Medicine:Meningococcal vaccine

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Short description: Vaccines used to prevent infection by Neisseria meningitidis
Meningococcal vaccine
Vaccine description
Target diseaseNeisseria meningitidis
TypeConjugate or polysaccharide
Clinical data
Trade namesMenactra, Menveo, Menomune, Others
AHFS/Drugs.comMonograph
MedlinePlusa607020
License data
Pregnancy
category
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Routes of
administration		Conjugate: intramuscular
Polysaccharide: subcutaneous
ATC code
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Meningococcal vaccine refers to any of the vaccines used to prevent infection by Neisseria meningitidis.[2] Different versions are effective against some or all of the following types of meningococcus: A, B, C, W-135, and Y.[2][3] The vaccines are between 85 and 100% effective for at least two years.[2] They result in a decrease in meningitis and sepsis among populations where they are widely used.[4][5] They are given either by injection into a muscle or just under the skin.[2]

The World Health Organization recommends that countries with a moderate or high rate of disease or with frequent outbreaks should routinely vaccinate.[2][6] In countries with a low risk of disease, they recommend that high risk groups should be immunized.[2] In the African meningitis belt efforts to immunize all people between the ages of one and thirty with the meningococcal A conjugate vaccine are ongoing.[6] In Canada and the United States the vaccines effective against four types of meningococcus (A, C, W, and Y) are recommended routinely for teenagers and others who are at high risk.[2] Saudi Arabia requires vaccination with the quadrivalent vaccine for international travellers to Mecca for Hajj.[2][7]

Meningococcal vaccines are generally safe.[2] Some people develop pain and redness at the injection site.[2] Use in pregnancy appears to be safe.[6] Severe allergic reactions occur in less than one in a million doses.[2]

The first meningococcal vaccine became available in the 1970s.[8] It is on the World Health Organization's List of Essential Medicines.[9]

Types

Neisseria meningitidis has 13 clinically significant serogroups, classified according to the antigenic structure of their polysaccharide capsule. Six serogroups, A, B, C, Y, W-135, and X, are responsible for virtually all cases of the disease in humans.

Quadrivalent (Serogroups A, C, W-135, and Y)

There are three vaccines available in the United States to prevent meningococcal disease, all quadrivalent in nature, targeting serogroups A, C, W-135, and Y:

  • three conjugate vaccines (MCV-4), Menactra, Menveo and MenQuadfi. The pure polysaccharide vaccine Menomune, MPSV4, was discontinued in the United States in 2017.

Menveo and MenQuadfi are approved for medical use in the European Union.[10][11]

Menveo

The first meningococcal conjugate vaccine (MCV-4), Menactra, was licensed in the U.S. in 2005 by Sanofi Pasteur; Menveo was licensed in 2010 by Novartis. Both MCV-4 vaccines have been approved by the Food and Drug Administration (FDA) for people 2 through 55 years of age. Menactra received FDA approval for use in children as young as 9 months in April 2011[12] while Menveo received FDA approval for use in children as young as two months in August 2013.[13] The Centers for Disease Control and Prevention (CDC) has not made recommendations for or against its use in children less than two years.[14]

Menomune

Meningococcal polysaccharide vaccine (MPSV-4), Menomune, has been available since the 1970s. It may be used if MCV-4 is not available, and is the only meningococcal vaccine licensed for people older than 55. Information about who should receive the meningococcal vaccine is available from the CDC.[14]

Nimenrix

Nimenrix (Pfizer). Meningoccal group A, C, W-135 and Y conjugate vaccine

Nimenrix (developed by GlaxoSmithKline and later acquired by Pfizer), is a quadrivalent conjugate vaccine against serogroups A, C, W-135, and Y.[15] In April 2012 Nimenrix was approved as the first quadrivalent vaccine against invasive meningococcal disease to be administered as a single dose in those over the age of one year, by the European Medicines Agency.[16] In 2016, they approved the vaccine in infants six weeks of age and older, and it has been approved in other countries including Canada and Australia, among others.[17][18] It is not licensed in the United States.[19]

Mencevax

Mencevax (GlaxoSmithKline) and NmVac4-A/C/Y/W-135 (JN-International Medical Corporation) are used worldwide, but have not been licensed in the United States.

Limitations

The duration of immunity mediated by Menomune (MPSV-4) is three years or less in children aged under five because it does not generate memory T cells.[20][21] Attempting to overcome this problem by repeated immunization results in a diminished, not increased, antibody response, so boosters are not recommended with this vaccine.[22][23] As with all polysaccharide vaccines, Menomune does not produce mucosal immunity, so people can still become colonised with virulent strains of meningococcus, and no herd immunity can develop.[24][25] For this reason, Menomune is suitable for travellers requiring short-term protection, but not for national public health prevention programs.

Menveo and Menactra contain the same antigens as Menomune, but the antigens are conjugated to a diphtheria toxoid polysaccharide–protein complex, resulting in anticipated enhanced duration of protection, increased immunity with booster vaccinations, and effective herd immunity.[26]

Endurance

A study published in March 2006, comparing the two kinds of vaccines found that 76% of subjects still had passive protection three years after receiving MCV-4 (63% protective compared with controls), but only 49% had passive protection after receiving MPSV-4 (31% protective compared with controls).[27] As of 2010, there remains limited evidence that any of the current conjugate vaccines offer continued protection beyond three years; studies are ongoing to determine the actual duration of immunity, and the subsequent requirement of booster vaccinations. The CDC offers recommendations regarding who they feel should get booster vaccinations.[28][29]

Bivalent (Serogroups C and Y)

On 14 June 2012, the FDA approved a combination vaccine against two types of meningococcal disease and Hib disease for infants and children 6 weeks to 18 months old. The vaccine, Menhibrix, prevents disease caused by Neisseria meningitidis serogroups C and Y and Haemophilus influenzae type b. This was the first meningococcal vaccine that could be given to infants as young as six weeks old.[30]

Serogroup A

A vaccine called MenAfriVac has been developed through a program called the Meningitis Vaccine Project and has the potential to prevent outbreaks of group A meningitis, which is common in sub-Saharan Africa.[31][32]

Serogroup B

Vaccines against serotype B meningococcal disease have proved difficult to produce, and require a different approach from vaccines against other serotypes. Whereas effective polysaccharide vaccines have been produced against types A, C, W-135, and Y, the capsular polysaccharide on the type B bacterium is too similar to human neural adhesion molecules to be a useful target.[33]

A number of "serogroup B" vaccines have been produced. Strictly speaking, these are not "serogroup B" vaccines, as they do not aim to produce antibodies to the group B antigen: it would be more accurate to describe them as serogroup independent vaccines, as they employ different antigenic components of the organism; indeed, some of the antigens are common to different Neisseria species.

A vaccine for serogroup B was developed in Cuba in response to a large outbreak of meningitis B during the 1980s. This vaccine was based on artificially produced outer membrane vesicles of the bacterium. The VA-MENGOC-BC vaccine proved safe and effective in randomized double-blind studies,[34][35][36] but it was granted a licence only for research purposes in the United States[37] as political differences limited cooperation between the two countries.[38]

Due to a similarly high prevalence of B-serotype meningitis in Norway between 1974 and 1988, Norwegian health authorities developed a vaccine specifically designed for Norwegian children and young adolescents. Clinical trials were discontinued after the vaccine was shown to cover only slightly more than 50% of all cases.[39] Furthermore, lawsuits for damages were filed against the State of Norway by persons affected by serious adverse reactions. Information that the health authorities obtained during the vaccine development were subsequently passed on to Chiron (now GlaxoSmithKline), who developed a similar vaccine, MeNZB, for New Zealand.[40]

A MenB vaccine was approved for use in Europe in January 2013. Following a positive recommendation from the European Union's Committee for Medicinal Products for Human Use, Bexsero, produced by Novartis, received a licence from the European Commission.[41] However, deployment in individual EU member countries still depends on decisions by national governments. In July 2013, the United Kingdom's Joint Committee on Vaccination and Immunisation (JCVI) issued an interim position statement recommending against adoption of Bexsero as part of a routine meningococcal B immunisation program, on the grounds of cost-effectiveness.[42] This decision was reverted in favor of Bexsero vaccination in March 2014.[43] In March 2015 the UK government announced that they had reached agreement with GlaxoSmithKline who had taken over Novartis' vaccines business, and that Bexsero would be introduced into the UK routine immunization schedule later in 2015.[44]

In November 2013, in response to an outbreak of B-serotype meningitis on the campus of Princeton University, the acting head of the Centers for Disease Control and Prevention (CDC) meningitis and vaccine preventable diseases branch told NBC News that they had authorized emergency importation of Bexsero to stop the outbreak.[45] Bexsero was subsequently approved by the FDA in February 2015.[46] In October 2014, Trumenba, a serogroup B vaccine produced by Pfizer, was approved by the FDA.[3]

Serogroup X

The occurrence of serogroup X has been reported in North America, Europe, Australia, and West Africa.[47] There is no vaccine to protect against serogroup X N. meningitidis disease.[2]

Side effects

Common side effects include pain and redness around the site of injection (up to 50% of recipients). A small percentage of people develop a mild fever. A small proportion of people develop a severe allergic reaction.[48] In 2016 Health Canada warned of an increased risk of anemia or hemolysis in people treated with eculizumab (Soliris). The highest risk was when individuals "received a dose of Soliris within 2 weeks after being vaccinated with Bexsero".[49]

Despite initial concerns about Guillain-Barré syndrome, subsequent studies in 2012 have shown no increased risk of GBS after meningococcal conjugate vaccination.[50]

Travel requirements

Travellers need to show proof of meningococcal vaccination...
  Upon arrival in the Hajj and Umrah zones (foreign and domestic pilgrims, workers, and residents of Mecca and Medina)
  Before departure to Hajj and Umrah in Saudi Arabia, and to certain African countries
  Before departure to and upon arrival from Saudi Arabia
  Before departure to Hajj and Umrah in Saudi Arabia
  Upon arrival
  African meningitis belt: vaccination recommended for visitors

Travellers who wish to enter or leave certain countries or territories must be vaccinated against meningococcal meningitis, preferably 10–14 days before crossing the border, and be able to present a vaccination record/certificate at the border checks.[51]:21–24 Countries with required meningococcal vaccination for travellers include The Gambia, Indonesia, Lebanon, Libya, the Philippines and, most importantly and extensively, Saudi Arabia for Muslims visiting or working in Mecca during the Hajj or Umrah pilgrimages.[52] For some countries in African meningitis belt, vaccinations prior to entry are not required, but highly recommended.[51]:21–24

Meningococcal vaccination requirements for international travel[52]
Country or territory Details
 Gambia All travellers must show proof of vaccination with quadrivalent meningococcal vaccine (ACYW135) upon arrival.[53]
 Indonesia Travellers arriving from or departing to Saudi Arabia must show proof of vaccination with quadrivalent ACYW-135.[54]
 Lebanon Proof of vaccination with quadrivalent ACYW-135 is required for travellers departing Lebanon and going to Hajj, Umrah, and to certain African countries.[55]
 Libya All travellers must show proof of vaccination with quadrivalent ACYW-135 upon arrival.[56]
 Philippines Proof of vaccination with quadrivalent ACYW-135 is required for travellers going to Hajj and Umrah (in Saudi Arabia).[57]
 Saudi Arabia
  • Proof of vaccination is required for travellers 2 years of age and older who are Hajj or Umrah pilgrims and seasonal or pilgrim workers in Hajj and Umrah areas. Vaccination with quadrivalent ACYW135 (either polysaccharide or conjugate) must be issued not less than 10 days before arrival and not more than 3 years (polysaccharide vaccine) or 5 years (conjugate vaccine) before arrival. The immunisation certificate should clearly state if the traveller was vaccinated with the conjugate vaccine for the 5-year validity to apply.[58]
  • Vaccination is also required for domestic pilgrims, residents of Mecca and Medina, and any persons participating in Hajj or Umrah or seasonal or pilgrimage work in Hajj and Umrah zones. At the discretion of the Ministry of Health, travellers may be administered prophylactic antibiotics upon arrival.[58]

References

  1. ↑ "TGA eBS - Product and Consumer Medicine Information Licence". https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2020-PI-02491-1. 
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 "Meningococcal vaccines : WHO position paper, November 2011". Wkly. Epidemiol. Rec. 86 (47): 521–540. November 2011. PMID 22128384. 
  3. ↑ 3.0 3.1 "First vaccine approved by FDA to prevent serogroup B Meningococcal disease". U.S. Food and Drug Administration (FDA) (Press release). 29 October 2014. Archived from the original on 15 June 2019. Retrieved 19 October 2019.
  4. ↑ Patel, M; Lee, CK (25 January 2005). "Polysaccharide vaccines for preventing serogroup A meningococcal meningitis.". The Cochrane Database of Systematic Reviews (1): CD001093. doi:10.1002/14651858.CD001093.pub2. CD001093. PMID 15674874. 
  5. ↑ Conterno, LO; Silva Filho, CR; Rüggeberg, JU; Heath, PT (19 July 2006). Conterno, Lucieni O. ed. "Conjugate vaccines for preventing meningococcal C meningitis and septicaemia.". The Cochrane Database of Systematic Reviews (3): CD001834. doi:10.1002/14651858.CD001834.pub2. PMID 16855979. 
  6. ↑ 6.0 6.1 6.2 "Meningococcal A conjugate vaccine: updated guidance, February 2015.". Wkly. Epidemiol. Rec. 90 (8): 57–62. 20 February 2015. PMID 25702330. https://www.who.int/wer/2015/wer9008.pdf. 
  7. ↑ "Saudi Arabia: Hajj/Umrah Pilgrimage". https://wwwnc.cdc.gov/travel/yellowbook/2018/select-destinations/saudi-arabia-hajj-umrah-pilgrimage. 
  8. ↑ Barrett, Alan D.T. (2015). Vaccinology : an essential guide. p. 168. ISBN 9780470656167. https://books.google.com/books?id=NvKyBwAAQBAJ&pg=PA168. 
  9. ↑ World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. 2019. WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO. 
  10. ↑ "Menveo EPAR". https://www.ema.europa.eu/en/medicines/human/EPAR/menveo. 
  11. ↑ "MenQuadfi EPAR". 15 September 2020. https://www.ema.europa.eu/en/medicines/human/EPAR/menquadfi. 
  12. ↑ "22 April 2011 Approval Letter - Menactra". https://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm252511.htm. 
  13. ↑ "1 August 2013 Approval Letter - Menveo". https://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm363785.htm. 
  14. ↑ 14.0 14.1 >"Meningococcal Vaccination - What You Should Know". 26 July 2019. https://www.cdc.gov/vaccines/vpd/mening/public/index.html. 
  15. ↑ Torresi, Joseph; Kollaritsch, Herwig (2019). "12. Recommended/required travel vaccines". in Keystone, Jay S. (in en). Travel Medicine (Fourth ed.). Elsevier. pp. 114. ISBN 978-0-323-54696-6. https://books.google.com/books?id=M4d7DwAAQBAJ&q=nimenrix&pg=PA115. 
  16. ↑ Assaf-Casals, Aia; Dbaibo, Ghassan (22 February 2016). "Meningococcal quadrivalent tetanus toxoid conjugate vaccine (MenACWY-TT, Nimenrix™): A review of its immunogenicity, safety, co-administration, and antibody persistence". Human Vaccines & Immunotherapeutics 12 (7): 1825–1837. doi:10.1080/21645515.2016.1143157. ISSN 2164-5515. PMID 26900984. 
  17. ↑ "Nimenrix". European Medicines Agency. 24 May 2012. https://www.ema.europa.eu/en/medicines/human/EPAR/nimenrix. 
  18. ↑ "Nimenrix - Summary of Product Characteristics (SmPC) - (emc)". https://www.medicines.org.uk/emc/medicine/26514#gref. 
  19. ↑ "Advisory Committee on Immunization Practices (ACIP)". CDC (June 2020).
  20. ↑ "Age-specific differences in duration of clinical protection after vaccination with meningococcal polysaccharide A vaccine". Lancet 2 (8447): 114–18. 1985. doi:10.1016/S0140-6736(85)90224-7. PMID 2862316. 
  21. ↑ "Persistence of antibody following immunization of children with groups A and C meningococcal polysaccharide vaccines". Pediatrics 60 (5): 673–80. 1977. PMID 411104. 
  22. ↑ "Reduced antibody response to revaccination with meningococcal serogroup A polysaccharide vaccine in adults". Vaccine 19 (9–10): 1129–32. 2000. doi:10.1016/s0264-410x(00)00317-0. PMID 11137248. 
  23. ↑ "Immune response to revaccination with meningococcal A and C polysaccharides in Gambian children following repeated immunization during early childhood". Vaccine 17 (23–24): 3086–93. 1999. doi:10.1016/S0264-410X(99)00139-5. PMID 10462244. 
  24. ↑ "Meningococcal carriage, meningococcal disease and vaccination". J Infect 16 (1): 55–9. 1988. doi:10.1016/S0163-4453(88)96117-8. PMID 3130424. 
  25. ↑ "Group A meningococcal carriage in travelers returning from Saudi Arabia". J Am Med Assoc 260 (18): 2686–89. 1988. doi:10.1001/jama.260.18.2686. PMID 3184335. 
  26. ↑ Deeks, E.D (October 2010). "Meningococcal quadrivalent (serogroups A, C, w135, and y) conjugate vaccine (Menveo): in adolescents and adults.". BioDrugs 4 (5): 72–6. PMID 21270745. 
  27. ↑ "Antibody persistence 3 years after immunization of adolescents with quadrivalent meningococcal conjugate vaccine". J Infect Dis 193 (6): 821–8. 2006. doi:10.1086/500512. PMID 16479517. 
  28. ↑ Centers for Disease Control and Prevention (CDC) (January 2011). "Updated recommendations for use of meningococcal conjugate vaccines --- Advisory Committee on Immunization Practices (ACIP), 2010". MMWR Morb Mortal Wkly Rep 60 (3): 72–6. PMID 21270745. 
  29. ↑ Centers for Disease Control and Prevention (CDC) (September 2009). "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 58 (37): 1042–3. PMID 19779400. 
  30. ↑ FDA approves new combination vaccine that protects children against two bacterial diseases , FDA Press Release, 14 June 2012
  31. ↑ "Eliminating epidemic Group A meningococcal meningitis in Africa through a new vaccine". Health Aff (Millwood) 30 (6): 1049–57. June 2011. doi:10.1377/hlthaff.2011.0328. PMID 21653956. 
  32. ↑ "Baseline Meningococcal Carriage in Burkina Faso before the Introduction of a Meningococcal Serogroup A Conjugate Vaccine". Clin Vaccine Immunol 18 (3): 435–43. March 2011. doi:10.1128/CVI.00479-10. PMID 21228139. 
  33. ↑ "An IgG monoclonal antibody to group B meningococci cross-reacts with developmentally regulated polysialic acid units of glycoproteins in neural and extraneural tissues". Journal of Immunology 138 (12): 4402–07. 1987. PMID 3108388. 
  34. ↑ "Immune Response Induction and New Effector Mechanisms Possibly Involved in Protection Conferred by the Cuban Anti-Meningococcal BC Vaccine". Infect Immun 69 (7): 4502–8. July 2001. doi:10.1128/IAI.69.7.4502-4508.2001. PMID 11401992. 
  35. ↑ "Outer membrane vesicles of the VA-MENGOC-BC vaccine against serogroup B of Neisseria meningitidis: Analysis of protein components by two-dimensional gel electrophoresis and mass spectrometry". Proteomics 6 (11): 3389–99. June 2006. doi:10.1002/pmic.200500502. PMID 16673438. 
  36. ↑ "Finlay Institute VA-MENGOC-BC Most frequent questions and answers". http://www.finlay.sld.cu/english/products/pregunvamengocbcenglish.htm. 
  37. ↑ "World: Americas Cuba vaccine deal breaks embargo". BBC News Online. 29 July 1999. http://news.bbc.co.uk/2/hi/americas/406780.stm. 
  38. ↑ NBC News Digital (12 November 2015). "Cuban scientist barred from receiving U.S. prize". Associated Press. http://www.nbcnews.com/id/10010619/ns/world_news-americas/t/cuban-scientist-barred-receiving-us-prize/. "A Cuban scientist who helped develop a low-cost synthetic vaccine that prevents meningitis and pneumonia in small children says he was offended the U.S. government denied his request to travel to the United States to receive an award." 
  39. ↑ P.G. Djupesland; G. Bjune; E.A. Hø; J.K. Grønnesby; R. Mundal (September 1997). "Serogroup B meningococcal disease in the Norwegian armed forces: What can we learn from an inconclusive vaccine protection trial?". European Journal of Public Health 7 (3): 261–266. doi:10.1093/eurpub/7.3.261. https://academic.oup.com/eurpub/article/7/3/261/503242. 
  40. ↑ Burstyn, Barbara Sumner (2005-02-07). "Investigation: The Meningococcal Gold Rush". Scoop. https://www.scoop.co.nz/stories/HL0502/S00064.htm. 
  41. ↑ "First ever MenB vaccine available for use". 24 January 2013. http://www.ovg.ox.ac.uk/OVG/blogs/ojohn/first-ever-menb-vaccine-available-use. 
  42. ↑ Joint Committee on Vaccination and Immunisation (JCVI) (July 2013). "JCVI interim position statement on use of Bexsero® meningococcal B vaccine in the UK". https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224896/JCVI_interim_statement_on_meningococcal_B_vaccination_for_web.pdf. 
  43. ↑ John Porter (Novartis) (March 2014). "UK review of vaccines flawed, says Novartis' John Porter". http://www.pharmatimes.com/Article/14-08-28/UK_review_of_vaccines_flawed_says_Novartis_John_Porter.aspx. 
  44. ↑ "Meningitis B vaccine deal agreed - Jeremy Hunt". BBC News. 29 March 2015. https://www.bbc.co.uk/news/health-32101921. 
  45. ↑ Aleccia, JoNell (2013-11-15). "Emergency meningitis vaccine will be imported to halt Ivy League outbreak". NBC News. https://www.nbcnews.com/health/emergency-meningitis-vaccine-will-be-imported-halt-ivy-league-outbreak-2D11603651. 
  46. ↑ "FDA approves a second vaccine to prevent serogroup B meningococcal disease" (Press release). United States Food and Drug Administration. 23 January 2015. Archived from the original on 16 March 2015. Retrieved 2015-03-15.
  47. ↑ Clonal Groupings in Serogroup X Neisseria meningitidis.
  48. ↑ "Vaccines: Vac-Gen/Side Effects". National Center for Immunization and Respiratory Diseases. https://www.cdc.gov/vaccines/vac-gen/side-effects.htm#mening. 
  49. ↑ Health Canada "Summary Safety Review - SOLIRIS (eculizumab) and BEXSERO - Assessing the Potential Risk of Hemolysis and Low Hemoglobin in Patients Treated with Soliris and Vaccinated with Bexsero". 23 October 2014. https://www.canada.ca/en/health-canada/services/drugs-health-products/medeffect-canada/safety-reviews/summary-safety-review-soliris-eculizumab-bexsero-multicomponent-meningococcal-vaccine.html.  16 September 2016
  50. ↑ Yih, Weiling Katherine; Weintraub, Eric; Kulldorff, Martin (1 December 2012). "No risk of Guillain-Barré syndrome found after meningococcal conjugate vaccination in two large cohort studies". Pharmacoepidemiology and Drug Safety 21 (12): 1359–1360. doi:10.1002/pds.3353. ISSN 1099-1557. PMID 23225672. 
  51. ↑ 51.0 51.1 "International Travel and Health. Chapter 6 - Vaccine-preventable diseases and vaccines (2019 update)". World Health Organization. United Nations. 2020. https://www.who.int/ith/CHAPTER_6_For_Publication.pdf. 
  52. ↑ 52.0 52.1 "Countries with risk of yellow fever transmission and countries requiring yellow fever vaccination (July 2019)". World Health Organization. United Nations. 4 July 2019. https://www.who.int/publications/m/item/countries-with-risk-of-yellow-fever-transmission-and-countries-requiring-yellow-fever-vaccination-(july-2019). 
  53. ↑ "Gambia Required Vaccinations: Meningococcal Meningitis". iamat.org. International Association for Medical Assistance to Travellers (IAMAT). 20 August 2020. https://www.iamat.org/country/gambia/risk/meningococcal-meningitis. 
  54. ↑ "Indonesia Required Vaccinations: Meningococcal Meningitis". iamat.org. International Association for Medical Assistance to Travellers (IAMAT). 20 August 2020. https://www.iamat.org/country/indonesia/risk/meningococcal-meningitis. 
  55. ↑ "Lebanon Required Vaccinations: Meningococcal Meningitis". iamat.org. International Association for Medical Assistance to Travellers (IAMAT). 20 August 2020. https://www.iamat.org/country/lebanon/risk/meningococcal-meningitis. 
  56. ↑ "Libya Required Vaccinations: Meningococcal Meningitis". iamat.org. International Association for Medical Assistance to Travellers (IAMAT). 20 August 2020. https://www.iamat.org/country/libya/risk/meningococcal-meningitis. 
  57. ↑ "Philippines Required Vaccinations: Meningococcal Meningitis". iamat.org. International Association for Medical Assistance to Travellers (IAMAT). 20 August 2020. https://www.iamat.org/country/philippines/risk/meningococcal-meningitis. 
  58. ↑ 58.0 58.1 "Saudi Arabia Required Vaccinations: Meningococcal Meningitis". iamat.org. International Association for Medical Assistance to Travellers (IAMAT). 20 August 2020. https://www.iamat.org/country/saudi-arabia/risk/meningococcal-meningitis. 

Further reading

External links



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