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      Meningococcal disease

      Latest update: - Authors: Ula Maniewski, Nele Alders

      Meningococcal disease is caused by the aerobic gram-negative encapsulated bacteria Neisseria meningitidis (meningococcus). It can cause life threatening septicaemia and meningitis.
      There are several types or serogroups but A, B, C, W, X and Y are the main types causing disease worldwide.
      Incidence of meningococcal meningitis and septicaemia characteristically peaks in infants and teenagers, but it can affect all age groups, therefore during epidemics the entire population can be at risk.

      Transmission

      The only known repository of N. meningitidis is the human nasopharyngeal tract. Transmission occurs through aerosol or direct contact with respiratory secretions of patients or healthy human carriers. Colonization typically does not cause disease. Under circumstances that are not completely understood, N. meningitidis can invade the bloodstream and cause invasive meningococcal disease. Smoking, close and prolonged contact including kissing or coughing, or living in close quarters, facilitate the spread of disease.

      Incubation period

      The transition between carriage and invasive disease usually takes place anywhere from day 1 to approximately 2 weeks after acquisition. An upper limit to the incubation period is unknown.

      Symptoms

      Symptoms of meningitis include a sudden onset of fever, intense headache, neck stiffness, nausea and vomiting. Symptoms of septicaemia are fever, chills, confusion and a rash. Both conditions may progress rapidly and are serious diseases with a high risk of complications and fatality
      If left untreated, meningitis is fatal in 50% of the cases. Even with early and adequate treatment 8-15% will die, and up to 20% of survivors have long-term complications, such as brain damage or disability.  

      Risk areas

      Clusters and outbreaks of meningococcal disease occur in all parts of the world

      The highest burden of disease is found in the ‘meningitis belt’, an area of sub-Saharan Africa with a population of more than 400 million, extending from Senegal to Ethiopia. The meningitis belt is characterised by seasonal epidemics during the dry season from December to June. Historically epidemics were mainly due to serogroup A but since the introduction of the monovalent serogroup A conjugate vaccine (MenAfriVac®) in the region starting in 2010 recent meningococcal outbreaks have primarily been due to serogroups C and W, although serogroup outbreaks are also reported. 

      The risk of meningococcal disease in travellers is generally considered to be low. Those travelling to areas in the extended meningitis belt of Africa or to a region with a current outbreak may have an increased risk. Travellers who have prolonged close contact with the local population, health workers and those visiting friend and relatives are considered at greater risk. 

      Outbreaks linked to attendance of pilgrimage to the Kingdom of Saudi Arabia (Mecca) for the Hajj and Umrah mass gatherings are well-recognised. In 1987 a meningococcal serogroup A outbreak triggered the introduction of mandatory vaccination against group A and C. The global outbreak of meningococcal serogroup W in 2000 and 2001 led to the implementation of the Men ACWY vaccine for all pilgrims, who are required to show proof of vaccination with the quadrivalent Men ACWY vaccine in order to obtain a visa.

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      Prevention

      Introduction

      There are different types of vaccines against N. meningitidis available:

      • The quadrivalent vaccine against serogroups A, C, W135 and Y (Nimenrix®, Menveo®) is the vaccine of interest in travel medicine.

      • The monovalent conjugated vaccine against serogroup C (Neisvac-C®) is offered free of charge in the vaccination schedule in Belgium, but the Belgian Superior Health Council advises this to be replaced by the meningococcal ACWY vaccine which is not free of charge.

      • The recombinant protein-based vaccine against serogroup B (Bexsero®, Trumenba®) is currently not incorporated in the routine schedule, has been shown to be effective with no major serious side effects and can be given at an individual choice to children, adolescents or people at increased risk, but there are no specific recommendations for travellers.

      Meningococcal ACW135Y vaccine

      There are 2 types of the quadrivalent vaccine:

      1. Non-conjugated meningococcal ACW135Y (Mencevax ACWY®)

        This is no longer available in Belgium. The induced immune response and duration of protection is inferior compared to the conjugated vaccine.

      2. Conjugated meningococcal ACW135Y (Nimenrix® and Menveo®):
        Use: Nimenrix® is registered for use from the age of six weeks, Menveo® from the age of two years. Both vaccines are interchangeable.
        Route of administration: Intramuscular
        Protection: Starting from 10 days after vaccination and lasting at least 5 years (for details see below).
        They prevent invasive disease and carriage, thereby reducing transmission and leading to herd protection.
        Contra- indications: Hypersensitivity to the active substances or to any of the excipients.
        Side effects: redness, pain or swelling at the side of injection; rarely generalized symptoms (e.g., fever following 24hrs after vaccination).

      Indications

      Indications for meningococcal ACW135Y vaccination in travellers:

      Meningitis belt

      Vaccination is recommended for travellers who reside in the meningitis belt during the dry season (between end of December and end of June) and who either:

      • have close contact with the local population (e.g., family visits, medical work, etc.),
      • stay there for four weeks or more,
      • have no or a badly functioning spleen (e.g., sickle cell anaemia),
      • suffer from certain forms of immunosuppression.
      Outbreak Vaccination is recommended when travelling to a region where there is an outbreak of meningitis.
      Pilgrimage to Mecca Vaccination is compulsory for everyone from two years of age going on pilgrimage to Mecca.
      Students In some countries (e.g., United Kingdom, United States of America) a proof of vaccination against meningococcal ACW135Y is requested from foreign students.

      Scheme

      Age Primary series Registered vaccines 

      6 weeks – 6 months

      Two doses at two-month intervals

      Booster dose at the age of twelve months, at least two months interval from last Nimenrix® vaccine

      Nimenrix®

      6 months- 12 months

      One dose

      Booster dose at the age of twelve months, at least two months interval from last Nimenrix® vaccine

      Nimenrix®

      >12 months – adults 

      One dose

      For some forms of immunosuppression, two doses are recommended

      Nimenrix® 
      -----------------
      Menveo® from > 2 year of age

      In case of continuous exposure (e.g., travellers) a booster is needed:

      • For people from 12 years of age who have been vaccinated with Nimenrix®, a booster is recommended after 10 years. For people vaccinated with Menveo® booster vaccination is recommended after 5 years
      • For children less than 12 years of age who received their primary immunisation before the age of 7 year, a booster dose 3 years after completion of the primary series and thereafter every 5 years is advised. For those who received their primary immunisation after the age of 7, a booster dose after 5 years is recommended. 
      • For pilgrimages to Mecca (Hajj or Umrah) the validity of the certificate remains 5 years.

      Administration of the vaccination certificate for pilgrims to Mecca

      People applying for a visa for a pilgrimage to Mecca (Hajj or Umrah) are required to present a certificate of vaccination against meningococcal ACW135Y, which must meet certain conditions:

      • The vaccine must have been administered at least 10 days before departure.
      • The vaccination certificate is usually valid for 3 years.
      • If a conjugate vaccine against (Nimenrix®, Menveo®) meningococcal ACW135Y is administered, the certificate is valid for 5 years provided that the doctor explicitly notes that it is a conjugate vaccine, and also notes the product name.
      • In theory, it does not need to be noted in the international certificate for vaccination and prophylaxis, but in practice this is often required.