Booster immunization of meningococcal meningitis vaccine among children in Hangzhou, China, 2014-2019.

BACKGROUND: Despite China's Expanded Program on Immunization (EPI) provides 2 doses of group A and group C meningococcal polysaccharide vaccine (MPV-AC) for children at 3 years and 6 years old, more self-paying group ACYW135 meningococcal polysaccharide vaccines (MPV-ACYW135) have been used as an alternative to MPV-AC to prevent Neisseria meningitidis serogroup C,Y,W135. We provide recommendations for Chinese booster immunization of meningococcal meningitis vaccine by analyzing the service status of MPV-AC and MPV-ACYW135.
METHODS: Reported data of routine immunization coverage from all districts of Hangzhou registered in the China Information Management System For Immunization Programming (CIMSFIP) between 2014 to 2019 were described and evaluated. Descriptive epidemiological methods were used to characterize the data. Adverse event following immunization (AEFI) were collected from Chinese national adverse event following immunization information system (CNAEFIIS) to compare the safety of MPV-AC and MPV-ACYW135.
RESULTS: 1376919 doses of booster immunization of meningococcal meningitis vaccine (MenV) in CIMSFIP were conducted in China Hangzhou from 2014 to 2019, with reported immunization coverage rates above 95%. The proportion of children using MPV-ACYW135 increased from 12.63% in 2014 to 29.45% in 2019. The incidence of AEFI of MPV-AC and MPV-ACYW135 were 49.75 per 100,000 and 45.44 per 100,000, respectively, without statistical difference.
CONCLUSION: Children in Hangzhou had high booster immunization of MenV coverage. The use amount and use rate of MPV-ACYW135 increased year by year, indicating more and more parents had chosen MPV-ACYW135 as an alternative to MPV-AC at their own expense for children. The use proportions of MPV-ACYW135 were different in urban, suburban and rural areas. Both MPV-AC and MPV-ACYW135 were safe for children.

Introduction

Meningococcal meningitis is a severe acute respiratory infection caused by neisseria meningitidis (Nm) that may lead fevers, rashes, meningeal irritations, meningitis and even deaths [1]. Apart from meningitis and septicaemia, the meningococcal disease occasionally causes arthritis, myocarditis, pericarditis and endophthalmitis [2]. Globally, meningococcal meningitis has become one of the most serious public health problems in many countries, affecting about 1.2 million people annually. Its mortality is up to 40% and about 20% of the cases are associated with long-term sequelae (such as neurological complications) [3]. The disease has a high incidence in Africa, known as the African meningitis belt which was defined by Molesworth and his coworkers in 2002 [4], and a low incidence in Europe and the United States [5]. There are 12 serogroups, divided into groups A, B, C, D, E, H, I, K, L, X, Y, Z and W135, but most invasive meningococcal infections were caused by groups A, B, C, X, Y and W-135, accounting for 95% of the meningococcal cases [6]. In Asia, particularly in developing countries, meningococcal epidemics of serogroups A and C have resulted in high morbidity and mortality, and the threat remains [7, 8]. In China, serogroup A or serogroup C meningococcal meningitis epidemic occurred in several provinces in late 2004 and early 2005 [9]. In recent years, most cases have occurred in children under 15 years of age, especially in infants aged between 6 months and 2 years [10].

Prophylactic medication can help prevent meningococcal meningitis at individual level, such as among family members and the close contacts of meningitis patients. However, its effectiveness of reducing disease risk in population level in response to the outbreaks of meningococcal disease may be limited [11]. Meningococcal vaccination is the most effective way to prevent meningococcal meningitis. In 1980s, group A meningitis vaccine had been widely used in China, and the incidence of meningococcal meningitis decreased significantly. Since 2006, group A meningococcal polysaccharide vaccine (MPV-A) and MPV-AC began to be administered free to children as EPI vaccines in Hangzhou, China. Children aged 6–18 months were qualified to receive two doses of MPV-A in at least three months apart, followed by two doses of MPV-AC booster at age 3 and 6 years. MPV-ACYW135 entered the market in Hangzhou in 2014 as a self-funded vaccine, mainly replacing MPV-AC for the children at the age of 3 or 6 years old. MPV-ACYW135 has not been included in the free EPI vaccination for the time being because the national financial resources cannot afford the cost of MPV-ACYW135 and the vaccine production capacity cannot currently meet the needs of all children.

The objective of our study is to understand the coverage rates of booster immunization of meningococcal meningitis vaccine, the use rate of MPV-AC and the trend in the use amount of MPV-ACYW135, in Hangzhou between 2014 and 2019.

Methods

Setting

Hangzhou is a metropolis in Zhejiang province of East China, with more than 10 million population. There are fifteen districts in Hangzhou, six of which are classified as urban areas (Shangcheng, Xiacheng, Jianggan, Gongshu, Xihu, and Xihufengjingmingsheng); six of which are suburb area (Binjiang, Xiaoshan, Yuhang, Qiantang, Fuyang, Linan); and the others are rural areas (Tonglu, Jiande, Chunan). Hangzhou has 200 vaccination clinics responsible for vaccinating all the children and adults living in the city, no matter they are local residents or migrants. EPI clinicians must inform parents the benefits and risks of MPV-AC or MPV-ACYW135 before vaccination.

Since 2014, China began to use the newly developed CIMSFIP to collect routine immunization report data. The routine immunization coverage of vaccines in the National Immunization Program (NIP) in China including Hangzhou were reported and summarized through this system. Our research team derived and analyzed the data from NIP in October 2020.

AEFI refers to the reaction during or after vaccination that may cause damage to tissues, organs, or functions of the recipients that are suspected to be related to vaccination. At present, Chinese national adverse event following immunization information system (CNAEFIIS) is the only designated system for collecting AEFI in China. According to the causes, the adverse events can be divided into the adverse reactions (including common adverse reactions and rare adverse reactions), the vaccine quality accidents, the implementation errors, coincidences and the psychogenic reactions. Our research team derived and analyzed data from CNAEFIIS in October 2020.

Vaccination status and AEFI collection

According to the NIP vaccine immunization procedures, the study reports the number of targeted children, the number of children vaccinated and the inoculation rates in the jurisdiction. The content of the report includes information such as vaccine, doses, household registrations and the coverage of vaccine. When a non-NIP vaccine is used as a replacement of NIP vaccination, its number of targeted children and vaccinated children will be included in the NIP vaccine routine immunization report. NIP data were derived from the "SAAS Vaccination System". When duplicate information appeared, we matched the child’s name, birth date, parents’ names and telephone number, combined the vaccination data and reported it. AEFI of MPV-AC and MPV-ACYW135 were exported from CNAEFIIS.

Statistical analysis

Annual incidences of AEFI in MPV-AC and MPV-ACYW135 were analyzed statistically. MenV AEFI per 100,000 populations was calculated using the number of MenV AEFI cases divided by the number of MenV vaccinated. All statistical analyses and graphs were made by SPSS statistical software for Windows (version 17.0, SPSS Inc., Chicago, IL, USA). A value of P<0.05 (2-sided) was considered statistically significant. The chi-square test was used to compare the proportions of children who used MPV-AC and MPV-ACYW135, the incidence of common adverse reaction and rare adverse reaction in MPV-AC and MPV-ACYW135. The chi-square trend test was also used to compare the proportion of children using MPV-AC or MPV-ACYW135 year by year.

Ethical considerations

This study was determined to be exempt from ethical review by the Hangzhou CDC institutional review board. The extraction of data from NIP and CNAEFIIS was safe, which was not linked to individual identifiers.

Results

MenV coverage

1,376,919 infants from 2014 to 2019 were registered in HZIIS. There were 124,466, 131,473, 118,584, 142,727, 116,239 and 149,305 children each year. The coverage rates were 99.50% in MenV-3 and 99.44% in MPV-6, consistently over 95% from 2014 to 2019 (Table 1).

Table 1

Reported immunization coverage rates of MenV by dose from 2014 to 2019 in Hangzhou.

year	MPV-3a			MPV-6b
	No. of children	No. of vaccination	coverage rates (%)	No. of children	No. of vaccination	coverage rates (%)
2014	124466	121906	97.94	83953	81790	97.42
2015	131473	131190	99.78	86282	86041	99.72
2016	118584	118350	99.80	93570	93328	99.74
2017	142727	142427	99.79	108336	108067	99.75
2018	116239	116026	99.82	116551	116281	99.77
2019	149305	148978	99.78	112746	112535	99.81
Total	782794	778877	99.50	601438	598042	99.44

a: meningococcal polysaccharide booster vaccine given to children aged 3 years

b: meningococcal polysaccharide booster vaccine given to children aged 6 years

Trend of MenV vaccination

From 2014 to 2019, the proportion of children using MPV-AC decreased year by year, from 87.37% in 2014 to 70.55% in 2019(χ2 = 18886.42, Pfor trend<0.05). The proportion of children using MPV-ACYW135 increased year by year, from 12.63% in 2014 to 29.45% in 2019(χ2 = 18886.42, Pfor trend<0.05) (Table 2).

Table 2

The proportion of children using MPV-AC or MPV-ACYW135.

year	No. Vaccinated	MPV-AC		MPV-ACYW135
		No.	Proportion (%)	No.	Proportion (%)
2014	203696	177975	87.37	25721	12.63
2015	217231	171927	79.14	45304	20.86
2016	211678	169188	79.93	42490	20.07
2017	250494	199689	79.72	50805	20.28
2018	232307	172176	74.12	60131	25.88
2019	261513	184495	70.55	77018	29.45
Total	1376919	1075450	78.11	301469	21.89

The proportion of children who used MPV-ACYW135 was highest in urban (46.88%), and lowest in suburb (5.87%) (χ2urban, suburb = 292375.33, χ2urban, rural = 15064.35, χ2suburb, rural = 68993.42, all P-value<0.05) (Table 3).

Table 3

The proportion of children using MPV-ACYW135 by geography.

year		urban			suburb			rural
	No. Vaccinated	No. ACYW135	Proportion (%)	No. Vaccinated	No. ACYW135	Proportion (%)	No. Vaccinated	No. ACYW135	Proportion (%)
2014	70823	19661	27.76	111520	2129	1.91	21353	3931	18.41
2015	75735	33674	44.46	119588	4204	3.52	21908	7426	33.90
2016	72054	30944	42.95	118317	5162	4.36	21307	6384	29.96
2017	85280	39839	46.72	141686	4775	3.37	23528	6191	26.31
2018	76284	42996	56.36	132819	10327	7.78	23204	6808	29.34
2019	83869	50420	60.12	152804	18989	12.43	24840	7609	30.63
total	464045	217534	46.88	776734	45586	5.87	136140	38349	28.17

AEFI of MPV-AC and MPV-ACYW135

For 2014 to 2019, 535 AEFI cases of MPV-AC and 137 AEFI cases of MPV-ACYW135 were reported in CNAEFIIS. The incidences of AEFI in MPV-AC and MPV-ACYW135 were 49.75 per 100,000 and 45.44 per 100,000(χ2 = 0.89, P>0.05), respectively. The incidences of common adverse reaction in MPV-AC and MPV-ACYW135, mainly the injection site erythema, injection site pain and fever, were 39.98 per 100,000 and 31.18 per 100,000, respectively (χ2 = 4.80, P<0.05). The incidence of rare adverse reaction in MPV-AC (8.18 per 100,000) was lower than that of MPV-ACYW135 (13.60 per 100,000) (χ2 = 7.38, P<0.05) (Table 4). Allergic rash was the main rare adverse reaction for both vaccines, and few cases of epilepsy, febrile convulsion, and angioedema were reported. There were no serious reactions or deaths.

Table 4

AEFI incidence of MPV-AC and MPV-ACYW135 vaccinated from 2014 to 2019.

Vaccine		Common adverse reaction		Rare adverse reaction		Coincidental event		Total
	No. Vaccinated	No. of cases	Reporting rate (/100 000 doses)	No. of cases	Reporting rate (/100 000 doses)	No. of cases	Reporting rate (/100 000 doses)	No. of cases	Reporting rate (/100 000 doses)
MPV-AC	1075450	430	39.98	88	8.18	17	1.58	535	49.75
MPV-ACYW135	301469	94	31.18	41	13.60	2	0.66	137	45.44

Discussion

Our study showed that children in Hangzhou had a high coverage of MenV booster vaccination. The proportions of MPV-AC or MPV-ACYW135 use changed by year, and MPV-ACYW135 was used more and more frequently for children from 2014 to 2019. Our finding demonstrated a positive safety profile of MenV with reasonable low incidences of AEFI for both MPV-AC and MPV-ACYW135. Urban children seem to be more likely use MPV-ACYW135 than suburb’s.

MenV has been continuously used for many years in Hangzhou. During 2014 to 2019, the coverage rates of the third or fourth dose of MenV were all above 95%, which was similar to the reported coverage rates of MenV in NIP in China 2014 (98.54% and 98.53%) [12], and was higher than the one in Dong Weibo’s research which was lower than 95% in Fenghua, Zhejiang [13], and the one in Xie Qun’s research in Xiamen, Fujian [14]. With the high immunization level of MenV, the incidence of meningococcal meningitis decreased. From 2006 to 2017, the morbidity and mortality of meningococcal meningitis in Zhejiang province decreased gradually by year. Since 2010, less than 10 cases a year have been reported in Zhejiang [15], especially in Hangzhou (S1 Table), meaning MenV effectively prevented the occurrence of meningococcal meningitis. In recent years, there were few cases of meningococcal meningitis in Hangzhou.

Based on the researches in recent years, MPV-AC had good immunogenicity in children aged between 2–6 years. It can achieve good protective effect one month after immunization, and its effect decrease two years after immunization [16]. A booster immunization with MPV-AC is necessary (S2 Table), which induces good immune response after primary immunization with either MPV-A or MCV-AC [17]. In the 20th century, there have been changes in epidemic flora of Nm in different countries and regions and the need for MPV-ACYW135 increase. After 2006, there have been reports of sporadic cases of group W135 [18, 19]. The surveys of Nm carriers in some areas of China show that healthy people’s serum bactericidal antibodies of group Y and W135remain low, which indicates that there is a risk of epidemic related flora [20-22].

The incidence of AEFI in MPV-AC and MPV-ACYW135 was lower in Hangzhou than Shanghai [23] and higher than Fujian [24]. There was no difference in the incidence of AEFI between MPV-AC and MPV-ACYW135, with allergic rash and urticaria which were the main events, and no more serious damage was caused, indicating that both vaccines were safe.

The proportion of children who used MPV-ACYW135 was highest in urban and lowest in suburb. The suburbs had the highest total number of MenV vaccinated, but the lowest rate of MPV-ACYW135. The economic income in rural had always been at a low level (S3 Table), but the vaccination rate of MPV-ACYW135 was not the lowest. Therefore, economic reasons may not be the main reason for parents to choose MPV-ACYW135 at their own expense.

In sum, the MPV-ACYW135 has stable clinical performance [25] and good immunological effects [26, 27], which are relatively safe for children. In particular, in order to make MPV-ACYW135 available to all children regardless of geographical location and promote health equity, the government should consider updating the current meningococcal meningitis immunization strategy in China to use MPV-ACYW135 for booster immunization in children at 3 years and 6 years old.

Limitations of the study

Due to the new CNAEFIIS system permissions and data conversion problems, AEFI data cannot be sorted by district or county for the time being, and it is impossible to compare AEFI reporting rates between regions.

A second limitation of our study was the findings that the suburb had the largest population and inoculation amount in Hangzhou, but its inoculation proportion of MPV-ACYW135 was not high. What causes the low inoculation proportion of MPV-ACYW135 in the suburb is a problem that needs to be further studied.

Conclusions

To sum up, children in Hangzhou had high booster immunization with MenV. In the case that MPV-AC and MPV-ACYW135 were equally safe, more and more children’s parents chose MPV-ACYW135 at their own expense instead of MPV-AC. The use proportions of MPV-ACYW135 were different in urban, suburban and rural areas.

Month distribution of meningococcal meningitis in Hangzhou from 1950 to 2019(No. of cases).

Since the 1980s, the number and incidence of meningitis in Hangzhou have been gradually decreasing. The periodic prevalence of meningitis has disappeared in Hangzhou and has been sporadic for many years, with zero incidence in some years. In recent years, both urban and suburban areas are in a sporadic state, and there is no cluster epidemic.

(DOCX)

Click here for additional data file.

Nma antibody levels in group A and group C of healthy people in an urban area of Hangzhou in 2018.

Another study in Hangzhou showed that the antibody concentration of group A or group C in the subjects would increase with increasing immunization times, and the average serum antibody concentration was the highest in people who received 4 doses of meningococcal vaccine. It can be seen that the two doses of basic immunization within 18 months of age and one dose of booster immunization at 3 and 6 years of age can produce high concentration of antibodies.

(DOCX)

Click here for additional data file.

Hangzhou’s per capita income over the years from 2016 to 2018.

Hangzhou’s financial per capita income from 2016 to 2018 shows that the urban per capita income is much higher than the rural per capita income. The disposable income of rural people is much lower than that of urban people.

(DOCX)

Click here for additional data file.

24 Feb 2021

PONE-D-21-02890

Booster immunization of meningococcal meningitis vaccine among children in Hangzhou, China, 2014-2019

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Reviewer #1: Here are my comments:

Typo: line 33 China Information Management System For Immunization Programming (CIMSFIP)

Line 66 A large serogroup A and Serogroup C???

Line 74 and 79 two dots

P value should be lower case in line 116

Typo in Table1) title is 2014-2018, should be 2014-2019

Line 123 the number should be 1,376,919 and not 1376,919

Use correct verb for the vaccine (not vaccined/ vaccinated is correct)

Line 158 fourth dose is correct

Line 200 We believe

In lines 105-107 authors mentioned about household registration. Why not having more info about rural and urban vaccination distribution in the study? Which location have received more MPV-ACYW135 and why? Any idea about “more populous municipalities had lower AEFI reporting rate than less populous ones”?

Please describe why the MPV-ACYW135 is self-paid? What are the reasons that government does not support its free or subsidized use of MPV-ACYW135 vaccination?

Any information about duplicate records and how did you handle it? Wu et al. (2019) found that “ an average of 3% duplicate records within provinces[China], and that duplicated record rates were higher in the eastern region than the western region”

Please check https://doi.org/10.1016/j.vaccine.2019.08.070

Reviewer #2: In this study, the authors investigated the coverage rates of booster immunization of meningococcal meningitis vaccines, and the proportion of use of MPV-AC and the change in the number of MPV-ACYW135 used, in Hangzhou between 2014 and 2019. They concluded that the reported immunization coverage rates of booster immunization of MenV were all above 95%, and children in Hangzhou had a high coverage of MenV booster vaccination. The proportion of children using MPV-ACYW135 increased from 12.63% in 2014 to 29.45 in 2019. The incidence rate of AEFI of MPV-AC and MPVACYW135 was 49.75 per 100,000 and 45.44 per 100,000, respectively. However, some conclusions cause concern, which must be addressed.

1. Line 198 The authors claimed, “we believe that MPV-ACYW135 has advantages of simultaneously preventing a variety of diseases, reducing the number of injections and simplifying immunization procedures,” however, the authors did not provide any data such as serum antibody concentration in Hangzhou, cost-effective to demonstrate the MPV-ACYW135 better than MPV-AC. Statistical analysis also show there is no difference in the incidence of AEFI between MPV-AC and MPV-ACYW135. All data only show children in Hangzhou had a high coverage of MenV booster vaccination, the number of MPV-ACYW135 was used more frequently for children from 2014 to 2019. Why authors recommended to use MPV-ACYW135 instead of MPV-AC for free in Chinese children aged 3-6 years?

2. Discussion: line 186-195 cause controversy. For an example, “The AEFI data used in this paper was passively monitoring data, which may not truly reflect the occurrence of AEFI of MPV-AC or MPV195-ACYW135 to some extent.” Need to rewrite this paragraph.

3. Minor error: line 127 from 2014 to 2018 in Hangzhou should be from 2014 to 2019 in Hangzhou.

Line 312 S3 Nma antibody levels May be S2 Nma antibody levels. (there no S3 table).

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31 Mar 2021

Response to the “Journal Requirements”:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at……

Authors’ response:

According to the requirements, we have checked the manuscript and ensure that our manuscript meets PLOS ONE's style requirements. If there are any formatting errors that we do not recognize, please specify them.

2. Thank you for providing the date(s) when patient medical information was initially recorded. Please also include the date(s) on which your research team accessed the databases/records to obtain the retrospective data used in your study.

Authors’ response:

As suggested, we have added the date(s) on which our research team accessed the databases/records used in our study in lines 102-103 as follows:” Our research team derived and analyzed the data from NIP in October 2020.”

3. In your ethics statement in the Methods section and in the online submission form, please provide additional information about the data used in your retrospective study. Specifically, please confirm whether all data were fully anonymized before you accessed them.

Authors’ response:

As suggested, we have added ethics statement in the Methods section and in lines 134-137 as follows:” Ethical considerations

This study was determined to be exempt from ethical review by the Hangzhou CDC institutional review board. The extraction of data from NIP and CNAEFIIS was safe, which was not linked to individual identifiers.”

4. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 1 in your text; if accepted, production will need this reference to link the reader to the Table.

Authors’ response:

As suggested, we have linked the reader to the Table in line 143.

Response to the reviewer's comments:

Response to the reviewer #1

1. Typo: line 33 China Information Management System For Immunization Programming (CIMSFIP)

Authors’ response:

As suggested, we have corrected the word ”programming” in line 33.

Line 66 A large serogroup A and Serogroup C???

Authors’ response:

As suggested, we have rephrased sentence in line 66 as follows:” serogroup A or serogroup C.”

Line 74 and 79 two dots

Authors’ response:

As suggested, we have deleted one dot in line 74.

P value should be lower case in line 116

Authors’ response:

As suggested, we have changed “P value” into “P value” in line 128.

Typo in Table1) title is 2014-2018, should be 2014-2019

Authors’ response:

As suggested, we have changed “2014-2018” into “2014-2019” in line144.

Line 123 the number should be 1,376,919 and not 1376,919

Authors’ response:

As suggested, we have changed “1376,919” into “1,376,919” in line 140.

Use correct verb for the vaccine (not vaccined/ vaccinated is correct)

Authors’ response:

As suggested, we have checked all verb for the vaccine in lines 114,117,126,153,157,169,205.

Line 158 fourth dose is correct

Authors’ response:

As suggested, we have used the right “fourth” in line 178.

Line 200 We believe

Authors’ response:

We reedited the entire text of the paragraph where "we believed" is.

In lines 105-107 authors mentioned about household registration. Why not having more info about rural and urban vaccination distribution in the study? Which location have received more MPV-ACYW135 and why? Any idea about “more populous municipalities had lower AEFI reporting rate than less populous ones”?

Authors’ response:

As suggested, we have added analysis about rural and urban vaccination distribution in the study in lines 154-157,204-209. AEFI data cannot be summarized by region due to system upgrade, so this study did not analyze and discuss it.

Please describe why the MPV-ACYW135 is self-paid? What are the reasons that government does not support its free or subsidized use of MPV-ACYW135 vaccination?

Authors’ response:

As suggested, we have explained the reason “why the MPV-ACYW135 is self-paid” in line 81-85.

Any information about duplicate records and how did you handle it? Wu et al. (2019) found that “ an average of 3% duplicate records within provinces[China], and that duplicated record rates were higher in the eastern region than the western region”

Please check https://doi.org/10.1016/j.vaccine.2019.08.070

Authors’ response:

As suggested, we have checked “https://doi.org/10.1016/j.vaccine.2019.08.070” and explain how did we handle duplicate records in 119-122.

Response to the reviewer #2

1. Line 198 The authors claimed, “we believe that MPV-ACYW135 has advantages of simultaneously preventing a variety of diseases, reducing the number of injections and simplifying immunization procedures,” however, the authors did not provide any data such as serum antibody concentration in Hangzhou, cost-effective to demonstrate the MPV-ACYW135 better than MPV-AC. Statistical analysis also show there is no difference in the incidence of AEFI between MPV-AC and MPV-ACYW135. All data only show children in Hangzhou had a high coverage of MenV booster vaccination, the number of MPV-ACYW135 was used more frequently for children from 2014 to 2019. Why authors recommended to use MPV-ACYW135 instead of MPV-AC for free in Chinese children aged 3-6 years?

Authors’ response:

As suggested, we agree with Reviewer 2. We have revised our conclusions in lines 224-228 and made changes to the discussion section.

2. Discussion: line 186-195 cause controversy. For an example, “The AEFI data used in this paper was passively monitoring data, which may not truly reflect the occurrence of AEFI of MPV-AC or MPV195-ACYW135 to some extent.” Need to rewrite this paragraph.

Authors’ response:

As suggested, we have rephrased this paragraph in lines 216-223.

3. Minor error: line 127 from 2014 to 2018 in Hangzhou should be from 2014 to 2019 in Hangzhou.

Line 312 S3 Nma antibody levels May be S2 Nma antibody levels. (there no S3 table).

Authors’ response:

As suggested, we have changed “2014-2018” into “2014-2019” in line144 and “S2 Nma antibody levels”in line 326.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

29 Apr 2021

Booster immunization of meningococcal meningitis vaccine among children in Hangzhou, China, 2014-2019

PONE-D-21-02890R1

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Reviewer #2: All comments have been addressed

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Reviewer #1: (No Response)

Reviewer #2: In order to demonstrate the MPV-ACYW135 better than MPV-AC ( immunological effects), the authors should compare the serum antibody titer or T cells response after booster immunization of MPV-ACYW135 or MPV-AC.

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Reviewer #1: Yes: ABOLFAZL GHASEMI

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14 May 2021

PONE-D-21-02890R1

Booster immunization of meningococcal meningitis vaccine among children in Hangzhou, China, 2014-2019

Dear Dr. Liu:

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