Influenza Vaccination
The committee is asked to comment on the minister's response to the committee's 13th report, on influenza vaccination. Members will recall that Richard Simpson was our reporter. New members will have picked up on the issues that were raised in that report.
The report grew out of the concerns that were expressed by members of the committee and others in the wake of the situation that arose in the winter of 1999-2000. There were questions about when an outbreak becomes an epidemic or a pandemic. There was a cross-border difference on that and there were also differences between Scotland and England in the mechanisms for GP payment, advertising and how vaccination was given. That was in addition to questions about the effectiveness of the service.
As a result of the concerns, Richard Simpson was asked to report to the committee. He produced an extensive report some months ago. We have now received the minister's response to his report. Richard Simpson will give the committee his thoughts on the Executive's response.
The most interesting point is, perhaps, that the Executive was responding as we were undertaking the investigations. Discussions that we had with SCIEH and others—
Can I ask you to explain what that is?
I was hoping that you would not do that, as I can never remember what it stands for. I think that it is the Scottish committee for infection and epidemiology, but I cannot remember what the H stands for.
The discussions that we had were matched by the Executive's desire to change radically the system of flu immunisation in Scotland. It introduced a new programme which, so far—touch wood—seems to have been beneficial, as I heard last week that the rates are 78 per 100,000 compared with 1,000 per 100,000 last year. That is having a massive beneficial effect on the health services as they are under considerably less strain. Whether by chance or design, the Executive has gone a long way to implementing the major recommendations of the report and started to do so even before the report was produced.
However, if the committee thinks it appropriate, we should pursue some residual questions with the Executive. It has accepted the overwhelming majority of the recommendations on which it had not already acted, but it has not referred to some others. We still do not have a pan-European definition of flu. I assume that it will continue to work towards one. That is important in the longer term.
The Executive has said that it will review the method of distribution. It introduced a central reserve supply this year, which was very helpful. I am concerned not only about under-supply in some areas being matched by a central reserve but about the fact that there is some waste: general practitioners, under the current ordering system, may be left with supplies of vaccine at the end of the season. The Executive has undertaken a review on that—we could perhaps ask it when it will be prepared to give us information on the conclusions.
I remain very concerned about the targeting of the under-65s. I think that the over-65 programme has been highly successful and I am told that uptake figures of 60 per cent and upwards have been reached. That is extremely welcome. However, we need to encourage the Executive to continue to monitor uptake among people under the age of 65 who are at risk, to ensure that that group is properly targeted and that measures are implemented so that that group receives the support, in the form of a call to vaccination, that the over-65s have received.
The Executive has indicated that it will continue discussions at a national level on whether immunisation among health service staff should be promoted. That is, in any case, being done on a voluntary basis, which is extremely welcome. I am not clear about the extent to which it is being done in nursing and residential homes, or among other care support workers, but the Executive has said that it will pursue the matter on a research basis.
It will be interesting to learn the outcome of the discussion with the Department of Health and about what further research is to be undertaken. I say that because the existing research, as I noted in my report, was excellent. The Scottish research was very good, but did not have sufficient certainty to indicate that staff immunisation programmes should be compulsory, as they are for German measles and hepatitis B, for example.
The Executive says that some of the research that I recommended is really a matter for the industry. I question that and will give a specific example. The effective dose is currently thought to be 15 microgrammes, although there are indications that 10 microgrammes may be sufficient. I do not think that it is in the industry's interest to reduce the dose by a third unless it can charge the same price. I hope that, if members agree, we might consider whether that is an area where there should be some sponsored research, perhaps on a European basis, to find out whether a dose of 10 microgrammes is effective. That would be of particular importance in the event of a pandemic. If we can get away with a lower dose, it would reduce production difficulties.
The Executive has rejected my proposed solution of either a nationalised production company—similar to that which exists in Holland—or a joint company, operated with private industry. That is not crucial in normal years, but I remain deeply concerned that we have only one supplier, with a production line based near Liverpool, to produce the required supplies in the event of a pandemic.
Further, I would want to know more about the contracts that the Executive has in place with the industry should there be such an eventuality, to ensure that emergency supplies are made available. To be frank, if I was in Belgium, France or Germany, where there are major production lines, and a pandemic emerged, I would say that we should supply our nationals—or rather the people living in our country—first and that, if there is some left over, the United Kingdom could get it.
For the benefit of newer members of the committee, can I stop you there, Richard? Will you tell them—and remind me—of the statistical details relating to pandemics and about why you are particularly concerned about them?
A pandemic is characterised by an incidence of at least 25,000 per 100,000, rather than 1,000 per 100,000. The stretch on the health service that led the committee to initiate this report last year was caused by a rate of something in the region of 1,000 per 100,000, which was a near-epidemic level. A pandemic would have a devastating effect. As is shown in the report, the last very, very serious outbreak was just after the first world war. The estimates of the number of deaths throughout the world vary: the minimum estimate is 20 million, which is regarded as a gross underestimate, and the most acceptable estimate is 40 million. The true number is likely to be greater than that, and is certainly substantially in excess of the number of people who died during the first world war.
The last serious epidemic was in 1956, but at a lower level. That was the Asian flu epidemic, which is still talked about today. That was the last very major shift in the viral pattern. There was a small outbreak of the Hong Kong virus in 1968, at pandemic levels. There has not been a pandemic since 1968, so we are getting towards the longest recorded period without one.
Are you saying that there is some sort of discernible pattern of pandemics?
Nobody knows, and nobody can predict when the next pandemic will occur. There was nearly one in 1997, again in Hong Kong—it was the Hong Kong chicken virus—but it was discovered, thank goodness, and did not transmit from human to human. All the deaths that occurred in Hong Kong in 1997 were from direct transmission of the avian virus, which is the normal route for new flu viruses.
The potential for a pandemic is present. If one occurs, the effects on the country in terms of deaths, illness and morbidity will be devastating. That is why emergency plans are in position. The Executive is updating them as I recommended—it was in the process of doing that anyway.
The health boards apparently hold two-yearly reviews of their procedures. I wonder how effective that is: I think that there should be trial runs. I do not know whether we can ask for further work to be done on that. In any case, the prospect of pandemics is the most frightening, although it is one for which we in Scotland could be quite well prepared if we take the matter seriously. The indications are that the Executive is doing that.
Mary Scanlon has a question for you, Richard, but, staying on the same point, I want first to comment on the fact that the Executive has clearly said no to the idea of having our own national production facility, which would enable production to be guaranteed. Has it done that on the basis of cost? If so, what would the cost involved be? Was that decision based on its not agreeing that there is something to be concerned about? I invite Mary Scanlon also to ask her question at this point, but would then invite you to answer both mine and hers.
Richard Simpson made a point about the vaccine's availability to all staff who work with patients. I understood that that was addressed on page 7 of the report, which says:
"Along with private and voluntary sector health care employers, social care employers have been similarly encouraged to offer vaccination to relevant staff."
I am therefore quite satisfied that the Executive has addressed the matter, but would like to hear Richard Simpson's comments.
I have a few brief questions. First, does Richard Simpson feel that the 60 per cent vaccination uptake target for over-65s is ambitious enough? Secondly, is he satisfied that the figures from the Scottish Centre for Infection and Environmental Health will be made available to all of us? That would allow us to consider where the outtakes occur and whether there is any correlation with the uptake of the vaccine. Finally, I have not heard much about flu epidemics elsewhere in the country or in Europe. Are we in a good flu year; are we at the opposite end of the spectrum from a pandemic year? Is Scotland faring better than other areas, or is it too early to recognise whether that is the case?
I will answer Margaret Smith's question first. It is not clear from the Executive's response why it rejected the idea of having our own national production facility—except to say that it simply does not believe that it is necessary. It deems the current supply arrangements to be satisfactory. I included the issue in the report because—apart from the most important aspect, which is that of pandemics—two or three years ago, there were difficulties with supply at the Liverpool factory, which is the only national supplier. This year, there were supply difficulties with Solvay Duphar, a Dutch-Belgian company, which held up some supplies in England, from where more extensive orders from that company had been made.
There are limitations on supply, and I am not totally satisfied that the Executive has considered the Dutch set-up. It might be worth encouraging the Executive to come back with a fuller answer on whether it has sent people to Holland and examined the advantages and disadvantages that the Dutch find in that system of production.
Has the Executive produced any costings?
I do not know. My guess is that it has simply said that supplies are satisfactory and is not interested in other matters.
The Executive encouraged other workers to have the vaccination, but I do not think that any significant system was established. My understanding is that the uptake among health professional workers and others was very low. Later, we should ask SCIEH whether it has information on that, and find out what is happening.
The SCIEH figures are published regularly in a bulletin. Pan-European publications also exist, but their figures are more delayed than those in the national Scottish publication. Nevertheless, figures are available. However, disaggregating them to local levels involves problems with validity. My report asked about that and said that the numbers should not be published unless they are valid. The Executive's response slightly skirts round that issue. It said that there were always difficulties with local figures, but did not say whether they would be beefed up. A new procedure that uses the continuous morbidity recording system will be introduced, which is what I recommended. If that system is further strengthened, the possibilities for local figures may increase. However, they are not really available at the moment.
The last question was, is it a good year for flu. My suspicion is that the answer is yes. The flu vaccination programme has been much more successful in Scotland this year than heretofore, but we will know whether that is a coincidence only when we have had a year or two with a new and unpleasant virus strain. If the levels of immunisation are maintained and the programme is not stretched, the flu programme will have been effective.
That returns me to the final point about whether 60 per cent is enough. The level is limited because people perceive the flu jag as one that can cause side effects. All the indications are that the side effects are minimal. There have been very few serious side effects from the flu injection in the 40 years during which it has been used extensively and controlled by the Medicines Control Agency.
The number of reports of serious consequences has been minuscule—about 102 for 19 million vaccinations. However, nothing is risk-free. Some older people feel that they have had a bad reaction to the vaccination or, more important, that it did them no good because they had a virus during the winter. Such myths are false, because older people often get a respiratory syncytial virus, which is not a flu virus, but one that occurs every winter.
It will be a constant battle to maintain the level at 60 per cent or push it up to 70 per cent, which I guess we might reach. We will never reach the level at which we can eliminate the virus, which changes every year anyway. It is not like measles. If we had a 95 per cent response for that from the population, we could eliminate the virus.
My two points have been partially covered, at least. The first concerned uptake. We should seek figures on vaccine uptake among health workers and at-risk under-65s too, because further efforts may be needed next year to increase those rates.
That task could continue throughout the year.
The second point related to Mary Scanlon's question about whether this year was good for flu. Richard Simpson mentioned a figure of 78 per 1,000 this year, compared with 1,000 per 100,000 last year. Is that figure as of now, or is it a prediction for the danger period? I have spoken to doctors who say that they expect any flu outbreak this year to occur in the latter half of January. It might be too early to tell how this year's figure will turn out.
I agree with Nicola Sturgeon about the follow-up, which is important. There is another aspect to that. We should ask the retail pharmacists in Scotland whether they have been comfortable with the programme's support systems and with local variation. It would help to have that view.
The figure that I produced is the last that I have that was produced weekly. October to March is the flu period, so we could still have an epidemic, but the risk is decreasing. It must also be remembered that there are both influenza A and influenza B. As in previous years, there may be a minor outbreak of influenza B in the second half of January. I think that that is what Nicola Sturgeon referred to. That often happens.
The current two weeks are the period in which the respiratory syncytial virus hits, so there will be a mini peak of non-flu-virus winter respiratory conditions at the moment. There may be a further small peak at the end of January, but even if influenza B reaches the same level as it did last year, it will not stretch the services. The figure will be about 100, 120 or 130, which is quite small.
I will recap the issues about which Richard Simpson still has some concerns, most of which I think the committee shares.
What work has the Executive done on a nationalised production facility and to plan for pandemics? Are the plans adequate? Has the cost of establishing our own production source been calculated? Why does the Executive believe that that is unnecessary? We will construct some further questions for the Executive and approach it again. As well as the pandemic question, supply issues can arise. I am worried that we have only one national UK supplier.
The Executive responded to Richard Simpson's questions about dosage levels by saying that the industry can take care of them. In the Accounts Commission for Scotland's report on prescribing of about a year ago, we saw evidence that there are several ways of slashing the NHS's prescribing budget by up to £50 million. We should constantly look for ways of making dosage and prescribing more effective. If they were more cost effective, resources would be freed up elsewhere in the health service. If the committee takes the view that we can pursue that issue, we should.
We will try to get our hands on the figures. I have heard anecdotal evidence that the staff take-up was quite good, but we should try to obtain figures for all groups. We need up-to-date figures for the over-65 and under-65 targeted people. It is possible that what can be called a good flu year might lead to some complacency in the following year. We must keep the pressure on for the targeted over-65s.
I would like us to advance the point of view that targeting under-65s should be a continuing task for general practitioners, if not other health professionals too. They deal with people with respiratory problems, asthma and other illnesses throughout the year. They should say to those people in October, "Have you thought about a flu jag?" People who are at risk should continually be made aware that the flu jag is part of their health care package every year. We can keep up the pressure on that.
Richard Simpson also added some points about continuing to work towards a review of distribution and a pan-European definition.
As for community pharmacists, although they are generally happy, some concerns about blips have been raised anecdotally with me and it would be useful to find out how they compare the situation this year with what happened last year.
Given that this time last year we were at the height of the flu epidemic—with 1,000 cases in every 100,000 compared with 78 cases in every 100,000 this year—at what point can we predict that we might have a bad flu year? I am thinking in particular of planning for flu jabs. Last year, the epidemic just seemed to happen, but we have not had one this year.
I cannot answer that question; all we can do is wait and see whether the figures rise. In England, the first warning comes through NHS Direct, which will start to receive more calls seeking advice. As its response makes clear, it will closely examine the research that is being undertaken to find out what sort of early warning can be given. However, up to that point, it is difficult to say whether there is an epidemic. Although a new virus has appeared this year, it does not seem to be having much of an effect; I do not know whether that is because it is not very infective.
So there is no early warning; we know that it is going to be a bad year only when an increasing number of people start coming down with flu.
That is right.
We will have a final point from Dorothy-Grace Elder and then wrap up the issue.
I want to return to Richard Simpson's initial report, which has sparked this response and done the public a great deal of good this winter. You said that, although it is easy to calculate the number of over-65s who are vulnerable, the numbers of vulnerable younger people are not known. We might be able to tackle that difficulty if the Executive provided a much more precise figure on the number of such people with chronic bronchitis and so on and involved the pharmaceutical industry in helping to publicise the problem. In some surgeries I have visited this winter, the publicity has been almost counterproductive; it is all "Are you over 65?" and then "Flu vaccination blah blah". That can make younger vulnerable people think that flu vaccination is not for them.
I suggest that we collect all the points made by Richard Simpson and other committee members and prepare a response for the Executive. Richard, are you happy to have a look at that response before we send it off?
Yes. I would be delighted to.
We will wait and see what response we receive from the Executive.
I suggest that we have a five-minute comfort break. Various members will do unspeakable things such as have a smoke; the rest of us can go to the loo.
Meeting adjourned.
On resuming—