Description

Meningococcal disease is an acute bacterial infection characterized by sudden onset with fever, intense headache, nausea, vomiting, stiff neck, and, frequently, a rash with pink macules that develops petechiae (1). Formerly, the case-fatality ratio exceeded 50%, but early diagnosis, modern therapy, and supportive measures have lowered the case-fatality ratio to about 10% in developed countries. Among survivors, 11%-19% have long-term sequelae, including hearing loss, neurologic disability, or limb loss (2). Up to 10% of populations in countries with endemic disease carry Neisseria meningitidis asymptomatically in the nose and throat (3).

Meningococci are classified into serogroups based on the composition of the capsular polysaccharide. Five major meningococcal serogroups associated with disease are A, B, C, Y and W-135 (3). In the past 30 years, meningococci serogroups B and C have been responsible for most disease in the Americas and Europe (3,4). Serogroup A meningococci and, to a lesser extent, serogroup C, account for most meningococcal disease cases in Africa and some areas in Asia. During the past years, serogroup Y has emerged as a cause of disease in Northern America, and serogroup W-135 has been associated with meningococcal disease epidemics in Saudi Arabia and Burkina Faso (5-7).

Occurrence

Sporadic cases and outbreaks of meningococcal disease occur throughout the world. In the sub-Saharan African “meningitis belt,” which extends from Mali to Ethiopia, peaks of serogroup A meningococcal disease occur regularly during the dry season (December through June) (8). In addition, major epidemics occur every 8-12 years (see Map 4-10). In 2000, a serogroup W-135 epidemic occurred in Saudi Arabia in association with the Hajj pilgrimage (6). Cases among returning pilgrims and their families occurred in a number of countries, including several cases in the United States. In 2002, a major meningococcal disease epidemic occurred in Burkina Faso caused by serogroup W-135 (7). Since 2002, serogroup W-135 has been detected in several African countries, but it has not caused major epidemics.

Risk for Travelers

Travelers to sub-Saharan Africa may be at risk for meningococcal disease. Travelers to the meningitis belt during the dry season should be advised to receive meningococcal vaccine, especially if they will have prolonged contact with local populations. Prompted by a serogroup A meningococcal disease outbreak associated with the 1987 Hajj, Saudi Arabia requires that Hajj and Umrah visitors have a certificate of vaccination with a tetravalent (A,C,Y,W-135) meningococcal vaccine before entering.

Clinical Presentation

Sudden onset of fever, intense headache, neck stiffness, nausea, and often vomiting are common signs and symptoms of meningococcal sepsis, with or without meningitis, in persons over the age of 2 years. These symptoms can develop over several hours, or they may take 1-2 days. Other symptoms may include photophobia and an altered mental status. In infants, a slower onset of signs and symptoms may occur with nonspecific symptoms, and neck stiffness may be absent.

Early diagnosis and treatment are critical. If symptoms occur, the patient should seek medical care immediately. The diagnosis is usually made by growing bacteria collected from cerebrospinal fluid (CSF), detection of the meningococcal antigen through latex agglutination in fresh CSF, or evidence of N. meningitidis DNA by polymerase chain reaction (1). N. meningitidis can also be identified in blood cultures. The signs and symptoms of meningococcal meningitis are similar to those of other causes of bacterial meningitis, such as Haemophilus influenzae and Streptococcus pneumoniae. Identification of the type of bacteria responsible is important for selection of correct antibiotics. Answers to frequently asked questions about meningitis can be found at the following website: http://www.cdc.gov/ncidod/dbmd/diseaseinfo.

Prevention

In January 2005, a tetravalent meningococcal polysaccharide-protein conjugate vaccine (MCV4) was licensed for use among persons aged 11-55 years. In October 2007, MCV4 vaccine was approved for use in children aged 2-10 years (11). Tetravalent meningococcal polysaccharide vaccine (MPSV4) is also available in the United States. Both vaccines protect against meningococcal disease caused by serogroups A, C, Y, and W-135 (Table 4-13). However, MCV4 is expected to be efficacious in young children, confer long-term protection, and provide herd immunity by reducing nasopharyngeal carriage and transmission. CDC’s Advisory Committee on Immunization Practices (ACIP) recommends vaccination with MCV4 at the earliest opportunity for persons aged 11-18 years and for college freshmen living in dormitories (2, 12). Vaccination is also recommended for persons who have certain medical conditions that place them at increased risk of meningococcal disease, particularly deficiencies in the terminal common complement pathway (C3, C5-9) and anatomic or functional asplenia.

The ACIP recommends vaccination against meningococcal disease to persons who travel to or reside in countries in which N. meningitidis is hyperendemic or epidemic, particularly if contact with the local population will be prolonged. MCV4 is preferred among persons aged 2-55 years. MPSV4 is the recommended vaccine among persons aged >55 years; MPSV4 is also an acceptable alternative for persons aged 2-55 years (2, 11).

Vaccination against meningococcal disease is not a requirement for travel to any country except Saudi Arabia, where travelers to Mecca during the annual Hajj and Umrah pilgrimage must have proof of vaccination. Vaccination is recommended for persons traveling to the meningitis belt in Africa during the dry season, December through June. Advisories for travelers to other countries will be issued when epidemics of meningococcal disease caused by vaccine-preventable serogroups are recognized (see the CDC Travelers’ Health website at http://wwwn.cdc.gov/travel).

For both MCV4 and MPSV4, approximately 7-10 days are required following vaccination for development of protective levels of anti-meningococcal antibodies. In general, use of MPSV4 should be restricted to persons at least 2 years of age; however, children as young as 3 months of age may be vaccinated to elicit short-term protection against serogroup A meningococcal disease. No vaccine is currently available in the United States to offer protection against serogroup B.

Serogroup C polysaccharide conjugate vaccines have been used in infants and children in Europe and Canada. Studies from the United Kingdom (UK) have reported that these vaccines are safe and immunogenic in infants and children and can decrease transmission, thus protecting unvaccinated individuals by inducing herd immunity (9).

Antibiotic chemoprophylaxis among close contacts of a patient with meningococcal disease is recommended for prevention of secondary cases in the United States and most industrialized countries. Antimicrobial regimens for prophylaxis include rifampin, ciprofloxacin or ceftriaxone, although rifampin is not recommended for pregnant women (1). Antimicrobial chemoprophylaxis should be considered for airline passengers who have had direct contact with respiratory secretions from the index patient, and for passengers seated directly next to the index patient on prolonged flights (>8 hours) (http://wwwn.cdc.gov/travel/contentMenin.aspx). A study in 2001 among U.S. Hajj pilgrims found that pathogenic meningococcal nasopharyngeal carriage was uncommon in this vaccinated population; CDC does not currently recommend antimicrobial chemoprophylaxis or cultures to determine carriage for returning pilgrims (6).

ADVERSE REACTIONS

Adverse reactions to both MCV4 and MPSV4 are usually mild, consisting principally of localized erythema that lasts 1-2 days. Among adolescents aged 11-18 years, pain and limited movement at the injection site were more common with MCV4 than MPSV4. Low-grade fever occurs in a small percentage of persons who receive MCV4 and MPSV4 (2).

PRECAUTIONS AND CONTRAINDICATIONS

Vaccination with MCV4 and MPSV4 is contraindicated among persons known to have a severe allergic reaction to any component of the vaccine, including diphtheria toxoid (for MCV4), or to dry natural rubber latex (2). Studies of MCV4 in pregnant women have not been done. Studies of MPSV4 during pregnancy have not documented adverse events among either women or neonates (1 month of age or younger) (2). Persons with a history of Guillain-Barré syndrome (GBS) might be at increased risk for GBS after MCV4 vaccination; therefore, a history of GBS is a precaution to administering MCV4. For children with a history of GBS, MPSV4 is an acceptable alternative for short-term (i.e., 3--5 years) protection against meningococcal disease (11).  (Section updated February 15, 2008)

(Section Updated February 15, 2008)

Treatment

Meningococcal disease is potentially fatal and should always be viewed as a medical emergency. Admission to a hospital or health center is necessary. Antibiotic treatment must be started early in the course of the disease (in patients with meningitis, lumbar puncture should be done before starting antibiotics if possible to ensure the bacteria will grow in culture). On presentation the appropriate antibiotics for treatment are dictated by the differential diagnosis; once the diagnosis is confirmed, several antibiotic choices are available, and an infectious disease consultant can be asked to assist in management (1).

References

1. LK American Academy of Pediatrics. Meningococcal infections. In: Pickering LK, editor. Red book: 2003 Report of the Committee on Infectious Disease. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003. p. 430-6.
2. CDC. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005;54(RR-7):1-21.
3. Raghunathan PL, Bernhardt SA, Rosenstein NE. Opportunities for Control of Meningococcal Disease in the United States. Ann Rev Med. 2004;55:333-53.
4. Rosenstein NE, Perkins BA, Stephens DS, Lefkowitz L, Cartter ML, Danila R, et al. The changing epidemiology of meningococcal disease in the United States, 1992-1996. J Infect Dis. 1999;180: 1894-901.
5. Rosenstein NE, Perkins BA, Stephens DS, et al. Meningococcal disease. N Engl J Med. 2001;344:1378-88.  
6. Dull P, Abdelwahab J, Sacchi CT, Becker M, Noble CA, Barnett GA, et al. Serogroup W-135 Neisseria meningitidis carriage among US travelers to the 2001 Hajj. J Infect Dis. 2005;191:33-9.
7. Raghunathan PL, Jones JD, Tiendrebeogo SR, Sanou I, Sangare L, Kouanda S, et al. Predictors of immunity after a major serogroup W-135 meningococcal disease epidemic, Burkina Faso, 2002. J Infect Dis. 2006;193:607-16.
8. Greenwood B. Meningococcal meningitis in Africa. Trans R Soc Trop Med Hyg. 1999;93:341-53.
9. Maiden MC, Stuart JM; UK Meningococcal Carriage Group. Carriage of serogroup C meningococci 1 year after meningococcal C conjugate polysaccharide vaccine. Lancet. 2002;359:1829-31.
10. CDC. Update: Guillain-Barré Syndrome among recipients of Menactra meningococcal conjugate vaccine—United States, October 2005-February 2006. MMWR Morbid Mortal Wkly Rep. 2006;55: 364-6.
11. CDC. Notice to Readers: 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 2007;56(48):1265-1266.
12. CDC. Notice to Readers: Revised Recommendations of the Advisory Committee on Immunization Practices to Vaccinate All Persons Aged 11-18 Years with Meningococcal Conjugate Vaccine. MMWR 2007;56(31):794-795.

MAP 4-10 Areas with frequent epidemics of meningococcal meningitis.

TABLE 4-13. Meningococcal vaccines

(Updated February 15, 2008)