The Doc­tor’s Surgery Tom Stuttaford

The Oldie - - CONTENTS -

Doc­tors are priv­i­leged. They are able to ask pa­tients and even friends per­sonal ques­tions with­out caus­ing of­fence or eva­sion.

The fear of menin­gi­tis is wide­spread, al­most univer­sal in the par­ents and grand­par­ents of young chil­dren, but even so not widely dis­cussed. How­ever, if a doc­tor were to ask a young mother what her great­est dread for her child was, a great num­ber would say ‘menin­gi­tis’. This is un­sur­pris­ing be­cause few peo­ple have not heard sto­ries of neigh­bours, col­leagues or rel­a­tives who have hap­pily gone off to work leav­ing be­hind a jolly and happy fam­ily only to find out later that one of their chil­dren was se­ri­ously and dan­ger­ously ill. Menin­gi­tis was sus­pected and the prog­no­sis was un­cer­tain.

So far so good, so long as menin­gi­tis sus­pected, and an ap­pro­pri­ate an­tibi­otic is given im­me­di­ately, by in­jec­tion, in which case the child will have a rea­son­able chance, no more than that, of sur­viv­ing. The sit­u­a­tion is not so hope­ful if the doc­tor is a jolly op­ti­mist, pro­vides un­jus­ti­fied re­as­sur­ance but fails to give im­me­di­ate treat­ment and ar­range trans­fer to hos­pi­tal.

The ef­fect of the sud­den death or dis­abil­ity of a child is so heart-rend­ing that it not un­ex­pect­edly has stim­u­lated huge and de­ter­mined med­i­cal re­search into menin­gi­tis.

There are sev­eral dif­fer­ent types of menin­gi­tis and the causative or­gan­ism may be vi­ral or bac­te­rial. Vi­ral menin­gi­tis, un­pleas­ant as it is, is rel­a­tively be­nign: most cases are self- lim­it­ing and the pa­tient usu­ally im­proves within a fort­night. Some of the types of bac­te­rial menin­gi­tis such as those caused by tu­ber­cu­lo­sis, strep­to­coc­cal in­fec­tions, staphy­lo­coc­cal in­fec­tions fol­low­ing head in­juries or the pneumococcal bac­te­ria also re­spond to ap­pro­pri­ate an­tibi­otics. But in­fec­tions with meningo­coc­cal B bac­te­ria have de­feated doc­tors de­spite decades-long con­cen­trated world­wide re­search. Un­for­tu­nately it is one of the most vi­cious forms of menin­gi­tis: one in ten cases die and one in four pa­tients sur­vive but have a last­ing dis­abil­ity, which can range from loss of a limb to deaf­ness or learn­ing dif­fi­cul­ties.

Much of the re­search into menin­gi­tis B was de­voted to dis­cov­er­ing a vac­cine to pro­vide pro­tec­tion from it. Doc­tors re­mem­ber­ing the suc­cess of a vac­ci­na­tion pro­gramme against hae­mophilus in­fluen­zae type B menin­gi­tis, which had pre­vi­ously been a hazard, strug­gled to find a vac­cine that would pro­duce the same level of im­mu­nity for pa­tients with meningo­coc­cal B. A year or two ago there was huge re­lief that a new vac­cine had been found and was be­ing man­u­fac­tured by Glax­osmithk­line and mar­keted as Bexsero.

The hopes and ju­bi­la­tion of the med­i­cal pro­fes­sion and par­ents and grand­par­ents were short-lived, how­ever. Tri­als had shown that the vac­cine was safe, rel­a­tively free of se­ri­ous side­ef­fects and would pro­vide peo­ple with pro­tec­tion against eighty to ninety per cent of strains of meningo­coc­cus B. De­spite this rev­o­lu­tion­ary ad­vance in medicine, it was re­jected by the ap­pro­pri­ate govern­ment com­mit­tee on grounds of ‘cost ef­fec­tive­ness’. How an ac­coun­tant can mea­sure the value of a live baby or child against one that is dead or dis­abled is un­known. How­ever, in 2014 Jeremy Hunt, the then new Health Sec­re­tary, started new ne­go­ti­a­tions with the ap­pro­pri­ate com­mit­tee and Glax­osmithk­line. Eight months later, in March 2015, an agree­ment was reached over the cost of Bexsero to the NHS. A vac­ci­na­tion pro­gramme was started later that year but un­for­tu­nately it only cov­ered young ba­bies. A mil­lion doses have now been given, 5,000 ba­bies have been vac­ci­nated and to date there has been no ev­i­dence of se­ri­ous prob­lems.

Menin­gi­tis B is most com­mon in young chil­dren un­der five and there is a sec­ond peak in ado­les­cence when ‘close bod­ily con­tact’, as it is known in the trade, be­comes more com­mon. A sur­pris­ing num­ber of ado­les­cents are car­ri­ers of meningo­coc­cal B. The Amer­i­cans have in­tro­duced a new vac­cine know as Tru­menba that is li­censed in America for use for peo­ple aged be­tween 10 and 25. Re­gret­tably it is not yet li­censed for use in Europe.

Bexsero, the Glax­osmithk­line vac­cine, has been avail­able pri­vately but such is the de­mand that doc­tors in pri­vate prac­tice have been asked not to start new pa­tients on it un­til the sum­mer when GSK hope there will be enough Bexsero for those who are able to find the money – not an ap­proach to medicine that ap­peals to doc­tors whether in pri­vate prac­tice, the NHS or both.

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