Meningococcal vaccines
Meningococcal vaccines
Neisseria meningitidis is endemic in South Africa, presenting as meningococcal bacteraemia or meningitis. HIV infection is an important risk factor for acquiring invasive meningococcal disease (IMD), with a relative risk 5-13 times greater than the general population 30,31,32,33 . Epidemiological data from South Africa show an increased case-fatality rate of IMD in HIV-infected patients (20% vs 11% in HIV-uninfected) that could be explained by their increased odds of bacteraemia compared to meningitis 33.
Currently in South Africa, meningococcal disease is a minor contributor to mortality among HIV-infected persons, when compared to other infections such as tuberculosis (TB) and pneumococcal disease 34. However, the availability of effective vaccines against meningococcal disease should warrant the use of these vaccines in HIV-infected adults where needed. In 2016, the ACIP added HIV infection as a high-risk condition for meningococcal disease, based on the growing body of evidence supporting an increased risk of meningococcal disease in HIV-infected individuals 30, 35. Prospective cohort studies or case-controlled studies are needed to evaluate this association and further clarify the level of immunosuppression at which the increased risk occurs.
Our recommendation is that, where possible, vaccination should be considered in HIV-infected adults with a CD4+ count above 200 cells/μL. Where resources are limited, routine meningococcal vaccination of HIV-infected adults should follow the indications for meningococcal vaccination for the general population.
The general indications for vaccine are:
- Functional or anatomic asplenia
- Complement deficiency
- Individuals at risk of exposure through travel or work settings (routine microbiology laboratories)
- Individuals living in hostels or university / college residences
- Individuals at risk through an outbreak, including men who have sex with men (MSM) who may be exposed to outbreak strains due to social interactions within the global MSM community.
Two quadrivalent meningococcal vaccines covering serogroups A, C, W135 and Y are currently available in South Africa. One is a polysaccharide vaccine and the other a protein-conjugated polysaccharide vaccine. Due to the hypo-immunity associated with repeated doses of the plain polysaccharide vaccine, it is recommended that HIV-infected individuals receive the conjugate vaccine 36. A two-dose primary schedule (given 8-12 weeks apart) is recommended to increase the likelihood of a protective primary immune response. This should be followed by booster doses every five years. HIV-infected persons should ideally be vaccinated before their CD4+ cell percent drops to < 25% (S Meiring SA recommendations 2017-in press).