What is the recommended prophylactic treatment for individuals at increased risk of meningococcal disease, such as college students, military recruits, or those with certain medical conditions?

Prophylactic Treatment for Meningococcus

Vaccination Prophylaxis

All adolescents aged 11-12 years should receive quadrivalent meningococcal conjugate vaccine (MenACWY) with a booster at age 16 years, and specific high-risk groups require additional vaccination strategies based on their exposure risk and underlying medical conditions. 1, 2

Routine Adolescent Vaccination

• Administer MenACWY at the preadolescent visit (age 11-12 years) with a mandatory booster at age 16 years to maintain protection during late adolescence when risk peaks 1, 2
• This two-dose schedule addresses the highest-risk period of late adolescence and early adulthood 1

High-Risk Populations Requiring MenACWY

Two-dose primary series (8-12 weeks apart):

• Persons with persistent complement component deficiencies 3, 1, 2
• Persons with anatomic or functional asplenia, including sickle cell disease (case fatality rate 40-70%) 3, 2
• Persons receiving complement inhibitor therapy (eculizumab) 3, 4

Single-dose vaccination:

• Military recruits 3, 2
• First-year college students living in dormitories 3, 2
• International travelers to hyperendemic/epidemic areas (particularly sub-Saharan Africa's "meningitis belt" during December-June dry season) 3, 2, 5
• Microbiologists routinely exposed to Neisseria meningitidis isolates 3, 2

Serogroup B Vaccination (MenB)

Administer MenB vaccine to persons aged ≥10 years with:

• Complement component deficiencies or complement inhibitor therapy 4
• Anatomic or functional asplenia, including sickle cell disease 4
• Occupational exposure (microbiologists) 4
• Outbreak exposure 4

For healthy adolescents aged 16-23 years: Use shared clinical decision-making, considering that serogroup B causes over 50% of cases in infants but college students have lower risk than the general population of similar age 3, 4, 2

Vaccine administration:

• MenB-4C (Bexsero): 2 doses at 0 and ≥1 month 4
• MenB-FHbp (Trumenba): 2 doses (0,6 months) for healthy adolescents OR 3 doses (0,1-2,6 months) for high-risk individuals 4
• The same vaccine product must be used for all doses; vaccines are not interchangeable 4

Antibiotic Chemoprophylaxis

Indications for Close Contacts

Administer chemoprophylaxis to close contacts of invasive meningococcal disease cases, including:

• Household members 2
• Child-care center contacts 2
• Anyone directly exposed to the patient's oral secretions 2

Timing and Selection

Administer chemoprophylaxis as soon as possible, ideally within 24 hours of identifying the index case; limited value if given >14 days after exposure 2

In areas WITHOUT ciprofloxacin resistance, first-line options include:

• Ciprofloxacin (most effective at 1-2 weeks follow-up, RR 0.03) 6
• Rifampin (effective up to 4 weeks, RR 0.20 at 1-2 weeks) 7, 6
• Ceftriaxone (more effective than rifampin at 1-2 weeks, RR 5.93) 6

In areas WITH ciprofloxacin resistance (≥2 cases AND ≥20% of cases resistant in rolling 12-month period), preferentially use:

• Rifampin 8
• Ceftriaxone 8
• Azithromycin 8

Specific Dosing Regimens

Rifampin for meningococcal carriers: 7

• Adults: 600 mg twice daily for 2 days
• Pediatric ≥1 month: 10 mg/kg (max 600 mg) every 12 hours for 2 days
• Pediatric <1 month: 5 mg/kg every 12 hours for 2 days

Critical Caveats

Vaccination does NOT replace chemoprophylaxis - administer both concurrently for close contacts 1, 2

Flag general practice records: Increased meningococcal disease risk persists for at least 6 months in contacts despite prophylaxis 1

Monitor for resistance: Rifampin-resistant isolates emerge following prophylactic treatment, making ciprofloxacin or ceftriaxone preferable in outbreak settings 6, 8

Do not use rifampin for treating active meningococcal infection due to rapid emergence of resistant organisms 7

Outbreak Control

Offer wider vaccination when ≥2 cases of probable/confirmed invasive meningococcal disease due to the same vaccine-preventable strain occur in the same educational or residential setting within 4 weeks 1

College campus outbreaks demonstrate 200- to 1400-fold increased risk during outbreak periods 3

Post-Exposure Management

Vaccinate unvaccinated contacts of cases caused by vaccine-preventable non-B serogroups (A, C, W, Y) 1

Vaccinate index cases under age 25 years who are unimmunized according to national schedule regardless of causative serogroup 1

Do not delay vaccination while awaiting serotype confirmation in contacts of vaccine-preventable serogroups 1

Epidemiologic Context

Despite appropriate antibiotic treatment, case-fatality ratio remains 10-14%, with 11-19% of survivors experiencing significant sequelae including neurologic disability, limb loss, and hearing loss 2

Serogroups B, C, and Y each cause approximately one-third of U.S. cases 2

Persons with terminal complement deficiencies have 1,000-10,000 times higher risk of meningococcal disease 2

Military vaccination programs since 1971 have reduced meningococcal disease rates by approximately 94% through 1998, with few cases caused by vaccine-represented serogroups 9