Reworking how we think about meningococcal vaccines
By Dr Nikki Turner, GP and Director of the Immunisation Advisory Centre
18 November 2020
If you’ve ever had the misfortune to encounter meningococcal disease, you’ll know it’s a very frightening bacterial disease that can rapidly escalate to meningitis or blood poisoning. It’s hard to diagnose because it can present with flu-like symptoms but can progress very rapidly, even within a few hours, to severe illness or death. Early medical intervention with antibiotics is vital, but even with excellent medical care the disease can still maim and kill.
In New Zealand we have five main types of meningococcal disease. About half of all disease is caused by Type B and mostly affects infants, young children, and adolescents with higher rates for Māori, Pasifika communities, and infants in low income situations. That’s the one we all vaccinated for when it was on the national schedule after it reached epidemic levels. The vaccine at the time only acted against the one strain and once the epidemic rates dropped, the vaccine was no longer used.
The other half of the disease burden is caused by four other types, A, C, Y and W. While C is the most common, in recent years Type W is on the increase and can be even more difficult to diagnose and more lethal than the other types.
New Zealand does have a vaccine for these strains of meningococcal but it’s not on the national schedule because overall the disease is rare across the community and the cost to benefit ratio is not considered high enough to publicly fund the vaccine for everyone.
The exception is that there is funding for a small group of children with very high medical risk, and all people aged between 13 to 25 who are living in boarding school hostels, tertiary education halls of residence, military barracks, or prisons because transmission of the bacterium is increased between people living in close quarters. The disease is no less dangerous for others in this age group, but it’s less likely that great numbers of their peer group are living together.
The availability of the vaccine, or it’s funded status for specific groups, isn’t always well known so I encourage you to discuss it with your patients and/or their accompanying family. Of course anyone who doesn’t fit the funding criteria can pay for the vaccine privately, although that’s not cheap, which sets up a real equity issue within our community especially when you consider that those at highest risk of meningococcal disease are least likely to be in a position to purchase the vaccine.
There’s a real place for vaccines in meningococcal disease reduction but if our national health services continue to feel this disease doesn’t reach the criterion to fund vaccines for all, then let’s get more creative at general practice about offering them to those who would benefit the most. Instead of waiting to see who can afford it, and who is aware of these vaccines, we should turn this inverse care law upside down and looks for ways to prioritise the vaccines to those who need them most.
Meningococcal disease – like so many other health issues – is a real equity issue. We know these viruses after higher rates of Māori and Pasifika people. We know that vaccines help. And we know that where low-income patients can’t afford the vaccine because it’s not on the schedule that we’ve got a problem with the health system. This is a disease where those who are at highest risk are least likely to purchase the vaccine.
We target many other services to those with highest needs and there is no reason why we cannot do so with meningococcal vaccines. Use of community services card is one simple way of targeting the highest needs group first. All general practices now get regular updates about patients with these cards making it feasible to identify and offer vaccines to this important group.
There’s a lot more that we could do as a country to manage this awful disease, but like many health conditions, it’s complicated. While we could put more effort into community and health service awareness, and rapid access to antibiotics, that will never fully stop the disease. We need big picture change; a reduction in poverty, massive and urgent improvement to the housing stock, and improvement to nutrition, particularly in those low-income, high-deprivation communities where poverty-driven issues like meningococcal disease, rheumatic fever, and bronchiectasis are creating life-long damage for (and sometimes killing) our kids.