Costs, compassion, and the case for vaccination

Costs, compassion, and the case for vaccination

If you want an overview of the major political issues in the UK, the government’s petitioning website is a good place to start. Calls for action on Islamic State, immigration, and the National Health Service (NHS) have all garnered hundreds of thousands of signatures. But the most popular current petition—indeed, the issue that has received the most signatures ever on the site— concerns meningitis B vaccination. More than 820 000 people have backed a campaign for all children up to the age of 11 years to receive GlaxoSmithKline’s Bexsero, which is currently used as part of routine vaccination for babies born since May 1, 2015, with doses at 2 months, 4 months, and a booster at 12 months. The government has rejected these demands, citing the advice of the Joint Committee on Vaccination and Immunisation (JCVI), which concluded that such an expansion would not be cost eff ective.

The situation shows how the debate between preventing serious disease on one hand, and the realities of how best to spend limited funds on the other, can put health-care systems in a bind. Patients and their families are understandably indignant about the government’s refusal to act solely because of cost. Invasive meningococcal disease can be diffi  cult to diagnose and patients can progress from showing no symptoms to death within 24 hours. About 10% of patients die, and a fi fth have serious permanent injuries, such as amputation of limbs, hearing loss, and neurological damage. The need for prevention seems obvious: why not vaccinate all children? Although the government’s answer—that it is too expensive—might sound callous, the situation is more subtle than simply not assigning a high enough price to a child’s life. Health-care systems have fi nite resources and the NHS must choose how to be most eff ective with the money it has. Paying for millions more doses of Bexsero, not to mention the logistics of a catch-up campaign, will deny funds to other diseases. The NHS came close to being unable to provide the vaccine at all. JCVI fi rst advised the UK Government to off er Bexsero in 2014, but a wrangle over the cost with Novartis, who originally owned the vaccine, led to months of delays. Only when GlaxoSmithKline acquired Bexsero was an agreement reached, in March last year. Even then, it was close to the threshold for costeff ectiveness.

And costs are not the sole concern. 

Relatively few children would benefit from the vaccine. Group B disease is rare and incidence is waning, with Public Health England reporting just over 400 laboratory confi rmed cases in 2014–15, versus around 1100 in 2005–06. Only 49 children aged 5–14 years had group B disease in 2014–15 and older children with risk factors for the disease already receive the vaccine on the NHS. Although the vaccine is generally safe, the potential for rare sideeff ects also argues against extending immunisation to large numbers of children with low risk of disease. Even if authorities did acquiesce to the petitioners’ demands, adolescents would still be unprotected despite being at risk. In 2014–15, adolescents aged 15–24 years accounted for 15% of all cases of invasive meningococcal disease in England, behind only children aged 1–4 years (22%), and those younger than 1 year (18%). The rationale for vaccinating children aged 5–11 years and not those aged 15–24 is not strong. In their initial decision about Bexsero in 2014, the JCVI said that vaccination in adolescence could be warranted but too much uncertainty exists about the duration of protection and prevention of meningococcal carriage to draw a reliable conclusion about cost-eff ectiveness in this group. 

Decisions on expanding vaccination are related not only to fi nancial considerations but also to a want of data. The UK is the only country in the world to include the vaccine in routine immunisation schedules. The incidence of group B meningococcal disease in the UK (1·44 cases per 100 000 per year) is similar to several other European countries—Belgium (1·20), Iceland (1·20), Malta (1·33), the Netherlands (1·40), and Ireland (2·08)—none of which use Bexsero in routine vaccination. They rely instead on outbreak control. In this sense, the NHS is doing more to protect children from group B disease than the health-care systems of any other country, even if the cold cost calculations are unpalatable. Paying for vaccines requires hard decisions, especially when subject to the full glare of public scrutiny. There is no easy solution. Each case will be debated, settled, and judged on its own merits. For meningitis B vaccination, it seems this particular debate is, for now, over.   

 ■ The Lancet Infectious Diseases