Oireachtas Joint and Select Committees

Thursday, 11 May 2017

Joint Oireachtas Committee on Health

Vaccination Programme: Discussion

9:00 am

Photo of Michael HartyMichael Harty (Clare, Independent)
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The purpose of the meeting is to engage with officials from the Department of Health and representatives of the HSE and the Royal College of Physicians of Ireland, RCPI regarding uptake levels of vaccines, a subject which is topical. On behalf of the committee, I welcome Dr. Colette Bonner, deputy Chief Medical Officer, Department of Health; from the HSE, Dr. Kevin Kelleher, assistant national director for public and child health, and Dr. Brenda Corcoran, consultant in public health medicine, national immunisation office, NIO; and, from the RCPI, Professor Mary Horgan, president designate and consultant specialist in infectious diseases, Cork University Hospital; Dr. Karina Butler, chairman and consultant paediatrician and paediatric infectious diseases specialist of the national immunisation advisory committee, NIAC; and Dr. Donal Brennan.

By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable. I advise witnesses that any submission or opening statement they make to the committee may be published on the committee website after the meeting.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable.

I now call Dr. Bonner to make her opening statement.

Dr. Colette Bonner:

I thank the committee for the invitation to attend the meeting to discuss the issue of uptake levels of vaccinations. I am pleased the committee has also invited colleagues from the HSE and RCPI. I would also like to welcome Dr. Joan Gilvarry, director of human products monitoring, Health Products Regulatory Authority, HPRA. We look forward to working with the committee and extending to members every co-operation and assistance in their work.

Vaccination is regarded as one of the safest and most cost-effective of all health care interventions. The World Health Organization, WHO, estimates that up to 3 million lives are saved each year as a result of vaccination. All vaccines undergo long and careful review by scientists, doctors, and regulatory authorities to make sure they are safe.

Routine immunisation programmes commenced in Ireland in 1932 with the introduction of diphtheria immunisation. The current national immunisation programmes include the primary childhood immunisation, PCI, programme, which offers vaccination against 13 infectious diseases, and the schools immunisation programme, SIP, which offers booster immunisations to all children and the important cancer-preventing HPV vaccine to girls. In addition the HSE, through GPs and pharmacies, provides seasonal influenza vaccine and pneumococcal vaccines for people aged 65 years and older and those in medically at-risk groups. Participation in immunisation programmes in Ireland is voluntary, and, in the case of childhood vaccines, requires parental consent.

Ireland's immunisation policy is influenced by the policies that are developed through the WHO for the European region. The process and outcome targets established by the organisation have been used to guide the objectives of the Irish programme. These have specified the coverage levels to be attained, and outcomes such as elimination of target diseases, for example, polio, measles, and diphtheria. Other relevant international bodies include the European Centre for Disease Prevention and Control, ECDC, and the European Medicines Agency.

Immunisation policy and processes in Ireland are underpinned by the following principles, which support the Healthy Ireland goal to protect the public from threats to health and well-being - a fair equitable safe and relevant policy based on best evidence, and provided within a sustainable budgetary framework; a system of immunisation delivery which is flexible and cost effective to ensure easy introduction of new vaccines; promotion of immunisation equity; immunisation coverage uptake rates to achieve WHO targets of 95%; strong surveillance system which detects changes in rates of VPD, or new strains not covered by existing vaccines; information systems that can provide data of uptake and early warning of reduced uptake; and an effective public communication system capable of providing understandable scientific information which challenges misinformation from whatever source.

A number of key stakeholders are involved in immunisation policy and delivery of immunisation programmes in Ireland and I will briefly outlines their roles. The Department has ultimate responsibility for policy decisions relating to immunisation. It is also involved in securing the funding of immunisation programmes through the Estimates process, the legislative and regulatory framework underpinning immunisation programmes, and co-ordination between key stakeholders. The NIAC is a committee of the RCPI. It is an independent national technical advisory committee, which advises the Department of Health on vaccines, immunisation and related health matters in the Irish context. The HSE has a key role in the delivery of immunisation programmes, which it supports through the national immunisation office, the Health Protection Surveillance Centre, primary care and community health offices which come under the aegis of the health and wellbeing directorate. The NIO is responsible for the implementation of national immunisation programmes, and has a number of roles, in particular, communication with professionals and with the public about vaccination. The Health Protection Surveillance Centre, HPSC, is responsible for national surveillance of infectious diseases, including vaccine preventable diseases, VPDs, and acts as the focal point for communication with international agencies on VPD and immunisation uptake. Local primary care and community health officers co-ordinate invitations and the monitoring of the PCIP and school immunisation teams administer the SIP in most regions. The Health Products Regulatory Authority is responsible for licensing of medicines, including vaccines, in Ireland. The HPRA also monitors and evaluates adverse events relating to vaccine. General practitioners are contracted to administer the primary childhood programme. In some regions they deliver the SIP. They also provide other vaccination such as influenza to risk groups under contract. Retail pharmacists who have undergone the required training can apply for a contract to administer certain adult vaccines. Currently, pharmacists can administer seasonal influenza, pneumococcal and herpes zoster vaccines.

The State's immunisation programmes have had a significant impact in improving the health of the people. Diseases that used to be common in this country and around the world, including polio, measles, diphtheria, whooping cough, meningococcal Band C and many other serious infectious diseases can now be prevented by vaccination.

However, vaccines also can prevent the development of cancer, as well as preventing disease. The hepatitis B vaccine given as part of the six-in-one vaccine in the primary childhood immunisation programme helps prevent cancer of the liver caused by hepatitis B infection, while the human papilloma virus, HPV, vaccine given to schoolgirls can prevent the development of cervical cancer from that virus.

Ireland’s uptake rates for many vaccines in the primary childhood immunisation programme are close to the WHO uptake target of 95%. However, challenges remain. In recent years, due to the success of our programme many vaccine-preventable diseases have become so infrequent that we have lost the collective memory of how serious some childhood illnesses can be. Furthermore, some people believe the perceived risks of vaccines outweigh the risks of forgotten serious infectious diseases. For example, a scare surrounding the MMR vaccine in the 1990s resulted in a large reduction in uptake rates for this vaccine. In January 2000, a large outbreak of measles occurred in Dublin and resulted in more than 100 children being hospitalised, 13 of whom required intensive care treatment and there were three measles-related deaths. It has taken many years to get MMR uptake rates up to the current national level of 92%. However, this figure masks a small number of areas of low uptake. These areas are therefore vulnerable to measles outbreaks. Several European countries are currently experiencing large measles outbreaks, the biggest of which are in Romania, Italy and the United Kingdom. Last year, 40 cases of measles were reported in Ireland related to three imported cases from Europe. Measles cases occurred in children who either had no vaccination or were under-vaccinated. If Ireland is to achieve the WHO target of eliminating measles by 2020, efforts must be made to identify children who are at risk and offer them vaccines. The HSE continues to work in this area. Details of the work will be given later in today’s proceedings.

A similar situation pertains with respect to the HPV vaccine. Unfounded false claims of an association between the HPV vaccine and a number of conditions experienced by a group of young women have been made. There is no scientific evidence that the HPV vaccine causes any long-term illness. However, this misinformation has led to a significant drop in uptake rates of the HPV vaccine. As recently as last week, the director of the national cancer registry stated the reduction in uptake rate of HPV vaccine among Irish girls is very concerning. The Irish Cancer Society states that based on national cancer statistics, the drop in the rate of uptake to 50 % for the 2016 to 2017 academic year will lead to the death from cervical cancer of at least 40 girls who did not receive the HPV vaccine. A further 100 girls will develop cervical cancer and require life-altering treatments. Another 1,000 girls may require invasive therapy to prevent the pre-cancerous form of HPV.

Despite the availability of free and effective vaccines, a small number of people choose not to vaccinate themselves or their children in the belief that vaccines are unsafe or no longer necessary. People need to be aware that a decision not to vaccinate has a wider public impact. Such a decision may put a person's own life and that of his or her child at risk, as well as vulnerable individuals with whom the person comes into contact including people with a reduced immunity such as sick and elderly vulnerable patients, pregnant women or small babies who have not yet completed all their vaccinations.

The uptake of the seasonal influenza vaccine in health care workers in Ireland is disappointingly low. As a result of the winter initiative campaign this year, there was an increase in uptake rates compared to previous seasons. Some units achieved above the target of 40 %. However, the national rate fell far short of the target. As people who care for sick and vulnerable patients, health care workers need to consider their duty of care to patients and make it a priority to receive the flu vaccine every year.

Parents want to do everything possible to ensure their children are healthy and protected from preventable diseases. Vaccination is the best way to do that. It is understandable that parents may feel anxious about vaccinating their child, in particular when they hear or read alarming stories about side effects of vaccination. I urge any parent who has doubts or questions about vaccination to engage with his or her family doctor or to visit the national immunisation office website. These sources of information are clear, accurate and will answer any queries parents may have about the benefits and risks of vaccination.

We all have a public health commitment to our communities to protect one another and one another’s children by vaccinating ourselves and our family members.

Dr. Kevin Kelleher:

I thank members for the invitation to attend this committee meeting to discuss the uptake levels for vaccinations. I am joined by my colleague, Dr. Brenda Corcoran, who is a consultant in public health medicine at the national immunisation office. We welcome the opportunity to appear before the committee and engage with members. I appeared before this committee 16 years ago on a review of the same topic. The committee subsequently produced a very influential report. Dr. Corcoran and I are very proud of what we have achieved in the 15 years since that report. As Dr. Bonner said, vaccination uptake rates have increased dramatically. We have also introduced new vaccines.

An immunisation programme is one of the great benefits a state can provide for its community. It protects its community, in particular the most vulnerable such as children and the elderly. It is one of the most cost-effective health interventions available, being second only to clean water. Each year, it saves millions of people worldwide from illness, disability and death. In 2005, the Harvard school of public health observed that the economic benefits of immunisation have been greatly underestimated, which is true and very important. People do not understand how much of a change has taken place. Today’s witnesses are all doctors. Each of us has seen a massive change during the 20, 30 or 40 years that we have been in practice. I am the only witness who has been in practice for 40 years. There has been a massive change. One saw things then that one simply does not see today. Doctors and consultants now do not encounter diseases which I encountered in the 1970s.

The national immunisation programme aims to prevent diseases in individuals and groups by achieving the World Health Organization vaccine uptake targets of 95% for childhood vaccines and 75% for seasonal influenza. To achieve these targets, a well-functioning immunisation programme is essential, involving a multidisciplinary integrated approach from all key stakeholders, including the bodies represented here today. Other witnesses will give evidence of the very robust national and international processes that underpin the introduction of new vaccines, with patient safety considerations always being paramount.

Ireland has a strong history of having a comprehensive dynamic immunisation programme. Nine new vaccines were introduced to the childhood schedule in the 20th century. Since the year 2000, there have been 12 changes to the childhood schedule, including three catch-up campaigns. We are moving on and are protecting more people against more diseases.

We now provide several programmes, one of which is the primary childhood immunisation programme. It is provided free of charge by GPs, who are in contract with the HSE, to approximately 65,000 babies per year. Children require five visits to their GP which take place at two, four, six, 12 and 13 months. They receive seven vaccines which prevent 13 diseases.

That includes, in the past year, the new meningococcal B and rotavirus vaccines that were introduced at the end of last year.

The school immunisation programme is provided by HSE school vaccination teams to 70,000 junior infants through two vaccines preventing seven diseases and to nearly 60,000 students in first year of secondary school. Boys receive two booster vaccines that prevent four diseases and girls receive three vaccines that prevent five diseases over two visits. In 2016, 900,000 vaccines were given to babies and schoolchildren to protect them and the wider community through herd immunity from 14 serious diseases.

Each year GPs, pharmacists and occupational health services provide the seasonal flu vaccine to everyone who is 65 years or older, people under 65 with certain long-term medical conditions, pregnant women and health care workers. We distribute around 800,000 doses of flu vaccine every year and estimate around 700,000 are used.

We continue to reach the target of 95% for most of the vaccines given to babies. The uptake of the MMR, or measles, mumps and rubella vaccine, declined to 69% in 2001 due to discredited vaccine safety allegations but it has slowly increased to 92% or 93% in 2016. We still see measles outbreaks because not all children and young adults are fully vaccinated. Most recently there was an outbreak of 40 cases last year, half of whom were hospitalised. The human papilloma virus, HPV, vaccine uptake was 87%. The uptake has dropped due to vaccine safety concerns and rumour and is now estimated to be around 50% for this year. The uptake of the influenza vaccine has remained at around 55% for those 65 years and older and less than 20% for pregnant women. Uptake among hospital health care workers is still low this season at just 31% although it has increased from 22% last year. The rate of uptake by nurses has almost doubled this season, which is very impressive.

Significant efforts are made each year to understand the factors that drive and motivate people to be vaccinated. Campaigns and public health messages are designed with key stakeholders and service users. All of this work is regularly evaluated and future work revised to take cognisance of learnings to date and shifting behavioural trends. It is very important to note the immense amount of work done by nurses - be they practice nurses, public health nurses or school nurses - doctors, GPs, community medical staff, occupational doctors, pharmacists and clerical administrative staff. I highly commend the work of the national immunisation office, the health protection surveillance centre and our communications partners, internally in the HSE and our colleagues elsewhere who are outside of the organisation.

Although overall public trust in vaccination is positive, as evidenced by the generally high uptake rates, current parental concerns about HPV vaccine safety on social and local media, which have no scientific basis, have left large numbers of girls at a future risk of cervical cancer and at short-term risk of anal-genital warts. There is concern that the reduction in HPV vaccine uptake may lead to reduced rates in other childhood vaccines and there is some evidence that is happening. This may be due to vaccine complacency as many of the diseases are not visible now due to the success of vaccination or are not perceived to be as serious and immediately life threatening as they are. Ongoing concerted efforts are required from all health care professionals and opinion leaders to improve and maintain vaccine confidence in HPV and all vaccines. The scientific evidence is clear. Vaccination is the most effective intervention for the prevention of many serious diseases. Vaccines are one of modern medicine's major success stories and this public health success must be sustained.

My colleagues and I are happy to answer any questions.

Photo of Michael HartyMichael Harty (Clare, Independent)
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I thank Dr. Kelleher. Are there more opening statements? Yes. I call on Professor Butler to commence.

Professor Karina Butler:

I am joined by my colleagues, Professor Mary Horgan, who is president elect of the college, and Professor Donal Brennan who is a consultant obstetrician and gynaecologist and scientist researcher into gynaecological issues. We thank the Chairman and committee for inviting us here today to focus on the important issue of vaccines.

I am a paediatrician and infectious disease specialist. I have worked in this area for a very long time; I shall not specify how long.

The benefits of vaccine are quite simply a matter of fact. Vaccines work. Vaccines save lives. Vaccines prevent illness, misery and hardship.

The committee has heard all of the numbers from Dr. Bonner and Dr. Kelleher. The numbers are dramatic. In 1959 there were over 15,000 cases of measles. In the 1970s, which is not that long ago, there were seven deaths a year on average. Last year there were 43 cases but that should have been zero. The number of diphtheria, pertussis and polio cases all tell the same story. I will not focus on the numbers but will try to give the real picture to the committee. When I think about the impact that vaccines have had on lives, I do not have to look very far. I can think of my own family in the 1940s, a time just before the initiation of vaccine programmes. My uncle, who was then four years of age, died of diphtheria. My grandfather shortly thereafter succumbed to oropharyngeal cancer. It is most likely such a cancer would now be preventable.

In the 1950s one of my generation, at six months of age, was taken from the family home in the midst of panic and driven to Cherry Orchard Hospital in Dublin. The child had polio and had to stay in an isolation ward in the hospital for over six months. I recall going to Cappagh Hospital in the 1960s and seeing alongside me the children who had been in the ward in Cherry Orchard Hospital. The wards were full of children wearing callipers and sitting in wheelchairs as a result of the polio epidemic.

In the 1960s we all experienced a series of measles, mumps, whooping cough and whatever. I remember them all. We were the lucky ones because we recovered. There are many people today who suffer chronic lung disease or blindness and there are those who did not survive.

In the 1980s there was another generation. My daughter almost died from haemophilus influenzae sepsis, while her playmate was in an intensive care unit with meningitis.

When I left my home this morning my two-year old grandchild, who was visiting me, ran around. I am delighted that he has had all of these vaccines and that I do not have to worry about him suffering those diseases. Luckily, he has also received the meningococcal B vaccine. I work in Temple Street and Crumlin hospitals and this week, I left the bedside of a child who is two years and four months old. He is fighting for his life having suffered meningococcal B meningitis because he was not lucky enough to be born in the era of a national campaign. We did not have funding for a catch-up campaign.

I have outlined the real impact of vaccinations. When misinformation spreads it denies people the benefits of vaccines, thus resulting in family tragedy and community tragedy. There has been a lot of misinformation about vaccines. We acknowledge that no medicine or therapy is 100% safe and nor is there a vaccine that is 100% safe for every person. It was not 100% safe for me to leave my house and drive my car here today. On a balancing of risks, the benefits of vaccines at an individual level and community level far outweigh those risks. It is important that we have close surveillance to pick up adverse events. We acknowledge that the history of vaccines is not without its problems. We now have very careful pre-licence and post-licence monitoring to detect signals that might say there is a problem.

Ireland, as a country and a community, cannot shy aware from problems. For example, narcolepsy has been associated with the pandemic flu vaccine. When a problem occurs it is investigated, acknowledged and then appropriate actions are taken.

If we contrast that with the current scares around the HPV vaccine, those concerns have been heard and I have seen patients with this constellation of symptoms in my clinic. It is a problem for the family. We do not deny that. These are very real issues when one has a son or daughter and saw the child performing very well, and suddenly it seems that the rug has been pulled from under him or her because he or she is tired and has muscle aches and pains. We do not understand that complex of symptoms. Those symptoms were there before the HPV vaccine. They are there in girls who are vaccinated. They are there in girls who are unvaccinated. They are there in boys. The European Medicines Agency, EMA, looked at it when that concern arose and the vigilance committee in the EMA looked at what the incidence rate was in the vaccinated and in the unvaccinated, and there was no difference. Contrast that with narcolepsy. When the EMA looked at it, there was a higher incidence in the vaccinated. The background instance had stayed the same. That is the difference between these two things, so we can be reassured that these symptoms, although they may temporarily occur after vaccines, are not causally related. What we may find, as Dr. Bonner has alluded to, is that children are missing out on the vaccines and will later suffer the impact from cervical cancers and other cancers, as Professor Donal Brennan can expand on later.

I put it to the committee that our national immunisation programme has safe and effective vaccines that benefit our community. We have to shatter the myths around vaccines, that diseases are extinct or no longer a threat, the myths such as happened with MMR that vaccines cause autism, the myth that HPV vaccine causes chronic fatigue symptom or the postural orthostatic hypotension syndrome. We have to communicate and learn how to better communicate that these vaccines are safe. What we really need to look at is how we can expand our vaccination campaign so we can protect the lives and health of others.

We need to look at how we can make sure that no other two-year old comes into our clinic with the meningococcal B infection when we know we have a very effective vaccine. It was introduced in the UK, our close neighbour, ahead of us. The UK has just published the data on the effectiveness of the first six months of the campaign, and the number of cases had already halved ten months after its introduction.

We have to look at why we are not using varicella chickenpox vaccine in this country. People have a wrong idea about chickenpox. They think it is a simple, uncomplicated illness. Just this week, I have tended four children hospitalised with serious complications from chickenpox. When they get chickenpox, they are vulnerable not only to its complications, but the complications of serious invasive bacterial disease. At the moment, we have a very invasive, nasty streptococcal disease that is causing bone infections and skin infections. It was called "the flesh-eating bug" in the newspapers, and we have seen that in children who have had chickenpox. I tended four children this week, two with bone infections and one with complicated seizures. There is an effective, safe, licensed vaccine. I have to ask why we are not using it in our programme. We would certainly like to.

We need to make sure that we strengthen our programme and expand it to benefit our community, both its health, but also, as Dr. Kelleher said, benefit it through the reduced economic cost. Thankfully, we have introduced rotavirus vaccine that will make a big difference to families and to workplaces, and to the country's economy.

I thank the committee for inviting us here today. I ask it to understand that all of us here are physicians. None of us wants to do any harm to any of our patients. We would not give vaccines if we did not truly believe they were safe. My girls were among the first to receive the vaccine, before it was introduced to the national programme. I gave them that vaccine because I had looked at the data and knew it was safe. I did not want to see my daughter, who now has one child and is expecting her second, succumb to cervical cancer in her 30s or 40s when her children are still young. However, I know someone who is in that very position today as we sit here debating the merits.

Photo of Michael HartyMichael Harty (Clare, Independent)
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I thank Dr. Butler. If there are no other opening statements, we are going to open the meeting to observations from our members. I call Deputy Louise O'Reilly.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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I apologise in advance because I was jotting down my questions as I went along and they might jump about a bit. My questions are for all the witnesses. I thank them for coming in and for their evidence.

The first question is on the low uptake of vaccinations among health professionals. Does anyone have a view on it? It would not exactly fill one with confidence if the person who is telling one that it is a good idea to be vaccinated is also part of a group offered vaccinations and not taking them up.

On the six-in-one vaccination, I have had representations from a constituent advising that in that person's opinion, this is better if taken individually rather than together. I see a nod from a witness and understand that it is known where that is coming from. In the interests of furthering our discussion on it, do the witnesses have any comment on whether there are any known benefits of breaking this into six individual vaccinations?

On the HPV vaccine, I had some very small and tangential involvement in this as a union official when it was being rolled out. We were in the Labour Relations Commission, LRC, at the time. It is the Workplace Relations Commission, WRC, now. There seemed to be a frantic rush to bring in this scheme, to the extent that we got approval in the early hours of the morning for self-certification for Garda clearance to be used. A particular group - teenage girls - is being dealt with. Garda clearance is necessary and appropriate. There was not enough time for Garda clearance for the doctors and public health nurses that were going to be rolling out the vaccine between when we in the LRC - I think Dr. Kelleher was there - and the roll-out of the programme in September. The HSE and Department of Health received clearance to allow the programme to go ahead on a self-certified basis. I could not understand at that time what the rush was. It was explained to us with regard to the shelf-life of the medicine itself. It was never effectively explained to us. I would be interested to know if it has improved from self-certification and if Garda clearance is now the norm.

A patient information leaflet is provided. My daughter would have received it in school, going back a number of years. Parents are given a small consent form. My understanding is that a much broader leaflet is available. Parents have a right to know but may not necessarily know that further information is available other than that which they get from the school. Can more be done, given the fact that there is a drop in the uptake rates, to give parents the information that they need? If I am asked, I take a very simple view. I advise people to go to their doctor, to talk to any health professional that they need to to put their mind at rest and to make their own decision. I would not seek to advise anyone. I am not a doctor. I appreciate that I am in a room full of doctors, but I am not one. I wonder if there is more information that can perhaps be made available to parents in advance. The new school term starts in September.

My final question is for Dr. Butler. She mentioned that the adverse incidents - I do not think she used the words "adverse incidents" and do not want to put words in her mouth - are investigated and acknowledged where issues arise.

The witness says surveillance takes place, but how is that done? Do clinicians wait for people to come to them with a problem or do follow-up questionnaires go to parents or through the school? When the witnesses say there is surveillance, investigation and follow-up, how do they find the people? Do they come or do the witnesses go to them?

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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I welcome the witnesses and thank them for their presentations. We have discussed this issue at this committee but the ears of the broader public do not seem receptive, particularly with regard to the human papillomavirus, HPV, vaccine. The evidence is overwhelming in terms of broad vaccination programmes, and the national immunisation programme is clearly responsible for thousands of being alive or without injury or illness. In the case of the HPV vaccine, the concerns being expressed by individuals are clearly being received by the people because the immunisation programme and the confidence around it are being undermined by social media, misinformation, false information and fears to the point that people have told me that when girls in first year are waiting to be vaccinated, some make a decision there and then not to go ahead with it. They are chatting among themselves and decide as a group not to go ahead with it. Those fears can be quite profound and ingrained.

In view of the fact we were late to the table with this vaccination programme for HPV and other countries are ahead, has there been any similar drop-off in other First World countries using this vaccination programme? We were at 87% or 88% at one stage but we are now down to 50%. We are now possibly beyond the critical mass for community or herd immunisation. Have there been similar difficulties in other countries in terms of a drop-off because of misinformation, a lack of understanding and all that flows from that? This has come about primarily because of Internet and social media, especially the sharing of information or misinformation, depending on how one looks at it. It involves the sharing of views and opinions and that almost escalates at times to crisis point in social media discussions. In India and other regions, voodoo or taboo-type concerns would be expressed about vaccination programmes, but this is what we must deal with here. Have we the capacity to explain this scientifically in a way that is friendly and comprehensible in a social media context?

Professor Karina Butler explained this in a passionate and simple way in order that it could be understood by people. I do not mean to be disrespectful but I am a layperson and sometimes when the medical community explains issues or formulates advertisements, it may not amount to what is required in the modern era of social media. That is something that should be looked at. Rather than going around on the issue, have there been similar problems in other countries and what has been done to address that? Are we unique in that we have seen a critical drop-off in the uptake of the Gardasil vaccine?

The cases in Denmark have been referenced on a number of occasions by groups like Reactions and Effects of Gardasil Resulting in Extreme Trauma, REGRET, and others who are campaigning against this particular vaccination programme. They are not necessarily always campaigning against it but rather arguing that the Gardasil vaccine is unsafe. They instance Japan and Denmark as examples, which are two First World countries with good safety records. Denmark referred Gardasil to the European Medicines Agency or the World Health Organization for investigation. Why did that happen? Do the countries still have a vaccination programme? Those issues are consistently being raised. As a proponent of immunisation and vaccines, it is important to have information put not just to this committee but put to the broader public fairly quickly. As the Irish Cancer Society has indicated, otherwise we could end up condemning 40 women to certain death.

Pandemrix was manufactured by GlaxoSmithKline around 2009 as a swine flu vaccination and there issues arising from it with regard to narcolepsy. It is accepted there were side effects and this is sometimes used by the people who campaign against the human papillomavirus, Gardasil. Were the checks and balances, including an evaluation of the Pandemrix vaccine, done in the exact same way as every other vaccine or was it rushed because there was a pandemic?

There is the issue of parental information. Parents have come to me and while some advocate the vaccination, others were very concerned and some had the view that it should not be given. In the context of information being provided at school level for the Gardasil vaccine, even by the clinicians or nurses providing it, a better effort may need to be made. As I already said, there are girls chatting in corridors while queuing for the vaccination programme and they are very uncertain about it. I had a case reported to me recently with people fainting in advance of getting the vaccine because of the fear of it. This was used on social media to undermine the credibility of the programme.

Article 50 has been triggered and negotiations will take place about Brexit. Is there any concern for the short and medium term that there could be a divergence between the UK and European thinking on issues related to community and herd immunisation on the island of Ireland? There may be different vaccination approaches, one without a vaccination programme in one or the other jurisdiction. Is there a concern in that context or a plan to ensure the issue is Brexit-proofed, as we say with everything else?

Photo of John DolanJohn Dolan (Independent)
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I welcome the opportunity to witness a masterclass and it is great to have people putting issues together succinctly. I appreciate that very much. I have a particular instinct or background that I wish to bring to this. The issue of confidence, language and how we promote this are important. Professor Butler made the final opening statement and it could be described as coming from a parent or grandparent who is also a doctor and very much involved with the issue. It struck me as an approach to better communication. The parents who are concerned about this want to do the right thing. There has been mention of social media and local broadcasts.

I was diagnosed with a condition called infantile paralysis and a little while later they figured out it was polio. I remember reading afterwards that they connected this with kids drinking Coke because they became paralysed afterwards. They concluded that drinking Coke or soft drinks caused the condition. There are always people making such connections.

I have seen here in Ireland young people with polio, thankfully not people who grew up here but people who came here from other countries. I believe the world is now free of polio or very close to it. We even had awful things, I think in Pakistan, with the Taliban going around killing the people involved in vaccinations. These things are cultural and political. There is lots of stuff going on. When people such as the witnesses are saying there is absolute evidence for it and people are making false claims, that is technically true, but how do we best communicate these things?

We need to reach that herd immunisation of 95% - it may be less for some conditions. I ask the witnesses to comment on the voluntary nature of immunisation. I can see why we might not want to go down that road. It is not simply a matter for an individual; the community, one's neighbours and society are impacted by it. Those are some of the issues.

When people lose confidence in banks, irrespective of whether they have buckets of money, certain things will happen. We need to realise that is the space we are in with Gardasil in particular and some other things. I believe Dr. Bonner talked about the collective memory. That is for those of us of a certain age, but we are talking about people who are a generation or two younger. How do we communicate that? How are we going to shatter the myth? The rug has been pulled from under us.

We have a massive communications, and hearts and minds issue to deal with. The witnesses will forgive me for saying this. The more they wear the white coats, the more it causes people to say "Well, you would say that". We need to suggest that people do the right thing or take advice. I do not know that those straightforward messages are enough. That is my point; it is not that they are wrong. Facts are facts and we need to deal with them.

People do not have confidence in our health services. No one wants to know about preventive science; they are bothered about trolleys, etc. The witnesses have been candid in saying there can be side effects, etc. Seatbelts save lives, but it does not mean they save every life. Given that people do not have confidence in our health services, if something unintended happens, I do not have the confidence that my son, daughter or anyone else will get a timely response and support. That is an issue not so much for the witnesses but for us.

Photo of Michael HartyMichael Harty (Clare, Independent)
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There are many questions there. We are under some time pressure this morning and we hope to conclude the meeting by 11.15 a.m. However, if we do not do that satisfactorily there is an opportunity to revisit the situation again. I do not want the witnesses to feel under pressure for time because we would like to do a complete review of this. We just have some pressure this morning because Mr. Michel Barnier is coming to address both Houses of the Oireachtas. If we do not get satisfactory completion this morning, we can revisit it at some other stage.

Dr. Kevin Kelleher:

The questions fall into two groups, the more general things about immunisation and the specific issue of the HPV vaccine. We will take the first group first and come back to the HPV issue.

We were asked about the low uptake of the flu vaccine among health care workers. It is a problem internationally. We are involved in a number of working studies. Last week, I attended a meeting with UK colleagues to discuss this issue. Internationally, people have taken two approaches to getting health care workers to take flu vaccines. It can be done through a major promotional campaign, which has a degree of success and we saw a significant change in the past year. However, it takes years. The UK has been going at that for some years. England has increased the uptake among health care workers to nearly 60% with some hospitals higher than 90%. They have been going at it for five or ten years. Interestingly, a number of states in the US have introduced mandatory flu vaccination for health care staff, primarily as a patient safety issue. Clearly, there are high uptake rates because it is mandatory.

There is an interesting thing about the attitude of health care workers, predominantly nurses. It is very difficult to say this because those of us on this side of the table are all doctors and it sounds classic doctor speak. Our problem has primarily been with nurses' uptake of the vaccine. We have been working very hard to try to understand that. Considerable work has been put in on it leading to changes. Clearly what works is having leadership in the institution concerned and, in particular, leadership from the nursing profession makes a big difference.

Incentives also work. I am not going to defend that, but it is clear that incentives work, including incentives for the institution or for individuals. They range from giving them chocolates - actually chocolates work extremely well and there is some very good evidence of that. Even the medical literature has some very good evidence of that. Chocolates, draws for iPads and things like that work very well in improving the rate of uptake. The Minister has been very clear about, and we are the same. This is a very important issue about us protecting our patients - how we do it and how we move on this into the future.

Interestingly, the push for the HPV vaccine came from outside the system - from the media and the public. There was a massive public campaign back at that time to introduce the HPV vaccine. Interestingly it coincided with the death of-----

Professor Karina Butler:

Jade Goody.

Dr. Kevin Kelleher:

Jade Goody. There was massive external pressure on us to introduce the vaccine and then to do the catch-up for the girls who had missed it as a result of it being delayed for a year or so. It was external. Of course, one then gets into these IR things - I was at a meeting until 2 a.m. or 3 a.m. There is no problem now. All the staff are clearly vetted and nobody starts the programme before going through the Garda vetting process. It is incredibly different from how it was in 2010. We have gone through that in quite a major way. It is important to realise that.

I ask Professor Butler to speak about the six-in-one vaccine versus individual injections and how vaccine problems are dealt with. We can then come back to the issue of confidence, etc., and move on the HPV.

Professor Karina Butler:

First, let me pick up on the flu vaccine. I can totally understand the question, "Are we not giving confidence?" There are some unique problems with the flu vaccine in the sense that flu changes every year so we are always in catch-up mode and we do not always catch up exactly on target.

We do not get 99% or 100% protection against 'flu. Our protection rates in the last season were approximately 68% or 70%.

Then there is the other issue, that people mistake what 'flu is. Even when the vaccine has protected them against real 'flu, they pick up another virus and think they have got 'flu. The protection that it affords is not as evident. The reality is it saves lives. Even when given to healthy children, it saves their lives. It saves the lives of elders in their community as well. The 'flu vaccine is unique. It is strange that those who have a difficulty with it are primarily among our nursing colleagues because also there is a perception we all have had 'flu, we will not get it again and it is a trivial illness.

Another big element that plays a key role - the chocolates work - is ease of access. One is on the floor and does not want to take time out to go and queue somewhere to get the 'flu vaccine. What the hospitals have been doing, because our occupational health colleagues have been looking at this, is bringing the vaccines to the floors and the uptake has increased. I anticipate we will see big improvements.

The 'flu has some unique issues in that there is not 100% guaranteed protection in any given season because the 'flu virus changes. We get lots of other illnesses that we mistake for 'flu. What made a difference in our hospital was when we had an outbreak in ICU and one of the nurses who was pregnant ended up in the ICU of an adult hospital. That changed a lot of attitudes towards the 'flu vaccine when it came round the following season. It comes back to Senator Dolan's point. It is a matter of communication and how we do that better.

The six-in-one vaccine was the question from Deputy Louise O'Reilly. Parents have concerns about giving the six-in-one vaccine because they think it will overload the immune system and one will get too many antigens. From a single infection, there would be multiples of the number of antigens that are in the 'flu vaccine and the body is more than capable of dealing with them all without any problem. What one has to do is ensure that there is no interaction, such as where giving one together with the other might blunt the response of the other, and that is done. That is always studied in any combination vaccine. Then it comes down to whether one wants to give his or her child six jabs by three - 18 injections - when one can, effectively and safely, give them together and, therefore, get protection quickly.

As for what we have in the six-in-one vaccine, one of the key elements in there is whooping cough vaccine. As for who is liable to die from whooping cough, the Deputy and I will not die. We will get a bad cough that will last for three weeks. If one's child under six months or one's six-to-12 months' old gets it, he or she will end up in ICU and die. That is why one would want to get in there early and why those vaccines are given in combination. As for who is most likely to get meningitis, our highest rates are among those under one year and the one-to-two year olds. That is why we want to get those vaccines in there efficiently. The reason we give combination vaccines is to make it easier for the child, not to give them so many shots and to get protection onboard at the time when the child needs protection, and immunologically, it is very effective and very safe.

Photo of Michael HartyMichael Harty (Clare, Independent)
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I thank Professor Butler.

Dr. Kevin Kelleher:

Professor Butler might address the issue of how we identify vaccine problems.

Professor Karina Butler:

On how we identify vaccine problems, in general, there is passive reporting for vaccines. Dr. Joan Gilvarry can come in on this. In some areas, we also have enhanced surveillance. For example, last year we partook, at the EMA's request to the vaccines companies, in what we call enhanced surveillance. Everybody who came in to whom we gave 'flu vaccine was given a card and number by us, there was a hotline and if they had any early problems, they could phone in. Therefore, those were categorised so that there would be an early red flag if there were any problems related to the vaccine. That is called enhanced surveillance.

However, in general, it is a passive surveillance system for vaccines. Dr. Gilvarry might want to speak to that.

Dr. Joan Gilvarry:

First, before any vaccine comes to the market, it must meet very clear pre-defined standards of quality, safety and efficacy before it gets its licence. Gardasil is licensed since 2006. We monitor the safety of the vaccine after it comes to the market by health care professionals telling us of adverse reactions or suspected adverse reactions they have seen. Similarly, we hear from patients, carers, public health doctors when they are out in the schools. We also put all of these adverse reactions that we get into the European database which gives us a much bigger global database of adverse reactions. One can interrogate that database much better than a small Irish database and look for signals. We also look at published literature, new clinical trials, any new epidemiology trials.

Also, the manufacturers of the vaccine must submit what we call a periodic safety update report to us. In the case of Gardasil, that has been submitted to the regulatory authorities and to the European agency every year since it was licensed. The product is now licensed in 130 countries worldwide and 72 million people have been vaccinated. This involved approximately 200 million doses because the girls get two-to-three doses, depending on their age. We have a vast amount of knowledge about this particular vaccine.

Specifically about Denmark and Japan that Deputy Billie Kelleher talked about, in mid-2015, Denmark did see some cases of chronic fatigue syndrome, chronic regional pain syndrome and POTS, as Professor Karina Butler has referred to, and the regulatory authority in Denmark asked the Commission to trigger a European-wide review. That was done via the European agency and its safety committee. The safety committee of the European agency is made up of expertise from all the member states including doctors, nurses and scientists. They reviewed every piece of data that was available. They pulled in experts on vaccines and on epidemiology. They talked to the patient groups. In fact, on the Pharmacovigilance Risk Assessment Committee, PRAC, which is the safety committee, there are patient groups and health care professional representatives. They came to the conclusion by consensus - every member state and every patient on the committee agreed - that there was no evidence to support a causal relationship between the syndromes that were being seen and the vaccine. That recommendation went from that committee at the European agency to the licensing committee, which we call - without giving the committee too much technical jargon - the CHMP, and it agreed with that recommendation, also by consensus. The European Commission, in early 2016, issued a legally binding decision that there was no causal relationship with this. The product has not been withdrawn worldwide by any regulatory authority. The Government of Japan has taken the product out of its immunisation programme, but not in agreement with the regulatory authority, and it continues to be used continuously in Denmark. The Danes accept the recommendation. They were a party to the recommendation from Europe.

There was another question on pandemics and whether there was a rush to licensing. There was no rush to licensing, but I must admit it was a different situation. Everyone was prepared at some stage for a pandemic. We, on the Irish pandemic group, were preparing for years previously because we were expecting a pandemic. What we did, from a European regulatory point of view, is license mock-up vaccines. We did not know what the strain would be and for the years before, the companies submitted to the European agency mock-up so-called "dossiers" - it was with the H5N1 - so that we were ready. These mock-ups were licensed by the European Commission for all the member states in 2007 so that when the pandemic was declared, and we knew it was H1N1, what needed to be done was to vary that licence and, essentially, take out the H5N1 and dip in the H1N1 that was then identified. There was then active surveillance. They were licensed, probably at the end of October 2009, and there was active surveillance. We were in constant communication on a weekly basis on any new data or any new adverse effects that were appearing. The immunisation programme here in Ireland ended at the end of March 2010. The first signal that came on narcolepsy was from the Finnish agency in August 2010 and nobody could have predicted it. There was no rush to judgment. In fact, as soon as Finland brought that to attention, a European-wide referral and review was started. However, it had really no impact on our programme because it was finished here in Ireland at that stage.

Dr. Kevin Kelleher:

Can I add to what has been said about the pandemic? My predecessor as director of the HPSE, Dr. O'Flanagan, conducted a study here in Ireland that actually replicated what had happened in Scandinavia and showed that there was an explicit link between the vaccine and those, predominantly children, who got narcolepsy.

We were part of that process, as Dr. Gilvarry has said. Dr. O'Flanagan carried out the study which showed very clearly that there was a link. That has formed part of our process since. However, just to reinforce this, in these other circumstances it has been shown there is no such link. It is not even possible to do such a study in the same way that Dr. O'Flanagan did because we do not have any specifics around it.

There is a group of questions about HPV. It may be better to take those first and then come back to more generic questions raised by Senator Dolan around confidence, mandatory vaccination and things like that, which are more general questions. Dr. Corcoran can begin on some of the issues around the HPV vaccine and perhaps Dr. Brennan can help.

Dr. Brenda Corcoran:

There were a number of questions relating to the HPV vaccination programme. I will take them in order. The first one related to the leaflet that we provide and whether we should provide supplementary information. The HSE is committed to providing clear, accurate information to all parents to allow them to choose whether to vaccinate their children in a school-based programme. In a school-based programme we do not meet the parents so we have to convey our information either through written information, the website or other media. We will talk a little bit about that later. Regarding the leaflet, at the start of the school year all parents receive a leaflet, consent form and invitation letter inviting them to take part in the HPV programme. They are also invited to get the other two vaccines that are given in the first year of secondary school. Those are a booster for tetanus and pertussis - that is whooping cough - and a meningococcal C booster. Three vaccines are given. The HPV vaccine is given to the girls and the other two vaccines are given to girls and boys.

The information leaflet we supply has been changed yearly, based on feedback from both parents and health professionals in the field. We also look at the information leaflets that are supplied in other countries that have had very successful immunisation programmes, particularly for HPV. We look at the information materials from the UK, where an uptake rate of over 85% has been sustained, and Australia, which sustains a 75% to 80% uptake rate. We compare our information materials with those supplied in those countries. We also have our information materials proofed by the National Adult Literacy Agency and they are in line with HIQA guidance on the use of plain English. That is why the information materials are worded and laid out in the way they are.

We work on what might be called an onion system, in that we provide layers of information. The information leaflet gives very clear guidance that if a person would like to receive more information they should go to our national immunisation website. That website is the only immunisation website in Ireland that has been accredited by the World Health Organization as having clear safety information on all our vaccines. It has had that status since 2008.

We do not provide the patient inserts, that is the licensed documentation, but in the leaflet we provide information on all side effects from the HPV vaccine that have been scientifically shown to be caused by the vaccine. The product insert, the patient information leaflet, is a licensed document, as has been referred to by Dr. Gilvarry. It is a licensed document that has been agreed by the European Medicines Agency. That document also contains a list of other symptoms that have been seen around the time of HPV vaccination, but for which there is no scientific evidence that the vaccine was the cause. The HSE includes the information on the side effects that are caused by the vaccine and in the information leaflet actively asks parents to go to our website, where there is a link to the patient leaflet where they can read all the information they want, as well as find a lot of other information on HPV vaccine safety, impact and facts. That is about the patient information leaflet but I fully accept all of the comments on communication with parents because that is a huge challenge for us.

As I already mentioned, we do not see the parents. That is why when we realised that the information was being misinterpreted and that there was a lot of misinformation in the public domain we developed a strategy to work with like-minded organisations. We have created an alliance with organisations such as the Royal College of Physicians in Ireland, the Irish Cancer Society, cancer support groups, the national cancer screening programme, the Irish Pharmacy Union, the Irish Medical Organisation, the Pharmaceutical Society of Ireland and the Marie Keating Foundation. All of us are working together to provide the same information.

In addition, we are working very closely with our colleagues in primary care. It is recognised, and there is a lot of research to show, that in spite of all the mistrust there is in the health services the primary reason that a parent chooses to have their child vaccinated is the recommendation of a trusted health professional. In that regard, we did a huge amount of training last year for HSE staff, but also for our colleagues in primary care - general practitioners and practice nurses - because they see parents on a day-to-day basis, perhaps about something completely different. We have given them information on the facts and figures and on the issues about which parents are concerned and we have asked them to act as advocates for us and to help us persuade parents to get this vaccine. We have also done some focus group work with parents to ask them the kind of information they want and we use that information to customise the information we give.

As we know, the uptake rate dropped to 50% for the first round. It is a two-dose vaccine, given firstly in September with a second dose in March. We instigated a programme to offer all parent a second chance in March or April when we returned to the schools. We sent all the parents another information leaflet, which was slightly modified based on the feedback that we received. Vaccination of those who took up the offer is being carried out in the schools at the moment and is ongoing. While it is very preliminary, the information from the schools so far is that the uptake appears to have stabilised. It has not dropped any further and there are a small number of parents who are coming forward to ask for their daughters to be given the first dose. It is good news but there is a huge amount of work yet to be done.

With regard to 2017-2018, we have already developed a leaflet for sixth class parents. That is being distributed to the schools to give parents more information in advance. That gives more information and advises parents to check the website. We will be running a comprehensive communications campaign between now and September and working with the partners that I have already mentioned and with HSE staff to introduce and implement the information in as clear a way as possible. This will include using social media, videos and bite-sized pieces of information backed up with scientific evidence while using the ways in which we now know parents communicate, adapting to this new landscape and bearing in mind all the constraints applied by not seeing the parents. We have to use other people to help us get our message out. There is a slight improvement, which is good news, but there is a lot more work to be done.

Photo of Michael HartyMichael Harty (Clare, Independent)
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I will bring in some other members of the committee to allow them to ask some questions. We will get to all the answers in time. I have a number of questions myself. On the influenza vaccination for pregnant women, is there a reason that vaccination is not offered in the ante-natal clinics? As a GP, I find it difficult to get the message across because pregnant women feel they should not take any drug or anything during their pregnancy as they feel it could have an adverse effect. That seems to be the barrier that I come across in giving pregnant women the influenza vaccine. Is it possible that it could be promoted through the ante-natal clinics?

Second, on HPV, is there a programme envisaged to offer HPV vaccine to boys? On the HPV vaccine and the problems that are causing a reduction in uptake, the Minister has announced that he is going to develop a care pathway for those who feel they have been affected by the vaccine.

The Minister had announced that he was going to develop a care pathway for those who feel they have been affected by the vaccine. This will enable them to get specialist opinion to examine their symptoms and provide them with treatment. I wonder whether that care pathway is still under discussion or development.

Photo of Colm BurkeColm Burke (Fine Gael)
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I thank all the witnesses for their presentations and for the work they have done over many years. Social media, which has been touched briefly during this debate, is a major influencer. When false information is given in the print media, it can be corrected reasonably quickly. There is a great deal of incorrect information on social media and it is difficult to correct it. We need to take a new approach to social media when vaccines are being rolled out. Has there been engagement with those who have expertise in social media to try to deal with this aspect?

A second issue is the need to engage with major influencers. A motion on the HPV vaccine was recently passed at a teachers' union conference. Have there been engagement with the teachers' unions, which are major influencers? I was appalled by the fact that a motion was passed because no medical expertise was offered to the conference before the decision was taken. Has there been engagement with that union since the motion was passed? What information will be given to members of that union in respect of the vaccine?

Third, I am working with transition year students in a school who are involved in a project called Young Social Innovators. The final is on today. Out of 400 projects submitted, it is down to the final 11 today, which includes the school I have worked with. I was impressed by the work of the students and the teachers. Can more be done to engage with young people because they are major influencers? I was mesmerised by the volume of information that the students in the school I worked with were able to put together. It was a detailed project, which will end up having a major influence on other young people because of the results they have achieved. There should be more engagement with young people on the HPV vaccine because they can influence people. The transition year students involved in this project can influence younger students entering secondary school. Has this been considered?

I thank Dr. Butler for the facts sheet relating to measles. I have not seen that information previously. There were 10,000 cases in 1980 but there were only 43 cases in 2016. That information needs to be publicised in respect of the success of immunisation and vaccines. More needs to be done with public representatives and people in the education sector in this regard. Has a programme been devised to publicise that information? That would be effective where there is a debate within a school on the matter.

Photo of Kate O'ConnellKate O'Connell (Dublin Bay South, Fine Gael)
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I thank the witnesses for attending. I am a community pharmacist and I am also the daughter of an infectious diseases nurse. I am sure she may have worked with them in Cherry Orchard back in the day. I come from a family of health care professionals. As someone who works in the community and who was among the first batch of pharmacists trained for the initial roll-out of the influenza vaccine, I was shocked when I entered the Dáil last year at the difference between what I perceived to be the understanding of vaccination and immunisation, and the emails and discussions I encountered around this vaccine on becoming a public representative. There was a gap between my understanding of people's understanding and what goes on in reality. There is a major gap between those of us who have been privileged enough to have been educated to a high level or who are scientists and who have been given that information, and getting that information into the public domain. The remarks on collective memory were helpful. My mother told me that I nearly died from measles as a child. People forget that these are serious illnesses. Awareness must be increased that risks should not be taken with measles and we have a body of work to do in this regard.

The falling take-up rate for the HPV vaccine is concerning and I have commented on this publicly. The Irish Cancer Society says 40 people would die, 100 would require cancer treatment and 1,000 would need treatment for precancerous cells annually if not for the vaccine. I operate a pharmacy close to St. Luke's Hospital in Rathgar. I have seen the 40 year old woman with two children at her ankles with stage 4 cancer. I recall the resistance to the vaccine when it came out first, but we have overcome that barrier. After clean water, this vaccine is the second greatest success in public health ever but people on the ground do not get that. They think public representatives or health professionals are dealing with it.

Regarding meningococcal B, there is a perception that it leads to death. I dealt with somebody whose child is deaf as a result of contracting this illness. We need to get the message out that these diseases can not only lead to death, but to a range of preventable conditions. I cannot imagine what it would be like as a parent not to have vaccinated my children and for them to die or become deaf or blind as a result of my decision about their health.

Senator Burke referred to major influencers, which sparked something in my mind about Jade Goody. The take-up rate of the HPV vaccine increased following her tragic death. Perhaps we need to examine who are the influencers. I am sure I do not influence many 15 year olds. Maybe I do and maybe Deputy Durkan does, but we need to get the people that young people listen to involved. When somebody such as Avril Lavigne has something wrong with her, they are all listening to her. We need to get somebody whom young people look up to and who is on the right side of science and facts.

Regarding barriers to access, Dr. Corcoran mentioned trusted health care professionals such as GPs and practice nurses. Pharmacists are open to this. I even had people working in hospitals coming into the pharmacy late at night because they did not have to queue when filling their prescription. It works well in the community pharmacy setting. Perhaps it is an aversion to the white coats, the doctor's surgery or being in a waiting room with other people.

We generally know the patients. We do not get busloads of people coming from elsewhere. They are generally the people we know from mass, the shop or SuperValu. We know these people and they trust us. We can leave them sitting there and chat with them while we are going about our business. The community pharmacy is a very good way of delivering this service. It is different for an elderly patient who is going to the GP anyway but for a healthy person, perhaps a nurse, it is very handy to nip into the community pharmacy. We have to do our very best to deal with this unmet need where people working in the delivery of health care are not being vaccinated, for example, a pregnant nurse in ICU. We need to get the message out there. Pregnant women have a difficulty with having vaccinations. One can understand that when considering things in the past. I was pregnant around the time of the swine flu vaccination in 2009. I think I have been pregnant the whole time since then, but at that time I was pregnant.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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I hope they were different pregnancies.

Photo of Kate O'ConnellKate O'Connell (Dublin Bay South, Fine Gael)
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For me, as a professional who is well up on these things, I was thinking we need to get that information out. If people like me, who are into vaccines, were worried about it, what was the other lady thinking?

Professor Karina Butler mentioned chickenpox. Is there any proposal to roll out the chicken pox vaccine in Ireland?

Professor Karina Butler:

Funding.

Photo of Kate O'ConnellKate O'Connell (Dublin Bay South, Fine Gael)
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It is done in other countries. Leaving aside the health benefits, there is a massive economic issue. As a working mother, one is nearly putting concealer on them going into the crèche. Once the pox is out, my view is that they should be sent to crèche, but there is a stigma attached to it and then the mother, father or granny has to take days off work. There is an economic loss attached to it. Most children are brought to their GP, but with chickenpox the GP cannot do anything. There are secondary infections such as impetigo or bacterial skin infections as a result. Though it is an expensive vaccine, there are economic and health benefits. It is something the committee should be pushing for. We have to get the message from the HSE and the Department down to the ground to deal with this.

Confidence has been mentioned. I am not sure where Dr. Brennan works. My experience of the public system for the treatment of cervical cancer is that the system is very good. We spend a lot of time in here complaining and saying everything is awful and everybody is on a trolley, but my understanding on the ground is that the system is working. People are being seen in a timely fashion and are getting the best possible treatment in this country. It is worth saying that young women are getting that treatment. What we really want is that in years to come my two young daughters and the children in crèche with them now are not in that category.

The committee has a body of work to do. It is important we get the message out that this is the second biggest public health breakthrough ever in the world. We have a duty as elected representatives. It is what we are here to do. We are here to try to improve people's lives. My colleagues and I will work with the Chairman and everybody else to try to get the message across. We have a body of work to do here. Time is of the essence. If we do not deal with this, trolleys will be the least of our worries. I thank all the witnesses for coming in today.

Photo of Margaret Murphy O'MahonyMargaret Murphy O'Mahony (Cork South West, Fianna Fail)
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I welcome all the witnesses and thank them for attending. Most of what I was going to ask has been asked by my colleagues already. I only have sons so the HPV vaccine does not arise. Many of my close friends have daughters who are due to have the vaccination. The fear they feel and the big decision they face on whether to vaccinate cannot be overemphasised. They are all very level-headed girls but their parents are torn with anxiety about whether they should get their daughters vaccinated. I welcome that Dr. Corcoran said sixth class girls are now getting the leaflet. It is an excellent idea. It buys time and is not just thrown on top of them. The witnesses said they do not meet the parents. Do they think it would be a good idea to start doing that? Is it for financial reasons or because of time constraints? Why have they not already started meeting parents of girls in fifth class to buy that time for the parents to decide whether to vaccinate?

Photo of Michael HartyMichael Harty (Clare, Independent)
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Finally, we will have a limited contribution from Deputy Durkan.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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All my contributions have been limited and sometimes even truncated. I apologise to our guests for arriving late. I was attempting tri-location, not under medical supervision, but I tried it and it did not work. I thank the witnesses for their submission. I am familiar with the territory. I come from a generation which, to a large extent, was pre-vaccination. I have family experiences from that particular time. It is true that many deaths occurred as a result of the lack of that kind of treatment in the 1940s, 1950s and even into the 1960s. I was a member of what was originally a large family but it did not finish up that way. There are salutary lessons to be learned from that. As public representatives, we have a duty that when an issue is raised, we have to be reasonably certain what we are telling the public is accurate to the best of our ability to prove it. I have no doubt at all that, generally speaking, the vaccination programme is in the best interests of children and families and the health of the nation. However, we live in a world of mass media communication and social media where quite a number of diverse opinions arise. Sometimes they are backed up scientifically and sometimes they are not. To what extent can the witnesses respond to these claims when they arise?

Are the witnesses satisfied that to the best of their ability the reaction to or the side effects of particular vaccinations can be more profound or long-lasting that others? That is just by way of reassurance that when we stand over something, we know exactly what we are talking about. Otherwise, we as public representatives and the medical profession can be accused of not testing sufficiently the issues that come before us. We as Members of both Houses have had numerous experiences over the years of issues arising, sometimes ones which we were not alert to in the time we should have been. Sometimes we were wrong and sometimes we were right.

Those are my questions. With regard to the metabolism of individual children are there exceptions to the rule? As a result of those exceptions to the rule in the metabolism of the child, can there be very different outcomes? I would like clarification on that. I thank the Chairman. That was my usual truncated fashion.

Photo of Michael HartyMichael Harty (Clare, Independent)
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Deputy Durkan excelled. Before I bring in Dr. Kelleher, Professor Horgan and Professor Brennan have not had an opportunity to speak yet so perhaps we will have Professor Horgan first and then Professor Brennan.

Professor Mary Horgan:

I will comment as a clinician in infection diseases and who treats adults, and also as a parent. One of the differences between uptakes is that if one gives meningococcal meningitis vaccine to children, everyone understands it. People die immediately of meningitis so for most parents, that is a no-brainer. As a clinician who has seen people die of meningitis, meningococcal disease, up to very recently - the figures have gone way down - I can say that it is a fantastic vaccine. We had one of our final medical students die from meningococcal C, despite all medical efforts about a decade ago, and it brings home to one that it could be one's own 20 year-old dying there. People get the immediate effects of why it is important to give the meningitis vaccine.

What is more challenging for many parents is seeing the benefits of a vaccine in ten or 20 years time. People do not get it when it is about giving a vaccine when someone is 12 or 13 years of age and saying that it will prevent cancer in 15 or 20 years, which Professor Brennan will talk about. When one sees it as a clinician, one gets it.

Professor Brennan will talk about people who get a preventable cancer. If, in the morning, someone told us we have a tablet that would prevent a cancer, people would take it. They would not even think about it. We have vaccines that prevent cancers. We have another one, hepatitis B, which is part of the childhood vaccine, that prevents liver cancer. Liver cancer is one of the major causes of death in south-east Asia, where chronic hepatitis B is very common. People give that to their children. It is a safe, effective vaccine that prevents cancer decades on.

It is trying to get the message across on what is totally effective now, people buy into the vaccine for meningitis, versuswhat is protecting them, say, when they are a grandparent. I am a mother and gave my daughter a vaccine before it was part of the routine vaccine programme. I paid for it myself because, like Professor Butler, I knew the data, I had been at the meetings and I spoke to those who developed it. The initial studies were pulled because the vaccine was so good.

We have people such as Dr. Gilvarry and the HPRA who monitor the effects of all vaccines. Vaccines are good because on a day-to-day basis, I see people coming into hospital, being on ventilators with influenza, getting liver cancer that could be prevented because it is caused by hepatitis B, seeing people with cancer of the cervix, again which can be preventable, it could be any of us or any of our children. When one is on the front line, one has the stories, one sees them. I am sure Professor Brennan will give more insight into this.

Professor Donal Brennan:

On ante-natal vaccination, we do advise the influenza vaccination to all ante-natal patients and also pertussis vaccination in the second or early third trimester. As Dr. Butler will confirm, we have had a number of cases of neo-natal pertussis in Dublin and a number of neo-natal deaths as a result, so we advise it. There is a logistical issue about where the vaccine is given which needs to be addressed and without doubt, there is an understandable worry among pregnant ladies about whether they should take any medication. That is part of all our roles as health care professionals to advise on the safety of the vaccination but also the dangers of influenza infection in the pregnant population as highlighted earlier.

I will spend a few minutes highlighting some of the consequences of cervical cancer in particular. We have talked a lot about death today. One of the reasons people have this issue about getting information down is that it is very hard for a person to think that his or her 13 year old daughter will die of cervical cancer. Many of us will believe that our 13 year old daughters are immortal. It is a very hard concept to understand but unfortunately there is much more to cervical cancer than death. There are more than 3,000 women alive today suffering the consequences of those treatments, as Deputy O'Connell spoke about, many of whom have been treated in what is an excellent service. We do meet all international standards in regard to seeing patients and treatments and our outcomes are comparable to all international standards. It is very important that we highlight some of the success stories in that. Possibly the greatest success story has been the cervical screening programme. We were late to the party but thanks to Dr. Gráinne Flannelly who is the clinical director of Cervical Check and the national screening programme, we are now meeting all international standards in that.

However, there are still 300 patients a year diagnosed with cervical cancer and they come into our clinics in the Mater Hospital and St. Vincent's Hospital on a weekly basis. The surgery or radiation that those patients have to endure is life changing. Many of those patients will tell one the treatment is worse than the disease. I have had numerous patients tell me that they came in feeling fine and three years later they feel terrible, asking what had I done to them.

We obviously perform surgery on a proportion of patients and in many cases this means that a young woman will lose all fertility. The long-term consequences of this are huge. Remember half of the women diagnosed are under the age of 50. They are mothers, daughters, aunts and they are all working in normal, important jobs and they often do not go back to work. The consequences are huge.

I will finish with a case. We recently had a lady who presented to us, having had six failed cycles of IVF. She presented with early bleeding in pregnancy and we diagnosed an advanced stage cervical cancer. This was obviously a very sought-after baby and she advised us that she did not want to do anything that would harm the baby so we proceeded after a long consultation to give this woman chemotherapy during the pregnancy. She proceeded to have four cycles of chemotherapy and delivered her baby at 34 weeks, which was a little early. She had to have a caesarian section and a radical hysterectomy which involved the removal of her uterus and all her cervix and part of her vagina and all the lymph nodes as well. Then she had to have radiotherapy.

She has had a year of very severe, hard medical treatment and unfortunately her little girl, who is beautiful, has significant hearing loss. I saw her last week, and before we came in here, I asked her if she would vaccinate her daughter and she said, "What do you think, doctor?" It is not just about the patients who die, which are very unfortunate, it is the patients who sometimes survive.

Just next week, we have a young woman, she is 38 years of age, who is going to come in and have her bladder, uterus and rectum removed because of her cervical cancer. She will spend the rest of her life with a stoma bag on one side for faeces and one on the other for urine. These are the real life stories that people need to understand. It not just those who die of cervical cancer, it is the survivors. Sometimes in cancer care in particular, we forget about the survivors because we think that once they survive that is all that matters.

I thank the committee for listening to us today and I hope that we have highlighted some of the issues around cervical cancer.

Dr. Colette Bonner:

I wanted to return to Deputy O'Connell's point on the chickenpox vaccine. The National Immunisation Advisory Committee, NIAC, makes recommendations to the Department of Health on vaccines. That is one that we have not had an official advice about yet. We have not gone through any process regarding that yet.

On HPV for boys, we are looking at the possibility of extending the programme to boys and the Department of Health has asked HIQA to do a health technology assessment in order to look at the effectiveness and the cost-effectiveness of introducing that particular programme. That health technology assessment has commenced and we hope to have a decision on that in September 2018. It is quite a long process because it involves quite a lot of modelling and so on. In the meantime, our focus is to increase the rates of HPV vaccination in girls.

Dr. Kevin Kelleher:

We may need to come back to the debate on one big issue which is the confidence in vaccines but more specifically, we have had considerable consultation with the Department of Education and Skills and the education bodies such as the unions, the parents' associations, school management bodies and so on, so we have done a lot of work there. I take up the point quite keenly about the young innovators. My daughter was in the final six or seven years ago.

It is something we could look at trying to get involved in and I thank the committee for the promotion.

With regard to Brexit, the UK already has different immunisation policies to us. There are variations, and the committee has heard we give hepatitis B vaccinations at birth while the UK does not. It has a programme for shingles for the elderly and we do not have this. It has changed its programme on the flu to being very much more concentrated on children. Clearly this is something we will have to do because it is beginning to show quite major success as a consequence. There are some differences but, having said that, it is very difficult to have total uniformity throughout Europe. Major attempts have been made to do so but they have failed for many different reasons. We are not that far off what the UK does. Sometimes we are ahead and sometimes it is ahead. I do not think there are too many more specific points. The more general point is the issue on confidence in vaccines, which will not be debated before the committee goes to its important meeting.

Photo of Michael HartyMichael Harty (Clare, Independent)
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There was a question on the care pathway.

Dr. Kevin Kelleher:

To be clear, we propose, and it is being led by Professor Alf Nicholson, who is the paediatric lead for the HSE, to put in place a care pathway for any adolescent boy or girl who has the symptoms being spoken about. It is not linked to the vaccine. We have to be very clear it is not being provided for anybody who claims he or she has those symptoms as a result of a vaccine. It will be provided to them and they can avail of it. We have clearly identified, and Professor Butler has intimated this, that these children have not been dealt with as well as they could have been, be they children today or children ten years ago. We want to make sure boys and girls all get the same care. Professor Nicholson has produced this pathway and we have tried to have discussions with the parents concerned but it has not been totally successful. It will be introduced within the next year. It is trying to provide clarity. It is very clear such children have always been there, and for longer than any of us in the room have been alive there has been evidence for it. We need to provide them with good services as a consequence.

Photo of Michael HartyMichael Harty (Clare, Independent)
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I thank Dr. Bonner, Dr. Kelleher and Dr. Corcoran, Dr. Joan Gilvarry, whom I forgot to introduce at beginning of the meeting, Professor Horgan, Professor Butler and Professor Brennan for appearing before the committee and for their very insightful outlining of the importance of vaccines, which I endorse entirely.

The joint committee adjourned at 11.25 a.m. until 1.30 p.m. on Wednesday, 17 May 2017.