There have been important changes in the epidemiology of meningococcal infection over the last few years, with consistent increases in the total number of cases and in the number of septicaemia cases. The proportion of cases caused by Group C meningococci has also increased. There have also been shifts of the ages affected, with more cases in older teenagers, amongst whom the case fatality rate is highest. Meningococcal Group C infection accounts for about 50% of all cases of meningococcal infection in Scotland; most of the other cases are Group B infection. The latest annual estimate (1998/99) is 160 cases of Group C disease in Scotland with approximately a 6% death rate.

Following the highly successful development of Hib vaccine, manufacturers have applied similar technology to the development of vaccines against Group C meningococcal infection. Development of vaccines against Group B infection, the other predominant strain causing disease in the UK, will take longer. These new Group C meningococcal vaccines use the meningococcal surface polysaccharide used in the presently available polysaccharide vaccine, and by conjugating this to protein, overcome the shortcomings of the presently available vaccine. The new meningococcal Group C conjugated vaccine is immunogenic in children from 2 months of age, and appears to induce immunological memory so that further boosting is likely not to be needed.

The recommended schedule for the new meningococcal Group C conjugate vaccine is 3 doses for children aged 2, 3 and 4 months, 2 doses for children over 4 months and under one year and one dose for all others. The new vaccines have been extensively tested by the manufacturers and by the Public Health Laboratory Service, and have been found to have excellent immunogenicity and safety profiles in all ages. The vaccines are currently undergoing the procedures necessary for licensing at the Medicines Control Agency.

Subject to licensure and availability, a new immunisation programme will start in the autumn with highest risk groups hopefully being immunised before the start of the winter ‘meningitis season’. As the meningococcal Group C conjugate vaccines are new, there are no established stocks in hand and implementation of the programme will proceed as rapidly as vaccine can be manufactured and distributed.

The new meningococcal Group C conjugate vaccine will have to be targeted by risk factors, primarily on the basis of age. In the first instance, the vaccines will be made available for:

• infants at the same time as their routine diphtheria/tetanus/pertussis, polio and Hib immunisations (at 2, 3 and 4 months);
• children receiving their first dose of MMR at around 13 months;
• and, those in the 4^th, 5^th and 6^th school years ie. 15/16/17 year old young people.

Children over 4 months and under 12 months will be recalled for immunisation in the first phase of the programme. The second phase will involve the immunisation of children over one year and up to 5 years. Thereafter, as supplies of the new meningococcal Group C conjugate vaccine become available, further groups will be offered vaccine, scheduled on the basis of age groups at risk. Children over 5 years will be immunised through a schools programme.

Young people receiving higher/further education, especially when living in halls of residence, are at higher risk of meningococcal disease. The first few weeks of the first term at college/university appear to be the high-risk time for those groups. However, the new meningococcal Group C conjugate vaccine will not be available until later in the year and it is therefore recommended that young people who will start at institutes of higher/further education this autumn should be offered a single dose of the presently available polysaccharide meningococcal Group C vaccine (ACvax (SmithKline Beecham) or Mengivac A+C (Pasteur Merieux MSD)), preferably before going to college/university. Students who miss their meningococcal vaccination by the GP before starting university/college, should be offered the opportunity to be immunised as soon as they start the term. Students will be able to have the new meningococcal Group C conjugate vaccine at a later date.

More detailed information for health professionals on the new meningococcal Group C conjugate vaccines, the timetables for specific groups and information for parents and recipients will be provided before the start of the new programme, which will commence in the autumn. This information will emphasise the importance of adhering to the timetable and of the continuing need to be aware and alert to the signs of meningococcal infection.

Responsibility for overall organisation, coordination and implementation of this programme locally rests with the Immunisation Coordinator. He/she will be supported in this by other health care professionals many of whose roles and responsibilities are summarised in this Letter. Coordinators/CPHMs will be responsible for organising relevant training for health care professionals, providing public information and delivering the overall programme. Coordinators/CPHMs will also be responsible for implementing the schools programme, in cooperation with relevant health and education officials, and should ensure that adequate arrangements are made to cover all schools within their health board area, including independent schools, colleges and universities, and young offenders institutions.

Further detailed information for Coordinators will be provided in due course. Scottish Executive officials will be meeting very soon with Coordinators to discuss taking forward this initiative. This issue will also form the main topic at the annual UK Immunisation Coordinators conference.

The first supplies of the new meningococcal Group C conjugate vaccine will be issued for use in children coming for their DTP/polio/Hib immunisations, and children coming for their first MMR vaccine. As these children are scheduled for immunisations automatically, no new appointments need be set up. During this first phase of the programme, children over 4 months of age and under 12 months of age will be given priority and recalled for two doses of the new meningococcal Group C conjugate vaccine. It is hoped that all children less than one year will be immunised in this first phase. The next phase will be for children over the ages of one year and under 5 years. Since the quantities of vaccine for primary immunisations ordered from each delivery point are known, it is possible to identify the monthly requirements for the new meningococcal Group C conjugate vaccine for all ages in the first phase of the programme. Farillon, the central vaccine distributor, will use this information to allocate the quantities of vaccine to each delivery point monthly. There is therefore no need to place orders for the new vaccine for the first phase of the programme. More information on the supply and distribution arrangements will be provided. Arrangements will need to be made to call children over 4 months and under one year for immunisation. Details of these arrangements will follow.

Please note especially that this new vaccine will only prevent Group C meningococcal disease, and awareness needs to be maintained for signs and symptoms of meningococcal disease caused by other strains.

Directors of Public Health will want to work in partnership with Immunisation Coordinators/CPHMs, Community Paediatricians, the School Health Service and agencies such as education authorities, higher education and private education providers in their area, together with social services and voluntary organisations involving children, to ensure that they are familiar with the new programme. It will be most important to stress that this new vaccine will only prevent Group C meningococcal disease, and awareness needs to be maintained for signs and symptoms of meningococcal disease caused by other strains.

Adequate arrangements will need to be in place to provide immunisations for travelling and homeless families, as well as children who are from asylum seeking families and refugees.

It will remain important to ensure that other public health protection programmes such as routine childhood immunisations, influenza immunisations, and cervical cytology arrangements are not compromised.

Directors of Public Health will want to work with Medical and Nursing Directors of Primary Care Trusts to ensure that all primary care staff involved in the new programme understand the nature of the new vaccine to be used, the schedule for immunisation and the priority groups, and have in place mechanisms to audit the implementation of all aspects of the new programme.

(a) Medical Directors

Medical Directors of Primary Care Trusts will wish to work with the Director of Public Health and their Local Health Care Cooperatives (LHCCs) to ensure that all primary care staff involved in the new programme understand the nature of the new meningococcal Group C conjugate vaccine to be used, the schedule for immunisation and the priority groups, and have in place mechanisms to audit the implementation of all aspects of the new programme. They will wish to ensure under clinical governance arrangements that all staff involved in the immunisation programme are appropriately trained in immunisation and in the management of anaphylaxis.

It will remain important to ensure that other public health protection programmes such as routine childhood immunisations, influenza immunisations, and cervical cytology arrangements are not compromised.

(b) Directors of Nursing Services

DNSs will be required to support primary care staff in the delivery of the 0-5 programme and should encourage innovative team approaches to enable the implementation of this major Public Health programme.

DNSs are responsible for ensuring that staff they employ receive training to enable them to reach accepted, appropriate levels of competence and DNSs should ensure that appropriate protocols and procedures are in place and that staff achieve a required level of competence.

DNSs should determine with LHCCs the most appropriate, effective and efficient use of staff working within primary care settings.

DNSs should ensure that midwives, paediatric nurses, neonatal nurses and nursing staff on A/E Departments are informed of this exercise and that they are aware of local arrangements.

As part of their forward planning Trust Chief Pharmacists are asked to consider the following key issues which will be needed to support the programme:

• allocation and ordering of quantities of the new meningococcal Group C conjugate vaccine and diluent needed for the vaccination programme;

• storage and distribution of the new vaccine;

• repackaging of the new meningococcal Group C conjugate vaccine from the original containers supplied by the manufacturers into smaller quantities where necessary for onward distribution; and,

• communication/dealing with enquiries from nurses, doctors, pharmacists and members of the public.

Please note that you will receive more detailed information about this new meningococcal Group C conjugate vaccine, its presentation and its introduction before implementation, but for clarification on this communication, please contact:

Dr Barbara Davis (Medical Issues) – Contact Number 0131 244 2158

Mr Michael Proctor (Nursing Issues) – Contact Number 0131 244 3467

Mrs Pamela S Warrington (Pharmacy Issues) – Contact Number 0131 244 2778

Miss Jean Goldie (Vaccine Supply Issues) – Contact Number 0131 244 2667

at the Scottish Executive Health Department, St Andrew’s House, Edinburgh.