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Meningococcal disease

  • Meningococcal disease is caused by invasive infection with the bacterium Neisseria meningitidis, also known as the meningococcus. There are 12 identified capsular groups of which groups B, C, W, and Y were historically the most common in the UK
  • Since the introduction of the routine MenC vaccination programme, cases of invasive meningococcal disease in the UK due to capsular group C have reduced dramatically, and capsular group B now accounts for the majority of cases
  • Meningococci colonise the nasopharynx of humans and are mostly harmless commensals. Between 5 and 11% of adults, and up to 25% of adolescents, carry the bacteria without any signs or symptoms of the disease. In infants and young children, the carriage rate is low
  • Meningococcal disease is transmitted by respiratory aerosols, droplets, or by direct contact with the respiratory secretions of someone carrying the bacteria. The incubation period is from 2–7 days and the onset of disease varies from fulminant with acute and overwhelming features, to insidious with mild prodromal symptoms
  • Meningococcal infection most commonly presents as either meningitis or septicaemia, or a combination of both. However, cases of meningococcal W have often presented with atypical clinical presentations with septic arthritis and severe respiratory tract infections (including pneumonia, epiglottis, and supraglottis) being over-represented among MenW cases compared with other meningococcal groups
  • Several adults with meningococcal W septicaemia have presented primarily with gastrointestinal symptoms without the characteristic rash making clinical diagnosis of the disease difficult

Who is affected

  • Meningococcal disease can affect all age groups, but the highest rates of disease are in children under 5 years of age, with the peak incidence in those under 1 year of age. There is a second peak in incidence in young adolescents aged 15–19 years

Vaccination against meningococcal disease for adolescents

The purpose of the routine programme

  • From 1 September 2015 the routine adolescent MenC vaccine (meningococcal capsular group C) was directly replaced with the MenACWY conjugate vaccine to offer direct protection against meningococcal capsular group W to those in academic school years 9 or 10 (13–15-year-olds)
  • Offering protection to this age group shoud prevent carriage of the meningococcus bacteria in the nose and throat before the age at which the highest rates of carriage have been observed
  • Offering protection and preventing carriage of the meningococcus bacteria in the adolescent population also provides indirect protection to all other age groups by generating population level herd immunity, thus preventing transmission of the bacteria
  • To ensure that best protection is achieved across all age groups, the MenC booster vaccine which was routinely administered at around 14 years of age was replaced with MenACWY conjugate vaccine
  • This vaccine continues to offer protection against meningococcus capsular group C as well as offering additional protection against W, A, and Y groups
  • From 1 September 2015, a MenACWY conjugate vaccine replaced the MenC vaccine routinely administered around 14 years of age (adolescent booster)
  • The recommended vaccines for the programme are the MenACWY conjugate vaccines Menveo® or Nimenrix®. These two vaccines will continue to offer protection against meningococcal capsular group C, while offering additional protection against groups A, W, and Y
  • Both vaccines are licensed for use in adolescents and adults and can be safely given with other routine adolescent vaccines
  • For the 2016/17 financial year, the MenACWY programme is targeted at:
    • 17/18-year-olds (born between 1 September 1997 and 31 August 1998) who are leaving school in summer 2016, and
    • freshers (born between 1 September 1991 and 31 August 1997) who start university or further education in autumn 2016
  • The MenACWY vaccine should be offered to all adolescents in the eligible cohort regardless of their intention to continue into further education

Catch up

  • Catch up with MenACWY is allowed for those who were school-leaving age in summer 2015 (born between 1 September 1996 and 31 August 1997) but did not receive vaccination during 2015/16. These individuals remain eligible until they reach 25 years of age. The vaccine can be given regardless of prior MenC status but vaccination is not required for those who have already received a dose of MenACWY conjugate vaccine after the age of 10 years

Opportunistic provision of MenACWY vaccine

  • The General Medical Service (GMS) Statement of Financial Entitlement (SFE) makes provision for GP practices to offer MenACWY vaccine opportunistically to children who miss out on the routine school-based MenACWY vaccination programme that usually takes place during school years 9 or 10

Other eligible groups

  • Any patient born on or after 1 September 2001 who has missed the school-based dose will remain eligible for this vaccine up to the age of 25 years
  • All individuals under 25 years who have never received a dose of MenC conjugate vaccine

Students with an unknown or uncertain immunisation history

How to order the vaccines

  • Menveo® and Nimenrix® vaccines are available to order via ImmForm
  • On rare occasions, ordering restrictions may be in place or vaccines may be temporarily unavailable. Healthcare professionals are therefore reminded to only order what they need for a 2–4 week period rather than over-ordering or stockpiling vaccines

How often MenACWY vaccine should be offered

  • MenACWY vaccine should be administered as a single dose only. The need for, and the timing of a booster dose of MenACWY vaccine in individuals has not yet been determined and therefore is not currently recommended

What to do if a person has already received the MenC conjugate vaccine at the age of 10 years or over

  • Those who have already received a MenC vaccine over the age of 10 years should still be offered MenACWY conjugate vaccine as part of a catch-up programme to ensure protection against the additional capsular groups A, W, and Y. The MenACWY conjugate vaccine can be administered at any interval after MenC vaccine

What to do if a person has already received MenACWY conjugate vaccine at the age of 10 years or over

  • Those who have already received a MenACWY conjugate vaccine at the age of 10 years or over (with the exception of close contacts of a confirmed case of MenACWY infection) for example, for travel purposes, do not require an additional dose as part of the MenACWY immunisation programme

Can students in their second or subsequent years of university be offered MenACWY conjugate vaccine?

  • No, fully immunised students returning for their second or subsequent years of university do not have the same level of risk compared to those entering university for the first time
  • The increased risk of meningococcal infection is higher for those entering university for the first time with exposure to the bacteria occurring in the first few days to months, particularly during the 'freshers' period
  • Students returning to university should be reassured that increased exposure to meningococcal bacteria occurring in the first year of university leads to asymptomatic carriage that boosts immunity to provide direct protection over subsequent years, thus there is no need for additional immunisations
  • Returning students requesting the MenACWY conjugate vaccine should have their immunisation history checked to ensure that they are up to date with all immunisations. Those aged less than 25 years who have never received MenC-containing vaccine previously (or where the MenC immunisation history is uncertain) should be offered a single dose of the MenACWY conjugate vaccine

Vaccine administration

How the vaccines are administered

  • Menveo® should be administered via intramuscular (IM) injection into the arm (deltoid muscle)
  • The vaccine is supplied in a box containing two separate vials, one vial containing MenA (powder) and the second vial containing MenCWY (solution)
  • The MenCWY solution should be injected into the MenA powder and should be vigorously mixed together prior to administration. Each dose contains 0.5ml
  • Nimenrix® should be administered via IM injection into the arm (deltoid muscle)
  • The vaccine is supplied containing one vial of powder and one pre-filled syringe
  • The contents of the pre-filled syringe should be vigorously mixed with the contents of the vial prior to administration providing one dose of 0.5 ml
  • Healthcare professionals are encouraged to familiarise themselves with the manufacturer's summary of product characteristics (SPC) to ensure vaccines are reconstituted correctly

The shelf life of Menveo® and Nimenrix®

  • Menveo® has a shelf life of 2 years when stored in its original packaging in a refrigerator at the recommended temperatures of +2°C and +8°C
  • Nimenrix® has a shelf life of 3 years when stored in its original packaging in a refrigerator at the recommended temperatures of +2°C and +8°C
  • However, it is recommended that health professionals only order what they need for a 2–4 week period rather than over-ordering or stockpiling vaccines
  • To ensure vaccines are ordered, stored, and monitored as per national recommendations, healthcare professionals should familiarise themselves with Public Health England's Protocol for ordering, storing, and handling of vaccines

The contraindications for receiving MenACWY vaccines

  • There are very few individuals who cannot receive meningococcal vaccines. Where there is doubt, appropriate advice should be sought from a consultant paediatrician with immunisation expertise, a member of the screening and immunisation team, or from the local health protection team rather than withholding immunisation
  • MenACWY conjugate vaccines should not be administered to those who have had:
    • a confirmed anaphylaxis to a previous dose of the vaccine OR
    • a confirmed anaphylaxis to any constituent or excipient of the vaccine
  • For the composition and full list of excipients of the vaccine, please refer to the manufacturer's SPC
  • In the event that MenACWY vaccines are administered at less than the recommended dose, the vaccination will need to be repeated because the dose that the individual received may not be sufficient to evoke a full immune response
  • Where possible, the dose of MenACWY vaccine should be repeated on the same day or as soon as possible after

Action to be taken if a healthcare professional forgets to reconstitute the MenA component of the Menveo® vaccine and only administers the MenCWY solution

  • Health professionals should inform the patient of the administration error and reassure them that no further action is required
  • The purpose of the routine adolescent programme is to ensure protection against meningococcal capsular groups C and W. In the UK, meningococcal capsular group A infections are extremely rare and therefore, they do not require an additional dose of vaccine
  • If in the future the patient plans to travel to a country where protection against meningococcal capsular group A is required, then they should be advised to be immunised with a further dose of MenACWY conjugate vaccine at that time
  • Health professionals should report the administration error via their local governance system(s), so that appropriate action can be taken, lessons can be learnt, and the risk of future errors minimised

Action to be taken if a healthcare professional forgets to reconstitute the MenACWY component of the Nimenrix® vaccine and only administers the contents of the pre-filled syringe

  • Nimenrix® vaccine must be reconstituted by adding the entire content of the pre-filled syringe of solvent to the vial containing the ACWY powder
  • In the event a health professional administers the contents of the pre-filled syringe without reconstituting the vaccine powder, the vaccination will need to be repeated as the solvent alone will not offer any protection against meningococcal capsular groups ACWY
  • Where possible, the dose of MenACWY vaccine should be repeated on the same day or as soon as possible after
  • Health professionals should report the administration error via their local governance system(s), so that appropriate action can be taken, lessons can be learnt, and the risk of future errors minimised

Action to be taken if an individual has received a MenACWY polysaccharide vaccine

  • Pupils in year 13 catch-up cohort and university freshers who have received MenACWY polysaccharide vaccine in the last 12 months should have sufficient immunity against MenACWY infection to cover their university student years
  • Therefore, vaccination with MenACWY conjugate vaccine is not necessary, unless the polysaccharide vaccine was administered more than 12 months ago. (In adults and older children, the polysaccharide vaccine induces immunity that only lasts approximately 3–5 years)
  • Adolescents in other age cohorts who have previously received the MenACWY polysaccharide vaccine should continue to receive the MenACWY conjugate vaccine as part of the national programme
  • The benefits of immunisation with conjugate vaccine outweigh any potential or theoretical harm associated with re-vaccination. Therefore, MenACWY conjugate vaccine should be given irrespective of the time interval since MenACWY polysaccharide vaccines

Should MenACWY conjugate vaccine be administered to those who are in the eligible cohort and are known to be pregnant?

  • Those in the eligible age cohorts and known to be pregnant are encouraged to discuss the benefits of being immunised against meningococcal capsular groups A, C, W, and Y with their GP or practice nurse prior to immunisation
  • While pregnancy itself does not elevate the risk of acquiring meningococcal disease, those in the eligible age cohort have been recommended to receive the vaccine by the Joint Committee on Vaccination and Immunisation and should be encouraged to be immunised while they remain eligible
  • Immunising those in the eligible cohorts will offer direct protection against a virulent strain of group W meningococcal disease (MenW) which causes serious illnesses, including meningitis and septicaemia
  • The meningococcal vaccine also reduces individual carriage of the bacteria in vaccinated individuals, which will contribute to population level herd immunity by reducing transmission of the bacteria to others
  • Those who are pregnant should be reassured that meningococcal vaccines do not contain any live bacteria and can be safely administered to pregnant or breast-feeding women, without any evidence of harm to the baby
  • There are clear benefits of vaccination to protect against a virulent MenW strain with no evidence of any harm associated with vaccinating pregnant and breastfeeding women
  • Healthcare professionals should discuss the benefits of vaccination with pregnant and breastfeeding women and can give the vaccine under a patient specific direction (PSD) rather than a PGD

 

View related immunisation content

 

full guideline from…
www.gov.uk/government/publications/menacwy-programme-information-for-healthcare-professionals

Public Health England. Meningococcal ACWY immunisation programme for adolescents: information for healthcare professionals. London: Public Health England. 
First included: November 2016.