Key information

Mode of transmission

By respiratory droplets or direct contact with nasopharyngeal secretions from a carrier or case.

Incubation period

2–10 days, commonly 3–4 days.

Period of communicability

Commonly 3–4 days without treatment, range 2–10 days. Certain antibiotic therapy eradicates N. meningitidis from mucosal surfaces within 24 hours, and the case is no longer considered infectious.

Funded vaccines

  • Meningococcal B recombinant (MenB): Bexsero
  • Quadrivalent meningococcal conjugate (MenACWY): MenQuadfi
  • Meningococcal group C conjugate (MenC): NeisVac-C

Other available vaccines

  • Quadrivalent meningococcal conjugate (MenACWY): Nimenrix

Dose, presentation, route

0.5 mL per dose.

Presentation:

  • MenB: pre-filled syringe
  • MenACWY; 
    • MenQuadfi - vial
    • Nimenrix - vial and pre-filled syringe, must be reconstituted before use
  • MenC: pre-filled syringe.

Intramuscular injection.

Funded vaccine indications

MenB (Bexsero)

  • All infants aged 3 months and 5 months, and booster given age 12 months.
  • Alternative approved schedule: ages 8 weeks and 4 months, plus booster at age 12 months.
  • If offered at age 6 weeks, this is off-label and requires prescription.
  • Catch-up is available from age 13 to 59 months.

MenB (Bexsero), MenACWY (MenQuadfi) and MenC (NeisVac-C) for:

  • patients pre- or post-splenectomy or with functional or anatomical asplenia
  • patients with HIV, complement deficiency (acquired, including monoclonal antibody therapy against C5, or inherited)
  • pre- or post-solid organ transplant
  • HSCT (bone marrow transplant) patients
  • patients prior to planned and following immunosuppression
  • close contacts of meningococcal cases (any group)
  • patients with prior meningococcal disease of any group.

MenB and MenACWY (MenQuadfi) for:

  • adolescents and young adults aged 13–25 years inclusive who will be living or are currently living in a boarding school hostel or university hall of residence, military barracks, youth justice residences or prison.

Recommended, unfunded

Laboratory workers handling bacterial cultures

Health care professionals in very close contact with cases.

Vaccine effectiveness

MenB: 75% reduction in group B cases in infants over a 3-year period in the UK and cross-protection against group W observed; 71% reduction in group B disease in adolescents.

MenACWY: 80–85%; effectiveness wanes to 50–60% within 2–5 years after vaccination.

MenC: effectiveness of 83–100%; antibody wanes within 2–3 years.

Potential responses to vaccines

MenB: increased risk of fever and fever-related events in children <2 years (prophylaxic antipyretic advised). Older age groups: localised pain, nausea, myalgia, malaise, mild fever and headache.

MenC and MenACWY: localised pain, irritability, headache and fatigue, mild fever.

Contraindications

No specific contraindications or precautions, except prior anaphylaxis to vaccine components.

Public health measures

All cases must be notified if clinically suspected.

Parenteral antibiotics should be administered as soon as possible in hospital or before admission to hospital if delays of longer than 30 minutes are likely.

Post-exposure prophylaxis

For chemoprophylaxis of contacts see section 13.8.2.

13.1. Bacteriology

Meningococcal disease is caused by Neisseria meningitidis, a gram-negative bacterium, causing sepsis, meningitis and some less common clinical syndromes. Groups B and W are currently the most important types in New Zealand. Increasingly, group W and Y organisms are the cause of bacteraemia and pneumonia in the elderly. Predominant groups differ between countries; group A is an important epidemic strain, particularly in Africa and the Middle East. Meningococci are spread from person to person by respiratory droplets or direct contact with nasopharyngeal secretions from a carrier or case.

13.2. Clinical features

Table 13.1 below describes the symptoms and signs of meningococcal disease – individuals may present with some or all of these. Meningococcal septicaemia is more common than meningitis, and presentation varies from a mild non-specific illness to rapid progression with fatal outcome. Symptoms and signs in infants are frequently non-specific. The classical rapidly progressing petechial or purpuric rash may not be present or may initially appear maculopapular. Atypical initial presentations, including gastrointestinal symptoms, septic arthritis and epiglottitis, are more frequently reported with meningococcal W disease, and may contribute to delayed diagnosis and increased case-fatality.[1, 2] Pneumonia is more frequently reported with group Y.

Table 13.1: Symptoms and signs of meningococcal disease

 Table 13.1: Symptoms and signs of meningococcal disease

Adolescents and adults

Young infants and children

  • Sepsis syndrome, including poor peripheral perfusion and tachycardia
  • Nausea/vomiting
  • Meningeal signs
  • Rash – petechial/purpuric, but may be maculopapular; rash may not be present early and absent in about one-third of cases
  • Sleepy, difficult to rouse
  • Occasionally in young adults, irrational behaviour
  • Arthralgia, myalgia, leg pain
  • Atypical presentation (particularly group W) may include pneumonia, septic arthritis, myocarditis or diarrhoea

As for adolescents and adults, plus the following:

  • bulging fontanelle
  • tachycardia
  • altered responsiveness
  • irritability and/or floppiness
  • refusing drinks or feeds
  • poor peripheral perfusion
  • atypical presentation may include epiglottis, diarrhoea or septic arthritis

Notify all suspected cases urgently to local medical officer of health, including out-of-hours.


Meningococcal disease covers a spectrum, from persistent fever with or without rash and arthritis to rapidly progressive purpuric rash and shock. Meningitis can occur with and without signs of sepsis. In fulminant cases, coma and death can occur within a few hours despite appropriate treatment.


Because of the potential for rapid progression, antibiotics should be administered (Table 13.2) as soon as possible, even before hospital admission. Antibiotics given prior to transfer should be clearly noted on information accompanying the patient to hospital.

Table 13.2: Recommended antibiotics for suspected cases

Check The New Zealand Formulary for up to date dosing details, as well as the Starship guidelines

Antibiotic

Children <30kg

Children >30kg and
Adults (max dose)

Ceftriaxonea
(first line treatment)

50 mg/kg when given by GP/primary care

100 mg/kg IV (or IM) up to 2g when given in ED

2 g IV (or IM)

Benzylpenicillinb
(second choice)

50 mg/kg IV (or IM)

2.4 g IV (or IM)

a.     Patients allergic to penicillin who do not have a documented history of anaphylaxis to penicillin can be given ceftriaxone.

b.     Patients with a documented history of anaphylaxis to penicillin and who are suspected of suffering from meningococcal disease should be sent immediately to hospital without pre‑admission antibiotics.

13.3. Epidemiology

13.3.1. Global burden of disease

Incidence and serotypes

The prevalence of meningococcal groups varies geographically. The highest burden of disease occurs in sub-Saharan Africa, where despite a dramatic fall in Group A disease following introduction of a Group A conjugate vaccine, in this ‘meningitis belt’ epidemics continue with around 30,000 cases reported annually, now including Group W.

The incidence in Canada, the US and Europe varies substantially from 0.2 to 3 per 100,000 persons per year.[3] Group B has become the predominant capsular group in Europe, Americas and Australia, with incidence typically highest in children aged under 2 years.[4] Group C disease has almost disappeared in countries with universal immunisation programmes, but outbreaks have been observed in men who have sex with men in the US and Europe.

Since 2009 there has been an emerging global incidence of Group W disease, initially in the United Kingdom and South America. Australia has experienced a rapid increase in Group W cases since 2013 with New Zealand also seeing a rapid increase in cases since 2017. Like group C clonal complex ST11 strains, group W ST11 strains have enhanced virulence. Higher rates of carriage of these ST11 strains has been noted within age groups where invasive group W disease is more prevalent (infants and the elderly).[5]

Some parts of the world, particularly Scandinavia, have reported an increase in group Y disease. In other regions, there is evidence of colonisation, but disease caused by group Y is rare. Patients with group Y strain disease are more likely to develop pneumonia and to be elderly.[3, 4]

This emergence of group W and Y strains has led to meningococcal C vaccines being replaced by quadrivalent (group A, C, W, Y) meningococcal conjugate vaccines (MenACWY).

Risk groups

The highest incidence of meningococcal disease occurs in children aged under 5 years (especially under 2 years) with a secondary peak in older adolescents (15–19 years).The age distribution for groups W and Y is more likely to include older people that for B and C. A pooled overall case-fatality rate of 8.3 percent (range 4.1–20 percent) is reported internationally, varying by group and age.[6]

Most infection occurs in healthy people, but those with certain rare immune deficiencies (of terminal components of complement (C5–9) or properdin) or asplenia are at much higher risk, particularly of recurrent meningococcal disease. Individuals with infection caused by groups other than A, B, C, W, Y and untypeable strains or who experience recurrent disease should be investigated.

Close contacts of primary cases of meningococcal infection are at increased risk of developing infection, such as the case’s household,[7] early childhood education services, semi-closed communities, schools, correctional facilities and military recruit camps. Students living in hostel accommodation may also be at higher risk.[8, 9, 10] In health care settings, only those with close exposure to oropharyngeal secretions of patients with meningococcal disease (as may occur during intubation or resuscitation) and microbiology laboratory workers are considered to be at increased risk.

It is not possible to calculate the incubation period for meningococcal disease for sporadic cases. Secondary cases (ie, in contacts of known cases of meningococcal disease) usually occur within four days, but it can be up to 10 days. The infectivity of patients with meningococcal disease is markedly reduced after 24 hours of antibiotic therapy, although treatment with cefotaxime, ceftriaxone, rifampicin or ciprofloxacin is necessary to reliably eradicate nasopharyngeal carriage (see section 13.8.2).

In high-income countries in the absence of immunisation, nasopharyngeal carriage of N. meningitidis occurs in approximately 10 percent of the overall population, rising from 2 percent in children aged under 4 years to a peak of 24.5 percent to 32 percent among 15–24-year-olds, then declining with increasing age.[3, 11] In adolescents and young adults, the overall and capsular group carriage vary between regions and age groups.[12] The relationship between risk factors for disease and those associated with carriage is incompletely understood.[3] Carriage prevalence does not predict the disease incidence nor the occurrence or severity of outbreaks, as most of the carried strains are non-encapsulated and do not cause disease.[3] Smoking, passive smoking, household crowding and upper respiratory tract infections increase carriage.

13.3.2. New Zealand epidemiology

Incidence and mortality

In 2021 the notification rate for meningococcal disease was 0.9 cases per 100,000 population, with a total of 44 cases notified (40 laboratory confirmed; ESR, 28 April 2022). Cases remained significantly lower than the peak annual incidence rate of 16.7 per 100,000 for all ages and 200 per 100,000 in children under 12 months as experienced in 2001 during the meningococcal epidemic from 1991 to 2007. The epidemic was largely due to a single Group B subtype (B:P1.7-2,4). The annual number of notified cases of meningococcal disease in New Zealand since 1970 is shown in Figure 13.1.

For further details and reports of meningococcal disease in New Zealand refer to the ESR surveillance reports.

Figure 13.1: Notified cases of meningococcal disease, 1970–2021

Figure 13.1: Notified cases of meningococcal disease, 1970–2021 Figure 13.1: Notified cases of meningococcal disease, 1970–2021 Figure 13.1: Notified cases of meningococcal disease, 1970–2021

Source: ESR

Meningococcal disease incidence is highest in Māori (2.6 per 100,000, 22 cases in 2021) compared with the total population. Household crowding is an important risk factor for meningococcal disease, independent of ethnicity.[13] In 2021, the highest age-specific disease rates were among those aged under 1 year (27.8 per 100,000, 17 cases) decreasing in ages 1–4 years (2.0 per 100,000, 5 cases). Three deaths occurred in 2021, giving a case fatality rate of 6.8 percent (ESR, 28 April 2022).

From 1 January to 30 November 2022, there were 69 cases of meningococcal disease (66 confirmed cases), which was an increase from the same period in 2020 and 2021 but lower than for the previous years in 2017, 2018 and 2019.[14] Of these cases 43 percent were children aged under 5 years and of Māori and/or Pacific ethnicity. There were three deaths, one aged under 1 year, one aged 1–4 years, and one adolescent aged 15–19 years.

Strain types

Strain type was determined for 36 of the 40 laboratory-confirmed cases in 2021. Group B strains were the most prevalent, causing 81 percent of the typed cases (Figure 13.2). The group B strain (B:P1.7b,4) responsible for the epidemic caused 22 percent of all meningococcal disease in 2021 (8 of the 36 typed cases). Cases of meningococcal disease caused by group C strains decreased since 2014 (Figure 13.2), while group W increased from five cases in 2016 to 36 in 2019. Cases in groups C, W and Y decreased in 2021, likely in part, due to the public health measures implemented to control the COVID-19 pandemic. Only group B increased from 2020.

In 2022 to 31 October, out of 56 cases with group identified, 45 (80 percent) were group B, eight (14 percent) were group Y and three (5 percent) group W. There were 14 different PorA types identified within the group B cases. The most common were B:P1.7-12, 14 (14 cases) and B:P1.7-2,4 (14 cases).[14]

Figure 13.2: Meningococcal disease notifications by group, 2014–2022 (provisional data for 2022)

Figure 13.2: Meningococcal disease notifications by group, 2014–2022 (provisional data for 2022) Figure 13.2: Meningococcal disease notifications by group, 2014–2022 (provisional data for 2022) Figure 13.2: Meningococcal disease notifications by group, 2014–2022 (provisional data for 2022)

Source: ESR

13.4. Vaccines

13.4.1. Available vaccines

Internationally, meningococcal vaccination programmes were revolutionised by the development of conjugate vaccines, which allow vaccination in younger children and induced herd immunity when used in population-wide programmes due to reduced nasopharyngeal carriage (see section 1.4.3).

The monovalent (C) and quadrivalent (ACWY) conjugate vaccines are conjugated to a protein, either CRM197 (diphtheria toxin-derived), diphtheria toxoid or tetanus toxoid. Previously used, polysaccharide-only vaccines provided three to five years’ protection in adults, but they are generally regarded as inferior to conjugate vaccines and are no longer approved for use in New Zealand. Those travelling to Africa, the Middle East and other areas with wide serogroup prevalence, including group A, require MenACWY vaccine for broad protection. In 2018, a multicomponent meningococcal group B recombinant vaccine (MenB, formerly abbreviated 4CMenB) was registered in New Zealand to protect against group B disease.

With the current New Zealand epidemiology, neither MenACWY nor MenB give protection across all prevailing meningococcal groups and both types of vaccine are recommended. The meningococcal vaccines registered and available are summarised in Table 13.3 below.

Table 13.3: Meningococcal vaccines registered and available in New Zealand

Name (manufacturer)

Vaccine type

Bexsero
(GSK)
Meningococcal group B four-component recombinant (MenB)
MenQuadfi
(sanofi-aventis)
Quadrivalent meningococcal conjugate (MenACWY-T): contains group A, C, W and Y polysaccharides conjugated to tetanus toxoid
NeisVac-C
(Pfizer NZ)
Meningococcal group C conjugate (MenC): contains group C polysaccharide conjugated to tetanus toxoid

Nimenrix
(Pfizer NZ)

Quadrivalent meningococcal conjugate (MenACWY-T): contains group A, C, W and Y polysaccharides conjugated to tetanus toxoid

Funded vaccines

Meningococcal B vaccine (Bexsero) is funded as part of the routine childhood Schedule for all infants. No meningococcal ACWY vaccines are currently on the routine Schedule, except for special groups. See section 13.5 for funded vaccines for special groups.

Four meningococcal vaccines are funded for certain groups (see section 13.5).

  • Recombinant meningococcal B vaccine, MenB (Bexsero, GSK) contains four components from the group B meningococcus: three recombinant N. meningitidis group B surface proteins associated with bacterial adhesion and survival (Neisseria heparin binding antigen fusion protein, adhesin A protein, and factor H binding protein) plus detoxified outer membrane vesicles containing antigen as used in the MenNZB epidemic vaccine. Other components include aluminium hydroxide, sodium chloride, histidine and sucrose.
  • Quadrivalent meningococcal conjugate vaccine MenACWY (MenQuadfi, sanofi-aventis). Each 0.5 mL dose contains 10 µg of capsular polysaccharide conjugated to 55 µg tetanus toxoid for each of the N. meningitidis group A, C, W and Y strains. Also contains sodium chloride, sodium acetate and water for injection. There is no preservative or adjuvant.
  • Meningococcal group C conjugate vaccine MenC (NeisVac-C, Pfizer NZ Ltd) contains 10 µg of polysaccharide derived from the group C capsule, conjugated to 10–20 µg of tetanus toxoid. Other components include aluminium hydroxide and sodium chloride.
The tetanus toxoid-conjugated meningococcal MenACWY vaccine (MenQuadfi) replaced Menactra as the funded vaccine in mid-2023, for use in individuals aged 12 months and over.

Other vaccines

A second tetanus toxoid-conjugated MenACWY vaccine (Nimenrix, Pfizer NZ) is available for use in New Zealand for individuals from age 6 weeks. This MenACWY vaccine contains 5 µg of each polysaccharide derived from the capsules of group A, C, W and Y N. meningitidis strains, conjugated to 44 µg of tetanus toxoid carrier protein. Other components and excipients include sodium chloride, trometamol and sucrose.

A two-component meningococcal group B recombinant vaccine (MenB-fHbp; Trumenba, Pfizer Ltd) is licensed from 10 years of age, including in the US, Europe and Australia. It is not available in New Zealand. 

Historic MeNZB vaccine

A strain-specific group B meningococcal vaccine (MeNZB, Chiron/Novartis) containing outer membrane vesicles derived from the epidemic strain B:4:P1.7b,4 (NZ 98/254) was developed for epidemic control in New Zealand and used between 2004 and 2008. The programme ceased in 2008 because of a decline in incidence of epidemic strain group B disease (see previous editions of the Handbook).

Since the immune response to MenNZB was short-lived, previous recipients who wish to be protected against meningococcal B disease will need to be fully immunised with MenB.

13.4.2. Efficacy and effectiveness

Meningococcal group B recombinant vaccine

Three years after initiation of the introduction of MenB to the national immunisation schedule in the UK, a 75 percent reduction in group B disease was reported in the vaccine-eligible age groups compared with a historical cohort.[15] With 88 percent coverage but a low number of cases (25), adjusted vaccine effectiveness for all group B strains was 59.1 percent (95% CI: -31.1–87.2) following two primary doses and one booster dose, with an estimated 277 cases prevented.[15] This research is ongoing.

Following MenB vaccination of adolescents aged 15-16 years in South Australian schools, there was an overall reduction of 71 percent (95% CI 15-90; p=0.02) in group B meningococcal disease cases aged 16–19 years: five cases in 2017–2018 (predicted 9.9 [95% predicted interval 3.9-17.5]) and one case in 2018–2019 (predicted 10.9 [4.4–19.1]).[16]

As was observed during college outbreaks in the US,[17, 18] in South Australia where MenB is administered in a school-based programme at age 15–18 years, MenB had no effect on disease-causing meningococcal carriage suggesting that vaccination of adolescents is unlikely to generate herd immunity.[19] A MenB vaccination campaign used during an isolated outbreak in a region of Québec, Canada outbreak demonstrated direct protection of 79 percent against outbreak strain group B disease and an overall impact of 86 percent in target groups with no herd effects.[20]

Cross-protection against meningococcal group W has been observed following vaccination of infants with MenB in the UK. Among age-cohorts that were fully and partially eligible to receive MenB, respectively, it was estimated that there were 69 percent (adjusted incidence rate ratio 0.31; 95% CI 0.2-0.67) and 52 percent (0.48; 0.28-0.81) fewer cases of group W disease than predicted in 2018/2019; this included direct and indirect protection over four years. An estimated 98 cases (95% CI 34-201) of group W disease were directly prevented in children aged under 5 years.[21] The researchers state that MenACWY conjugate vaccines would still be required for direct and indirect protection against those groups, since the degree of cross-protection is dependent on the expression of vaccine antigens on the meningococcal surface.[21]

There is limited data on its use in patients with chronic medical conditions and those immunocompromised by medication or disease, such as HIV infection or hereditary immune system defects. In a phase 3 clinical trial, children aged 2­–17 years showed good but reduced immunogenicity in those with immunocompromise.[22] Immunogenicity in children with asplenia and splenic dysfunction was similar to healthy children but reduced in children with complement deficiencies.[23]

The safety and efficacy of MenB in adults above 50 years of age have not been established.

Quadrivalent meningococcal conjugate vaccines

Clinical trial data use immunogenicity and bactericidal antibody titres as a proxy for efficacy. Effectiveness of conjugate meningococcal vaccination against laboratory-confirmed disease is difficult to assess due to the low incidence of cases, even during localised epidemics, such that data is limited around the effectiveness of the MenACWY vaccines. With the emergence of group W and Y strains, more countries have implemented mass campaigns and routine immunisation programmes to control outbreaks with MenACWY vaccines and can assess impact through disease incidence and carriage studies. The current evidence indicates that MenACWY (MenQuadfi) has similar or superior immunogenicity to other MenACWY vaccines; real-world effectiveness data is limited to date as it was first licensed in 2020.

Several phase II and III clinical trials have assessed the immunogenicity of the MenACWY vaccine, MenQuadfi. These studies have included healthy vaccine-naive toddlers aged from 12 months; vaccine-naïve older children and adolescents; booster doses in toddlers, children and adolescents following prior MenACWY or MenC vaccination; given concurrently with routine vaccines (DTaP-IPV-HepB/Hib, MMR, VV, PCV13, Tdap and HPV); and in adults aged over 56 years.[24] In all studies, robust antibody responses were observed in all groups, immunogenicity was non-inferior to comparator vaccines and booster responses were observed.

Bactericidal antibody responses in adults (aged 18-55 years) were two to six times greater in those vaccinated with MenQuadfi, compared those vaccinated with diphtheria-toxoid conjugated MenACWY (Menactra), and a higher proportion of participants had a positive seroresponse.[25]

One clinical trial observed lower antibody responses to FHA, PRN and FIM2/3 pertussis antigens but not pertussis toxin, when MenACWY was given concurrently with Tdap and HPV in adolescents compared with without MenACWY.[26] The clinical relevance is unknown and has been observed with other MenACWY vaccines.[24] No interference was documented with other vaccines. There is no published data to date on effectiveness or use in immunocompromised individuals.

The other MenACWY-T vaccine (Nimenrix) is registered in New Zealand for individuals from aged 6 weeks. Clinical trials showed that the vaccine elicited bactericidal antibodies against all four groups from age 2 months with acceptable reactogenicity and safety profile.[27]

There is no published data on effectiveness in older adults for these vaccines.

Meningococcal group C conjugate vaccine

Meningococcal C conjugate vaccines were used successfully in national immunisation and mass vaccination programmes from 1999 in the UK, resulting in almost complete elimination of group C disease.[28] A targeted immunisation campaign during an epidemic in Salvador, Brazil demonstrated MenC vaccination to be 98 percent effective against group C disease in young children.[29] A booster dose in the second year of life was indicated in the UK for sustained protection.[30] The greatest impact from meningococcal immunisation campaigns was obtained through herd immunity and a reduction in transmission was observed across all age groups, including in unvaccinated adults, where catch-up programmes in adolescents were implemented.[31, 32]

With the emergence of group W and group Y meningococci, MenC has largely been replaced by MenACWY vaccines on national programmes for infants and adolescents.

13.4.3. Transport, storage and handling

Transport according to the National Standards for Vaccine Storage and Transportation for Immunisation Providers 2017 (2nd edition).

Store at +2°C to +8°C. MenACWY vaccines and MenB should be protected from light. Do not freeze.

Reconstitution

The MenACWY vaccine, Nimenrix, must be reconstituted with the supplied diluent and used as soon as possible. The other meningococcal vaccines are fully liquid formulations and do not require reconstitution.

13.4.4. Dosage and administration

Meningococcal group B recombinant vaccine (MenB)

Each MenB (Bexsero) dose is 0.5 ml, administered by intramuscular injection (see section 2.2.3).

  • For infants aged 8 weeks to 11 months, two doses are given with a minimum of eight weeks between doses, with a booster given at least six months after the second dose, from age 12 months.
  • For toddlers aged 12­–23 months (at time of first dose) a primary course of two doses is given at least eight weeks apart. A booster dose is recommended from 12 to 23 months after dose two.
  • For children aged from 2 years (at time of first dose) and adults, two doses are given at least eight weeks apart (see section 13.5.1 for reduced spacing). (Note: the safety and efficacy in individuals aged over 50 years have not been established, but no safety concerns are expected.)

Generally, the need for booster doses from the age 2 years or older at the time of their first dose has not been established. A booster dose can be considered for individuals at continued risk of exposure to meningococcal disease. Booster doses are funded five-yearly for some high-risk individuals (see Table 13.6).

MenB can be administered concurrently with other scheduled vaccines, in separate syringes and at separate sites (see section 2.2.7).

See section 13.5.1 for recommendations around antipyretic prophylaxis use with delivery in children aged under 2 years.

Quadrivalent meningococcal conjugate vaccines (MenACWY)

Each MenACWY dose is 0.5 mL, administered by intramuscular injection (see section 2.2.3).

MenACWY and MenC vaccines can be concurrently administered with other vaccines in separate syringes and at separate sites.

MenQuadfi

MenQuadfi is given as a single dose to individuals aged 12 months and over. See Table 13.6 for schedules and dosing for certain special groups.

A single booster dose may be given to adolescent and adults who have been primed with another MenACWY vaccine at least 4 years previously. There is currently no data available to indicate the need for or timing of a booster dose.

Nimenrix 

MenACWY-T (Nimenrix) is available (not funded) in New Zealand for individuals from age 6 weeks.

  • For infants aged under 12 months, two doses are given eight weeks apart, plus a booster from age 12 months at least six months after second dose.
  • Healthy infants aged 6 months to under 12 months, who are not immunocompromised, can be given one dose instead of two primary doses, plus a booster from age 12 months, at least eight weeks later.
  • For adults and children from age 12 months, one dose is given.
  • Booster doses may be indicated in some individuals.

Meningococcal group C conjugate vaccine (MenC)

Each MenC (NeisVac-C) dose is 0.5 mL, administered by intramuscular injection (see section 2.2.3). See Table 13.6 for schedules for at-risk individuals.

For infants aged under 12 months, two doses are given at least eight weeks apart, with the first dose given not earlier than age 6 weeks. One dose of MenACWY is recommended in the second year of life at age 12 months or over.

In view of the New Zealand epidemiology, a quadrivalent (MenACWY) vaccine would be preferable, to obtain broader meningococcal protection.

13.5.1. Usual childhood schedule

A primary course of MenB is recommended and funded for all children at ages 3 months, 5 months and a booster given at age 12 months. In an alternative approved schedule, MenB can be given at ages 2 months (ie, approved from 8 weeks) and 4 months with a booster at age 12 months; this would be outside the standard scheduled immunisation visits. Do not delay the 6-week vaccination event for the other Schedule vaccines.

For children at high risk of meningococcal disease aged younger than 8 weeks, to align with the routine schedule visit, MenB can be given at ages 6 weeks and 3 months. This is off-label use and requires a prescription for both events. No prescription is required if given as per the alternative schedule at ages 2 and 4 months.

A catch-up programme of MenB is funded for children aged 13 months to 59 months until 31 August 2025. All children eligible for meningococcal B catch-up should be vaccinated at the earliest opportunity. Give two doses 8 weeks apart. For children those aged 12 to under 24 months at time of their first dose, a further dose can be given from 12 to 24 months after second dose. If MenB is started before the age 5 years, then the funded course can be completed. There is now some flexibility for children eligible for catch-up who then turn 5 years old before receiving their first MenB dose. These children can still be offered the funded vaccine course; this should be given at the earliest opportunity and before the end of the catch-up period.

As an antipyretic, prophylactic paracetamol is recommended to be given up to 30 minutes prior to or immediately after MenB vaccination and give up to two further doses four to six hours apart for children aged under 2 years. Ibuprofen may be given as an alternative to paracetamol six to eight hourly (see section 13.7.1).

Age 

Dose 

Comment 

National Immunisation Schedule 

3 monthsa 

Dose 1 

Given together with routine vaccinations 

5 months 

Dose 2 

12 months 

Dose 3 (booster) 

Approved alternative schedule 

8 weeksa

Dose 1 

Additional visit 

4 months 

Dose 2 

Additional visit if dose one received at age 2 months 

12 months 

Dose 3 (booster) 

Given together with routine vaccinations 

Catch-up for those aged 12–59 months at time of first dose 

Age 12–23 months 

Give 2 doses at least 8 weeks apartb.

A booster dose can be given 12–24 months after dose two. 

Age 24–59 months 

Give 2 doses at least 8 weeksc apart, no booster. 

a.     For children at high risk of meningococcal disease aged younger than 8 weeks, to align with the routine schedule visit, MenB can be given at ages 6 weeks and 3 months. This is off-label use and requires a prescription for both doses. No prescription is required if given as per the alternative schedule at ages 2 months (ie, 8 weeks) and 4 months. See Table 13.6 for high-risk infants.

b.     For children aged 8 weeks to under 24 months, spacing between dose one and two can be reduced to 6 weeks, if indicated with a prescription.

c.     For children aged 2 years and over, spacing between doses can be reduced to four weeks, if indicated. No prescription required.

13.5.2. Individuals at increased risk

Meningococcal vaccines are funded in special circumstances, as described in the shaded section of Table ‎13.5; Table ‎13.6 shows the recommended dosing schedules.

See sections 4.3, 4.4 and 4.5 for more information about vaccination of special groups, including recommended immunisation schedules for high-risk individuals with certain medical conditions.

The meningococcal vaccines are recommended (but not funded) for other individuals at risk, as described in non-shaded rows in Table 13.5.

Before travel

There are areas of the world where the risk of meningococcal disease is increased. Nevertheless, the risk to travellers to the developing world has been estimated as being less than one in a million per month. Recurrent epidemics of meningococcal disease occur in the sub-Saharan ‘meningitis belt’, from Senegal in the west to Ethiopia in the east, usually during the dry season (December to June). Epidemics are occasionally identified in other parts of the world, including in Europe and the Americas. Generally, countries outside of Africa experience smaller outbreaks, but case-fatality rates can be high.

The preferred vaccines (MenACWY and/or MenB) for travel would be based on the epidemiology of the country. For website sources for information about meningococcal vaccines for travellers, see the WHO website. Quadrivalent meningococcal vaccine is a requirement for pilgrims to the Hajj.

Before moving into communal living situations

MenACWY and MenB are recommended and funded from age 13–25 years inclusively for individuals who will be living in communal accommodation within the next three months, or who are in their first year of living in communal accommodation (specifically, boarding school hostels, tertiary education halls of residence, military barracks, youth justice residences or prisons) as they are likely to be at higher risk of acquiring meningococcal infection.

Table 13.5: Meningococcal vaccine recommendations

Note: Funded circumstances are in the shaded rows.
See the Pharmaceutical Schedule for any changes to the funding decisions.

Recommended and funded

MenB is recommended and funded for:

  • all infants at ages 3a months, 5 months and 12 months
  • an alternative primary schedule, at ages 8 weeks and 4 months, can be used, requiring additional visitsa
  • catch-up is available to those aged 13 months to <5 years (until 31 August 2025).

MenB and MenACWY or MenC (according to age) are recommended and funded for:

  • patients pre- or post-splenectomy or with functional or anatomical aspleniab,c
  • patients with HIV, complement deficiency (acquired, including monoclonal antibody therapy against C5, or inherited)
  • patients who are pre- or post-solid organ transplantc
  • HSCT (bone marrow transplant) patientsc
  • patients prior to planned immunosuppressionc,d
  • patients following immunosuppressionc,d
  • close contacts of meningococcal cases of any groupe
  • individuals who have previously had meningococcal disease of any groupe,f

    MenB and MenACWY are recommended and funded for:

  • individuals aged 13–25 years inclusively who are entering within three months or are in their first year of living in boarding school hostels, tertiary education halls of residence, military barracks, prisons or youth justice residences.

Recommended but not funded

Priority groups

MenACWY and MenB are recommended, but not funded, for:

  • individuals are laboratory workers regularly handling meningococcal cultures
  • adolescents and young adults living in communal or overcrowded accommodation not covered by funded vaccine
  • individuals who are travelling to high-risk countries (see the WHO website) or before the Hajj.

MenACWY (Nimenrix) is recommended but not funded for high-risk infants age under 12 months in place of MenC.

Other groups

MenACWY and MenB are recommended but not funded for all infantsg, young children, adolescents and young adults (see Table ‎13.7).

a.     For children at high risk of meningococcal disease aged younger than 8 weeks, to align with the routine schedule visit, MenB can be given at ages 6 weeks and 3 months. This is off-label use and requires a prescription for both doses. No prescription is required if given as per the alternative schedule at ages 8 weeks and 4 months.

b.     Pneumococcal, Hib, influenza and varicella vaccines are also recommended for individuals pre- or post-splenectomy or with functional asplenia. See section 4.3.4.

c.     See section 4.3.4 for more information.

d.     The period of immunosuppression due to steroid or other immunosuppressive therapy must be longer than 28 days.

e.     For close contacts and individuals who have had previous meningococcal disease, given as per the routine dosage schedule (see section 13.4.4).

f.      Regardless of time elapsed since disease. Vaccination can commence at any time from when the person is no longer acutely unwell.

g.     Nimenrix can be given from age 6 weeks (unfunded); MenQuadfi from age 12 months. MenB is routinely funded for infants and catch-up is available for children aged 13 months to <5 years (until 31 August 2025).

 

Note: See the Pharmaceutical Schedule for any changes to funding decisions.

Age at diagnosis

Vaccine
(trade name)

Recommended vaccine schedule

Infants aged 8 weeksa to under 12 months

MenC
(NeisVac-C)

  • Give 2 doses of MenC 8 weeks apart, followed by MenACWY. (See alternative unfunded MenACWY (Nimenrix) option in Table 13.7.)
  • When infant reaches age of 12 monthsb, then give twoc doses of MenACWY (MenQuadfi) 8-12 weeks apart.
MenB (Bexsero)
  • Give 2 doses 8 weeks aparta, plus booster given at least 6 months after second dose, from age 12 months and then 5 yearlyd.
Children aged 12 months to under 18 years MenACWY
(MenQuadfi)
  • If aged 12 monthsb – under 7 years at diagnosis, give 2 doses of MenACWYc 8–12 weeks apart followed by a booster dose after 3 years, then 5‑yearly.d
  • If aged 7 years or older give 2 doses of MenACWY 8 weeks apart followed by a booster dose 5-yearly.c,d
MenB (Bexsero)
  • For toddlers aged 12 –23 months (at time of first dose), give 2 doses 8 weeks apart and a booster dose 12 –23 months after second primary dose
  • From age of 2 years (at time of first dose), give 2 doses 8 weeks aparte.
  • Give booster dose 5-yearly from age 2 yearsd
Adults aged 18 years and older MenACWY
(MenQuadfi)

Give 2 doses 8 weeks apart, then 1 dose every 5 years.d

MenBf (Bexsero) Give 2 doses 8 weeks aparte, then booster 5 yearly.d
Individuals aged between 13 and 25 years, in certain communal living situationsg MenACWY
(MenQuadfi)

1 dose, no booster requiredh

MenB Give 2 doses 8 weeks aparte

a.     For children at high risk of meningococcal disease aged younger than 8 weeks, to align with the routine schedule visit, MenB can be given at ages 6 weeks and 3 months. This is off-label use and requires a prescription for both doses. No prescription is required if given as per the alternative approved schedule at ages 8 weeks and 4 months.

b.     If an infant has received two doses of Nimenrix (unfunded) instead of MenC before age 12 months, give just one dose of MenQuadfi at least 6 months after dose two, from age 12 months.

c.     A second primary dose of MenACWY (MenQuadfi) from age 12 months is off-label and requires a prescription from an authorised prescriber under section 25 of the Medicines Act.

d.     MenACWY and MenB boosters funded for individuals pre- and post-splenectomy and for patients with functional or anatomic asplenia, HIV, complement deficiency (acquired or inherited), or pre- or post-solid organ transplant.

e.     From age 2 years, MenB can be given 4 weeks apart if there is a clinical need.

f.      Although there is limited data safety and efficacy of administering MenB to adults age over 50 years, no safety concerns are expected when given to adults aged over 50 years.

g.     Funded for individuals aged 13–25 years inclusively who either: are entering within three months or who are in their first year of living in boarding school hostels, tertiary education halls of residence, military barracks, youth justice residences or prisons.

h.     A single booster dose can be given to adolescents and young adults who were primed at least 4 years previously with any MenACWY vaccine.

13.5.3. Recommendations for children and adolescents

Non-high-risk children and adolescents may be offered meningococcal vaccines. These vaccines are only funded for certain groups (see Table 13.4). Table ‎13.7 suggests the most appropriate ages for this, reflecting the known ages of increased risk. The predominant meningococcal strains in New Zealand in childhood are B, W and Y. With the current New Zealand epidemiology, neither MenACWY nor MenB give protection across all prevailing meningococcal groups and both types of vaccine are recommended. For those who are likely to travel, the broadest protection is preferable because of the differing serotype patterns between countries.

Note: Vaccine immunity is not long-lasting. The suggested ages of vaccination are not expected to protect individuals through all of childhood but focused on protection during the ages of highest risk. Due to being at lowest risk, healthy children aged 5–11 years are not specifically recommended meningococcal vaccination in this table. This does not apply to epidemic situations.

Age at time of consultation

Vaccine options
(trade name)

Number of dosesa

6 weeks to <12 months

MenACWY (Nimenrix)

ages 6 weeks­–5 months 2 doses  or 1 dose if aged from 6 monthsb

plus a booster from age 12 months

12 months to <5 years

MenACWY
(MenQuadfi or Nimenrix)

1 dose MenACWY

Early adolescence
(12 to <16 years)c,d

MenB (Bexsero)

2 dosesd

MenACWY
(MenQuadfi or Nimenrix)

1 dose plus a booster 5 years laterd

Late adolescence
≥16 yearsc,d

MenB (Bexsero)

2 doses

MenACWY
(MenQuadfi or Nimenrix)

1 dose, no booster required

a.     Refer to section 13.4.4 for the intervals between doses.

b.     Infants aged from 6 months to ≤12 months who are not immunocompromised, can instead be given one dose plus booster from age 12 months at least two months later.

c.     For individuals aged 13–25 years not eligible for funded vaccine, particularly living in crowded private homes, other hostels or private student accommodation, or planning overseas travel.

d.     A booster dose of MenACWY and MenB can be given if it is at least 5 years since primary dose of these vaccines. The need for MenB vaccination is not established for this group but can be considered if at continued risk.

13.5.4. Pregnancy and breastfeeding

There are no reports of any adverse effects among pregnant women who have been vaccinated during pregnancy.[33] Meningococcal vaccines may be given in pregnancy and to those who are lactating, if indicated.[34, 35]

13.5.5. (Re)vaccination

Meningococcal conjugate vaccines, MenC, MenACWY and MenB are funded for vaccination or re-vaccination of eligible individuals, as follows. See also section 4.3.

Meningococcal conjugate vaccines

For MenC (age 11 months and under) and MenACWY (age 12 months and over), up to three doses plus booster doses (as appropriate) are funded for individuals:

  • pre- or post-splenectomy
  • pre- or post-solid organ transplantation
  • with functional asplenia
  • with complement deficiency (acquired or inherited)
  • who are HIV-positive.

Two doses are funded for individuals:

  • post-haematopoietic stem cell transplantation
  • prior to planned and following immunosuppression for longer than 28 days.

Recombinant meningococcal B vaccine, MenB

  • Age under 12 months – up to three doses, plus booster after age 12 months and every five years (as appropriate)
  • Age from 12 – 23 months – up to two doses plus booster given 12 to 23 months after second dose, and booster every five years (as appropriate)
  • Age from 2 years – up to two doses plus a booster every five years (as appropriate)

Primary vaccination plus booster doses funded individuals:

  • pre- or post-splenectomy
  • pre- or post-solid organ transplantation
  • with functional or anatomic asplenia
  • with complement deficiency (acquired or inherited)
  • who are HIV-positive.

Two primary doses are funded for individuals aged from 12 months:

  • post-haematopoietic stem cell transplantation
  • prior to planned and following immunosuppression for longer than 28 days.

13.6. Contraindications and precautions

See also section 2.1.3 for pre-vaccination screening guidelines and section 2.1.4 for general contraindications for all vaccines.

There are no specific contraindications for meningococcal vaccines, except for anaphylaxis to a previous dose or any component of the vaccine.

13.7. Potential responses and AEFIs

13.7.1. Meningococcal B recombinant vaccine

There is an increased risk of fever and medically attended fever-related events, such as sepsis screening and febrile seizures associated with MenB in some children age under 2 years.[4, 36, 37, 38, 39] These events peaked at six hours post-vaccination and generally subsided by day 3. Fever of at least 38°C was observed in 80 percent of infants who received MenB and routine vaccines concomitantly, and 71 percent who had MenB and routine vaccines separately, compared with 51 percent who receive routine vaccines only.[40, 41] Paracetamol was show to reduce the incidence of fever. Prophylaxic paracetamol is recommended from 30 minutes prior to or immediately after vaccination, then two further doses can be given four to six hours apart for children aged under 2 years. Some infants will still develop a fever and/or injection-site pain even though they have received paracetamol doses.[42]

In clinical trials, most infants and young children had at least one solicited adverse reaction (84–97 percent)[41], including injection-site tenderness and irritability. Adolescents and adults may experience localised pain, nausea, myalgia, malaise, mild fever and headache.

13.7.2. Quadrivalent meningococcal conjugate vaccine

Potential adverse reactions after meningococcal conjugate vaccines include localised injection-site pain, irritability, headache, malaise and fatigue.[27, 43] The safety profile of all the MenACWY vaccines are very similar.[27, 33, 44] In infants, unusual crying, irritability, drowsiness and vomiting have been reported in clinical trials.[25, 45] Fever is reported by 2–5 percent of adolescents and less than 10 percent of infants who receive MenACWY. Concurrent administration with routine vaccines did not increase solicited systemic responses in young children (when given with PCV13) but was slightly increased in adolescents (with Tdap and HPV) during clinical trials of MenQuadfi.[25, 44, 45]

Guillain–Barré syndrome

There is no evidence of an association between meningococcal conjugate vaccines and GBS. An early report in the US of a suspected temporal association between MenACWY (Menactra) and GBS was followed by a large retrospective cohort study in the US that found no evidence of an increased risk of GBS following administration of MenACWY.[34, 46] If indicated, meningococcal conjugate vaccines may be administered to individuals with a history of GBS.[47]

13.7.3. Meningococcal group C conjugate vaccine

A Cochrane Review assessed the safety of MenC against group C disease.[48] MenC vaccines were shown to have an excellent safety profile in infants. The events more frequently reported in infants were fever (1–5 percent), irritability (38–67 percent), crying more than expected (1–13 percent), redness at the site of vaccination (6–97 percent), tenderness at the site of vaccination (11–13 percent) and swelling at the site of vaccination (6–42 percent). Anaphylaxis was reported at a rate of one per 500,000 doses distributed.[4]

13.8. Public health measures

Invasive meningococcal disease must be notified on suspicion to the local medical officer of health.

For details of public health control measures see the Communicable Disease Control Manual

The overall rate of secondary cases in untreated adults is around 1 per 300. Adults and children in close contact with primary cases of invasive meningococcal infection are recommended to receive antibiotic prophylaxis, preferably within 24 hours of the initial diagnosis, but prophylaxis is recommended up to 14 days after diagnosis of illness.

Blood or cerebrospinal fluid culture is the main diagnostic method, but blood PCR may be useful if antibiotics are given without prior access to blood culture. It is recommended that in primary care 3–5 mL of blood should be taken in an ethylenediaminetetraacetic acid (EDTA) anticoagulant tube (usually with a purple top) prior to administration of antibiotics unless blood culture is available. This should accompany the patient to hospital.

13.8.1. Contacts

A contact is anyone who has had unprotected contact with upper respiratory tract or respiratory droplets from the case during the seven days before onset of illness to 24 hours after onset of effective treatment.[49] Contacts at particular risk include:

  • those sleeping at least one night in the same household, dormitory, military barrack or student hostel bunkroom (not residents of nursing or residential homes who sleep in separate rooms) as the case, or who have been in a seat adjacent to the case in a plane, bus or train for more than eight hours
  • health care workers who have had intensive unprotected contact (not wearing a mask) with a case during intubation, resuscitation or close examination of the oropharynx
  • exchange of upper respiratory tract secretions, including intimate kissing
  • other contacts as determined by the medical officer of health on a case-by-case basis, such as children and staff attending an early childhood service.

Prophylaxis is not routinely recommended for health care personnel unless there has been intimate contact with oral secretions (eg, performing mouth-to-mouth resuscitation or suctioning of the case before antibiotic therapy has started).

13.8.2. Chemoprophylaxis for contacts

Recommended antibiotics

The recommended antibiotics are rifampicin, ceftriaxone or ciprofloxacin, preferably given within 24 hours of initial diagnosis, but prophylaxis is recommended up to 14 days after diagnosis of illness.

Rifampicin

The recommended dose of rifampicin is 10 mg/kg (maximum dose 600 mg) every 12 hours for two days. For infants aged under 4 weeks, the recommended dose is 5 mg/kg every 12 hours for two days.

Rifampicin should be avoided for pregnant or lactating women.

Ceftriaxone

A single dose of intramuscular ceftriaxone (125 mg for children aged under 12 years and 250 mg for older children and adults) has been found to have an efficacy equal to that of rifampicin in eradicating the meningococcal group A carrier state. Ceftriaxone is the drug of choice in a pregnant woman because rifampicin is not recommended later in pregnancy. Ceftriaxone may be reconstituted with lignocaine (according to the manufacturer’s instructions) to reduce the pain of injection. A New Zealand study demonstrated that ceftriaxone and rifampicin were equivalent in terms of eliminating nasopharyngeal carriage of N. meningitidis group B.[50]

Do not use in infants under aged under 4 weeks.

Ciprofloxacin

Ciprofloxacin given as a single oral dose of 500 mg or 750 mg is also effective at eradicating carriage. This is the preferred prophylaxis for women on the oral contraceptive pill and for prophylaxis of large groups.[49]

Ciprofloxacin is not generally recommended for pregnant and lactating women or for children aged under 18 years.[51] Consult the manufacturer’s data sheet for appropriate use and dosage of ciprofloxacin in children.

Use of meningococcal vaccines for close contacts

Close contacts of cases of any group (including group A, B, C, W or Y) meningococcal disease may be offered both MenB and MenACWY (or MenC if aged under 9 months) meningococcal vaccines (see section ‎13.5).

See below for the use of the vaccines for the control of outbreaks, as initiated by the local public health service.

13.8.3. Outbreak control

When there is an outbreak of meningococcal disease of a specific vaccine group, an immunisation programme may be recommended and funded for a defined population. The local medical officer of health will determine the necessary action in discussion with Health NZ | Te Whatu Ora.

For more details on control measures, refer to the ‘Neisseria meningitidis invasive disease’ chapter of the Communicable Disease Control Manual .

13.9. Variations from the vaccine data sheets

The MenQuadfi data sheet states to give a single dose for individuals from age 12 months. Health NZ | Te Whatu Ora recommends that two doses are given to individuals at high risk of meningococcal disease (see Table ‎13.6 and section ‎4.3), with booster doses every five years. If the first MenACWY dose was given before age 7 years, give a booster after three years then five-yearly.[43]

The MenC data sheet states that the first dose of vaccine is not be given earlier than age 8 weeks. However, Health NZ recommends that MenC may be given from age 6 weeks to infants at high risk of meningococcal disease (see Table 13.5 and Table 13.6).

The MenB data sheet states that the vaccine is indicated from age 8 weeks or older. However, Health NZ recommends that MenB can be given from age 6 weeks to infants at high risk of meningococcal disease (see Table ‎13.6). This is an off-label use and requires a prescription from an authorised prescriber. The datasheet states that infants who received their primary course from ages 6 to 11 months can receive a booster in the second year of life at least 2 months later. The Ministry recommends that all infants aged 11 months or less receive a booster dose at least 6 months after the primary doses, from the age of 12 months.

The data sheet recommends two doses of MenB to be given eight weeks apart between ages 12 and 23 months and not less than one month apart from the age of 2 years. Health NZ recommends two doses of MenB be given at least eight weeks apart for those aged 12 months or older at the time of the first dose, this may be reduced to at least 4 weeks if required.

References

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