The shingles vaccination campaign has not exactly had a smooth ride. Its bizarre system of allocation to the chosen few aged 70 or 79 has left many an elderly couple bewildered, as one half of a loving relationship leaves the surgery ‘protected’ while the other remains at risk – but is cheerfully told not to worry. Then there have been the problems with supply. This could be awkward if patients start to cross the magical age barrier of 79 before the vaccine is available in their area – as we are told the vaccine is effective at 79, but destined to lose this protective quality the moment you become an octogenarian. The question we should really be asking, though, is why we are doing this at all – how beneficial is it, and is it a good use of scarce NHS resources?
Here I am grateful to Klaus Green, a fellow Godalming GP who decided to look into the issue when a patient said to him: ‘This shingles vaccine, Doc, is it worth me having?’ Being the diligent doctor Klaus is, he wasn’t content to say ‘of course it is, now roll your sleeve up!’ He decided to look into it instead – what really was the value for his patient? The more he found out, the more astonished he became, and the more he started to question its value, not just for the patient, but for the NHS as a whole.
One fundamental difference with the shingles vaccine compared to most other vaccines, is that it will do nothing at all to circulating levels of virus in the population. There is no herd immunity, no benefit to wider society and no possibility of eliminating varicella-zoster infection. The vaccine was originally developed with this in mind, in the form of Varivax, as a vaccination against chicken pox (the only difference being that Zostavax is a more concentrated form of the same live attenuated viral strain). The prospect of a national programme for vaccination against chicken pox, however, has no immediate prospect of blessing the balance books at Sanofi, since the Joint Committee on Vaccination and Immunisation (JCVI) decided in 2010 that it could actually make matters worse. It risked leading to more adult break-through infections and an increased risk of shingles, as regular contact with the chicken pox virus through our lifetimes provides a valuable boost to immunity against shingles.
The case for preventing shingles, however, was not going to be easy either. There are few deaths for starters (1 in 1000 cases is quoted, but it’s hard to believe that these are not in immunocompromised individuals who would not be able to receive a live vaccine anyway). Then there’s the inconvenient fact that treatment for shingles is not that expensive – hospital admissions are rare, aciclovir is off patent and amitriptylline cheap as chips. The case could hardly be made on cost savings, so no-one bothered with that – but didn’t NICE agree to fund treatment on the basis of Quality Of Life Years (QALY) though? £30,000 per QALY is the accepted rate, so get agreement in principle from the Department of Health, do some QALY research, set the price of the vaccine to make sure the cost comes in respectably below £30,000 and Hey Presto, the vaccine is a going concern once more. Which is pretty much what seems to have happened – and the fact that even Sanofi concede that non-one knows how effective the vaccine is after as little as four years is a fact that seems to have been conveniently brushed under the carpet.
The Daily Telegraph recently picked up the story, detailing the overall cost of the campaign in these cash-strapped times of £250m. Their understanding is that the cost to the Department of health per vaccine comes in at around £55 (even though as GPs we buy it and are remunerated at just over £100 a jab). The QALY model the JCVI have based their assessment upon came up with the figure for the cost of one QALY being £22,300. At £55 per person you can vaccinate 371 people for that sum, which means the one QALY gained has to be shared out between a large number of patients. Let’s call it a nice round 365 – which means one QAL-day per patient.
Dr Green went back to his patient to give him the conclusion of his findings – he would gain, on average, one quality of life day, part of which he would have to spend in the surgery having his vaccine. I don’t know what his patient decided.
Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68