Experts on lessons learned from MeNZB

As the Northland District Health Board attempts to vaccinate up to 40,000 young people against the meningococcal C disease, new research has been published that is highly critical of aspects of the Government’s $200 million 2004 – 2008 meningococcal B (MeNZB) immunisation programme.

Dr Nikki Turner

Health officials were aware of the need for a vaccine from 1996. An early vaccine for the NZ stain had been trialled when the Ministry of Health met experts in Baltimore that year, but the nation-wide immunisations with a new vaccine did not start until eight years later. The latest review repeatedly points to a lack of “engagement” or “late engagement” by the MoH.

Researchers led by Professor Diana Lennon, a specialist in community paediatrics at Auckland University, and writing in the Journal of Paediatrics and Child Health*, claim a delay in progressing that vaccine strategy against serotype B, “led to unnecessary and potentially avoidable deaths and sequelae, many lifelong”.

The research also found that though children of Pacific ethnicity — who had the highest burden of disease — achieved the highest vaccination, this did not apply to other high-risk ethnic groups, such as Maori children.

Researchers decried a lack of data to pin down the effectiveness of the MeNZB vaccinations: “It is also unfortunate that every effort was not taken to robustly assess the contribution of MeNZB to the decline in meningococcal disease in NZ… some decisions made were rather short-sighted”.

A dozen people have fallen sick in the Northland since July with meningococcal C, a different strain of the disease but with the same symptoms, and another dozen in Wellington, with a total of five known deaths. Health advisers are currently considering whether meningococcal should be added to the national immunisation schedule.

* The research, Reducing Inequalities with Vaccine: New Zealand’s MeNZB Vaccine Initiative to Control an Epidemic, is available to registered journalists in the SMC Resource Library.

The SMC put the following questions to Dr Nikki Turner, Immunisation Advisory Centre director and Senior Lecturer, General Practice & Primary Health Care at University of Auckland (Dr Turner was not involved in the MeNZB immunisation programme):

The paper refers to the Health Ministry’s “late engagement” with the vaccine development/immunisation programme. How could such problems be avoided in future?

“In general terms, the importance of a government that recognises and responds in a timely fashion to vaccine preventable diseases is about political awareness and rapid response — a health sector that effectively raises the issues rapidly, an effective Ministry of Health that reviews and advises well, an aware Minister of Health who is engaged and interested, an ability to lobby for the funding and resources to respond.”

How many patients fell sick between 1996, when detailed advice was flowing to the MoH and 2004 when the immunisation started, how many of those patients died or suffered lasting effects, and what data is there to show the incidence of the disease fell more sharply than could have been expected from the natural end of the epidemic?

“These are hard to answer absolutely. We know the amount of cases and deaths – it does look like the epidemic peaked just prior to the introduction of the vaccine so one could speculate that if we had moved earlier and got the vaccine delivered to New Zealand kids earlier we would expect to have seen a stronger effect of the vaccine. We only have descriptive epidemiology and mathematical modeling to suggest the vaccine did have some effectiveness, but this paper is correct in stating we are unable to be sure how effective the vaccine itself was and we will never know for sure.”

How could the New Zealand health bureaucrats, policy-makers and decision-makers have performed better in that epidemic of serogroup B meningococcal disease?

“It is clear that it would have been expected to be more effective if we could have managed to get the vaccine delivered to New Zealand children earlier than 2004/2005. However, on the other side this was a big undertaking for New Zealand and the fact that we managed to get a tailor-made vaccine to the New Zealand market is also a remarkable achievement for New Zealand as a small country with relatively limited resources and expertise. This was no small feat!!”

Why do you think children of Pacific ethnicity had the highest vaccination rates, while the children of Maori ethnicity — at the next-highest risk of infection — fell markedly short of these levels?

“We are consistently getting higher immunisation coverage rates for Pacific children. Pacific communities and Maori are quite different. The challenge for coverage for Maori is actually for Maori kids from low income backgrounds — the ones who are most likely to miss out on immunisation are often from very deprived backgrounds in the large cities, the families move houses a lot, often solo parent mothers, lots of other stressers and not always regularly enrolled in a general practice. Pacific communities have quite a different pattern. We are now doing a lot better in the last couple of years for Maori immunisation rates and are starting to close the gap with effective primary health care, more effort into systematically chasing and recalling the children and outreach services.”

You said in March that “…we need to be thinking about whether we should include the meningococcal C vaccine on the (immunisation) schedule”. To what extent may it now be time to publicly fund a vaccine against meningococcal C?

“NZ does consider this issue and has a technical advisory group that considers these issues, of which I chair – the decision to introduce a vaccine includes a lot of issues around the epidemiology of the disease, the type of vaccines available and how effective they will be. We will continue to actively consider this issue.”

Factbox on Meningococcal disease:

– Meningococcal disease is caused by bacteria that normally live harmlessly in the back of the throat.

– There is no difference in the the symptoms or severity of the different strains such as meningococcal B or C strains. They are simply different mutations of the bacteria.

– The bacteria are passed by close contact that occurs such as when kissing, sharing drinking vessels or sharing the same living space.

– Early symptoms of meningococcal disease can be similar to flu and can include fever, headache, aversion to light, vomiting, a rash that does not fade when pressed, confusion and a decreased level of consciousness.

– The disease can develop over a matter of hours: when in doubt ask for medical help. If you are worried about someone you should go for medical help and if still worried, go again. People concerned about symptoms in themselves or another person, should phone Healthline, 0800 611 116, or their GP.

– Meningitis is inflammation of the meninges – the membranes around the brain. There are many sorts of meningitis – infective meningitis can be broadly grouped into bacterial and viral illnesses. Meningococcal disease can cause one type of bacterial meningitis. It can also cause septicaemia (blood poisoning). However, other infections, including pneumococcal and HIB disease, can also cause bacterial meningitis.

– There are no publicly-funded meningococcal vaccines in New Zealand except for some particularly high-risk groups, such as people without a spleen. A single-dose meningococcal C vaccine is available for those who want to pay for it and can be arranged through a family doctor. A combination vaccine against meningococcal A, C, Y and W135 is also available, but is not effective in children under two. It is mostly used by people travelling to countries that are considered high-risk for the disease.

– There are publicly-funded vaccines for pneumococcal and HIB that prevent bacterial meningitis caused by pneumococcal and HIB diseases, but these do not prevent meningococcal meningitis. Before the introduction of the HIB vaccine, HIB meningitis used to be the most common type of bacterial meningitis in NZ, it is now rare with vaccination. Pneumococcal meningitis also is now rare.

– Between 2004 and 2008, the Government funded (at a cost of around $200 million) the MeNZB campaign, which immunised about one million young New Zealanders against an epidemic sub-type of meningococcal B that was prevalent during the 1990s and early 2000s. The last stockpiles of the vaccine expired in March 2011.