexial, vaccination may be postponed, in order not to confuse signs or symptoms from the vaccine with a developing illness.
- In pregnancy there is no evidence that any meningococcal vaccine is unsafe but the usual advice is to avoid unless the mother is at high risk of disease.
- The vaccines are safe to give women who are breast-feeding.
- Individuals with a previous confirmed anaphylactic reaction to any component of the vaccine, including meningococcal polysaccharide, diphtheria toxoid or the CRM197 carrier protein or tetanus toxoid, should not receive vaccination.
For MenC conjugate vaccine (was given at 3 months prior to July 2016):
- Pain, tenderness, swelling or redness at the injection site and mild fevers are common in all age groups.
- In infants and toddlers - crying, irritability, drowsiness, impaired sleep, reduced eating, diarrhoea and vomiting can be common.
- In older children and adults - headaches, myalgia and drowsiness may occur.
- Neurological reactions such as dizziness, febrile/afebrile seizures, faints, numbness and hypotonia following MenC conjugate vaccination are very rare.
For Hib/MenC conjugate vaccine:
- Mild side-effects, such as irritability, loss of appetite, pain, swelling or redness at the site of the injection and slightly raised temperature, commonly occur.
- Crying, diarrhoea, vomiting, atopic dermatitis, malaise and fever over 39.5°C are less common side-effects.
For quadrivalent (ACWY) conjugate vaccine:
- Very common or common reported reactions have included injection site reactions including pain, erythema, induration and pruritus.
- Other very common or common reactions may include headache, nausea, rash and malaise.
For MenB protein-based vaccine:
- Very common side-effects include fever and irritability. Pain, tenderness, swelling or redness at the injection site are also very common, as are diarrhoea, vomiting, unusual sleepiness and loss of appetite. Rash is common.
- Seizures, including febrile seizures, are uncommon. Kawasaki disease has been reported rarely - 1 in 1000.
- Fever is more common when Bexsero® is given along with routine immunisations. Paracetamol, given at the time of the immunisation or just after, reduces the fever and does not impair the effectiveness of either the Bexsero® or concomitantly given routine immunisations:
- Advise prophylactic paracetamol at the time of Bexsero® administration.
Giving the vaccines
- Store vaccine at 2-8°C. Do not freeze vaccine or diluent.
- Giving the injection intramuscularly (IM) in the upper arm or anterolateral thigh is recommended. It is recommended that Bexsero® is given into the left thigh so that any local reactions are more easy to monitor.
- A deep subcutaneous route is advised for patients with thrombocytopenia or haemophilia.
- Immunisation with MenACWY should be at least 10 days prior to travel.
- Booster intervals:
- Children over 1 year of age, who have previously received one, two or three doses of Menveo® as infants, should be given an additional dose of Menveo® if they are travelling to an area that puts them at risk from meningococcal infection.
- The meningococcal ACWY conjugate vaccine is likely to provide longer-lasting protection than the polysaccharide vaccine. However, the need for, and the timing of, a booster dose of Menveo® has not yet been determined.
- Seek urgent medical advice if the patient becomes short of breath, has swelling of the mouth or throat or has a rash within a few days of immunisation.
- Parents should give a dose of paracetamol if their child develops a fever post-immunisation, keeping the child cool and seeking medical advice if the fever persists after a second dose.
- Travel immunisation for meningococcal meningitis is not routinely available on the NHS. Provision and payment is at the discretion of the practice and may require attendance at an alternative surgery.
Further reading and references
Meningococcal: the green book, chapter 22; Public Health England (July 2015)
Summary of Product Characteristics (SPC) - Bexsero® Meningococcal Group B vaccine for injection in pre-filled syringe, Novartis vaccines, electronic Medicines Compendium. Date of first authorisation: 14 Jan 2013.
Meningococcal ACWY programme: information for healthcare professionals; Public Health England, 8 Jul 2015
Makwana N, Riordan FA; Bacterial meningitis: the impact of vaccination. CNS Drugs. 200721(5):355-66.
Maiden MC, Ibarz-Pavon AB, Urwin R, et al; Impact of meningococcal serogroup C conjugate vaccines on carriage and herd immunity. J Infect Dis. 2008 Mar 1197(5):737-43. doi: 10.1086/527401.
Prasad K, Karlupia N; Prevention of bacterial meningitis: An overview of Cochrane systematic reviews. Respir Med. 2007 Oct101(10):2037-43. Epub 2007 Aug 13.
Segal S, Pollard AJ; Vaccines against bacterial meningitis. Br Med Bull. 2005 Mar 3172:65-81. Print 2004.
Introduction of Men B Immunisation for Infants, PHE and NHS England (letter), 22 June 2015; Public Health England
Shea MW; The Long Road to an Effective Vaccine for Meningococcus Group B (MenB). Ann Med Surg (Lond). 2013 Nov 42(2):53-6. doi: 10.1016/S2049-0801(13)70037-2. eCollection 2013.
Cooper B, DeTora L, Stoddard J; Menveo(R)): a novel quadrivalent meningococcal CRM197 conjugate vaccine against serogroups A, C, W-135 and Y. Expert Rev Vaccines. 2011 Jan10(1):21-33.
Black S, Block SL; Use of MenACWY-CRM in adolescents in the United States. J Adolesc Health. 2013 Mar52(3):271-7. doi: 10.1016/j.jadohealth.2012.07.017. Epub 2012 Sep 25.
Immunizations - travel; NICE CKS, December 2014 (UK access only)
Meningococcal meningitis; National Travel Health Network and Centre (NaTHNaC)