Preventing the Worst: An Expert Forum on Strategies to Optimize Meningococcal VaccinationWhat Pediatricians Need to Know About Invasive Meningococcal Disease

what do you need to know about meningococcal disease.

[00:09:04]

The Burden of Invasive Meningococcal Disease (IMD)

So this is what you need to know.

[00:09:09]

IMD Is Very Serious… 

The first is that IMD is extremely serious. This is a patient we had years ago that had purpura fulminans. It can present as sepsis and it can present as meningitis.

[00:09:20]

… And Can Be Deadly

And it can be deadly. This is a study that looked at case fatality rates by age. And the circles are the size of the study in terms of numbers of patients. And the y-axis is the case fatality rate. So there are 3 arrows on the graph. The first 1 shows that the case fatality rate for young infants is somewhere around 10%, but it's actually higher for adolescents, somewhere around 15% to 20%. And then it's very high for older individuals who suffer from IMD.

[00:10:01]

Clinical Presentation

So lots of patients die from this disease. It presents predominantly as meningitis, about 50% of cases, and septicemia in about 30% of cases. But almost all patients with meningitis are bacteremic.

And you can see here the clinical presentation, headache, stiff neck, nausea. You know the signs of meningitis. And then the signs of sepsis are - are also well known to you.

[00:10:27]

IMD Is Difficult To Recognize in The Early Stages

The problem with IMD is in the early stages it looks just like other things. So here's an example of a patient with meningococcemia on the left. And on the right is a kid with enterovirus infection which is a largely benign viral infection. And I don't know that you can tell these 2 kids apart when you see them in the emergency room.

[00:10:53]

Survivors May Have Lifelong Sequelae 

Another point is that survivors may have lifelong sequelae. And this can be a significant burden on their families and on caregivers. This is a little girl who lost her legs to disseminated intravascular coagulopathy from meningococcal disease.

[00:11:12]

Limited Data Regarding Sequelae

And I would make the point that sequelae is something that we really don't know a lot about, because there have been historically so few cases that have been studied. And there are elements of the burden of disease among sequelae that—among survivors that we really haven't studied.

So, for example, PTSD is not something that we know a lot about, but we're sure that that happens in families of survivors of IMD.

[00:11:41]

Colonization Precedes Infection

Okay, you need to know that colonization precedes infection. So you're exposed to the bacteria. It lands in your nasopharynx, and then it establishes a colonization state.

[00:11:58]

Colonization Rates Increase During Adolescence

And then whenever it has the opportunity, it can invade into the bloodstream and can replicate. Colonization rates increase among adolescence. So you can see here this is a meta-analysis of multiple studies looking at what is the colonization rate among adolescents or as a function of age. And again, the circle is proportional to the size of the study. And you can see there's a very obvious peak in colonization rates right around age 16-18.

[00:12:41]

Transmission Requires Close Contact

So why does that happen? It's because the bacterium is transmitted through close physical contact. And that's what teenagers do. They are in close proximity to each other. And they exchange secretions with each other.

[00:12:57]

IMD Is Extremely Rare

Here's the problem. And I say that sort of facetiously, because the problem is the disease is very rare. And in fact, the incidence of the disease has gone down steadily since the late 1990s. And it's not really clear why that has happened. For sure, there has been an impact of the MenACWY program and subsequently the MenB program. But that impact really was - was on top of what was already declining incidence rates.

So when the meningococcal vaccines were first being formulated, the incidence was 1.2 per 100,000 in the United States. Now it's 0.13 per 100,000.

[00:13:52]

Selected Vaccine Preventable Diseases

I like to envision meningococcus as the top hanging fruit in the vaccine tree. So the low-hanging fruit were the widespread childhood diseases that every child got, they were dangerous. There were severe outcomes. And these were the first diseases that we went after to target on a mass scale, measles and pertussis, varicella, HIB, not as common, but deadly.

With meningococcus, we have a unique situation, right? We have an extremely rare disease that has extremely high morbidity and mortality, but overall low societal costs, and that's why the cost per QALY saved is very high for this vaccine compared to other vaccines.

[00:14:46]

Disease Incidence at Time of Vaccine Introduction

This chart shows you the various vaccine programs in the left-hand column, the year the vaccination started, and what the incidence of the disease was at the time the vaccine was implemented.

So measles was 2100 per 100,000 and MenACWY in 2005, when it was first implemented, universal was only 0.44 per 100,000. So orders of magnitude less common, but at the individual level, just as or potentially more dangerous.

[00:15:27]

Specific Age Groups Are at Increased Risk

So this is the epidemiology by serogroup of meningococcal infection. You can see here there's a peak in infancy. There's another peak in adolescence, and then there's a peak in elderly.

So why is there a peak in infants? It's because babies are protected in the first few months by maternal antibody, and that wears off. And that's when they become susceptible. They're also exposed to colonized adolescents, like their older siblings or their cousins.

We've already talked about why there's a peak in adolescence. And the reason for the peak in older adults is because of immune senescence.

[00:16:16]

The Epidemiology Is Unpredictable

This graph makes the point that meningococcal epidemiology is very unpredictable. So, for example, in the past few years, there has been widespread outbreaks of serogroup Y disease, which we really hadn't seen much of for a couple of decades. That happens to be due to the introduction of a virulent clone of serogroup Y. But the point is that that was not predicted, right?

[00:16:48]

The Epidemiology Is Unpredictable 

And when you look at the global epidemiology, you can see that the various serogroups are proportionately different depending on what part of the globe you're in. So for example, serogroup C is much more prevalent in Africa than it is in developed countries like in Canada and in Europe.

Remember that we can't look at this in isolation, because those serogroups that are circulating in Africa or in Asia or in Europe are just a plane flight away from being introduced into the United States.

[00:17:29]

Risk Factors Other Than Age

So other than age, what are the other risk factors for IMD? I’d like to think of them in terms of the biology of the host and the epidemiology, the environment in which the host is living. So the biology has to do with do you have a spleen? You need a spleen in order to handle encapsulated bacteria like meningococcus. Or do you have all your complement components, right?

And you know that if you are deficient in a spleen or in complement components, you are a candidate for routine immunization against both ACWY and B.

But then there's also epidemiology. Do you work with the bacteria? Are you a microbiologist in the lab or are you traveling to Saudi Arabia for the Hajj? And then there are some risk factors that sort of overlap between biology and epidemiology. So for example HIV infection puts people at risk because of a host defense issue, but also epidemiologically, because in the case of serogroup Y, that's a strain that has spread among HIV infected individuals.

And bars and clubs are a risk factor for teenagers and young adults because of the exposure, close knit, lots of people, exchange of secretions. But there's also a biological factor because you are in a smoke environment, there's alcohol. The normal epithelial barrier that prevents you from going from colonized to infected, can be disrupted.

[00:19:15]

Serogroup B Predominates in Adolescents

So going back to the serogroup epidemiology, you'll notice that in the peak that occurs in adolescence, the blue which is serogroup B is the most common serogroup. And it's a little bit ironic that we have routine immunization against ACWY. But as you'll learn from Jana, we have shared decision-making for serogroup B vaccination, even though serogroup B is the most prevalent.

[00:19:46]

Outbreaks Occur on College Campuses

You also need to know that outbreaks occur. These classically occur in congregate living environments like college campuses. And in fact, if you look at the college outbreaks of IMD that occurred between 2011 and 2020, all of them were due to serogroup B. And again here, the size of the circle is - is proportionate to the number of cases.

[00:20:15]

Serogroup B Cases Occur in Non-College Students

But don't make the mistake of thinking that IMD or serogroup B only occurs among college students, because a third of the cases in adolescents and young adults occur in people who are not going to college. So I think we can't just immunize the kids who are going to college.

[00:20:35]

Counseling Recommendations

So just to distill it down to some talking points on how we should counsel teenagers about IMD. The first talking point is that IMD is rare, but it is serious. The second, adolescents and young adults are at higher risk simply because they do what adolescents and young adults do, and they live in the environments that those folks live in.

Three, exposure to the bacterium is difficult to avoid. There's some studies that show that 20% of adolescents are colonized with meningococcus. Not all of those are invasive encapsulated serogroups, but they are colonized.

Fourth, the disease is unpredictable, but it's preventable through vaccination. And remember what I showed you about the early signs looks like a viral infection. The problem here is by the time you realize it's a little bit more than a viral infection, I want to start antibiotics, it may be too late. This can really have an explosive onset, and patients can very, very rapidly get sick. So because it's unpredictable and we don't know that's what you have when you first come in with fever and a rash. Knowing you've been immunized is a really important piece of this.

And then finally routine vaccination is recommended against MenB under shared clinical decision-making but routinely for ACWY.

So I'm going to turn it over to Patti now to tell us her very personal story.

Patti Wukovits: Thank you. So this is a collage of pictures of my daughter Kimberly, because I don't like her to be remembered as this beautiful 17-year-old girl that died from bacterial meningitis, meningitis B. I don't want that to define her life. So she was my infant, my toddler, my young child, my adolescent. And she was a really funny kid.

She was the type of kid that would come sliding into the room, like in the kitchen floor with her socks and a hairbrush, microphone. You know, she just would love to laugh. She'd make everyone happy. She was just a really silly kid. And at the same time as she, you know, became closer to 17, she was a voice of reason for many of her friends. So she went from complete silliness to mature.

So Kimberly was 17 years old. She was a high school student. She was actually 6 weeks away from turning 18. She lived at home with me. She was perfectly healthy. Kim's dream was to be a pediatric nurse. She wanted to follow in my footsteps for nursing, but she really loved kids and she would have been a great pediatric nurse. The role would have been perfect for her.

She called me or texted me one afternoon. This is now in June of 2012. She texted me, she said, “Mommy, I have body aches, and I had a fever but I took some ibuprofen and I am feeling better, but please come home from work soon.”

So I got home. She was perfectly fine. She was skipping and dancing and singing around the house like nothing ever happened. She insisted I call the pediatrician, which I did, and he said, “You know, if these what sound like flu-like symptoms get worse, you know, bring her in tomorrow morning. But just keep an eye on her.”

So when we went to bed that night, she was perfectly fine. And I did ask her all of the questions, you know, is your neck stiff? And, you know, I just went through the whole thing. And no, no, no, no headache, nothing. For some reason, I slept in the bed with her that night. That's not something I typically would do. Is it me?

Okay. So for some reason, I slept in the bed with her. Mother's intuition, I don't know. Wake up the next morning. And things were very, very, very different. Kimberly could barely talk with me. She couldn't lift her head. She couldn't get out of bed. And she said to me, “Mommy, everything hurts me from my eyelashes down to my toes. Everything hurts me. We need to go to the emergency room.”

And then she said to me, “Mommy, I feel like my ankles are bleeding.” And I pull back the sheets and she had petechiae on her ankles. And that was my moment of, “Okay, we're going to the ED. Something's really going on here.”

As soon as we got to the ED, they knew exactly what Kim had. By now, she had a purpuric rash traveling up her entire body. And they knew exactly what she had. They did blood cultures, IV antibiotics. She was in isolation. And all of the doctors were asking her, “Where had you been the last few days?” And she told them, “I went to a concert in Manhattan. I took the Long Island Railroad.” Crowded situation and the concert is crowded.

She said, “I went to my next door neighbor's birthday party.” She had a steady boyfriend at the time. Really nice kid. And, you know, so she trying to figure out—they were trying to figure out obviously contact tracing. And she just said, “Oh, my God, my back hurts so badly.” And we lifted her shirt up and I just literally saw this rash go up from her waistline all the way up, right in front of our eyes. It was horrifying.

So 1 of the doctors pulled me outside of the room and she said, “We suspect that your daughter has bacterial meningitis.” And I said, “It can't be that. My daughter was vaccinated at 11 and 16. I made sure both of my children are up to date on all their vaccines.” And that's when she explained to me that your daughter most likely has serogroup B or meningitis B, and she did assure me that we don't have a vaccine for meningitis B. The meningitis B vaccine became available in the US in 2014.

So I know firsthand the devastation of not having a vaccine available. My daughter died because of this. So things happened very, very quickly with Kim. And, you know, the doctor was explaining everything to me, and I still couldn't wrap my head around the fact how could my daughter have bacterial meningitis when she was vaccinated? Everything was going very quickly. She was brought up to the PICU, and by then she was in multiorgan failure. And she was septic—and in septic shock.

She never urinated again. And they prepared me for the worst. But at the same time, they really had a lot of hope. And so I did. And things went downhill really quickly for her. And she never asked me why she was in the hospital. She just said, “Mommy, why are my cousins here?” And I just said, “They're here to see you. They love you.” And I never told her she had meningitis. She was in the hospital for 9 days.

So there was a lot of talk about should we start dialysis or not? And we all, you know, came to agreement that we should do that. When they started dialysis on her, I want to say it was Day 3. I was actually down in the chapel with my husband, and she went into cardiac arrest, and they resuscitated her within a minute. And then she was placed on a ventilator.

I'm thankful that I didn't witness that or hear the code. And from there, you know, everybody was just monitoring her. We still had hope because she had significant brain activity. But they did tell me because at this point there was severe tissue necrosis, her limbs were black. And they did explain to me that if Kimberly survives this, she will likely be a quadruple amputee.

As a few more days went on, she was also losing blood flow to her brain, and it was determined that she had an impending brain herniation. So I had to make the decision at that point to remove her from life support. My son was in Army basic training. He had to come home. I talked to him every single day because he didn't have a cell phone, and the pediatric intensivist had to call the Red Cross. The Red Cross had to get in touch with the army, and then the army had to locate where my son Chris was, and then he can call me. So we did that for the first 7 or 8 days. And then when it got to be so severe and we didn't have any more hope, then I had to tell him, you need to come home.

So we were all with Kim when she passed and took her off life support. And it was surreal, you know. My daughter was so healthy. How did this happen to her? And I took her to the hospital within 15 hours of her first symptoms. That's how fast this disease goes. So Kimberly was— actually before she went into the hospital, she was looking forward to prom and high school graduation the next week.

So I actually buried her in her prom dress. It had been hanging on her closet door. And of course, this was devastating for the whole family and the community. And since Kimberly died, I created the Kimberly Coffey Foundation, which is located in New York. And through that, I educate and I also offer nursing scholarships for all High school students who are looking to pursue a nursing education. So her name lives on. That makes me very happy. Her legacy continues on.

And then I met another mom who also had a very similar condition with her daughter, a situation with her daughter. Her name is Alicia Stillman. And Alicia lost her daughter Emily to Meningitis B at the age of 19. And Emily had been living in a dorm at a local college in Michigan.

Emily had the same thing, except Emily had severe headache. So in the middle of the night, she asked her suitemates to take her to the ER. And once she got there, they were treating her for meningitis, and they did a craniotomy to try to relieve some of the swelling in her brain. That didn't help, unfortunately. And Emily died within 36 hours of her first headache.

So Alicia and I have worked together, and we created the American Society for Meningitis Prevention, and our daughters are our inspiration to go on with this nonprofit that we have.

[00:32:52]

Posttest 3

Dr Marshall: I think Patti's story is a great example of turning tragedy into triumph. And her daughter and Alicia –

Patti Wukovits: Alicia's daughter, Emily.

Dr Marshall: Alicia's daughter lives on in that way. You know, as I was listening to that story, I was thinking. So this is the dilemma. We have a disease that pretty much occurs 1 in a million. And when you're a public health policymaker, you think do we give every single adolescent a vaccine for a disease that occurs 1 in a million. Right. And how do we trade that off with where else we could put our money or what other things we could prevent.

But at the individual level, at Kimberly's level and Patti, why would you not take the vaccine? Like, what's the reason not to be vaccinated? Costs money and you get a sore arm. Pretty much, right? So anyway, lots more to talk about, I think.

So here's your post-test 3. Which of the following serogroups predominates in adolescents? This is where we're testing you to see if you learned anything. Is it:

1. A;
2. B;
3. C;
4. W; and
5. Y.

[00:35:02]

Posttest 3: Results

And pre is the grey. Pre/post. So okay. Well, post everybody got B. It's a little confusing because one of the lines - one of the columns is orange and the others are grey. But anyway everybody learned that. Wonderful.

[00:35:25]

Posttest 3: Rationale

And - and that is the correct answer. And it's also again the cause of really all of the college outbreaks.

[00:35:32]

Preventing the Worst: The Power of Meningococcal Vaccines

Okay. I'm going to turn it over to Jana, and she's going to talk to us about the - actual the vaccines that we have available for this.

Dr Shaw: Thank you, Gary. And thank you, Patti, for sharing your story. I find it extremely moving. I have 3 children myself and they are young adolescents and adults, so it really touches me deeply. I apologize, I'm a little emotional at the moment.

[00:35:59]

Available Meningococcal Vaccines for Healthy Adolescents

I'm here today to talk about the vaccines. We live in a privileged time where we have access to 6 different meningococcal vaccines. As of 2025, there are 2 ACWY vaccines on the market known as Menveo and MenQuadfi. We have 2 meningococcal B vaccines, Trumenba and Bexsero. And we now have 2 pentavalent vaccines that protect children against serogroups ABCWY known under the product names as Pembraya and Penmemvy.

The ACWY vaccines have age indications down to infancy. MenB and pentavalent vaccines for individuals ages 10 to 25.

[00:36:50]

MenACWY and MenB Vaccines: ACIP Recommendations

ACIP has provided recommendations for use of meningococcal vaccines for the quadrivalent MenACWY vaccine. The routine recommendation is to vaccinate at 11-12 years of age, followed by a booster dose at 16 years of age. There's also indication or recommendation, I should say, for high-risk individuals, where depending on age, those children may need 2-4 doses, followed by additional doses if they are younger than 7 years of age. The follow up booster dose should be given 3 years, and then every 5 years afterwards. For children who are 7 years or older, the boosters are given every 5 years.

For MenB vaccination, vaccines are recommended for children ages 16-23, with a preferred age 16-18, under shared clinical decision-making. There are no boosters recommended. The MenB vaccines are 2-dose series, 0 and 6 months of age.

MenB vaccination has routine recommendation for high-risk individuals. Those vaccines are usually recommended as 3 dose vaccines and also have booster recommendations, with 1 year after completion of dose primary series and then every 2-3 years.

And Gary has already mentioned the high-risk medical conditions that predispose children to more severe meningococcal disease. They include complement deficiencies, biologics that limit complement function, those living with functional or anatomic asplenia and so on.

[00:38:45]

MenACWY and MenB Vaccines: Duration of Protection

So how long do meningococcal vaccines protect children after vaccination? There is somewhat limited data available from the literature. Here, I'm sharing a brief table that summarizes the length of protection and vaccine effectiveness. So that would refer to the real life experience of the vaccines for MenACWY diphtheria toxoid vaccine, which is no longer available on the market.

The protection lasted anywhere from 3 to less than 8 years after vaccination, and the vaccine effectiveness for this vaccine was estimated at 79% within the first years following vaccination, and it declined to 61% 3-7 years following vaccination.

For MenB, we do have a real-world experience from Australia, where they implemented meningococcal B vaccination program for infants and adolescents, and the data shows 92.3 vaccine effectiveness with waning protection a year or 2 after primary vaccination.

[00:39:58]

Pentavalent Meningococcal Vaccines

Let's talk about pentavalent vaccine. So there are 2 pentavalent vaccines currently available on the market. The first 1 was MenACWY tetanus toxoid factor H binding protein vaccine that was approved in 2023, followed by additional approval for MenACWY-CRM and B-4C vaccine in 2025.

The ACIP recommendation is for the use of pentavalent vaccine that allows for use of the vaccine for children who present for vaccination and require MenACWY and B at the same visit under the shared clinical decision-making administration for MenB. And there is a recommendation as well for patients at increased risk for meningococcal disease. Age is 10 years and older.

It's important to note that if you use pentavalent vaccine, you have to follow up with the MenB vaccine from the same manufacturer as the MenB component is not interchangeable.

[00:41:06]

Efficacy of FDA-Approved Pentavalent Meningococcal Vaccines

So pentavalent vaccines have undergone extensive and rigorous clinical program development and testing. So there were large phase III randomized controlled trials for both of the pentavalent vaccine products. There were over 7000 adolescents and young adults ages 10 to 25 years of age across multiple different countries. And those 2 products included in the studies. And the studies did include both MenACWY naive and primed individuals.

The pentavalent arm was compared to MenACWY vaccines and MenB vaccines, with the endpoints being the human serum bactericidal antibodies responses and persistence of immunity and booster responses, along with safety and reactogenicities were included in trials as well.

The efficacy of those clinical trials was measured as inferred from the immunogenicity data. Given the rarity of this disease as such, we cannot really measure the impact on IMD and it’s the immunogenicity that's used to infer protection since the real-world evidence from MenACWY and MenB vaccines supports effectiveness.

Both vaccines were found to be non-inferior to licensed comparator vaccines and showed strong booster responses to both durable immune responses. And both of those vaccines were well tolerated, with no major safety concerns detected during trials.

[00:42:45]

Estimated Vaccination Coverage: Adolescents 13-17 Yr

So how well are we doing vaccinating against a serious disease? We do a pretty good job initiating the MenACWY series in adolescents at the ages 11 to 12. Here you are looking at a line graph from NIST data for adolescents 13 to 17 years of age from 2024. And as you can appreciate, an initiation rate for MenACWY is 86.6%. So that's pretty good. There's still room for improvement, but nearly 9 out of 10 children received this vaccine.

Unfortunately, the vaccination coverage drops to 61.1% for adolescents ages 17. And the numbers when it comes to vaccination coverage are even more discouraging when you look at the MenB vaccination use with 36.9% adolescents only initiating vaccination series and only 16% completing the vaccination series.

And as Dr Marshall mentioned, it's the serogroup B that really creates a substantial or major burden of disease in adolescents, so we do need to do a better job.

[00:44:06]

Meningococcal Vaccination Coverage: Disparities

There are also disparities in vaccination coverage, noted for both MenACWY and MenB, with the lowest uptake in multiracial and other race adolescents. The vaccination acceptance also is lower in older population, as I mentioned, and there are some geographic disparities across the country with higher uptake in states with secondary school mandates.

School vaccine entry requirements have been extremely effective in ensuring that children are properly vaccinated, and 36 states in the United States require MenACWY vaccine for school entry, and as such those states have better protection rates—vaccination rates.

North Dakota came out interesting as a state that is able to vaccinate against MenB with 70% of the individuals or children being vaccinated in that state. So there's certainly - it's doable. And as such, we do need to increase awareness and ensure that all children who are eligible for meningococcal B vaccines receive this vaccine.

[00:45:20]

Meningococcal Vaccine Coverage: Individuals With Increased Risk for Disease

So how are we doing when it comes to protection of those who are at increased risk or highest risk for severe disease, and those are children living with high-risk conditions? And this table summarizes vaccination coverage rates for individuals with asplenia, excluding sickle cell disease, complement component deficiencies, and HIV.

And for the MenACWY vaccine, the coverage ranged anywhere from 4.6% to 28.1%. And for MenB, the numbers are even lower, with 2.2% to 9.7%. So these are really sad numbers. These are individuals that are in particular increased risk for disease and the coverage is extremely low.

[00:46:09]

Revising the Adolescent Meningococcal Vaccine Schedule: Goals

So what can we do to do better? During the June ACIP meeting and also during the February meeting last year, CDC has discussed a desire to revise and modify adolescent meningococcal vaccination schedule with the goal to optimize protection, to take into consideration the ages at higher risk for meningitis. And those are the 16 to 18, 16 to 25 years old. Also taking into consideration recent meningitis epidemiology.

And as Gary mentioned, we have seen increase of meningococcal disease post pandemic. And as such, it's important that we take that into consideration, recognize that this disease might - is dynamic and unpredictable.

In addition, CDC Meningococcal Working Group also discussed the duration of vaccine-induced protection and to optimize the timing of vaccination, and as such, to align the meningococcal vaccine recommendations with the existing adolescent platforms, with the opportunity to incorporate pentavalent vaccines to reduce the number of injections needed and improve compliance and vaccination.

[00:47:31]

Dosing Schedule Options Under Consideration: MenACWY

So last year, starting in February and then the conversation continued in June 2024, the Meningococcal Working Group of CDC has discussed potential changes to meningococcal vaccination program. So I'll walk you through this busy table.

At the top row, you see the current recommendations, with 11, 12 year olds receiving dose 1, and 16-year-old receiving dose 2. And for MenB, the dose 1 being administered at preferred ages 16 to 18 and second dose 2 months later under shared clinical decision-making.

CDC and ACIP have recognized that shared clinical decision-making does not work. Unfortunately, that approach has led to low vaccination uptake, uncertainty and confusion among providers, with many not recommending the vaccine, whether that was because they felt the vaccine may not be important since it doesn't have routine recommendation and is not required for school entry, or simply not understanding how to engage with patients in a conversation.

As such, patient or parents would not hear about availability of MenB vaccine. So we now understand this is not probably the approach to take, and there has been a shift towards recognizing that we need either to use routine or risk-based recommendations when it comes to MenB vaccine.

But let me talk first about the MenACWY potential changes and proposal. You'll see there are 5 policy recommendations. The 1 and 2 continues to recommend or will continue to recommend 11- and 12-year-old dose, as is currently recommended with a dose at 16 years of age. But the policy number 3 and 5 includes consideration for removal of 11- and 12-year-old vaccination.

And I know there are pediatricians in the room, and I'd like to pause here and just maybe ask you to briefly think about what would that mean - for your patients, for your practice, what would that mean for you as providers who have routinely provided this vaccine to 11-year-old, probably with other vaccines that are recommended, essentially have this robust adolescent platform at that age. And what does that mean for you and your practice? And I welcome your comments in the end of the session.

[00:50:09]

Risks of Removing Routine MenACWY Vaccine for Adolescents Aged 11-12 Yr

We have recently published an article that addressed the dangers of removing 11- and 12-year-old MenACWY dose. We included data from a recent modeling study that predicted that there would be 900-plus additional cases and 130-plus deaths over a 10-year period, should the dose be removed.

In addition, we would expect the vaccination initiation rate actually to drop as well, because we know only 60%, 61% of 16-year-olds will complete the vaccination series. So being conservative, you know, the initiation rates probably would not get any better than that knowing that adolescent visits decline after 15 years of age.

In addition, we were concerned how that would erode trust. You know, challenging, long standing recommendation without compelling scientific reason would undermine public and provider confidence in CDC recommendation.

In addition, we know that MenACWY vaccines have impact on colonization, and as such, there is a concern that once you remove the vaccination, you will change the colonization dynamics and we could reverse the progress we have accomplished with MenACWY vaccines.

In addition, if you live in a state where MenACWY vaccines are required for school entry, you know that would create a problem for your practice. It would create a problem for - for children and schools. And that could lead to rescinding existing mandates and potentially leading to lower coverage and also affecting mandates for other vaccines that are required for school entry.

And, of course, you know, always concerns about exacerbation of disparities, loss of insurance coverage for vaccines that are not recommended or removed.

[00:52:14]

Dosing Schedule Options Under Consideration: MenB

So what are the considerations for policy regarding MenB vaccination? And I should mention here that certainly those conversations were held last year. We have not received any additional updates, so it's quite possible that the conversation will change in the upcoming months or years. But this summary really includes what was most active conversation in terms of how adolescent meningococcal vaccination should be revised.

So for the MenB, the considerations were shifting towards including risk-based strategies or simply moving forward with routine vaccination, which, as Gary mentioned already, you know, this is the most common serogroup in this age group. It would really make most sense that that's what we do since we have routine recommendation for MenACWY.

[00:53:17]

MenB Vaccination Among Adolescents: How to Identify Risk Groups and Settings

So there was a lot of conversation regarding who is at risk, when it comes to MenB infection. And as mentioned earlier, those are children who plan to go to college. Those in the first year of college are - have the highest risk. Those engaging in Greek life, living in residence halls, participating in school sports are certainly at increased risk. But there was also a conversation— we recognized meningococcal infection. IMD also occurs in people who are not in college. And as such, making sure that those children have access to vaccination and including permissive recommendation for those who want to be vaccinated is really important.

[00:54:05]

Options for Revising Adolescent Vaccine Schedule: MenB

There was also conversation regarding moving the MenB vaccination to age 15 to ensure coverage during peak incidence in young adulthood. And as I mentioned, there has been a strong consensus to avoid the shared clinical decision-making, given the low uptake, probably due to that recommendation.

[00:54:30]

Introduction of Pentavalent Vaccines: Considerations for Transition

So let me briefly touch upon the pentavalent vaccines. They offer benefit to meningococcal immunization program, since they offer a simplified vaccination schedule. They improve on-time vaccination, and using pentavalent vaccine may reduce missed opportunities since you are giving or providing protection against 5 different serogroups, and as you all know, children that receive fewer vaccine doses and shots than more. As such, this would provide an increased coverage for meningococcal disease and reduces numbers of injections needed. And for parents, that means fewer office visits.

[00:55:19]

Conclusions

So in conclusion, I'd like to summarize that the current ACIP recommendation includes routine vaccination for 11-, 12-year-old and 16-year-old booster for MenACWY vaccines. The MenB vaccine is recommended for high-risk adolescents and - and those healthy teens with under shared clinical decision-making. And the pentavalent vaccine may be used when both MenACWY and B vaccines are indicated at the same visit, and the B component should be followed by MenB vaccine from the same manufacturer 6 months later.

There are significant risks of removing the 11-, 12-year-old dose, and as such, that policy should be discouraged. And vaccination coverage rates need to improve, especially when it comes to completion of the menACWY vaccination series and initiation and completion for MenB vaccination.

As such, there are urgent priorities that should include updating harmonizing the adolescent schedule to incorporate combination vaccine pentavalent vaccine. And we will need to improve our education, both providers, but also parents to make them aware about this disease, severity of the disease and the preventive steps parents can take to protect their children. Thank you.

[00:56:51]

Posttest 4

Dr Marshall: So thank you, Jana. I - I have a couple points I want to follow up on. And then we're going to pretty much base the rest of the program on some panel discussion and then questions from the audience.

But first you need to do the post-test question 4. Healthy adolescent received MenACWY 4-valent at age 11 and is now at their 16-year-old checkup. What meningococcal vaccine schedule would you recommend?

1. Pentavalent now and MenB 6 months later;
2. Pentavalent now and pentavalent 6 months later;
3. 4-valent now and MenB 6 months later; or
4. MenB now and 4-valent 6 months later.

[00:58:08]

Posttest 4: Results

Good. Everybody got the right answer, which is the pentavalent now, which covers your second dose of ACWY and your first dose of B, and then following that 6 months later with the monovalent MenB.

[00:58:28]

Closing the Gap: Strategies to Increase Meningococcal Vaccination in Your Clinical Practice

Just a couple of quick things I wanted to say. Jana told us that shared clinical decision-making for MenB essentially has been a failure because we have 30% for first dose and maybe half of them get the second dose. But is it really—is that the failure like, is the uptake rate the failure? And I would argue that if the goal was 100% uptake, then the recommendation would have been a routine recommendation.

In other words, what's the failure here? And I think my point would be the failure is not having the conversation. So under shared decision-making, a conversation should take place. And that's when the decision is made to vaccinate. But I just want to kind of present that that perspective on this, that it's—you know, we could make the rates much better if we just said every child should get it.

Another thing is, Jana told you about what the proposed possible revisions to the schedule are that were first presented in February of 2024. We've had very little information about what ACIP might be considering going forward. And remember, that was at a time where the ACIP was a different organization than it is now.

So we really have no idea where they're going to go with this. And likewise, you know that now we are seeing a balkanization of immunization recommendations. And we have the Academy coming strong with its recommendations and the vaccine integrity project.

And I don't really have a good sense for where the Academy might be going in terms of its meningitis[?] recommendations.

And 1 last thing. What would be your ideal meningococcal program? I know that's putting you on the spot, but we're friends, so I can do that.

Dr Shaw: So for me, I've always been vocal and open about it. I think it should be to keep the MenACWY at 11 and then follow with penta-penta. It should be the QPP recommendation. It makes most sense. It's essentially quadrivalent vaccine given at 11, 12. We have established platform. It has worked really well for us. It's been safe, effective. And then we have 2 pentavalent vaccines now that - that offer protection for all serogroups. They have been tested in previously MenACWY primed individuals. So the concern over additional antigen is not a concern.

And as such, QPP makes most sense for pediatricians, primary care for providers practices. It simplifies the number of vaccines providers need to carry, avoids the confusion vaccine errors, for example, because now if 1, you know, pediatricians practice carries certain product, they carry different product for B, then you cannot combine them. So QPP would be the simplest, smoothest recommendation and is aligned with FDA licensure.

Dr Marshall: Yeah. And that's a point to make which is the current recommendation which is that option—option A here, right, the pentavalent, and then 6 months later MenB. That's actually - the pentavalent vaccines are licensed as 2-dose schedule. So the recommendation is really differs from what the FDA label is.

What would be—I mean, those of you who are in practice, could probably attest to the problem of having multiple types of vaccines for the same disease. So you have a pentavalent in your refrigerator, you have a quadrivalent in your refrigerator. You know they're going to get mixed up. You know there's going to be problems with keeping the inventory separate and all that. So what would be the problem with a penta, penta-penta or penta-penta-penta schedule?

You know I think the only - I mean that would simplify things. You just need 1 vaccine. But there'd be a few little things about it though. For example, some populations are at risk for ACWY, but not B, like HIV infected individuals. So you'd essentially be there where you don't really need to unless they opt for it.

Also travel. MenB is not recommended for travel but ACWY is. So you get an extra antigen there. But the 1 thing I think we're missing is data on extended intervals between the 2 penta doses. And that's something that I think the manufacturers are working on.

Dr Shaw: Yes. And I think we will still need ACWY for infants because penta is licensed for those 10 through 25. And there are high-risk infants where they will need ACWY plus the triple penta-penta-penta has not been tested as far as I'm aware. And as such, I would be hesitant to advocate for that schedule.

But if we could just simplify it to ACWY-penta-penta, I mean it seems like a no brainer and a victory right there.

Dr Marshall: Yeah, I think we've had other situations where recommendations were so complicated, like adult pneumococcal, where it just was changing every couple of years and different vaccines coming along that, no wonder why people are confused, right?

[01:04:36]

Improving Immunization Rates

We have some time to engage the panel in some of these questions here. I'm going to take the last 1 here, which is, the difference between - you know, parents ask when you say, I think it's time for your vaccine. And they're like, “Well, is it required?” But what do they mean by is it required? Sometimes I think they mean is it recommended? And that is different from it's indication.

So I think it's really important for, you know, to educate parents about what these terms mean. So you know that. The indication means what the FDA has said this vaccine can be used for. The recommendation is what the ACIP or the AAP or the AFP says. We - this is what we think you should do. And then the requirement is really something at the local level. That is what does your state or your college say about whether a student or a attendee at the - at the high school has to have in order to attend that school. So I think it's important to just differentiate those.

Narratives. We heard a narrative that none of us will forget. What narratives should we use in the exam room to convince parents that this would be an important thing to?

Patti, you talk to adolescents all the time. What resonates with them?

Patti Wukovits: I do. You know, scare tactics actually don't work with adolescents. We learned that through some surveys we did with ASMP and engaging with teenagers. All of our resources are for the student, for the child. It's empowerment. You can make it—you know, you can help yourself. You can do it instead of scare tactics. But kids really need to know this as well for the vaccine, because if their healthcare provider doesn't bring it up, they now have that knowledge.

And when I do a talk at my children's local high school every year, and I give out a scholarship, each time I'm educating, I tell Kim's story. I talk about the 3 different vaccines, and I get emails and phone calls the very next day, “Thank you so much. I had no idea there was another vaccine. I thought that when my child fulfilled the requirement for New York State that they were good to go.” So they're all under the false impression because of the requirement that the child is fully protected against all 5 serogroups.

Dr Shaw: And if I may to add, I had a similar experience last year. We admitted a college student who came in for invasive meningococcal disease and the mom was a nurse. And when I asked him, “Is he fully vaccinated?” He was out of state. She said, “No, he's fully protected. He always got all the vaccine. He got the meningitis vaccine.” But when we actually got the record, the child did not get MenB vaccine.

So I'd like to share that story because it highlights that parents, even educated informed, may not know either that there is MenB vaccine and the child is not fully protected or not know about meningococcal vaccines at all. So as such, it's really important to, as providers, to talk about MenB vaccines and to share clinical decision making. I agree with you, Gary. If the provider doesn't initiate a conversation, it doesn't happen. So really the coverage rate is probably a failure of the provider not having really the conversation with the parent.

And speaking of the - also the adolescents and you mentioned that they thank you. We did a study where we ask middle aged, middle school students, how much involvement they want to have in vaccine conversation when they go for - for their well-child visit.

30% of the students told us, “I want to be part of the conversation. I want to be able to make a decision.” And 25% of them said, “Nobody ever asked me anything.” So I think it highlights and supports what you are saying is really - and these were middle schoolers, especially high schoolers. They want that sense that we respect them, that we are here to support them. We are open-minded and we value their opinion. Because my experience really has been that most of the time the teenagers say, I want a vaccine and it's not - it's HPV or other vaccines when they learn about the dangers of the disease.

Dr Marshall: So we - we learned from studies of HPV vaccine in adolescents that taking a presumptive approach seems to work. That is walking into the exam room and saying everything looks good, we've talked about sex, drugs, and rock and roll, and you're ready to go. Before you leave, we're going to give you your HPV vaccine to prevent you from getting cancer, and that approach seems to work. But what do you think about in the case of meningitis? Are there differences? Do you get pushback? Is that the approach that should be taken as opposed to the participatory? You know, this is due today. What do you think about this?

Dr Shaw: Yeah, I think that's an important question, because we have certainly felt and experienced that with COVID vaccines. I personally have not had pushback for meningococcal vaccines. But I certainly appreciate that for some parents, when you walk in and you use the presumptive approach, Johnny is to receive these vaccines that some parents may feel like, wait, wait, wait. You know, don't push it on me. So I think it really comes to knowing your patients. And we had that conversation earlier. It has to be all built on trust.

But certainly using presumptive approach is better than using participatory approach. And then if you experience pushback, skillfully navigate the conversation through motivational interview techniques. Understanding the parents values, fears, concerns is most effective to ensure that the parents in the end decide to vaccinate.

Dr Marshall: So, you know, you showed us data on the uptake rates. So we have 85%, 90% uptake of the first dose of ACWY, and it falls to 60% for the second dose. And if you don't get that second dose, you're not protected when you're 18 or 19. So why does that happen? Why does that fall off? And I guess I'd ask the same question for MenB, we have 30% getting the first dose, but only 15% get a second dose, so only half of them follow through. And that's just a 6.

I mean, I guess the answer to the first 1 is they're only 11, 12 years old. They're just going to do what you tell them, right? Mom, dad's going to just drag them in and they're going to get their shots.

Dr Shaw: Yeah. I think there are several reasons for the 16-year-old dropping. First, kids don't show up. They usually don't have those visits scheduled or the school doesn't require. Most states require, the 11-, 12-year-old and school vaccination requirements are extremely effective in getting children vaccinated. So dropping well visits, kids not showing up, and maybe the vaccine not being required for the second dose significantly, I think contribute to the lower completion rates.

Patti Wukovits: Yeah. So we did a study through ASMP asking pediatricians, you know, why they may not—what was the common reason why you may not have a conversation with your patient about MenB? And the reason was that their patient was not going to college. So we know that's not okay. And then we also asked parents why they didn't get meningitis B vaccination. And for the same reason, because it's not a required vaccination for my students school—for my child's school.

Dr Marshall: You know, a couple other things I just thought about adding. One is we've talked about requirements, school attendance requirements. The way things are going, I think those are not going to last very long.

[01:13:48]

Improving Immunization Rates: MenACWY

So we relied on the school mandates since the measles outbreaks in the late 80s. But I am worried that we're going to see mandates go away. And that's going to put a burden on providers because they're going to have to now explain it's not required. But here's why I think you should do it anyway.

And another along the same lines, none of us love shared clinical decision-making, but I think it's going to be used more in the future. And I think there's a possibility that large parts of the routine childhood schedule could become shared clinical decision-making. And again, that will put a burden back on us.

Patti Wukovits: I have a short story to tell you about shared clinical decision-making. We have an advocate from California whose son was going to college, and she took him for his precollege exam, asked if he was up to date with all of his vaccinations. And yes, he was told that he was by the pediatrician. Pediatrician never mentioned MenB. He went to school and he died from MenB.

So that pediatrician, by not having a shared clinical decision-making conversation, made the decision on his own. It wasn't a shared decision. And when the mom asked him, you know, after everything had happened, you know, why didn't you tell me about MenB vaccination? And the doctor told her, “Well, I do stock it in the refrigerator, I have it, but I only give it if the - if the parent asks for it.” How many parents know about MenB?

Dr Marshall: So that's tragic. But the tragedy in my mind is our failure to clarify and explain what SCDM means. And to the point, when SCDM first sort of rolled out in a big way in 2015, all of those approaches were acceptable within the CDCs explanation of what SCDM is. In other words, a provider might decide, I'm going to give MenB to all my teenagers regardless, or could decide I'm not going to give it to any of them, or I'll give it to the ones who ask, or I'll have the conversation with the ones I know are going to college. All of that was technically correct according to when it first came out, and that was part of the problem. That's why people were so confused.

And we made a point early on in a letter to pediatrics saying, no, it means you have to have the conversation. But I don't know that CDC ever got to that language saying that conversation is mandatory.

Dr Shaw: You know, and my concern also is that the shared clinical decision-making sends a message to pediatricians. It's not that important. So you decide.

Dr Marshall: And to parents, right?

Dr Shaw: And to parents.

Dr Marshall: Right.

Patti Wukovits: My kid's doesn't need it for requirement for school, then I don't want it.

Dr Marshall: Right. So what explains the 30% initiation of MenB? And half of them don't get the second dose, which is 6 months later. What explains that? There obviously those 30% are motivated. They're like, sure, I'll take that. And I'm sure they're told when they come in you need to come back for a second dose. Half of them don't get it.

Dr Shaw: Yeah. And I think it's just a failure of best practices. Probably first kids not showing up. We are not tracking them. We are not sending reminders. We are not prepping charts when we are prepping for the visit, noticing that actually the child needs second dose. Using every visit as an opportunity to vaccinate. So I think this is—because you are right, 30% of those really agree to getting vaccinated. So they certainly are aware and they want the protection, unless there is a small proportion who experience local reaction and he said never again.

I think it's more of a failure of the providers and then just being realistic about access to care and maybe to visit is not convenient for the parent when they are available. And as such, they - they miss - miss the dose and then they forget.

Dr Marshall: Do you think they understand that 1 dose doesn't protect them? I wonder how explicit providers are when they give that first dose.

Dr Shaw: I don't think they know.

Dr Marshall: You know, because I'd have to believe if - if they're a motivated family and they know 1 dose is not enough, that they would get the second dose. So I think it's - it's - it's really a dilemma.

[01:18:44]

Take-home Strategies to Improve Immunization Rates

So okay, we've talked a lot about improving immunization rates. And these are sort of take-home points for strategies. And Jana mentioned this, you know, using every opportunity that you have to give the vaccines, even acute care visits, even here because I sprained my ankle but I'm going back to high school, you know, in the fall. Implement a presumptive approach and discuss vaccination, including MenB with every eligible patient. And you're eligible for MenB if you're 16 to 18 years old.

[01:19:25]

Addressing Vaccine Hesitancy

So I think, we won't really talk about vaccine hesitancy. That's another entire program. But you know that vaccine hesitancy has increased markedly, and now it's become political. And I don't get the feeling with meningococcal that it's the same kinds of hesitancy issues that you see from the other vaccines, like, you know, the infant vaccines where they're worried about autism and things like that. I don't see that with meningitis.

Dr Shaw: I agree, I think and we know vaccine hesitancy is vaccine and context specific. And as such, thankfully for meningococcal vaccination, the challenge is providers recognizing the importance of the vaccination and routine and recommending MenB vaccination. So the challenge with under vaccination for meningococcal disease is lack of awareness and best practices to ensure that all kids are fully protected. And as such, there is hope because those changes can take place in a practice, but it will take commitment and effort at individual practice or healthcare system level. Whether it's developing encounter plans, we check off boxes when kids show up for well visits and follow ups. Anything, but there has to be a concerted effort and commitment on the provider side to ensure that we do better.

[01:21:10]

Q&A

Dr Marshall: Yeah. Yeah, I agree. So we have a few minutes left for some of the audience questions, and these are all really good questions. Some of them pretty quick. So is there a preference - is there a preference between the 2 MenB vaccines? No.

Dr Shaw: No.

Dr Marshall: No, there's no preference. They have the exact same dosing schedules now, zero and 6 for healthy and 0, 1 to 2 and 6 for immunocompromised or high-risk, or I need the vaccine quickly before I go to school. So there is no preference by any organization between the 2 vaccines.

So I work at a university, and the hurdle we face is that the MenB vaccine is $200, and it may not be covered by insurance. Well, here's - here's where we didn't talk about insurance coverage and VFC coverage. But if a vaccine is recommended by ACIP, either routine or SCDM, then it is a mandated that insurance covers it. And it is - it is usually follows that VFC will pay for it.

In other words, it's a separate - it's a separate decision by ACIP to add the vaccine to VFC. But they always do that if they have recommended it in routine or shared decision-making. So this is the thing. Some college students are 19, right? And by the time they're 19, they're - they're not eligible for VFC. So I think this is more reason to vaccinate them before they get to college, not when they're in college.

This is not a question, but it's a comment. One of the folks in the - in the audience. I don't know if it's a virtual audience or in person. Heard the story of Rayna DuBose. I don't know if any of you have ever heard - heard that. But I - I have seen her speak. So she was a star high school basketball player that was recruited to Virginia Tech, and then developed IM - IMD right before she matriculated, I think. And she lost all 4 limbs. She survived. But this is a person who was going to have a career in basketball and then lost her arms and legs.

I saw her speak, and she actually has some very effective prostheses which allow her to walk and kind of use her arms. Yeah.

Speaker: I'd like to preach to the choir for just 1 second.

Dr Marshall: Sure, do you want to?

Speaker: I think I'm the only one that has a 50-year tag on here. All of you advocate for vaccines. I'm passionate about vaccines. My aunt died at 15 months of diphtheria in 1908. In the 50s, growing up, I had a friend 1 year older, another 1, 2 and 3 years younger that got polio during the - the 50s. My best friend at 10 fell off the porch onto a rosebush and got impaled. And because the money was tight for the family, they hadn't spent the $3 to $5 to get tetanus shots. He died of - of tetanus. I went to medical school in the 70s and did my training in the mid-70s and the like. During the training, I don't think there was a week went by that we didn't have a HIB patient in the hospital. We were a referral center and so we got them from all around.

I'm very good still at doing LPs. You did one to diagnose them. You did one 24-48 hours after being on antibiotics, and you did one if they - it was a debate. Do you do it at the end of the treatment, or do you wait till they bit off antibiotics 2 days and do one? But I did a whole lot of LPs and I can still do an LP with my eyes closed.

Pneumococcal infections, septicemia. It was common back then. We had to go to the autopsies of all of the kids, our patients that died, and when they took off the brain, the skull. You can always tell which is pneumococcal because it looked like vanilla pudding was poured on their heads. And so I've seen the advantages.

I think I've had 4 or 5 kids with meningitis, I couldn't – meningococcal. I couldn't tell you if they were A or B. Every one of them I diagnosed either in the office or in the emergency room. And when I had them, when they draw the blood, get the blood culture and start the antibiotics right now before I did the LP and they were like, your daughter, they all died, Oh, with starting the antibiotics instantly, they're - not mine lasted as many days, probably 20 - within 24 hours sometimes with just a few hours they were gone.

My heart is sad. What's happening now? Our kids are going to - to die. My hometown where I grew up is 40 miles from Gaines County, where we just had the - the measles outbreak and the - the like. These kids don't have to die. They don't have to get their arms amputated. They don't have to get any of these things. We have vaccines. And I hope some of y'all will start - I hate the new AAP policy on ethics and the like. We're supposed to be dispassionate about our patients. I'm sorry. I've practiced the last 40 years in Aspen, Colorado. I have an intimate relationship with my patients.

And when we do a shared decision-making, which I think I do, but I think it's a bunch of hooey. I recommend things because with all my heart, I believe it. I want to do what's best for my patient. Several times when there's been a John Doe in the hospital in the ER with a unconscious and the like, I come in and go, well, that's Joey Jones there. I don't need his ID. I know who he is. And so when I'm telling him, I recommend you get this, it's out of love and conviction.

Dr Marshall: I think this highlights a difference in how we train doctors. So in the old days, doctors - and I'm not defending paternalism, but Marcus Welby told you what you needed, and you did it. But we train doctors now to be partners in care with the patient, which sometimes is called a client. And I feel like the younger doctors do not feel empowered to take a strong stand. And I really think that's - that's a problem. But anyway, I appreciate your - your testimonial there.

I think we - we are almost at close. A couple really quick answers to questions. Could you use the pentavalent vaccine for a high risk child under 10? No. Not labeled. Also, MenB not labeled. And that's a problem. And I don't know if you're doing this, but like, if you had an asplenic who was 5 years old. Some places are giving them MenB off-label, but we're not doing it.

And then wouldn't the effect of the immunogenicity of B diminish when you combine it with the other antigens? The answer to that is no, because that's what was studied. I mean, that's - that's the biologics license application that was given to the FDA said, “Look, we compared the penta to the separate vaccines and the antibody titers, and the sero response rates were the same. So those are just a couple of the quick - we can't really get to all of these questions.

[01:29:27]

Posttest 1

But before we close, we need to do the post test questions. So post-test one. I have effective strategies for counseling adolescents and their caregivers about the risk and complications of IMD.

1. Strongly agree;
2. Disagree;
3. Neither agree nor disagree;
4. Agree;
5. Strongly agree.

You better have effective strategies after having listened to us for an hour and a half. Okay.

[01:30:07]

Posttest 1: Results

So I think most people agree or strongly agree that they do have now effective strategies.

[01:30:18]

Posttest 2

Post test 2. I have effective strategies to overcome barriers to meningococcal vaccination in adolescents and young adults.

1. Strongly agree; all the way through to E - sorry, A is strongly disagree. E is strongly agree.

So do you have effective strategies to overcome the barriers.

[01:30:56]

Posttest 2: Results

Okay. Good. Again, there's been movement toward having strategies that you can deploy in your offices.

[01:31:09]

Poll 5

And do we need to do this poll?

Speaker: Nah.

Dr Marshall: We're done - are we done with this? Okay. Any other, you know, questions, comments, anything to share with the - with the group? I really appreciate you all sticking it out and - yes.

Speaker: I'm from upstate New York. Thank you for sharing your story and for a great discussion. It's a complex issue, as we found out during the presentation before. Physicians do have the responsibility to educate, but we also realize at the end of the discussion and - I didn't think I needed it, but - but we also realize that there are other issues that create that lack of vaccination is requirement by the schools, shared decision-making. We identified it as that has to play. And parents say, “Hey, if it's not required, I see it all the time. We are not getting it.”

And the cost is - is an issue. Even though I heard from the panel that, you know, ACIP recommendation and the insurances cover it. Seven out of 10 times in western New York, where I practice, if we give a MenB vaccine, 7 out of 10 times private insurances don't cover it, even though it's an ACIP recommendation. So parents pay out of pocket. So that's where the hesitancy.

So even though we are one country, we all know state to state coverage varies. So in an ideal condition and world, we will have unified vaccine coverage for all the vaccines. And all districts and across the states will be similar. So that's our hope.

I don't understand that. And I wonder if there's anyone here who could - could maybe shed some light on this. I thought that under the Affordable Care Act, which is still the law of the land, insurance companies are mandated to pay first dollar, no cost to the patient for recommended vaccines. How does an insurance company get away with not paying for it?

Does anybody have any insight into that? Any - any of our –

Speaker: That's not the case where I am in rural western New York. There's still quite a bit of the time parents do end up paying for MenB, even if the kids go to.

Dr Marshall: Any - any - anybody here, you know, from industry that maybe might have some knowledge about this, but I - I - I don't understand that.

Speaker: [Inaudible] Medicaid covers it.

Dr Marshall: Yeah. Okay. Well, that's news to me.

Dr Shaw: Yeah. Tariq[?], maybe we can connect because, you know, I'm in central New York and upstate New York, North Country, and we have not had that issue. So I wonder - and we do have private patients as well. So maybe you and I can connect and look into it together.

Dr Marshall: Yeah.

Dr Shaw: Because it's - it's unusual. I agree.

Dr Marshall: Thank you for bringing that up, though.

Dr Shaw: Yes.

Dr Marshall: Any other comments? Okay. Well, thank you all for your attention.

Patti Wukovits: Thank you.

[END OF TRANSCRIPT]