EDITORIAL
Vol. 20 No. 3 November 2004
In July this year the long awaited national meningococcal B campaign to immunise 1.15 million of those New Zealanders under 20 years of age, was rolled out in the Counties Manukau District Health Board area of South Auckland. The New Zealand Government has committed up to $200 million to this massive programme which includes the price of the MeNZB™ vaccine, clinical trials, management and administration, education, public communication and national immunisation programme roll out.
It is now well known that meningococcal disease is a serious illness which can cause death or permanent disability such as deafness or disfigurement. New Zealand has been experiencing an epidemic of group B meningococcal disease since mid 1991 with more than 5,400 cases of meningococcal disease being recorded since the epidemic began with no signs that the epidemic is waning. Prior to this epidemic, there were about 50 cases of meningococcal disease per year in New Zealand, Now it is estimated that one in every 66 Pacific children, one in every 117 Maori children and one in every 438 children of European or other ethnicity will contract meningococcal disease by the time they turn five years of age. It seems that no other infectious disease creates quite the same fear among parents, mostly because of its swiftness and severity and because the first symptoms can be so much like other viral illnesses and therefore more difficult to diagnose.
In England it is the meningococcal C strain (rather than B) which accounts for about 40 out of every 100 cases in England and in Australia meningococcal C occurs at rates 13 times lower than the rate meningococcal B occurs in New Zealand. Persistently high levels of meningococcal B disease have occurred in other countries, but because of the subtle differences in the make up of the bacterium, a vaccine had to be developed specifically for the New Zealand strain.
Clearly immunisations save lives. Successful immunisation programmes in New Zealand such as poliomyelitis, tetanus, small pox and diphtheria are well documented. Rates of Haemophilus influenzae type b (Hib) have been reduced by over 90% since introduction of the Hib vaccine in 1994. Practice nurses who have historically been the main childhood vaccinators for many years have played a significant role in the success of these programmes. Public health nurses have also contributed.
For this meningococcal B campaign, nurses will continue to be key providers not only in the practical application of the vaccines but also in disseminating immunisation information to parents and/or caregivers and as a major part of the Ministry of Health’s clinical trial team.
However with any major undertaking of such size as the meningococcal B campaign there were bound to be some fish hooks. Frustration began to be experienced by some nurses early in the campaign when it appeared that in spite of major publicity drives many Maori parents did not appear to be ‘getting the message’. By mid September this year - seven weeks after the programme commenced in South Auckland - it was estimated that only approximately 40 per cent of Maori pre schoolers had received their first injection.
One nurse commented that ‘We put everything to one side the first day, expecting to be inundated with people. But they didn’t come’. It appears that a large number of Maori simply did not know such a vaccine was available.
For many practice nurses this came as no surprise. With many years of vaccination experience behind them a number of these nurses were aware that the non uptake and non acceptability of the campaign for some Maori was inevitable and should have been addressed from the start.
I well remember the huge effort by practice nurses which went into the Hepatitis B and Haemophilus Influenza B immunisation campaigns some years ago. In the short time frame we were given to prepare for the application of the new programme we possibly fell short on many of the issues parents raised, but we did learn valuable lessons as to how to recruit and engage Maori in the immunisation process.
Many Maori may not have been aware of the meningococcal B vaccine because they don’ regularly watch television at critical times required for information dissemination, such as the news, nor do they read the newspapers. Some Maori are poorly educated and don’t have the skills necessary to assimilate such information; and many Maori parents used to tell us of their inability to keep appointments because they didn’t have diaries or calendars.
In previous campaigns colleagues and I went with a Maori community worker to where Maori actually were. We went to the local pubs, TABs, shopping malls, markets and kohanga reo. Our previous low immunisation coverage suddenly increased from 52% to 91% in a period of 11 months. This was a nursing initiative which lost impetus when the two of us responsible for its success left the practice. A community based approach however had clearly worked more successfully than relying on written or televised promotional material.
Transport costs are also usually a major factor for Maori and relying on presentation at a general practice setting rather than nurses taking the vaccinations to the community, seems to be a system failure in this campaign.
It will take about a year for the MeNZB™ vaccine to be available throughout the country, due to the logistics of delivering such a large programme. The complex issues relating to such a massive campaign will probably be ironed out more smoothly by the time the campaign is completed. Nurses in various parts of the country will have different issues to deal with and will no doubt do an excellent job in the process. Nevertheless it is rather a shame that a fair slice of the media coverage and the resulting kudos has been based on the role of the general practitioners rather than the nurses pivotal input. Some nurses contracted in to carry out the immunisations seem poorly reimbursed and other nurses already providing the vaccinations in the course of their busy daily activities have seen little or no ‘bonus’ for this hard work.
Whatever remedial lessons are learned from this campaign let us hope it will include utilising the expert knowledge which exists amongst these nurses and allow them a strong voice and input into the subsequent evaluation of the programme.
Barbara Docherty
RN MCNA(NZ) Post Grad Dip Health Sc
Barbara Docherty is the National project Director of the TADS (Training and Development Services) Brief Interventions for Harmful Behaviour Programme at the Department of General Practice and Primary Health Care, School of Population Health, University of Auckland. Barbara was previously in clinical practice as a practice nurse for 20 years.
