Life used to be simple. 25 years ago, meningitis, an infection of the covering of the brain and spinal cord, was a real and present danger in pediatrics. All doctors had patients who had come down with meningitis, and it was fast and deadly (or disabling). The most common form of meningitis was caused by Haemophilus influenzae type B, or “HiB”. A large practice such as mine would almost always have at least one patient in the hospital who had or was recovering from HiB meningitis. Then, in 1987 the first HiB vaccine was licensed, and HiB meningitis went away fairly quickly. I haven’t seen a case in 20 years. The next most common type of bacterial meningitis, caused by streptococcus pneumoniae (or “pneumococcus”), also started to go away when a very effective vaccine, called “Prevnar,” was developed. We are now on our 3rd version of Prevnar, and it not only prevents meningitis and blood infections in infants and young children, but also is known as the “pneumonia vaccine” for the elderly. It is a stunning success story.
Today, we are being inundated with ads in magazines and on TV for vaccines that guard against another type of meningitis, called meningococcal meningitis. There are 5 strains of meningococcus that cause most cases of meningitis and “invasive disease” – A, B, C, W and Y. There are lots of other strains but the others cause milder or more rare cases of infection. And as you might imagine, there are also vaccines to help prevent meningococcal disease. Unfortunately, there are 2 different types of vaccine which each protect against different strains of meningococcus. One type of vaccine, called MCV4 and sold under the branded names Menactra and Menveo, protects against strains A, C, Y, and W. The other type of vaccine, branded as the Trumenba and Besexero vaccines, protects against strain B. Yes, I know, the names are difficult and ugly. Unfortunately, that’s the drug industry for you. Now, back to the ads. We see these ads because different companies make the 4 different vaccines, and each wants their slice of the healthcare dollar.
How prevalent are the different types of meningococcal disease? Well, by the numbers, the majority of cases in the US are cause by Type B. Type B infections roughly equal the number of infections of A, C, Y, and W. However, most Type B infections happen in infants under 1 year of age, and there is no vaccine available for this age range.
Currently, it is standard to give the MCV4 vaccine to all children in the US at ages 11 and 16 years old. This is because the decade of life between 16 and 26 years old is the highest risk decade for meningococcal disease for strains A/C/Y/W. Most colleges specifically require this vaccine for incoming students, and it is also standard for military recruits and for people entering some other career paths. The FDA terms this vaccination of everyone practice “routine use”, and this is what all drug makers crave – a vaccine that is given by default to everyone – the Holy Grail of vaccines. On the other hand, Type B meningococcal vaccines are also approved for use, but instead of routine use in every patient, these are given by joint decision of doctor and patient (or patient’s family). This is called “permissive use” – still covered by insurance, but not required, and not considered “standard”. The reason is because of the numbers above – Type B vaccines add a lot of cost, but prevent less disease. This is definitely considered “second class” in the pharma industry, because it requires a lot more discussion in a doc’s office, will not be opted for by many patients, and thus does not stand to make nearly as much money over time for the manufacturer as a “routine use” vaccination. As a result, the companies that make the Trumenba and Besexero, the type B meningococcal vaccines, spend a lot of money on medical journal and direct-to-consumer ads, trying to raise awareness of their products in order to sell more. Sad but true. The upside, if you ask me, if that ideally these ads create a forum for discussion between docs and patients and in the end, if getting a “Type B” vaccine is the right decision, it’s pretty easily done and will be covered by insurance.
How was that for a medical economics lesson?
Usual Pediatric Schedule:
- First dose age 11
- Booster dose age 16