Meningococcal Vaccines: How to Make the Choice

Clinicians face two choices with the meningococcal B vaccines, Trumemba and Bexsero.

First, should you offer to vaccinate patients?

The CDC does not recommend routine use of either vaccine to immunocompetent individuals, but instead says vaccination should be “optional.”

There are some unknowns to consider:

• How long does protection last? 
• Does it affect nasopharyngeal carriage? 
• What percentage of meningococcal disease will vaccination prevent? (Neither vaccine covers all the B strains.)

Another concern: is vaccination the best use of healthcare dollars? A complete series costs more than $300.

Do you know how many US cases of meningococcal disease (all strains) were reported in 2015?A. 50

B. 375

C. 480

D. 613

Please click on "next" below for answer and discussion.

The correct answer is B. 375 cases of meningococcal disease, all strains

Between 1950 and 1990, about 3000 cases per year occurred. Between 1998 and 2007, the attack rate dropped 64% for unknown reasons; the drop included cases of B disease, a strain not covered in the quadravalent vaccine that was licensed in 2005.

Approximately one-third of the annual cases are caused by the B strain; the highest attack rate is seen in the under-1-year-of-age cohort. Because meningococcal disease is so rare, it has been estimated that about one million teens will need to be vaccinated to prevent a single death. Insurance generally covers the direct cost to the patient, but widespread use will lead to increased health insurance premium costs in a healthcare system in which current premium rates already lead many to forego coverage.

The second choice clinicians face should they choose to offer meningococcal B vaccine: which of the 2 vaccines to offer?

We will never know which vaccine is more effective against B disease; the number of annual cases is just too small to mount a head-to-head study. However, 1 of the 2 vaccines is closely related to a meningococcal B vaccine called MeNZB. MeNZB was shown retrospectively to be 31% effective in preventing gonorrhea in a study reported in Lancet of about 15,000 young adults in New Zealand. This vaccine was developed in response to an outbreak and is no longer being made. Due to the increased prevalence and increasing drug resistance of Neisseria gonorrhea, a vaccine is desperately needed, but until now no trials have shown efficacy. While a 31% efficacy rate leaves a lot to be desired, a 31% reduction in the more than 800,000 new cases of gonorrhea per year in the US is significant.

Bexsero is the vaccine closely related to MeNZB. Bexsero contains the single antigen used in MeNZB along with 3 other antigens against other B strains. Does this make it the best choice against B disease?  Two caveats:

• The study in New Zealand was funded by GSK-the same company that produces Bexsero.
• Bexsero itself has not been studied for effectiveness against gonorrhea. Trumemba lacks the antigen component found in MeNZB and Bexsero.

So, we are still left with questions: Will Bexsero show the same effectiveness against N. gonorrhea? If so, how long does the protection last? Would booster shots extend the protection?

It will be years before we have these answers. Until then, clinicians do have to choose between vaccines. Hoping that Bexsero will indeed prove helpful in combating the rising incidence of gonorrhea, Bexsero is what I offer in my office.

Disclosures:
Dr. Brenneman does not have any conflicts of interest relevant to any of the companies noted in this article.

Resources

Centers for Disease Control (CDC). Pink Book. Epidemiology and Prevention of Vaccine-Preventable Diseases. Meningococcal Disease.

Cohn AC, MacNeil JR, Harrison LH, et al. Changes in Neisseria meningitidis disease epidemiology in the United States, 1998-2007: implications for prevention of meningococcal disease. Clin Infect Dis. 2010;50:184-91. doi: 10.1086/649209.

Petousis-Harris H, Paynter J, Morgan J, et al.  Effectiveness of a group B outer membrane vesicle meningococcal vaccine against gonorrhoea in New Zealand: a retrospective case-control study. The Lancet. 2017;390:1603–1610.

Liu A. Could a MenB vaccine protect against gonorrhea? GSK wants to find out [Vaccines]. Fierce Pharma. Jul 11, 2017.