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Editor,—Hoare has recently highlighted the fragmentation of research into meningococcal disease, and suggested adopting the model of the Medical Research Council trials in acute leukaemia as a potential way forward.1 Such suggestions are timely as last year meningococcal disease became the most common cause of death in children between the ages of 2 and 5 years.
The Medical Research Council trials in acute leukaemia clearly demonstrated improved survival for children enrolled in collaborative trials and for those cared for in participating centres.2Before these trials the outlook for children with leukaemia was bleak; case fatality was in the order of 70% with children receiving diverse management in a wide range of units. Improving the outcome for meningococcal disease requires a similar approach but is more challenging because of three main differences:
- the sickest children with meningococcaemia are already cared for in a regionalised network of paediatric intensive care units each seeing at least 20 such cases per year
- the case fatality rate of meningococcal disease is already low and declining: from 15% in 1989 to 10% (or less in some centres) in 1997
- in meningococcal disease we are dealing with a rapidly progressive acute illness where early management is crucial to outcome.
A forum of excellence for furthering the management of meningococcal disease could easily be developed as a joint venture between the Paediatric Intensive Care Society, the Royal College of Paediatrics and Child Health, and the Public Health Laboratory Service. The UK Children’s Cancer Study Group has already shown us that a simple process of registration can lead to improved patient survival through the introduction of standardised treatment approaches in participating units.
A similar approach could be followed with dissemination of basic protocols through paediatric intensive care units, and the role of novel treatments could be clarified through the application of relevant clinical trials. For this to be successful a group methodology would need to be adopted aimed at achieving consensus. Many fundamental questions require unequivocal answers in meningococcaemia including: the role of human albumin in fluid resuscitation3; the optimal correction of coagulopathy; and the use of haemofiltration.4 5
Currently more than 300 children have been enrolled worldwide in an international multicentre randomised trial of bactericidal permeability increasing protein in severe meningococcaemia. To gain the maximum benefit from the huge amount of data collected, ongoing registration is required between clinical trials. The formation of a central coordinating group is long overdue.