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Meningococcal Groups A, C, Y, and W-135 Vaccine

Class: Vaccines
ATC Class: J07AH01
VA Class: IM100
Brands: Menactra, MenHibrix (combination), Menomune, Menveo

Introduction

Inactivated (polysaccharide) vaccine.1 108 152 228 Commercially available in US as conjugated meningococcal polysaccharide vaccine (MenACWY) and unconjugated meningococcal polysaccharide vaccine (MPSV4).1 105 108 152 228 There are 2 different conjugated (MenACWY) vaccines in US: meningococcal (groups A, C, Y and W-135) polysaccharide diphtheria toxoid conjugate vaccine (MenACWY-D; Menactra)108 and meningococcal (groups A, C, Y and W-135) oligosaccharide diphtheria CRM197 conjugate vaccine (MenACWY-CRM; Menveo).152 Unconjugated (MPSV4) vaccine available as meningococcal polysaccharide vaccine, groups A, C, Y and W-135 combined (MPSV4; Menomune).1 All 3 are quadrivalent vaccines containing A, C, Y, and W-135 capsular polysaccharide antigens extracted from Neisseria meningitidis.1 108 152 228 Fixed-combination vaccine containing 2 conjugated meningococcal capsular polysaccharide antigens (groups C and Y) with Haemophilus influenzae type b (Hib) tetanus toxoid conjugate vaccine (Hib-MenCY; MenHibrix) also available in US.227

Uses for Meningococcal Groups A, C, Y, and W-135 Vaccine

Prevention of Meningococcal Infection

Prevention of meningococcal infection caused by N. meningitidis serogroups A, C, Y, and W-135 in adults, adolescents, children, and infants ≥2 months of age.1 105 108 152 157 161 165 166 199 200 228

N. meningitidis can cause invasive meningococcal disease that usually presents as severe and potentially life-threatening meningitis and/or meningococcemia with abrupt onset;105 166 228 transmitted person to person by the respiratory route.6 105 166 228 In the US, N. meningitidis serogroups B, C, and Y cause most cases of meningococcal disease and serogroup W-135 causes a small percentage of cases;105 166 228 237 approximately 75% of cases in adults and adolescents ≥11 years are caused by serogroups C, Y, or W-135.105 166 Although overall incidence of meningococcal disease in the US has been historically low during the last 10–15 years,105 166 228 overall case fatality rate has remained 10–15% (even with anti-infective treatment)105 166 228 and fatality rate may be as high as 40% in those with meningococcemia.166 In addition, long-term sequelae (e.g., hearing loss, neurologic disability, digit or limb amputations) reported in 11–20% of patients.105 166 228 While 98% of US cases of meningococcal disease are sporadic, localized outbreaks do occur and most outbreaks have been caused by serogroups B and C.166 228

USPHS Advisory Committee on Immunization Practices (ACIP), AAP, and others recommend routine vaccination against meningococcal serogroups A, C, Y, and W-135 infection in all adolescents, preferably at 11 through 12 years of age, followed by a booster dose at 16 years of age.105 157 199 228 Catch-up vaccination recommended at 13 through 18 years of age for those not previously vaccinated;105 157 199 228 catch-up vaccination also recommended for all first-year college students through 21 years of age living in residence halls who did not receive a dose of meningococcal vaccine on or after their 16th birthday.200 228 (See Preexposure Vaccination Against Meningococcal Infection in High-risk Groups under Uses.)

ACIP, AAP, and others also recommend routine primary and booster vaccination against meningococcal serogroups A, C, Y, and W-135 infection in selected infants, children, adolescents, and adults at increased risk for the disease because of certain chronic medical conditions (e.g., persistent complement component deficiencies, anatomic or functional asplenia, HIV infection) or because they will be traveling to or residing in areas with hyperendemic or epidemic meningococcal disease caused by serogroups represented in the vaccine.105 157 161 199 228 Also recommended in some other individuals at increased risk (e.g., certain health-care and laboratory personnel, military recruits).156 157 199 200 228 235 (See Preexposure Vaccination Against Meningococcal Infection in High-risk Groups under Uses.)

Meningococcal groups A, C, Y, and W-135 vaccine may be used as an adjunct to anti-infective prophylaxis in household and other close contacts of individuals with invasive meningococcal disease105 228 235 when clusters or outbreaks are occurring and are caused by meningococcal serogroups represented in the vaccine (i.e., A, C, Y, W-135).62 105 199 228 (See Outbreak Control under Uses.)

MenACWY (Menactra, Menveo) is preferred for primary and booster vaccination or revaccination against meningococcal serogroups A, C, Y, and W-135 infection in infants ≥2 months of age, children, adolescents, and adults 19 through 55 years of age.157 166 199 200 228 ACIP and others state that MenACWY also is preferred in adults ≥56 years of age who previously received MenACWY if revaccination indicated or multiple booster doses anticipated (e.g., individuals at increased risk because of certain chronic medical conditions, laboratory personnel).228

ACIP and others state reserve use of MPSV4 (Menomune) for use in previously unvaccinated adults ≥56 years of age when a single dose of meningococcal groups A, C, Y, and W-135 vaccine is expected to be required (e.g., travelers, community outbreaks) and for use as an alternative in adults, adolescents, and children ≥2 years of age when MenACWY is unavailable or contraindicated.157 166 200 228

Although routine vaccination against meningococcal serogroups A, C, Y, and W-135 infection not recommended in infants who are not at increased risk,105 162 ACIP, AAP, and others state that the fixed-combination vaccine Hib-MenCY (MenHibrix) may be used for primary immunization against Hib in infants 6 weeks through 18 months of age who are at increased risk for meningococcal disease because of certain chronic medical conditions or because they reside in communities with outbreaks of meningococcal serogroup C or Y.162 199 228

MenACWY and MPSV4 provide protection only against N. meningitidis serogroups represented in the vaccines (i.e., serogroups A, C, Y, W-135);1 105 108 152 166 228 will not prevent meningococcal infection caused by other serogroups (e.g., serogroup B) and will not prevent infections caused by other pathogens.1 105 108 152 166 228

Hib-MenCY provides protection only against N. meningitidis serogroups C and Y;162 228 will not prevent meningococcal infection caused by other serogroups (e.g., serogroups A, B, W-135).162 228

Preexposure Vaccination Against Meningococcal Infection in High-risk Groups

Infants 6 weeks through 18 months of age who are receiving primary immunization against Hib infection and are at increased risk for invasive meningococcal infection because they have certain chronic medical conditions (e.g., persistent complement component deficiencies or anatomic or functional asplenia, including sickle cell disease) or reside in communities with outbreaks caused by meningococcal serogroup C or Y may receive Hib-MenCY (MenHibrix).162 199 228 Does not provide adequate protection for infants and children traveling to or residing in areas with high endemic rates of meningococcal disease since it does not provide protection against meningococcal serogroups A and W-135;162 199 228 unlikely to provide persistent protection against meningococcal infection until 11 through 12 years of age, the age of recommended routine adolescent meningococcal vaccination.162

Infants 2 through 23 months of age with certain chronic medical conditions (e.g., persistent complement component deficiencies, anatomic or functional asplenia, HIV infection) and those who will be traveling to or residing in areas where meningococcal infection is hyperendemic or epidemic are at increased risk for meningococcal infection and should receive routine primary and booster immunization against meningococcal serogroups A, C, Y, and W-135 infection using age-appropriate MenACWY (Menactra, Menveo).157 161 165 199 228 If Hib-MenCY (MenHibrix) was used for primary immunization in this age group, ACIP states a dose of MenACWY not necessary until usually recommended first booster dose indicated (i.e., 3 years after completion of the primary immunization series), unless infant will be traveling to or residing in areas with high endemic rates of meningococcal disease.228 Routine vaccination against meningococcal serogroups A, C, Y, and W-135 infection not recommended in infants not at increased risk.105 157 162 165

Children 2 through 10 years of age with certain chronic medical conditions (e.g., persistent complement component deficiencies, anatomic or functional asplenia, HIV infection) and those who will be traveling to or residing in areas where meningococcal infection is hyperendemic or epidemic are at increased risk for meningococcal infection and should receive routine primary and booster immunization against meningococcal serogroups A, C, Y, and W-135 infection using MenACWY (Menactra, Menveo).105 157 161 199 228 Routine vaccination against meningococcal serogroups A, C, Y, and W-135 infection not recommended in children 2 through 10 years of age not at increased risk for meningococcal disease.105 127 157 228

Adolescents 11 through 18 years of age are at increased risk for meningococcal infection and should receive routine primary immunization against meningococcal serogroups A, C, Y, and W-135 disease using MenACWY (Menactra, Menveo).105 157 199 228 ACIP, AAP, and others recommend a dose of MenACWY in all young adolescents at 11 through 12 years of age, followed by a booster dose of MenACWY at 16 years of age.105 157 199 228 Catch-up vaccination recommended at first opportunity for all older adolescents 13 through 18 years of age not vaccinated at 11 through 12 years of age.105 157 199 228 If first dose of MenACWY given at 13 through 15 years of age, a booster dose of MenACWY recommended at 16 through 18 years of age;157 199 228 booster dose not needed if first dose given at ≥16 years of age.157 199 228

College freshmen through 21 years of age living in dormitories are at increased risk for meningococcal infection and should receive primary immunization against meningococcal serogroups A, C, Y, and W-135 infection using MenACWY (Menactra, Menveo) if they did not receive a dose at ≥16 years of age.200 228

Individuals with persistent complement component deficiencies (e.g., inherited or chronic deficiencies in C3, C5–C9, properdin, factor D, factor H) or anatomic or functional asplenia (e.g., sickle cell disease) and those receiving eculizumab are at increased risk for invasive meningococcal disease,53 67 85 105 157 228 236 and ACIP, AAP, and others recommend routine age-appropriate primary and booster immunization against meningococcal serogroups A, C, Y, and W-135 infection using MenACWY.105 157 199 200 228 If not previously vaccinated, individuals undergoing elective splenectomy should receive MenACWY at least 14 days before surgery whenever possible.134

HIV-infected individuals are at increased risk for invasive meningococcal disease,119 156 161 166 228 and ACIP recommends routine age-appropriate primary and booster immunization against meningococcal serogroups A, C, Y, and W-135 infection in all HIV-infected adults, adolescents, children, and infants ≥2 months of age using MenACWY.161 Because HIV-infected individuals may not respond optimally to a single dose,157 199 200 228 use 2-dose primary series of MenACWY in all previously unvaccinated HIV-infected individuals ≥2 years of age.157 161 199 200 228 HIV-infected individuals ≥2 years of age who previously received only a single dose for primary immunization should receive a booster dose of MenACWY at the earliest opportunity (provided it has been ≥8 weeks after previous dose).161 Use usually recommended age-appropriate multiple-dose primary series of MenACWY in HIV-infected infants 2 months to <2 years of age.161 Consider that meningococcal vaccines may be less immunogenic in immunocompromised individuals.1 108 134 152 228 (See Individuals with Altered Immunocompetence under Cautions.)

Health-care and laboratory personnel with certain chronic medical conditions known to increase risk for meningococcal disease (e.g., persistent complement component deficiencies, anatomic or functional asplenia, HIV infection) and those who are routinely exposed to isolates of N. meningitidis or will be traveling to areas where meningococcal disease is hyperendemic or epidemic should be vaccinated against meningococcal serogroups A, C, Y, and W-135 disease.200 228 235 ACIP and Healthcare Infection Control Practices Advisory Committee (HICPAC) state that routine immunization against meningococcal serogroups A, C, Y, and W-135 disease is not recommended in other health-care personnel.235 However, in the setting of a community or institutional outbreak of meningococcal disease, vaccination of health-care personnel may be indicated if the outbreak is caused by a meningococcal serogroup represented in the vaccine.228 235 Regardless of vaccination status, postexposure anti-infective prophylaxis against meningococcal infection (i.e., 2-day regimen of oral rifampin or single dose of IM ceftriaxone, oral ciprofloxacin, or oral azithromycin) is recommended for all health-care personnel who have had unprotected (i.e., without wearing a mask) intensive contact (i.e., mouth-to-mouth resuscitation, endotracheal intubation or endotracheal tube management) with an infected patient.228 235

Military recruits are at increased risk for meningococcal disease228 and should receive a single dose of MenACWY.200 228

Travelers to and residents of areas where N. meningitidis is hyperendemic or epidemic are at risk for exposure to meningococcal disease and should be vaccinated against meningococcal serogroups A, C, Y, and W-135 infection.105 115 157 228 Although reported worldwide, highest incidence of meningococcal disease occurs in sub-Saharan Africa in area known as the “ meningitis belt” extending from Senegal and Guinea eastward to Ethiopia;43 44 45 115 228 meningococcal disease is hyperendemic in this region with epidemics occurring periodically during dry season (December through June).43 44 45 115 228 N. meningitidis serogroup A predominates in meningitis belt, but serogroups C, X, and W-135 also reported.115 ACIP, AAP, CDC, and others recommend age-appropriate primary immunization against meningococcal serogroups A, C, Y, and W-135 disease for individuals ≥2 months of age who will be traveling to or residing in hyperendemic or epidemic areas, including the meningitis belt during dry season, especially if prolonged contact with local populations is expected.75 101 115 157 199 228 In those previously vaccinated, booster dose of MenACWY recommended if it has been ≥5 years since last dose of meningococcal vaccine.228 Hib-MenCY (MenHibrix) does not provide adequate protection for infants traveling to or residing in areas with high endemic rates of meningococcal disease since it does not provide protection against meningococcal serogroups A and W-135.162 165 228 Immunization against meningococcal disease not a requirement for entry into any country, but officials in Saudi Arabia require that individuals ≥2 years of age traveling to their country for annual Hajj and Umrah pilgrimage must have a certificate of vaccination against meningococcal disease issued ≤3 years prior to arrival and those 3 months through 2 years of age must have documentation of 2 doses of vaccine against meningococcal serogroup A.115 228 The most recent information concerning geographic areas for which vaccination against meningococcal disease is recommended is available from international health clinics for travelers, state health departments, CDC at 877-394-8747, or CDC Travelers’ Health website ().115 228

Household and other close contacts of individuals with invasive meningococcal disease are at increased risk for meningococcal infection.14 62 79 105 228 Whenever a case of invasive meningococcal disease occurs, anti-infective prophylaxis (i.e., 2-day regimen of oral rifampin or single dose of IM ceftriaxone, oral ciprofloxacin, or oral azithromycin) is indicated for close contacts of index case (e.g., household contacts, day-care center contacts, individuals exposed to index case’s oropharyngeal secretions)79 105 228 and is principal means of preventing secondary cases.79 90 228 In some situations, meningococcal groups A, C, Y, and W-135 vaccine may be recommended as an adjunct to anti-infective prophylaxis.49 62 66 90 105 228

Outbreak Control

If a suspected outbreak of meningococcal disease occurs in US and is caused by vaccine-preventable serogroups of N. meningitidis, public health authorities will determine whether large-scale vaccination programs are indicated.62 105 199 228 Most meningococcal outbreaks in US are caused by serogroups B, C, and Y;166 228 each serotype is responsible for about one-third of cases.166 228

Whenever sporadic or cluster cases or outbreaks of meningococcal disease occur in US, anti-infective prophylaxis (i.e., 2-day regimen of oral rifampin or single dose of IM ceftriaxone, oral ciprofloxacin, or oral azithromycin) is principal means of preventing secondary cases in household and other close contacts.79 90 105 228

Mass vaccination programs to prevent meningococcal disease may be indicated in some meningococcal outbreaks;228 decision to implement such vaccination campaigns depends on whether the occurrence of >1 case represents an outbreak or an unusual clustering of endemic disease.228 If an outbreak occurs in the US, public health authorities will determine whether mass vaccinations (with or without mass anti-infective prophylaxis) are indicated.105 228 Consult CDC Meningitis and Vaccine Preventable Diseases Branch at 404-639-3158 for information on outbreaks and other issues regarding meningococcal disease.3

MenACWY, MPSV4, and Hib-MenCY indicated for meningococcal serogroup B outbreaks since they do not stimulate immunity to serogroup B.1 3 48 79 84 85 86 108 152 166 228

Meningococcal Groups A, C, Y, and W-135 Vaccine Dosage and Administration

Administration

MenACWY (Menactra, Menveo): Administer IM.108 152

MPSV4 (Menomune): Administer sub-Q.1

Hib-MenCY (MenHibrix): Administer IM.227

Syncope (vasovagal or vasodepressor reaction; fainting) may occur following vaccination;134 152 227 may be accompanied by transient neurologic signs (e.g., visual disturbance, paresthesia, tonic-clonic limb movements).227 Occurs most frequently in adolescents and young adults.134 Have procedures in place to avoid falling injury and restore cerebral perfusion following syncope.134 227 Syncope and secondary injuries may be averted if vaccinees sit or lie down during and for 15 minutes after vaccination.134 If syncope occurs, observe patient until symptoms resolve.134

May be given simultaneously with other age-appropriate vaccines.105 134 228 When multiple vaccines are administered during a single health-care visit, give each parenteral vaccine with a different syringe and at different injection site.134 228 Separate injection sites by at least 1 inch (if anatomically feasible) to allow appropriate attribution of any local adverse effects that may occur.134

IM Administration

Depending on patient age, administer IM into deltoid muscle or anterolateral thigh.134 In infants and children 6 weeks to 2 years of age, anterolateral thigh is preferred;134 227 alternatively, deltoid muscle can be used in those 1 through 2 years of age if muscle mass is adequate.134 227 In adults, adolescents, and children ≥3 years of age, deltoid muscle is preferred.134 152

To ensure delivery into muscle, make IM injections at a 90° angle to the skin using a needle length appropriate for the individual’s age and body mass, thickness of adipose tissue and muscle at injection site, and injection technique.134 149 150 Consider anatomic variability, especially in the deltoid;149 150 use clinical judgment to avoid inadvertent underpenetration or overpenetration of muscle.149 150

Avoid injection into gluteal area or into or near blood vessels or nerves.134 Generally do not administer vaccines into gluteal area or any area where there may be a major nerve trunk.134 If the gluteal muscle is chosen for infants <12 months of age because of special circumstances (e.g., physical obstruction of other sites), it is essential that clinician identify anatomic landmarks prior to injection.134

MenACWY-D (Menactra)

Administer only by IM injection.108

Do not dilute.108

Shake well prior to use.108 Should appear as a clear to slightly turbid liquid;108 discard if it contains particulate matter, appears discolored, or cannot be resuspended with thorough agitation.108

Do not mix with any other vaccine.108

MenACWY-CRM (Menveo)

Administer only by IM injection.152

Supplied by manufacturer as 2 components that must be combined prior to administration: single-dose vial containing meningococcal A conjugate component (MenA) in lyophilized form and single-dose vial containing liquid meningococcal C, Y, and W-135 conjugate component (MenCYW-135).152

Withdraw entire contents of vial containing liquid component into a syringe and inject into vial containing lyophilized component.152 Invert vial;152 shake well until completely dissolved.152

Reconstituted vaccine should be a clear, colorless solution;152 do not use if it contains particulate matter or appears discolored.152

Use immediately after reconstitution;152 may be stored at ≤25°C for up to 8 hours.152 (See Storage under Stability.)

Do not mix individual components or reconstituted vaccine with any other vaccine or diluent.152

Hib-MenCY (MenHibrix)

Administer only by IM injection.227

Reconstitute single-dose vial of lyophilized vaccine by adding 0.6 mL of 0.9% sodium chloride diluent supplied by the manufacturer;227 shake well.227 Consult manufacturer’s labeling for specific information regarding reconstitution.227

Administer immediately after reconstitution.227

Do not mix with any other vaccine.227

Sub-Q Administration

MPSV4 (Menomune)

Administer only by sub-Q injection, preferably into the deltoid.1

To ensure appropriate delivery, make sub-Q injections at a 45° angle using a 5/8-inch, 23- to 25-gauge needle.134

Reconstitute single-dose vial of lyophilized vaccine by adding 0.6 mL of diluent supplied by the manufacturer (sterile, preservative-free distilled water).1

Reconstitute multiple-dose vial of lyophilized vaccine by adding 6 mL of diluent supplied by the manufacturer (sterile distilled water containing thimerosal as a preservative).1 (See Thimerosal Precautions under Cautions.)

Swirl vial until vaccine is completely dissolved.1 Reconstituted vaccine is a clear, colorless solution.1

Use single-dose vial immediately after reconstitution.1

Multiple-dose vial may be stored at 2–8°C after reconstitution;1 use within 35 days.1

Do not mix with any other vaccine.1

Dosage

Dosing schedule (i.e., number of primary and booster doses) and specific vaccine administered (MenACWY [Menactra, Menveo], MPSV4 [Menomune], Hib-MenCY [MenHibrix]) depend on individual’s age, immunization status, and risk factors.1 108 152 227 228 Follow age-appropriate recommendations for specific preparation used.1 108 152 227 228

ACIP, AAP, and others state that MenACWY (Menactra, Menveo) is preferred meningococcal vaccine for primary and booster immunization against N. meningitidis serogroups A, C, Y, and W-135 in infants and children 2 months through 10 years, adolescents 11 through 18 years, and adults 19 through 55 years of age.157 199 200 228 MPSV4 (Menomune) usually reserved for use in unvaccinated adults ≥56 years of age when single dose indicated and as an alternative in adults, adolescents, and children ≥2 years of age when MenACWY unavailable or contraindicated.166 228 (See Uses.)

Limited data suggest that MenACWY-D (Menactra) and MenACWY-CRM (Menveo) can be used interchangeably.157 228 Although ACIP states that same MenACWY vaccine should be used for all doses in the vaccination series whenever feasible,153 161 these experts and AAP state that any age-appropriate MenACWY vaccine can be used if previously used vaccine is not available or not known.153 157 161

Pediatric Patients

Preexposure Vaccination Against Meningococcal Serogroups A, C, Y, and W-135 in High-risk Groups
Infants 6 Weeks through 18 Months of Age (Hib-MenCY; MenHibrix)
IM

Each dose is 0.5 mL.227

Primary immunization in previously unvaccinated infants: Use a series of 4 doses.162 199 227 228 Give doses at 2, 4, 6, and 12 through 15 months of age.199 227 228

Although initial dose usually given at 2 months of age, may be given as early as 6 weeks of age.162 227 228 Fourth dose may be given as late as 18 months of age.162 227 228

If first dose given at ≥12 months of age, give a series of 2 doses at least 8 weeks apart.162 228

Booster doses in those who received primary immunization with Hib-MenCY and remain at prolonged increased risk for meningococcal disease: ACIP recommends a dose of MenACWY (Menactra, Menveo) at 3 years after completion of the primary immunization series and every 5 years thereafter.228

Infants 2 through 23 Months of Age (MenACWY-CRM; Menveo)
IM

Each dose is 0.5 mL.152

Primary immunization in infants 2 months of age at increased risk because of certain chronic medical conditions (e.g., persistent complement component deficiencies, anatomic or functional asplenia, HIV infection) or travel to areas with hyperendemic or epidemic meningococcal disease: Use a series of 4 doses.152 161 165 199 Give doses at 2, 4, 6, and 12–15 months of age.152 161 199

Primary immunization in previously unvaccinated infants 7 through 23 months of age at increased risk because of certain chronic medical conditions (e.g., persistent complement component deficiencies, anatomic or functional asplenia, HIV infection) or travel to areas with hyperendemic or epidemic meningococcal disease: Use 2-dose regimen.152 161 199 Give second dose in second year of life and at least 3 months (12 weeks) after first dose.152 161 199

Booster doses in those who remain at prolonged increased risk for meningococcal disease: ACIP and AAP recommend a booster dose of MenACWY at 3 years after completion of primary immunization series and every 5 years thereafter.105 157 161 228

Infants 9 through 23 Months of Age (MenACWY-D; Menactra)
IM

Each dose is 0.5 mL.108

Primary immunization in those at increased risk because of certain chronic medical conditions (e.g., persistent complement component deficiencies, anatomic or functional asplenia, HIV infection) or travel to areas with hyperendemic or epidemic meningococcal disease: Give 2 doses 3 months apart (minimum 8 weeks apart).105 108 157 161 199 228 If necessary before travel, AAP states the doses can be given 2 months apart.105 157

Booster doses in those who remain at prolonged increased risk for meningococcal disease: ACIP and AAP recommend a booster dose of MenACWY at 3 years after completion of primary immunization series and every 5 years thereafter.105 157 161 228

Children 2 through 10 Years of Age (MenACWY-D; Menactra or MenACWY-CRM; Menveo)
IM

Each dose is 0.5 mL.108 152

Primary immunization in those at increased risk because of certain chronic medical conditions (e.g., persistent complement component deficiencies, anatomic or functional asplenia, HIV infection): ACIP, AAP, and others recommend 2 doses of MenACWY given 2–3 months apart (minimum 8 weeks apart).105 157 161 199 228

Primary immunization in those at increased risk because they are travelers to or residents of areas with hyperendemic or epidemic meningococcal disease: ACIP and AAP recommend a single dose of MenACWY.105 157 228

Booster doses in those who received primary immunization at 2 through 6 years of age and remain at prolonged increased risk for meningococcal disease: ACIP and AAP recommend a booster dose of MenACWY at 3 years after completion of primary immunization series and every 5 years thereafter.105 157 161 228

Booster doses in those who received primary immunization at ≥7 years of age and remain at prolonged increased risk for meningococcal disease: ACIP and AAP recommend a booster dose of MenACWY at 5 years after completion of primary immunization series and every 5 years thereafter.105 157 161 228

MenACWY-D (Menactra): Manufacturer states a single dose can be used for primary immunization.108

MenACWY-CRM (Menveo): Manufacturer states a single dose can be used for primary immunization and a second dose may be administered 2 months after first dose in those 2 through 5 years of age at increased risk.152

Children 2 through 10 Years of Age (MPSV4; Menomune)
Sub-Q

Each dose is 0.5 mL.1

Manufacturer states a single dose can be used for primary immunization.1

Booster doses in those who received primary immunization with MPSV4 at 2 through 6 years of age and remain at prolonged increased risk for meningococcal disease: ACIP and AAP recommend a booster dose of meningococcal vaccine at 3 years after primary immunization and every 5 years thereafter (preferably using MenACWY).105 161 228

Booster doses in those who received primary immunization with MPSV4 at ≥7 years of age and remain at prolonged increased risk for meningococcal disease: ACIP and AAP recommend a booster dose of meningococcal vaccine at 5 years after primary immunization and every 5 years thereafter (preferably using MenACWY).105 161 228

Adolescents 11 through 18 Years of Age (MenACWY-D; Menactra or MenACWY-CRM; Menveo)
IM

Each dose is 0.5 mL.108 152

Routine primary immunization in adolescents: ACIP, AAP, and others recommend a primary dose of MenACWY at 11 through 12 years of age, followed by a booster dose of MenACWY at 16 years of age.105 157 199 228

Catch-up vaccination recommended at first opportunity for all adolescents 13 through 18 years of age not vaccinated at 11 through 12 years of age.105 157 199 228 If first dose of MenACWY given at 13 through 15 years of age, give a booster dose at 16 through 18 years of age (at least 8 weeks after first dose);157 199 228 booster dose not needed if first dose of MenACWY was given at ≥16 years of age.157 199 228

Primary immunization in adolescents 11 through 18 years of age at increased risk because of certain chronic medical conditions (e.g., persistent complement component deficiencies, anatomic or functional asplenia, HIV infection): ACIP, AAP, and others recommend 2 doses of MenACWY given 2–3 months apart (minimum 8 weeks apart).105 157 161 199 228 For those who remain at prolonged increased risk for meningococcal disease, give booster dose of MenACWY every 5 years.161 166 200 228

Manufacturers state a single dose can be used for primary immunization.108 152

Adolescents 11 through 18 Years of Age (MPSV4; Menomune)
Sub-Q

Each dose is 0.5 mL.1

Manufacturer states a single dose can be used for primary immunization.1

ACIP and others recommend that individuals who received primary immunization with MPSV4 and remain at prolonged increased risk for meningococcal disease should receive a booster dose of meningococcal vaccine every 5 years (preferably using MenACWY).166 200 228

Adults

Preexposure Vaccination Against Meningococcal Infection in High-risk Groups
Adults ≥19 Years of Age (MenACWY-D; Menactra or MenACWY-CRM; Menveo)
IM

Each dose is 0.5 mL.108 152

Primary immunization in adults 19 through 55 years of age at increased risk because of certain chronic medical conditions (e.g., persistent complement component deficiencies, anatomic or functional asplenia, HIV infection): ACIP and others recommend 2 doses of MenACWY given 2–3 months apart (minimum 8 weeks apart).161 200 228

Primary immunization in adults 19 through 55 years of age at increased risk because they are health-care or laboratory personnel, military recruits, or travelers to or residents of areas with hyperendemic or epidemic meningococcal disease: ACIP and others recommend a single dose of MenACWY.200 228

Booster doses in those who remain at prolonged increased risk for meningococcal disease: ACIP and others recommend a booster dose of MenACWY every 5 years.161 200 228

Adults ≥56 years of age: ACIP recommends MenACWY when revaccination indicated or multiple booster doses anticipated in those who previously received MenACWY.161 228

Manufacturers state a single dose can be used for primary immunization.108 152

Adults ≥19 Years of Age (MPSV4; Menomune)
Sub-Q

Each dose is 0.5 mL.1

Manufacturer states a single dose can be used for primary immunization.1

ACIP and others recommend that adults who received primary immunization with MPSV4 and remain at prolonged increased risk for meningococcal disease should receive a dose of meningococcal vaccine every 5 years (preferably using MenACWY).166 200 228

Special Populations

Hepatic Impairment

No specific dosage recommendations.

Renal Impairment

No specific dosage recommendations.

Geriatric Patients

MPSV4 (Menomune): No specific dosage recommendations in this age group.1 166

MenACWY (Menactra, Menveo): Not labeled by FDA for use in individuals ≥56 years of age.108 152 (See Geriatric Use under Cautions.)

Cautions for Meningococcal Groups A, C, Y, and W-135 Vaccine

Contraindications

  • MenACWY-D (Menactra): Severe allergic reaction (e.g., anaphylaxis) after previous dose of the vaccine, any vaccine component, or any vaccine containing meningococcal capsular polysaccharide, diphtheria toxoid, or diphtheria CRM197.108

  • MenACWY-CRM (Menveo): Severe allergic reaction (e.g., anaphylaxis) after previous dose of the vaccine or any vaccine containing meningococcal antigens, diphtheria toxoid, or diphtheria CRM197.152

  • MPSV4 (Menomune): Severe allergic reaction (e.g., anaphylaxis) to the vaccine or any vaccine component.1

  • Hib-MenCY (MenHibrix): Severe allergic reaction (e.g., anaphylaxis) to the vaccine, any vaccine component, or any vaccine containing meningococcal, Hib, or tetanus antigens.227

Warnings/Precautions

Sensitivity Reactions

Hypersensitivity Reactions

MenACWY (Menactra, Menveo): Hypersensitivity reactions (e.g., anaphylactic/anaphylactoid reaction, wheezing, difficulty breathing, upper airway swelling, urticaria, erythema, pruritus, hypotension, erythema multiforme) reported rarely.108 146 152

MPSV4 (Menomune): Hypersensitivity reactions (e.g., anaphylaxis, rash, urticaria, pruritus, dyspnea, angioedema) reported;1 hypersensitivity reactions also reported with other unconjugated vaccines, including bivalent (groups A and C) meningococcal vaccines (not commercially available in US) and monovalent (group A) meningococcal vaccine (not commercially available in US).22 73

Hib-MenCY (MenHibrix): Allergic reactions (e.g., anaphylactic/anaphylactoid reactions, angioedema) reported.227

Prior to administration, take all known precautions to prevent adverse reactions, including a review of patient’s history with respect to possible hypersensitivity to the vaccine, vaccine components, or similar vaccines.1 108 152 227

Epinephrine and other appropriate agents and equipment should be readily available in case anaphylaxis or other serious allergic reaction occurs.1 108 152 227

Latex Sensitivity

MPSV4 (Menomune): Packaging components (i.e., vial stoppers) contain dry natural rubber latex.1

Some individuals may be hypersensitive to natural latex proteins.1 134 Take appropriate precautions if MPSV4 (Menomune) is administered to individuals with history of latex sensitivity.1 134

ACIP states that vaccines supplied in vials or syringes containing dry natural rubber or natural rubber latex may be administered to individuals with latex allergies other than anaphylactic allergies (e.g., history of contact allergy to latex gloves), but should not be used in those with a history of severe (anaphylactic) allergy to latex unless the benefits of vaccination outweigh the risk of a potential allergic reaction.134 Contact-type allergy is the most common type of latex sensitivity.134

Thimerosal Allergy

MPSV4 (Menomune): Following reconstitution, multiple-dose vials contain thimerosal (25 mcg of mercury per 0.5-mL dose).1 129 (See Thimerosal Precautions under Cautions.)

Hypersensitivity reactions to thimerosal contained in vaccines reported in some individuals.129 132 137 139 These reactions usually manifest as local, delayed-type hypersensitivity reactions (e.g., erythema, swelling),129 132 134 but a generalized reaction manifested as pruritus and an erythematous, maculopapular rash on all 4 extremities has been reported rarely.139 Even when patch or intradermal tests for thimerosal sensitivity are positive, most individuals do not develop hypersensitivity reactions to thimerosal administered as a component of vaccines.132 134

ACIP states that a history of delayed-type hypersensitivity to thimerosal is not a contraindication to use of vaccines that contain thimerosal.134

Guillain-Barré Syndrome

MenACWY-D (Menactra): Postmarketing reports of Guillain-Barré Syndrome (GBS) temporally associated with vaccination.108 109 110 122 123 124

GBS is a serious neurologic disorder involving inflammatory demyelination of peripheral nerves and may occur spontaneously or after certain antecedent events (e.g., infections).110 111 Characterized by subacute onset of progressive, symmetrical weakness in legs and arms, with loss of reflexes.110 Sensory abnormalities, cranial nerve involvement, and paralysis of respiratory muscles may also develop.110 GBS can be fatal; up to 20% of hospitalized patients may have prolonged disability.110

FDA and CDC investigating possible relationship between MenACWY-D (Menactra) and GBS.109 110 111 122 123 124 As of February 2008, the Vaccine Adverse Events Reporting System (VAERS) had received 26 confirmed case reports of GBS occurring within 6 weeks of MenACWY-D vaccination.124 Most cases occurred in vaccine recipients 11 through 19 years of age.110 122 123 124 Although rate of GBS among recipients of MenACWY-D based on cases reported within 6 weeks of vaccination is similar to number of expected cases in this age group over a 6-week period, timing of onset of neurologic symptoms relative to vaccination is of concern.124

GBS risk following administration of MenACWY-D (Menactra) evaluated retrospectively using data from >9 million individuals 11 through 18 years of age (15% received MenACWY).108 Based on 72 chart-confirmed cases of GBS, no patients received MenACWY-D within 42 days of symptom onset.108 Additional 129 cases of potential GBS could not be confirmed or excluded using chart review.108 GBS risk estimated to range from 0–5 additional cases per 1 million vaccinees within 6 weeks following vaccination.108

Because of known risk for meningococcal exposure and limited data indicating an association between MenACWY-D vaccination and GBS, CDC continues to recommend routine vaccination with MenACWY for adolescents, college freshmen living in dormitories, and other populations at increased risk for infection.123 124

MenACWY-D (Menactra): Manufacturer states that individuals with history of GBS may be at increased risk of GBS following administration of the vaccine;108 take into account benefits and risks of immunization before deciding to administer MenACWY-D.108

MenACWY-CRM (Menveo): Manufacturer states that, because GBS reported in temporal relationship following administration of another US quadrivalent polysaccharide meningococcal conjugate vaccine, take into account potential benefits and risks when deciding to administer the vaccine in an individual with a history of GBS.152

Hib-MenCY (MenHibrix): Manufacturer states that, if GBS occurred within 6 weeks of receipt of a vaccine containing tetanus toxoid, base decision to administer a dose of any vaccine containing tetanus toxoid (including Hib-MenCY) on careful consideration of potential benefits and possible risks.227

After reviewing available safety data, ACIP concluded that benefits of meningococcal vaccination outweigh risks of GBS recurrence in individuals with history of GBS.228

Clinicians should remain alert to possibility of vaccine-associated GBS and report any suspected cases to VAERS at 800-822-7967 or .109 110 111 123 124

Individuals with Altered Immunocompetence

May be administered to individuals immunosuppressed as the result of disease or immunosuppressive therapy.134 161 228 Consider possibility that the immune response to the vaccine and efficacy may be reduced in these individuals.1 108 134 152 227 228

MenACWY (Menactra, Menveo): Immunogenicity not specifically studied in immunocompromised individuals.108 152 Age-appropriate regimen of MenACWY recommended by ACIP for routine primary and booster immunization against meningococcal serogroups A, C, Y, and W-135 infection in HIV-infected individuals ≥2 months of age.161 (See Preexposure Vaccination Against Meningococcal Infection in High-risk Groups under Uses.)

MPSV4 (Menomune): Data not available regarding use in HIV-infected adults.161

Hib-MenCY (MenHibrix): Safety and efficacy not evaluated in immunosuppressed children.227

If possible, administer meningococcal vaccine prior to initiation of immunosuppressive therapy or defer until immunosuppressive therapy is discontinued.134 (See Specific Drugs under Interactions.)

Concomitant Illness

A decision to administer or delay vaccination in an individual with a current or recent acute illness depends on the severity of symptoms and etiology of the illness.108 134

ACIP, AAP, and others state that minor acute illness, such as mild upper respiratory infection (with or without fever) or mild diarrhea, usually does not preclude vaccination.105 134 Generally defer vaccination of individuals with moderate or severe acute illness until they have recovered from the acute phase of the illness.1 105 134

Individuals with Bleeding Disorders

ACIP states that vaccines may be given IM to individuals who have bleeding disorders or are receiving anticoagulant therapy if a clinician familiar with the patient’s bleeding risk determines that the preparation can be administered with reasonable safety.134 In these cases, use a fine needle (23 gauge) to administer the vaccine and apply firm pressure to the injection site (without rubbing) for ≥2 minutes.134 If patient is receiving antihemophilia therapy, administer the IM vaccine shortly after a scheduled dose of such therapy.134

Advise individual and/or their family about the risk of hematoma from IM injections.134

Thimerosal Precautions

Although there is no convincing evidence that the low concentrations of thimerosal (a mercury-containing preservative) contained in some vaccines is harmful to vaccine recipients,11 134 135 138 140 141 142 143 144 145 efforts to eliminate or reduce the thimerosal content in vaccines is recommended as a prudent measure to reduce mercury exposure in infants and children and part of an overall strategy to reduce mercury exposures from all sources, including food and drugs.102 103 104 133 134

It was suggested that thimerosal in vaccines theoretically could have adverse effects in vaccine recipients; however, there is no conclusive evidence that the low levels of thimerosal contained in vaccines cause harm in vaccine recipients.11 133 134 135 138 140 141 142 143 144 145 A link between thimerosal in vaccines and neurodevelopmental disorders in children (autism, attention deficit/hyperactivity disorder [ADHD], speech or language delay) possibly related to mercury neurotoxicity has been theorized; however, considerable evidence has accumulated that supports the absence of substantial risk for neurodevelopmental disorders or other harm resulting from exposure to thimerosal-containing vaccines.11 135 138 140 141 142 143 144 145 In 2004, the Immunization Safety Review Committee of the IOM examined the hypothesis that thimerosal-containing vaccines are causally associated with autism and concluded that the body of epidemiological evidence favors rejection of a causal relationship between these vaccines and autism.145

MPSV4 (Menomune): Following reconstitution with the diluent supplied by the manufacturer, multiple-dose vials contain thimerosal (25 mcg of mercury per 0.5-mL dose).1 Menomune supplied in single-dose vials and reconstituted with the preservative-free diluent supplied by the manufacturer does not contain thimerosal.1

MenACWY (Menactra, Menveo) and Hib-MenCY (MenHibrix): Do not contain thimerosal or any other preservative.108 152 227

Use of Combination Vaccines

Hib-MenCY (MenHibrix): Combination vaccine containing meningococcal and Hib antigens;227 consider cautions, precautions, and contraindications associated with each antigen.227 Do not use concomitantly with any other Hib vaccine.228

Limitations of Vaccine Effectiveness

May not protect all vaccine recipients against meningococcal infection.1 105 108

Protective antibody levels may be achieved within 7–10 days after vaccination.115

MenACWY (Menactra, Menveo) and MPSV4 (Menomune) provide protection only against those meningococcal serogroups represented in the vaccines (i.e., serogroups A, C, Y, W-135).1 105 108 152 166 228 Will not prevent infection caused by other serogroups (e.g., serogroup B) and will not prevent infections caused by other pathogens.1 105 108 152 166 228

Hib-MenCY (MenHibrix) contains antigens representing only 2 meningococcal serogroups (i.e., serogroups C, Y) and will not prevent infection caused by other serogroups (e.g., serogroups A, B, W-135).162 228 Although Hib-MenCY contains Hib antigen conjugated to tetanus toxoid, this vaccine is not a substitute for routine immunization against tetanus.227

Extent and duration of the immunologic response to MPSV4 (Menomune) vary depending on the age of the recipient; the vaccine is less immunogenic in children <2 years of age than in older children and adults.9 24 28 31 42 46 62 84 85 86 228 Although children as young as 3 months of age may have an immunologic response to the group A antigen contained in the vaccine, response to the other antigens is poor in children <2 years of age.105 228

While there is evidence that meningococcal vaccines can stimulate antibody responses in individuals with inherited complement deficiencies and individuals without spleens, efficacy not fully established in these individuals and the vaccines may not provide complete protection.134 (See Preexposure Vaccination Against Meningococcal Infection in High-risk Groups under Uses.)

Duration of Immunity

Duration of immunity after primary immunization with MenACWY (Menactra, Menveo) or MPSV4 (Menomune) not fully determined.105 108 152 228

Because MPSV4 (Menomune) is an unconjugated vaccine, the vaccine antigens do not induce long-lasting immunity or an anamnestic response after subsequent exposure to the same antigens.134 228 Bactericidal antibodies formed in response to MPSV4 decline markedly during the first 2–3 years after vaccination.1 30 50 69 228 Although levels of anticapsular antibody after vaccination with MPSV4 are likely to persist in school-aged children and adults for ≥3 years,1 30 39 50 69 75 106 levels decline more rapidly in infants and children <5 years of age.1 3 29 70 71 228

Although MenACWY (Menactra, Menveo) is expected to provide a longer duration of protection than MPSV4,228 additional studies needed to determine relative duration of protection after primary immunization as well as duration of protection when individuals are revaccinated with conjugated or unconjugated vaccine after previously receiving the other vaccine type.106

Meningococcal antigens in MenACWY are conjugated to protein carriers containing T-cell epitopes.108 152 228 This may result in improved primary response to the antigens and strong anamnestic response after reexposure to the antigens and may result in longer-lasting immunity than that provided by unconjugated vaccine.108 134 152 228

Because of waning immunity, a single dose of MenACWY (Menactra, Menveo) administered at 11 through 12 years of age is unlikely to provide protection against meningococcal disease through 16 through 21 years of age.228 Duration of protective antibody after a booster dose of MenACWY given at 16 through 18 years of age is not known, but is expected to last at least through 21 years of age.228

Revaccination or booster doses of MenACWY (Menactra, Menveo) may be necessary in individuals who previously received MenACWY or MPSV4 and continue to be at prolonged increased risk for exposure to meningococcal infection.1 105 161 157 200 228 (See Dosage under Dosage and Administration.)

Improper Storage and Handling

Improper storage or handling of vaccines may reduce vaccine potency resulting in reduced or inadequate immune response in vaccinees.134

Inspect all vaccines upon delivery and monitor during storage to ensure that the appropriate temperature is maintained.134

Do not administer meningococcal vaccine that has been mishandled or has not been stored at the recommended temperature.134 (See Storage under Stability.) If there are concerns about mishandling, contact the manufacturer or state or local immunization or health departments for guidance on whether the vaccine is usable.134

Specific Populations

Pregnancy

MenACWY-D (Menactra): Category C.108 Pregnancy registry at 800-822-2463.108 Instruct clinicians or vaccinees to report any exposure to the vaccine that occurs during pregnancy.108

MenACWY-CRM (Menveo): Category B.152 Pregnancy registry at 877-311-8972.152 Instruct clinicians or vaccinees to report any vaccine exposures that occur during pregnancy.152

MPSV4 (Menomune): Category C.1

Hib-MenCY (MenHibrix): Category C.227 Not labeled by FDA for use in adolescents or adults.227

ACIP and AAP state MenACWY or MPSV4 may be used during pregnancy if indicated in a woman at increased risk of meningococcal disease.105 228

Lactation

Not known whether antigens contained in meningococcal vaccine are distributed into milk.1 108 152 Because inactivated vaccines do not multiply within the body, ACIP states these vaccines should not pose any unusual problems for lactating women or their infants.134

MenACWY (Menactra, Menveo) and MPSV4 (Menomune): Manufacturers state use with caution in nursing women.1 108 152

Hib-MenCY (MenHibrix): Not labeled by FDA for use in adults, including lactating women.227

Pediatric Use

MenACWY-D (Menactra): Safety and efficacy not established in pediatric patients <9 months of age.108

MenACWY-CRM (Menveo): Safety and efficacy not established in pediatric patients <2 months of age.152

MPSV4 (Menomune): Safety and efficacy not established in children <2 years of age.1 Has been used in children 3–24 months of age for short-term protection against meningococcal serogroup A in infants traveling to an area hyperendemic or epidemic for meningococcal disease or for outbreak control.71 76 90 105 (See Prevention of Meningococcal Infection under Uses.)

Hib-MenCY (MenHibrix): Safety and efficacy not established in infants <6 weeks of age or in infants or children >18 months of age.227

Apnea reported following IM administration of vaccines in some infants born prematurely.152 227 Base decisions regarding when to administer an IM vaccine in premature infants on consideration of the individual infant's medical status and potential benefits and possible risks of vaccination.152 227

Geriatric Use

MenACWY-D (Menactra): Safety and efficacy not established in adults ≥56 years of age, including geriatric adults.108 ACIP recommends use in certain adults in this age group.228 (See Prevention of Meningococcal Infection under Uses.)

MenACWY-CRM (Menveo): Safety and efficacy not established in adults ≥56 years of age, including those ≥65 years of age.152 ACIP recommends use in certain adults in this age group.228 (See Prevention of Meningococcal Infection under Uses.)

MPSV4 (Menomune): May be used in geriatric adults.1 Clinical studies did not include sufficient numbers of individuals ≥65 years of age to determine whether they respond differently than younger adults.1

Hib-MenCY (MenHibrix): Not labeled by FDA for use in adults, including geriatric adults.227

Common Adverse Effects

MenACWY-D (Menactra): Injection site reactions (e.g., pain, induration, erythema, swelling), headache, fatigue, malaise, arthralgia, diarrhea, anorexia, chills, fever, vomiting, rash.108

MenACWY-CRM (Menveo): Injection site reactions (tenderness, erythema), irritability, sleepiness, persistent crying, change in eating habits, vomiting, diarrhea in infants 2 through 23 months of age; injection site reactions (pain, erythema, induration), irritability, sleepiness, malaise, headache in children 2 through 10 years of age;152 injection site pain, headache, myalgia, malaise, nausea in adults and adolescents.152

MPSV4 (Menomune): Injection site reactions (e.g., pain, erythema, induration, swelling), headache, malaise, chills, fever.1

Hib-MenCY (MenHibrix): Injection site reactions (e.g., pain, redness, swelling), systemic effects (e.g., fever, irritability, drowsiness, loss of appetite).227

Interactions for Meningococcal Groups A, C, Y, and W-135 Vaccine

Other Vaccines

Although specific studies may not be available,1 152 simultaneous administration with other age-appropriate vaccines, including live virus vaccines, toxoids, or inactivated or recombinant vaccines, during the same healthcare visit is not expected to affect immunologic responses or adverse reactions to any of the preparations.1 90 105 108 134 228 Immunization with meningococcal vaccine can be integrated with immunization against diphtheria, tetanus, pertussis, Hib, hepatitis A, hepatitis B, human papillomavirus (HPV), influenza, measles, mumps, rubella, pneumococcal disease, poliomyelitis, and varicella.105 134 Each parenteral vaccine should be administered using a different syringe and different injection site.105 134 228

Specific Drugs

Drug

Interaction

Comments

Diphtheria and tetanus toxoids and pertussis vaccine adsorbed (DTaP)

MenACWY-D (Menactra): Limited data suggest interference with immune response to meningococcal antigens when administered after DTaP in children 2 though 6 years of age228

Hib-MenCY (MenHibrix): Concurrent administration with DTaP-HepB-IPV (Pediarix) and pneumococcal 7-valent conjugate vaccine (PCV7; Prevnar; no longer commercially available in US) in infants at 2, 4, and 6 months of age did not reduce antibody response to DTaP or the other antigens227

MenACWY-D (Menactra): In children 2 through 6 years of age, administer before, simultaneously with, or >6 months after DTaP;228 if administered inadvertently within 6 months after DTaP, no need to repeat dose;228 if child is traveling to high-risk area or is at risk during a community outbreak, administer regardless of interval since DTaP228

MenACWY-CRM (Menveo): May be administered simultaneously with or at any interval before or after DTaP228

Hib vaccine

Meningococcal and Hib vaccines may be administered simultaneously (using separate syringes and separate injection sites)105

Alternatively, fixed-combination vaccine (Hib-MenCY; MenHibrix) can be used when Hib vaccine is indicated in infants 6 weeks through 18 months of age at increased risk for meningococcal disease162 227 228

Hepatitis B (HepB) vaccine

Hib-MenCY (MenHibrix): Concurrent administration with DTaP-HepB-IPV (Pediarix) and PCV7 (Prevnar) in infants at 2, 4, and 6 months of age did not reduce antibody response to HepB or the other antigens227

HPV vaccine

MenACWY-D (Menactra): Concurrent administration with Tdap (Adacel) and with either quadrivalent HPV vaccine (4vHPV; Gardasil) or 9-valent HPV vaccine (9vHPV; Gardasil 9) at 3 different injection sites in adolescents did not interfere with antibody responses to any of the vaccine antigens;231 232 increased incidence of swelling at 4vHPV or 9vHPV injection site compared with administration of the HPV vaccine alone231 232

MenACWY-CRM (Menveo): Concurrent administration with 4vHPV and Tdap in adolescents 11 through 18 years of age did not interfere with immune response to the meningococcal antigens;152 systemic adverse reactions were more frequent in those receiving MenACWY-CRM with 4vHPV and Tdap compared with those receiving MenACWY-CRM alone152

MenACWY-D (Menactra): May be administered simultaneously with 4vHPV using separate syringes and separate injection sites232

Immune globulin (immune globulin IM [IGIM], immune globulin IV [IGIV]) or specific immune globulin (hepatitis B immune globulin [HBIG], rabies immune globulin [RIG], tetanus immune globulin [TIG], varicella zoster immune globulin [VZIG])

No evidence that immune globulin preparations interfere with immune response to inactivated vaccines134

Meningococcal vaccine may be given simultaneously with or at any interval before or after immune globulin preparations134

Immunosuppressive agents (e.g., alkylating agents, antimetabolites, corticosteroids, radiation)

Potential for decreased antibody response to vaccines1 61 72 108 134 152 227 228

If possible, avoid vaccination during chemotherapy or radiation134

Meningococcal vaccine may be administered at least 2 weeks before initiation of immunosuppressive therapy or deferred until ≥3 months after such therapy is discontinued134

Consider patients unvaccinated if they received meningococcal vaccine during or within 14 days before starting immunosuppressive therapy; revaccinate at least 3 months after such therapy is discontinued if immunocompetence restored134

Measles, mumps, and rubella vaccine (MMR)

MenACWY-D (Menactra): Concurrent administration with MMR and VAR (or MMRV) and PCV7 (Prevnar) in infants 12 months of age did not affect antibody responses to MMR108 228

MenACWY-CRM (Menveo): Concurrent administration with MMRV in infants 12 months of age did not affect antibody responses to MMRV;152 no increase in rate of solicited local or systemic adverse effects compared with administration of either vaccine alone152

Hib-MenCY (MenHibrix): Concurrent administration with MMR, VAR, and PCV7 in infants 12 through 15 months of age did not interfere with immune response to MMR227

Meningococcal vaccine

MenACWY-D (Menactra): Concurrent administration with meningococcal group B vaccine (MenB-FHbp; Trumenba) did not affect immune response to meningococcal serogroups in either vaccine236

MenACWY: May be administered concurrently with MenB vaccine (MenB-4C; Bexsero or MenB-FHbp; Trumenba) using separate syringes and separate injection sites200

Pneumococcal vaccine

Pneumococcal 13-valent conjugate vaccine (PCV13; Prevnar 13): Manufacturer states data insufficient to assess concurrent administration with MenACWY vaccine in children and adolescents181

PCV7 (Prevnar): Simultaneous administration with MenACWY-D (Menactra) at 12 months of age decreased antibody responses to 3 of the 7 pneumococcal serotypes compared with administration of PCV7 without MenACWY-D108 228

PCV7 (Prevnar): Simultaneous administration with MenACWY-CRM (Menveo) at 2, 4, 6, and 12 months of age resulted in possible interference with antibody response to 2 of the pneumococcal vaccine serotypes at 1 month after third dose, but no evidence of interference with immune response to any pneumococcal vaccine serotypes after fourth dose152

Hib-MenCY (MenHibrix): Concurrent administration with PCV7 and DTaP-HepB-IPV (Pediarix) in infants at 2, 4, and 6 months of age did not reduce antibody response to PCV7 or the other antigens227

PCV13 (Prevnar 13): Do not administer MenACWY-D (Menactra) concurrently or within 4 weeks after PCV13;105 228 to avoid possible interference with immune response in infants and children with anatomic or functional asplenia, complete PCV13 vaccination series first and then administer MenACWY-D at least 4 weeks later228

Pneumococcal 23-valent polysaccharide vaccine (PPSV23; Pneumovax 23): May be administered simultaneously with MenACWY or MPSV4 at different sites using separate syringes105

Hib-MenCY (MenHibrix): May be administered simultaneously with PCV13 in infants 2 through 18 months of age at different sites using separate syringes228

Tests to diagnose Hib disease

Hib-MenCY (MenHibrix): May interfere with interpretation of antigen tests used to diagnose Hib disease; administration of Hib vaccine results in antigenuria227

Hib-MenCY (MenHibrix): Urine antigen detection may not have diagnostic value in evaluating suspected Hib disease in children within 1–2 weeks following administration of the vaccine227

Antigen testing of urine and serum specimens no longer recommended for diagnosis of Hib infection105 166

Tetanus and diphtheria toxoids adsorbed (Td)

MenACWY-D (Menactra): Concurrent administration with Td did not reduce antibody responses or increase adverse effects;108 228 although clinical importance unclear, antibody responses to diphtheria and certain meningococcal antigens were higher when MenACWY-D was given concurrently with Td compared with administration 1 month after Td108 228

MenACWY or MPSV4: May be administered simultaneously with (using different syringes and different injection sites) or at any interval before or after Td108 128 134

Tetanus toxoid and reduced diphtheria toxoid and acellular pertussis vaccine adsorbed (Tdap)

MenACWY-D (Menactra): Concurrent administration with Tdap (Adacel) and with either v4HPV (Gardasil) or 9vHPV (Gardasil 9) at 3 different injection sites in adolescents did not interfere with antibody responses to any of the vaccine antigens231 232

MenACWY-CRM (Menveo): Concurrent administration with Tdap alone or with 4vHPV in adolescents 11 through 18 years of age did not interfere with MenACWY-CRM immune response;152 although clinical importance unclear, antibody response to some pertussis antigens was decreased;152 systemic adverse reactions were more frequent in those receiving MenACWY-CRM with Tdap and 4vHPV compared with those receiving MenACWY-CRM alone152

MenACWY (Menactra, Menveo): No evidence of interference with MenACWY immune response when administered following Tdap228

MenACWY (Menactra, Menveo): May be administered simultaneously with Tdap (using different syringes and different injection sites);116 117 134 if this is not feasible, administer the vaccines at least 1 month apart116

Typhoid vaccine

Parenteral inactivated typhoid vaccine (Typhim Vi): Has been administered concomitantly with MenACWY-D (Menactra) without reduced antibody response or increased adverse effects108 228

Oral live typhoid vaccine (Vivotif): May be administered simultaneously with or at any interval before or after MenACWY or MPSV4134

Parenteral inactivated typhoid vaccine (Typhim Vi): May be administered simultaneously with (using different syringes and different injection sites) or at any interval before or after MenACWY or MPSV4134

Varicella vaccine (VAR)

MenACWY-D (Menactra): Concurrent administration with VAR and MMR (or MMRV) and pneumococcal conjugate vaccine (PCV7; Prevnar) in infants 12 months of age did not affect VAR antibody responses108

Hib-MenCY (MenHibrix): Concurrent administration with VAR, MMR, and PCV7 in infants 12 through 15 months of age did not interfere with immune response to VAR227

Yellow fever vaccine

MPSV4 (Menomune): Concomitant administration with yellow fever vaccine did not interfere with antibody response to either vaccine and was not associated with any unusual adverse effects92

Stability

Storage

Parenteral

Solution, for IM Use

MenACWY-D (Menactra): 2–8°C.108 Do not freeze;108 if freezing occurs, discard vaccine.108 Protect from light.134

MenACWY-CRM (Menveo) lyophilized and liquid components: 2–8°C;152 protect from light.152 Do not freeze;152 discard if freezing occurs.152 Maintain at 2–8°C during transport.152 Use immediately after reconstitution, but may be stored at ≤25°C for up to 8 hours.152

Hib-MenCY (MenHibrix) lyophilized vaccine: 2–8°C;227 protect from light.227 Store 0.9% sodium chloride diluent supplied by manufacturer at 2–25°C;227 do not freeze; discard if freezing occurs.227 Use immediately after reconstitution.227 Discard reconstituted vaccine if frozen.227

For Injection, for Sub-Q Use

MPSV4 (Menomune) lyophilized vaccine and diluent provided by manufacturer: 2–8°C;1 do not freeze.1

Use single-dose vials immediately after reconstitution.1

Store multiple-dose vials at 2–8°C after reconstitution;1 134 discard if not used within 35 days.1 Diluent supplied with multiple-dose vials contains thimerosal as a preservative.1 (See Thimerosal Precautions under Cautions.)

Actions

  • MenACWY-D (Menactra) contains purified capsular polysaccharide antigens A, C, Y, and W-135 extracted from N. meningitidis and conjugated to diphtheria toxoid protein.108

  • MenACWY (Menveo) contains purified capsular polysaccharide antigens A, C, Y, and W-135 extracted from N. meningitidis and conjugated to diphtheria CRM197 protein.152

  • MPSV4 (Menomune) contains purified capsular polysaccharide antigens A, C, Y, and W-135 isolated from N. meningitidis.1 84 The antigens are unconjugated.1

  • Hib-MenCY (MenHibrix) contains meningococcal groups C and Y and Hib antigens individually conjugated to tetanus toxoid.227

  • Meningococcal vaccines stimulate active immunity to meningococcal infection by inducing production of specific IgG, IgM, and IgA antibodies.9 13 17 18 33 69 79 The relative importance of each type of antibody in providing initial and long-term bactericidal protection against N. meningitidis not determined.9 13 17 42 46 69 79 91

  • Unconjugated antigens contained in MPSV4 cannot induce long-lasting immunity or an anamnestic response after subsequent exposure to the same antigens since polysaccharide antigens alone are T-cell independent.108 134 228

  • Antigens contained in MenACWY are conjugated to protein carriers containing T-cell epitopes; these can elicit immune responses involving T cells and may provide longer-lasting immunity than that provided by MPSV4.108 134 152 228

  • Extent and duration of immunologic response to MPSV4 (Menomune) vary depending on age of the recipient; the vaccine is less immunogenic in children <2 years of age than in older children and adults.9 24 28 31 42 46 62 84 85 86 228

  • MenACWY-D (Menactra) is at least as immunogenic as the unconjugated meningococcal vaccine (MPSV4) in individuals 2 through 55 years of age.106 108 114

  • Immune response to single dose of MenACWY-CRM in individuals 2 through 55 years of age is similar to that reported with single dose of MenACWY-D.152

  • Reduced immune responses to meningococcal vaccines and lower antibody titers may occur in immunocompromised individuals (e.g., HIV-infected individuals, those with leukemia, lymphoma, or generalized malignancy, those receiving immunosuppressive therapy).1 108 134 228

  • Protective antibody levels may be achieved within 7–10 days after a dose of MenACWY or MPSV4.115

  • Duration of immunity against N. meningitidis serogroups A, C, Y, and W-135 after primary immunization with MenACWY or MPSV4 not fully determined.105 108 152 228 (See Duration of Immunity under Cautions.)

  • In adolescents 11 through 18 years of age who previously received primary immunization with single dose of MenACWY-D (Menactra) or MenACWY-CRM (Menveo), revaccination with MenACWY-CRM resulted in protective antibody titers in ≥99%.228 Data not available to date regarding revaccination with MenACWY-D following primary immunization with MenACWY-CRM.228

  • Principal mode of transmission of meningococcal infection is respiratory, most commonly through close personal contact with an individual with invasive meningococcal disease or direct exposure to nasopharyngeal secretions from an infected individual.1 14 62 79 105 115 166 228 However, vast majority of meningococcal disease cases in US occur in individuals with no known exposure who presumably acquire infection from an asymptomatic carrier.90 Invasive infection with N. meningitidis usually results in meningitis and/or meningococcemia.1 105 108 228 Onset of illness is usually sudden with signs and symptoms including fever, severe headache, stiff neck, nausea, vomiting, and rash.105 115 Invasive meningococcal disease occurs most frequently in children <5 years of age and in adolescents and young adults 16 through 21 years of age.105 228

  • Minimum titer of anticapsular antibodies conferring protection against N. meningitidis serogroups A, C, Y, and W-135 not established;1 50 69 studies evaluating serogroup A and C meningococcal disease indicate that anticapsular antibody levels of ≥2 mcg/mL may be protective.50 69 71 Seroconversion usually is defined as ≥2-fold increase in serum anticapsular antibody titers1 50 or ≥4-fold increase in bactericidal antibody titers.8 50 59 60

Advice to Patients

  • Prior to administration of the vaccine dose, provide a copy of the appropriate CDC Vaccine Information Statement (VIS) to the patient or patient’s legal representative (VISs are available at ).1 108 120 152 227

  • Advise patient and/or patient’s parent or guardian of the risks and benefits of vaccination with meningococcal vaccine.1 108 120 152 227

  • Advise patient and/or patient's parent or guardian of the importance of completing the full primary immunization series.152

  • Advise patient and/or patient’s parent or guardian that routine meningococcal vaccination is recommended in US for all adolescents at 11 through 12 years of age, followed by a booster dose at 16 years of age; catch-up vaccination recommended at 13 through 18 years of age for those not previously vaccinated.120 199 228 Also advise that meningococcal vaccine is recommended for individuals at increased risk for exposure to meningococcal disease (e.g., college students, individuals with certain chronic medical conditions, international travelers, household contacts, health-care or laboratory workers).120 199 200 228

  • Advise patient and/or patient’s parent or guardian that revaccination or booster doses may be needed in individuals who receive primary immunization against meningococcal infection and remain at prolonged increased risk for exposure to the disease.119 228

  • Advise patient and/or patient’s parent or guardian that meningococcal vaccine may not provide protection in all vaccinees.1 108

  • Advise patient and/or patient’s parent or guardian that fainting (sometimes resulting in falling with injury) can occur following vaccination, especially in adolescents and young adults; patient should sit or lie down during and for 15 minutes after vaccine administration.120 134

  • Importance of informing clinicians of a history of allergic reactions to meningococcal vaccine, any vaccine component (e.g., diphtheria CRM197, diphtheria toxoid, tetanus toxoid), or packaging component (e.g., latex).1 108 152 227

  • Importance of informing clinicians if any adverse reactions (including allergic reactions) occur with meningococcal vaccine.1 108 120 152 227 Clinicians or individuals can report any adverse reactions that occur following vaccination to the Vaccine Adverse Event Reporting System (VAERS) at 800-822-7967 or .1 108 120 152 227

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, and any concomitant illnesses.1 108 152 227

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1 108 152

  • Importance of informing patients of other important precautionary information.1 108 152 227 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Meningococcal (Groups A, C, Y and W-135) Polysaccharide Diphtheria Toxoid Conjugate Vaccine (MenACWY-D)

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection, for IM use

4 mcg each of meningococcal A, C, Y, W-135 capsular polysaccharides conjugated to approximately 48 mcg of diphtheria toxoid protein carrier per 0.5 mL

Menactra

Sanofi Pasteur

Meningococcal (Groups A, C, Y and W-135) Oligosaccharide Diphtheria CRM197 Conjugate Vaccine (MenACWY-CRM)

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

For injection, for IM use

10 mcg of meningococcal A capsular polysaccharide and 5 mcg each of meningococcal C, Y, W-135 capsular oligosaccharides conjugated to 32.7–64.1 mcg of diphtheria CRM197 protein carrier per 0.5 mL

Menveo

Novartis

Meningococcal Polysaccharide Vaccine, Groups A, C, Y and W-135 Combined (MPSV4)

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

For injection, for subcutaneous use

50 mcg each of meningococcal A, C, Y, W-135 capsular polysaccharides per 0.5 mL

Menomune-A/C/Y/W-135

Sanofi Pasteur

Meningococcal Groups C and Y and Haemophilus b Tetanus Toxoid Conjugate Vaccine (Hib-MenCY)

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

For injection, for IM use

5 mcg of meningococcal C capsular polysaccharide conjugated to approximately 5 mcg of tetanus toxoid protein carrier, 5 mcg of meningococcal Y capsular polysaccharide conjugated to approximately 6.5 mcg of tetanus toxoid protein carrier, and 2.5 mcg of Haemophilus b capsular polysaccharide conjugated to approximately 6.25 mcg of tetanus toxoid protein carrier per 0.5 mL

MenHibrix

GlaxoSmithKline

AHFS DI Essentials. © Copyright 2017, Selected Revisions January 23, 2017. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

1. Sanofi Pasteur. Menomune–A/C/Y/W-135 (meningococcal polysaccharide vaccine, groups A, C, Y and W-135 combined) solution for subcutaneous injection prescribing information. Swiftwater, PA; 2016 Mar 14.

3. Centers for Disease Control and Prevention. Prevention and control of serogroup C meningococcal disease and meningococcal disease and college students: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2000; 49(RR-7):1-20.

6. Trotter CL, Andrews NJ, Kaczmarski EB et al. Effectiveness of meningococcal serogroup C conjugate vaccine 4 years after introduction. Lancet. 2004; 364:365-7. [PubMed 15276396]

8. Hankins WA, Gwaltney JM Jr, Hendley JO et al. Clinical and serological evaluation of a meningococcal polysaccharide vaccine groups A, C, Y, and W135 (41306). Proc Soc Exp Biol Med. 1982; 169:54-7. [PubMed 6801667]

9. Gold R, Lepow ML. Present status of polysaccharide vaccines in the prevention of meningococcal disease. In: Barness LA, ed. Advances in pediatrics. Chicago: Year Book Medical Publishers, Inc; 1976; 23:71-93.

10. Gotschlich EC, Rey M, Etienne J et al. The immunological responses observed in field studies in Africa with group A meningococcal vaccines. Prog Immunobiol Stand. 1972; 5:485-91.

11. Institute of Medicine. Immunization safety review: thimerosal-containing vaccines and neurodevelopmental disorder. Washington DC; National Academy Press; 2001. From IOM website. Accessed 2003 Jul 24.

12. Carvalho AA, Giampaglia CMS, Kimura H et al. Maternal and infant antibody response to meningococcal vaccination in pregnancy. Lancet. 1977; 2:809-11. [PubMed 71611]

13. Gotschlich EC, Goldschneider I, Artenstein MS. Human immunity to the meningococcus: IV. Immunogenicity of group A and group C meningococcal polysaccharides in human volunteers. J Exp Med. 1969; 129:1367-84. [PubMed 4977283]

14. Apicella MA. Neisseria meningitidis. In: Mandell GL, Bennett JE, Dolin R eds. Mandell, Douglas and Bennett’s principles and practices of infectious diseases. 4th ed. New York: Churchill Livingstone; 1995:1896-909.

15. Khoo SH, St Clair Roberts J, Mandal BK. Safety and efficacy of combined meningococcal and typhoid vaccine. BMJ. 1995; 310:908-9. [PubMed 7719181]

16. McLeod Griffiss J, Brandt BL, Altieri PL et al. Safety and immunogenicity of group Y and group W135 meningococcal capsular polysaccharide vaccines in adults. Infect Immun. 1981; 34:725-32. [PubMed 6800954]

17. Goldschneider I, Gotschlich EC, Artenstein MS. Human immunity to the meningococcus: I. The role of humoral antibodies. J Exp Med. 1969; 129:1307-26. [PubMed 4977280]

18. Goldschneider I, Gotschlich EC, Artenstein MS. Human immunity to the meningococcus: II. Development of natural immunity. J Exp Med. 1969; 129:1327-48. [PubMed 4977281]

19. Weibel RE, Villarejos VM, Vella PP et al. Clinical and laboratory investigations of monovalent and combined meningococcal polysaccharide vaccines, groups A and C (39563). Proc Soc Exp Biol Med. 1976; 153:436-40. [PubMed 827748]

20. Farquhar JD, Hankins WA, DeSanctis AN et al. Clinical and serological evaluation of a meningococcal polysaccharide vaccine groups A, C, and Y (39995). Proc Soc Exp Biol Med. 1978; 157:79-82. [PubMed 414235]

21. Peltola H, Käyhty H, Kuronen T et al. Meningococcus group A vaccine in children three months to five years of age. J Pediatr. 1978; 92:818-22. [PubMed 417160]

22. Mäkelä PH, Peltola H, Käyhty H et al. Polysaccharide vaccines of group A Neisseria meningitidis and Haemophilus influenzae type b: a field trial in Finland. J Infect Dis. 1977; 136(Suppl):S43-50.

23. Artenstein MS, Gold R, Zimmerly JG et al. Prevention of meningococcal disease by group C polysaccharide vaccine. N Engl J Med. 1970; 282:417-20. [PubMed 4983754]

24. Gold R, Lepow ML, Goldschneider I et al. Clinical evaluation of group A and group C meningococcal polysaccharide vaccines in infants. J Clin Invest. 1975; 56:1536-47. [PubMed 1202084]

25. Peltola H, Mäkelä PH, Elo O et al. Vaccination against meningococcal group A disease in Finland 1974–75. Scand J Infect Dis. 1976; 8:169-74. [PubMed 788143]

26. Cunliffe NA, Snowden N, Dunbar EW et al. Recurrent meningococcal septicemia and properdin deficiency. J Infect Dis. 1995; 31:67-8.

27. Wilkins J, Wehrle PF. Further characterization of responses of infants and children to meningococcal A polysaccharide vaccine. J Pediatr. 1979; 94:828-32. [PubMed 109592]

28. Monto AS, Brandt BL, Artenstein MS. Response of children to Neisseria meningitidis polysaccharide vaccines. J Infect Dis. 1973; 127:394-400. [PubMed 4632878]

29. Käyhty H, Karanko V, Peltola H et al. Serum antibodies to capsular polysaccharide vaccine of group A Neisseria meningitidis followed for three years in infants and children. J Infect Dis. 1980; 142:861-8. [PubMed 6780634]

30. Lepow ML, Goldschneider I, Gold R et al. Persistence of antibody following immunization of children with groups A and C meningococcal polysaccharide vaccines. Pediatrics. 1977; 60:673-80. [PubMed 411104]

31. Gold R, Lepow ML, Goldschneider I et al. Immune response of human infants to polysaccharide vaccines of groups A and C Neisseria meningitidis. J Infect Dis. 1977; 136(Suppl):S31-5. [PubMed 408431]

32. Gold R, Lepow ML, Goldschneider I et al. Kinetics of antibody production to group A and group C meningococcal polysaccharide vaccines administered during the first six years of life: prospects for routine immunization of infants and children. J Infect Dis. 1979; 140:690-7. [PubMed 118997]

33. Hoffman TA. Meningococcemia. In: Braude AI, Davis CE, Fierer J, eds. Medical microbiology and infectious diseases. Philadelphia: WB Saunders Company; 1981:1413-7.

34. Harrison LH. The worldwide prevention of meningococcal infection: still an elusive goal. JAMA. 1995; 273:419-21. [PubMed 7823389]

36. Peltola H. Indications for use of meningococcal vaccine. J Pediatr. 1980; 97:330-1. [PubMed 6772752]

37. Farquhar JD, Hankins WA, DeSanctis AN et al. Clinical and serological evaluation of purified polysaccharide vaccines prepared from Neisseria meningitidis group Y (39828). Proc Soc Exp Biol Med. 1977; 155:453-5. [PubMed 408813]

38. Mäkelä PH, Käyhty H, Weckström P et al. Effect of group-A meningococcal vaccine in army recruits in Finland. Lancet. 1975; 2:883-6. [PubMed 53370]

39. Brandt BL, Artenstein MS. Duration of antibody responses after vaccination with group C Neisseria meningitidis polysaccharide. J Infect Dis. 1975; 131(Suppl):S69-72. [PubMed 805191]

41. Brandt BL, Smith CD, Artenstein MS. Immunogenicity of serogroup A and C Neisseria meningitidis polysaccharide vaccines administered together in humans. J Infect Dis. 1978; 137:202-5. [PubMed 415099]

42. Goldschneider I, Lepow ML, Gotschlich EC. Immunogenicity of the group A and group C meningococcal polysaccharides in children. J Infect Dis. 1972; 125:509-19. [PubMed 4623437]

43. Binkin N, Band J. Epidemic of meningococcal meningitis in Bamako, Mali: epidemiological features and analysis of vaccine efficacy. Lancet. 1982; 2:315-7. [PubMed 6124726]

44. Mohammed I, Zaruba K. Control of epidemic meningococcal meningitis by mass vaccination. Lancet. 1981; 2:80-3. [PubMed 6113451]

45. Greenwood BM, Wali SS. Control of meningococcal infection in the African meningitis belt by selective vaccination. Lancet. 1980; 1:729-32. [PubMed 6103155]

46. Goldschneider I, Lepow ML, Gotschlich EC et al. Immunogenicity of group A and group C meningococcal polysaccharides in human infants. J Infect Dis. 1973; 128:769-76. [PubMed 4203078]

48. Centers for Disease Control and Prevention. Serogroup B meningococcal disease—Oregon, 1994. MMWR Morb Mortal Wkly Rep. 1995; 44:121-4. [PubMed 7845348]

49. Centers for Disease Control. Meningococcal disease—United States, 1981. MMWR Morb Mortal Wkly Rep. 1981; 30:113-5. [PubMed 6789057]

50. Lepow ML, Beeler J, Randolph M et al. Reactogenicity and immunogenicity of a quadrivalent combined meningococcal polysaccharide vaccine in children. J Infect Dis. 1986; 154:1033-6. [PubMed 3097160]

51. Twumasi PA, Kumah S, Leach A et al. A trial of a group A plus group C meningococcal polysaccharide-protein conjugate vaccine in African Infants. J Infect Dis. 1995; 171:632-8. [PubMed 7876610]

53. Ruben FL, Hankins WA, Zeigler Z et al. Antibody responses to meningococcal polysaccharide vaccine in adults without a spleen. Am J Med. 1984; 76:115-21. [PubMed 6419602]

54. The Meningococcal Disease Surveillance Group. Analysis of endemic meningococcal disease by serogroup and evaluation of chemoprophylaxis. J Infect Dis. 1976; 134:201-4. [PubMed 823273]

55. The United States pharmacopeia, 23rd rev, and The national formulary, 18th ed. Rockville, MD: The United States Pharmacopeial Convention, Inc; 1995:948-9.

57. Gotschlich EC, Goldschneider I, Artenstein MS. Human immunity to the meningococcus. J Exp Med. 1969; 129:1349-65. [PubMed 4977282]

59. Ambrosch F, Wiedermann G, Crooy P et al. Immunogenicity and side-effects of a new tetravalent meningococcal polysaccharide vaccine. Bull World Health Organ. 1983; 61:317-23. [PubMed 6407768]

60. Armand J, Arminjon F, Mynard MC et al. Tetravalent meningococcal polysaccharide vaccine groups A, C, Y, W 135: clinical and serological evaluation. J Biol Stand. 1982; 10:335-9. [PubMed 6818232]

61. Grabenstein JD. Drug interactions involving immunologic agents: Part 1. Vaccine-vaccine, vaccine-immunoglobulin, and vaccine-drug interactions. DICP. 1990; 24:67-81. [PubMed 2405589]

62. Jackson LA, Schuchat A, Reeves MW et al. Serogroup C meningococcal outbreaks in the United States: an emerging threat. JAMA. 1995; 273:383-9. [PubMed 7823383]

63. Band JD, Chamberland ME, Platt T et al. Trends in meningococcal disease in the United States, 1975–1980. J Infect Dis. 1983; 148:754-8. [PubMed 6313816]

64. McCormick JB, Gusmao HH, Nakamura S et al. Antibody response to serogroup A and C meningococcal polysaccharide vaccines in infants born of mothers vaccinated during pregnancy. J Clin Invest. 1980; 65:1141-4. [PubMed 6767739]

65. Shahid NS, Steinhoff MC, Hoque SS et al. Serum, breast milk, and infant antibody after maternal immunisation with pneumococcal vaccine. Lancet. 1995; 346:1252-7. [PubMed 7475716]

66. Vetter R, Iverson GR, Kuzel MD. Adult meningitis: rapid identification for prompt treatment. Postgrad Med. 1993; 93:99-102,105,106,109-112. [PubMed 8418463]

67. Andreoni J, Käyhty H, Densen P. Vaccination and the role of capsular polysaccharide antibody in prevention of recurrent meningococcal disease in late complement component-deficient individuals. J Infect Dis. 1993; 68:227-31.

68. Kafidi KT, Rotschafer JC. Bacterial vaccines for splenectomized patients. Drug Intell Clin Pharm. 1988; 22:192-7. [PubMed 3284730]

69. Zangwill KM, Stout RW, Carlone GM et al. Duration of antibody response after meningococcal polysaccharide vaccination in US Air Force personnel. J Infect Dis. 1994; 169:847-52. [PubMed 8133100]

70. Reingold AL, Hightower AW, Bolan GA et al. Age-specific differences in duration of clinical protection after vaccination with meningococcal polysaccharide A vaccine. Lancet. 1985; 2:114-8. [PubMed 2862316]

71. King WJ, MacDonald NE, Wells G et al. Total and functional antibody response to a quadrivalent meningococcal polysaccharide vaccine among children. J Pediatr. 1996; 128:196-202. [PubMed 8636811]

72. Molrine DC, George S, Tarbell N et al. Antibody responses to polysaccharide and polysaccharide-conjugate vaccines after treatment of Hodgkin disease. Ann Intern Med. 1995; 123:828-34. [PubMed 7486464]

73. Yergeau A, Alain L, Pless R et al. Adverse events temporarily associated with meningococcal vaccines. CMAJ. 1996; 154:503-7. [PubMed 8630839]

74. O’Dempsey TJD, McArdle T, Ceesay SJ et al. Meningococcal antibody titres in infants of women immunised with meningococcal polysaccharide vaccine during pregnancy. Arch Dis Child. 1996; 74:F43-6.

75. Barnett ED, Chen R. Children and international travel: immunizations. Pediatr Infect Dis J. 1995; 14:982-92. [PubMed 8584367]

76. Peltola H, Safary A, Käyhty H et al. Evaluation of two tetravalent (ACYW135) meningococcal vaccines in infants and small children: a clinical study comparing immunogenicity of O-acetyl-negative and O-acetyl-positive group C polysaccharides. Pediatrics. 1985; 76:91-6. [PubMed 3925430]

77. Vodopija I, Baklaic Z, Hauser P et al. Reactivity and immunogenicity of bivalent (AC) and tetravalent (ACW135Y) meningococcal vaccines containing O-acetyl-negative or O-acetyl-positive group C polysaccharide. Infect Immun. 1983; 42:599-604. [PubMed 6417019]

78. Lieberman JM, Chiu SS, Wong VK et al. Safety and immunogenicity of a serogroups A/C Neisseria meningitidis oligosaccharide–protein conjugate vaccine in young children: a randomized controlled trial. JAMA. 1996; 275:1499-503. [PubMed 8622225]

79. Kirsch EA, Barton RP, Kitchen L et al. Pathophysiology, treatment and outcome of meningococcemia: a review and recent experience. Pediatr Infect Dis J. 1996; 15:967-79. [PubMed 8933544]

80. Ross SC, Densen P. Complement deficiency states and infection: epidemiology, pathogenesis and consequences of neisserial and other infections in an immune deficiency. Medicine (Baltimore). 1984; 63:243-73. [PubMed 6433145]

81. Orren A, Potter PC, Cooper RC et al. Deficiency of the sixth component of complement and susceptibility to Neisseria meningitidis infections: studies in 10 families and five isolated cases. Immunology. 1987; 62:249-53. [PubMed 3679285]

82. Ross SC, Rosenthal PJ, Berberich HM et al. Killing of Neisseria meningitidis by human neutrophils: implications for normal and complement-deficient individuals. J Infect Dis. 1987; 155:1266-75. [PubMed 3106511]

83. Ross SC, Berberich HM, Densen P. Natural serum bactericidal activity against Neisseria meningitidis isolates from disseminated infections in normal and complement-deficient hosts. J Infect Dis. 1985; 152:1332-5. [PubMed 3934293]

84. Ala Aldeen DAA, Cartwright KAV. Neisseria meningitidis: vaccines and vaccine candidates. J Infect. 1996; 33:153-7. [PubMed 8945702]

85. Mayon-White RT, Heath PT. Preventative strategies on meningococcal disease. Arch Dis Child. 1997; 76:178-81. [PubMed 9135255]

86. Herbert MA, Heath PT, Mayon-White RT. Meningococcal vaccines for the United Kingdom. Commun Dis Rep CDR Rev. 1995; 5(Suppl):R130-5. [PubMed 7670576]

90. Reviewers’ comments (personal observations)

91. Pasteur Merieux Connaught, Swiftwater, PA: Personal communication.

92. Staples JE, Gershman M, Fischer M et al. Yellow fever vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010; 59(RR-7):1-27.

93. Tapiero B, Arhin FF, Arena B et al. Antibody response to Neisseria meningitidis group C polysaccharide vaccine in children with sickle cell disease. Proceedings of ICAAC New Orleans 1996. Abstract No. G81.

98. Letson GW, Little JR, Ottman J et al. Meningococcal vaccine in pregnancy: an assessment of infant risk. Pediatr Infect Dis J. 1998; 17:261-3. [PubMed 9535263]

99. Centers for Disease Control and Prevention. Meningococcal disease among college students: ACIP modifies recommendations for meningitis vaccination. Press release. 1999 Oct 20.

100. Harrison LH, Dwyer DM, Maples CT et al. Risk of meningococcal infection in college students. JAMA. 1999; 281:1906-10. [PubMed 10349894]

101. Centers for Disease Control and Prevention. Change in recommendation for meningococcal vaccine for travelers. MMWR Morb Mortal Wkly Rep. 1999; 48:104. [PubMed 10084899]

102. Centers for Disease Control and Prevention. Thimerosal in vaccines: a joint statement of the American Academy of Pediatrics and the Public Health Service. MMWR Morb Mortal Wkly Rep. 1999; 48:563-5. [PubMed 10418806]

103. Centers for Disease Control and Prevention. Recommendations regarding the use of vaccines that contain thimerosal as a preservative. MMWR Morb Mortal Wkly Rep. 1999; 48:996-8. [PubMed 10577494]

104. American Academy of Pediatrics Committee on Infectious Diseases and Committee on Environmental Health. Thimerosal in vaccines: an interim report to clinicians (RE9935). Pediatrics. 1999; 104:570-4. [PubMed 10469789]

105. American Academy of Pediatrics. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015.

106. Centers for Disease Control and Prevention. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005; 54(RR-7):1-21.

108. Sanofi Pasteur. Menactra (meningococcal [groups A, C, Y and W-135] polysaccharide diphtheria toxoid conjugate vaccine) solution for intramuscular injection prescribing information. Swiftwater, PA; 2016 Sept.

109. Food and Drug Administration. FDA and CDC issue alert on Menactra meningococcal vaccine and Guillain-Barré syndrome. FDA News. Rockville, MD: Food and Drug Administration; 2005 Sept 30.

110. Centers for Disease Control and Prevention. Guillain-Barré syndrome among recipients of Menactra© meningococcal conjugate vaccine-United States, June–July 2005. MMWR Morb Mortal Wkly Rep. 2005; 54:1023-25. [PubMed 16224452]

111. Decker, MD, Sanofi Pasteur. Dear health care provider letter reports regarding reports of GBS following the administration of Menactra©, meningococcal (groups A, C, Y and W-135) polysaccharide diphtheria toxoid conjugate vaccine. Swiftwater, PA; 2005 Oct 3.

114. Pichichero M, Casey J, Blatter M et al. Comparative trial of the safety and immunogenicity of quadrivalent (A, C, Y, W-135) meningococcal polysaccharide-diphtheria conjugate vaccine versus quadrivalent polysaccharide vaccine in two- to ten-year-old children. Pediatr Infect Dis. 2005; 24:57-62.

115. Centers for Disease Control and Prevention. CDC health information for international travel, 2016. Atlanta, GA: US Department of Health and Human Services. Updates may be available at CDC website.

116. American Academy of Pediatrics Committee on Infectious Diseases. Policy statement on prevention of pertussis among adolescents: recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. Dec 12, 2005. From the AAP website. Accessed on Dec 28, 2005.

117. Centers for Disease Control and Prevention. ACIP votes to recommend routine use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines (Tdap) for adolescents. December 9, 2005. From the CDC website. Accessed on Dec 29, 2005.

118. Centers for Disease Control and Prevention. Revised recommendations of the Advisory Committee on Immunization Practices to vaccinate all persons aged 11–18 years with meningococcal conjugate vaccine. MMWR Morb Mortal Wkly Rep. 2007; 56:794-5. [PubMed 17694617]

119. Centers for Disease Control and Prevention. Recommendation from the Advisory Committee on Immunization Practices (ACIP) for use of quadrivalent meningococcal conjugate vaccine (MCV4) in children aged 2–10 years at increased risk for invasive meningococcal disease. MMWR Morb Mortal Wkly Rep. 2007; 56:1265-6.

120. Centers for Disease Control and Prevention. Meningococcal ACWY vaccines information statement. 2016 Mar 31. From CDC website. Accessed Jul 19, 2012.

122. Centers for Disease Control and Prevention. Update: Guillain-Barré syndrome among recipients of Menactra© meningococcal conjugate vaccine-United States, October 2005–February 2006. MMWR Morb Mortal Wkly Rep. 2006; 55:364-6. [PubMed 16601664]

123. Centers for Disease Control and Prevention. Update: Guillain-Barré syndrome among recipients of Menactra© meningococcal conjugate vaccine-United States, June 2005–September 2006. MMWR Morb Mortal Wkly Rep. 2006; 55:1120-4. [PubMed 17060898]

124. Centers for Disease Control and Prevention. GBS and Menactra meningococcal vaccine. From CDC website. Accessed Sep 6, 2012.

126. Centers for Disease Control and Prevention. Syncope after vaccination—United States, January 2005–July 2007. MMWR Morb Mortal Wkly Rep. 2008; 57:457-60. [PubMed 18451756]

127. Centers for Disease Control and Prevention. Report from the Advisory Committee on Immunization Practices (ACIP): decision not to recommend routine vaccination of all children aged 2–10 years with quadrivalent meningococcal conjugate vaccine (MCV4). MMWR Morb Mortal Wkly Rep. 2008; 57:462-5. [PubMed 18451758]

128. Centers for Disease Control and Prevention. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006; 55(RR-3):1-34.

129. Food and Drug Administration. Thimerosal in vaccines. From FDA website. Accessed Oct 27 2008.

132. Aberer W. Vaccination despite thimerosal sensitivity. Contact Dermatitis. 1991; 24:6-10. [PubMed 2044374]

133. Food and Drug Administration. Thimerosal in vaccines. Frequently asked questions (FAQ). From FDA website. Accessed 2008 Oct 27.

134. National Center for Immunization and Respiratory Diseases. General recommendations on immunization --- recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011; 60:1-64.

135. Thompson WW, Price C, Goodson B et al. Early thimerosal exposure and neuropsychological outcomes at 7 to 10 years. N Engl J Med. 2007; 357:1281-92. [PubMed 17898097]

137. Zheng W, Dreskin SC. Thimerosal in influenza vaccine: an immediate hypersensitivity reaction. Ann Allergy Asthma Immunol. 2007; 99:574-5. [PubMed 18219843]

138. Madsen KM, Lauritsen MB, Pedersen CB et al. Thimerosal and the occurrence of autism: negative ecological evidence from Danish population-based data. Pediatrics. 2003; 112:604-6. [PubMed 12949291]

139. Lee-Wong M, Resnick D, Chong K. A generalized reaction to thimerosal from an influenza vaccine. Ann Allergy Asthma Immunol. 2005; 94:90-4. [PubMed 15702823]

140. Parker S, Todd J, Schwartz B et al. Thimerosal-containing vaccines and autistic spectrum disorder: a critical review of published original data. Pediatrics. 2005; 115:200. [PubMed 15630018]

141. Schechter R, Grether JK. Continuing increases in autism reported to California’s developmental services system: mercury in retrograde. Arch Gen Psychiatry. 2008; 65:19-24. [PubMed 18180424]

142. Andrews N, Miller E, Grant A et al. Thimerosal exposure in infants and developmental disorders: a retrospective cohort study in the United kingdom does not support a causal association. Pediatrics. 2004; 114:584-91. [PubMed 15342825]

143. Verstraeten T, Davis RL, DeStefano F et al. Safety of thimerosal-containing vaccines: a two-phased study of computerized health maintenance organization databases. Pediatrics. 2003; 112:1039-48. [PubMed 14595043]

144. Hviid A, Stellfeld M, Wohlfahrt J et al. Association between thimerosal-containing vaccine and autism. JAMA. 2003; 290:1763-6. [PubMed 14519711]

145. Institute of Medicine. Immunization safety review: vaccines and autism. Washington DC; National Academy Press; 2004. From IOM website. Accessed 2008 Oct 28.

146. Studdiford J, Oppenheim L, McCann E et al. Erythema multiforme after meningitis vaccine: patient safety concerns with repeat immunization. Pharmacotherapy. 2006; 26:1658-61. [PubMed 17064213]

149. Lippert WC, Wall EJ. Optimal intramuscular needle-penetration depth. Pediatrics. 2008; 122:e556-63. [PubMed 18694903]

150. Groswasser J, Kahn A, Bouche B et al. Needle length and injection technique for efficient intramuscular vaccine delivery in infants and children evaluated through an ultrasonographic determination of subcutaneous and muscle layer thickness. Pediatrics. 1997; 100:400-3. [PubMed 9282716]

152. Novartis Vaccines and Diagnostics, Inc. Menveo (meningococcal [Groups A, C, Y and W-135] oligosaccharide diphtheria CRM197 conjugate vaccine) solution for intramuscular injection prescribing information. Cambridge, MA; 2013 Aug.

153. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of meningococcal conjugate vaccines --- Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep. 2011; 60:72-6. [PubMed 21270745]

155. Panel on Opportunistic Infection in HIV-infected Adults and Adolescents, US Department of Health and Human Services (HHS). Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America (September 17, 2015). Updates may be available at HHS AIDS Information (AIDSinfo) website.

156. Panel on Opportunistic Infection in HIV-exposed and HIV-infected children, US Department of Health and Human Services (HHS). Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children: recommendations from the National Institutes of Health, Centers for Disease Control and Prevention, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics (Nov 6, 2013). Updates may be available at HHS AIDS Information (AIDSinfo) website.

157. American Academy of Pediatrics Committee on Infectious Diseases. Updated recommendations on the use of meningococcal vaccines. Pediatrics. 2014; 134:400-3. [PubMed 25070306]

158. Siberry GK, Williams PL, Lujan-Zilbermann J et al. Phase I/II, open-label trial of safety and immunogenicity of meningococcal (groups A, C, Y, and W-135) polysaccharide diphtheria toxoid conjugate vaccine in human immunodeficiency virus-infected adolescents. Pediatr Infect Dis J. 2010; 29:391-6. [PubMed 20431379]

159. Lujan-Zilbermann J, Warshaw MG, Williams PL et al. Immunogenicity and Safety of 1 vs 2 Doses of Quadrivalent Meningococcal Conjugate Vaccine in Youth Infected with Human Immunodeficiency Virus. J Pediatr. 2012; :. [PubMed 22622049]

160. Siberry GK, Warshaw MG, Williams PL et al. Safety and immunogenicity of quadrivalent meningococcal conjugate vaccine in 2- to 10-year-old human immunodeficiency virus-infected children. Pediatr Infect Dis J. 2012; 31:47-52. [PubMed 21987006]

161. MacNeil JR, Rubin LG, Patton M et al. Recommendations for Use of Meningococcal Conjugate Vaccines in HIV-Infected Persons - Advisory Committee on Immunization Practices, 2016. MMWR Morb Mortal Wkly Rep. 2016; 65:1189-1194. [PubMed 27811836]

162. Centers for Disease Control and Prevention (CDC). Infant meningococcal vaccination: Advisory Committee on Immunization Practices (ACIP) recommendations and rationale. MMWR Morb Mortal Wkly Rep. 2013; 62:52-4. [PubMed 23344698]

165. MacNeil JR, Rubin L, McNamara L et al. Use of MenACWY-CRM vaccine in children aged 2 through 23 months at increased risk for meningococcal disease: recommendations of the Advisory Committee on Immunization Practices, 2013. MMWR Morb Mortal Wkly Rep. 2014; 63:527-30. [PubMed 24941332]

166. Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases. 13th ed. Washington DC: Public Health Foundation; 2015. Updates may be available at CDC website.

181. Wyeth Pharmaceuticals. Prevnar 13 (pneumococcal 13-valent conjugate vaccine [diphtheria CRM197 protein] suspension for intramuscular injection. Philadelphia, PA; 2016 Aug.

199. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP) recommended immunization schedules for persons aged 0 through 18 years–United States, 2016. Updates may be available at CDC website.

200. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP) recommended adult immunization schedule–United States, 2016. Updates may be available at CDC website.

227. GlaxoSmithKline. MenHibrix (Meningococcal groups C and Y and Haemophilus b tetanus toxoid conjugate vaccine) solution for intramuscular injection prescribing information. Research Triangle Park, NC; 2012 Jun.

228. Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, CDC. Prevention and control of meningococcal disease. MMWR Recomm Rep. 2013; 62(RR-2):1-22.

229. Alexion Pharmaceuticals, Inc. Soliris (eculizumab) concentrated solution for intravenous infusion prescribing information. Chesire, CT; 2015 Dec.

231. Merck & Co. Gardasil 9 (human papillomavirus 9-valent, recombinant) suspension for intramuscular injection prescribing information. Whitehouse Station, NJ; 2015 Dec.

232. Merck & Co. Gardasil (human papillomavirus quadrivalent [types 6,11,16, and 19] vaccine, recombinant) suspension for intramuscular injection prescribing information. Whitehouse Station, NJ; 2015 Apr.

233. Reisinger KS, Block SL, Collins-Ogle M et al. Safety, tolerability, and immunogenicity of gardasil given concomitantly with Menactra and Adacel. Pediatrics. 2010; 125:1142-51. [PubMed 20439595]

235. Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention (CDC). Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011; 60(RR-7):1-45.

236. Folaranmi T, Rubin L, Martin SW et al. Use of Serogroup B Meningococcal Vaccines in Persons Aged ≥10 Years at Increased Risk for Serogroup B Meningococcal Disease: Recommendations of the Advisory Committee on Immunization Practices, 2015. MMWR Morb Mortal Wkly Rep. 2015; 64:608-12. [PubMed 26068564]

237. Centers for Disease Control and Prevention. Meningococcal Disease: Clinical information. From the CDC website. Accessed on Dec 7, 2015.

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