Helping to Advert Tragedy: Helping to Protect Against Invasive Meningococcal Disease

During my two-decade tenure in pediatric emergency medicine, one experience that stands out was the death of a young boy from invasive meningococcal disease (IMD). I witnessed a parent’s worst nightmare unfold right in front of me. The immense grief over the loss of this beautiful child shattered his family and community alike. Parents were left to explain to their elementary school-aged children the death of a peer; for many, the first person they had ever lost.

The ripple of grief was followed by a tsunami of terror. The child had been at school as well as sports and choir practice in the days before he died. Because this illness progressed so quickly, hundreds of parents worried that their children had been exposed and might succumb to a similar fate.

I would never wish this experience on any family or community. I do wish I could bottle the resulting sense of urgency and use it to help protect patients. There is something families can do to help protect their children from IMD, but it requires that they take action before their child is exposed.

It may be rare, but it progresses quickly and can have devastating consequences

Compared to the millions of people who come down with the flu in the U.S. each year, IMD is relatively rare. But the risk should not be ignored because the consequences are severe. About 10-15% of cases result in death. Even if a patient is lucky enough to survive, 10-20% are faced with hearing loss, neurological damage, loss of a limb, and/or other permanent health problems.¹

The severity of IMD is further compounded by the rapid pace at which it progresses. One morning a child may appear healthy, yet, by that same evening, the consequences could be fatal. The impact is further compounded by its deceptive nature. At first, it can appear similar to other flu-like illnesses. By the time a healthcare professional is able to correctly identify the disease, they are often left with limited (or no) time to react with treatment.^2-3

Absolutely no reason to risk it

Luckily, this isn’t a risk patients need to take, as we have safe and effective vaccines for IMD. For nearly two decades, the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) has routinely recommended the meningococcal vaccine against types A, C, W, and Y (MenACWY) to help protect adolescents against these IMD serogroups. The vaccine is recommended for all adolescents at 11 or 12 years of age and again at 16 years of age. The second dose is particularly important to remember because older adolescents represent one of the higher risk groups for IMD, as many high-risk behaviors occur at that age (such as kissing, sharing drinks, living in close quarters or visiting clubs), which can spread disease. Additionally, the ACIP recommends the administration of two doses of meningococcal vaccine against types B (MenB) to adolescents 16-18 years of age based on shared clinical decision making (for those who want to be immunized based on the benefits and risks of the vaccine).

The proof is in the numbers! In 2005, the ACIP issued a universal recommendation to administer the MenACWY to all young adolescents in the U.S. so long as they did not have a contraindication to it. Since then, cases of serogroups C, W and Y dropped by more than 90% among adolescents, the age group that is the target of the meningococcal vaccination program in the U.S.⁴

This past year, the ACIP convened to discuss recommendations around meningococcal vaccination. This October meeting focused on how to incorporate a recently licensed pentavalent vaccine that helps protect against five meningococcal serogroups (A, B, C, W, and Y) into the existing adolescent schedule. The ACIP voted to allow the pentavalent vaccine as an option when both MenACWY and MenB are indicated at the same visit (e.g., when a healthy 16-year-old, in for routine MenACWY administration, chooses to also receive MenB through shared clinical decision making). Though this recommendation means that meningococcal vaccination recommendations remain largely unchanged, it does underscore the continued attention and importance that is still rightfully placed on meningococcal vaccination.

Increasing vaccine adherence: the problem isn’t what you think

Maximizing MenACWY vaccination rates among adolescents remains a public health priority. Despite the substantial decline in IMD cases in adolescents, outbreaks still occur. Earlier this year, at the February 2023 ACIP meeting, the CDC presented at least three outbreaks caused by serogroup C or Y, two of which were still ongoing at the time of the ACIP meeting.

CDC data show that adherence rates are high for the first dose. I rarely encountered parents unwilling or even hesitant to receive the MenACWY vaccine, something I attribute to the general understanding of the severity of this disease. The mere mention of the word “meningitis” can trigger fear; so, it goes without saying that most families are willing to take the necessary steps to prevent it.

I currently serve as a Director for Research for Immunize.org, a nonprofit organization that works to increase vaccination rates and prevent disease through advocacy and education. They put it best when they describe booster doses in a letter promoting meningococcal vaccination by saying, “you’re not done if you give just one.” Most families understand that not all vaccines last a lifetime, but other challenges exist when it comes to MenACWY second dose uptake.

When children are due for their first dose – around 11 to 12 years of age – families are often still in the habit of coming in for regular preventive care visits. But older adolescents, around the age of 16, who are due for a second dose, often only visit the doctor when they’re sick. Children and adolescents are unlikely to be vaccinated during sick visits. When an adolescent arrives in an office with an illness, injury or a mental health concern, neither the provider nor the staff is concentrating on vaccination; the focus of the visit is elsewhere.

Interestingly, the recent October 2023 ACIP meeting has spurred conversations among some regarding whether we should continue to vaccinate against IMD starting at age 11-12 or if we should instead begin at age 16. The ACIP will certainly need to consider the successes we have seen in vaccination rates among the younger adolescent age group and the challenges we continue to experience in increasing adherence with preventive care visits among older adolescents. As the ACIP reviews the full adolescent schedule, it is imperative that they consider several important factors, including the current climate for vaccines (especially in the post-pandemic period) and how increases in vaccine hesitancy have impacted adherence, leaving adolescents more vulnerable to preventable diseases like IMD. As ACIP thoughtfully reviews all the evidence, the value of each child’s life and well-being, as well as population health, will be considered.

Tips to increase adherence

Most primary care offices are extremely busy places! So, my advice to increase adherence is all about simplification. The more the administrative processes can be streamlined for vaccines currently recommended by the ACIP, the more healthcare professionals can focus their attention on the complex and time-consuming conversations with parents and patients about topics other than infectious diseases.

Here are a few tips that will help boost vaccination adherence among your patients:

1. Implement standing orders so vaccine administration isn’t contingent upon whether you remembered to put in an order. In addition to allowing you to accommodate unanticipated vaccinations, it streamlines the ordering process in general. Not sure where to start? Organizations like Immunize.org offer relevant resources to get the ball rolling.

1. Identify a vaccine champion. Most offices have at least one staff member who is ultra-passionate about preventing IMD. Find this person and identify ways to translate their commitment into results. Ask them to run annual reports to determine which of your patients haven’t yet received their MenACWY and make calls to get them into the office and up to date.

Consider a flu vaccine clinic. Offering families an evening where they can swing by to get their flu vaccine quickly and efficiently is the ultimate convenience play for families and clinics alike. How does this help with MenACWY adherence? It gets patients in the door in large numbers. While they’re on site getting their flu shot, you can check the status of their MenACWY, as well as other adolescent vaccines they may be due for, and administer it on the spot, if appropriate.

A hopeful outlook

I cannot overstate the urgency of protecting adolescents and young adults from IMD. Increasing vaccine adherence among our patients may require a bit of added diligence, but your team’s legwork today could prevent the potentially devastating and irreversible consequences of not taking action. Each member of the office team can play an important role, taking the necessary steps to increase Men ACWY coverage. We will never know which patient would have been disabled by meningococcal disease without our efforts. Together, you and your staff can help reduce the risk that families experience the heartache of losing a child to this preventable disease and provide a brighter, healthier future for our youth.

References:

• Ask the Experts: Meningococcal ACWY. Immunize.org. https://www.immunize.org/askexperts/experts_meningococcal_acwy.asp. Published August 22, 2023. Accessed October 3, 2023.
• Meningococcal Vaccination for Preteens and Teens: Information for Parents. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/vpd/mening/public/adolescent-vaccine.html. Published October 12, 2021. Accessed October 3, 2023.
• Disease and Prevention Information. National Meningitis Association. https://nmaus.org/nma-disease-prevention-information/. Accessed October 3, 2023.
• MacNeil JR, Blain AE, Wang X, Cohn AC. Current epidemiology and trends in meningococcal disease-United States, 1996–2015. Clin Infect Dis 2018;66: 1276–81.

Bio:

Sharon G. Humiston, MD, MPH, FAAP, recently retired from her position as a Professor of Pediatrics at Children’s Mercy and University of Missouri-Kansas City, Kansas City, MO. Beyond of her clinical work, Dr. Humiston’s career centers on immunization delivery in three ways: research, quality improvement, and education. Her research and QI work focus on effective and sustainable methods to increase immunization rates. Her experience as an immunization educator includes development and implementation of print, live, video, and interactive Internet forms of immunization education for clinicians. She is the Director for Research for Immunize.org and Associate Editor of the newsletter, IZ-Express.

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