health & science
Meningitis: a deadly alphabet soup
The fourth in a series on vaccine-preventable diseases looks at meningococcal meningitis and the conundrum of a disease that requires two expensive vaccines. Farah Hancock reports.
Today there will be sausages and syringes at Northland’s Hikurangi Primary School.
The sausages are for the community. The syringes, which contain a vaccine for the deadly meningococcal W strain, are for the students.
In the midst of an outbreak, the community crowdfunded to vaccinate its five to 12-year-old children who were ineligible for the free vaccine available as a result of the outbreak.
It has good reason to do this. Last year the school lost seven-year-old Alexis Albert to meningococcal meningitis.
When the free vaccination programme was announced to control the Northland outbreak of the W strain, many of the school’s students weren’t eligible as most fell outside the age range of children under five years, or between 13 and 19.
Those aged five to 12, like seven-year-old Albert, miss out.
The effort was led by local woman Shona Whitehead, who approached the school with the proposal to raise funds for the vaccine.
With the community’s help her efforts raised $20,000 - enough to vaccinate all of the school’s pupils.
At approximately $150 per dose at a doctor’s clinic, the vaccine’s cost is a hurdle to many families wishing to protect their children, said Whitehead.
“We lost a child last year. That’s the biggest reason for fundraising, but I also wanted to cater for the families who have multiple children.”
A fast-moving killer
Meningococcal meningitis is the formula one car of illnesses. It moves at lightning speed through the human body and can cause swelling of the layer of tissue surrounding the brain - as well septicaemia.
What starts out feeling and looking like a cold can kill in a matter of hours.
Caught early, it’s treatable with antibiotics, but by the time the tell-tale marks on the skin appears, treatment becomes harder.
New Zealand’s Meningitis Foundation’s tagline is 'Every second counts'. Spokesperson Andrea Brady said by the time meningococcal meningitis is diagnosed it can be too late to treat.
“There is no other disease that we know of, or that the medical practitioners talk about, where you can go from being healthy in the morning to dead that night. Within the course of 24 hours, it can be one of the most devastating and life-changing illnesses.”
For those who manage to survive, the battle isn’t necessarily over.
“Some people survive without any effects whatsoever. Others can be left severely disabled to the point where they have had limbs amputated, or there is long-term brain injury, deafness or there is major damage to other organs within the body.”
There are vaccines available, but they are only funded for very high-risk groups, like those who have had their spleen removed.
When asked if the vaccine should be available to all children, Brady gave an emphatic "yes".
“When talking to some of the medical professionals, cost is the biggest factor. What it comes down to in all decisions is how do you carve up that health budget?”
Part of the difficulty is due to two different vaccines being needed to treat the one disease.
The deadly alphabet soup
Meningococcal bacteria come in an alphabet soup of strains. Strain B and C have previously been more common in New Zealand. However, since 2017, cases of the W strain have increased.
It’s a particularly deadly strain. While B and C kill about 7 percent of those who contract it, the W strain kills 18 percent.
In 2018, 33 of New Zealand’s 120 cases of meningococcal meningitis were due to the W strain. The B strain accounted for 51 cases, and C dropped to just 10.
Vaccines are expensive and there’s not a universal one effective against all strains.
New Zealand mainly uses two types of vaccines. One covers strains A, C, W and Y and another covers B.
At around $150 per dose it would cost abound $450 to cover a healthy child against all five strains, as two doses of the vaccine effective against the B strain are needed.
An added consideration is how long the effect of the vaccines last. Figures vary depending on age. After vaccination, children under five would be protected against the B strain for one to three years and for three to five years against the strains of A,C,Y and W.
For older people the protection could last a little longer.
University of Auckland’s Dr Helen Petousis-Harris explains the problem this creates when considering how to implement the vaccine in the current immunisation schedule, and how to manage the need for boosters.
“If you're going to put it on the schedule and make it free for everybody, where would you put it?”
If under-fives receive the vaccination, the protection will decrease by adolescence.
The disease's blistering pace means a teen vaccinated as an under five would not have enough time to create antibodies to fight it.
“It's just not quick enough. You need to maintain antibodies in your blood and these wane over time, even though you've got memory. You need to get a booster.”
This is important because teenagers are one of the groups particularly susceptible to meningococcal meningitis. And moving out of home and into crowded flatting or dormitory situations can expose them.
Petousis-Harris thinks the reason neither vaccine forms part of the free schedule comes down to cost.
“You would need two vaccines, there’s not yet one vaccine to rule them all.”
The troublesome B strain
The reason for two vaccines is the problematic B strain.
There are many ways a vaccine against a bacterium can be made.
Sometimes they can work against a toxin the bacteria creates, which is how the vaccines for tetanus, diphtheria and whooping cough work.
For others, the vaccine tries to trigger a person’s immune response against the sugar coating of bacteria. This worked for strains A, C, Y and W.
Petousis-Harris describes this approach as “okay”. The duration its protection is short and can’t be boosted. A game-changing break-through came when the sugar coating was linked to a protein.
For the most prevalent strain in New Zealand, the B strain approach is an issue. The sugar coating looks the same as foetal neural tissue.
In the 1980s, Norway and Cuba came up with a solution using a “chunk” out of the outer membrane. In layperson’s terms, Petousis-Harris explained, there were “goodies” on the outer membrane which vaccine creators can work with.
“In these bacteria you get these little bits that bleb out like little bubbles out the side of the bacteria, they’re called outer membrane vesicles.”
Again, the B strain proved problematic. The outer membrane vesicle vaccines were most effective against a particular sub-strain of the B strain they had been made from. A vaccine which works in Cuba might not work well in New Zealand.
More recently the genome was sequenced and three proteins likely to be on the outside of the bacteria were selected. This has been a more effective approach, and the B strain vaccine given in New Zealand combines these proteins with the active component of the MeNZB vaccine used 10 years ago.
“It's used a cutting-edge technology throughout its development so at the moment it's quite expensive,” said Petousis-Harris.
Crowdfunding for health care
National Party MP for Whangarei Dr Shane Reti gave advice to Shona Whitehead about how to go about fundraising for the vaccine drive at Hikurangi Primary, and arranged for the purchase of the vaccines at cost.
Today, he’ll be rolling up his sleeves to help vaccinate the school’s students.
He said the current situation is unfair.
“We're crowdsourcing vaccines for children. We're in an outbreak - we called this an outbreak area - and we won't vaccinate that group in the middle?”
Reti worked in healthcare in Northland through other outbreaks of meningitis.
“I worked in Northland clinically through MenB and through MenC, and here we are now with MenW. To answer your question, yes. I think the meningitis vaccination should be on the schedule.”
Reti thinks both vaccines should be free for all children. He said the Ministry of Health had ben tardy responding to the rise of the W strain.
"The Ministry is late to waking up to MenW. There had already been outbreaks in Australia. There had already been outbreaks in the US."
He's also raised the issue of just one dose per Northland child under two given freely. The recommendation that the vaccine be two doses eight weeks apart is best for this age group.
"I think what annoys me even more, which I've said in the public domain, is that last year Winston Peters gave $10 million for a vaccination campaign to Papua New Guinea. And even more galling is the $1 million he gave to Fiji from meningitis vaccination program. That's really not fair."
Reti estimates vaccinating the five to 12-year-olds in Northland missing out of the free vaccinations would cost $700,000. Hikurangi Primary is the second school in the area to provide vaccines for that age group through fundraising, or cancelling school trips.
Hikurangi Primary’s principal Bruce Crawford is grateful for the $20,000 fundraising effort, which will hopefully mean his school doesn't lose another student to the disease. He said he's looking forward to “firing up the barbecue” for celebratory sausages and describes himself as a bit of a curmudgeon when it comes to vaccination.
“I’m a keen believer in vaccination. Science shows us it works. I’ve got no time for those anti-vaxxers, they can go and join the flat earth people.”
Crawford thinks that of the roughly 200 pupils at the school, around 170 may have consent forms from their parents.
If the final numbers pan out as he anticipates, the vaccination rate at the school would surpass that of the free vaccines administered through the Northland District Health Board.
Only 63.2 percent of those eligible have taken up the offer, despite a concerted attempt once the Ministry of Health made the vaccines available.
The vaccine was offered to under children under five and 13 to 19-year-olds at 607 clinics, from schools, to pharmacies, to maraes. The publicity campaign reached 422,488 people and 14,353 were vaccinated.
Northland DHB chief executive Nick Chamberlain told TVNZ vaccination rates in the area dropped after an anti-vaccination film was screened there.
For a region where poverty affects many and may mean over-crowded living conditions, an under or unvaccinated population provides ample opportunity for diseases like meningitis to spread.
Most cases of meningitis occur during the winter months.
- Up to 15 percent of the population carry the bacteria without getting sick. These people can unknowingly infect others.
- It is spread through saliva or mucus in the air by sneezing or coughing, or through direct contact such as kissing or sharing utensils.
- Symptoms include a headache, fever, vomiting, joint and muscle pain, a stiff neck, sensitivity to light, delirium and spots or bruising.
- It can be treated successfully with antibiotics if caught early.
- Individuals can buy the vaccines from their doctor, or receive them free if they are in an approved high-risk group.