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Canadian Immunization Guide

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Part 4
Active Vaccines

Meningococcal Vaccine

Key Information (Refer to text for details)

What

  • Almost all invasive meningococcal disease (IMD) is associated with Neisseria meningitidis serogroups A, B, C, Y, and W-135.
  • Worldwide, IMD occurs sporadically and in focal epidemics. IMD is endemic in Canada but occurs at low rates.
  • In Canada, the incidence of IMD is highest in infants and most cases are serogroup B for which there is no vaccine.
  • Persons at higher risk of IMD include:
    • persons with functional or anatomic asplenia
    • persons with congenital complement, properdin, factor D or primary antibody deficiencies
    • persons with acquired complement deficiencies (e.g., those receiving eculizumab (Soliris™)
    • travellers to areas with high rates of endemic meningococcal infection or transmission, including travellers to the meningitis belt of sub-Saharan Africa and pilgrims to the Hajj in Mecca, Saudi Arabia
    • research, industrial and clinical laboratory personnel who are potentially routinely exposed to N. meningitidis
    • military personnel who are at increased risk of meningococcal disease
    • HIV positive individuals should be considered for vaccination, especially if HIV is congentially acquired
  • Meningococcal vaccines are initially highly effective; effectiveness wanes over time.
  • Monovalent conjugate meningococcal vaccine (Men-C-C) effectiveness in infants is 97% within one year of vaccination. Vaccine effectiveness of the quadrivalent conjugate meningococcal vaccine Menactra® in adolescents is 80% to 85% within 3 to 4 years of vaccination.
  • There may be redness, swelling and soreness at the injection site.

Who

  • Healthy children: should be immunized with a Men-C-C vaccine routinely at 12 months of age; however, they may begin meningococcal immunization earlier depending on provincial/territorial schedules. If not previously immunized as infants or toddlers Men-C-C vaccine should be given to children less than 5 years of age and considered for children 5 to 11 years of age.
  • Adolescents and young adults: either a Men-C-C or a quadrivalent conjugate meningococcal (Men-C-ACYW-135) vaccine (depending on local epidemiology and programmatic considerations) is recommended for adolescents (routinely at 12 years of age) and young adults even if previously vaccinated as an infant or toddler.
  • High risk individuals: Men-C-ACYW-135 vaccine is recommended for children and adults with increased risk of IMD. The choice of vaccine and recommended schedule vary with age. Periodic booster doses are recommended.
  • Post-exposure management: chemoprophylaxis is recommended for close contacts. If the serogroup is vaccine-preventable, immunoprophylaxis should also be considered depending on the exposure history. Recommendations for immunoprophylaxis in those previously vaccinated are provided.

How

  • Routine infant immunization: give Men-C-C vaccine to healthy infants according to provincial/territorial schedules.
  • 12 months to 11 years of age: give one dose of Men-C-C vaccine at 12 to 23 months of age (routinely at 12 months) whether immunized as an infant or not. For previously unimmunized children less than 5 years of age, give one dose of Men-C-C vaccine. Consider one dose of Men-C-C vaccine in children aged 5 to 11 years who were previously unimmunized.
  • 12 to 24 years of age: give adolescents (routinely at 12 years of age) and young adults one dose of either Men-C-C or Men-C-ACYW-135 vaccine, even if previously vaccinated as an infant or toddler.
  • Men-C-C vaccine may be administered concomitantly with routine childhood vaccines and Men-C-ACYW-135 vaccine may be administered concomitantly with adolescent and adult age-appropriate vaccines at different injection sites using separate needles and syringes.
  • Menveo can be administered with routine paediatric vaccines; however, further studies are needed with regard to concomitant administration with pneumococcal 13-valent conjugate vaccine.

Why

  • IMD mortality is approximately 10%.
  • Of IMD survivors, 10% to 20% have long term sequelae which include hearing loss, neurologic disabilities, and digit or limb amputations.

Since the publication of the 2006 Canadian Immunization Guide:

  • Two new quadrivalent conjugate meningococcal vaccines for serogroups A, C, Y, and W-135 have become available.
  • Bivalent polysaccharide meningococcal vaccine is no longer available in Canada.
  • Recommendations for routine vaccination have been modified.
  • Schedules (including booster doses) have been revised for high risk individuals as has the list of high risk individuals.
  • Recommendations for post-exposure immunoprophylaxis of close contacts of IMD who have been previously immunized have been provided.

For additional information, refer to the National Advisory Committee on Immunization (NACI) Statement/Update on the Use of Quadrivalent Conjugate Meningococcal Vaccines.

Epidemiology

Disease description

Infectious agent
Meningococcal disease is caused by an aerobic encapsulated diplococcus, Neisseria meningitidis (meningococcus). Meningococcal serogroups are classified according to the immunologic reactivity of the polysaccharide capsule. Almost all invasive meningococcal disease (IMD) is associated with serogroups A, B, C, Y, and W-135. Meningococcal serogroups A, B, and C cause the majority of disease worldwide and are responsible for most sporadic cases and outbreaks.

Reservoir
Humans are the only reservoir for N. meningitidis.

Transmission
Meningococci are transmitted person-to-person by mucosal contact with respiratory droplets from the nose and throat of infected persons. Most people who are colonized with meningococci are asymptomatic carriers. Meningococcal disease is characterized by a short incubation period (2 to 10 days, usually 3 to 4 days).

Risk factors
Risk factors for the development of IMD include: complement, properdin or factor D deficiencies; functional or anatomic asplenia (including sickle cell disease); certain genetic risk factors; household exposure to an infected person; concurrent respiratory tract infection; recent influenza; household crowding; and active and passive smoking. Persons with HIV infection may be at increased risk for meningococcal disease; especially if HIV is congenitally acquired.

Seasonal/temporal patterns
Although disease occurs year-round, there is seasonal variation with the majority of cases occurring in the winter-spring period in temperate climates and in the dry season in tropical climates. Most noteworthy is the “meningitis belt” of sub-Saharan Africa where the majority of cases occur from December to June. For further information, refer to the Committee to Advise on Tropical Medicine and Travel (CATMAT) website at: About CATMAT

Spectrum of clinical illness
Invasive meningococcal disease usually presents as an acute febrile illness with rapid onset and features of meningitis or septicemia (meningococcemia), or both, and a characteristic non-blanching petechial or purpuric rash. Symptoms of meningococcal meningitis include intense headache, fever, nausea, vomiting, photophobia and stiff neck. Meningococcemia is characterized by circulatory collapse, haemorrhagic skin rash and a high fatality rate. Overall mortality is approximately 10%, and 10% to 20% of survivors have long term sequelae which include hearing loss, neurologic disabilities, and digit or limb amputations.

Disease distribution
Incidence/prevalence

Global
Invasive meningococcal disease occurs sporadically worldwide and in focal epidemics. The traditional endemic areas of the world include the savannah areas of sub-Saharan Africa (known as the meningitis belt) extending from Gambia and Senegal in the west to Ethiopia and Western Eritrea in the east. Serogroup A disease predominates in Africa and Asia, while serogroup B disease is predominant in Europe and most of the Americas. Meningococcal disease is also associated with the Hajj, an Islamic pilgrimage to Mecca, Saudi Arabia.

National
Invasive meningococcal disease is endemic in Canada, but rare. From 1985 to 2010, the overall incidence of IMD ranged between 0.4 to 1.6 cases per 100,000 population (refer to Figure 1). Incidence peaked in 1990 and again in 2001 due to localized outbreaks of serogroup C disease. Immunization campaigns using meningococcal serogroup C polysaccharide and conjugate vaccines were implemented in some regions during outbreaks from 1999 to 2001. Between 2002 and 2007, all Canadian provinces and territories implemented routine vaccination programs at various ages with monovalent meningococcal (serogroup C) conjugate vaccine, and since 2007 some have implemented routine adolescent quadrivalent meningococcal (serogroups A, C, Y, W-135) conjugate vaccination programs.

From 2005 to 2010, an average of 197 cases of IMD was reported annually in Canada, with an average incidence of 0.60 cases per 100,000 population. During this time period, incidence rates were highest among infants less than one year of age (average 7 cases per 100,000), followed by 1 to 4 year olds (1.81), and 15 to 19 year olds (1.18). As seen in Figure 2, the majority of cases with serogroup information from 2005 to 2010 were due to serogroup B (59%), which is not preventable by current vaccines. Serogroup C incidence has fallen dramatically to the extent that in 2010 its incidence fell to a level similar to that of serogroup W-135. Serogroup Y replaced C as the second most frequent serogroup by 2007. Cases caused by other serogroups were rare. The average number of cases caused by serogroups B, C, Y, and W-135 reported annually from 2005 to 2010 were 110, 29, 31, and 11, respectively. From 2005 to 2010, 6.7% of reported cases died. Case fatality ratios differed by serogroup, with serogroup C having the highest at 13% and serogroups B and W-135 having the lowest at around 4%.

Figure 1: Reported cases and incidence (per 100,000) of invasive meningococcal disease in Canada, 1995 to 2010Figure 1 - Footnote *

Figure 1

Text Equivalent - Figure 1

Enlarge Figure 1

Figure 1 - Footnote *
Case data obtained from the National Enhanced Invasive Meningococcal Disease Surveillance System. Data for 2007 to 2010 are preliminary. Population data obtained from Statistics Canada annual estimates.

Figure 2: Incidence of invasive meningococcal disease per 100,000 population in Canada by serogroup and year, 1995 to 2010Figure 2 - Footnote *

Figure 2

Text Equivalent - Figure 2

Enlarge Figure 2

Figure 2 - Footnote *
Case data obtained from the National Enhanced Invasive Meningococcal Disease Surveillance System. Data for 2007 to 2010 are preliminary. Population data obtained from Statistics Canada annual estimates.
Recent outbreaks

Current meningococcal disease outbreak information is available from the World Health Organization (WHO) at: Global Alert and Response (GAR) - Meningococcal diseaseExternal Link

Preparations Authorized for Use in Canada

Meningococcal vaccines

Monovalent conjugate meningococcal vaccines (Men-C-C)

  • Meningitec®: meningococcal group C oligosaccharides conjugated to CRM197 protein, Berna Biotech, AG (manufacturer), Pfizer Canada Inc. (distributor). (Men-C-C)
  • Menjugate®: meningococcal group C oligosaccharide conjugated to CRM197 protein, Novartis Vaccines and Diagnostics (sponsor), Novartis Pharmaceuticals Canada Ltd. (distributor). (Men-C-C)
  • NeisVac-C®: meningococcal group C polysaccharide conjugated to tetanus toxoids, Baxter (manufacturer), GlaxoSmithKline Inc. (distributor). (Men-C-C)

Quadrivalent conjugate meningococcal vaccines (Men-C-ACYW-135)

  • Menactra®: meningococcal groups A, C, Y, and W-135 polysaccharides conjugated to diphtheria toxoid protein, sanofi pasteur Ltd. (Men-C-ACYW-135)
  • Menveo: meningococcal groups A, C, Y and W-135 oligosaccharide conjugated to CRM197 protein, Novartis Vaccines and Diagnostics Inc. (Men-C-ACYW-135)

Quadrivalent polysaccharide meningococcal vaccine (Men-P-ACYW-135)

  • MENOMUNE® A/C/Y/W-135: meningococcal groups A, C, Y and W-135 polysaccharide antigens, Sanofi Pasteur Inc. (manufacturer), sanofi pasteur Ltd. (distributor). (Men-P-ACYW-135). Polysaccharide meningococcal vaccine is available in Canada but its use is not routinely recommended.

Vaccines against meningococcal serogroup B disease are under development.

For complete prescribing information, consult the product leaflet or information contained within Health Canada’s authorized product monographs available through the Drug Product DatabaseExternal Link. Refer to Table 1 in General Considerations in Part 1 for a list of all vaccines available for use in Canada and their contents.

Efficacy, Effectiveness and Immunogenicity

Efficacy and effectiveness

A study of Men-C-C vaccine demonstrated effectiveness in infants of 97% within one year of vaccination, decreasing to 68% after 1 year. Longer term vaccine effectiveness requires receipt of a booster dose in the second year of life for those immunized in infancy. Vaccine effectiveness of Menactra® within 3 to 4 years of vaccination in adolescence is 80% to 85%; however, effectiveness wanes over time. There is no efficacy or effectiveness data available for Menveo. Vaccine effectiveness measured at individual level may under-estimate the impact of the program on meningococcal disease burden in the community due to the additional benefit conferred by herd immunity.

Immunogenicity

Men-C-C and Men-C-ACYW-135 vaccines are immunogenic in infants and toddlers but those vaccinated in infancy show a waning immune response. Vaccination with conjugate meningococcal vaccine primes the immune system for memory and induces good anamnestic responses; however, anamnestic response may not be sufficient to prevent disease after exposure and circulating antibodies are thought to be essential. In comparison to polysaccharide meningococcal vaccine, conjugate meningococcal vaccines demonstrate greater immunogenicity and induce better immunologic memory. Conjugate meningococcal vaccines do not result in hyporesponsiveness and have been shown to overcome the hyporesponsiveness evident with polysaccharide meningococcal vaccine usage.

Recommendations for Use

Healthy infants and children (2 months to 11 years of age)

Infants may receive Men-C-C vaccine beginning at 2 months of age depending on the provincial/territorial schedule and the incidence of meningococcal serogroup C disease in their jurisdiction. Men-C-C vaccine is recommended for all children at 12 to 23 months of age regardless of any doses given at less than 12 months of age. It is routinely given at 12 months and is recommended in unimmunized children less than 5 years of age. Men-C-C vaccine may be considered for children 5 to 11 years of age if not previously immunized as infants or toddlers.

Healthy adolescents and young adults (12 to 24 years of age)

Either Men-C-C or Men-C-ACYW-135 vaccine (depending on local epidemiology and programmatic considerations) is recommended for adolescents (routinely at 12 years of age) and young adults, even if previously vaccinated as an infant or toddler.

High risk groups
Underlying medical conditions

Individuals with increased risk of meningococcal disease because of underlying medical conditions are as follows:

  • persons with functional or anatomic asplenia (including sickle cell disease)
  • persons with congenital complement, properdin, factor D or primary antibody deficiencies
  • persons with acquired complement deficiency due to receipt of the terminal complement inhibitor eculizumab (Soliris™)
  • Men-C-ACYW-135 vaccine should be considered for individuals with HIV, especially if congenitally acquired.

Table 3 outlines the recommended schedule for vaccination of individuals who are at high risk due to underlying medical conditions. For those 1 year of age or older, two doses of Men-C-ACYW-135 vaccine, 8 weeks apart, are recommended.

There is limited evidence on the need for boosters. Based on expert opinion and the evidence to date, a booster dose for individuals in high risk groups is recommended every 3 to 5 years if vaccinated at 6 years of age and younger, and every 5 years for those vaccinated at 7 years of age and older. If a one dose primary series was used, give the second dose at the next available opportunity and then begin the booster doses based on the above intervals after the second dose.

Increased risk of exposure

Men-C-ACYW-135 vaccine is recommended for individuals at increased risk of exposure to meningococcal disease as follows:

  • travellers (2 years of age and older) when meningococcal vaccine is recommended or required, including travellers to sub-Saharan Africa and pilgrims to the Hajj in Mecca, Saudi Arabia. Refer to Table 1 for recommendations for travellers 2 to 23 months of age.
  • laboratory personnel who are potentially routinely exposed to N. meningitidis
  • military personnel during recruit training and on certain deployments

A booster dose is recommended every 5 years if individuals in these groups remain at ongoing risk (every 3 to 5 years in children vaccinated at 6 years of age or younger). Refer to Travellers or Workers sections for additional information.

Meningococcal vaccine is also recommended for most close contacts of a case of IMD and for outbreak control, if the disease is caused by a serogroup contained in the vaccine. Refer to Post-exposure management and Outbreak control for additional information.

Age considerations for choice of vaccine for high risk groups

2 to 23 months of age
Based on available published data in this age group, Menveo™ should be used because it has been found to be safe and immunogenic. Routine meningococcal C conjugate vaccine does not need to be administered in addition to Menveo™.

24 months to 55 years of age
Either Men-C-ACYW-135 vaccine may be used.

56 years of age and older
Either Men-C-ACYW-135 vaccine should be considered.

Refer to Schedule for additional information, Table 1 for recommended vaccination for certain travellers and Table 3 for recommended vaccination of high risk individuals with underlying medical conditions.

Persons with inadequate immunization records

Children and adults lacking adequate documentation of immunization should be considered unimmunized and started on an immunization schedule appropriate for their age and risk factors. Conjugate meningococcal vaccine, as appropriate for age, may be given regardless of possible previous receipt of the vaccine as adverse events associated with repeated immunization have not been demonstrated. Refer to Immunization of Children and Adults with Inadequate Immunization Records in Part 3 for additional general information.

Pregnancy and breastfeeding

Conjugate meningococcal vaccines have not been studied in pregnancy; however, there is no theoretical reason to suspect adverse events will occur and, in circumstances in which the benefits outweigh the risks, the use of conjugate meningococcal vaccines in pregnancy may be considered. Inactivated vaccines, such as conjugate meningococcal vaccines, may be administered to women who are breastfeeding. Refer to Immunization in Pregnancy and Breastfeeding in Part 3 for additional general information.

Infants born prematurely

Premature infants in stable clinical condition should be immunized with conjugate meningococcal vaccine at the same chronological age and according to the same schedule as full-term infants. Infants born prematurely (especially those weighing less than 1,500 grams at birth) are at higher risk of apnea and bradycardia following vaccination. Hospitalized premature infants should have continuous cardiac and respiratory monitoring for 48 hours after their first immunization. Refer to Immunization of Infants Born Prematurely in Part 3 for additional general information.

Patients/residents in health care institutions

Residents of long-term care facilities should receive meningococcal vaccine as appropriate for their risk factors. Refer to Immunization of Patients in Health Care Institutions in Part 3 for additional general information.

Immunocompromised persons

Quadrivalent conjugate meningococcal vaccine is recommended for certain high risk individuals as outlined under High risk groups above. When considering immunization of an immunocompromised person, consultation with the individual’s attending physician may be of assistance in addition to the guidance provided below. For complex cases, referral to a physician with expertise in immunization and/or immunodeficiency is advised.

Congenital (primary) immunodeficiency

Persons with complement, properdin, factor D or primary antibody deficiencies should be vaccinated with Men-C-ACYW-135 vaccine. Refer to Table 3 for additional information.

Acquired (secondary) immunodeficiency

Hematopoietic stem cell transplantation (HSCT- autologous or allogeneic)
For children and adults, the effect of any previous meningococcal vaccine will be diminished following HSCT; therefore, HSCT recipients should be vaccinated as per recommendations for the previously unvaccinated based on their age or risk factors for IMD. If routinely indicated based on age or other risk factors, conjugate meningococcal vaccine can be given as early as 6 months after transplantation, unless needed earlier for management of a close contact or outbreak. However, if it is given earlier than 6 months after transplant the response may not be optimal and consideration should be given to repeating the dose at least 6 months after transplant (and at least 8 weeks after the previous dose) if ongoing protection is needed.

Solid organ transplantation
Conjugate meningococcal vaccine (type of vaccine as appropriate for age) is recommended to be given at least two weeks before transplantation if routinely indicated based on age or risk factors for IMD. If not given prior to transplant and routinely indicated based on age or other risk factors, meningococcal vaccine can be given any time after 6 months post-transplant and at least one month after discontinuation of treatment for acute rejection unless needed earlier for management of a close contact or outbreak. However, if it is given earlier than 6 months after transplant or earlier than 1 month after discontinuing treatment for acute rejection, the response may not be optimal and consideration should be given to repeating the dose at least 6 months after transplant and at least 1 month after discontinuing treatment for acute rejection (and at least 8 weeks after the previous dose) if ongoing protection is needed.

HIV-infected
Two doses of Men-C-ACYW-135 vaccine should be considered for individuals with HIV infection. Refer to Table 3 for additional information.

Acquired complement deficiency
People with conditions such as paroxysmal nocturnal hemoglobinuria who are receiving the terminal complement inhibitor eculizumab (Soliris™) should receive two doses of Men-C-ACYW-135 vaccine. They must be vaccinated at least two weeks prior to receiving the first dose of eculizumab, if possible, and every 5 years thereafter if they continue to use the drug. Refer to Table 3 for additional information.

Refer to Booster doses and re-immunization for additional information and Immunization of Immunocompromised Persons in Part 3 for additional general information.

Persons with chronic diseases

Asplenia
Two doses of Men-C-ACYW-135 vaccine are recommended for persons with anatomic or functional asplenia (including sickle cell disease). When elective splenectomy is planned, all recommended vaccines should ideally be completed at least 2 weeks before surgery; if only one dose can be given before surgery, the second dose should be given 8 weeks after the first dose (with a minimum interval of 4 weeks). In the case of an emergency splenectomy, two doses of vaccine should ideally be given beginning 2 weeks after surgery but can be given earlier, before discharge, if the person might not return for vaccination after discharge. Note that persons one year of age and older with asplenia who have not received Men-C-ACYW-135 vaccine should receive two doses administered 8 weeks apart (with a minimum interval of 4 weeks). Periodic booster doses are also recommended.

Refer to Table 3 for vaccination recommendations of high risk individuals due to underlying conditions based on age. Refer to Booster doses and re-immunization for additional information and Immunization of Persons with Chronic Diseases in Part 3 for additional general information.

Travellers

Travellers going to destinations where risk of meningococcal transmission is high should be vaccinated with Men-C-ACYW-135 vaccine. Men-C-C vaccine alone is not appropriate for protection of travellers as it does not protect against serogroup A, which is endemic in selected regions of the world, or serogroup W-135 disease. Current meningococcal disease outbreak information is available from the WHO at: Global Alert and Response (GAR) - Meningococcal diseaseExternal Link.

For travellers 2 months to 10 years of age, Men-C-ACYW-135 vaccine is indicated. For children 2 to 23 months, Menveo™ is recommended based on expert opinion and clinical trial data; however, Menveo™ is not authorized for use in this age group. For children 2 years to 10 years of age, Men-C-C vaccine should already have been administered. If Men-C-C vaccine has not been given previously, it should be administered to children at least 4 weeks after the Men-C-ACYW-135 vaccine. Refer to Table 1 for recommended immunization for travellers to destinations where risk of meningococcal transmission is high.

Refer to the Committee to Advise on Tropical Medicine and Travel (CATMAT) information on assessing a traveller’s need for pre-travel vaccination at: About CATMAT.

Proof of meningococcal immunization may be required by certain countries. For example, Saudi Arabia requires proof of meningococcal immunization for pilgrims to the Hajj in Mecca (refer to Ministry of Hajj - Kingdom of Saudi ArabiaExternal Link). For travel to the Hajj, re-immunization at an interval of less than 5 years from the last dose may be required. Refer to Immunization of Travellers in Part 3 for additional general information.

Table 1: Recommended immunization for travellers to destinations where risk of meningococcal transmission is high, not previously immunized with Men-C-ACYW-135Table 1 - Footnote *1 vaccine.
Age Recommended vaccine(s) Schedule
Table 1 - Footnote *1
Men-C-ACYW-135: Menactra® or Menveo™
Table 1 - Footnote *2
Menveo™ is not authorized for use in children less than 2 years of age; there are no authorized schedules for these children. The schedules in this table are based on those used in published clinical trials and the recommendation that a dose of meningococcal conjugate vaccine be given in the second year of life (12 to 23 months) for children vaccinated at less than 1 year of age.
Table 1 - Footnote *3
Doses may be given a minimum of 4 weeks apart if accelerated immunization needed
Table 1 - Footnote *4
A booster dose should be given every 3 to 5 years if vaccinated at 6 years of age or younger and every 5 years for those vaccinated at 7 years of age and older. Travellers to the Hajj should check recommendations for re-vaccination at: http://www.hajinformation/com/main/p3001.htm as more frequent re-vaccination may be required.
Table 1 - Footnote *5
Children 2 to 10 years of age should have already received Men-C-C vaccine. If not, it should be administered 4 weeks after the Men-C-ACYW-135 vaccine.
Table 1 - Footnote *6
Men-C-ACYW-135 vaccines are not authorized for use in those 56 years of age and older; however, based on limited evidence and expert opinion its use is considered appropriate.
2 to 11 months of age Menveo™Table 1 - Footnote *2 2 or 3 doses given 8 weeks apart (with another dose between 12-23 months of age that is at least 8 weeks from the previous dose)Table 1 - Footnote *3 and booster dosesTable 1 - Footnote *4
12 to 23 months of age Menveo™Table 1 - Footnote *2 2 doses at least 8 weeks apartTable 1 - Footnote *3 and booster dosesTable 1 - Footnote *4
24 months of age and olderTable 1 - Footnote *6 Men-C-ACYW-135Table 1 - Footnote *1 1 doseTable 1 - Footnote *5 and booster dosesTable 1 - Footnote *4
Persons new to Canada

Health care providers who see persons newly arrived in Canada should review the immunization status and update immunization for these individuals. Review of meningococcal vaccination status is particularly important for persons from areas of the world where sickle cell disease is present as persons with sickle cell disease are at risk of serious meningococcal infections. In many countries outside of Canada, conjugate meningococcal vaccines are in limited use. Information on vaccination schedules in other countries can be found on the following website: WHO Vaccine Preventable Diseases Monitoring SystemExternal Link. Refer to Immunization of Persons New to Canada in Part 3 for additional general information.

Workers

Laboratory workers
Research, industrial and clinical laboratory personnel who are potentially routinely exposed to N. meningitidis should be offered one dose of Men-C-ACYW-135 vaccine. Re-vaccination is generally recommended every 5 years. Routine infection control precautions should be practiced at all times to minimize the risk of exposure in laboratory workers and post-exposure prophylaxis should be offered after recognized exposures. Refer to Booster doses and re-immunization for additional information.

Health care workers (HCW)
There is no evidence to recommend routine meningococcal immunization of HCW. Nosocomial transmission of IMD is very uncommon. HCW are considered as close contacts only if they have had intensive, unprotected contact (without wearing a mask) with infected patients (e.g., intubating, resuscitating or closely examining the oropharynx). It is recommended that HCW use barrier precautions to avoid direct contact with respiratory secretions of patients with meningococcal disease until the patient has completed 24 hours of effective antibiotic therapy.

Military personnel
Military personnel may be at increased risk when accommodated in close quarters or through deployment to endemic or epidemic countries.

Refer to Immunization of Workers in Part 3 for additional general information.

Post-exposure management

Contacts of cases
Close contacts of individuals with meningococcal infections have an increased risk of developing IMD; this risk is greatest for household contacts. The increased risk of disease for household contacts persists for up to 1 year after disease in the index case and beyond any protection from antibiotic chemoprophylaxis. In general, this prolonged risk is not seen in contacts who do not have ongoing exposure.

Chemoprophylaxis should be offered to all persons having close contact with a case of IMD from 7 days before onset of symptoms in the case to 24 hours after onset of effective treatment in the case, regardless of their immunization status. Refer to the Public Health Agency of Canada Guidelines for the Prevention and Control of Meningococcal Disease for information about chemoprophylaxis in the management of close contacts of individuals with meningococcal infection.

Vaccination or re-vaccination of certain close contacts should be considered in addition to chemoprophylaxis when the serogroup is vaccine preventable as it may further reduce the risk of subsequent meningococcal disease.

Close contacts requiring chemoprophylaxis and consideration for immunoprophylaxis
The following individuals (regardless of immunization status) should receive chemoprophylaxis and, if the meningococcal serogroup identified in the case of IMD is vaccine preventable, should also be considered for immunoprophylaxis:

  • Household contacts of a case of IMD
  • Persons who share sleeping arrangements with a case of IMD
  • Persons who have direct nose or mouth contamination with oral or nasal secretions of a case of IMD (e.g., kissing on the mouth, shared cigarettes, shared drinking bottles)
  • Children and staff in contact with a case of IMD in child care or nursery school facilities

Refer to Table 2 for specific recommendations for immunoprophylaxis of close contacts of IMD cases according to the serogroup in the index case and the age and underlying conditions of the contact.

Re-vaccination criteria for those previously vaccinated against IMD
The following provides criteria for the re-vaccination of previously vaccinated close contacts when the index case has a vaccine preventable IMD serogroup or there is a vaccine preventable outbreak of IMD:

  • Those previously vaccinated with a serogroup that differs from the index case or outbreak strain should be vaccinated immediately with the appropriate vaccine (as outlined in Table 2);
  • Those previously vaccinated with a serogroup that is the same as the index case or outbreak strain should be re-vaccinated with the appropriate vaccine (as outlined in Table 2):
    • If they were less than 1 year of age at last meningococcal vaccination and more than 4 weeks has passed since their last meningococcal vaccine;
    • If they have an underlying medical condition that puts them at risk for meningococcal disease and more than 4 weeks has passed since their last meningococcal vaccine;
    • If more than a year has passed since their last meningococcal vaccine if they were not less than 1 year of age at the time of their last meningococcal vaccination and if they have no underlying medical condition that puts them at risk for meningococcal disease.

Close contacts requiring chemoprophylaxis only
The following individuals should receive chemoprophylaxis only, immunoprophylaxis is not necessary:

  • Health care workers who have had intensive unprotected contact (without wearing a mask) with infected patients (i.e., intubating, resuscitating or closely examining the oropharynx).
  • Airline passengers sitting immediately on either side of the case (but not across the aisle) when the total time spent aboard the aircraft was at least 8 hours.
  • Close contacts of a case of IMD due to serogroups not present in meningococcal vaccines, or when the serogroup in the index case has not been determined.
  • Previously vaccinated close contacts who do not meet the criteria for re-vaccination as outline above.
Outbreak control

Outbreaks of meningococcal disease
Consultation with public health officials and/or experts in communicable disease is important in the assessment and control of meningococcal disease outbreaks. Outbreaks may be controlled by the use of a conjugate meningococcal vaccine. The type of vaccine to use in an outbreak is dependent on the serogroup causing the outbreak and the age of those being vaccinated as outlined in Table 2. Re-vaccination criteria of previously vaccinated individuals are outlined above in Re-vaccination criteria for those previously vaccinated against IMD.

Table 2: Recommended vaccination of close contacts for post-exposure management and for outbreak control
Group Recommended vaccine(s) Schedule
Table 2 - Footnote *1
Men-C-C: Meningitec® or Menjugate® or NeisVac-C®
Table 2 - Footnote *2
At high risk due to underlying medical conditions - refer to Underlying medical conditions
Table 2 - Footnote *3
Men-C-ACYW-135: Menactra® or Menveo™
Table 2 - Footnote *4
Menveo™ is not authorized for use in children less than 2 years of age; there are no authorized schedules for these children. The schedules in this table are based on those used in published clinical trials and the recommendation that a dose of meningococcal conjugate vaccine be given in the second year of life (12 to 23 months) for children vaccinated at less than 1 year of age.
Table 2 - Footnote *5
In general, a minimum four week interval is recommended between doses of conjugate meningococcal vaccines; however, in an outbreak or to manage a close contact of a case of IMD, the second dose of conjugate meningococcal vaccine may be given as soon as indicated to provide protection to a close contact who is unvaccinated for the implicated serogroup.
Table 2 - Footnote *6
Individuals at high risk due to underlying medical conditions routinely need two doses of Men-C-ACYW-135.

Close contacts and outbreak control of serogroup C invasive meningococcal disease

2 months to less than 12 months of age

Men-C-CTable 2 - Footnote *1

Unvaccinated: 1 dose immediately after exposure then complete the routine series of Men-C-C

Previously vaccinated: If previously vaccinated then re-vaccinate with Men-C-C if at least 4 weeks since last dose, then complete the routine series of Men-C-C if necessary

12 months – 10 years of age

Men-C-CTable 2 - Footnote *1

Unvaccinated: 1 dose immediately after exposure

Previously vaccinated: If previously vaccinated at less than 1 year of age OR person is at high risk for IMD due to underlying medical conditionsTable 2 - Footnote *2, then re-vaccinate with one dose of Men-C-C if at least 4 weeks since last dose; otherwise re-vaccinate if at least 1 year since last dose

11 years of age and older

Men-C-CTable 2 - Footnote *1

OR

Men-C-ACYW-135Table 2 - Footnote *3

Unvaccinated: 1 dose immediately after exposure

Previously vaccinated: If previously vaccinated at less than 1 year of age OR person is at high risk for IMD due to underlying medical conditionsTable 2 - Footnote *2, then re-vaccinate with one dose of vaccine of choice if at least 4 weeks since last dose; otherwise re-vaccinate if at least 1 year since last dose

Close contacts and outbreak control of serogroup A, Y, or W-135 invasive meningococcal disease

2 months to less than 12 months of age

Menveo™Table 2 - Footnote *4

Unvaccinated: 2 or 3 doses given 8 weeks apart with another dose between 12 and 23 months and at least 8 weeks from the previous dose

Previously vaccinated:

  • If previously vaccinated with only Men C-C, give Menveo™ as for unvaccinated persons, regardless of when Men-C-C was previously givenTable 2 - Footnote *5
  • If previously vaccinated with Men-C-ACYW-135, then re-vaccinate with one dose of Menveo™ if at least 4 weeks since last dose of Men-C-ACYW-135 vaccine; then complete series

12 to 23 months of age

Menveo™Table 2 - Footnote *4

Unvaccinated: 2 doses at least 8 weeks apart

Previously vaccinated:

  • If previously vaccinated with only Men C-C, give Menveo™ as for unvaccinated persons, regardless of when Men-C-C was previously givenTable 2 - Footnote *5
  • If previously vaccinated with Men-C-ACYW-135 at less than 1 year of age OR if person is at high risk for IMD due to underlying medical conditionsTable 2 - Footnote *2, then re-vaccinate with one dose of Menveo™ if at least 4 weeks since last dose of Men-C-ACYW-135; otherwise re-vaccinate with one dose of Menveo™ if at least 1 year since last dose of Men-C-ACYW-135

2 years and older

Men-C-ACYW-135Table 2 - Footnote *3

Unvaccinated: 1 dose immediately after exposureTable 2 - Footnote *6

Previously vaccinated:

  • If previously vaccinated with only Men C-C, give Men-C-ACYW-135 as for unvaccinated persons, regardless of when Men-C-C was previously givenTable 2 - Footnote *5
  • If previously vaccinated with Men-C-ACYW-135 at less than 1 year of age OR if person is at high risk for IMD due to underlying medical conditionsTable 2 - Footnote *2, then re-vaccinate with one dose of Men-C-ACYW-135 if at least 4 weeks since last dose of Men-C-ACYW-135; otherwise re-vaccinate with one dose of Men-C-ACYW-135 if at least 1 year since last dose of Men-C-ACYW-135

Vaccine Administration

Dose, route of administration, and schedule

Dose
Each dose of meningococcal vaccine is 0.5 mL.

Route of administration
Conjugate meningococcal vaccine should be administered intramuscularly (IM). Refer to Vaccine Administration Practices in Part 1 for additional information.

Schedule

Recommended meningococcal immunization schedules and products vary across provinces/territories depending upon the epidemiology of meningococcal disease in the jurisdiction and other programmatic factors.

Healthy infants and children (2 to 23 months of age)
The manufacturer-recommended infant schedule varies with the Men-C-C vaccine used. For routine infant immunization, three doses of Menjugate® may be administered separated by at least 4 weeks, from 2 months of age. Two doses of NeisVac-C® or Meningitec® may be administered at least 2 months apart, from 2 months of age. If Men-C-C vaccine is given to infants less than 12 months of age, a booster dose should be given between 12 to 23 months of age. If the booster dose is missed, it can be given at the next vaccination opportunity.

Healthy children, adolescents and young adults
One dose of Men-C-C vaccine is recommended for previously unimmunized children 12 months to less than 5 years of age and may be considered for children 5 to 11 years of age. In addition to routine Men-C-C vaccine for infants and young children, adolescents and young adults (12 to 24 years of age) should receive one dose of either Men-C-C or Men-C-ACYW-135 vaccine, based on local epidemiology and programmatic considerations, with around 12 years being the preferred age for the routine dose

High risk individuals due to underlying medical conditions
High risk individuals are those with underlying conditions that make them more likely to develop IMD. Schedule options for high risk individuals who have not previously received a quadrivalent conjugate meningococcal vaccine are included in Table 3. As noted in Table 3, previously unimmunized high risk persons 12 months of age and older should receive a two dose primary series administered 8 weeks apart (with a minimum interval of 4 weeks).

Table 3: Recommended immunization for high risk groups because of underlying medical conditionsTable 3 - Footnote *1 not previously immunized with Men-C-ACYW-135Table 3 - Footnote *2 vaccine
Age Recommended vaccine(s) Schedule
Table 3 - Footnote *1
At high risk due to underlying medical conditions: refer to Underlying medical conditions
Table 3 - Footnote *2
Men-C-ACYW-135: Menactra® or Menveo™
Table 3 - Footnote *3
Menveo™ is not authorized for use in children less than 2 years of age; there are no authorized schedules for these children. The schedules in this table are based on those used in published clinical trials and the recommendation that a dose of meningococcal conjugate vaccine be given in the second year of life (12 to 23 months) for children vaccinated at less than 1 year of age.
Table 3 - Footnote *4
Doses may be given a minimum of 4 weeks apart if accelerated immunization needed
Table 3 - Footnote *5
A booster dose should be given every 3 to 5 years if vaccinated at 6 years of age or younger and every 5 years for those vaccinated at 7 years of age and older.
Table 3 - Footnote *6
Men-C-ACYW-135 vaccines are not authorized for use in those 56 years of age and older; however, based on limited evidence and expert opinion its use is considered appropriate.
2 to 11 months of age Menveo™Table 3 - Footnote *3 2 or 3 doses given 8 weeks apart (with another dose between 12-23 months of age that is at least 8 weeks from the previous dose)Table 3 - Footnote *4 and booster dosesTable 3 - Footnote *5
12 to 23 months of age Menveo™Table 3 - Footnote *3 2 doses at least 8 weeks apartTable 3 - Footnote *4 and booster dosesTable 3 - Footnote *5
24 months to 55 years of age Men-C-ACYW-135 2 doses 8 weeks apartTable 3 - Footnote *4and booster dosesTable 3 - Footnote *5
56 years of age and older Men-C-ACYW-135Table 3 - Footnote *6 2 doses 8 weeks apartTable 3 - Footnote *4 and booster dosesTable 3 - Footnote *5
Booster doses and re-immunization

Circulating antibodies are considered necessary to protect an individual against IMD. Re-vaccination is recommended as follows:

  • Individuals at high risk of developing meningococcal disease due to underlying conditions as outlined in Underlying medical conditions. Re-vaccination is recommended every 3 to 5 years for those vaccinated at 6 years of age and younger and every 5 years for those vaccinated at 7 years of age and older.
  • When travelling to areas where meningococcal vaccine is recommended or required. Re-vaccination is recommended every 3 to 5 years of age if vaccinated at 6 years of age and younger, and every 5 years for those vaccinated at 7 years of age and older. Previously vaccinated travellers are advised to check requirements for re-vaccination with meningococcal vaccines prior to travel to the Hajj as more frequent vaccination may be required (refer to Ministry of Hajj - Kingdom of Saudi ArabiaExternal Link and Travellers).
  • Military personnel who remain at risk due to travel or overcrowded conditions. A booster dose is recommended every 5 years if at ongoing risk
  • At the time of exposure for contacts of a case of IMD in some circumstances. Refer to Post-exposure management.
  • During a community outbreak of IMD in some circumstances. Refer to Post-exposure management.
  • All laboratory personnel who are potentially routinely exposed to N. meningitidis. Booster doses should be given at routine 5 year intervals for those laboratory workers who remain at ongoing risk of exposure. Refer to Workers.

People previously vaccinated with a polysaccharide meningococcal vaccine should be re-vaccinated with the appropriate conjugate meningococcal vaccine if they remain at ongoing risk for meningococcal disease, with at least a 6 month interval following vaccination with polysaccharide meningococcal vaccine.

Serologic Testing

Serologic testing is not recommended before or after receiving meningococcal vaccine.

Storage Requirements

Menactra®, Meningitec®, NeisVac-C®: Store in a refrigerator at +2ºC to +8ºC. Do not freeze.

Menjugate®, Menveo: Store in a refrigerator at +2ºC to +8ºC. Do not freeze. Protect from light.

Refer to Storage and Handling of Immunizing Agents in Part 1 for additional general information.

Simultaneous Administration with Other Vaccines

Men-C-C vaccine may be administered concomitantly with routine childhood vaccines and Men-C-ACYW-135 vaccine may be administered concomitantly with adolescent and adult age appropriate vaccines at different injection sites using separate needles and syringes.

Menveo can be administered with routine paediatric vaccines; however, further studies are needed with regard to concomitant administration with pneumococcal 13-valent conjugate vaccine. Co-administration of Menveo and combined tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) may result in a lower immune response to the pertussis antigens than when Tdap vaccine is given alone; however, the clinical significance of this is unknown. Tdap vaccine given one month after Menveo™ induces the strongest immunologic response to pertussis antigens. Refer to Timing of Vaccine Administration in Part 1 for additional general information.

Vaccine Safety and Adverse Events

Refer to Vaccine Safety and Adverse Events Following Immunization Part 2 for additional general information.

Common and local adverse events
Conjugate meningococcal vaccines

Men-C-ACYW-135 vaccines
Injection site reactions occur in up to 59% of vaccinees. Fever is reported in up to 5% of recipients and systemic reactions, such as headache and malaise, are reported in up to 60% of recipients.

Men-C-C vaccines
Mild reactions, including injection site reactions (redness, tenderness, and swelling), occur in up to 50% of vaccinees. Irritability occurs in up to 80% of infants and fever in up to 9% when other vaccines were administered. Headaches and malaise occur in up to 10% of older children and adults. These reactions last no more than a few days.

Less common and serious or severe adverse events

Serious adverse events are rare following immunization and, in most cases, data are insufficient to determine a causal association. A concern regarding Guillain Barre Syndrome (GBS) following Menactra® was raised because of case reports to the United States Vaccine Adverse Event Reporting System (VAERS). Subsequently, two large epidemiologic studies were conducted. No cases of GBS were observed during the six weeks following over 2.2 million doses given to individuals aged 11 to 21 years. This evidence supports the conclusion that there is no increased risk of GBS following Menactra®.

Guidance on reporting Adverse Events Following Immunization (AEFI)

Vaccine providers are asked to report, through local public health officials, any serious or unexpected adverse event felt to be temporally related to vaccination. An unexpected AEFI is an event that is not listed in available product information but may be due to the immunization, or a change in the frequency of a known AEFI. Refer to Box 1 in Vaccine Safety in Part 2 and Reporting Adverse Events Following Immunization (AEFI) in Canada for additional information about AEFI reporting.

Contraindications and precautions

Meningococcal vaccine is contraindicated in persons with a history of anaphylaxis after previous administration of the vaccine and in persons with proven immediate or anaphylactic hypersensitivity to any component of the vaccine or its container. Refer to Table 1 in General Considerations in Part 1 for lists of all vaccines available for use in Canada and their contents. For meningococcal vaccines, potential allergens include:

  • Menactra®: diphtheria toxoid protein
  • Meningitec®: latex in vial stopper, diphtheria CRM197 toxoid carrier protein Menjugate®: latex in tip cap of syringe, diphtheria CRM197 toxoid carrier protein
  • Menomune®: thimerosal, latex
  • Menveo: diphtheria CRM197 toxoid carrier protein
  • NeisVac-C®: tetanus toxoid protein

There are very few individuals who cannot receive meningococcal vaccines. In situations of suspected hypersensitivity or non-anaphylactic allergy to vaccine components, investigation is indicated which may involve immunization in a controlled setting. Consultation with an allergist is advised. Menomune® may be considered in the rare circumstance that someone is allergic to components (other than latex) in the conjugate meningococcal vaccines.

Administration of meningococcal vaccine should be postponed in persons with moderate or severe acute illness. Persons with minor acute illness (with or without fever) may be vaccinated.

Refer to General Contraindications and Precautions in Part 2 for additional general information.

Interchangeability of vaccines

There are no published data regarding the interchangeability of Men-C-C vaccines, but the vaccines have been safely interchanged without a noticeable decrease in efficacy. When possible, the infant series should be completed with the same vaccine. Either Men-C-ACYW-135 vaccine may be used for re-vaccination, regardless of which meningococcal vaccine was used for initial vaccination. Refer to Principles of Vaccine Interchangeability in Part 1 for additional general information.

Selected References

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  • Borrow R, Fox AJ, Richmond PC et al. Induction of immunological memory in UK infants by a meningococcal A/C conjugate vaccine. Epidemiol Infect 2000;124(3):427-32.
  • Borrow R, Southern J, Andrews N et al. Comparison of antibody kinetics following meningococcal serogroup C conjugate vaccine between healthy adults previously vaccinated with meningococcal A/C polysaccharide vaccine and vaccine-naive controls. Vaccine 2001;19(23-24):3043-50.
  • Canadian Immunization Committee. Supplement: Advice for Consideration of Quadrivalent (A, C, Y, W135) Meningococcal Conjugate Vaccine, for use by Provinces and Territories. Can Commun Dis Rep 2010;36(S2):1-35.
  • Centers for Disease Control and Prevention. Laboratory-acquired meningococcemia – California and Massachusetts. MMWR Morb Mortal Wkly Rep 1991;40(3):46-7, 55.
  • Centers for Disease Control and Prevention. Prevention and control of meningococcal disease: rec­ommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2005;54(RR-7):1-21.
  • Centers for Disease Control and Prevention. Updated Recommendations for Use of Meningococcal Conjugate Vaccines --- Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep 2011;60(03):72-76.
  • Choo S, Zuckerman J, Goilav C et al. Immunogenicity and reactogenicity of a group C meningococcal conjugate vaccine compared with a group A+C meningococcal poly­saccharide vaccine in adolescents in a randomised observer-blind controlled trial. Vaccine 2000;18(24):2686-92.
  • Committee to Advise on Tropical Medicine and Travel (CATMAT). Statement on meningococcal vaccination for travellers. Can Commun Dis Rep 2009;35(ASC4):1-22.
  • Cooke RP, Riordan T, Jones DM et al. Secondary cases of meningococcal infection among close family and household contacts in England and Wales, 1984-7. BMJ 1989;298(6673):555-58.
  • De Wals P, De Serres G, Niyonsenga T. Effectiveness of a mass immunization campaign against serogroup C meningococcal disease in Quebec. JAMA 2001;285(2):177-81.
  • English M, MacLennan JM, Bowen-Morris JM et al. A randomised, double-blind, controlled trial of the immunogenicity and tolerability of a meningococcal group C conjugate vac­cine in young British infants. Vaccine 2000;19(9-10):1232-38.
  • Erickson L, De Wals P. Complications and sequelae of meningococcal disease in Quebec, Canada, 1990-1994. Clin Infect Dis 1998;26(5):1159-64.
  • Fairley CK, Begg N, Borrow R et al. Conjugate meningococcal serogroup A and C vaccine: reactogenicity and immunogenicity in United Kingdom infants. J Infect Dis 1996;174:1360-63.
  • Gilmore A, Stuart J, Andrews N. Risk of secondary meningococcal disease in health-care workers. Lancet 2000;356(9242):1654-55.
  • GlaxoSmithKline Inc. Product Monograph - NeisVac-C®. June 2010.
  • Gold R, Lepow ML, Goldschneider I et al. Immune response of human infants of polysaccharide vaccines of group A and C Neisseria meningitidis. J Infect Dis 1977;136:S31-5.
  • Hastings L, Stuart J, Andrews N. A retrospective survey of clusters of meningococcal disease in England and Wales, 1993 to 1995: estimated risks of further cases in household and educational settings. Commun Dis Rep CDR Rev 1997;7(13):R195-200.
  • MacDonald NE, Halperin SA, Law BJ et al. Induction of immunologic memory by conjugated vs plain meningococcal C polysaccharide vaccine in toddlers: a randomized controlled trial. JAMA 1998;280(19):1685-9.
  • MacLennan J, Obaro S, Deeks J et al. Immune response to revaccination with meningococcal A and C polysaccharides in Gambian children following repeated immunisation during early childhood. Vaccine 1999;17(23-24):3086-93.
  • MacLennan J, Obaro S, Deeks J et al. Immunologic memory 5 years after meningococcal A/C conjugate vaccination in infancy. J Infect Dis 2001;183(1):97-104.
  • MacLennan JM, Shackley F, Heath PT et al. Safety, immunogenicity, and induction of immunologic memory by a serogroup C meningococcal conjugate vaccine in infants: a randomized controlled trial [see comments]. JAMA 2000;283(21):2795-801.
  • National Advisory Committee on Immunization. Statement on conjugate meningococcal vaccine for serogroups A, C, Y and W135. Can Commun Dis Rep 2007;33(ACS-3):1-24.
  • National Advisory Committee on Immunization. Statement/Update on the Use of Quadrivalent Conjugate Meningococcal Vaccines. Can Commun Dis Rep 2012
  • National Advisory Committee on Immunization. Update on the Invasive Meningococcal Disease and Meningococcal Vaccine Conjugate Recommendations. Can Commun Dis Rep 2009;36(ACS-3):1-40.
  • Neal KR, Nguyen-Van-Tam J, Monk P et al. Invasive meningococcal disease among university undergraduates: association with universities providing relatively large amounts of catered hall accommodation. Epidemiol Infect 1999;122(3):351-57.
  • Novartis Pharmaceuticals Canada Ltd. Product Monograph - MENJUGATE®. February 2011.
  • Novartis Vaccines and Diagnostics Inc. Product Monograph - Menveo. June 2011.
  • Pfizer Canada Inc. Product Monograph - MENINGITEC®. October 2010.
  • PHLS Meningococcal Infections Working Group and Public Health Medicine Environmental Group. Control of meningococcal disease: guidance for consultants in communicable disease control. Commune Dis Rep CDR Rev 1995;5(13):R189-95.
  • Public Health Agency of Canada. Guidelines for the prevention and control of meningococcal disease. Can Commun Dis Rep 2005;31(S1):1-26.
  • Ramsay ME, Andrews N, Kaczmarski EB et al. Efficacy of meningococcal serogroup C conjugate vaccine in teenagers and toddlers in England. Lancet 2001;357(9251):195-96.
  • Richmond P, Borrow R, Goldblatt D et al. Ability of 3 different meningococcal C conjugate vaccines to induce immunologic memory after a single dose in UK toddlers. J Infect Dis 2001;183(1):160-63.
  • Richmond P, Borrow R, Miller E et al. Meningococcal serogroup C conjugate vaccine is immunogenic in infancy and primes for memory. J Infect Dis 1999;179(6):1569-72.
  • Richmond P, Goldblatt D, Fusco PC et al. Safety and immunogenicity of a new Neisseria meningitidis serogroup C-tetanus toxoid conjugate vaccine in healthy adults. Vaccine 1999;18(7-8):641-46.
  • Richmond P, Kaczmarski E, Borrow R et al. Meningococcal C polysaccharide vaccine induces immunologic hyporesponsiveness in adults that is overcome by meningococcal C conjugate vaccine. J Infect Dis 2000;181(2):761-64.
  • Sanofi Pasteur Ltd. Product Monograph - MENOMUNE® - A/C/Y/W-135. October 2005.
  • Sanofi Pasteur Ltd. Product Monograph - Menactra®. April 2011.
  • Trotter CL, Andrews NJ, Kaczmarski EB et al. Effectiveness of meningococcal serogroup C conjugate vaccine 4 years after introduction. Lancet 2004;364(9431):365-67.
  • United Kingdom Health Protection Agency. UK Immunization Guide Chapter 22 Meningococcal. accessed March 2012 at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_125942.pdf

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