Memorandum by the UK Vaccine Industry
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
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 UKAventis 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
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
The process of policyforward looking and
8. The development and implementation of
vaccination policies and their resulting success, is driven by
a number of important factorssurveillance 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 voicehindrance 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 stakeholdersprofessional organisations, patient
groups and UVIGa 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
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
diseasehigh 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
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
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;
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)