Real cost of cancer vaccine cuts


The Government has been condemned for its decision to scrap plans to provide teenage girls with a cervical cancer vaccine, particularly for such relatively small financial savings, writes Eithne DonnellanHealth Correspondent

NICOLA ROWNTREE was full of the joys of life. She was 21 years of age, recently married and got pregnant on her honeymoon. But when the pregnancy ended in miscarriage a few months later, and she had a cervical smear test that indicated she had pre-cancerous cells in the neck of her womb, her joy soon turned to gloom.

"It knocked me for six," she recalls. However, after several months of treatment at the National Maternity Hospital at Holles Street, Dublin, she made a recovery and went on to have "three wonderful, healthy children".

With a history of cancer in her family, the mother of two girls, who now lives near Westport in Co Mayo, was naturally delighted when she heard 20 years on that a cervical cancer vaccine was coming on the market which could guard against the most common strains of the virus that causes cervical cancer. "When I heard about this vaccine I thought this was absolutely brilliant," she says. There was no question in her mind that her daughters should get it.

Then came a recommendation earlier this year to the Minister for Health Mary Harney from the Health Information and Quality Authority (HIQA) that it should be given to all 12-year-old girls in the State and that to do so would be cost-effective. HIQA also recommended that, on a once-off basis, a catch-up programme of vaccinations should be given to all 13- to 15-year-old girls.

It said the annual cost of vaccinating 12-year-olds - some 31,000 of them - would be €9.7 million, while the catch-up programme for about 93,000 girls in the 13- to 15-year-old age group would be €29.2 million. But it concluded the programme would in due course prevent more than 50 deaths a year from cervical cancer, as well as preventing thousands developing pre-cancerous cells. It advised administering the vaccinations to students at second level. The cost per child would be about €390.

Harney, having considered the HIQA report, announced in August that the vaccination programme for 12-year-olds would commence in September 2009, after the HSE had time to plan its roll-out. But, she said, there was no money for the catch-up programme for 13- to 15-year-olds.

The HSE prepared an implementation plan for September 2009, costed it and submitted it to the Department of Health before the end of last September. It has since emerged that it wanted to wait until September 2010 to start the programme to allow time to prepare for it.

It said its preference was to deliver the vaccinations at second level - Harney favoured doing it in primary schools - but said there would have to be meetings with schools, parents and students, initially to explain what was involved in a bid to achieve an 80 per cent uptake.

It also said that, given that the vaccine had to be administered in three doses over a period of several months, more staff would be required.

Although it couldn't include the exact price it would be charged for the vaccine until it had tendered for it - two drug companies, Glaxosmithkline and Sanofi Pasteur, would be battling to win the contract - it included estimated costs for purchasing the vaccine in its plan, calculated following initial contacts with the manufacturers. Ultimately, the HSE's plan stressed that the cost of vaccinating all 12-year-old girls would be around 20 per cent higher than that estimated by HIQA. It sought the required funding to implement the programme.

ON BUDGET DAY, it became clear to the HSE that no money had been provided for the plan. But it wasn't until Tuesday last, when most eyes were on the US elections, that the Minister for Health issued a statement shortly before 5pm rowing back on her announcement of three months ago. She said that given how the economic situation had "rapidly and seriously deteriorated" she would not be proceeding with the introduction of the vaccination programme.

The Irish Cancer Society, Well Woman, the Marie Keating Foundation and Opposition parties, among others, condemned the U-turn, and there have been many calls on the Minister to reconsider.

When she initially announced the programme in the summer, Harney said: "I accept the expert advice that the introduction of a universal, high uptake, vaccination programme for young girls, in conjunction with population-based cervical screening, could significantly reduce overall cervical-cancer rates."

Rowntree says that now, when money is tight, it seems lives don't matter. "It's absolutely scandalous," she says. "Once again they are not looking at anything long-term. Surely it would be more cost-effective to give the vaccine to girls at 12 rather than treating them when they get cervical cancer. The whole thing is supposed to be about prevention, not cure. This should not be about cost. This is about life and death. They should have sought savings elsewhere. Do we really need the Government jet? Do ministers really need to drive around in the latest Mercedes with drivers? They are constantly hitting the vulnerable. First it was the old, now it's the young."

Harney insists money is scarce and difficult decisions have to be made. If such a drastic decision as this, which could cost lives, is made to save between €10-€20 million a year, then it is an indication that worse cuts are coming in the weeks and months ahead. The flu vaccine for all over-50s, as recommended by an expert group in July, has already been shafted, due to a lack of funds this year.

Harney points out that Finland has also decided it can't afford a cervical-cancer vaccination programme at present but the UK can afford it. Now children in Northern Ireland are getting the vaccine. Children in the Republic are not.

Cervical cancer, the eighth most frequently diagnosed cancer in women in the State, claims up to 90 lives a year. About 200 new cases are diagnosed annually.

Although vaccination of young girls to prevent them getting the most common strains of the sexually transmitted HPV virus, which causes cervical cancer, is extremely important, the vaccine protects against only about 70 per cent of cases of cervical cancer. Therefore vaccination needs to be coupled with a national cervical cancer screening programme to target older women who were never vaccinated, as well as to pick up cases where vaccinations would never work.

A national cervical screening programme finally commenced in the Republic this September and €30 million has been provided for its continuation in 2009. But the Government can't exactly slap itself on the back for this - the national screening programme began eight years after the idea was first piloted in the midwest region and decades after such programmes were introduced in places such as Canada and the UK.

When a national screening programme was introduced in the UK in 1989 cervical cancer rates fell substantially. They will fall here too, but critically they would already be falling were it not for the same procrastination over the introduction of the screening programme in recent years as there now is over the HPV vaccine.

DR GRÁINNE FLANNELLY, consultant obstetrician and gynaecologist at the National Maternity Hospital, explains that the cervical cancer screening programme is aimed at women aged 25 to 60 years.

"The vaccination strategy is aimed at a different group . . . it had the potential to protect current and future generations of 12-year-olds," she says. "It's therefore disappointing that for the foreseeable future this doesn't seem to be an option or a priority."

She is encouraging parents who can afford it to have their daughters in the relevant age range vaccinated, though she recognises the obvious inequality of this, with well-off families more likely to be able to protect their children's future health.

Getting the vaccine privately through a family GP is likely to cost up to €600, to cover the cost of three doses of the vaccine (around €345 plus VAT) as well as the three GP visits.

Rowntree is on a medical card but she says she will pay the fee "because my daughter's health is a damn sight more important".

Alison Begas, chief executive of Dublin Well Woman, accuses the Minister for Health of being "extremely short-sighted" and says she should reconsider her decision. "While short-term budget savings may be made by not proceeding with the vaccination programme, the reality is that unnecessary deaths will arise among the cohort of girls who were to be targeted," she says.

Fine Gael's health spokesman Dr James Reilly, himself a GP, blames Harney for leaving the bloated bureaucracy of the HSE untouched, the bonuses for managers unscathed, and the pay-outs to consultancies undisturbed, while aiming her hatchet instead at a service that would save lives.

Sinn Féin's health spokesman Caoimhghín Ó Caoláin claims the savings should have been made by abolishing tax breaks for private-hospital developers. Meanwhile, Labour's health spokeswoman Jan O'Sullivan stresses the amount of money that will be saved "by the axing of this vital service is minuscule".

Harney insists that last Tuesday's announcement wasn't timed for a day when it was good to bury bad news. She also stresses that the HPV vaccination plan will be re-introduced as soon as funds become available. In the current climate it is difficult to estimate when that might be.

Cervical cancer vaccine the European approach

At least 13 European countries already have vaccination programmes running, or about to commence. These include the UK, Belgium, Denmark, France, Germany, Austria, Greece, Italy, Luxembourg, Portugal, Spain, Sweden, and Switzerland.

In several other European countries, HPV vaccination has been recommended but vaccination programmes have not yet commenced. These include Norway, the Netherlands, Finland, Iceland and Ireland.

The manner in which the vaccination programmes are delivered varies. School- based programmes are in place in the UK. In France, the government reimburses those who avail of the vaccine.

The ages for which the vaccination is recommended also vary. For example, in May 2007 Belgium announced it would target 10- to 13-year-old girls, with a catch-up programme for girls up to 15 years. Under the French programme, 14-year-old girls are targeted with a catch-up programme for girls up to 23 years of age. The UK's programme is aimed at girls aged 12 to 13 years with a catch-up programme for girls aged 14 up to 18 years.