Preventing Meningococcal Disease in US Adolescents and Young Adults Through Vaccination

Abstract

In 2022, experts convened under the name Advancing Strategies to Prevent Meningococcal Disease (ARTEMIS) to gather insights on issues related to invasive meningococcal disease (IMD) and meningococcal vaccination in the US. Discussions regarding successes, challenges, and future directions for the US meningococcal vaccination program are summarized. Current vaccination recommendations target adolescents/young adults (AYA), who are at increased risk of IMD. Suboptimal vaccination rates, particularly for meningococcal serogroup B disease, may stem from gaps in knowledge surrounding IMD and meningococcal vaccination among healthcare providers (HCPs), parents, and AYA; confusion among HCPs regarding the shared clinical decision-making recommendation for serogroup B vaccinations; demographic variables; and lack of preventive healthcare visits. ARTEMIS proposed strategies to address knowledge gaps and access barriers at the HCP, parent/AYA, and educational institution/policymaker levels. Alternative vaccination schedules using a recently approved MenABCWY vaccine that provides protection against all five major serogroups may simplify meningococcal vaccination and increase coverage.

Plain Language Summary

In 2022, a group of experts under the name of Advancing Strategies To Prevent Meningococcal Disease (ARTEMIS) was formed to address invasive meningococcal disease (IMD) and meningococcal vaccination in the United States. They reviewed the successes, challenges, and future directions of the US meningococcal vaccination program, which mainly targets young people (adolescents and young adults), who are at higher risk of IMD. Even though many vaccines are available, rates of vaccination are still too low, especially for the type of IMD caused by meningococcal type B bacteria. This is partly because many healthcare providers, parents, and young people do not have full knowledge and awareness about the disease and the vaccines. Healthcare providers may also be unsure about vaccination guidelines and when and how to discuss vaccination with patients (i.e., shared clinical decision-making). In addition, young people often do not have regular preventive healthcare visits during which vaccines could be recommended and administered. ARTEMIS suggested several solutions to these problems, including better education on IMD and vaccines for healthcare providers, parents, and young people and changes to public health policies. They also suggested using a new kind of vaccine called MenABCWY, which protects against the five major types of meningococcal bacteria that cause IMD. The use of MenABCWY vaccines could make vaccination simpler and increase the number of people who get vaccinated.

Key Summary Points

Advancing Strategies to Prevent Meningococcal Disease (ARTEMIS) convened experts to discuss successes, challenges, and future directions on issues related to invasive meningococcal disease (IMD) and meningococcal vaccination in the United States.

Vaccination rates remain low among adolescents and young adults, who are at increased risk for IMD.

Drivers of suboptimal vaccination rates include knowledge gaps about IMD and meningococcal vaccination among health care providers (HCPs), parents, adolescents and young adults; demographic factors; and limited access or lack of preventive healthcare visits.

Confusion among HCPs regarding the shared clinical decision-making recommendation for meningococcal serogroup B vaccination may also contribute to suboptimal vaccination rates.

Several strategies are proposed to address knowledge gaps and eliminate or reduce barriers, including introducing alternative vaccination schedules using the recently approved vaccine for serogroups A, B, C, W, and Y.

Introduction

In 2022, a group of experts was convened under the name Advancing Strategies to Prevent Meningococcal Disease (ARTEMIS) to gather insights on key issues related to invasive meningococcal disease (IMD) and meningococcal vaccination in the United States. Members of ARTEMIS have diverse professional backgrounds and experience in clinical infectious diseases, public health, and vaccine development, providing a rich background for discussion of IMD and its sequelae, implementation of vaccination programs, and the evolving immunization landscape at the personal, regional, and national levels. The goal of the group was to review the current educational gaps and barriers to meningococcal vaccination in the United States, identify opportunities to address educational gaps, and overcome barriers to vaccination to increase meningococcal vaccine uptake. This report summarizes key points from ARTEMIS discussions spanning two years that considered historical successes and challenges of the US meningococcal vaccination program and deliberated on directions for the future. This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Epidemiology and Clinical Challenges of Meningococcal Disease

Neisseria meningitidis, the cause of IMD, is classified into 12 serogroups on the basis of its capsular polysaccharide structure [1]. Nearly all IMD worldwide is caused by serogroups A, B, C, W, and Y [2]. US Centers for Disease Control and Prevention (CDC) surveillance data showed that annual population-wide IMD incidence was 0.10–0.11 per 100,000 individuals during 2017 to 2019 [3, 4–5]. Serogroup B accounted for 26% to 38% of all IMD cases, whereas serogroups C, W, and Y were collectively responsible for 41% to 51% of cases [3, 4–5]. There were six serogroup E cases and no serogroup A cases; for the remaining cases, the serogroup was unknown or the isolate was non-groupable [3, 4–5].

The highest incidence of IMD is observed in infants and young children, with a secondary peak in adolescents and young adults (AYA) [2]. CDC surveillance from 2017–2019 showed that annual IMD incidence among AYA 16–23 years of age was 0.10–0.20 per 100,000 compared with ≤ 0.09 per 100,000 among those 11–15 or 24–44 years of age [3, 4–5]. College students 18–24 years of age were at particular risk, with incidence rates 1.6–3.1 times greater than rates observed among individuals in the same age group who were not attending college [3, 4–5]. Although the incidence of IMD has generally declined in the United States over the past few decades [6, 7], reaching trough levels during the COVID-19 pandemic in 2020 (235 cases) and 2021 (208 cases), case numbers began to increase in 2022 (312 cases) [8, 9–10]. More recent data from after the ARTEMIS meeting confirm this upward trend, with 438 and 477 cases reported in 2023 and 2024, respectively [11]. Additionally, 14 outbreaks occurred at university campuses from 2011 through March 2019, involving an at-risk student population of about 253,000 across 13 campuses; all of these outbreaks were caused by serogroup B [12]. More recently, a serogroup C outbreak occurring between 2021 and 2023 among gay and bisexual men in Florida has been linked to at least 24 cases and six deaths [13, 14]. Between June 2022 and February 2025, 41 cases of serogroup Y IMD were reported in Virginia, resulting in eight deaths [15].

Although incidence is very low, meningococcal vaccination programs are justified because of the unpredictability, high mortality rate, and considerable burden of sequelae in survivors associated with IMD [16]. The most common clinical manifestations of IMD are meningitis, septicemia, or a combination thereof, but IMD may also present as pneumonia or septic arthritis [17, 18]. Worthy of particular attention is the nonspecific nature of initial IMD symptoms, which makes it difficult to recognize the disease; this, in addition to the extremely rapid disease progression, contributes to the high case fatality rate (CFR) [19]. The CFR across all ages is estimated at 8.3% and increases to > 30% among elderly adults [20]; CFRs for meningococcal meningitis may be as high as 50% in the absence of treatment [21]. In addition to fatal outcomes, approximately 20% of survivors experience long-term physical sequelae, including hearing loss and amputation; psychological (e.g., anxiety) and cognitive (e.g., learning difficulties) sequelae are also common [22, 23]. Specific sequelae reported in a study of 391 survivors of serogroup B IMD included deafness (7.2%), skin scarring (6.4%), amputation (3.8%), neurologic sequelae (3.6%), seizures (2.6%), and renal dysfunction (2.0%) [22]. A study of 76 survivors of meningococcal meningitis and 72 healthy individuals reported cognitive impairment in 28% of the survivors compared with 6% of the controls [24]. A matched cohort study involving adolescents 15–19 years of age found that more than half of survivors had major physical sequelae at 18–36 months after infection, including skin scarring (18% of survivors), mobility problems (13%), and speech issues (13%) [25]. Additionally, survivors had poorer mental health (lower life stress-adjusted United Kingdom Short Form 36 Health Survey, version II mental health component scores compared with age- and gender-matched controls, coefficient: – 8.8 [95% CI – 16.2, – 1.5]; P = 0.02), quality of life (self-rated on a Likert scale compared with baseline, – 0.10 among survivors versus 0.96 among controls; P < 0.0001), and poorer educational achievement (survivors achieved an average 8 ± 2.6 General Certificate of Secondary Education examination passes versus 9 ± 2.8 in the control group; P = 0.02) [25]. Studies show that IMD survivors without physical sequelae also experience reduced quality of life several years after infection [23]. The negative psychological effects of IMD are also experienced by family members and caregivers; for example, parents can suffer post-traumatic disorder-like and depressive symptoms in both the acute phase of IMD and in the long term [26].

In addition to being disruptive at the community level and personally devastating to infected individuals, outbreaks can be expensive: it was estimated that the total cost is as much as $1.8 million per IMD case [27]. The true economic burden of an outbreak is likely to be higher when additional indirect costs, such as lost wages and societal factors, are included [26]. Additionally, cost-effectiveness analyses and public health policy often fail to consider substantial neglected burdens of IMD, such as psychological stress, legal burdens (e.g., cost of hiring lawyers for malpractice lawsuits), fear of IMD, and social crisis management [26].

Meningococcal Vaccines and Vaccination Recommendations in the United States

Meningococcal vaccines currently available in the United States are listed in Table 1, with additional details regarding dates of vaccine availability presented in Fig. 1. In addition to the two currently available quadrivalent protein-polysaccharide conjugate vaccines directed against serogroups A, C, W, and Y (MenACWY vaccines; one using diphtheria CRM₁₉₇ as a carrier protein [MenACWY-CRM; Menveo^®, GSK Vaccines, Srl, Bellaria-Rosia, Sovicille, Italy] and one using tetanus toxoid [TT] as a carrier protein [MenACYW-TT^®; MenQuadfi^®, Sanofi Pasteur Inc, Swiftwater, PA, USA]), a third MenACWY vaccine, MenACWY-D (Menactra^®; Sanofi Pasteur Inc., Swiftwater, PA, USA) was previously licensed in the United States but was discontinued in 2022 [28, 29–30]. MenACWY-TT (Nimenrix^®; Pfizer Europe MA EEIG, Brussels, Belgium), another MenACWY vaccine with a TT carrier protein formulation similar to that of MenACYW-TT, is licensed in more than 80 countries outside of the United States [31]. Two monovalent vaccines that protect against serogroup B (MenB vaccines) are currently licensed in the United States: MenB-fHbp (Trumenba^®; Wyeth Pharmaceuticals LLC, a subsidiary of Pfizer Inc, Philadelphia, PA, USA) and 4CMenB (Bexsero^®; GlaxoSmithKline, Research Triangle Park, NC, USA); both use surface-exposed proteins as antigens because the polysaccharide for serogroup B is poorly immunogenic [28, 29]. In 2023, the first-in-class pentavalent MenABCWY vaccine developed by Pfizer (Penbraya^®; Pfizer Ireland Pharmaceuticals, Cork, Ireland), which combines components from MenACWY-TT and MenB-fHbp, received approval in the United States for prevention of IMD caused by serogroups A, B, C, W, and Y [32, 33]. More recently, another MenABCWY vaccine developed by GSK (Penmenvy™, GSK Vaccines, Srl, Bellaria-Rosia, Sovicille, Italy), which combines components from MenACWY-CRM and 4CMenB, was licensed in 2025 for the same indication [34, 35].

Table 1. Meningococcal vaccines currently available and licensed in the United States

Serogroup(s) vaccine	Trade name	Manufacturer	Description	Year licensed	Approved ages
ACWY
MenACWY-CRM [104]	Menveo	GSK Vaccines, Srl	Serogroup A, C, W, and Y capsular polysaccharides individually conjugated to CRM197 carrier protein	2010	2 months to 55 years
MenACYW-TT [105]	MenQuadfi	Sanofi Pasteur Inc	Serogroup A, C, W, and Y capsular polysaccharides individually conjugated to tetanus toxoid carrier protein	2020	≥ 2 years
B
MenB-fHbp [106]	Trumenba	Pfizer Inc	Recombinant lipidated factor H binding proteins from subfamily A (variant A05) and subfamily B (variant B01)	2014	10–25 years
4CMenB [107, 108]	Bexsero	GSK Vaccines, Srl	Recombinant Neisseria adhesin A protein (peptide 8 variant 2/3), neisserial heparin binding antigen protein (peptide 2), and nonlipidated subfamily B factor H binding protein (variant B24); outer membrane vesicles	2015	10–25 years
ABCWY
Pfizer MenABCWY vaccine [32, 109]	Penbraya	Pfizer Ireland Pharmaceuticals	Includes components from MenACWY-TT (serogroup A, C, W, and Y capsular polysaccharides individually conjugated to tetanus toxoid carrier protein) and MenB-fHbp (serogroup B recombinant lipidated factor H binding proteins from subfamily A [variant A05] and subfamily B [variant B01])	2023	10–25 years
GSK MenABCWY vaccine [34, 35]	Penmenvy	GSK Vaccines, Srl	Includes components from MenACWY-CRM (serogroup A, C, W, and Y capsular polysaccharides individually conjugated to CRM197 carrier protein) and 4CMenB (serogroup B recombinant Neisseria adhesin A protein [peptide 8 variant 2/3], neisserial heparin binding antigen protein [peptide 2], and nonlipidated subfamily B factor H binding protein [variant B24]; outer membrane vesicles)	2025	10–25 years

[See PDF for image]

Fig. 1

Timeline of AYA meningococcal vaccination licensure and recommendations in the United States: 2005–2025 [29, 33, 35, 36, 37, 38–39, 41, 102, 103]. ACIP US Advisory Committee on Immunization Practices, AYA adolescents and young adults, FDA US Food and Drug Administration, GSK MenABCWY vaccine meningococcal serogroups A, B, C, W, and Y vaccine based on components from MenACWY-CRM and 4CMenB (Penmenvy®), MenACWY meningococcal serogroups A, C, W, and Y polysaccharide conjugate vaccine, MenACWY-CRM diphtheria CRM₁₉₇-conjugated MenACWY vaccine (Menveo®), MenACWY-D diphtheria toxoid-conjugated MenACWY vaccine (Menactra®), MenACYW-TT tetanus toxoid-conjugated MenACWY vaccine (MenQuadfi®), MenB meningococcal serogroup B vaccine, MenB-fHbp MenB factor H binding protein vaccine (Trumenba®), Pfizer MenABCWYvaccine meningococcal serogroups A, B, C, W, and Y vaccine based on components from MenACWY-TT (tetanus toxoid-conjugated MenACWY vaccine [Nimenrix®]) and MenB-fHbp (Penbraya®), 4CMenB 4-component MenB vaccine (Bexsero®), y years of age

In 2005, the US Advisory Committee on Immunization Practices (ACIP) recommended a single MenACWY vaccine dose for all adolescents 11–12 years of age (Fig. 1) based on the need to increase the importance of the preadolescent healthcare visit and to increase vaccination coverage during adolescence [36]. In 2010, a MenACWY booster was recommended at age 16 years based on data showing waning immunity after the first dose [37]. The effectiveness of MenACWY vaccines at the population level has been demonstrated by surveillance data indicating that the incidence of IMD due to serogroups C, W, or Y among vaccine-eligible adolescents 11–15 years of age declined by 67.0% compared with the prevaccine period following the 2005 MenACWY primary dose recommendation, and by 88.8% following the 2010 MenACWY booster dose recommendation [6]. Incidence of IMD due to serogroups C, W, or Y in individuals 16–22 years of age also declined by 77.2% during the post-booster period [6].

In 2015, ACIP recommended a MenB vaccine series for individuals 16–23 years of age (preferred age, 16‒18 years) subject to shared clinical decision-making (SCDM; called a Category B recommendation at the time) [38]. Universal MenB vaccination was not recommended for several reasons, including low incidence of disease, limited data regarding the duration of protection, unknown effects on carriage and herd protection, and uncertainty about strain coverage; ACIP also noted the high cost of routine vaccination against meningococcal serogroup B per quality-adjusted life-year [38].

Individuals ≥ 2 months of age with a high-risk condition for IMD, such as HIV infection, anatomic or functional asplenia, or complement deficiency, are recommended to receive routine MenACWY vaccination [39, 40]. MenACWY vaccination is also recommended for travelers to high-risk areas [39, 40]. MenB vaccination is recommended for individuals ≥ 10 years of age with asplenia, complement deficiency, or outbreak or laboratory exposure [39, 40].

In October 2023, ACIP recommended that the Pfizer MenABCWY vaccine may be used when a MenB and a MenACWY vaccine are indicated at the same healthcare visit [41]. The recommendation applies to healthy individuals 16–23 years of age when SCDM favors administration of a MenB vaccine, and to individuals ≥ 10 years of age who are at increased risk of IMD [41]. We understand that, as of April 2025, the ACIP is formalizing similar recommendations for use of the GSK MenABCWY vaccine [42, 43]. Because MenB vaccines are not interchangeable, use of the Pfizer MenABCWY vaccine in this way should be followed by a dose of MenB-fHbp to complete the MenB vaccine series [40].

Meningococcal Vaccination Coverage

According to 2022 survey data, 89% of adolescents 13–17 years of age had received ≥ 1 dose of MenACWY; however, only 61% of those 17 years of age had received ≥ 2 MenACWY doses, 29% had received ≥ 1 MenB vaccine dose, and 12% had received ≥ 2 MenB vaccine doses, indicating that many AYA remain vulnerable to IMD [44]. The same survey found a decrease in coverage for ≥ 1 MenACWY dose among individuals born in 2008 (i.e., 11 and 12 years old in 2019 and 2020, respectively, and thus eligible for MenACWY vaccination), suggesting that medical care disruptions during the COVID-19 pandemic resulted in lower vaccine coverage [44]. Additionally, parental hesitancy surrounding pediatric COVID-19 vaccines during the pandemic may have reduced parents’ confidence in routine childhood vaccines, with data showing notable increases from April 2020 to March 2022 in the percentages of parents who agreed that routine childhood vaccines “may lead to illness or death” (13.2% increase) and “have many known harmful side effects” (6.1% increase) [45].

Challenges with Meningococcal Vaccination

Knowledge Gaps in IMD and Meningococcal Vaccination

Multiple knowledge gaps exist among healthcare providers (HCPs) in terms of awareness of IMD, serogroup epidemiology, vaccination recommendations, and insurance reimbursement. In a survey that included 407 US physicians (of whom 385 were MenACWY vaccinators and 391 were MenB vaccinators), 50% were not aware that serogroup B was responsible for the highest proportion of cases among AYA in the United States, 18% were not aware that MenACWY vaccination was routinely recommended, and 54% were not aware that MenB vaccination was recommended under the SCDM framework [46]. Furthermore, 45% of pediatricians and 58% of family physicians were unaware that the Vaccines for Children (VFC) program and private insurance cover both routine and SCDM-recommended vaccines [47]. Relatedly, another study found that financial considerations were the main reason why HCPs did not prescribe either MenACWY (7% of HCPs) or MenB (8% of HCPs) vaccines [48]. For high-risk populations in particular (e.g., people with HIV or asplenia), low meningococcal vaccination rates [49, 50] indicate a need to educate HCPs about routine recommendations and ensure healthcare access for vulnerable patients. Specifically, only 16.3% of MenACWY vaccine-eligible individuals diagnosed with HIV within a commercially insured population were estimated to have received ≥ 1 dose of the MenACWY vaccine by 24 months after HIV diagnosis [49]. Additionally, only 28.1% and 9.7% of commercially insured patients diagnosed with asplenia were reported to have received ≥ 1 dose of MenACWY and MenB vaccines, respectively, in the 3 years after diagnosis [50].

Knowledge gaps among parents were highlighted by a survey showing that nearly one-quarter of parents of US adolescents were not aware that vaccines against IMD were available, and a majority had not heard of specific MenACWY and MenB vaccines [51]. However, once made aware of vaccine availability, most parents were willing to vaccinate their adolescent with MenACWY (91%) and MenB (90%) vaccines [51]. In addition to lack of awareness, parents may not vaccinate their child against meningococcal serogroup B in the absence of an HCP recommendation [52], with another survey finding that parents were 4.8 times more likely to vaccinate their adolescent with a MenB vaccine when it was recommended by an HCP [53].

Knowledge gaps in IMD and vaccines also exist among AYA. A study conducted at a US university that experienced a meningococcal serogroup B disease outbreak in 2013–2014 found that 20 months after the outbreak, only 32% of the 195 surveyed students expressed a high level of confidence in their knowledge of IMD; 32% felt very confident about their knowledge of MenB vaccine [54]. Nevertheless, an overwhelming 95% of the students surveyed stated that they would recommend the MenB vaccine [54]. Another study among students at a Canadian university where a meningococcal serogroup B disease outbreak took place showed that although university students generally had good knowledge about IMD and MenB vaccines, knowledge about different meningococcal serogroups was low [55].

SCDM for MenB Vaccination

Although the SCDM recommendation for MenB vaccination imparts the important advantage of cost coverage by private insurance and VFC [56, 57], there is a lack of clarity surrounding its implementation. As stated by ACIP, the default decision for routine, catch-up, and risk-based recommendations is to vaccinate [56]. By contrast, colloquial interpretations of SCDM recommendations vary from the default decision not to offer the vaccine to the default decision to advocate for vaccination with all eligible patients, as well as many intermediate positions (e.g., having the conversation but not advocating for vaccination) [48, 58]. Regardless of interpretation, it is clear that the perceived strength of the MenB vaccine recommendation is less than that of routine vaccinations, and given competing needs to address other important health issues at preventive care visits and the lack of school entry vaccination requirements, HCPs often forego SCDM conversations around MenB vaccination, relegating the discussion to parent/patient initiation [46, 48, 52, 58, 59–60].

Healthcare providers may find the SCDM recommendations for MenB vaccines confusing, and the language may be perceived as complex and self-contradictory. For example, ACIP states that “[i]t’s up to the provider” to decide which patients to discuss SCDM recommendations with, further noting that “[s]ome health care providers may choose to discuss immunizations recommended for shared clinical decision-making with all or most of their patients who could receive it, while some providers may be more selective…” [56]. However, ACIP also states that “[SCDM] recommendations are…informed by a decision process between the health care provider and the patient or parent/guardian” [56] and various models for SCDM delineate that the decision whether or not to vaccinate should be based on a discussion between the HCP and patient/family about vaccination risks and benefits and the patient’s values and preferences, among other factors [52, 61]. Thus, if a provider decides not to have the conversation, as per the first quoted ACIP statement, how can the SCDM recommendation be fulfilled [61, 62].

Disparities in Meningococcal Vaccination Rates

Disparities in meningococcal vaccination rates have been identified among AYA. For example, MenACWY coverage rates among adolescents 13–17 years of age are typically lowest in states without school entry requirements (e.g., Colorado, Oregon, Tennessee, Mississippi) [60, 63]. There also are differences in coverage at the county level within states: for example, data from the Indiana Immunization Information System (https://chirp.in.gov/main.jsp) indicates that coverage for the first MenB vaccine dose ranges from 12% to 69% across the 92 counties in Indiana [G Zimet, personal communication, April 2023]. MenB vaccination rates are higher in counties that are less rural, have more primary care providers (PCPs) per capita, and have fewer uninsured children [G Zimet, personal communication, April 2023]. Other demographic factors, such as ethnicity and race, socioeconomic status, insurance status, and healthcare access, may also contribute to differences in coverage [64].

Lack of Preventive Healthcare Visits

A commonly identified reason for the low vaccination coverage rates among adolescents is that they tend to have fewer preventive healthcare visits relative to younger children. Despite the recommendation from the American Academy of Pediatrics for annual preventive care visits, which include vaccine administration, for individuals 3–21 years of age [65], several surveys analyzing healthcare utilization patterns during 2011 to 2012 found that only 43% to 81% of adolescents had a preventive healthcare visit in the 12 months preceding the survey [66]. Recent data have shown that the percentage of adolescents 12–17 years of age who had previously had a preventive healthcare visit in the past year declined from 78.7% in 2016–2017 to 69.6% in 2020–2021 [67]. Additional data indicate that the frequency of preventive visits decreases among adolescents after the age of 16 years [68], resulting in missed opportunities for vaccination.

Optimizing Meningococcal Vaccination

Addressing Knowledge Gaps about IMD and Meningococcal Vaccination

Specific approaches and strategies to address knowledge gaps and access barriers to vaccination were proposed by ARTEMIS members and a consensus was reached on which approaches to include. The potential impact of each approach on vaccine uptake and the feasibility of execution of the approach were rated as a consensus score among the ARTEMIS members as low, medium, or high. The specific approaches and strategies proposed by ARTEMIS members to address knowledge gaps and access barriers among HCPs, parents and AYA, and educational institutions/policymakers are summarized in Tables 2, 3, and 4.

Table 2. Approaches to addressing knowledge gaps and access barriers among healthcare providers

Approach	Impact			Feasibility
	Low	Medium	High	Low	Medium	High
Leverage survivor stories			✔			✔
Create community programs using cross-specialty small groups (e.g., dinner program)			✔			✔
Operationalize SCDM (distinguish between “lower case scdm” [i.e., general recommended approach healthcare providers] and “upper case SCDM” [i.e., a specific recommendation])			✔			✔
Encourage 16-year-olds to have their own access to vaccines (e.g., clinic, pharmacy, school)			✔			✔
Apply best practices derived from sharing among practices (e.g., medical assistants cross-training at other offices) to meningococcal vaccines; also provide an opportunity for continuing medical education			✔			✔
Work toward medical society endorsement (e.g., position paper, infographic)			✔		✔
Promote vaccine programs (e.g., Vaccines for Children) to alleviate any cost concerns			✔		✔
Develop performance measure/benchmark for vaccination within each practice			✔		✔
Generate certification requirement content as an educational tool			✔		✔
Develop action-oriented EHR prompts (e.g., “discuss and administer meningococcal vaccines”); state registry prompts		✔			✔
Develop best practices advertisements		✔			✔
Develop infographics for waiting rooms, other touchpoints; must include pictures with calls to action and QR codes (patients should be able to opt in)	✔					✔
Expand vaccination access in the medical home (e.g., assistance with inventory control, billing, documentation into electronic medical record and state immunization information systems)			✔		✔

EHR electronic health records, QR quick-response, scdm/SCDM shared clinical decision-making

The impact and feasibility scores of low, medium, and high are consensus scores among the ARTEMIS members

Table 3. Approaches to addressing knowledge gaps and access barriers among patients and parents/caregivers

Audience		Approach	Impact			Feasibility
Patient	Parent/Caregiver		Low	Medium	High	Low	Medium	High
✔	✔	Bring vaccines to patients and caregivers (e.g., school, pharmacy); pair with other vaccines (“vaccine days”)			✔		✔
✔	✔	Leverage existing mobile outreach organizations to assist with transportation issues (e.g., mobile clinic, food bank, Young Men’s Christian Association, religious groups)			✔	✔
✔	✔	Leverage college/university orientations and college nights at high schools			✔		✔
✔	✔	Collaborate with walk-in clinics/urgent care facilities		✔		✔
✔	✔	Create direct-to-consumer ads (compelling/relatable; e.g., survivors’ stories); TV/mass media with advocacy groups		✔				✔
✔	✔	Use school to educate either at parents’ nights or in combination with other health education (e.g., school nurses)		✔				✔
✔	✔	Develop social media campaigns (consider target age in platform selection)		✔			✔
✔	✔	Develop educational materials within offices including pharmacy ads (“protects against” language and age-based recommendations should be included)		✔				✔
✔	✔	Incorporate reminders for vaccination directly from provider (could include links to educational materials and appointment scheduler)		✔			✔
✔		Leverage high school science classes to talk about meningococcal disease and vaccines		✔		✔
✔		Educate patients in absence of parents to overcome anti-vaccination parents	✔				✔
	✔	Address cost concerns (e.g., “save lives and money now, or pay later”)		✔				✔
	✔	Leverage existing parent vaccine advocacy groups (e.g., use Science Moms to get “Back to the Vax”)		✔			✔

The impact and feasibility scores of low, medium, and high are consensus scores among the ARTEMIS members

Table 4. Approaches to addressing knowledge gaps and access barriers among educational institutions and policymakers

Audience		Approach	Impact			Feasibility
Educational institution	Policymaker		Low	Medium	High	Low	Medium	High
✔		Collaborate with higher education organizations (e.g., National Association of Student Personnel Administrators) to push campus leaders to vaccinate		✔			✔
✔		Educate administrators about financial programs for meningococcal vaccination		✔			✔
✔		Work with student organizations (e.g., Greek or other social clubs)	✔					✔
✔	✔	Prepare for pentavalent MenABCWY vaccine by talking about meningococcal serogroups A, C, W, and Y and serogroup B (e.g., “B [MenB] protected”)		✔				✔
✔	✔	Communicate value of vaccines as health prevention (similar to mammography or cancer screens, for example)		✔			✔
	✔	Incentivize vaccine coverage (e.g., goal of 80%)			✔	✔
	✔	Address need to de-politicize vaccination in the post-COVID era			✔	✔
	✔	Advocate for nationwide pharmacist vaccination for individuals < 18 years of age and mandatory immunization registries		✔		✔

The impact and feasibility scores of low, medium, and high are consensus scores among the ARTEMIS members

Existing knowledge gaps among HCPs and the reliance of patients/parents on HCPs for vaccination recommendations highlight the imperative to increase knowledge about meningococcal disease among HCPs. Efforts to provide HCPs with up-to-date information about meningococcal disease and vaccination, including comprehensive epidemiological data, as well as interventions to improve vaccine awareness and completion (e.g., trackers, reminders, vaccination databases), should be intensified. Targeted training sessions, webinars, and educational materials can be offered to improve HCPs’ communication regarding IMD in addition to their knowledge about the benefits and safety of meningococcal vaccines.

Parents and adolescents deserve to know about IMD and meningococcal vaccination. Whereas they are likely to learn about these topics primarily from their HCPs, other methods (e.g., public service announcements, school-based programs) can be harnessed to provide them with this information.

Addressing Knowledge Gaps about SCDM for MenB Vaccination

Because the number of SCDM recommendations is growing (e.g., the 2019 recommendation for human papillomavirus [HPV] vaccination of adults 27‒45 years of age [69]), there is an urgent need to reduce confusion about the exact definition of SCDM and how these recommendations should be implemented. In fact, ACIP recently rescinded a SCDM recommendation (i.e., the 2023 recommendation for respiratory syncytial virus vaccination of adults ≥ 60 years of age) in an effort to simplify vaccine decision-making [70, 71]. Targeted educational materials may help HCPs implement certain SCDM recommendations. For example, a patient/parent handout was developed to help initiate and standardize HCP SCDM conversations regarding the need for MenB vaccination (Fig. 2) [61]. The handout includes three stages of discussion—an overview of meningococcal serogroup B disease, currently available MenB vaccines, and reasons to get vaccinated—with bulleted, easy-to-read discussion points shown for each stage [61]. Most of the 88 HCPs who responded to a survey found the materials useful: 77% agreed or strongly agreed that the handout helped prepare them to initiate conversations with patients and families about vaccination, and 81% felt that it better prepared them to address questions from patients/families [61]. Additionally, the vast majority of HCPs agreed or strongly agreed that the materials should be shared with colleagues (93%) and parents/patients (95%) [61]. Thus, the materials developed were valuable to initiating discussions, which is a necessary prerequisite to SCDM [61]. Further research is needed to evaluate whether the materials influence the number of discussions between HCPs and parents/patients and the subsequent decisions to receive MenB vaccination [61].

[See PDF for image]

Fig. 2

a Front and b back of a patient/parent handout developed to help initiate and standardize healthcare provider shared clinical decision-making conversations regarding MenB vaccination. Reprinted with permission from Middleman et al. Acad Pediatr. 2022;22(4):564–572 [61]. MenACWY meningococcal serogroups A, C, W, and Y, MenB meningococcal serogroup

[See PDF for image]

Addressing Disparities and Barriers

Encouraging annual preventive care visits for adolescents represents an opportunity to increase vaccination initiation rates; subsequent assistance from HCPs with reminders for subsequent doses within multidose series may also help improve vaccination completion rates [72, 73]. In addition to preventive care visits, receipt of other recommended vaccines is associated with initiation of vaccination. Thus, building a “culture of preventive healthcare” by combining preventive messaging about adolescent disease risks and available vaccines (e.g., MenACWY, MenB, and HPV) and presenting consistent messages across touch points [74] may be an effective approach to increasing vaccination rates and thereby reducing vaccination disparities among AYA.

Data suggest that health insurance coverage is related to disparities in vaccination coverage. For meningococcal vaccines in particular, data from the 2015 NIS-TEEN survey indicated that 72.9% of uninsured AYA (13–17 years of age) compared with 81.7% of their insured peers received ≥ 1 MenACWY vaccine dose; data from the 2022 NIS-TEEN survey confirmed persistence of this trend [44, 75]. A critical strategy for enhancing immunization coverage in AYA without insurance coverage includes referrals to the VFC program (eligible individuals must be ≤ 18 years of age) through any participating provider (e.g., hospitals, schools, public or community clinics, and pharmacies) [76, 77]. Individuals > 18 years of age who no longer qualify for VFC programs should be encouraged to ask their PCP or college health center about vaccine assistance programs [78].

Allowing adolescents to consent to receiving meningococcal vaccines can be another effective approach to improving vaccination rates in this age group. Adolescents generally feel marginalized in the vaccine decision-making process but express a desire for participation [79]. Many states have laws granting adolescents rights to make healthcare decisions related to certain issues, such as mental health, reproductive health, and sexually transmitted infections [80], and medical societies including the Society for Adolescent Health and Medicine and the American Medical Association support the expansion of adolescent consent to vaccination [81, 82]. Because vaccination is a critical component of preventive healthcare, allowing adolescents to participate in the decision-making process regarding their own health empowers them to take ownership of their well-being [65, 83]. In addition, because adolescents are a unique population with distinct healthcare needs [84], actively involving adolescents in the decision-making process enables policymakers to ensure that vaccination policies are tailored to adolescents’ specific needs. This approach may in turn lead to improved vaccination rates and health outcomes among adolescents [81, 82].

School vaccination requirements are important tools for achieving high vaccination rates and reducing vaccine-preventable diseases. Although states generally have vaccination requirements for school entry, as of May 2024, all states offer exemptions to school vaccination requirements for medical reasons and 46, in addition to the District of Columbia, offer non-medical exemptions for religious reasons and/or personal belief/philosophical reasons [85]. Several studies have examined the impact of school entry vaccination requirements on vaccination rates [86, 87–88]. In one study conducted in metropolitan Philadelphia, more stringent school entry requirements for vaccination were associated with modest increases in Tdap (required vaccine; 86.9% to 88.5%; P = 0.018) and MenACWY (required; 86.9% to 88.7%; P = 0.008) vaccination rates among adolescents 12–13 years of age and more substantial increases in MenACWY (required; 69.8% to 74.2%; P < 0.001), MenB (optional; 10.2% to 40.6% for one dose; P < 0.001), and HPV (optional; 68.8% to 73.4% completing the vaccination series; P < 0.001) among adolescents 17–18 years of age [86]. Another study found that the elimination of nonmedical exemptions (i.e., based on religious or personal belief) for school entry vaccination requirements in California resulted in a 3.3% increase in measles, mumps, and rubella vaccine coverage at the state level and a 4.3% (P < 0.001) increase in overall vaccine coverage for children entering kindergarten at the county level [87]. Furthermore, a systematic review involving 20 studies (18 from the United States) found consistent evidence that school entry requirements for vaccination generally were associated with higher vaccination rates [88]. Thus, there is ample evidence supporting the effectiveness of school entry vaccination requirements in increasing vaccination rates across vaccines; however, the degree of impact may vary depending on factors such as the specific vaccine, the population studied, and the implementation of the requirement. In the United States, 26 states require MenACWY vaccination for entry into college or university; however, there are few requirements for MenB vaccination [89].

For young adults in particular, it is important to recognize increasing enrollment in skilled trade programs in recent years against a backdrop of overall declines in college and graduate school enrollment [90]. Similar to college campuses, these programs may serve as environments that promote increased close physical contact, which in turn may increase the risk of IMD [91]; consequently, the SCDM process needs to account for specific educational journeys among AYA. Trade schools or programs should also be considered as potential settings for vaccination.

Expanding Vaccination Access in the Medical Home

There is a particular need to promote vaccine availability for all across the medical home, a key tenet of which is coordination between different healthcare settings to comprehensively address medical needs [92]. Specific issues to be addressed in this context include inventory control, billing assistance, and documentation into electronic medical record and state immunization information systems. Coordinated documentation of vaccination across the medical home is important for informing vaccinators which (if any) vaccines have been received by a given patient; more broadly, this information may provide insight into relationships between prior vaccination and subsequent vaccine selections.

Pharmacists play a critical role in adolescent vaccination within the medical home. Pharmacists are allowed to administer vaccines in all 50 states and the District of Columbia; however, many states have restrictions on pharmacist-administered vaccination with regard to specific vaccines, eligible patient age groups, and whether a patient-specific prescription is required for a given vaccine and patient age [93]. In general, physicians and parents have positive perceptions of pharmacies providing vaccinations to adolescents, as shown by US national surveys. In two US national surveys conducted in 2014 and 2015, 39% of physicians and 29% of parents expressed unconditional endorsement of pharmacists providing HPV vaccination for adolescents who are past due [94]. Another 40% of the physicians and 52% of the parents indicated endorsement if pharmacists were in receipt of proper vaccination training, reported received vaccine doses to adolescents’ PCPs, and referred adolescents to PCPs for other health services [94]. In another survey of parents with at least one child between ages 3–10 conducted in the US in 2020, 69.7% reported that they would be willing to have their child vaccinated at a pharmacy and 56.7% reported that they wanted to take their child for their next vaccination [95]. Pharmacist involvement in the vaccination process, whether as educators, facilitators, or administrators, has been shown to result in increased vaccination rates [96]. Based on the likelihood that additional venue choices (i.e., pharmacies) will improve vaccination rates, the American Pharmacists Association and the National Adult and Influenza Immunization Summit have proposed the “immunization neighborhood” approach to address the unmet vaccination needs within a community [97]. This initiative is akin to the collaborative aspect of the medical home and aims to meet the needs of patients and increase vaccination access and equity through the coordination of all vaccination stakeholders, including physicians, pharmacists, nurses, public health officials, community leaders, and payers [97].

Future of Meningococcal Vaccination

During the 2022 ARTEMIS meeting, use of MenABCWY vaccines was discussed as a potential solution to low MenB vaccine uptake at the US population level. After the meeting, the Pfizer MenABCWY vaccine was added as an option in the US meningococcal adolescent vaccination platform following a quadrivalent (Q; i.e., any licensed MenACWY vaccine), pentavalent (P; the Pfizer MenABCWY vaccine) and MenB-fHbp (B) vaccine dosing schedule (i.e., Q–P–B), per updated ACIP recommendations for adolescent meningococcal vaccinations wherein a single dose of the Pfizer MenABCWY vaccine replaces the MenACWY vaccine booster dose and the first MenB vaccine dose when both MenACWY and MenB vaccines are due at the same healthcare visit [39, 40–41]. Compared with the current standard of care (i.e., routine MenACWY vaccination at 11–12 and 16 years of age plus two MenB vaccine doses at 16–23 years of age under SCDM), the Q–P–B schedule would reduce the number of injections from four to three [40]. Additionally, use of the Pfizer MenABCWY vaccine in place of a MenACWY vaccine in eligible AYA may incentivize initiation of vaccination against meningococcal serogroup B in cases when it may not have occurred otherwise [98]. However, implementation of the Q-P-B schedule requires vaccine providers to stock three separate vaccine products (i.e., a MenACWY vaccine, the Pfizer MenABCWY vaccine, and MenB-fHbp). In 2023, the ACIP initiated a reevaluation of the adolescent meningococcal vaccination platform that will continue through 2025 and may lead to recommendations for alternative vaccination schedules that include MenABCWY vaccines (e.g., Q–P–P) [99, 100]. Such recommendations could further simplify the vaccination schedule by requiring two as opposed to three vaccine products, which may help reduce inventory management complexities, improve vaccination completion rates, and would be aligned with US Food and Drug Administration licensure [32, 100]. Additionally, the reduced number of injections associated with use of combination vaccines may help alleviate concern about the number of injections and also potentially improve vaccination coverage rates [101]. Because HCPs, patients, and parents generally lack comprehensive understanding surrounding the needs and/or recommendations for both MenB and MenACWY vaccines, alternative MenABCWY vaccination schedules may help simplify discussions between HCPs and patients/parents about the different serogroups and the available vaccines needed for IMD protection.

Conclusions

In conclusion, there is a lack of knowledge surrounding IMD epidemiology and the benefits of meningococcal vaccines at the HCP, parent, and patient levels. Although the universal MenACWY vaccination program has successfully reduced the burden of IMD [29], HCPs harbor low awareness of the importance of meningococcal serogroup B disease and face several challenges with implementing MenB vaccination recommendations based on SCDM. The strategies proposed here could help to address knowledge gaps and overcome barriers to vaccination to increase protection against all five serogroups causing serious meningococcal disease among AYA in the United States.

Acknowledgements

Medical Writing, Editorial, and Other Assistance

Medical writing support was provided by Qi Yan, PhD, of Pfizer Inc (Collegeville, PA, USA), and Judith Kandel, PhD, of ICON (Blue Bell, PA, USA) and was funded by Pfizer Inc.

Author Contributions

All authors were involved in the conception and design of the study and analysis and interpretation of the data. Ruth Carrico, Jaime E. Fergie, Stephanie Hanenberg, Gary S. Marshall, Kaitlyn Rivard, Jana Shaw, Gregory D. Zimet, Jessica Presa, and Paula Peyrani were involved in drafting the manuscript or revising it critically for intellectual content. All authors agree to be accountable for all aspects of the work and approved the final version of the manuscript to be published.

Funding

This work, including the organization and funding of the 2022 ARTEMIS meeting, was supported by Pfizer Inc. The journal’s publication fees were funded by Pfizer Inc.

Data Availability

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Declarations

Conflict of Interest

The following authors received honoraria from Pfizer Inc to attend the 2022 ARTEMIS meeting: Ruth Carrico, Jaime E. Fergie, Stephanie Hanenberg, Gary S. Marshall, Kaitlyn Rivard, Jana Shaw, and Gregory D. Zimet. Ruth Carrico is a consultant and advisory board member for Pfizer, Moderna, Sanofi, and Novavax, and a speaker for Pfizer. Jaime E. Fergie is a consultant and speaker for Pfizer, Sanofi, and GSK and a consultant for Moderna, Novavax, and Merck. Gary S. Marshall has received grants and/or contracts (paid to the institution) from GSK, Merck, Pfizer, Sanofi, and Seqirus. He further discloses advisory board participation, consulting fees, and travel/meeting support from GSK, Merck, Moderna, Pfizer, Sanofi, and Seqirus. Kaitlyn Rivard serves as an advisory board member for Pfizer and is a paid consultant for Wolters Kluwer. Jana Shaw is a consultant and speaker for Pfizer Inc, and a consultant for GSK. Gregory D. Zimet has served as an external advisory board member for Merck, Pfizer, and Moderna and as a consultant to Merck; has received investigator-initiated research funding from Merck administered through Indiana University; and serves as an unpaid member of the Board of Directors for the Unity Consortium, a nonprofit organization that supports adolescent health through vaccination. Jessica Presa, Paula Peyrani, and Alejandro Cane are current employees of Pfizer and may have stock or stock options.

Ethical Approval

This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

1. Harrison, OB; Claus, H; Jiang, Y et al. Description and nomenclature of Neisseria meningitidis capsule locus. Emerg Infect Dis; 2013; 19, pp. 566-573.1:CAS:528:DC%2BC2cXhslantLjK [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/23628376][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647402]

2. Pardo de Santayana C, Tin Tin Htar M, Findlow J, Balmer P. Epidemiology of invasive meningococcal disease worldwide from 2010–2019: a literature review. Epidemiol Infect. 2023;151:e57.

3. Centers for Disease Control and Prevention. Enhanced Meningococcal Disease Surveillance Report, 2018. Available at: https://stacks.cdc.gov/view/cdc/111348. Accessed September 23, 2022.

4. Centers for Disease Control and Prevention. Enhanced Meningococcal Disease Surveillance Report, 2017. Available at: https://stacks.cdc.gov/view/cdc/75419. Accessed March 03, 2025.

5. Centers for Disease Control and Prevention. Enhanced Meningococcal Disease Surveillance Report, 2019. Available at: https://stacks.cdc.gov/view/cdc/140466. Accessed March 03, 2025.

6. Mbaeyi, S; Pondo, T; Blain, A et al. Incidence of meningococcal disease before and after implementation of quadrivalent meningococcal conjugate vaccine in the United States. JAMA Pediatr; 2020; 174, pp. 843-851. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/32687590]

7. Centers for Disease Control and Prevention. Meningococcal Disease Surveillance and Trends (last updated November 12, 2024). Available at: https://www.cdc.gov/meningococcal/php/surveillance/index.html. Accessed February 17, 2025.

8. Centers for Disease Control and Prevention. CDC Stacks. National Notifiable Diseases: Infectious Weekly Tables. Meningococcal Disease. Week ending December 30, 2023. Available at: https://stacks.cdc.gov/view/cdc/140265. Accessed April 09, 2025.

9. Centers for Disease Control and Prevention. CDC Stacks. National Notifiable Diseases: Infectious Weekly Tables. Meningococcal Disease. Week ending December 31, 2022. Available at: https://stacks.cdc.gov/view/cdc/123383. Accessed April 09, 2025.

10. Centers for Disease Control and Prevention. Enhanced Meningococcal Disease Surveillance Report, 2020. Available at: https://www.cdc.gov/meningococcal/downloads/NCIRD-EMS-Report-2020.pdf. Accessed April 09, 2025.

11. Centers for Disease Control and Prevention. CDC Stacks. National Notifiable Diseases: Infectious Weekly Tables. Meningococcal Disease. Week ending December 28, 2024. Available at: https://stacks.cdc.gov/view/cdc/175359. Accessed March 26, 2025.

12. Marshall, GS; Dempsey, AF; Srivastava, A; Isturiz, RE. US college students are at increased risk for serogroup B meningococcal disease. J Pediatric Infect Dis Soc; 2020; 9, pp. 244-247. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/31077326]

13. Centers for Disease Control and Prevention. CDC Archive. Meningococcal Disease Outbreak Among Gay, Bisexual Men in Florida, 2021–23. Available at: https://archive.cdc.gov/#/details?q=https://www.cdc.gov/meningococcal/outbreaks/FL2022.html&start=0&rows=10&url=https://www.cdc.gov/meningococcal/outbreaks/FL2022.html. Accessed April 09, 2025.

14. Centers for Disease Control and Prevention. CDC Archive. CDC Assists with Meningococcal Disease Outbreak Investigation in Florida. Available at: https://archive.cdc.gov/#/details?archive_url=https://archive.cdc.gov/www_cdc_gov/media/releases/2022/p0622-Meningococcal-Outbreak.html. Accessed April 09, 2025.

15. Virginia Department of Health. Meningococcal Disease Outbreak Response. Available at: https://www.vdh.virginia.gov/surveillance-and-investigation/meningococcal-disease-outbreak-response/. Accessed April 03, 2025.

16. Soumahoro, L; Abitbol, V; Vicic, N; Bekkat-Berkani, R; Safadi, MAP. Meningococcal disease outbreaks: a moving target and a case for routine preventative vaccination. Infect Dis Ther; 2021; 10, pp. 1949-1988. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/34379309][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8572905]

17. Deghmane, A-E; Taha, S; Taha, M-K. Global epidemiology and changing clinical presentations of invasive meningococcal disease: a narrative review. Infect Dis; 2022; 54, pp. 1-7.

18. Nadel, S; Ninis, N. Invasive meningococcal disease in the vaccine era. Front Pediatr; 2018; 6, 321. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/30474022][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6237846]

19. Thompson, MJ; Ninis, N; Perera, R et al. Clinical recognition of meningococcal disease in children and adolescents. Lancet; 2006; 367, pp. 397-403. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/16458763]

20. Wang B, Santoreneos R, Giles L, Haji Ali Afzali H, Marshall H. Case fatality rates of invasive meningococcal disease by serogroup and age: a systematic review and meta-analysis. Vaccine. 2019;37:2768–82.

21. Guedes, S; Bricout, H; Langevin, E; Tong, S; Bertrand-Gerentes, I. Epidemiology of invasive meningococcal disease and sequelae in the United Kingdom during the period 2008 to 2017 - a secondary database analysis. BMC Public Health; 2022; 22, 521. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/35296287][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8928586]

22. Bettinger, JA; Scheifele, DW; Le Saux, N et al. The disease burden of invasive meningococcal serogroup B disease in Canada. Pediatr Infect Dis J; 2013; 31, pp. e20-e25.

23. Olbrich, KJ; Muller, D; Schumacher, S et al. Systematic review of invasive meningococcal disease: sequelae and quality of life impact on patients and their caregivers. Infect Dis Ther; 2018; 7, pp. 421-438. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/30267220][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6249177]

24. Hoogman, M; van de Beek, D; Weisfelt, M; de Gans, J; Schmand, B. Cognitive outcome in adults after bacterial meningitis. J Neurol Neurosurg Psychiatry; 2007; 78, pp. 1092-1096. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/17353256][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117539]

25. Borg, J; Christie, D; Coen, PG; Booy, R; Viner, RM. Outcomes of meningococcal disease in adolescence: prospective, matched-cohort study. Pediatrics; 2009; 123, pp. e502-e509. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/19254985]

26. Martinón-Torres, F. Deciphering the burden of meningococcal disease: conventional and under-recognized elements. J Adolesc Health; 2016; 59, pp. S12-20. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27449145]

27. Candrilli SD, Kurosky S. The response to and cost of meningococcal disease outbreaks in university campus settings: a case study in Oregon, United States. Research Triangle Park (NC): 2019.

28. Centers for Disease Control and Prevention. Meningococcal Vaccination (updated June 26, 2024). Available at: https://www.cdc.gov/meningococcal/vaccines/index.html. Accessed February 11, 2025.

29. Presa, J; Findlow, J; Zimet, GD. Meningococcal vaccination of adolescents in the United States: past successes and future considerations. J Adolesc Health; 2024; 74, pp. 1068-1077. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/38430074]

30. California Department of Public Health. Replacement of Menactra with Menquadfi Meningococcal Conjugate Vaccine on the ADAP & PrEP-AP Formulary. Available at: https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_ADAP_MM_2022_20_Replacement_of_Menactra_with_Menquadfi_Meningococcal_Conjugate_Vaccine.aspx#:~:text=Effective%20September%2026%2C%202022%2C%20Menactra,Meningococcal%20Conjugate%20Vaccine%20in%202022. Accessed April 2, 2024.

31. Serra, L; Webber, C; Burman, C et al. Clinical trial and postmarketing safety experience with MenACWY-TT, a meningococcal group A, C, W, and Y tetanus conjugate vaccine. Vaccine; 2022; 40, pp. 7014-7021.1:CAS:528:DC%2BB38XislWksbvK [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/36283896]

32. Penbraya (meningococcal groups A, B, C, W, and Y vaccine). Full Prescribing Information, Pfizer Ireland Pharmaceuticals, Cork, Ireland, 2023.

33. Pfizer Inc. FDA Approves Penbraya™, the First and Only Vaccine for the Prevention of the Five Most Common Serogroups Causing Meningococcal Disease in Adolescents. Available at: https://www.pfizer.com/news/press-release/press-release-detail/fda-approves-penbrayatm-first-and-only-vaccine-prevention. Accessed April 28, 2025.

34. US Food and Drug Administration. PENMENVY Package Insert, Updated 02/2024. Available at: https://www.fda.gov/vaccines-blood-biologics/penmenvy. Accessed April 01, 2025.

35. GSK. Press release February 15, 2025. Penmenvy, GSK’s 5-in-1 meningococcal vaccine, approved by US FDA to help protect against MenABCWY. Available at: https://www.gsk.com/en-gb/media/press-releases/penmenvy-gsk-s-5-in-1-meningococcal-vaccine-approved-by-us-fda-to-help-protect-against-menabcwy/. Accessed April 29, 2025.

36. Bilukha, OO; Rosenstein, N. National Center for Infectious Diseases/Centers for Disease Control and Prevention. Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep.; 2005; 54, pp. 1-21. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/15917737]

37. Updated recommendations for use of meningococcal conjugate vaccines --- Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep. 2011;60:72–6.

38. MacNeil, JR; Rubin, L; Folaranmi, T et al. Use of serogroup B meningococcal vaccines in adolescents and young adults: recommendations of the Advisory Committee on Immunization Practices, 2015. MMWR Morb Mortal Wkly Rep; 2015; 64, pp. 1171-1176. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/26492381]

39. Mbaeyi, SA; Bozio, CH; Duffy, J et al. Meningococcal vaccination: recommendations of the Advisory Committee on Immunization Practices, United States, 2020. MMWR Recomm Rep; 2020; 69, pp. 1-41. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/33417592][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527029]

40. Centers for Disease Control and Prevention. Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger. Available at: https://www.cdc.gov/vaccines/hcp/imz-schedules/downloads/child/0-18yrs-child-combined-schedule.pdf?CDC_AAref_Val=https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf. Accessed September 13, 2024.

41. Centers for Disease Control and Prevention. ACIP Recommendations. Available at: https://www.cdc.gov/acip/vaccine-recommendations/?CDC_AAref_Val=https://www.cdc.gov/vaccines/acip/recommendations.html. Accessed October 17, 2024.

42. Advisory Committee on Immunization Practices. April 15–16, 2025 Meeting. GSK Pentavalent (MenABCWY) Vaccine: Review of Updated EtR and Work Group Considerations. Available at: https://www.cdc.gov/acip/meetings/presentation-slides-april-15-16-2025.html. Accessed April 29, 2025.

43. University of Minnesota Center for Infectious Disease Research and Policy (CIDRAP). CDC Advisers Update Recommendations for Meningococcal, RSV, Chikungunya Vaccines. Available at: https://www.cidrap.umn.edu/chikungunya/cdc-advisers-update-recommendations-meningococcal-rsv-chikungunya-vaccines. Accessed April 29, 2025.

44. Pingali, C; Yankey, D; Elam-Evans, LD et al. Vaccination coverage among adolescents aged 13–17 years - National Immunization Survey-Teen, United States, 2022. MMWR Morb Mortal Wkly Rep; 2023; 72, pp. 912-919.1:CAS:528:DC%2BB2cXlt1ersb0%3D [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/37616185][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10468222]

45. Shah, MD; Szilagyi, PG; Shetgiri, R et al. Trends in parents’ confidence in childhood vaccines during the COVID-19 pandemic. Pediatrics; 2022; 150, [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/35831931]e2022057855.

46. Herrera-Restrepo O, Bunniran S, Mond T, et al. United States physicians’ knowledge, attitudes, and practices regarding meningococcal vaccination for healthy adolescents and young adults. J Adolesc Health. 2024;13:S1054–139X(23)00975–8.

47. Kempe, A; Allison, MA; MacNeil, JR et al. Knowledge and attitudes regarding category B ACIP recommendations among primary care providers for children. Acad Pediatr; 2018; 18, pp. 763-768. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/29678594][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6123258]

48. Huang, L; Goren, A; Lee, LK et al. Disparities in healthcare providers’ interpretations and implementations of ACIP’s meningococcal vaccine recommendations. Hum Vaccin Immunother; 2020; 16, pp. 933-944. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/31634035]

49. Ghaswalla, PK; Marshall, GS; Bengtson, LGS et al. Meningococcal vaccination rates among people with a new diagnosis of HIV infection in the US. JAMA Netw Open; 2022; 5, [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/35486405][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9055456]e228573.

50. Ghaswalla, PK; Bengtson, LGS; Marshall, GS et al. Meningococcal vaccination in patients with newly diagnosed asplenia in the United States. Vaccine; 2021; 39, pp. 272-281. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/33309081]

51. Basta, NE; Becker, AB; Li, Q; Nederhoff, D. Parental awareness of meningococcal B vaccines and willingness to vaccinate their teens. Vaccine; 2019; 37, pp. 670-676. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/30587431]

52. Fergie, J; Howard, A; Huang, L; Srivastava, A. Implementation experience with meningococcal serogroup B vaccines in the United States: impact of a nonroutine recommendation. Pediatr Infect Dis J; 2021; 40, pp. 269-275. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/33565815]

53. Srivastava, A; Dempsey, A; Galitsky, A; Fahimi, M; Huang, L. Parental awareness and utilization of meningococcal serogroup B vaccines in the United States. BMC Public Health; 2020; 20, 1109. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/32664872][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362432]

54. Ulrich, AK; McKearnan, SB; Lammert, S et al. Validity of university students’ self-reported vaccination status after a meningococcal B outbreak. J Am Coll Health; 2022; 70, pp. 824-829. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/32672510]

55. MacDougall, DM; Langley, JM; Li, L et al. Knowledge, attitudes, beliefs, and behaviors of university students, faculty, and staff during a meningococcal serogroup B outbreak vaccination program. Vaccine; 2017; 35, pp. 2520-2530.1:STN:280:DC%2BC1cvhs1CitA%3D%3D [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/28347501]

56. Centers for Disease Control and Prevention. ACIP Shared Clinical Decision-Making Recommendations (updated January 7, 2025). Available at: https://www.cdc.gov/acip/vaccine-recommendations/shared-clinical-decision-making.html. Accessed February 14, 2025.

57. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices Vaccines for Children Program: Vaccines to Prevent Meningococcal Disease. Available at: https://www.cdc.gov/vaccines-for-children/downloads/meningococcal-508.pdf. Accessed 21 May 2025.

58. Kempe, A; Allison, MA; MacNeil, JR et al. Adoption of serogroup B meningococcal vaccine recommendations. Pediatrics; 2018; 142, [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/30126935]e20180344.

59. Niccolai, LM; Hansen, CE. Suboptimal uptake of meningococcal vaccines among older adolescents: barriers, solutions, and future research directions. Hum Vaccin Immunother; 2020; 16, pp. 3208-3212. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/32614695][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8641614]

60. Immunization Action Coalition. MenACWY Vaccine Requirements for Secondary School. Available at: https://www.immunize.org/official-guidance/state-policies/vaccine-requirements/menacwy-secondary/. Accessed April 4, 2024.

61. Middleman, AB; Zimet, GD; Srivastava, AK; Auslander, BA. Making a shared decision on meningococcal B vaccine: provider feedback on an educational tool developed for use with patients. Acad Pediatr; 2022; 22, pp. 564-572. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/35081471]

62. Marshall, GS; Tan, L. Understanding the category B recommendation for serogroup B meningococcal vaccine. Pediatrics; 2017; 139, [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/28557743]e20163484.

63. Centers for Disease Control and Prevention. TeenVaxView: Vaccination Coverage among Adolescents (13–17 Years). Available at: https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/index.html. Accessed April 5, 2024.

64. Masaquel, C; Schley, K; Wright, K et al. The impact of social determinants of health on meningococcal vaccination awareness, delivery, and coverage in adolescents and young adults in the United States: a systematic review. Vaccines (Basel); 2023; 11, 256. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/36851134]

65. Bright Futures/American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care. Available at: https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf. Accessed March 22, 2024.

66. Adams, SH; Park, MJ; Irwin, CE, Jr. Adolescent and young adult preventive care: comparing national survey rates. Am J Prev Med; 2015; 49, pp. 238-247. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/25935503]

67. U.S. Department of Health and Human Services. Healthy People 2030. Available at: https://health.gov/healthypeople/objectives-and-data/browse-objectives/adolescents/increase-proportion-adolescents-who-had-preventive-health-care-visit-past-year-ah-01/data. Accessed May 22, 2024.

68. Rand, CM; Goldstein, NPN. Patterns of primary care physician visits for US adolescents in 2014: implications for vaccination. Acad Pediatr; 2018; 18, pp. S72-S78. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/29502641]

69. Meites, E; Szilagyi, PG; Chesson, HW et al. Human papillomavirus vaccination for adults: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep; 2019; 68, pp. 698-702. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/31415491][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6818701]

70. Melgar, M; Britton, A; Roper, LE et al. Use of respiratory syncytial virus vaccines in older adults: recommendations of the Advisory Committee on Immunization Practices - United States, 2023. MMWR Morb Mortal Wkly Rep; 2023; 72, pp. 793-801. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/37471262][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10360650]

71. Centers for Disease Control and Prevention. CDC Updates RSV Vaccination Recommendation for Adults. June 26, 2024. Available at: https://www.cdc.gov/media/releases/2024/s-0626-vaccination-adults.html. Accessed April 04, 2025.

72. Rand, CM; Shone, LP; Albertin, C et al. National health care visit patterns of adolescents: implications for delivery of new adolescent vaccines. Arch Pediatr Adolesc Med; 2007; 161, pp. 252-259. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/17339506]

73. Cataldi, JR; Kerns, ME; O’Leary, ST. Evidence-based strategies to increase vaccination uptake: a review. Curr Opin Pediatr; 2020; 32, pp. 151-159. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/31790027]

74. Espinosa, CM; Marshall, GS; Woods, CR et al. Missed opportunities for human papillomavirus vaccine initiation in an insured adolescent female population. J Pediatric Infect Dis Soc; 2017; 6, pp. 360-365. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/29036336][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5907852]

75. Lu, PJ; Yankey, D; Jeyarajah, J et al. Association of health insurance status and vaccination coverage among adolescents 13–17 years of age. J Pediatr; 2018; 195, 256–62 e1.

76. Centers for Disease Control and Prevention (CDC). About the Vaccines for Children (VFC) Program. Available at: https://www.cdc.gov/vaccines-for-children/about/index.html. Accessed 04 April, 2025.

77. Centers for Disease Control and Prevention (CDC). Vaccines for Children (VFC) Program: Information for Parents. Available at: https://www.cdc.gov/vaccines-for-children/vfc-information-for-parents/index.html. Accessed April 04, 2025.

78. Centers for Disease Control and Prevention (CDC). Resources for Adult Vaccination Insurance and Payment. Available at: https://www.cdc.gov/vaccines-adults/hcp/adult-payment-insurance-resources/index.html#:~:text=Private%20Insurance%20Coverage,not%20met%20their%20yearly%20deductible. Accessed April 04, 2025.

79. Herman, R; McNutt, LA; Mehta, M et al. Vaccination perspectives among adolescents and their desired role in the decision-making process. Hum Vaccin Immunother; 2019; 15, pp. 1752-1759. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/30735440][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746506]

80. Sharko, M; Jameson, R; Ancker, JS et al. State-by-state variability in adolescent privacy laws. Pediatrics.; 2022; [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/35531640][DOI: https://dx.doi.org/10.1542/peds.2021-053458]

81. American Medical Association. AMA Adopts New Policies on First Day of Voting at 2019 Annual Meeting. Available at: https://www.ama-assn.org/press-center/press-releases/ama-adopts-new-policies-first-day-voting-2019-annual-meeting. Accessed April 4, 2024.

82. Society for Adolescent Health and Medicine, English A, Ford CA, et al. Adolescent consent for vaccination: a position paper of the Society for Adolescent Health and Medicine. J Adolesc Health. 2013;53:550–3.

83. Watson, D; Mhlaba, M; Molelekeng, G et al. How do we best engage young people in decision-making about their health? A scoping review of deliberative priority setting methods. Int J Equity Health.; 2023; [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/36698119][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9876416][DOI: https://dx.doi.org/10.1186/s12939-022-01794-2]

84. Alderman, EM; Breuner, CC Committee on Adolescence. Unique needs of the adolescent. Pediatrics.; 2019; [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/31740496][DOI: https://dx.doi.org/10.1542/peds.2019-3150]

85. Immunize.org. Exemptions Permitted for State Childcare and School (Kg–Gr 12). Available at: https://www.immunize.org/official-guidance/state-policies/vaccine-requirements/exemptions-childcare-school/. Accessed May 8, 2024.

86. Srivastava, T; Emmer, K; Feemster, KA. Impact of school-entry vaccination requirement changes on clinical practice implementation and adolescent vaccination rates in metropolitan Philadelphia. Hum Vaccin Immunother; 2020; 16, pp. 1155-1165. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/31977274][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227691]

87. Nyathi, S; Karpel, HC; Sainani, KL et al. The 2016 California policy to eliminate nonmedical vaccine exemptions and changes in vaccine coverage: an empirical policy analysis. PLoS Med; 2019; 16, [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/31869328][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6927583]e1002994.

88. Greyson, D; Vriesema-Magnuson, C; Bettinger, JA. Impact of school vaccination mandates on pediatric vaccination coverage: a systematic review. CMAJ Open; 2019; 7, pp. E524-E536. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/31431485][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6703989]

89. Immunize.org. State Meningococcal ACWY (MenACWY) Vaccine Requirements for Colleges and Universities. Available at: https://www.immunize.org/laws/menin.asp. Accessed November 3, 2023.

90. National Student Clearinghouse Research Center. Term Enrollment Estimates Spring 2022. Available at: https://nscresearchcenter.org/wp-content/uploads/CTEE_Report_Spring_2022.pdf. Accessed April 11, 2024.

91. Azzari, C; Diez-Domingo, J; Eisenstein, E et al. Experts’ opinion for improving global adolescent vaccination rates: a call to action. Eur J Pediatr; 2020; 179, pp. 547-553. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/32072304][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080665]

92. Stange, KC; Nutting, PA; Miller, WL et al. Defining and measuring the patient-centered medical home. J Gen Intern Med; 2010; 25, pp. 601-612. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20467909][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2869425]

93. National Alliance of State Pharmacy Associations. Pharmacist Administered Vaccines. Available at: https://naspa.us/wp-content/uploads/2021/01/Pharmacist-Immunization-Authority-April-2023.pdf. Accessed April 4, 2024.

94. Shah, PD; Calo, WA; Marciniak, MW; Gilkey, MB; Brewer, NT. Support for pharmacist-provided HPV vaccination: national surveys of U.S. physicians and parents. Cancer Epidemiol Biomarkers Prev.; 2018; 27, pp. 970-8. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/29871883][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6092750]

95. Varisco, TJ; Downs, CG; Sansgiry, SS et al. Parents’ intention to have their child vaccinated at a community pharmacy: a national cross-sectional survey. J Am Pharm Assoc; 2023; 63, pp. 511-7e8.

96. Isenor, JE; Edwards, NT; Alia, TA et al. Impact of pharmacists as immunizers on vaccination rates: a systematic review and meta-analysis. Vaccine; 2016; 34, pp. 5708-5723.1:STN:280:DC%2BC2srksFOhuw%3D%3D [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27765379]

97. Rothholz, M; Tan, LLJ. Promoting the immunization neighborhood: benefits and challenges of pharmacies as additional locations for HPV vaccination. Hum Vaccin Immunother; 2017; 13, pp. 1856-1858. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27216035]

98. Marshall, GS; Fergie, J; Presa, J; Peyrani, P. Rationale for the development of a pentavalent meningococcal vaccine: a US-focused review. Infect Dis Ther; 2022; 11, pp. 937-951. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/35357651][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8969818]

99. McNamara L. Plan for Revisiting the Adolescent Schedule for Meningococcal Vaccines. Available at: https://www.cdc.gov/acip/downloads/slides-2023-10-25-26/02-Meningococcal-McNamara-508.pdf#:~:text=Plan%20for%20revisiting%20the%20adolescent%20schedule%20for%20meningococcal. Accessed September 17, 2024.

100. Collins J. Advisory Committee on Immunization Practices (ACIP) Meeting. October 25, 2023. Summary of EtR and proposed recommendations for Pfizer’s MenABCWY vaccine. Available at: https://www.cdc.gov/acip/downloads/slides-2023-10-25-26/04-Meningococcal-Collins-508.pdf. Accessed 21 May 2025.

101. Kroger A, Bahta L, Long S, Sanchez P. General Best Practice Guidelines for Immunization. 2023. Available at: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf. Accesssed 20 May 2025.

102. Folaranmi, T; Rubin, L; Martin, SW et al. Use of serogroup B meningococcal vaccines in persons aged ≥10 years at increased risk for serogroup B meningococcal disease: recommendations of the Advisory Committee on Immunization Practices, 2015. MMWR Morb Mortal Wkly Rep; 2015; 64, pp. 608-612. [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/26068564][PubMedCentral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4584923]

103. 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. 2009;58:1042–3.

104. Menveo (meningococcal [groups A, C, Y, and W-135] oligosaccharide diphtheria CRM₁₉₇ conjugate vaccine). Full Prescribing Information, GlaxoSmithKline, Durham, NC, 2022.

105. MenQuadfi (meningococcal [groups A, C, Y, W] conjugate vaccine). Full Prescribing Information, Sanofi Pasteur Inc., Swiftwater, PA, 2022.

106. Trumenba (meningococcal group B vaccine). Full Prescribing Information, Wyeth Pharmaceuticals LLC, a subsidiary of Pfizer Inc, Philadelphia, PA, 2024.

107. Bexsero (meningococcal group B vaccine). Full Prescribing Information, GlaxoSmithKline, Research Triangle Park, NC, 2022.

108. Findlow, J; Borrow, R; Stephens, DS et al. Correlates of protection for meningococcal surface protein vaccines: current approaches for the determination of breadth of coverage. Expert Rev Vaccines; 2022; 21, pp. 753-769.1:CAS:528:DC%2BB38XhsFansLfI [PubMed: https://www.ncbi.nlm.nih.gov/pubmed/35469524]

109. US Food & Drug Administration. Summary Basis for Regulatory Action. PENBRAYA. November 17, 2023. Available at: https://www.fda.gov/media/174155/download. Accessed April 02, 2025.