1. Aetna considers meningococcal vaccine a medically necessary preventive service according to the recommendations of the Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP).
   The ACIP recommends immunization with meningococcal vaccine of all adolescents 11 through 18 years of age.
   The ACIP also recommends meningococcal immunization for persons with one or more of the following risk factors:
   
   
   1. Functional asplenia (sickle-cell disease);
   2. Anatomic asplenia (surgical or congenital);
   3. Persons with terminal complement component deficiencies;
   4. Persons who are infected with HIV; or
   5. Persons who are traveling to countries in which N. meningitides is hyperendemic or epidemic, particularly if contact with the local population will be prolonged.*

   Aetna considers unconjugated meningitis vaccine (Menomune, Aventis Pasteur, Swiftwater, PA) an acceptable alternative to conjugated meningitis vaccine (Menactra, Aventis Pasteur, Swiftwater, PA) for medically necessary indications.

2. Aetna considers meningococcal vaccine medically necessary for solid organ transplant recipients.

3. Aetna considers meningococcal vaccine experimental and investigational for all other indications.

Meningococcal meningitis, caused by the bacterium Neisseria meningitides, is a potentially fatal bacterial infection that afflicts between 2500 and 3000 persons in the United States each year. Approximately 10 percent of individuals who contract meningococcal disease will die. Of survivors, up to one in five suffer long-term permanent disabilities such as hearing loss, brain damage and limb amputations.

Advisory Committee on Immunization Practices (ACIP) currently recommends tetravalent meningococcal conjugate vaccine for all 11-to-18 year olds (CDC, 2007). The previous recomendations for meningococcal conjugate vaccine administration consisted of three cohorts: 11-to-12 year oldes, adolescents entering high school (or 15-year olds), and other persons at increased risk for meningococcal disease, such as incoming colllege freshman who would be living in dormitories. Because many adolescents do not see a doctor regularly, the expanded recommendations allow physicians to vaccinate adolescent patients whenever the opportunity to do so arises. The revised recommendations continue to emphasize that 11- to 12-year-olds should receive the meningococcal conjugate vaccine at the 11- to 12-year-old preventive care visit, along with other routine adolescent vaccinations.  The ACIP has stated that their goal is routine vaccination of all adolescents beginning at age 11 years.

Adolescents and young adults in particular are at increased risk of contracting meningococcal meningitis because of certain lifestyle factors, such as crowded living conditions, moving to a new residence, attending a new school with students from geographically diverse areas, sharing beverages or utensils, going to bars, active or passive smoking, and irregular sleeping patterns (NMA, 2004). A CDC study of 83 reported meningitis cases in college students from September 1998 through May 1999, a rate of 1.4 cases per 100,000 freshmen, and 3.8 cases per 100,000 freshmen living in dormitories. The rate for all 18- to 22-year-olds was 1 case per 100,000. According to the American College Health Association, between 100 and 125 college students get meningitis each year, and up to 10 die.

Meningococcal [Groups A, C, Y and W-135] polysaccharide diphtheria toxoid conjugate (Menactra, Sanofi Pasteur Inc., Swiftwater, PA) is a purified meningococcal polysaccharide conjugated with an diphtheria toxin in order to prolong the immunogenic effect of the vaccine. Whereas standard unconjugated meningitis vaccine (i.e., Menomune meningococcal [Groups A, C, Y and W-135] polysaccharide vaccine (Sanofi Pasteur Inc.) induces protective immunity for three to four years, conjugated meningitis vaccines are expected to provide protective immunity for up to eight years.  Both Menactra and Menomune are currently approved by the U.S. Food and Drug Administration (FDA) for persons aged 2 years and older. The FDA approved Menactra for use in children aged 2 - 10 years on October 17, 2007, in addition to its prior approval for use in persons aged 11 - 55 years.  Previous ACIP recommendations called for vaccination with Menomune for children aged 2 - 10 years who are at increased risk for meningococcal disease.  However, ACIP revised its recommendation during its October 24, 2007 meeting to state that meningococcal conjugate vaccine is preferable to meningococcal polysaccharide vaccine for vaccination of children aged 2 - 10 years who are at increased risk for meningococcal disease.  The two meningococcal vaccine products are administered by different routes. Menactra is administered intramuscularly, while Menomune is administered subcutaneously. Generally, only a single dose of either vaccine is indicated. 

The Advisory Committee on Immunization Practices states that revaccination may be indicated for persons previously vaccinated with meningococcal vaccine who remain at high risk for infection (i.e., those with terminal complement deficiencies, with anatomic or functional asplenia, those infected with HIV, travelers to hyperendemic or epidemic areas), particularly for children who were first vaccinated when they were less than 4 years of age. According to the ACIP, such children should be considered for revaccination after 2 to 3 years if they remain at high risk. For children aged 2 -10 years who have previously received meningococcal polysaccharide vaccine and remain at increased risk for meningococcal disease, ACIP recommends vaccination with meningococcal conjugate vaccine at 3 years after receipt of meningococcal polysaccharide vaccine. Children who last received meningococcal polysaccharide vaccine more than 3 years ago and remain at risk for meningococcal disease should be vaccinated with meningococcal conjugate vaccine as soon as possible.  Although the need for revaccination in adults and older children has not been determined, antibody levels decline rapidly over 2-3 years after the polysaccharide vaccine is given, and if indications still exist for vaccination, revaccination may be considered within 3-5 years.

In a single, randomized, modified double-blind, controlled study of healthy U.S. children aged 2 - 10 years that compared meningococcal conjugate vaccine with meningococcal polysaccharide vaccine, serum bactericidal antibody geometric mean titers against all four serogroups were significantly higher at both 28 days and 6 months after vaccination in the children who received meningococcal conjugate vaccine. In the same study, rates of most solicited local and systemic adverse events after vaccination with meningococcal conjugate vaccine were comparable to rates observed after vaccination with meningococcal polysaccharide vaccine (Pichichero, et al., 2005). It is anticipated that more data will become available within the next 5 years to guide recommendations on revaccination for persons who were previously vaccinated with meningococcal polysaccharide vaccine.

Meningococcal vaccine is contraindicated in persons with allergy to vaccine components and persons with acute, moderate or severe illnesses with or without fever. Persons with moderate or severe illness should be immunized as soon as they have recovered from the acute phase of the illness. Minor illnesses (e.g., upper respiratory tract infection, allergic rhinitis) with or without fever should not contraindicate the use of meningococcal vaccine.

The Surgical Infection Society (Howdieshell et al, 2006) stated that there are limited data on the use of vaccines after injury. In particular, the recommendations that all persons (aged 2 to 64 years) who have undergone splenectomy, should receive 23-valent pneumococcal vaccine and meningococcal vaccine, with Haemophilus influenzae type B vaccine administered to high-risk patients as well are grade D (very low quality recommendations). 

At its February 2008 meeting, the ACIP decided not to recommend routine vaccination of children aged 2 to10 years against meningococcal disease unless the child is at increased risk for the disease. The ACIP continues to recommend routine vaccination against meningococcal disease for all persons aged 11 to 18 years and those persons aged 2 to 55 years who are at increased risk for meningococcal disease.