Meningococcal disease is most commonly manifested as meningitis or sepsis but can also present as septic arthritis or pneumonia. The case fatality varies from 7% for meningitis to as high as 19% for meningococcaemia without meningeal involvement. On the other hand, meningococci colonise the nasopharynx of 5-11% of adults and up to 25% of adolescents. The carriage rate is low in infants and young children.
Based on surface polysaccharide, Neisseria meningitidis, the causative organism, is divided into 13 serogroups of which serogroups A, B, C, X, Y, Z, W135 and L, have been associated with invasive disease. Serogroup A and C are the main cause of epidemic meningococcal meningitis. Serogroup B is generally associated with sporadic disease but may cause some upsurges or outbreaks. Serogroup W135 has caused international outbreaks in 2000 and 2001 among Hajj pilgrims and household contacts of returning pilgrims. Studies in the UK and US have revealed that students, in their first year of college and who are living in dormitories are at a higher risk of meningococcal disease, compared to other college students and age matched general population.
- Currently, tetravalent vaccines protecting against A, C, Y and W135 are available. These vaccines are derived from the capsular polysaccharide and can be either conjugated to diphtheria/tetanus toxoid or CRM197 (a non-toxic protein of Corynebacterium diphtheriae). These vaccines offer no protection against serogroup B organisms.
- A vaccine against serogroup B meningococcal disease is used in some countries but it is not currently available in Malaysia. It is a multicomponent vaccine made from three N. meningitidis proteins and capsular group B outer membrane vesicles.
Vaccines Available in Malaysia
- Quadrivalent (ACWY) conjugate vaccine
(serogroups A, C, W135 and Y polysaccharides conjugated with diphtheria toxoid protein)
Sanofi Aventis (M) Sdn Bhd/Sanofi Pasteur, US
(serogroups A, C, W135 and Y polysaccharides conjugated with non-toxic C. diphtheriae CRM197 protein)
GlaxoSmithKline Pharmaceutical Sdn Bhd/GlaxoSmithKline Vaccines, Italy
(serogroups A, C, W135 and Y polysaccharides conjugated tetanus toxoidcarrier proteins)
Pfizer (M) Sdn Bhd/Pfizer, Belgium
Mode of Administration
- Persons with high-risk medical conditions such as functional or anatomical asplenia or complement component disorders, need a 2-dose primary schedule, approximately 8 weeks apart. They should also receive a conjugate vaccine at 5-yearly intervals.
- Persons at risk of meningococcal diseases such as laboratory personnel or those travelling to parts of the world where epidemics of group A, W135 or Y disease are frequent, should receive a single dose of quadrivalent conjugate vaccine every 5 years if still at risk of meningococcal exposure.
- The different conjugate vaccine products can be used interchangeably for the booster doses.
- If Menactra. is used, it should be administered at least four weeks after completion of all pneumococcal conjugate vaccine doses.
Target Groups in Malaysia
Pilgrims attending the Hajj or Umrah in Saudi Arabia. Saudi Arabian authorities require a valid certificate of vaccination, within the past 2-3 years, as a condition to enter the country. Accompanying children aged ≤2 years should receive the full course of conjugated meningococcal vaccine (ie ie Menactra® or Nimenrix®)
- Laboratory staff who frequently handle N. meningitidis isolates.
- Travelers who intend to visit parts of the world where epidemics of group A, W135 or Y disease are frequent (a current list of those countries is available at either www.who.int/ith or www.who.int/disease-outbreak-news).
- Adults with high-risk medical conditions, such as functional or anatomical asplenia or complement component disorders (C5-C9, properdin, factor D or factor H), persons receiving treatment with eculizumab (a monoclonal antibody directed against complement component C5), or those posthaematopoietic stem cell transplantation.
- Vaccination can be used in conjunction with chemoprophylaxis during outbreaks for close (household or household-like) contacts, aged ≥9 months, if the outbreak is due to A, C, Y or W135 serogroups.
Certain groups of adolescents (15-19 years old) e.g military and police recruits, schools/college/university students who live in hostels are at higher risk of contracting meningococcal disease. In many countries, routine meningococcal vaccination is recommended in these groups.
Contraindications and Adverse Effects
- Vaccination should be avoided during acute febrile illnesses. It is contraindicated in persons with previous serious reactions to the vaccine or its components. For the conjugate vaccines, adverse reaction is generally mild with pain and redness at the injection site, fever, headache, anorexia and nausea. While there were initial concerns Guillain-Barré syndrome (GBS) with Menactra®, recent safety studies found no increased risk in general population of those with history of GBS. Meningococcal vaccines are not routinely recommended for pregnant or breastfeeding women but can be given if clinically indicated.
- To date, the most frequently reported adverse events for meningococcal vaccines received by the National Pharmaceutical Regulatory Agency (NPRA) include local site reactions such as injection site rash and tenderness, fever, muscle pain and rash.
Evidence for Effectiveness
The meningococcal conjugate vaccines elicit a T cell-dependent memory response that results in an improved primary response to vaccination and a strong anamnestic response at re-exposure when compared with polysaccharide vaccines. The effectiveness of Menactra. has been estimated to be 80-85%. However, the effectiveness seems to wane with time. Five years post vaccination, the proportion with protective antibody levels drop to 56-72% among adolescents.
- Andersen, B.M. (1978) Mortality in meningococcal infections. Scand J of Infect Dis.;10(4):277-8.
- Bruce, M.G., Rosenstein, N.E., Capparella J.M., Shutt K.A., Perkins B.A., Collins M. (2001) Risk factors for meningococcal disease in college students. JAMA;286(6):688-93
- Cohn, A.C., MacNeil, J.R., Clark, T.A., Ortega-Sanchez, I.R., Briere, E.Z., Meissner, H.C., et al. (2013) Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunisation Practices (ACIP). MMWR Recommendations and reports: MMWR. Recommendations and reports / Centers for Disease Control. 62(Rr-2):1-28
- Keyserling, H., Papa, T., Koranyi, K., Ryall, R., Bassily, E., Bybel, M.J., et al (2005). Safety, immunogenicity, and immune memory of a novel meningococcal (groups A, C, Y, and W-135) polysaccharide diphtheria toxoid conjugate vaccine (MCV-4) in healthy adolescents. ArchPediatr Adolesc Med. 159(10):907-13
- Macneil, J.R., Cohn, A.C., Zell, E.R., Schmink, S., Miller, E., Clark, T., Messonnier, N.E. (2011). Active Bacterial Core surveillance (ABCs) Team and MeningNet Surveillance Partners. Early estimate of the effectiveness of quadrivalent meningococcal conjugate vaccine. Pediatr Infect Dis J. 30(6):451-5
- The Malaysian National Centre of Adverse Drug Reactions Database [Accessed: 10 October 2019]
- Meningococcal disease, serogroup W135. Releve epidemiologique hebdomadaire / Section d’hygiene du Secretariat de la Societe des Nations. Wkly Epidemiol Rec/Health Section of the Secretariat of the League of Nations. 2001;76(19):141-2
- National Pharmaceutical Regulatory Agency (NPRA), Ministry of Health Malaysia. Senarai Produk Vaksin Berdaftar Dengan Pihak Berkuasa Kawalan Dadah. Received on September 5, 2019.
- Nelson, S.J., Charlett, A., Orr, H.J., Barker, R.M., Neal, K.R., Taylor, C., et al (2001). Risk factors for meningococcal disease in university halls of residence. Epidemiol Infect.126(2):211-7
- Warshawsky, T.S.W.P.B.D.B. (2013). UPDATE ON THE USE OF QUADRIVALENT CONJUGATE MENINGOCOCCAL VACCINES: An Advisory Committee Statement (ACS) National Advisory Committee on Immunization (NACI). Can Commun Dis Rep. 39 (ACS-1):1-40.
- Wilder-Smith, A., Barkham, T.M., Ravindran, S., Earnest, A., Paton, N.I. (2003) Persistence of W135 Neisseria meningitidis carriage in returning Hajj pilgrims: risk for early and late transmission to household contacts. Emerg Infect Dis. 9(1):123-6