Select Committee on Science and Technology Minutes of Evidence


Memorandum by the UK Vaccine Industry Group (UVIG)

INTRODUCTION

  1.  The UK Vaccine Industry Group (UVIG) welcomes the opportunity to submit evidence to the Science and Technology Sub-Committee in advance of its report on human infectious disease.

  2.  UVIG, working within the Association of the British Pharmaceutical Industry (ABPI), represents the seven pharmaceutical companies that research, manufacture and supply vaccines to the UK—Aventis Pasteur MSD, Baxter Healthcare, Chiron Vaccines, GlaxoSmithKline, Wyeth Vaccines, Powderject/Evans Vaccines and Solvay Healthcare. UVIG's aims are to promote the positive benefits of vaccination as a key element in public health, and to represent the UK vaccine industry to all interested parties.

  3.  The following paper relates directly to the role of vaccines and vaccination policy in managing infectious disease in the UK.

  4.  Vaccines and their use in the national immunisation programmes continue to rank among the most important contributions to public health in the UK. The previously immense burden of morbidity and mortality associated with "common" childhood diseases such as diphtheria and pertussis is now rare. However, as acknowledged in the Government's "Getting Ahead of the Curve" strategy, more can be done. Further opportunity to reduce the impact of infectious diseases through prevention is still present. Taking preventative measures when managing public health has benefits for the individual, the population as a whole, and for the NHS through efficient use of health care resources.

  5.  UVIG believes that by promoting greater access to licensed vaccines, planning more thoroughly for the introduction of new vaccines, targeting previously unmanageable infectious diseases (such as meningitis B and rotavirus), and undertaking effective dialogue with stakeholders, more can be achieved as part of an overall programme to fight infectious disease.

  6.  Failure to address issues of process and to improve access to new and existing vaccines, will inevitably lead to an increasing health burden as a direct result of infectious diseases.

What are the problems facing surveillance, treatment and prevention of human infection in the United Kingdom?

  7.  Focusing on vaccination policies and therefore the prevention of infectious disease, there are two broad issues, which have a direct impact on the effectiveness of surveillance, and prevention of human infection in the UK. First, the question of process by which national immunisation policies are developed and implemented. And second, but by no means of lesser importance, is the influence of the public. The consumer voice can dictate the success or failure of national policy.

The process of policy—forward looking and inclusive?

  8.  The development and implementation of vaccination policies and their resulting success, is driven by a number of important factors—surveillance of disease, monitoring of uptake of vaccines, targeting of vaccines to specific population groups, and structures and processes in the NHS to deliver policy.

  9.  The surveillance of infectious disease provides information to assess the success of existing vaccination programmes and plays a key part in identifying future priorities. However, there are a number of areas that require review and attention if the system of surveillance is going to protect the UK population from infectious disease.

  10.  Microbiological data must be linked to clinical outcomes. There is clear guidance on the notification of communicable diseases set out in "Immunisation against infectious disease"1 but the nature of infectious disease is such that the morbidity and mortality is not necessarily identified at the point of infection. Surveillance systems in the UK must be integrated across the public health system and the NHS to ensure that not only infectious disease is reported, but the long-term impact of infection. For example, hepatitis B infection is a notifiable disease and whilst the immediate infection has morbidity and mortality associated with it, a proportion of people will go on to develop liver cancer or cirrhosis in later years. The coding of these diseases is poor with death certificates rarely differentiating between liver cancers or cirrhosis. The true picture of the impact of hepatitis B in the UK is therefore under-reported. Moreover, this under-reporting has a direct impact on the assessment of the need for vaccination programmes making it impossible for the UK to fully evaluate the impact of hepatitis B infection and therefore develop appropriate policies to prevent infection through access to hepatitis B vaccines.

  11.  A similar picture is seen with varicella infection in adults (chicken pox) and herpes zoster.

  12.  The lottery of vaccination. Vaccination programmes are either targeted at the population as a whole or are driven by age, such as the childhood programmes. However, the NHS cannot readily target groups by other criteria such as co-morbid disease, occupation or lifestyle, which leaves large sections of the population at risk from infectious disease, and in turn leads to an inability to measure the effectiveness of policy. This is evident from the poor uptake of several currently available vaccines: flu vaccine in those aged under 65 who are in at risk groups; hepatitis B vaccines; and pneumococcal vaccines. Table 1 shows that, whilst it is estimated that about 150 in every 1,000 people are at risk from pneumococcal disease, in Gwent only about 30 people in every 1,000 have received the vaccine, and there is a considerable disparity between the best and worst performing GP practices in the county.

  13.  However, as with other areas of health care, the effectiveness of policies is often dependent on local NHS resources and priorities. IT systems in the NHS vary across the country making it impossible to produce a national picture of at risk groups and therefore leading inevitably to variations in implementation. The success or failure of targeted at risk vaccination programmes is dependent on local initiatives put in place by Primary Care Trusts or at a regional level with implementation of national policy varying across England, Scotland, Northern Ireland and Wales. Whilst, it has now become a cliché, people at risk from certain infectious diseases are subject to a postcode lottery.

  14.  Timely to this consultation is the Winter 2002 flu programme, which continues to promote vaccination for those aged 65 years and over, whilst leaving the targeting of at risk groups to local initiatives (tables 2 and 3). A UK-wide policy is failing due to a lack of working systems which can identify those at risk and which can be used to monitor uptake across the country. Whilst the appropriateness of target payments for GPs may be a moot point, there is a clear need for consistency of policy to ensure delivery of the public health goals.

  15.  In a recent UK wide survey commissioned by UVIG (Annex 2), 45 per cent of people with asthma or diabetes were not aware of the national flu vaccination policy and a third of those at risk had never been vaccinated.

Consumer voice—hindrance or help?

  16.  The consumer is increasingly demanding accurate information in order to make a choice when accessing healthcare. Public confidence in both the policy and the vaccine is instrumental in protecting the population from infectious disease. Currently dissemination of consumer information is at best patchy and at worst inconsistent. Moreover, as has been seen with recent health "scares" a failure to provide accurate and consistent information at the outset leads to distrust and lack of confidence in the relevant health care programmes. This in turn leads to poor uptake of vaccines, exposing large sections of the population to the risk of infectious disease.

  17.  The Department of Health has a key role to play in building consumer confidence by providing information that sets out the rationale for vaccination programmes as well as the implementation details. Furthermore, by greater liaison with all stakeholders—professional organisations, patient groups and UVIG—a consistency of message can be achieved.

  18.  It is in this context that the media plays an integral role in disseminating information to the general public and is becoming increasingly important as key audiences are reached via an ever-growing multimedia mix. The media may affect public attitudes and the public's perception of risk re infectious diseases through the manner in which it imparts knowledge. The media can support vaccination policies by encouraging uptake of vaccine such as flu for those aged over 65 years and meningitis vaccination prior to the Hajj pilgrimage to Mecca.

  19.  It is important for those with a part to play in the management of infectious diseases to assist the media in gaining accurate information, keeping in mind the sometimes conflicting demand by the public for this information. The role of the media should be a two-way street with healthy relationships being developed between the media, industry, government organisations and NGOs, enabling a balanced viewpoint to be presented to the general public.

  20.  Ensuring accurate information to build consumer confidence has an integral role to play in ensuring the success of vaccination programmes. Following the pertussis scare in the mid 1970's it took nearly 10 years for this vaccination programme to recover and to protect children from a serious disease1. Creating an environment that supports informed choice will support existing and future vaccination programmes.

Will these problems be adequately addressed by the Government's recent infectious disease strategy, "Getting Ahead of the Curve"?

  21.  UVIG welcomes the recent publication "Getting Ahead of the Curve" and the commitment to improving public health in the UK. The proposed strategy sets out to create a modern system to prevent, investigate and control the threat of infectious disease. The actions will, inter alia include the creation of new national bodies to ensure an integrated approach to public health, focus on education and communication to professionals and the public, and develop a programme of new vaccine development. The focus must now be on developing the detail and implementing the proposals to deliver the public health goal.

  22.  Vaccines and their implementation continue to rank among the most important contributions to public health in the UK. However, as acknowledged in "Getting Ahead of the Curve", more can be done.

  23.  The challenge for the Government is to take the strategy on to the next level producing a comprehensive implementation plan with clear goals, responsibilities and timelines. Essential to this will be multi-agency and stakeholder support, which will require the Department of Health to liaise and consult with all relevant organisations in a transparent and inclusive manner. Furthermore, consideration is needed as to how to address the regional issues across the UK.

  24.  Currently liaison with stakeholders is patchy, has no clear process and lacks transparency. As is being seen in other areas of health policy such as the development of guidelines by the National Institute for Clinical Excellence or the National Service Framework programmes, all stakeholders are invited to contribute to the policy either through formal consultation opportunities or as part of appropriate working groups. As the "Getting Ahead of the Curve" strategy is developed and implemented the contribution of stakeholders will be essential. Further more, to maintain credibility the process by which these contributions are made must be equitable, fair and transparent.

  25.  This is of particular relevance to UVIG and its members as the research, development and manufacture of vaccines is a lengthy and involved process. Dialogue is needed during development and implementation of vaccination policy at all levels to ensure that industry time frames and priorities are aligned to the public health strategy.

  26.  Secondly, the strategy is for England only, yet the Department of Health acknowledges that infectious diseases have no boundaries by developing national immunisation policies for the UK. To this end, the strategy must consider the means by which agencies and the NHS can work together across geographical boundaries to eliminate the lottery of access to vaccines, and to ensure surveillance systems are able to monitor the UK as a whole to monitor effectiveness.

  27.  UVIG looks forward to participating fully in the process by which the strategies in "Getting Ahead of the Curve" are developed and implemented.

Should the United Kingdom make greater use of vaccines to combat infection and what problems exist for developing new, more effective or safer vaccines?

  28.  Vaccines have delivered, and will continue to deliver, some of the biggest improvements in public health by preventing infectious disease. In recent years the UK has seen improvements to existing vaccines with the ability to combine antigens thus reducing the number of injections for the recipient and leading to a more effective use of resources. In addition, new vaccines have been developed to target diseases previously not preventable through vaccination. Moreover, there is now evidence that some diseases such as cancers are triggered by infectious agents and are therefore either treatable or indeed preventable by vaccines and vaccine technology.

  29.  In order to make greater use of vaccines the Government, in addition to the strategies set out in "Getting Ahead of the Curve", needs to create an environment which encourages greater investment in vaccine research and development in the UK.

  30.  The economic considerations for UVIG member companies to continue to invest in vaccines' R&D and manufacture are less than favourable. Vaccines are niched within public health and with little recognition as part of the wider health agenda. Clinical and NHS structural priorities do not explicitly include vaccines and the resources required to implement vaccination policy. Through greater recognition of the role of vaccines in the National Service Framework programme, Strategy for Sexual Health and adequate inclusion in the horizon scanning apparatus, the profile of vaccines will be raised.

  31.  Furthermore, environmental and policy issues exist which discourage investment in R&D, raises the costs of vaccines and leads to delays in the licensing and introduction of vaccines for the UK market. With the current public debate regarding the safety of vaccines, particularly for children, it is becoming increasingly difficult to enrol subjects into UK clinical trials. Moreover, the different vaccination schedule which exists in the UK (for instance, primary infant vaccination takes place at two, three and four months, whereas other countries use a two, four, six month schedule, or a three, five, 12 month schedule) raises the costs of introducing new vaccines to the UK and delays their possible introduction because additional clinical trials have to be undertaken.

Which infectious diseases pose the biggest threats in the foreseeable future?

  32.  "Getting Ahead of the Curve" identifies a number of specific diseases targeted for action in the future. UVIG supports these priorities but would suggest that the biggest threat from infectious disease in the future will be the failure to effectively monitor and implement existing policies, maximising the benefits of vaccines currently licensed for use in the UK.

  33.  As previously discussed the action in the immediate term should focus on utilising existing vaccines, create a surveillance and monitoring system that works across all relevant agencies and NHS sectors, and crosses the boundaries that exist either through devolution or as a direct result of the NHS structure.

  34.  The UK has enjoyed a reputation of having one of the most effective vaccination programmes to manage infectious disease—high coverage rates with low incidence of diseases and associated morbidity such as congenital rubella syndrome being a distant memory. If new policies fail to address issues of implementation and communication the UK may lose its status as a leader in public health.

  35.  The annual impact of influenza on the NHS is well recognised. Even in winters when the incidence of flu is low, there are around 3,000-4,000 deaths in the UK1; however in epidemic years the death toll is very much higher (eg 26,000 excess deaths in 1989-90).2 Although the UK Department of Health has largely addressed poor uptake rates of influenza vaccine in the elderly, by instigating an age-related policy and target payment scheme for patients aged 65 years and over, there is considerable concern that most high-risk patients under 65 years of age do not receive annual vaccination in accordance with official recommendations.3 In addition, vaccination of health and social care workers against influenza is highly suboptimal,4 although the evidence in support of this is now compelling.5 Influenza vaccination is a highly cost-effective intervention (table 4); if official policy were fully implemented, the burden of influenza related morbidity and mortality would be further reduced, and winter pressures on the NHS would be further alleviated.

  36.  Pneumococcal polysaccharide vaccine is currently licensed and freely available in the UK. Unlike influenza vaccination, there is currently no national age-based recommendation in place (local policy exists in Northern Ireland). In spite of the fact that in most patients for whom influenza vaccine is currently recommended, pneumococcal vaccine is also recommended, the latter is still grossly under utilised. (table 1) Each year, one in every 1,000 adults are estimated to be affected by pneumococcal pneumonia, with 10-20 per cent of patients dying.1 However, a recent study in Scotland has illustrated that among the elderly the incidence is far higher (8.5 cases per 1,000 persons aged 65 years and over; 10.7 per 1,000 in 75-84 year olds).6 Uptake of the polysaccharide vaccine in the elderly remains low. In Scotland, a national survey of nursing homes revealed that although 85 per cent of residents had been vaccinated against influenza, only 11 per cent had received pneumococcal vaccine.7 Since pneumococcal vaccine is 60-70 per cent efficacious in preventing pneumococcal pneumonia,1 more effective implementation of pneumococcal vaccination through an age-based recommendation and target payment scheme would considerably reduce the NHS burden resulting from pneumococcal disease.

  37.  Research and development is ongoing in a number of areas including vaccines to protect against meningitis B, rotavirus, and the human papilloma virus (HPV), which is known to be the cause of cervical cancer.

  38.  Hepatitis B is transmitted through blood and body fluids and as such poses a particular threat to sections of the population due to their occupation or life style. Whilst occupational programmes work efficiently to protect certain groups, large sections of the population remain at risk due to the inability of the NHS to be able to identify risk groups and ensure they are vaccinated. Economic evaluation suggests that a universal, age related vaccination programme could be a more effective use of resources, protecting a significant proportion of the population.

  39.  Inactivated polio (IPV) vaccines are licensed in the UK in combination with existing vaccines thereby offering safer protection from polio with no added interventions. The UK is on the point of eradication of polio and IPV combination vaccines are licensed in the UK ready for inclusion in national policy to deliver appropriate health gain, patient acceptability and efficient use of NHS resources.

What policy interventions would have the greatest impact on preventing outbreaks of and damage caused by infectious disease in the United Kingdom?

  40.  The most effective means of managing outbreaks of diseases and damage caused by infection is through prevention. Whilst UVIG acknowledges that not all infectious diseases are preventable by vaccination, much can be achieved with current vaccines and the inclusion of new vaccines.

  41.  With no doubt the benefits of vaccines in preventing infectious disease can only be realised by the development and implementation of a unified strategy.

  42.  UVIG believes that the UK could achieve more in improving public health and more efficient use of health care resources through greater use of existing and new vaccines. In addition, to ensure that these policies are implemented to best effect the process for developing, implementing and monitoring policy must be reviewed. The engagement of all stakeholders in this process is key.

  43.  Policy must target existing vaccines to best effect through greater investment in NHS infrastructure and prioritisation of vaccination within the wider health agenda. Failure to do so with hepatitis B, flu, pneumococcal and varicella have led to missed opportunities to protect large sections of the population. There is strong clinical support at a grass roots level for more universal, age related programmes thereby protecting individuals before they become "at-risk" and using scarce NHS resources more efficiently.

  44.  Horizon scanning, investment in R&D and surveillance must anticipate and create space for new vaccines within the public health strategy. Future policies to target rotavirus, meningitis B, HPV and more imminently varicella for at risk women of childbearing age, will make a significant contribution to public health in the UK.

  45.  The process by which policy is developed and implemented must be reviewed. Whilst UVIG is encouraged by the strategies set out in Getting Ahead of the Curve, and more recently the launch of the Joint Committee on Vaccination and Immunisation website, these are just the first steps in creating a consultative, transparent and open dialogue.

  46.  UVIG possesses enormous experience and expertise in research, development, communication and implementation, and welcomes the opportunity to work alongside professional organisations, patient groups and NHS agencies in a more open and transparent manner.

REFERENCES:

  1.  Immunisation against Infectious Disease. Eds Salisbury D and Begg N HMSO 1996.

  2.  Ashley J, Smith, T, Dunnell K. Deaths in Great Britain associated with the influenza epidemic of 1989-90. Population Trends 1991;65:16-20.

  3.  Nguyen-Van-Tam J S, Kyaw M H, Pearson J C G. Age is not only criterion for flu vaccine. Br Med J, 1998; 317:946-947.

  4.  Joseph. Public Health Laboratory Service: Personal communication, 2002.

  5.  Hitoshi Oshitani. Influenza vaccination levels and Influenza-like illness in long-term care facilities for Elderly people in Niigate, Japan. Infection Control and Hospital Epidemiology, November 2000, Concise Communication.

  6.  A Ament. Cost-Effectiveness of Pneumococcal Vaccination of Older People: A study in 5 Western European counties.

  7.  Moe H Kyaw, Influenza and pneumococcal vaccination in Scottish nursing homes: coverage, policies and reasons for receipt and non-receipt of vaccine. Vaccine 20 (2002) 2516-2522.

October 2002


 
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