Legacy of bacterial meningitis in infancy
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7312.523 (Published 08 September 2001) Cite this as: BMJ 2001;323:523All rapid responses
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Dear Sir,
It is reassuring to see that someone in this country has been
involved in looking at a few of the many potential modifiable risk factors
for meningitis.
Persuading the Government housing provider to add rooms to crowded
houses, improve insulation, and getting the medical profession to link
families to support agencies could potentially be useful,... providing the
families who rent these houses, can be persuaded not to bring in more
people to fill up the additional rooms, as is their culture... and
actually use the support agencies to which they are recommended.
The problem is that these minor state funded home adjustments, and
referral to support agencies, don't actually address what the importance
of what goes on in the top two inches of the at-risk population's cranial
grey-matter.
For instance, how does this eliminate smoking - a major risk factor
in this group for SIDS as well as meningitis? The study mentioned found
an association with the use of analgesics (which not only worsens the
outcome for meninigitis, but also for chickenpox and all other viral
infections). The inappropriate use of Pamol by parents to keep children
quiet has become rampant in this country, yet little is done to educate
any parents as to the risks to a child's immune system of paracetamol.
Yet the studies in the medical literature are legion.
Keeping people drier and warmer may make them feel more comfortable,
but it does not deal with the other vital issues related to the fact that
we are what we eat, and what we put into the body dramatically affects the
way the immune system works. To bring up children well and appropriately,
requires head knowledge and an understanding as to why. These are life
skills which can be applied, no matter where, or under what circumstances
you live.
A start has been made on the "brick and mortar" aspects. But is this
enough? All people concerned about Meningococcal meningitis world-wide
would be equally as interested in any studies done on the impact of
improving "parenting skills" and whether "habit re-education" this might
have far broader reaching implications on meningitis and health in
general.
Sincerely,
Hilary Butler.
Competing interests: No competing interests
RESPONSE TO HILARY BUTLER LETTER (BMJ 2001; 323: 523-4)
We would like to respond to Hilary Butler's letter regarding a recent
BMJ editorial. While we share Ms Butler's view regarding the need to
address socio-economic determinants of this disease we would like to
correct several statements that might mislead your readers.
Firstly, it must be stated that the group with the highest incidence
of meningococcal disease remains the under one year-olds. Unfortunately Ms
Butler's quote was based on a misquote from the New Zealand Herald that
was later retracted.
Secondly, we would like to point out that New Zealand has not been
ignoring potentially modifiable risk factors. This unit has been involved
in a large case-control study attempting to identify potentially
modifiable risk factors for this serogroup B meningococcal disease
epidemic . Risk of disease in children under 8 years of age was strongly
associated with overcrowding, as measured by the number of adolescent and
adult (10 years and older) household members per room [odds ratio 10.7,
95% confidence interval 3.9-29.5], resulting in a doubling of risk with
the addition of 2 adolescents or adults to a 6-room house. Risk of disease
was also associated with analgesic use by the child, number of days at
large social gatherings, number of smokers in the household, sharing an
item of food, drink, or pacifier, and preceding symptoms of a respiratory
infection in a household member. Many of these risk factors are
potentially modifiable. In particular, this has sparked collaboration
between regional health agencies and the state housing provider (Housing
New Zealand) in tackling overcrowding in those areas with the highest
rates of meningococcal disease and the highest proportion of crowded homes
in New Zealand. This intervention, which is not yet evaluated, involves
adding rooms, improved insulation, and linking families to support
agencies.
R. Whittaker (Public Health Medicine Registrar), C. Bullen (Public
Health Medicine Specialist), N.Jones (Public Health Medicine Specialist)
Public Health Protection,
Auckland District Health Board,
Private Bag 92-605,
Symonds St,
Auckland,
New Zealand
Competing interests: No competing interests
Dear Sir,
In this issue's wide ranging Editorial on the global burden of
meningitis, the New Zealand author, Keith Grimwood, Professor of
Paediatrics At Wellington School of Medicine and Health Sciences,
discusses data from Canada and Melbourne, which is interesting, as is
Bedford et al's questionnaire results. He also briefly touches on the
disease burden in countries which don't use certain vaccines because of
cost.
New Zealand is hoping to be at the forefront of the development of a
vaccine against Meningitis type B. According to media files, we are in
the 11th year of an epidemic estimated to have another 10 years to run,
and have a unique sub-type.
As of August 5th this year, there had been 296 cases, and 15 deaths.
Last year, there were 476 cases, nationwide, and 18 deaths. In 1999 there
were 505 cases and 23 deaths. The total is now well over 3,000 for the 10
1/2 years.
This year, the disease burden in Auckland has been primarily in the
adolescent age, from 10 - 14, and according to Public Health Unit
registrar, Dr Robyn Whittaker, "These teenagers include white, middle-
calss kids. Everyone is susceptible...) (New Zealand Herald, August 2,
2001, A7). Up until this year, the bigger numbers of the cases in
Auckland have hit the under-ones in South Auckland.
This being the eleventh year of a predicted 21 year epidemic, a
unique opportunity exists for someone to publish a study, not only using
the parameters Keith Grimwood discusses to clarify the outcomes for those
already having had the disease (educational intervention) but also about
other factors not investigated thoroughly enough to date.
The worldwide vaccination call may be the mood of the moment, but
from the long-term New Zealand statistics, the causes of death from any
sort of meningitis have gone in swings and roundabouts. Sometimes it is
meningitis A, sometimes Hib, sometimes meningitis B.
But overall, when you look at New Zealand deaths in general, while
the Hib vaccine may have dealt with one problem, it could be said that it
simply assisted in clearing the way for another pathogen to step into its
shoes. Because unlike the state, the total annual deaths from meningitis
of any sort, do not appear to have decreased.
It is no co-incidence, that in this country, the meningitis disease
burden was primarily seen in the lower-socioeconomic group who suffer
major inequities in housing, education, parenting skills, nutritional
knowledge, and job opportunities. Which are the very living skills also
lacking in the under-developed countries who cannot afford the vaccine.
Though they also have the additional problems of civil war, or political
goonism, and often not being able to obtain good food, skills, and
necessities of life. At least here, everyone has a choice as to what to
buy with what monetary resources they have.
Observation of many middle-class white adolescents - and some upper
class one for that matter, shows that while the monetary problems of this
"class" are perhaps not as pressing as those previously stated to be at
risk, some other living skills (in particular, nutrition and habits which
increase the spread of pathogens of any kind) would appear to be equally
as bankrupt as many lower-socioeconomic people.
That aside, as we know in this family, at a certain age, teenagers
congregate far too regularly in little tribal huddles under the big M
sign, or whatever fast and cheap option is available to them. To sit in a
food hall, and observe what these teenagers fill their tanks on, is akin
to wondering how a car, supposed to be fueled on 91 octane, will function
on sugar-water.
As parents, getting a good diet and life skills into this age group
is hard work. And requires ongoing persistence, and skillful maneouvring
- something many parents opt out of.
But the mental image adolescents have, that junk food is okay as a
primary nutritional source, is certainly not helped when you go to the
major children's hospital in this country, to find that right in the major
entry-way is ... a MacDonald's.
In a world in which the bacteria types often change, new types arise,
and health finances are becoming increasingly more restricted, to think
only of a vaccine, is missing a huge opportunity.
Which is that of identifying the preventable risk factors at both a
societal and immunological level, to any meningitis, no matter the type,
and reducing those by deliberate social intervention by the front line
medical profession who see these cases. This could lead to a grass roots
plan to assist in reducing the global burden of actual meningitis cases -
no matter what the pathogen.
More importantly, it is also possible that the attempt to educate
those most susceptible to menigitis might also fix the problems of rampant
diabetes, obesity, heart disease, other respiratory infections, and other
diseases rampant through life-skill deficiencies.
There may come a time, when someone looks at how Hospital funding is
actually used in this country, that such a study will be an economic
necessity. Since without it, there might be no end to the rapidly
burgeoning funding being put into being ambulances at the bottom of the
life-skill-deficiency cliffs. While other who have problems not of their
making, are placed on endless waiting lists.
Sincerely,
Hilary Butler.
Competing interests: No competing interests
Meningitis and Later life Cancer
Indeed the association with developmental problems associated with
certain deficits resulting from early age bacterial meningitis is a worthy
topic. But I have yet to find recognition or analysis of a possible link
between the complications which are a legacy of bacterial meningitis and
certain cancers developed at a much later time. Conceivably their might
be a neoplastic response to early tissue damage and could take the form of
any of the CNS cancers. But my question concerning this is more than
curiosity. Such cancers with their origins from an early insult might
have a far better outcome than neoplasms appearing spontaneously or
resulting from developing genetic failures. In fact individuals who have
experienced surprisingly favorable outcomes for such cancers as
glioblastoma multiform, might be the beneficiaries of such a process. In
their cases, excising and radiation could amount to a cure.
Competing interests:
None declared
Competing interests: No competing interests