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Joint Committee on Vaccination and Immunisation

Volume 573: debated on Wednesday 8 January 2014

It is a pleasure to be here today under your chairmanship, Mr Gray. I am grateful to Mr Speaker for granting this debate on the work of the Joint Committee on Vaccination and Immunisation. I requested this debate following the JCVI’s decision on the 2 October 2013 to undertake further work on key issues surrounding the human papillomavirus, or HPV, vaccination programme. I understand that some colleagues may wish to comment on other aspects of the JCVI’s work. I want to focus particularly on the Committee’s decision to consider—I use its word—“urgently” vaccinating men who have sex with men, on attendance at sexual health services, and adolescent males. I intend to focus my remarks on that work now being undertaken with regard to the HPV vaccination programme, specifically in terms of exposure to HPV-related cancers, which are increasing in boys who have sex with females and the MSM community.

The decision of the JCVI to prioritise consideration of vaccinating MSM is noteworthy, not least because the minutes of its October meeting accept that a full economic model might not be necessary where sexual health clinicians can develop independent guidelines. Historically, the JCVI has often rejected vaccination of adolescent boys and MSM on economic grounds, so it is a major step forward for it to say that heath clinicians with expertise—particularly at sexual health clinics—can take such a decision on clinical grounds. That is welcome.

It is important—I have no doubt that my hon. Friend the Minister will need to ensure it—that any decision on extending vaccinations is clinically and financially sound. I do not seek to undermine that decision. I wish to stress the economic benefits of extending the vaccination swiftly, rather than stress other issues of equality, which I raised in an Adjournment debate last year.

I thank the hon. Gentleman for bringing this important health matter to Westminster Hall for consideration. There have been significant positive results from vaccinating women and girls for HPV, so clearly there is an advantage shown in doing that. That consolidates the hon. Gentleman’s request for the same vaccination to take place in men and boys as well. Does he agree that the same should happen with regard to men as has happened for women and girls?

The hon. Gentleman makes a good point that repeats some of the discussion we had in last year’s Adjournment debate. The success of the vaccination programme among girls has had a dramatic impact on HPV-related cancers among women. However, the flaw was that it assumed herd immunity for boys who were having sex either with girls or within the herd. But of course, not all boys have sex with girls: some—shock, horror!—have sex with other boys, and not all boys have sex within the herd. Increasingly, in a global economy, and particularly in Europe where the vaccination programme is not the same, adolescent boys in this country are exposed to women who have not been vaccinated. It is important to close the loophole for adolescent boys having sex with unvaccinated girls and those having sex with unvaccinated boys, who, obviously, grow to be unvaccinated men.

If the JCVI has agreed to urgently review the economic case for extending the vaccination programme, why is this debate needed? Before I discuss that, it is worth reminding ourselves what health problems we are trying to prevent. I recall, during the Adjournment debate, seeing the duty Whip sink ever further on the Bench as we discussed certain topics and cancers. This is not a pleasant subject, but I would rather discuss an unpleasant subject than have to deal with it in our hospitals.

Nine out of 10 cases of genital warts are HPV-related; oral-related HPV infections—men are six times more likely than women to have oral infections—increase the risk of cancers of the mouth, throat, neck and head cancers; and there are HPV-related penile and anal cancers: HPV is associated with 80% to 85% of anal cancer in men. In 2009, just after the HPV vaccination programme started, there were more than 6,500 cases of these cancers, with 47% of penile cancer and 16% of head and neck cancers thought to be HPV-related. The latest incidence data show that in 2010 there were 437 incidences of anal cancer and 5,637 of oropharyngeal cancer, 515 instances of penile cancer and 180,000 instances of genital warts. Rates of HPV-related cancers are on the rise in the UK. Throat cancer has overtaken cervical cancer as the leading HPV-related cancer. I am pleased that the JCVI has accepted that there is an urgent need to review the clinical and economic case for extending the programme to adolescent boys and MSM.

I should like to put on record my thanks to the Minister’s predecessor, my hon. Friend the Member for Broxtowe (Anna Soubry),for her support in this matter and for facilitating a teleconference, which she and I and representatives of the Terrence Higgins Trust had with the Chairman of the JCVI, which I believe gave some impetus to this change of heart and the speeding up of the work by the JCVI. That was a significant breakthrough.

The key point in this debate is that although the JCVI’s urgent report is due at some unspecified point later this year, the procurement of the next round of HPV vaccinations will commence in October or November this year. I am concerned that if the JCVI does not report in time and this procurement round is missed, we may have to wait four more years—I believe it is a four-year procurement round—before the HPV vaccination programme is extended to adolescent boys and MSM, if that is the recommendation.

I congratulate the hon. Gentleman on bringing this subject to the House. I share his concerns. Is he also concerned that although the JCVI undoubtedly does some excellent work, it does not share the flexibilities of the National Institute for Health and Clinical Excellence, in terms of its medical and health assessment processes? Would he welcome some movement there, which might in turn help bring this vaccine forward more quickly?

The hon. Lady makes a good point and speaks, probably, with more knowledge than I have. If NICE is able to react more swiftly than the JCVI, I am sure that my hon. Friend the Minister will take that point away and consider whether the two organisations could share best practice. Clearly, as new drugs come on the market and new issues arise, we must ensure that the health advisers are able to respond quickly to changes.

The key point I was making is that if we miss the procurement window, and if we have to wait four more years, boys and the MSM community would be unnecessarily exposed to HPV-related cancers. There is not just a personal cost to those who become exposed to HPV-related cancers: the NHS would be exposed to treatment costs that might be mitigated or avoided if we get the JCVI to report in time for the procurement round later this year.

If we look at the costs, we can start to see the scale of the savings. To put that into perspective, the three-dose HPV vaccination programme currently costs some £260. I understand that the JCVI is also considering whether that may be reduced to a two-dose vaccination, which would reduce the outlay. Let us compare that with the £13,000 cost per patient of treating anal cancer, the £11,500 cost per patient of treating penile cancer, the £15,000 cost per patient of treating oropharyngeal cancer, or the £13,600 cost per patient of treating vulvar and vaginal cancer transmitted by an infected male. In 2010, the total cost to the NHS of treating genital warts was £52.4 million. If we multiply those figures by four, we can see the clear economic benefits of bringing forward the decision to coincide with the next procurement round.

The clinical reasons and the economic benefits are evident, and I hope that my hon. Friend the Minister will confirm today that, at best, the JCVI will be able to report in time for the procurement round later this year or, at worst, that any contract procured later this year will have flexibility built in to allow the Minister and the Department of Health to extend the vaccination programme to adolescent boys and MSM at some point after the report.

It is a delight to serve under your chairmanship, Mr Gray. I congratulate my hon. Friend the Member for Finchley and Golders Green (Mike Freer) on securing this important debate.

I wish to change the subject and address meningitis B. A vaccine is available, and the Minister and the Department have decided that it is not cost-effective. I wonder what costs they have taken into account. Was it the lifelong costs of looking after a child such as my constituent Isabelle, who contracted meningitis B when she was seven years old? Isabelle was given a 0.7% chance of survival. She survived, but she had to have both her arms and both her legs amputated. She is the most amazing little girl. She is so bubbly, so bright and so cheerful given what she has to deal with, but there is the cost to the NHS, the cost of education and the cost of continuing care for the rest of her life—she is now 10 years old. She has to have four sets of legs and two sets of arms, which change regularly and cost thousands of pounds each. She has to have two wheelchairs, one portable and one mechanical, because she cannot walk far.

Isabelle has to have continuing care in school. Someone has to sit with her in classes because, clearly, there are things that she cannot do. She cannot easily carry her books from class to class, for instance, and she will need such care not just for the rest of her school and university life but for the rest of her working life, because she will be limited in what she is able to do.

Isabelle is the most amazing child that I have ever come across. She has come through such terrible circumstances. Her family had to make the awful decision that both her legs and both her arms had to be amputated. No parent should have to make that decision, and no child should have to live with that consequence for the rest of their life. She is not the only such child in this country; there are a lot of children in that situation with varying degrees of disability.

When the Minister reconsiders universal vaccination, will she bear it in mind that, although it is expensive, the emotional costs of what Isabelle’s family went through outweigh that expense? The Minister should consider the matter in the round, not just the cost to the NHS of vaccinating every child. We should consider what vaccination is doing for the whole country in saving money and preventing parents from having to make such a terrible decision. It must have been agony for the parents, the child and the family to survive in that situation. Will the Minister reconsider what can be done to ensure universal vaccination against meningitis B?

It is a pleasure to serve under your chairmanship, Mr Gray.

I congratulate my hon. Friend the Member for Finchley and Golders Green (Mike Freer) on securing this debate and on again bringing this important subject before the House. He has been a great champion. I also congratulate my hon. Friend the Member for Mid Derbyshire (Pauline Latham) on raising another vital aspect of the Joint Committee on Vaccination and Immunisation’s work, to which I will also respond, albeit briefly.

It may help the House if I provide some background. The JCVI is an independent departmental expert committee, and it is a statutory body constituted to advise the Secretary of State for Health on the provision of vaccination and immunisation services. The committee and its invited experts represent some of the finest clinicians and academics in the UK and Europe, and all members are selected for their expert knowledge of matters concerning vaccination, immunisation and associated disciplines, including immunology, virology, bacteriology, paediatrics, general practice, public health and health economics.

We all recognise that the NHS budget is a finite resource. New vaccination programmes and extensions to existing programmes represent a significant cost to the health service in terms of both vaccine procurement and administration. Obviously, it is essential that any recommendations from the JCVI on changes to the national vaccination programme are supported by evidence of cost-effectiveness.

The JCVI has adopted a methodology for assessing cost-effectiveness that is in line with that used by the National Institute for Health and Clinical Excellence. Using those processes, the committee basically ensures that increased spending on immunisation does not result in an overall decrease in the health of the population because resources are diverted from more cost-effective health care interventions. We all recognise that those decisions are not easy.

My hon. Friend the Member for Mid Derbyshire makes a powerful case for the meningitis B vaccine, which the JCVI is currently reconsidering. The updated statement published on 25 October 2013 reflects the JCVI’s recognition of the burden and severity of meningococcal meningitis and septicaemia in the UK and the need to explore the potential for their prevention through immunisation. The situation is difficult when we have a new vaccine, in this case against meningitis B, but lack important evidence on its effectiveness. We need to know how well the vaccine will protect, how long it will protect for and whether it will stop the bacteria spreading from person to person. At the committee’s next meeting in February, if it feels it is in a position to make such a decision because it is in possession of all the relevant facts, the JCVI will make a final recommendation on whether meningitis B immunisation should be introduced. Obviously at that point we will carefully consider and respond to the recommendation. I hope that my hon. Friend is reassured that the recommendation will get proper and careful attention.

On the issue raised by my hon. Friend the Member for Finchley and Golders Green, the primary aim of the UK’s national HPV vaccination programme, which began in 2008, is to prevent cervical cancer related to HPV infection. The HPV vaccine protects against two strains of HPV—16 and 18—that currently cause some 70% of cervical cancer.

As HPV is responsible for virtually all cases of cervical cancer, preventing the disease is the major aim, but as my hon. Friend rightly says, HPV infection has been associated with other cancers, including cancer of the penis and anus, and some cancers of the head and neck. The precise proportion of those diseases that can be attributed to HPV infection is less well defined, but evidence is emerging all the time, so HPV infection should be taken seriously.

Evidence from clinical trials demonstrates that the HPV vaccine has a very high efficacy against the precursors of cervical cancer. Evidence of efficacy against cancers at other sites is emerging, and it is recognised that the current programme may therefore provide protection against a wider range of HPV-related cancers in females and, indirectly, in males than originally envisaged.

It is also worth saying that the UK’s HPV vaccination programme has been a considerable success, with this country having some of the highest coverage in the world—something we can be very proud of. A recently published study by Public Health England provided new evidence that the programme is successfully preventing HPV infections in young women in England, and that adds to our confidence that the programme can achieve its aim of reducing cervical cancer.

With a high uptake of HPV vaccination among girls, transmission of HPV between girls and boys should, as my hon. Friend said, be substantially lowered. Many boys will be protected against HPV infection and will, therefore, be at reduced risk of developing the related cancers we have spoken about, such as anal, head and neck cancers. However, I appreciate that he is particularly concerned that the current programme does not extend to men who have sex with men. He argued strongly that that is an apparent health inequality, and he raised the issue with my predecessor in last July’s debate, for which I was present.

As my hon. Friend will know, the JCVI has recognised that, under the current programme, the protection that accrues from reduced HPV transmission from vaccinated girls may not extend to men who have sex with men. He made the additional point about men who might have sex with girls and women from elsewhere who have not been subject to the broad coverage provided by our programme.

That is why, in October 2013, the JCVI agreed to set up a sub-committee on HPV vaccination to assess, among other issues, the question of extending the programme to MSM, adolescent boys or both. The JCVI therefore recognises the issue as a priority, and I congratulate my hon. Friend on championing it, because the attention it received in Parliament was obviously part of the reason that it was given a fresh look and is regarded as a priority. I know the JCVI took events in Parliament into account, and, indeed, my hon. Friend made his case directly.

The sub-committee will aim to identify and evaluate the full range of options for extending protection from HPV infection to men who have sex with men, and that will cover a range of settings, including genito-urinary medicine clinics. However, as my hon. Friend will be aware, GUM clinics may not be the best setting for offering vaccination, as those presenting may already have been exposed to infection, so their ability to benefit from vaccination will inevitably be limited.

The sub-committee is scheduled to meet for the first time on 20 January, when it will assess currently available scientific evidence and consider what further evidence is required to advise the JCVI on the suitability of possible changes to the HPV programme. For the reasons I outlined earlier, any proposals for the vaccination of additional groups will require supporting evidence to show that it would be a cost-effective use of NHS resources.

Public Health England has begun preliminary modelling to assess the impact and cost-effectiveness of vaccinating MSM, in anticipation of further guidance on the issue when the HPV sub-committee meets. Further work to assess the impact and cost-effectiveness of vaccinating adolescent boys against HPV infection is also planned, but it will take some time to do that important modelling, and I am conscious that that is one of the predominant concerns on my hon. Friend’s mind. These are complex issues, and the development of the evidence base and the mathematical models by PHE, as well as the deliberations of the JCVI itself, take time. However, that process and the time that it takes ensure that we get important decisions right and that decisions are taken on the basis of the best evidence. We cannot, therefore, undertake to take decisions hurriedly, because they are big decisions with, potentially, big implications.

Should the JCVI recommend the targeted vaccination of MSM, flexibility around contracted volumes in the current vaccine contract may allow a programme to be undertaken without the need for a new round of vaccine procurement—the numbers involved are relatively small in the context of the existing programme—if additional vaccine was available from the manufacturer in the required quantities. We are therefore cautiously optimistic that we can accommodate targeted vaccination of MSM in the existing programme, were it to be recommended by the JCVI. I hope that is a little encouraging for my hon. Friend.

Vaccine supply contracts are let for as long a period as is considered appropriate, taking into account the timing of potential changes to JCVI advice, policy and market forces, as well as Government procurement guidance. Obviously, longer contracts can secure firm prices for a longer period and allow for more accurate budget planning. However, we are exploring the flexibility that we have in existing contracts to align the window for the new contractual discussions with any potential recommendations by the JCVI, especially on the wider vaccination programme, were that what it recommended. We have not completed that work yet, but what I have seen so far leads me to conclude that we might be able to do something around the existing contract. We are looking at that to ensure that we do not miss the window of opportunity, which my hon. Friend identified as a chief cause of concern.

In conclusion, this important work has yet to be completed. We have to get some clarity on the time lines. We cannot achieve one of the things my hon. Friend mentioned—bringing the work on the assessment forward—because we have to review the available evidence and fill in any gaps if further evidence is needed. A decision on the vaccination of adolescent boys will probably require the development of quite a complex model to determine whether vaccination would be cost-effective, because the numbers involved are large. Such a model may identify a need to generate additional evidence, so a decision on that wider programme is not likely before 2015. However, as I said, the evidence to support a decision on a selective programme to target men who have sex with men may become available during 2014.

I can certainly give my hon. Friend the commitment that I will keep under careful review the timetable for key decisions when the committee makes its assessment and look at how they align with what we know about the flexibility that we have under the procurement contract. We will keep that under careful consideration. I conclude by congratulating him again on bringing this important issue before us and on continuing to keep it on the Government’s agenda.

Sitting suspended.