On 14 February 2016, a two-year old girl in Kent died of meningococcal septicaemia. The cause was meningitis B. It acted as a reminder to the British public that meningitis can and does kill. But, should everyone be vaccinated against meningitis B, what about the other strains, and what are the risks of getting the disease?
Meningitis: an overview
Meningitis is the swelling of the meninges (a protective layer around the brain). It is usually caused by a bacterial or viral infection. Many different bacteria can cause meningitis, including, but not limited to:
- Haemophilus influenzae type B or HiB (part of the UK childhood vaccination schedule)
- Streptococcus pneumoniae (part of the childhood vaccination schedule)
- Mycobacterium tuberculosis (causes TB and the vaccine is offered to those at increased risk of infection)
- In newborns a variety of pathogens, including group B Streptococcus, Listeria, E. coli
- Neisseria meningitidis (split into several serogroups, see below)
Different types of meningitis may have different severities, but bacterial meningitis can be fatal, or have lifelong consequences.
Meningitis A, B, C, W, Y, Z
Meningitis A, B, C, W, Y and Z are all caused by Neisseria meningitidis. Currently children are offered a vaccine against meningitis C as part of the UK childhood vaccination schedule, and then a vaccine against A, C, W and Y as teenagers (important as there has been an increase in Men W cases in this age group recently).
As a child, I remember several children contracting meningitis C. Just before university I was vaccinated as part of the Meningitis C vaccination campaign, and since then cases have reduced dramatically.
The vaccination for Meningitis B has been longer in the making, due to some specific properties of the bacteria. But, finally, in 2015 a vaccine was approved for the UK childhood vaccination schedule (there was a lot of wrangling over price to try to make it cost-effective to the NHS).
Meningitis B: The vaccine and the cases
Looking at the graph above, you can see that Meningitis B account for the majority of cases of meningitis caused by Neisseria meningitidis in England and Wales. It accounted for 80% of cases in infants and 86% in toddlers (see the latest report from Public Health England). Case numbers are still small however, with 418 cases reported from July 2014 to June 2015, with 25 deaths. To put that into perspective, there were an average of 224 deaths due to childhood cancer in England and Wales each year from 2009-2011. Hopefully now that children are being vaccinated against Meningitis B, this will reduce even further.
Why no catch-up campaign?
One thing the death of the little girl in February 2016 highlighted, is that unlike the Meningitis C vaccination campaign 15 years ago, the Meningitis B vaccination strategy has no catch up programme (well, almost none). She was two years old, and therefore born before the vaccination campaign had started, and like all other two year olds, would not receive the vaccination as part of the childhood vaccination schedule. Following her death, a petition to give the vaccination to children up to 11 reached over 800,000 signatures, and was subsequently debated in the House of Commons.
But why has the government not implemented this already? Well, I don’t know. But here are some possible reasons. Firstly, it is expensive – it’s a very complicated vaccine. The Joint Committee on Vaccines and Immunisations (JCVI) position statement shows that it really didnt appear to be cost-effective. The problem is that the disease is so rare, that even if the vaccine was cheap, it was unlikely to be cost-effective in the eyes of the NHS. I know this is of little reassurance to parents, or individuals affected, but the NHS can’t fund everything. That being said, the debate that followed the petition highlighted some major issues with the model that is used to calculate the cost-effectiveness. More research into the best cost-effectiveness model is still ongoing.
Secondly, the highest risk is in children under the age of one, so this is the group being protected. I know my graph shows more cases in those aged one to four, but there are more children in that age group. Proporionally, most of the cases and deaths are in the under ones. There’s a much better graph here. In the debate in the House of Commons it was clear that many MPs favoured a catch up campaign for the under fives, and it was agreed that those aged 1-4 were the next most at risk after the under ones. However, vaccinating them wasn’t cost-effective in the current model.
Finally, and perhaps most importantly, there is still not very good data on how the vaccine is performing. Meningitis B is so rare that it wasn’t feasible to conduct clinical trials to measure effectiveness prior to launching the vaccination campaign. How well the vaccine protects, and how long protection lasts is key to cost-effectiveness. Even the manufacturer reports a reduction in protection after just eight months, and I’ve found another study reporting between 41 and 75% of children were protected areas 3yrs 4 months. Though only small numbers, this suggests a preschool booster would be required to protect children to age 5, and possibly more to protect through childhood. If this turns out to be the case, and protection is short-lived, it may be that children vaccinated in infancy will not be protected by the time that they are three or five, for example. By this time, they will have got past the most risky period, but it has major implications for any catch-up campaign. If the vaccine is expensive for two or three doses, it would be prohibitively so if you have to vaccinate every child every few years to ensure they are protected up until 11.
We will begin to get information on how the vaccination is performing in September 2017. Even then that is only preliminary data. I think it’s unlikely there’ll be a catch up campaign before then, and at that point, those children vaccinated in the first few months of the programme will be reaching two. Realistically, I think by the time we have information on vaccine effectiveness and cost-effectiveness, those at most risk will have been vaccinated in the original campaign and we will have no need for a catch-up campaign for the under fives.
Are there any positives?
Following the debate in the House of Commons, the Government have committed to a major public awareness campaign. This is great news, as acting quickly with a case of meningitis can really make a difference to outcomes.
How cost-effectiveness is calculated is being reviewed, and the controversial “discounting” rate reconsidered. This discounting rate causes the cost-effectiveness model to favour short term gains. Any cost of disease is discounted by 3.5% for each year of life, until it reaches zero. For a disease like meningitis which often strikes when children are very young and leaves them with lifelong complications, this means the true costs of illness are not really represented. I hope this changes, as it would swing the cost-effectiveness calculations in the favour of preventative medicine – prevention is always better than cure in my book!
Finally, vaccination of adolescents is being considered. While they don’t often suffer from the disease, they are the main carriers. Menigitis B lives in their nasal passages causing no problem. If the vaccine is shown to reduce nasal carriage in teenagers, then vaccinating them may protect the rest of the population.
What would I do?
Well. I can be a bit needle-happy with the kids at the best of times, so I was going to get both my children vaccinated privately (a relatively expensive option). However, there is currently a shortage of Meningitis B vaccine for the private market (those who are eligible for the vaccine should be fine). In the meantime, my children are getting older. While Boybug is still younger than the girl that died in February, the chances of either of them contracting Meningitis B remain low, and are decreasing. That, teamed with my new knowledge that we do not know how well the vaccine is going to perform, means I may hold off. For what it’s worth, I signed the petition. In an ideal world, I believe the vaccine should be available to those that want it. However, I think it’s unlikely that this will happen, and now I’ve looked into it a bit further I don’t think the science is yet there to support a catch-up campaign up to age 11. That might be quite a controversial view-point, and my view may change as we learn more about how the vaccine is performing.