Updated Recommendations on the Use of Meningococcal Vaccines

Neisseria meningitidis is responsible for a spectrum of infections, such as meningitis, bacteremia, and pneumonia, and may be associated with long-term sequelae and death. Five serogroups of N. meningitidis (A, B, C, W, and Y) are responsible for the vast majority of disease in children and adults. Specific meningococcal serogroups appear to cause a preponderance of disease in certain age groups and geographic areas. For example, in the United States, N. meningitidis serogroup B is predominant in children younger than age 5 years, whereas serogroups C and Y are responsible for the majority of cases in adolescents. N. meningitidis serogroup A is hyperendemic in sub-Saharan Africa (the so-called “meningitis” belt) but it is rarely diagnosed in the United States.

For unknown reasons, the incidence of meningococcal disease has decreased in the United States since the late 1990s. The decrease started before the availability of the meningococcal conjugate vaccine and recommendations for routine meningococcal vaccine use in adolescents. Declines in incidence have occurred in all serogroups, including serogroup B, which is currently not included in any meningococcal vaccine licensed in the United States.

In the United States, 4 licensed meningococcal vaccines are available. One is a quadrivalent (A, C, W-135, Y) polysaccharide vaccine (MPSV4 [Menomune, Sanofi Pasteur, Inc, Swiftwater, PA]). There are 2 quadrivalent conjugate vaccines (A, C, W, Y) (MenACWY-D [Menactra, Sanofi Pasteur, Inc] and MenACWY-CRM [Menveo, Novartis Vaccines and Diagnostics, Inc, Cambridge, MA]), and 1 bivalent (C; Y) conjugate vaccine (HibMenCY-TT [MenHibrix, GlaxoSmithKline Biologicals, Research Triangle Park, NC]), which is also approved as a vaccine for Haemophilus influenzae type b (Table 1).

Meningococcal vaccines are recommended routinely for adolescents and for selected groups of children at increased or persistent risk for invasive meningococcal disease (Table 2). There are 2 types of meningococcal vaccines: (1) polysaccharide and (2) conjugated polysaccharide vaccines. Conjugated polysaccharide vaccines use a T-cell–dependent mechanism that results in a more robust primary immune response and immunologic memory and boosting potential, as compared with polysaccharide-only vaccines that use a T-cell independent mechanism.

The new indications and newly licensed vaccines address immunization of younger children at increased risk for meningococcal disease.

This document provides a complete update of policy recommendations of the American Academy of Pediatrics for children and adolescents.

The following are meningococcal vaccination recommendations (Table 3):

1. For the pediatric population, an age-appropriate meningococcal conjugate vaccine is preferred to the meningococcal polysaccharide vaccine, unless there is a contraindication for the meningococcal conjugate vaccine.

2. Adolescents should be routinely immunized at 11 to 12 years of age and given a booster dose at 16 years of age with a quadrivalent conjugated meningococcal vaccine.

3. Adolescents who received their first dose at age 13 to 15 years should receive a booster at age 16 to 18 years at least 8 weeks or up to 5 years after their first dose.

4. Adolescents who receive their first dose of meningococcal conjugate vaccine at or after 16 years of age do not need a booster dose.

5. Unvaccinated or previously vaccinated first-year college students through age 21 years living in residence halls who received their last dose before their 16th birthday (ie, incompletely vaccinated) should receive a single dose of quadrivalent meningococcal conjugate vaccine.

6. For individuals who are at increased risk for invasive meningococcal disease because of persistent complement (eg, C3, C5–C9, properdin, factor H, or factor D) deficiency or functional or anatomic asplenia, a 2-dose primary series (MenACWY-D or MenACWY-CRM) is administered to individuals 2 to 55 years of age, and a 4-dose primary series (MenACWY-CRM or Hib-MenCY-TT) is administered to children 2 to 18 months of age. MenACWY-D can be administered as a 2-dose series to infants 9 to 23 months of age with persistent complement component deficiency, and in infants up to 23 months of age after the fourth dose of the primary pneumococcal conjugate vaccine has been given in children who have functional or anatomic asplenia.

7. HIV infection is not an indication for routine MenACWY immunization before 11 years of age. However, HIV-infected children 11 years of age or older should be given a 2-dose primary series 8 to 12 weeks apart (MenACWY-D or MenACWY-CRM) with a single booster dose, consistent with recommendations for healthy adolescents.

8. For children older than age 2 years who have persistent risk for meningococcal disease because of complement component deficiency or asplenia, their primary series should include 2 doses of quadrivalent meningococcal conjugate vaccine 8 to 12 weeks apart (MenACWY-D or MenACWY-CRM).

9. For children 2 months to 6 years of age at persistent risk for meningococcal disease (Table 2), a booster dose should be given 3 years after the primary series and every 5 years thereafter. For children and adolescents 7 years or older at persistent risk for meningococcal disease (Table 2) whose initial meningococcal vaccination was administered at 7 years or older, boosters of quadrivalent meningococcal conjugate should be repeated every 5 years (Table 4).

Routine vaccination against meningococcal disease is not recommended for healthy children 2 months to 10 years of age unless they are at increased or persistent risk for meningococcal disease (Table 2). Hib-MenCY-TT (MenHibrix) may be administered to any infant for routine vaccination against Haemophilus influenzae type b (Hib). If Hib-MenCY-TT is used for protection against meningococcal disease, it should be used for all 4 doses of Hib vaccine, and other Hib-containing vaccines should not be used.

Limited data suggest that different conjugate vaccine products can be used interchangeably. If the same vaccine product used for the first dose is not available or if it is not known which vaccine product was used previously, administration of the vaccine should not be deferred if indicated, and any licensed age-appropriate conjugate vaccine can be administered.

The meningococcal vaccine is not routinely recommended for HIV-infected children until they reach 11 years of age, similar to other non–HIV-infected adolescents. HIV-infected children should receive 2 doses as their primary series.

A primary series consisting of 2 or more doses (depending on the age of the child) is indicated for children who have asplenia (reduced antibody response after a single primary dose) and complement component deficiency (higher antibody levels are needed for bacterial clearance mechanisms, such as opsonization, and more rapid antibody waning).¹ 

For travelers to areas with high meningococcal endemicity (parts of sub-Saharan Africa [the so-called “meningitis belt”] or the Hajj in Saudi Arabia), an age-appropriate meningococcal vaccine that includes serogroups A and W is indicated. Periodically, there may be other areas in the world with meningococcal outbreaks (eg, serogroup W in Chile). Travelers need to monitor this possibility. Completion of the entire series is preferred before travel as follows: (1) for children <9 months of age: 2, 4, and 6 months of age (with booster at 12 to 18 months of age) with MenACWY-CRM; (2) for children ≥9 months to 23 months of age: 2 doses separated by at least 8 weeks (MenACWY-D) or 2 doses separated by at least 3 months (Menveo); and (3) for people >24 months of age: a single dose (MenACWY-D or MenACWY-CRM).

Pregnancy and breastfeeding do not preclude vaccination with MenACWY (Menactra or Menveo) or MPSV4 (Menomune) if indicated.

Vaccination with any meningococcal vaccine is contraindicated in people known to have a severe allergic reaction to any component of the vaccine. Conjugate vaccines that contain diphtheria or tetanus toxoid are contraindicated in people who have severe allergic reactions to these toxoids. A history of Guillain-Barré syndrome is not a contraindication or precaution for meningococcal vaccination. A previous temporal relationship between MenACWY-D and Guillain-Barré syndrome was not determined to be causally related. All currently licensed meningococcal vaccines are inactivated. They can be administered to people who are immunosuppressed as a result of disease or medication. However, the response to meningococcal vaccine in immunosuppressed children may be less than optimal.

Michael T. Brady, MD, FAAP, Chairperson – Red Book Associate Editor

Carrie L. Byington, MD, FAAP

H. Dele Davies, MD, FAAP

Kathryn M. Edwards, MD, FAAP

Mary Anne Jackson, MD, FAAP – Red Book Associate Editor

Yvonne A. Maldonado, MD, FAAP

Dennis L. Murray, MD, FAAP

Walter A. Orenstein, MD, FAAP

Mobeen H. Rathore, MD, FAAP

Mark H. Sawyer, MD, FAAP

Gordon E. Schutze, MD, FAAP

Rodney E. Willoughby, MD, FAAP

Theoklis E. Zaoutis, MD, FAAP

Henry H. Bernstein, DO, FAAP – Red Book Online Associate Editor

David W. Kimberlin, MD, FAAP – Red Book Editor

Sarah S. Long, MD, FAAP – Red Book Associate Editor

H. Cody Meissner, MD, FAAP – Visual Red Book Associate Editor

Marc A. Fischer, MD, FAAP – Centers for Disease Control and Prevention

Bruce G. Gellin, MD – National Vaccine Program Office

Richard L. Gorman, MD, FAAP – National Institutes of Health

Lucia H. Lee, MD, FAAP – US Food and Drug Administration

R. Douglas Pratt, MD – US Food and Drug Administration

Jennifer S. Read, MD, MS, MPH, DTM&H, FAAP – US Food and Drug Administration

Joan L. Robinson, MD – Canadian Pediatric Society

Marco Aurelio Palazzi Safadi, MD – Sociedad Latinoamericana de Infectologia Pediatrica

Jane F. Seward, MBBS, MPH, FAAP – Centers for Disease Control and Prevention

Jeffrey R. Starke, MD, FAAP – American Thoracic Society

Geoffrey R. Simon, MD, FAAP – Committee on Practice Ambulatory Medicine

Tina Q. Tan, MD, FAAP – Pediatric Infectious Diseases Society

Jennifer M. Frantz, MPH

AAP

American Academy of Pediatrics

CDC

Centers for Disease Control and Prevention

Hib

Haemophilus influenzae type b