The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) has released updated recommendations on the management of meningococcal disease. The ACIP recommendations appear in the May 27, 2005, issue of Morbidity and Mortality Weekly Report. The full report is available online athttp://www.cdc.gov/mmwr/preview/mmwrhtml/rr5407a1.htm.
Approximately 1,400 to 2,800 cases of meningococcal disease occur annually in the United States. Although meningococcus responds to many widely available antibiotics, 10 to 14 percent of patients with the disease die, and 11 to 19 percent of survivors have sequelae. Previous ACIP guidelines have recommended a meningococcal tetravalent polysaccharide vaccine (MPSV4; Menomune) for high-risk patients. Although the incidence of Streptococcus pneumoniae and Haemophilus influenzae type b infections has decreased dramatically, Neisseria meningitidis has become a leading cause of bacterial meningitis in the United States. This report includes ACIP’s recommendations regarding the use of a new tetravalent meningococcal polysaccharide-protein conjugate vaccine (MCV4; Menactra), and updated recommendations regarding MPSV4 and antimicrobial chemoprophylaxis to manage meningococcal disease.
Recommendations for Specific Groups
PREADOLESCENTS 11 TO 12 YEARS OF AGE
Routine vaccination with a single dose of MCV4 is recommended at the preadolescent office visit (11 to 12 years of age). If the patient does not receive the vaccine at this time, vaccination at high school entry (approximately 15 years of age) is also acceptable.
ADULTS 20 TO 55 YEARS OF AGE
Vaccination is not recommended for this group. MCV4 is approved for this age group, however, and a patient may elect to receive the vaccine.
CHILDREN YOUNGER THAN 11 YEARS AND ADULTS OLDER THAN 55 YEARS
MCV4 is not approved for use in these age groups. Routine vaccination with MPSV4 is not recommended for low-risk patients in these age groups.
Patients at high risk of contracting meningococcal disease include college freshmen living in dormitories, microbiologists who are routinely exposed to isolates of N. meningitidis, military recruits, persons who travel to or live in countries in which N. meningitidis is endemic, persons who have terminal complement component deficiencies, and persons who have anatomic or functional asplenia.
High-risk patients younger than two years should not be vaccinated routinely with MPSV4 or MCV4. However, MPSV4 may be considered for short-term protection against serogroup A disease in patients three to 18 months of age (two doses, three months apart) and for patients 19 to 23 months of age (single dose). High-risk patients who are two to 10 years of age or who are older than 55 years should receive a single dose of MPSV4. High-risk patients 11 to 55 years of age should receive MCV4, but MPSV4 is an acceptable alternative.
MCV4 should be administered intramuscularly as a single 0.5-mL dose. MPSV4 should be administered subcutaneously as a single 0.5-mL dose. Both vaccines may be administered concomitantly with other vaccines, but at different anatomic sites.
High-risk patients vaccinated with MPSV4 may need revaccination. High-risk children who were vaccinated when they were younger than four years should be revaccinated after two to three years if they are still at a high risk.
The need for revaccination after receiving MPSV4 is unclear, although antibodies decline rapidly two to three years after vaccination. If vaccination is indicated, a patient may be revaccinated after five years. MCV4 is recommended for revaccination of patients 11 to 55 years of age, but MPSV4 is an acceptable alternative.
Patients with moderate to severe illness should not be vaccinated until their condition improves. MCV4 or MPSV4 should not be administered if a patient has known allergies to any components of the vaccines. Patients who are immunosuppressed may receive vaccination, although it may be less effective. Patients who are pregnant may receive MPSV4 if indicated, but no data exist on the safety of MCV4.
Antimicrobial chemoprophylaxis should be used to treat persons who are in close contact with patients who have invasive meningococcal disease (e.g., household members, child care contacts, and anyone directly exposed to the patient’s oral secretions). Ideally, antimicrobial chemoprophylaxis should be administered less than 24 hours after the index patient presents. Administration after 14 days most likely is ineffective.