The population is getting older, and there is an increase in co-morbidities, requiring an endless pit of resources.
Under the UK, there is a limit to the resources available (manpower, drugs and procedures). This means waiting lists, NICE policies on treatment protocols, and limitations to screening programs.
Priorities in the allocation of resources
This has to take into account not only of the prevalence but also the seriousness of the condition. Prevalence meaning both mortality as well as morbidity.
What priorities should be given to those with the worst prognosis?
When should small benefits to a large number of people outweigh large benefits to a small number of persons?
Consideration of costs has become part of medical training and frequently we are told to order the cheapest rather than the best investigation first (compare that to the US where every single A&E seems to have a CT scanner!). With the advent of reforms to the NHS and GPs having more say in the allocation of resources, the difficult decision that they are forced to make on a daily basis will now be clouded by finical consideration more so than ever before.
NICE (National Institute for health and Clinical Excellence) use QALYs (Quality Adjusted Life Years) as a measure of health-related outcomes as related to cost-effectiveness.
QALY tries to quantify the length as well as quality of life gained by an intervention.
- The lower the cost of QALY the greater the efficiency of a healthcare system
The current debate surrounds rare diseases and the very expensive drugs that can be used to treat it. Applying the NICE cost-effectiveness guidelines, it would deprive these rare patients with the drugs that they need the most. But what happens if you are deciding on treatment between 2 different therapies for 2 different patients both with the same QALY?
Ethics of resource allocationUtilitarian: Striving the greatest good for the most amount of people would favour public health initiatives (vaccination, the proposed "polypill" to reduce cardiac events) but deny expensive treatments (intensive care or say transplants)
Libertarian: People in the UK have no right to treatment, but the rich can have private healthcare insurance and thus are able to pay for it like any other commodity.
ConclusionDespite all that is said, who can truly judge another person's life? Everyone has different thresholds and values for different reasons.
Laws on Vaccination within the UK
1840 Act: Made variolation (inoculation of smallpox material as opposed to vaccination) illegal, provided optional vaccination free of charge
1853 Act: Made vaccination (against smallpox) compulsory for all children in their first 3 months of life by a medical practitioner. Parents who did not comply were liable to a fine or imprisonment.
1867 Act: Extended the age for vaccination compliance to 14, with cumulative penalties for non-compliance
1896: Report by the royal commission was published, recommending that vaccination was protective against smallpox and the abolition of penalties for non-compliance.
1898 Act: Removed penalties for non-compliance. Enabled parents to obtain exemption for their child if they did not believe the vaccine to be effictive/safe.
National Health Service Act 1946
- Every local health authority should arrange the immunisations of people in the local area against smallpox* and diphtheria.
- Similar arrangements can be made for vaccination against other diseases by agreement with between health authority and minister of health/by order of minister of health. Previous vaccination acts made obsolete. Compulsory vaccination removed.
- Subsequently updated by National Health Act 1977 and National Health Act 2006 with no change on vaccination policy.1
- In 1963, the Joint Committee on Vaccination and Immunisation (JCVI) established as an independent advisory board to make recommendations to the government regarding mandatory vaccination schedules and safety of vaccines.2
- The UK Laws on vaccination are listed at the bottom of the page.
*However, in 1971 the smallpox vaccination abandoned as likelihood of smallpox introduction into UK was low and risks of smallpox vaccine outweighed risks of disease.3
Vaccine prioritisation during a pandemic: who should get them?
- There have been many pandemics in the western world in the past, affecting millions of people.
- When a vaccine has become available to the population governments subsidise their purchase.
- In such situations it is also important for the government and health organisations to prioritise who should get the vaccine.
- The 1918 flu pandemic is often employed as a model for future or current planning. Mortality rates in 1918 due to influenza were highest in the 20-40year old age ranges, whilst in subsequent pandemics (1957 and 1968), the young and the very old were most affected.4
- It is unlawful and unethical to force a vaccination or immunisation upon an individual against their will, even during a pandemic with the current laws.5
- In situations such as pandemics therefore it is important to educate those who are susceptible and allocate the appropriate resources to them should they want it.
There have been many pandemics in the western world in the past, affecting millions of people. Throughout history in such pandemics when a vaccine has become available to the population, in quantities which are necessary for the population, governments subsidise their purchase.
Mandatory Vaccinations for healthcare workers
- The idea of mandatory vaccinations for healthcare workers (HCW) has been increasingly important in recent years with the rise of flu epidemics and concerns over pandemic strains.
- Instead of forced vaccinations, it means limiting the work of individuals who have not had the vaccine.
- Vaccinating HCW has been shown cause a relative reduction of mortality in patients by up to 40%, reduce lost working days and possibly provide a cost saving.
- Duty not to harm others. It can be argued that knowingly risking infecting your patients when prevention is possible amounts to a culpable omission of care.
- Herd immunity in an institution.
- Trust in health system: Public trust may decline if it is known that HCW are foregoing vaccination
- Consistency between what HCW preach and their own actions.
- Freedom of choice (autonomy)
- Alternatives such as increasing hygiene levels
- Costs (both financial and on morale) of hunting down people who do not comply with the programme
- Educating staff better (and giving incentives?) should produce sufficiently high voluntary uptake as to make a mandate unnecessary.
Arguments in favour of mandatory vaccination6:
- All HCWs, including students and trainees, who have direct contact with patient's blood or other potentially infectious body fluids or tissues should be immunised against HBV
- Non-responders to vaccination should be investigated for HBV infection to identify those who may pose a risk of infection to their patients during Exposure prone procedures.
- HCWs whose hepatitis B carrier status is not known should be tested before carrying out EPPs.
Concerns over Effectiveness
There are three main criticisms of vaccinations regarding the effectiveness:
- Drops in communicable disease rates are due to changes in sanitation, diet, hygiene etc rather than vaccination programmes.
- Critics argue that immunity given by vaccines is only temporary and requires boosters, whereas those who survive the disease become permanently immune
- Vaccinations (e.g. against diphtheria) lower the overall mortality rate, however they may increase the risk to old/immunocompromised adults7.
In the UK during the 70s and 80s a prominent academic claimed that the pertussis vaccine was only marginally effective. This caused vaccine uptake in the UK to decrease from 81% to 31% and was caused ensuing pertussis epidemics. As uptake increased, the epidemics ceased8.
Safety of Vaccines
- As with most medical treatment there are potential side effects, vaccines are no different. Often vaccines are given to healthy people, some of whom are intolerant to the possibility of side effects.
- There is a Vaccine Damage Payment Scheme (VDPS) in the UK which allows disabled vaccine injury patients (up to the age of 21) to claim for adverse events due to immunisations.
- There are a variety of safety concerns that have been raised over the years. Each has been thoroughly investigated and the current vaccines are of sufficiently high safety standards that the scare stories in the press are not justified.
Case Study: MMR Vaccine Scare
Most infamous of these is the alleged link between MMR and autism spectrum disorder (Wakefield et al. 1998)9
- The paper (since formally retracted by the Lancet and 10 of his 12 co-authors) alleged that the triple vaccine of MMR was linked to the development of autistic spectrum disorders in 12 children and Wakefield suggested that giving the vaccines in 3 separate doses would have been safer.
- It was revealed that Wakefield had received funding from litigants against vaccine manufacturers (and not informed anyone the journal or co-authors of this conflict of interest) and falsified study data to arrive at a predetermined conclusion.
- Subsequently, systematic reviews by the Cochrane library revealed no credible link between the MMR vaccine and autism10.
- In situations where parents believe the scare stories regarding MMR vaccinations it is important to make sure that the parents are as informed on the matter as possible, in the hope that they will change their mind (many GP practices have leaflets regarding vaccinations).
As mentioned before, vaccines are not compulsory. A parent has the right to refuse consent to have their child vaccinated even if the doctor believes the reasons to be misguided/illogical.
Individual Liberty and Religion
In some countries such as the US (although not the UK), there is a mandate for vaccination for children attending public schools. In other countries, such as Australia, certain welfare benefits are dependent upon adherence to the vaccination programme.
- These policies are somewhat controversial as it is seen as the government infringing on the right of the individual to choose what medication they do/do not choose to take.
- However, if disease threat is sufficiently low, people may rely on heard immunity, and should the unvaccinated population rise too much then the population as a whole is at risk11.
HPV VaccineHPV Background and Clinical Issues
- It was shown that at any given time 26.8% of women between 14 and 59 were infected with at least one strain of HPV between 2003 and 2004.
- Most HPV infections are temporary with 70% resolving within one year. When the infection lingers however, in 5-10% of women there is a very high risk precancerous lesions developing in the cervix, With the process developing into cancer over the course of 15-20 years
- HPV is the most common sexually transmitted infection with women becoming infected just after they become sexually active.
- Since the development of a HPV vaccine it has become important to immunise the population to reduce the risk and prevalence of HPV infection and thus cervical cancer in women.
- The HPV vaccination programme/cervical cancer jab, aims to vaccinate girls between 12 and 13 years, there is also a three-year catch-up programme for girls aged 14 to 17 years. The vaccine consists of 3 shots given into the arm; the second one is given to two months after the first and the third five months after that.
HPV vaccine ethical issues
- Religious and conservative groups have stated that they believe that giving the vaccine to such young girls will make them sexually active at a younger age. To rebut this Dr. Christine Peterson, director of the University of Virginia's Gynaecology Clinic, said, "The presence of seat belts in cars doesn't cause people to drive less safely. The presence of a vaccine in a person's body doesn't cause them to engage in risk-taking behaviour they would not otherwise engage in." 12
- People's reasons for exempting their children from vaccination include: 13
- Devotion to "natural" or alternative healing
- Opposition to state power
- Mistrust of pharmaceutical companies
- Safety fears
- Beliefs that children receive too many shots than is beneficial for them
- At this point it may also be useful to inform the parents that it is not only their child that they are helping but also the wider community.
- However, as stated earlier in this article, it is not legal to force vaccinations on individuals without their consent especially in the case of minors.
- Just as parents may refuse to have their daughter vaccinated, the patient is also within her rights to refuse HPV if she is deemed to be Gilllick competent: "sufficient understanding and intelligence to understand fully what is proposed." (Lord Scarman)
- Remember that minors have a right to be protected against vaccine preventable illness, and society has an interest in safeguarding the welfare of children who may be harmed by the choices of their parents or guardians.