Recently, we have had several providers contact us with questions about addressing meningococcal vaccinations in practice, so we thought it might be helpful to provide some background and resources as practices work to create office-wide policies. The discussion herein is specific to healthy adolescents and teens, not those considered to be high risk based on health conditions.
Summary of meningococcal ACWY recommendations for teens
- Adolescents are recommended to get two doses of meningococcal ACWY vaccine. One dose between 11 and 12 years of age and a booster at 16 years of age.
- Those whose first dose is administered between 13 and 15 years of age should get a second dose between 16 and 18 years of age. Doses should be separated by at least eight weeks.
- Teens who get the first dose at the age of 16 or older only require one dose unless they are at increased risk for meningococcal disease.
- Although 19- to 21-year-olds are not routinely recommended to get a dose of MenACWY vaccine, it can be administered as a catch-up recommendation through 21 years of age for those who have not had a dose after their 16th birthday.
From the recommendations, “Healthcare personnel should use every opportunity to provide the booster dose when indicated, regardless of the vaccine brand used for the previous dose or doses.”
Rationale for these recommendations
Healthy individuals are at increased risk of meningococcal infection during three periods of life: younger than 1 year old, between 16 and 21 years of age, and 65 years of age and older. Although disease burden is greatest in infants, young adults are considered to be the greatest source of transmission as evidenced by their having the highest rates of nasopharyngeal carriage.
As data emerged about the effectiveness of meningococcal ACWY vaccine, it became apparent that one dose of vaccine during adolescence would not protect most teens during the period of greatest risk between 16 and 21 years old. The ACIP considered three dosing regimens in revising the recommendations and concluded that a dose in adolescence (11 to 12 years old) with a booster at 16 years of age would avert the most cases and deaths. Refer to table 5 in the recommendations to see this comparison.
Summary of meningococcal B recommendations for teens
- Those 16 to 23 years old may get meningococcal B vaccine (either Trumenba® or Bexsero®) to provide short-term protection against most strains of serogroup B meningococcal disease.
- The preferred age is 16 to 18 years old.
- For healthy 16- to 23-year-olds, two doses separated by one (Bexsero) or six (Trumenba) months should be administered regardless of version used. (Note: Dosing is different for high-risk individuals; consult the recommendations.)
- Trumenba and Bexsero vaccines are not interchangeable.
Rationale for these recommendations
Although the cases of meningococcal disease, including meningococcal serogroup B, have been low in recent years in the U.S., about 50 to 60 cases and 5 to 10 deaths result from meningococcal B disease each year. About 80 percent of these occur in 16- to 23-year-olds.
While the recommendations published in 2015 suggest that the incidence of meningococcal B infection is greatest among non-college students between 18 and 23 years of age, a study conducted between 2014 and 2016 indicated the reverse. Dr. Offit presented these data generated by the CDC in our Spring 2018 webinar:
Incidence of meningococcal disease by serogroup in persons aged 18-24 years and relative risk among college students — United States, 2014-2016
About 15 to 29 cases and two to five deaths could be prevented with routine adolescent immunization depending on the age at which vaccination is recommended. Based on the data, immunizing 16- to 18-year-olds would be most effective at preventing disease and death. Refer to table 2 in the recommendations to see the comparison data.
When the CDC was considering recommendations, limited data were available related to alignment with circulating serogroup B strains, duration of protection, vaccine effectiveness related to clinical disease endpoints, and impact on both nasopharyngeal carriage and herd immunity.
All of these data, related to both disease epidemiology as well as vaccine effectiveness, and increased opportunity to gather more safety data, led to the category B recommendation.
What should we consider related to the Category B recommendation for meningococcal B vaccine?
- Who should be vaccinated? It is important to realize that while college-bound teens are at increased risk, any 16- to 23-year-old is at risk of infection with meningococcal B.
- Should we offer the vaccine to 16-year-olds or wait until children are closer to 18 years? The data suggest almost equal impact whether immunizing 16- or 18-year-olds. While waning immunity may be a concern at 16 years of age, this consideration needs to be balanced against the missed opportunities that might occur if delaying immunization until 18 years of age. Because teens are due for a second dose of meningococcal ACWY at age 16, it is a natural opportunity to offer meningococcal B vaccine.
- What do the different categories of recommendation mean? A category B recommendation means that the physician may choose to administer the vaccine or not. This is distinct from a category A recommendation, in which the vaccine is recommended for use unequivocally. The meningococcal B vaccine received a category B recommendation because, as stated above, the vaccine will not prevent a large number of cases and efficacy might be short lived. That said, parents could reasonably choose to get it because the vaccine is safe and some protection is better than no protection.
- What about costs? Because the meningococcal B vaccine has received a category B recommendation, it is covered by VFC and should be covered by most, if not all, insurers.
Resources with additional information for providers
- Prevention and control of meningococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Cohn AC, MacNeil JR, et. al. MMWR 2013 March 22; 62(RR02);1-22.
- Use of serogroup B meningococcal vaccines in adolescents and young adults: Recommendations of the Advisory Committee on Immunization Practices, 2015. MacNeil JR, Rubin L, et. al. MMWR 2015 Oct. 23; 64(41); 1171-6.
- Updated recommendations for use of MenB-FHbp serogroup B meningococcal vaccine – Advisory Committee on Immunization Practices, 2016. Patton ME, Stephens D, et. al. MMWR 2017 May 19; 66(19); 509-13.
- Current Issues in Vaccines, Spring 2018 webinar presented by Dr. Offit; co-sponsored by PA Chapter, AAP and supported by the Thomas F. McNair Scott Endowed Research and Lectureship Fund.]
- In the Journals, Vaccine Update article, September, 2018, issue — Dr. Offit reviewed a recently published survey of pediatricians and family physicians related to their likelihood of recommending meningococcal B vaccine.
- Technically Speaking, Vaccine Update article, July, 2017, issue — Dr. Wexler discussed the routine schedules for both meningococcal vaccines and provided links to a variety of resources.
Resources to use with parents and families