Further supplementary memorandum submitted
by the Department of Health (SAGE 00c)
Thank you for your letter of 20 January regarding
the Committee's inquiry into Scientific Advice and Evidence in
Emergencies. You asked for information relating to the swine flu
(H1N1) pandemic of 2009-10—in particular, why the seasonal
flu vaccination programme's strategy regarding vaccination of
healthy children in 2010-11 differs to that adopted during the
pandemic.
It is important to be clear about the differences
between seasonal flu and pandemic flu. Seasonal flu occurs every
winter and there is some level of pre-existing immunity to the
flu strains that circulate from exposure to these or similar strains
in previous winters. In contrast, pandemic flu is a rare occurrence
when a new influenza virus emerges for which people have little
or no immunity and as a result we have limited understanding of
its clinical pattern. This allows it to spread widely, easily
and to potentially cause more serious illness.
The aim of the seasonal flu vaccination programme
is to offer protection to those who are most at risk of serious
illness or death should they develop seasonal flu. The groups
that receive seasonal flu vaccine have been identified by the
independent scientific expert advice by the Joint Committee on
Vaccination and Immunisations (JCVI).
The JCVI considers all the evidence and gives
advice which includes consideration of cost effectiveness. The
groups include all those aged 65 years and older and all those
aged six months to under 65 years in groups with medical conditions
that are considered to put them at greater risk from flu (seasonal
flu clinical risks groups). Healthy children have never been included
in the seasonal flu vaccination programme. Evidence on the effectiveness
of seasonal flu vaccine in young children is limited.
When the pandemic flu virus emerged in 2009,
pandemic preparedness plans were triggered. One element of these
plans was the vaccination of groups of the population that would
be identified based upon the epidemiology of the pandemic flu
strain. Advice on the priority groups to receive pandemic vaccine
was provided by JCVI in August[57]
and October 2009[58]
following consideration of the available data on the epidemiology
of influenza A (H1N1v) and from clinical trials on the safety
and immunogenicity of H1N1v vaccines. The committee confirmed
that the primary objective of the pandemic vaccination programme
would be to reduce mortality and morbidity and advised that the
following groups should be prioritised to receive vaccine:
— Individuals aged between six months and
up to 65 years in the current seasonal flu vaccine clinical at-risk
groups.
— Household contacts of immunocompromised
individuals.
— People aged 65 and over in the current
seasonal flu vaccine clinical at-risk groups.
At that time JCVI considered that "the
available epidemiological evidence does not indicate that any
one age group of the healthy population should be offered vaccine
preferentially once all those in the priority groups had received
vaccine."
In November 2009, following further consideration
of emerging data on the epidemiology of influenza A (H1N1v) and
on the safety and immunogenicity of H1N1v vaccines, particularly
in children, JCVI provided additional scientific advice:[59]
"The committee still did not consider that
the epidemiological picture indicated any particular age group
as being the next priority for vaccination. | The committee considered
that the use of mass
vaccination campaigns, including school based programmes,
were not indicated and noted that school based programmes would
incur significant opportunity costs for other public health interventions
in schools and the wider community. Since operationally the offer
of vaccination to anyone who requested it in the remaining population
might best be done in a phased manner the committee considered
that it was reasonable to commence this by making the Pandemrix
vaccine available on request to healthy children aged six months
and over to under five years of age as proposed by the Department
of Health. The committee also noted that the epidemic may be waning
and that this could obviate the need for further vaccination if
it continues to decline."
Following this advice all children aged between
six months and below five years were offered pandemic vaccine.
This advice was specific to the 2009-10 pandemic vaccination programme.
Following the pandemic, JCVI provided scientific
advice on seasonal flu vaccinations during the 2010-11 seasonal
flu vaccination programme in light of the experience of the pandemic
and the expectation that the influenza A (H1N1v) would be the
predominating flu strain this winter.[60]
It did not recommend the continued vaccination of healthy children.
This was because H1N1v infection resulted in
predominantly mild illness for healthy people and it was considered
that a substantial proportion of children were likely to have
been exposed to H1N1v during the pandemic and developed immunity
to H1N1v.
In light of the emerging epidemiology of flu
this winter, JCVI met on 30 December to review the latest evidence
and to consider specifically the vaccination of healthy children.
The committee issued a statement:
"JCVI was presented with data on the current
seasonal influenza epidemiology, seroepidemological data collected
during the 2009-10 pandemic, modelling of the impact of vaccination
strategies during the pandemic, data on the effectiveness of influenza
vaccines in the young and vaccine uptake and safety data.
JCVI noted that a large proportion of those individuals
with severe disease are in recognised risk groups for influenza
but unfortunately were not vaccinated. It strongly re-iterated
its previous advice that all individuals in risk groups should
be vaccinated as soon as possible, particularly those aged less
than 65 years.
The committee considered the issue of offering
vaccination to healthy children either 0-4 years and/or 5-15 years
of age. However, although there is a high incidence of influenza-like
illness currently in these age groups, a significant proportion
of this is due to other viruses such as Respiratory Syncytial
Virus (RSV). In addition, only a very small proportion of those
with severe disease are in these age groups. Based on previous
seasonal influenza epidemiology it would be hoped that influenza
circulation will have subsided within a month. We do not believe
that seasonal or pandemic vaccine should be used for these or
other healthy person groups. The greatest gain will be achieved
in increasing vaccine uptake in the clinical risk groups. These
are:
— Chronic respiratory disease, including
asthma.
— Chronic neurological disease.
— Chronic kidney disease.
JCVI hopes that stakeholder groups such as Scope
and the Neurological Alliance will emphasise the importance of
vaccination to their constituencies." [61]
The draft minute of that meeting has yet to
be finalised by the committee (it will be finalised when the committee
meets on 2 February 2011) but is appended in draft form to provide
you with further background to the above advice. [62]However,
I would be grateful if you could refer to the finalised minute
in any public statement that the Science and Technology Committee
may make. I have also attached a table showing estimated mortality
rates influenza by age-group, September 2010 to 19 January 2011,
UK.
As with all vaccination programmes, JCVI as
an independent scientific advisory committee will keep this matter
under review. During 2011 they will consider a study that is underway
to assess the impact and cost effectiveness of seasonal flu vaccination
programme and possible extensions to it and any other new relevant
data.
I hope that the Committee finds this response
helpful in understanding the Government's policy on seasonal flu
vaccination.
Rt Hon Andrew Lansley CBE MP
Secretary of State for Health
27 January 2011
POPULATION MORTALITY RATES FOR INFLUENZA
BY AGE-GROUP, SEPTEMBER 2010 TO 19 JANUARY 2011, UK
| Age-group | Number of fatal cases
| Rate per 100,000 population |
| 0-4 | 7 | 0.19
|
| 5-14 | 11 | 0.16
|
| 15-44 | 59 | 0.23
|
| 45-64 | 78 | 0.50
|
| 65 and over | 55 | 0.54
|
| Source: HPA | |
|
57
JCVI statement of August 2009. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/digitalasset/dh_104372.pdf Back
58
Minute of JCVI meeting on 8 October 2009. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/digitalasset/dh_108833.pdf Back
59
JCVI statement of November 2009. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/digitalasset/dh_108832.pdf Back
60
JCVI statement February 2010 (updated in March and July) http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/digitalasset/dh_118093.pdf Back
61
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/digitalasset/dh_123209.pdf Back
62
Not printed. Back
| 
