Meningitis wars: the next chapter
Meningitis may have good claim to the title of most-feared childhood illness in Western countries. All of us will have witnessed the look of blind panic in the eyes of the parents of an unwell child. Some of us may even have been those parents ourselves.
Although meningitis can be caused by virtually any type of micro-organism, most cases in the UK are caused by meningococcal bacteria. There are at least 12 serogroups. Groups B, C, W and Y have historically been the most common in the UK. Other causative organisms may be pneumococcus or Haemophilus influenzae type b (Hib). Serogroup C's contribution has fallen dramatically since the introduction of childhood vaccination against the disease in November 1999. Indeed, the disease has been virtually eliminated in the UK with just a handful of meningococcal group C (Men C) cases each year, mainly in older, unvaccinated adults. Serogroup B is now responsible for 80% of cases in the UK.
In the past 20 years, between 500 and 1,700 people every year, mainly babies and young children, have suffered from meningococcal group B (Men B)disease, with around 1 in 10 dying from the infection. Serogroup A is extremely rare in the UK and is most commonly seen in Africa. Serogroup W has increased in the UK since 2009.
In England, Men W and Men Y are usually responsible for only 10-20% of cases, but currently, Men W alone accounts for almost a quarter of all meningococcal infections in England. From 2009 to 2012, an average of four people died of meningitis W each year. Most of the people who died were elderly. But during 2013 and 2014, there were 24 deaths from Men W disease including, for the first time in over a decade, babies and toddlers.
The current UK routine child vaccination schedule already contains vaccines covering pneumococcus, Hib and Men C, but the Joint Committee on Vaccination and Immunisation decided to introduce two new weapons this year, to combat additional serotypes.
Bexsero®, a vaccine against Men B, was introduced into the UK's routine childhood immunisation schedule for all infants in July 2015. It is expected to protect against infection from most (88%) of the Men B strains in the UK. It is given at 2, 4 and 12-13 months of age.
Nimenrix® and Menveo® are Men ACWY vaccines. All 17- and 18-year-olds and first-time university students (up to the age of 25) are eligible for the Men ACWY vaccine as part of the NHS vaccination programme from autumn 2015. The meningococcal groups ACWY (Men ACWY) vaccines have also been added to the routine adolescent schools programme, as a direct replacement for the men C vaccination. Cases of meningitis caused by Men W have been increasing in England; from 22 cases in 2009 to 117 in 2014. The increase seems to be speeding up in 2015, caused by an aggressive strain. Men W infections are particularly severe and usually need to be treated in intensive care. The infections also have a higher death rate than the more common Men C and Men B strains.
I expect there will be questions on the safety and efficacy of these new vaccines, as a fair degree of scepticism still persists around vaccinations. Like all vaccines, the Men ACWY vaccine can cause side effects, but studies suggest they are generally mild and soon settle. The most common side effects seen in teenagers and young people are redness, hardening and itching at the injection site, headache, nausea and fatigue. Any unusual reaction which may be due to the vaccine should be reported via the Yellow Card Scheme.
Efficacy can be roughly gauged from a mass vaccination campaign in Burkino Faso, in response to a meningococcal disease epidemic. More than 1.68 million children and adults aged from 2 to 29 years were vaccinated. The vaccine effectiveness against group A and W135 disease was 95.8% for those who had been vaccinated.
Against this news of an increase in the vaccination programme come reports that some areas in England are losing their health visitor-led vaccination clinics. Local authorities across England are set to take over commissioning of child public health services, including health visiting, from NHS England on 1 October. The London Borough of Hackney council has said it has been told by NHS England that immunisations are the responsibility of GPs. The council will give 60 days notice to end immunisations for 0- to 5-year-olds (currently provided by health visitors) when it takes over the service. Child immunisations will continue to be commissioned nationally from GPs by NHS England, but local GPs fear the decision to end the supplementary health visitor provision could threaten herd immunity. This reduces the efficacy of the whole programme and causes a capacity crisis for practices expected to pick up the work.
Is your practice ready?
Could you cope with extra demand, if you lose health visitor clinics?