Childproof: Meningococcal Vaccine for Very Young At-Risk Travelers
Childproof: Meningococcal Vaccine for Very Young At-Risk Travelers
Abstract and Commentary
By Puja J. Umaretiya and Philip R. Fischer, MD, DTM&H
Dr. Fischer is Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN. Ms. Umaretiya is a student at Mayo Medical School in Rochester, Minnesota.
Neither Dr. Fischer nor Ms. Umaretiya report any financial relationship to this field of study.
Synopsis: A quadrivalent meningococcal conjugate vaccine (MenACWY-D) should be given to children 9-23 months of age who are traveling to countries where meningococcal disease is either hyper-endemic or epidemic. This is particularly relevant to children who are traveling to visit friends or relatives (VFR).
Sources: Recommendation of the Advisory Committee on Immunization Practices (ACIP) for Use of Quadrivalent Meningococcal Conjugate Vaccine (MenACWY-D) Among Children Aged 9 Through 23 Months at Increased Risk for Invasive Meningococcal Disease, 2011. Morb Mortal Wkly Rep 2011;60:1391-1392 and JAMA 2011;306:2211-2212.
The Advisory Committee on Immunization Practices (ACIP) set forth new guidelines in October 2011 for the use of a quadrivalent meningococcal conjugate vaccine (MenACWY-D) in children, ages 9 to 23 months, that are at increased risk for meningococcal disease. It is the first American recommendation to address the use of the meningococcal vaccine in children below the age of 2 years and comes after US Food and Drug Administration approval for the usage of the meningococcal conjugate vaccine (MenACWY-D) (Menactra®, Sanofi Pasteur) by children ages 9 to 23 months in April 2011.
The ACIP recommends that children ages 9 to 23 months at high risk for invasive meningococcal disease should receive the MenACWY-D primary series in 2 doses that are 3 months apart with an initial booster after 3 years and subsequent boosters at 5-year intervals, if the child remains at increased risk. The ACIP defines children at high risk for invasive meningococcal disease as those that have persistent complement component deficiencies (e.g C5-C9, properdin, factor H, or factor D), children who are traveling to or residents of countries where meningococcal disease is hyper-endemic or epidemic, and children who are in a defined risk group during a community or institutional meningococcal outbreak. Anatomic or functionally asplenic children are also at increased risk, but there is evidence that concurrent administration of meningococcal and pneumococcal vaccines might decrease the body's immune response to the pneumococcal antigens.
The recommendation comes after the ACIP Meningococcal Vaccine Work Group reviewed four clinical studies that show the safety and immunogenicity of the quadrivalent meningococcal conjugate vaccine, MenACWY-D, in healthy children aged 9 to 23 months. The initial booster is recommended at 3 years after the second dose in the primary series, because antibody persistence was shown to be less than the accepted measure of protection in more than 50% of subjects after 3 years. After the initial booster, 98% of subjects either met or exceeded the accepted amount of antibody persistence for adequate protection. Though there were no serious adverse events associated with the administration of MenACWY-D in the studies, the most common adverse events noted in healthy children aged 9 to 23 months were injection site tenderness and irritability.
Commentary
New guidelines for use of the MenACWY-D vaccine in children ages 9 to 23 months are highly relevant for travel medicine practitioners. It is not at all unusual for young children to travel and visit extended family members in parts of Africa where meningococcal disease is relatively common. These VFR [visiting friends and relatives] travelers provide excellent opportunities for the provision of helpful pre-travel care. While previously not known to be effective in toddlers and older infants, use of this vaccine in children less than two years of age is now well-supported by new data and expert guidelines.
Even though VFR travelers have a higher risk of acquiring certain infectious diseases, they often do not receive adequate pre-travel health care. VFR travelers are defined as travelers whose primary purpose is to travel and visit friends or relatives, where there is a gradient of epidemiological risk between home and destination.1,2 Thus, they are often traveling to countries where there are higher risks for certain infectious diseases. Furthermore, VFR travelers are more likely than others to travel for a longer duration and to more remote regions with subpar healthcare.2,3 This only increases the need for proper pre-travel health care; however, they often do not receive such care due to barriers in access to care. Language issues, lack of knowledge about offered services, and the common perception that they are immune to the infections in their country of origin.2,4 This is especially problematic for young children, because pediatric patients younger than age 5 are twice as likely to be VFR travelers than are adults.2,5 Meningitis, due to high morbidity and mortality rates, is of special concern for pediatric VFR patients traveling to the region of sub-Saharan Africa known as the meningitis belt. During the dry season, June to December, meningococcal meningitis occurs at an estimated rate of up to 1000 cases per 100,000 people in this region, and has a fatality rate of 10 to 15%.2 Hajj and Umrah pilgrimages to Saudi Arabia have experienced large outbreaks of meningitis in the past, and thus all travelers above the age of 2 are now required to receive a meningococcal vaccine prior to applying for a visa.6 However, the age group that is most susceptible to the disease is children under the age of 4, with an especially high incidence in children under the age of 1.7 Previous ACIP recommendations have focused on the rate of teenage meningococcal meningitis by encouraging health care providers to vaccinate adolescents at the age of 11 and give an additional booster vaccination at the age of 16. However, this new recommendation addresses the high susceptibility of young children to meningitis.8 While the MenACY-W quadrivalent vaccine has been approved for use in children under the age of 2 that are at higher risk for the disease, the major hurdle will be appropriately identifying at risk groups and encouraging them to get the vaccine. Though there are many barriers to vaccination, especially among the VFR travelers, recent studies have shown the effectiveness of community-based initiatives in educating VFR populations about the importance of vaccination.9 At the same time, nearly half of all American adolescents have not received their now-recommended meningococcal vaccines10, and there are new guidelines for a routine meningococcal vaccine booster.11 Pre-travel consultations serve as an excellent opportunity to make sure that all travelers are up-to-date on routine and travel-related vaccinations.
References
- Barnett E, et al. The visiting friends or relatives (VFR) traveler in the 21st century: time for a new definition. J Travel Med 2010; 17: 163-170.
- Hendel-Paterson B, et al. Pediatric travelers visiting friends and relatives (VFR) abroad: Illnesses, barriers and pre-travel recommendations. Travel Med Infec Dis 2011; 9: 192-203.
- Angell SY, et al. Risk Assessment and Disease Prevention in Travelers Visiting Friends and Relatives. Infect Dis Clin N Am2005;19: 49-65.
- Bacaner N, et. Al. Travel medicine considerations for North American immigrants visiting friends and relatives. JAMA 2004; 291: 2856-2864.
- Hagmann S, et al. Illness in children after international travel: analysis from the GeoSentinel Surveillance Network. Pediatrics 2010;125(5):e1071-1080.
- National Travel and Health Network Centre. Advice for Pilgrims for the Hajj and Umrah Season of 1432 (2011). http://bit.ly/xpdvkb, accessed 12-18-2011.
- Harrison LH, et al. Global epidemiology of meningococcal disease. Vaccine 2009; 27(S2): B51-B3.
- Scully, M. ACIP 2010 Vaccine Updates: Meningococcal Conjugate Vaccines and Tdap. Travel Medicine Advisor 2011; 21(4): 17-19.
- Leder K, et al. Innovative community-based initiatives to engage VFR travelers. Travel Med Infec Dis 2011; 9: 258-261.
- Stokley S, et al. Adolescent vaccination-coverage levels in the United States: 2006-2009. Pediatrics 2011;128:1078-1086.
- Committee on Infectious Diseases, American Academy of Pediatrics. Meningococcal conjugate vaccines policy update: booster dose recommendations. Pediatrics 2011;128:1213-1218.
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