Meningococcal disease

Meningococci are rare and fast. A child or a teenager who complains of a headache in the morning can become an emergency within hours. It is precisely this combination – low frequency, dramatic course – that makes advising about this vaccination difficult and important at the same time. For young women it often coincides with the appointment at which the HPV vaccination is being discussed anyway.

What meningococci are

Neisseria meningitidis is a bacterium that occurs only in humans and colonises the nose and throat. About one person in ten carries it at times without being ill; among adolescents and young adults it is considerably more – in some studies up to a quarter.

This colonisation is the normal case and as a rule harmless. It is even useful: the contact makes the immune system form antibodies, which is why most adults are protected without ever having been vaccinated.

Only very rarely does the organism manage to penetrate the mucous membrane and enter the bloodstream. Why this happens in one person and not in a thousand others is not fully understood. Preceding viral infections, smoking and passive smoking, living in close quarters and certain immune deficiencies all make it more likely.

Serogroups are distinguished by the sugar capsule. Worldwide, A, B, C, W and Y are the ones that matter. In Europe group B has predominated for years; groups W and Y have increased in some countries.

The organism is transmitted by droplets during close contact – coughing, sneezing, kissing, shared drinking bottles. Outside the body it survives only briefly; infection via door handles or objects plays practically no part.

How the illness runs

There are two main forms, which can also occur together. Meningitis shows itself with high fever, severe headache, neck stiffness, sensitivity to light, nausea and increasing drowsiness. Blood poisoning runs its course without these signs and is the more dangerous form: high fever, a rapidly increasing sense of being ill, cold hands and feet, muscle pain and pinpoint bleeding into the skin.

The speed is what is decisive. Less than twenty-four hours can lie between the first symptoms and a life-threatening condition. In the first hours the illness can hardly be distinguished from an ordinary viral infection – that is its most dangerous characteristic.

The early signs that have proved particularly informative in studies are not the classic ones: pain in the legs, cold hands and feet and an unusual skin colour appear on average hours earlier than neck stiffness or a rash. A child with a fever who complains of pain in the legs and has cold extremities should be looked at.

Pinpoint bleeding into the skin is the best-known sign and at the same time a late one. The glass test is simple: press a transparent glass firmly onto the spot – if it stays visible, it is not an ordinary rash. Then call the ambulance on 144 immediately. Important: the absence of a rash excludes nothing.

Despite intensive care, about eight to ten per cent of those who fall ill die. In up to a fifth of survivors consequences remain – hearing loss, seizure disorders, difficulties with concentration and learning, and after blood poisoning also tissue damage extending to the loss of limbs.

Who falls ill

The frequency has two peaks. The first is in the first and second year of life, the second between fifteen and twenty-four years.

The second peak has to do with circumstances of life. Adolescents and young adults carry the organism in the throat more often and pass it on more often – close contact, shared drinks, kissing, parties, halls of residence, sports teams. In several countries outbreaks occurred in student accommodation.

For gynaecology this is the point of connection. The appointment at which a young woman comes to a gynaecological practice for the first time – often because of the HPV vaccination, contraception or her cycle – falls precisely into this age range. It is the obvious opportunity to go through the vaccination record.

Overall, meningococcal disease is rare in Austria: it amounts to a few dozen cases a year. This rarity is the reason why the vaccination needs attention – and at the same time the reason why it often gets lost in the discussion.

The vaccinations: two separate ones

There is no vaccine covering all serogroups. Two different ones are needed, and there is a biological reason for that.

Against groups A, C, W and Y there are conjugate vaccines: the sugar capsules are coupled to a carrier protein, which makes them produce a response with memory in small children too. The principle comes from the Hib vaccination.

Against group B this does not work. Its sugar capsule resembles a structure that occurs in human nerve tissue – the immune system does not recognise it as foreign, and a vaccine made from it would be both ineffective and delicate. A different route was therefore chosen: the vaccine contains proteins from the bacterial surface instead of the capsule. More on this on the page Bexsero.

In Austria both vaccinations are recommended, but they are established differently. The vaccination against meningococci ACWY is included in the free programme for children of school age; the vaccination against meningococci B is recommended from the second month of life and was for a long time paid for privately. How it is regulated at present is stated in the immunisation schedule currently in force – more changes here than with other vaccinations.

The immunisation schedule

Meningococci B is given from the completed second month of life, with two to three doses depending on the age at the start and a booster in the second year of life. The earlier it is begun, the more doses are needed – a child starting only at the age of two needs just two.

Meningococci ACWY is given in Austria at school age, usually between the tenth and thirteenth year of life. A single dose is enough. The timing is deliberately chosen so that protection is in place during the years of the second peak of the illness.

Anyone who missed the vaccination at school age can catch it up later – that is one of the points that come up in the gynaecological consultation with young women. It is particularly worthwhile before a stay abroad, before studying with hall accommodation, and before travel to certain regions.

Separate rules apply to travel. In the African meningitis belt – a strip south of the Sahara from Senegal to Ethiopia – the ACWY vaccination is expressly recommended, especially in the dry season between December and June. For the pilgrimage to Mecca it is a condition of entry and has to be documented in the international certificate of vaccination.

Why this vaccination is so hard to explain

Meningococci are a textbook example of how difficult it is to communicate risks that are rare and serious at the same time.

On one side stands an illness that affects a few dozen people a year in Austria. Arithmetically the probability that a particular child falls ill is very small – smaller than many risks taken in everyday life without a second thought.

On the other side stands the course of the illness. There are few illnesses in which a healthy child complains of a headache in the morning and lies in intensive care in the evening. Anyone who has witnessed such a course argues differently about vaccinations afterwards – and anyone who has not can find the urgency hard to grasp.

Both points of view are legitimate, and no statistic resolves the contradiction. What helps is precision: the vaccination does not protect against everything, it protects against particular serogroups. It is well tolerated, with the known tendency to fever in the case of the B vaccine. In some cases it costs money. And it prevents a rare illness whose individual case weighs so heavily that the calculation works out despite the rarity.

The same consideration applies to several vaccinations in childhood. It merely appears particularly clearly with meningococci, because here the rarity is especially great and the course especially dramatic.

Meningococci and pregnancy

Both vaccines are inactivated vaccines – the ACWY vaccine contains capsular sugar with a carrier protein, the B vaccine surface proteins. Neither contains organisms capable of multiplying.

There is no general recommendation for pregnant women in Austria, because the risk in this age group is low and systematic studies are lacking. Where there is a clear indication – absence of the spleen, certain immune deficiencies, an outbreak situation, travel to a risk area – the decision is taken case by case, and then little speaks against it.

Anyone planning a pregnancy who has a gap in their protection is best dealing with it beforehand. That applies to meningococci as to the other vaccinations gone through in preconception advice.

Protection carried over from the mother is hardly to be expected against meningococci. Antibodies against sugar capsules are low in unvaccinated adults, and what is transferred does not go far. This is why the child's own vaccination against meningococci B begins earlier than most others – from the second month of life.

What happens after contact

Meningococcal disease is notifiable in Austria, and the notification leads to an investigation of the surroundings by the public health authority.

Close contacts are given a preventive antibiotic regardless of their vaccination status, if possible within twenty-four hours. The aim is not to treat an infection that has already occurred but to clear colonisation of the throat.

A close contact is anyone living in the same household, anyone who has had contact with secretions – kissing, shared cutlery, resuscitation – or anyone who has had close contact in a care setting. The whole school class as a rule does not belong in this category.

Suitable preparations are available for pregnant women; ceftriaxone as a single injection is the agent of choice here, because ciprofloxacin and rifampicin are not preferred in pregnancy. The decision is taken by the public health authority together with the treating services.

The vaccination record in young women

Because this text refers to it several times, here in detail is what such an appointment actually covers. Between the last vaccination at school and the first gynaecological appointment there are often years in which nobody has looked at the vaccination record – and it is a stage of life in which several deadlines overlap.

The HPV vaccination is free of charge in Austria up to the completed 21st year of life, and recommended up to the completed 30th, self-funded from 21 on. Anyone who missed it at school age therefore still has time – but time that is running out. It protects against the types that cause around ninety per cent of cervical cancers, and works best before first sexual intercourse, though it remains worthwhile afterwards. More on the page HPV.

Measles, mumps and rubella should be checked, because two vaccinations have to be in place before a pregnancy and a month's interval must be kept afterwards. It is precisely the birth cohorts now between twenty and forty that have the biggest gap here – often only a single vaccination is recorded, and one is not enough. See measles and rubella.

Chickenpox for the same reason: a live vaccine that belongs before pregnancy, and an illness that can have serious consequences in pregnancy.

Meningococci for the years in which the second peak of the illness lies – and especially before a stay abroad.

Tetanus and diphtheria, because the booster is due every ten years and the commonest answer to the question about the last vaccination is “some time after a cut”.

That sounds like a lot and is gone through in a single appointment. What actually follows from it is usually one or two vaccinations – and the clarification later spares you, in a pregnancy, the uneasy feeling of having missed something that can no longer be made up.

Tolerability

The ACWY conjugate vaccine is well tolerated: redness, swelling and pain in the upper arm for one to two days, occasionally headache or fatigue.

The B vaccine causes fever in infants considerably more often than other vaccinations – that is its best-known characteristic and is described in detail on the page Bexsero.

The vaccination is not given where there has been a documented severe allergic reaction to one of its components. An acute febrile illness leads to postponement.

How it is treated

Where suspicion is well-founded, nobody waits for results. Blood cultures are taken, then a high-dose antibiotic is given immediately into the vein – in Europe usually a third-generation cephalosporin. In adults corticosteroids are added, which lower the frequency of hearing damage.

Examination of the cerebrospinal fluid follows as soon as the circulation permits. With blood poisoning and circulatory failure it is deferred, because the puncture would then be too risky – treatment is given nonetheless, and the organism can usually be detected in the blood.

The rest is intensive care: circulatory support, correction of clotting, and with extensive tissue damage surgical treatment. Treatment lasts weeks, rehabilitation often longer.

After recovery a hearing test becomes a fixed part of follow-up, because hearing loss is the commonest lasting consequence and can be treated if recognised early. And because having had the illness protects only against the serogroup concerned, vaccination is given afterwards.

What happens next

For young women the appointment at the gynaecological practice is often the first at which anybody has looked at the vaccination record for years. Bring it with you – alongside the HPV vaccination, meningococci, measles-mumps-rubella and the tetanus booster can all be sorted out in one go. Arranging an appointment.

Where meningococcal disease is suspected, call the ambulance on 144. This practice is not an emergency department.

In case you are unsure whether a situation is urgent: the health line 1450 is staffed around the clock and exists to answer exactly that question. Calling it is not an imposition – the number exists so that people do not have to decide alone between “wait and see” and “call an ambulance”. With the early signs described above together with fever, however, no long phone call should be made.