Memorandum by Joint Committee on Vaccination
and Immunisation (JCVI)
I write on behalf of the Joint Committee on
Vaccination and Immunisation (JCVI), an independent advisory committee
of the Department of Health, with terms of reference "To
advise the Secretaries of State for Health, Scotland, Wales and
Northern Ireland on matters relating to communicable diseases,
preventable and potentially preventable through immunisation".
Practice in the field, in which the UK is a
leader, is dependent upon the means of ascertaining the degree
and nature of infectious disease risk in the population, and the
availability of safe and effective vaccines. These have to be
matched practically by population acceptance of benefit from immunisation,
and robust service immunisation arrangements.
Reliable data, as have been obtained by standard
surveillance methods and through the Public Health Laboratory
Service (PHLS), are essential in determining who is at risk, and
the extent to which that risk is reduced by immunisation. The
formation of the Health Protection Agency should provide the opportunity
for further supporting and enhancing the work of the PHLS. Disease
surveillance depends upon sustained and coherent national, regional
and local action in support. Current proposals to devolve a significant
quantum of the PHLS functions to NHS laboratories can bring significant
strengthening provided that standard clinical work does not take
precedence over the less immediate, but nevertheless real benefits
from disease monitoring. It is therefore important that devolved
surveillance functions are properly supported, with control by
staff with specialist interests. At the same time, there will
remain a need for a network of laboratories with specialist epidemiological
and clinical pathological support, which is likely to form the
mainstay in developing new technical methods, and in exploring
changes in disease behaviour or frequency. These laboratories
need to be under the direct control of the agency, with some form
of central funding. At the same time, adequate support for the
research and development function has to be ensured. The acquisition
of reliable sets of data which can be confidently used to extrapolate
back to the general population require that information collection
is not limited by over-narrow interpretation of the Data Protection
Act, although with appropriate safeguards to individual anonymity.
The expanding range of vaccines makes it essential
that adequate effort is devoted to examining the extent to which
individual vaccines can be combined particularly in childhood.
Outside the range of conventional vaccines there is a need, amongst
others, for effective vaccines against respiratory syncytial virus,
hepatitis C, Helicobacter pylori and the papilloma virus [see
Department of Health "Getting Ahead of the Curve", a
strategy document which presents overall a logical and sensible
way forward in enhancing protection against infectious disease].
The UK has an excellent record in instituting
new immunisation practices, as evidenced by the introduction of
immunisation against meningitis C.
Effort needs devoting to examining the extent
to which different vaccines will give protection of long duration,
and to ways in which that protection can be enhanced.
Tuberculosis. The resurgence of tuberculosis,
and the raised risk in the immuno-compromised emphasise the need
for more effective versions of BCG (as does the significantly
raised incidence of the disease in immigrant populations, which
appear less well protected than native populations by BCG).
Pneumococcal disease. The overall efficacy,
or comparative efficacy in terms of practical population benefit
of differing varieties of pneumococcal vaccines is currently unclear.
Thus, it is likely that such vaccines have significant value in
the elderly, but the degree of benefit, and its duration are unclear.
Hepatitis B. Although hepatitis B is relatively
uncommon in the UK it is an important cause of morbidity and mortality
through cirrhosis and hepatocellular carcinoma, and the risk is
enhanced in those exposed to sexually transmitted disease. Possible
extension of immunisation policies outside at-risk populations
Public interest in immunisation, particularly
its safety, is very high. Such interest probably stems from a
declining knowledge at first hand of the often severe or fatal
consequences of diseases such as measles, compounded by the need
to immunise a child when healthy against a disease then seen by
the parent as a non-immediate risk. Combating fears about the
safety of immunisation depend upon the availability of sound information
about the benefits and risks (or lack of risks) from immunisation,
underlining the need for robust surveillance systems. That information
must then be made available as openly as possible, with the decision-making
process also being as open as possible. It is for such reasons
that JCVI now has lay membership, and produces open minutes of
its meetings, and that the Department of Health has recently opened
a web-site currently devoted to issues related to MMR.
It is important that, at a time of managerial
reorganisation of the Health Service, accompanied by a range of
targets for improving health, the needs of effective immunisation
based on high general coverage of the at-risk population are not
forgotten. "Getting Ahead of the Curve" rightly stresses
the importance of an integrated approach to health protection.
The requirement of access to high quality consistently
available data needs stressing. Transfer of data [appropriately
handled to safeguard individuals] between one part of the NHS
and another must be facilitated, and the need to report infections
for public health purposes must be practically supported. Molecular
biological techniques need general application in the tracing
of the patterns of outbreaks of infectious disease, and the population
responses to immunisation need a means of consistent identification
of what batch of vaccine was used where and when (such as bar-coding).
Linkage to existing databases such as the General Practitioner
Research Database would then provide a powerful means of scrutinising
UK immunisation practice is currently amongst
the best. That position needs safeguarding by the provision of
adequate resources for maintaining and extending activities, and
by ensuring that the importance of immunisation is accepted in
practical terms within the reorganised NHS.