Diphtheria death prompts call for action to boost vaccination

Correction (May 5): A Croakey reader reports having diagnosed diphtheria in another patient a few years ago (see comments below), so the Brisbane case is not the first for nearly two decades as previously reported. I have asked for the reader to provide more details and confirmation, and will post these when they become available.

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As Medical Observer reported yesterday, a young woman has died in a Brisbane hospital from diphtheria, in Australia’s first case of the infection for nearly two decades.

The woman, who was not vaccinated against the disease, reportedly contracted the infection from a vaccinated friend who had recently returned from overseas.

The news has prompted Dr Sue Page, a GP in rural NSW and an adjunct associate professor at the University of Sydney, to look at what should be done to reduce the toll of vaccine preventable diseases.

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Some practical advice for action on vaccination

Dr Sue Page writes:

Certain types of germs don’t just breed in the host, causing fevers and illness; they produce toxins that poison the body causing massive destruction of tissue. Diphtheria is one of those.

Within 2-5 days of exposure, usually by breathing in germs from someone who is coughing but sometimes by wearing their infected clothing, the throat will become sore and weep a greyish green fluid which progressively thickens until the person struggles to breathe. As their lungs fail, the toxin attacks their heart and nervous system.

Anyone who has walked through a cemetery will have seen clusters of children’s graves, often several children in the same family who all died within a few days as diphtheria ripped through their town in the early 1900s, killing more Australians than any other single disease.

Even now, with the anti-toxin and our most powerful modern antibiotics 10% will die. It is a really, really, horrible disease.

The vaccination introduced in 1932 is remarkably successful and it is nearly 20 years since we have had a case in Australia. How utterly heartbreaking that last weekend saw the death of a young woman in Brisbane from something so preventable.

Although often criticised, the Australian health care system is good. It returns amongst the highest life expectancy for efficient cost price. So what part of the system failed here?

1.    We need to establish a “whole of life” vaccination register as part of the new national eHealth record. We have over 90% vaccination rates nationally for our children aged up to 6 years, which allows for herd immunity at the population level but does not protect an unvaccinated individual who is directly exposed. Adults remain a cohort of unvaccinated and worn-off vaccination and consideration should be given to increasing government subsidies for adult boosters.

2.    As international travel is common, we need specific programs to raise awareness of the risk of vaccine-preventable disease not just to the traveller but to their family and friends. The younger traveller may be at particular risk given the crowded nature of back-packer accommodation and propensity for less expensive third world travel. They may also be less likely to plan ahead and to afford (unsubsidised for adults) vaccinations, and less likely to access mainstream health care advice.

3.    We need greater government attention toward countering the anti-vaccination lobby rather than leaving the (valiant) efforts to the private sector (eg here and here). We also need greater accountability from government and the health sector into the way we manage vaccination side-effects. The Panic Virus by Seth Mnookin is an excellent starting point to understanding the growth of the anti-vaccination lobby. Our lowest rates of vaccination are usually in regions where parents are educated but “alternative’ in viewpoint and they are bombarded by anti-vaccination misinformation. The rate of disease in these areas is reportedly 8 times the rate in vaccinated regions. The role of some alternative providers of health care has been noted, and the new national registration process allows scope to consider the role of regulation.

4.    We have under-estimated the impact of complacency toward vaccination in an otherwise healthy population. We need regular consumer-friendly campaigns so parents can compare the great risk of disease against the small risk of vaccination. Canada does this well I think.

5.    We have focussed too much on the hospital sector with not enough investment in disease prevention. In the last 12 months we have seen an increase in hospitalisations for vaccine preventable illnesses of roughly 9.4% (from 16,345 in 2008-09 to 17,895 in 2009-10).

6.    General practice is critical to obtaining adequate vaccination coverage and we need to continue the ACIR incentives.

7.    We under-estimate the impact of difficulty accessing care. Even willing parents may fail to complete vaccination in the busy period after childbirth, and yet this is a critical time to protect the infant. Subsequent children of parents with chronic illness are less likely to be vaccinated than children in remote areas, showing that funding for active programs with mobile clinics may be beneficial.

Above all, we cannot afford to be complacent, we need to be whole hearted in our vaccination programs. Life is too precious a gift.