Day: May 2, 2005

Who Should Get the New Meningococcal Vaccine?

Patient Presentation
A 16-year-old female came to clinic for her health supervision visit. She is a healthy individual with normal adolescent health concerns.
Her pertinent physical exam is normal including her growth parameters.
The evaluation included reviewing her immunization records which were up-to-date including influenza vaccine. She has not received any meningococcal vaccine.
The diagnosis of healthy adolescent was made and the risks and benefits of the meningococcal vaccine were discussed. She and her parents elected to receive the vaccine.

Discussion

Meningococcal disease is caused by Neisseria meningitidis and affects about 2500 people each year in the U.S. with a death rate of ~10-14% despite treatment. There is a high rate of morbidity due to the vascular and neurological sequelae.
Neisseria meningitidis is a normal commensal organism of the upper respiratory tract but has certain factors which make it more virulent (i.e. polysaccharide capsule, endotoxin, and IgA1 protease). Transmission is by respiratory droplets.
High risk groups include:

  • Children < 2 years of age
  • Adolescents 15-19 years
  • College students living in dormatories – especially in their first year of college
  • Military personnel
  • Patients with asplenia
  • Patients with terminal complement deficiencies

Meningococcal disease may take several forms including occult disease, bacteremia, overwhelming sepsis and meningitis. Meningococcemia often presents with abrupt onset of fever, chills, joint and muscle pain, and a petechial rash.
Septic shock may occur. If septic shock occur with bilateral hemorrhage into the adrenal glands leading to adrenal insufficiency this is termed Waterhouse-Friederickson Syndrome.
Meningococcal meningitis often affects infants < 1 year of age. Symptoms can be non-specific including fever, emesis, irritability and/or lethargy.

Treatment is to use antibiotics, especially penicillin or ceftriaxone intravenously. Supportive measures to treat shock and other problems may also be necessary. Despite appropriate and aggressive treatment the mortality is ~10-14%. Hearing loss is the most common sequelae (~9-38%).

Meningococcal vaccines have been available since the 1970s. The meningococcal polysaccaride quadravlant vaccine (MPSV4) has been available but was not recommended routinely for the general population. Coverage is for ~3 years.
The meningococcal vaccine conjugate vaccine (MCV4, MenactaTM) was licensed for routine use in the general population in January 2005. It protects against 4 serotypes (A,C,Y and W135). It confers immunity for ~8 years.
It is given by 0.5 milliliter intramuscular injection in the deltoid. It can be given with other vaccines.
Risks of the vaccine include mild pain and/or redness in up to 50% of people. A small percentage develop a fever. Severe anaphylaxis is rare.
Contraindications include previous allergic reaction to either vaccine, a life-threatening allergy to a vaccine component, or moderate to severe illness at the time the vaccine would be given (mild illness is not a contraindication).

The target population is about 12 million individuals but only about 5 million doses will be delivered soon. It is expected that it will take 3 years to have significant coverage of the adolescent population.

Learning Point
MCV4 is the preferred vaccine for people 11-55 years and should be given to:

  • All adolescents at their 11-12 year health maintenance visit
  • All adolescents as they enter high school if not previously immunized
  • Other adolescents who want to decrease their risk of meningococcal disease
  • College freshmen living in dormitories
  • Microbiologists
  • U.S. Military recruits
  • People living in or traveling to areas where meningococcus is endemic
  • People with a damaged spleen or asplenia
  • People with terminal complement deficiency
  • People exposed during a meningococcal outbreak

MPSV should be given to:

  • Children 2-10 years
  • People > 55 years
  • When the MCV4 vaccine is not available

The patient in this case was not in one of the target age groups but wanted to decrease her risk of meningococcal disease. MCV4 vaccine was available and therefore it was given to her. It should protect her through the peak risk age range and into her college years.

Questions for Further Discussion
1. What other vaccines should be routinely given at the 11-12 year health maintenance visit?
2. What other meningococcal serotypes cause significant disease?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for these topics: Bacterial Meningitis and Lumbar Puncture (Spinal Tap).

Centers for Disease Control and Prevention, National Immunization Program, Meningococcal Vaccines Information Statement. Available from the Internet at http://www.cdc.gov/nip/publications/vis/vis-mening.pdf(rev. 4/4/05, cited 4/25/05).

Centers for Disease Control and Prevention, National Immunization Program, ACIP Recommends Meningococcal Vaccine for Adolescents and College Freshmen. Available from the Internet at http://www.cdc.gov/nip/vaccine/meningitis/mcv4/mcv4_acip.htm(rev. 3/9/05, cited 4/25/05).

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
May 2, 2005