Today, and exactly one week ago, evidence was heard by MPs on the feasibility of extending the vaccine to all children under the age of eleven. All thanks to an online petition that has, to date, received over 800,000 signatures. I wrote a piece on meninigits when the petition first went vital, which you can read here.
The first session saw evidence from the parent of those affected, including the creators of the online petition. Their views and experiences were important to hear, and the minutes are now available on line.
Today, there was a second session. Two meningitis charities, Meningitis Now and Meningitis Research Foundation; a select group of scientisits and paediatricians; and representatives from the Joint Committee on Vaccination and Immunisation (JCVI) and Public Health England (PHE) were questioned.
Although two hours long, it was an interesting and, I think, balanced discussion. Both charities and scientists were in agreement that after under ones those under five years of age are the most at risk and, in an ideal world, should be vaccinated. However, limitations in what we know about the vaccine and about how we calculate cost-effectiveness were raised. While research is ongoing into these, I got the impression that any change to the age groups vaccinated would be after these areas are better understood. Here’s a quick run down of some of the issues discussed.
Data on the vaccine
Early on in the proceedings, the Meningitis Research Foundation called for further research into how well the vaccine is performing. This was echoed by others over the course of proceedings.
The problem we have with Meningitis B is its rarety. It’s so rare that traditional efficacy studies couldn’t be done before it was launched. So, we’re still not sure how well the vaccine will protect people (though laboratory studies seem to show good protection), or how long for. Now it’s been rolled out, it’ll take a few years (Dr Nadel, a Consultant in paediatric intensive care, said maybe five to ten) to work out how well it’s performing. Without that information it’s hard to truely assess whether it’s good value for money.
What both charities and scientists are keen to avoid is a false sense of security. There are other types of meningitis not covered by the vaccine, including other strains of Meninigits B, and we don’t know how well the vaccine will work. So education and awareness alongside prevention is key. The paediatricians were quick to point out that this education is even more important as the disease gets rarer thanks to the vaccination.
There was much talk of the way the JCVI determined cost-effectiveness. The JCVI highlighted they are bound by the rules set down by the National Institute of Clinical Excellence (NICE), which relate to all health technologies.
The Meningitis Research Foundation discussed several limitations of the current model, including:
- Peace of mind should be accounted for, but currently isn’t. There is a benefit for parents having the peace of mind that their child is protected, and meningitis has been shown to be one of parents’ biggest fears.
- Public preference is not well accounted for. Preventing several minor illnesses may be valued the same as one major one in the model, but that is not how we make decisions in real life. Also the public often have a preference for treating children that isnt accounted for in the model.
- Discounting: the economic models favour short term health benefit. A multiple amputee may cost the NHS £3 million over the course of their life, but this is discounted by 3.5% to favour more immediate effects. The vaccine may be cost-effective in under fives if this discounting rate was reduced.
It’s worth bearing in mind that these things couldn’t be applied only to Meningitis B, and that a review of the way we make these decisions may have implications for how we deal with cost-effectiveness of all health interventions.
The JCVI highlighted that as well as the cost-effectiveness model they also considered number of cases, the burden on the health system and how well the vaccine was performing; and that the process was the same for all vaccines. Interestingly, there was general agreement that the models may have limitations. JCVI emphasised that they had used a “quality adjusted factor”, a tool that hadnt been used for vaccines before and which aimed to try to account for the points mentioned above. This is the most that was allowed within the rules set out by NICE, but that a concern that this wasnt good enough has lead to a review of the methods. This review is on-going and aims to investigate whether the rules for health technologies are suitable for vaccines.
Which age groups?
There seemed to be a general agreement that the under fives should be the next age group to target, if possible. Dr Mary Ramsey from Public Health England gave a more detailed breakdown of last years cases by age group:
Under 1s: 101 cases
1 year: 78 cases
2 years: 29 cases
3 years: 20 cases
4 years: 12 cases
Based on that information, further calculations are being done regarding the possibility of extending the vaccination to under twos. However, by May next year all children under two will have been offered the vaccine as a baby.
Interestingly it was reported that Ireland have just launched their vaccination campaign, again limited to children under 1 year of age due to cost-effectiveness. To date it has only been the UK and Ireland that have found the vaccine to be cost-effective, as the rates of Meningitis B are higher here than elsewhere.
Vaccinations for teenagers?
A longer term goal is to look at vaccinations in adolescents. While not a major risk group for Meningitis B disease, this is the group that most often carry the bacteria. If the vaccine can prevent them carrying it, it may offer herd immunity to the at-risk groups. This may prove to be a cost-effective way of making a long term impact on disease transmission – infants and young children rarely carry the bacteria, so by vaccinating them we’re protecting the individual but not necessarily solving the problem. However, the study has only just started. Currently the project is looking at the rate of Meningitis B carriage in teenagers, it’ll be years before they vaccinate a sample and determine whether the vaccine would work for this purpose.
No conclusions were given for the meeting, but I came away with a sense of mild optimism. I think it’s encouraging that actually a lot of the concerns of the two meningitis charities are being addressed. I think what is clear is that any changes are not going to happen immediately. The meningitis charities themselves seemed to acknowledge that more research into both the efficacy and cost effectiveness of the vaccine is needed.
While this may leave some parents worried, I am glad that a considered approach is being taken. I hope the openness and collaboration between the various stakeholders goes some way to convince the general public that those making these decisions don’t do so lightly, and that they are trying to improve the health of the nation and protect as many people as possible.
It also left me feeling hopeful that the balance of cost-effectiveness may be tipped slightly towards preventative medicine. Perhaps this review of the way cost-effectiveness is calculated for vaccinations may also allow other vaccinations, currently too expensive, to make it onto the schedule – chicken pox for example?