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Meningococcal vaccines

Author
Michael Apicella, MD
Section Editors
Stephen B Calderwood, MD
Sheldon L Kaplan, MD
Deputy Editor
Elinor L Baron, MD, DTMH

INTRODUCTION

Meningococcal disease, especially meningococcal meningitis, is one of the most devastating infections for an individual or community; Neisseria meningitidis tends to strike young, previously well individuals and can progress over a matter of hours to death.

Issues related to meningococcal vaccination in HIV-uninfected individuals will be reviewed here; issues related to meningococcal vaccination in HIV-infected patients are discussed separately. (See "Immunizations in HIV-infected patients".)

The microbiology, pathobiology, epidemiology (including the rationale for meningococcal vaccination in selected individuals), clinical features, diagnosis, treatment, and prevention of meningococcal infections are discussed separately. (See "Microbiology and pathobiology of Neisseria meningitidis" and "Epidemiology of Neisseria meningitidis infection" and "Clinical manifestations of meningococcal infection" and "Diagnosis of meningococcal infection" and "Treatment and prevention of meningococcal infection".)

AVAILABLE VACCINE FORMULATIONS

Available meningococcal vaccine formulations include [1,2]:

A quadrivalent meningococcal polysaccharide conjugate vaccine-diphtheria toxoid carrier (Menactra, MenACWY-DT) was approved for use in the United States in 2005 [3].

                         
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Literature review current through: Oct 2017. | This topic last updated: Nov 08, 2017.
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References
Top
  1. Cohn AC, MacNeil JR, Clark TA, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013; 62:1.
  2. American Academy of Pediatrics Committee on Infectious Diseases. Updated recommendations on the use of meningococcal vaccines. Pediatrics 2014; 134:400.
  3. Menactra: a meningococcal conjugate vaccine. Med Lett Drugs Ther 2005; 47:29.
  4. Centers for Disease Control and Prevention (CDC). Licensure of a meningococcal conjugate vaccine (Menveo) and guidance for use - Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep 2010; 59:273.
  5. Pellegrino P, Perrone V, Radice S, et al. Immunogenicity of meningococcal quadrivalent (serogroup A, C, W135 and Y) tetanus toxoid conjugate vaccine: systematic review and meta-analysis. Pharmacol Res 2015; 92:31.
  6. Vesikari T, Forsten A, Bianco V, et al. Immunogenicity, Safety and Antibody Persistence of a Booster Dose of Quadrivalent Meningococcal ACWY-tetanus Toxoid Conjugate Vaccine Compared with Monovalent Meningococcal Serogroup C Vaccine Administered Four Years After Primary Vaccination Using the Same Vaccines. Pediatr Infect Dis J 2015; 34:e298.
  7. FDA news release. First vaccine approved by FDA to prevent serogroup B meningococcal disease. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm420998.htm (Accessed on October 30, 2014).
  8. FDA news release. FDA approves a second vaccine to prevent serogroup B meningococcal disease. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm431370.htm (Accessed on January 28, 2015).
  9. Trotter CL, Lingani C, Fernandez K, et al. Impact of MenAfriVac in nine countries of the African meningitis belt, 2010-15: an analysis of surveillance data. Lancet Infect Dis 2017; 17:867.
  10. https://wwwnc.cdc.gov/travel/news-announcements/menomune-discontinuation (Accessed on October 03, 2017).
  11. https://www.unicef.org/supply/files/Meningitis_Vaccine_Market_Supply_Update.pdf (Accessed on October 23, 2017).
  12. MacNeil JR, Rubin L, McNamara L, et al. Use of MenACWY-CRM vaccine in children aged 2 through 23 months at increased risk for meningococcal disease: recommendations of the Advisory Committee on Immunization Practices, 2013. MMWR Morb Mortal Wkly Rep 2014; 63:527.
  13. Robinson CL, Romero JR, Kempe A, et al. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger - United States, 2017. MMWR Morb Mortal Wkly Rep 2017; 66:134.
  14. US Food and Drug Administration news release. FDA approves the first vaccine to prevent meningococcal disease in infants and toddlers. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm252392.htm (Accessed on April 29, 2011).
  15. Centers for Disease Control and Prevention (CDC). 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. MMWR Morb Mortal Wkly Rep 2011; 60:1391.
  16. Novartis media release. FDA expands age indication for Menveo®, first and only quadrivalent meningococcal vaccine for infants as young as 2 months of age. http://www.novartisvaccines.com/newsroom/media-releases/2013/US_Menveo_Infant_FDA_Approval_Press_Release_US.pdf (Accessed on August 16, 2013).
  17. Centers for Disease Control and Prevention (CDC). Infant meningococcal vaccination: Advisory Committee on Immunization Practices (ACIP) recommendations and rationale. MMWR Morb Mortal Wkly Rep 2013; 62:52.
  18. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of meningococcal conjugate vaccines --- Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep 2011; 60:72.
  19. Kim DK, Riley LE, Harriman KH, et al. Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2017. Ann Intern Med 2017; 166:209.
  20. Morgan BP, Orren A. Vaccination against meningococcus in complement-deficient individuals. Clin Exp Immunol 1998; 114:327.
  21. Centers for Disease Control and Prevention (CDC). Updated recommendation from the Advisory Committee on Immunization Practices (ACIP) for revaccination of persons at prolonged increased risk for meningococcal disease. MMWR Morb Mortal Wkly Rep 2009; 58:1042.
  22. New York State Department of Health. New York State Department of Health expands vaccination recommendation in response to meningococcal disease outbreak among high risk HIV positive men in New York City. http://www.health.ny.gov/press/releases/2012/2012-10-05_meningitis.htm (Accessed on October 26, 2012).
  23. Commonwealth of Masschusetts Department of Public Health. Health Advisory: Meningococcal vaccine recommendations for men who have sex with men. October 25, 2012.
  24. Centers for Disease Control and Prevention (CDC). Notes from the field: serogroup C invasive meningococcal disease among men who have sex with men - New York City, 2010-2012. MMWR Morb Mortal Wkly Rep 2013; 61:1048.
  25. Simon MS, Weiss D, Gulick RM. Invasive meningococcal disease in men who have sex with men. Ann Intern Med 2013; 159:300.
  26. NYC Health. 2014 Alert #28 - Update: Invasive meningococcal disease in men who have sex with men. https://a816-health29ssl.nyc.gov/sites/NYCHAN/Lists/AlertUpdateAdvisoryDocuments/HAN%20IMD%20in%20MSM%20Sept%202014.pdf (Accessed on April 13, 2015).
  27. County of Los Angeles Public Health. Public Health issues new vaccination recommendations for men who have sex with men (MSM) at-risk for invasive meningococcal disease http://www.publichealth.lacounty.gov/docs/PressReleaseIMDRecommend-4-2-14.pdf (Accessed on April 15, 2015).
  28. New York State Department of Health. New York State Department of Health expands meningococcal vaccination recommendation statewide. http://www.health.ny.gov/press/releases/2013/2013-03-25_expansion_meningococcal_vaccination.htm (Accessed on May 14, 2013).
  29. Centers for Disease Control and Prevention. Serogroup B meningococcal vaccine and outbreaks. http://www.cdc.gov/meningococcal/outbreaks/vaccine-serogroupB.html (Accessed on June 20, 2014).
  30. Folaranmi T, Rubin L, Martin SW, et al. Use of Serogroup B Meningococcal Vaccines in Persons Aged ≥10 Years at Increased Risk for Serogroup B Meningococcal Disease: Recommendations of the Advisory Committee on Immunization Practices, 2015. MMWR Morb Mortal Wkly Rep 2015; 64:608.
  31. COMMITTEE ON INFECTIOUS DISEASES. Recommendations for Serogroup B Meningococcal Vaccine for Persons 10 Years and Older. Pediatrics 2016; 138.
  32. Patton ME, Stephens D, Moore K, MacNeil JR. Updated Recommendations for Use of MenB-FHbp Serogroup B Meningococcal Vaccine - Advisory Committee on Immunization Practices, 2016. MMWR Morb Mortal Wkly Rep 2017; 66:509.
  33. MacNeil JR, Rubin L, Folaranmi T, et al. Use of Serogroup B Meningococcal Vaccines in Adolescents and Young Adults: Recommendations of the Advisory Committee on Immunization Practices, 2015. MMWR Morb Mortal Wkly Rep 2015; 64:1171.
  34. http://www.cdc.gov/meningococcal/downloads/interim-guidance.pdf (Accessed on June 11, 2015).
  35. Centers for Disease Control and Prevention. Princeton University meningococcal disease outbreak. http://www.cdc.gov/meningococcal/outbreaks/princeton.html (Accessed on August 01, 2014).
  36. McNamara LA, Shumate AM, Johnsen P, et al. First Use of a Serogroup B Meningococcal Vaccine in the US in Response to a University Outbreak. Pediatrics 2015; 135:798.
  37. Soeters HM, McNamara LA, Whaley M, et al. Serogroup B Meningococcal Disease Outbreak and Carriage Evaluation at a College - Rhode Island, 2015. MMWR Morb Mortal Wkly Rep 2015; 64:606.
  38. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6422a2.htm?s_cid=mm6422a2_e (Accessed on June 11, 2015).
  39. De Wals P, Deceuninck G, Lefebvre B, et al. Impact of an Immunization Campaign to Control an Increased Incidence of Serogroup B Meningococcal Disease in One Region of Quebec, Canada. Clin Infect Dis 2017; 64:1263.
  40. http://vaccine-schedule.ecdc.europa.eu/Pages/Scheduler.aspx (Accessed on October 05, 2017).
  41. Pollard AJ, Riordan A, Ramsay M. Group B meningococcal vaccine: recommendations for UK use. Lancet 2014; 383:1103.
  42. Christensen H, Trotter CL, Hickman M, Edmunds WJ. Re-evaluating cost effectiveness of universal meningitis vaccination (Bexsero) in England: modelling study. BMJ 2014; 349:g5725.
  43. Ali A, Jafri RZ, Messonnier N, et al. Global practices of meningococcal vaccine use and impact on invasive disease. Pathog Glob Health 2014; 108:11.
  44. http://www.who.int/immunization/policy/position_papers/meningococcal/en/ (Accessed on October 13, 2017).
  45. Control and prevention of serogroup C meningococcal disease: evaluation and management of suspected outbreaks: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1997; 46:13.
  46. Bijlsma MW, Brouwer MC, Spanjaard L, et al. A decade of herd protection after introduction of meningococcal serogroup C conjugate vaccination. Clin Infect Dis 2014; 59:1216.
  47. Keyserling H, Papa T, Koranyi K, et al. Safety, immunogenicity, and immune memory of a novel meningococcal (groups A, C, Y, and W-135) polysaccharide diphtheria toxoid conjugate vaccine (MCV-4) in healthy adolescents. Arch Pediatr Adolesc Med 2005; 159:907.
  48. Pina LM, Bassily E, Machmer A, et al. Safety and immunogenicity of a quadrivalent meningococcal polysaccharide diphtheria toxoid conjugate vaccine in infants and toddlers: three multicenter phase III studies. Pediatr Infect Dis J 2012; 31:1173.
  49. Pichichero M, Casey J, Blatter M, et al. Comparative trial of the safety and immunogenicity of quadrivalent (A, C, Y, W-135) meningococcal polysaccharide-diphtheria conjugate vaccine versus quadrivalent polysaccharide vaccine in two- to ten-year-old children. Pediatr Infect Dis J 2005; 24:57.
  50. Pichichero M, Papa T, Blatter M, et al. Immune memory in children previously vaccinated with an experimental quadrivalent meningococcal polysaccharide diphtheria toxoid conjugate vaccine. Pediatr Infect Dis J 2006; 25:995.
  51. Food and Drug Administration. Product approval information-licensing action, package insert: Meningococcal (groups A, C, Y, W-135) polysaccharide diphtheria toxoid conjugate vaccine Menactra®. Sanofi Pasteur. Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Biologics Evaluation and Research; 2005 www.fda.gov/cber/label/menactralb.pdf (Accessed on May 29, 2008).
  52. Snape MD, Perrett KP, Ford KJ, et al. Immunogenicity of a tetravalent meningococcal glycoconjugate vaccine in infants: a randomized controlled trial. JAMA 2008; 299:173.
  53. Klein NP, Reisinger KS, Johnston W, et al. Safety and immunogenicity of a novel quadrivalent meningococcal CRM-conjugate vaccine given concomitantly with routine vaccinations in infants. Pediatr Infect Dis J 2012; 31:64.
  54. Klein NP, Shepard J, Bedell L, et al. Immunogenicity and safety of a quadrivalent meningococcal conjugate vaccine administered concomitantly with measles, mumps, rubella, varicella vaccine in healthy toddlers. Vaccine 2012; 30:3929.
  55. Nolan TM, Nissen MD, Naz A, et al. Immunogenicity and safety of a CRM-conjugated meningococcal ACWY vaccine administered concomitantly with routine vaccines starting at 2 months of age. Hum Vaccin Immunother 2014; 10:280.
  56. Abdelnour A, Silas PE, Lamas MR, et al. Safety of a quadrivalent meningococcal serogroups A, C, W and Y conjugate vaccine (MenACWY-CRM) administered with routine infant vaccinations: results of an open-label, randomized, phase 3b controlled study in healthy infants. Vaccine 2014; 32:965.
  57. Halperin SA, Gupta A, Jeanfreau R, et al. Comparison of the safety and immunogenicity of an investigational and a licensed quadrivalent meningococcal conjugate vaccine in children 2-10 years of age. Vaccine 2010; 28:7865.
  58. Johnston W, Essink B, Kirstein J, et al. Comparative Assessment of a Single Dose and a 2-dose Vaccination Series of a Quadrivalent Meningococcal CRM-conjugate Vaccine (MenACWY-CRM) in Children 2-10 Years of Age. Pediatr Infect Dis J 2016; 35:e19.
  59. Food and Drug Administration. Product approval information: package insert. Menveo (Meningococcal [Groups A, C, Y and W-135] oligosaccharide diphtheria CRM197 conjugate vaccine). http://www.fda.gov/downloads/biologicsbloodvaccines/vaccines/approvedproducts/ucm201349.pdf (Accessed on May 25, 2010).
  60. Macneil JR, Cohn AC, Zell ER, et al. Early estimate of the effectiveness of quadrivalent meningococcal conjugate vaccine. Pediatr Infect Dis J 2011; 30:451.
  61. Centers for Disease Control and Prevention (CDC). Syncope after vaccination--United States, January 2005-July 2007. MMWR Morb Mortal Wkly Rep 2008; 57:457.
  62. FDA News. FDA and CDC issue alert on Menactra meningococcal vaccine and Guillain Barre Syndrome. September 30, 2005. www.fda.gov/bbs/topics/NEWS/2005/NEW01238.html (Accessed on May 29, 2008).
  63. Centers for Disease Control and Prevention (CDC). Guillain-Barré syndrome among recipients of Menactra meningococcal conjugate vaccine--United States, June-July 2005. MMWR Morb Mortal Wkly Rep 2005; 54:1023.
  64. Centers for Disease Control and Prevention (CDC). Update: Guillain-Barré syndrome among recipients of Menactra meningococcal conjugate vaccine--United States, June 2005-September 2006. MMWR Morb Mortal Wkly Rep 2006; 55:1120.
  65. Centers for Disease Control and Prevention (CDC). Notice to readers: Recommendation from the Advisory Committee on Immunization Practices (ACIP) for use of quadrivalent meningococcal conjugate vaccine (MCV4) in children aged 2--10 years at increased risk for invasive meningococcal disease. MMWR Morb Mortal Wkly Rep 2007; 56:1265.
  66. Velentgas P, Amato AA, Bohn RL, et al. Risk of Guillain-Barré syndrome after meningococcal conjugate vaccination. Pharmacoepidemiol Drug Saf 2012; 21:1350.
  67. Broder KR, Cortese MM, Iskander JK, et al. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006; 55:1.
  68. Centers for Disease Control and Prevention (CDC). Inadvertent misadministration of meningococcal conjugate vaccine--United States, June-August 2005. MMWR Morb Mortal Wkly Rep 2006; 55:1016.
  69. Weston WM, Friedland LR, Wu X, Howe B. Immunogenicity and reactogenicity of co-administered tetanus-diphtheria-acellular pertussis (Tdap) and tetravalent meningococcal conjugate (MCV4) vaccines compared to their separate administration. Vaccine 2011; 29:1017.
  70. Jackson LA, Yu O, Nelson J, et al. Risk of medically attended local reactions following diphtheria toxoid containing vaccines in adolescents and young adults: a Vaccine Safety Datalink study. Vaccine 2009; 27:4912.
  71. Gasparini R, Tregnaghi M, Keshavan P, et al. Safety and Immunogenicity of a Quadrivalent Meningococcal Conjugate Vaccine and Commonly Administered Vaccines After Coadministration. Pediatr Infect Dis J 2016; 35:81.
  72. Block SL, Shepard J, Garfield H, et al. Immunogenicity and Safety of a 3- and 4-dose Vaccination Series of a Meningococcal ACWY Conjugate Vaccine in Infants: Results of a Phase 3b, Randomized, Open-label Trial. Pediatr Infect Dis J 2016; 35:e48.
  73. American Academy of Pediatrics. Meningococcal infections. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.556.
  74. Spoulou V, Tzanakaki G, Lekka S, et al. Natural and vaccine-induced immunity to Neisseria meningitidis serogroup C in asplenic patients with β-thalassemia. Vaccine 2011; 29:4435.
  75. Stoehr GA, Luecken J, Zielen S, et al. Mode of splenectomy and immunogenicity of meningococcal vaccination in patients with hereditary spherocytosis. Br J Surg 2008; 95:466.
  76. Centers for Disease Control and Prevention (CDC). Serogroup A meningococcal conjugate vaccine coverage after the first national mass immunization campaign-Burkina Faso, 2011. MMWR Morb Mortal Wkly Rep 2012; 61:1022.
  77. Daugla DM, Gami JP, Gamougam K, et al. Effect of a serogroup A meningococcal conjugate vaccine (PsA-TT) on serogroup A meningococcal meningitis and carriage in Chad: a community study [corrected]. Lancet 2014; 383:40.
  78. Kristiansen PA, Diomandé F, Ba AK, et al. Impact of the serogroup A meningococcal conjugate vaccine, MenAfriVac, on carriage and herd immunity. Clin Infect Dis 2013; 56:354.
  79. Novak RT, Kambou JL, Diomandé FV, et al. Serogroup A meningococcal conjugate vaccination in Burkina Faso: analysis of national surveillance data. Lancet Infect Dis 2012; 12:757.
  80. Sow SO, Okoko BJ, Diallo A, et al. Immunogenicity and safety of a meningococcal A conjugate vaccine in Africans. N Engl J Med 2011; 364:2293.
  81. Sambo L, Chan M, Davis S, et al. A Vaccine Meets Its Promise: Success in Controlling Epidemic Meningitis in Sub-Saharan Africa. Clin Infect Dis 2015; 61 Suppl 5:S387.
  82. Okwo-Bele JM, LaForce FM, Borrow R, Preziosi MP. Documenting the Results of a Successful Partnership: A New Meningococcal Vaccine for Africa. Clin Infect Dis 2015; 61 Suppl 5:S389.
  83. Santolaya ME, O'Ryan ML, Valenzuela MT, et al. Immunogenicity and tolerability of a multicomponent meningococcal serogroup B (4CMenB) vaccine in healthy adolescents in Chile: a phase 2b/3 randomised, observer-blind, placebo-controlled study. Lancet 2012; 379:617.
  84. Gossger N, Snape MD, Yu LM, et al. Immunogenicity and tolerability of recombinant serogroup B meningococcal vaccine administered with or without routine infant vaccinations according to different immunization schedules: a randomized controlled trial. JAMA 2012; 307:573.
  85. Vesikari T, Esposito S, Prymula R, et al. Immunogenicity and safety of an investigational multicomponent, recombinant, meningococcal serogroup B vaccine (4CMenB) administered concomitantly with routine infant and child vaccinations: results of two randomised trials. Lancet 2013; 381:825.
  86. Parikh SR, Andrews NJ, Beebeejaun K, et al. Effectiveness and impact of a reduced infant schedule of 4CMenB vaccine against group B meningococcal disease in England: a national observational cohort study. Lancet 2016; 388:2775.
  87. Read RC, Baxter D, Chadwick DR, et al. Effect of a quadrivalent meningococcal ACWY glycoconjugate or a serogroup B meningococcal vaccine on meningococcal carriage: an observer-blind, phase 3 randomised clinical trial. Lancet 2014; 384:2123.
  88. Hong E, Giuliani MM, Deghmane AE, et al. Could the multicomponent meningococcal serogroup B vaccine (4CMenB) control Neisseria meningitidis capsular group X outbreaks in Africa? Vaccine 2013; 31:1113.
  89. Soeters HM, Whaley M, Alexander-Scott N, et al. Meningococcal Carriage Evaluation in Response to a Serogroup B Meningococcal Disease Outbreak and Mass Vaccination Campaign at a College-Rhode Island, 2015-2016. Clin Infect Dis 2017; 64:1115.
  90. Basta NE, Mahmoud AAF, Wolfson J, et al. Immunogenicity of a Meningococcal B Vaccine during a University Outbreak. N Eng J Med 2016; 375:220.
  91. Parikh SR, Newbold L, Slater S, et al. Meningococcal serogroup B strain coverage of the multicomponent 4CMenB vaccine with corresponding regional distribution and clinical characteristics in England, Wales, and Northern Ireland, 2007-08 and 2014-15: a qualitative and quantitative assessment. Lancet Infect Dis 2017; 17:754.
  92. Lujan E, Winter K, Rovaris J, et al. Serum Bactericidal Antibody Responses of Students Immunized With a Meningococcal Serogroup B Vaccine in Response to an Outbreak on a University Campus. Clin Infect Dis 2017.
  93. 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. JAMA 2000; 283:2795.
  94. Perrett KP, Winter AP, Kibwana E, et al. Antibody persistence after serogroup C meningococcal conjugate immunization of United Kingdom primary-school children in 1999-2000 and response to a booster: a phase 4 clinical trial. Clin Infect Dis 2010; 50:1601.
  95. Trotter CL, Andrews NJ, Kaczmarski EB, et al. Effectiveness of meningococcal serogroup C conjugate vaccine 4 years after introduction. Lancet 2004; 364:365.
  96. McIntyre PB, O'Brien KL, Greenwood B, van de Beek D. Effect of vaccines on bacterial meningitis worldwide. Lancet 2012; 380:1703.
  97. Maiden MC. The impact of protein-conjugate polysaccharide vaccines: an endgame for meningitis? Philos Trans R Soc Lond B Biol Sci 2013; 368:20120147.
  98. Offit PA, Peter G. Meningococcal conjugate vaccine in the UK: an update. Lancet 2004; 364:309.
  99. Maiden MC, Ibarz-Pavón AB, Urwin R, et al. Impact of meningococcal serogroup C conjugate vaccines on carriage and herd immunity. J Infect Dis 2008; 197:737.
  100. Ramsay ME, Andrews NJ, Trotter CL, et al. Herd immunity from meningococcal serogroup C conjugate vaccination in England: database analysis. BMJ 2003; 326:365.
  101. De Wals P, Deceuninck G, Boulianne N, De Serres G. Effectiveness of a mass immunization campaign using serogroup C meningococcal conjugate vaccine. JAMA 2004; 292:2491.
  102. De Wals P, Deceuninck G, Lefebvre B, et al. Effectiveness of serogroup C meningococcal conjugate vaccine: a 7-year follow-up in Quebec, Canada. Pediatr Infect Dis J 2011; 30:566.
  103. Sadarangani M, Scheifele DW, Halperin SA, et al. The impact of the meningococcal serogroup C conjugate vaccine in Canada between 2002 and 2012. Clin Infect Dis 2014; 59:1208.
  104. Ramsay ME, Andrews N, Kaczmarski EB, Miller E. Efficacy of meningococcal serogroup C conjugate vaccine in teenagers and toddlers in England. Lancet 2001; 357:195.