health & science

Emma Espiner: How we fought meningitis last time

* New Zealand is in the grip of a meningitis outbreak. This week the government announced an urgent vaccination campaign for the hardest hit communities in Northland.
* Vaccines are in short supply internationally, as many other countries struggle to deal with their own outbreaks.

Here, Emma Espiner looks back to the meningitis epidemic in New Zealand in the late 90s and how a small group of public health researchers and community members helped turn around meningitis rates in the most affected communities in South Auckland.

Public health is the battleground on which many of the pivotal conflicts of our time are being fought. The rise of anti-vaccination sentiment, antibiotic stewardship, climate change, obesity prevention, to name a few.

It’s been recognised by governments as the great hope for increasingly burdened health systems. It is superseding robot surgery or other sci-fi dreams some of us might have held for the future of healthcare by applying the logic that preventing illness is the most cost-effective and humane thing we can do.

It’s also a branch of medicine that doesn’t stay in its lane. It is often in conflict with powerful interests.

We see this every time economic considerations are weighed as carefully as health gains, when losses for exporters are leveraged as reasons to keep borders open during pandemics, when industry brings its lawyers to fight impoverished communities for the right to sell cheap alcohol to their families or take food out of children’s mouths via pokies.

It isn’t all heroism. Public health gets it wrong, frequently. Most egregiously in its method of communicating with people. There are wincingly bad campaigns to reduce alcohol consumption, reduce smoking, reduce gambling and pretty much every vice activity. You can see in some cringe-worthy campaigns that there was nobody around the table brave enough or human enough to put up their hand and say “guys, isn’t this a bit off?”

The other failure of public health has been in the often parochial and superficial manner of its dealings with ‘hard to reach’ communities. It’s not uncommon, still, to see public health practitioners put forward a great plan to reach Māori communities. A great plan which consists of putting an ad on Māori television or translating a pamphlet into Te Reo.

This is where leaders like Dame Tariana Turia have been important in flipping the script. She is the one who told us that our people aren’t vulnerable, they’re valuable and ought to be honoured as such. They aren’t hard to reach - you’re just not trying hard enough. It’s not hard to understand this when you’re Māori and you watch your aunties, uncles and grandparents die before your Pākehā friends’ family members but some people still need it spelled out.

In light of all this, it’s satisfying when you see public health being done well. The meningitis disease awareness campaign in South Auckland which launched in 1998 is one. It is an example of public health and community working together and gaining from one another’s strengths, and it worked.

In the six months after it was initiated, there were no deaths from meningitis for the first time in the five years since the beginning of the outbreak.

I spoke to one of the project leads, Professor Chris Bullen from the University of Auckland:

Set the scene for us, what was happening in the 90s with the meningitis epidemic?

There was no vaccine. Year on year case numbers were increasing. The most affected were Pacific Island and Māori children under 5. There was a high case fatality rate, public confusion and very little understanding about early prevention.

Sounds apocalyptic.

It was a scary time for people all over the country.

You focused on South Auckland, why?

We found that cases were clustering around four communities in South Auckland and we wanted to do something about that.

Why were Pacific Island and Māori whānau affected? The usual stuff or something else?

No, it was the usual stuff. There was a study done by Baker and others in Auckland back then looking at risk factors for contracting meningitis. The first was household crowding, and the risk was increased proportional to the numbers in the household. So one extra adult increased the risk by so much, two extra adults increased it even more and so on.

That sounds familiar.

Yes. We have all the conditions for another epidemic right now.

Great. What was the second risk factor?

Exposure to secondhand smoke.

Get out of here.

No, truly. In fact it was the implication of tobacco in meningitis and pretty much every other thing that’s going wrong for us, health-wise, which was why I started to focus on tobacco control in my work. It was where I saw the opportunity to do the most good.

Did you have a particular equity focus? It seems like you were just getting on with the job without pissing around with mission statements or targets to achieve for brown people.

No we didn’t, a lot of it was just intuition. In the work I’ve done myself or observed in remote communities including in Papua New Guinea and in rural parts of New Zealand, it just seemed practical and logical to respect the community you’re working with and allow them to lead.

You articulate that like it’s just common sense but it’s not ubiquitous across public health in practice is it?

No.

So what did you do?

We recruited community members, many of whom had been long-term unemployed, to go door to door and deliver simple messages about the signs and symptoms of meningitis. They were all trained by experts, had to prove they could deliver the messages as taught, and they were given resources to distribute to the families they visited. They stressed the importance of early treatment and even gave out cards requesting urgent attention in English in case the families encountered difficulties gaining attention from medical providers or didn’t feel confident communicating in English. Our educators visited more than 11,000 households.

You wrote an editorial detailing the results from the campaign in 2000. I saw that you didn’t have a lot of money and that the people working for you would do five or six days of work even though they were only paid for three.

Yes it was an extraordinary thing, the enthusiasm and the commitment. But it’s not really surprising. When you work through people from the community you’re trying to serve, you’re going to get more buy in. On the other hand, it highlighted for us the discrepancy between the increasing demands on communities to shoulder the responsibility for these sorts of programmes, and the limited or absent pay for the work they do. That’s a problem.

You mentioned working in Papua New Guinea and how that helped you to see the potential in community, what did you mean specifically?

When you work in areas like PNG where I was the only doctor for 65,000 people, you simply have to work through others and leverage the expertise of the community. We saw this in our awareness programme - it would never have had anywhere near the success that it did without the practical knowledge of our educators and the community groups who provided input. Everything from where people with young children were living, the times of day they were mostly likely to be home, how much access people had to telephones, cars and the most commonly spoken languages.

You mentioned the power of telling stories.

Yes, we found that the most effective way of conveying the risks of untreated meningitis was through telling stories. Our educators used local examples of people who’d either experienced meningitis in their family or stories about grandma or aunty who took the baby to the doctor after noticing the symptoms and that everything was ok after that. It was about reflecting people’s realities in ways that were meaningful to them.

Do you think there could be a role for a programme like yours in the current outbreak? It’s a different time now, particularly with Facebook and Twitter. What role would there be for social media?

Well it carried on right up until a vaccine was developed and then we lost funding. I think it was a really effective awareness-raising programme and it could definitely have a role now if someone wanted to kick it off again.

Social media would be a great adjunct, in that there’s a democratising effect of social media - helping us reach people who we might not have reached previously through other means. But there is no substitute for face to face contact.

There was some research looking into primary care prescribing practices and some confusion back then around the most appropriate use of antibiotics. Antibiotic stewardship seems a more urgent concern nowadays, do you think that could have an impact on the treatment of potential meningitis cases?

No. This is very much in the hands of primary care practitioners and there are very straightforward protocols to follow. The treatment for meningitis consists of a single intramuscular dose of a strong penicillin antibiotic so it’s a very low risk for building antibiotic resistance - especially weighed against the extremely serious consequences of not treating meningitis.

Disclaimer: Emma Espiner writes a regular opinion column for Newsroom, she is also the National Communications Lead for Hāpai Te Hauora and a fourth year medical student at the University of Auckland.

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If you’re worried about meningitis, these are the Ministry of Health guidelines about what to look for. More information can be found here https://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/meningococcal-disease-including-meningitis

Meningococcal disease is spread in a similar way to the common cold – by coughing and sneezing. Basic steps like covering your nose or mouth when you sneeze or cough ... can help reduce the chance of spreading bacteria.

Meningococcal disease can be difficult to diagnose because it can look like other illnesses, such as the flu.

Symptoms of meningitis can develop suddenly and include:

- a high fever

- headache

- sleepiness

- joint and muscle pains.

There can also be some more specific symptoms, such as:

- a stiff neck

- dislike of bright lights

- vomiting

- crying

- refusal to feed (in infants)

- a rash consisting of reddish-purple pin-prick spots or bruises.

What to do

If you or anyone in your family has these symptoms, call your doctor straight away or dial 111.

Say what the symptoms are. You can also call Healthline free on 0800 611 116, 24 hours a day – even if you have already been seen by a health professional.

If you have seen a doctor and gone home, but are still concerned, don't hesitate to call your doctor again or seek further medical advice. Don’t be put off. Insist on immediate action.

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