Childhood Vaccinations Committee

Monday 15th June 2026

(began 6 hours, 52 minutes ago)

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None Portrait Speaker 2
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Yes, thank you very much, chair. And by way of introduction, I'm Ruth Tennant. I'm a director of public health in Solihull in the West Midlands, and I'm also here representing the Association of Directors of Public Health. So there are some elements, for example, extending the use of the NHS app um making. So there are some elements, for example, extending the use of the key elements in there that are really important in improving access to vaccination. NHS app, um, making sure that people know how to access vaccinations, uh, looking at how to deliver, deliver vaccination in convenient locations and also being very clear that it does need a systems response.

It needs to be key elements in there that are really important in improving access to vaccination and take up of vaccination. So there are some elements, for example, extending the use of the NHS app um making. Sure that people know how to access vaccinations, uh, looking at how to deliver, deliver vaccination in convenient locations and also being very clear that it does need a systems response, it needs icbs directors of public health. Um, all our partners in the NHS, particularly general practice and voluntary organisations working together to make this a success.

We particularly want to draw out the importance of inequalities. We know that there are certain groups that are particularly disproportionately affected that we really need to get to. So again, the focus on that inequalities dimension, um, is to be is to be welcome. Um, and data, I know we have a question about later on, but also some important measures about data in there. I think in terms of what we need next. And again, speaking as someone who's been working on the ground and dealing with really quite significant measles outbreaks, a very large one in the West Midlands a couple of years back, um, I think what we would really want to see is a sense of urgency and a sense of quite how important it is to get this right.

We know that it will take quite a long time. This is not going to be a quick fix. We're probably talking about a good ten years to get all the parts of the system working and to get some of those coverage levels up, particularly around MMR, where we have a decline for a number of time. Um, and actually what we really need is really clear leadership. So who has got the job card for holding that target?Uh, um, in the public consciousness in all our consciousness is and really making sure that is driven through.

Um, so obviously it was a disappointment when we lost our 95% uptake and lost that w.h.o status. And we really do think that it's really important that that's a really, really important goal to move towards. It won't be done overnight, but what we do need is a really strong, well-led and credible plan with all the component parts to, uh, to, to make that happen. So I think I'll stop at that point, but I'm very happy to pick up details later. Thank you chair.
14:20
None Portrait Speaker 1
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Thank you very much. And I, I hope that this committee's report will play its part in that. And I'm quite sure the House of Commons report that we recently had will also play its part. And thank you for the association's written evidence, which was very helpful. And also the evidence sent to us by Baroness Gerada with the recommendations in that, uh, both of those were very, very helpful. Can I move to you, Baroness Gerada?Yes, thank you sir.

By way of introduction, uh, I've spent 40 years, until very recently, being a GP in the same practice. Uh, the practice started as a one practice on one site and is now about ten practices across ten sites across London. So in serving a population of 100, around about 110,000 patients. So I'm hoping to bring to this committee, uh, my experience of being the bad, the good, and the not so good. And what I've learnt throughout that time. And as you know, I'm also, uh, someone that.

Immersed my life in mental health and there is an awful overlap. So I don't disagree at all in what Ruth has said. And I think one of the recommendations I know one of the problems about the strategy, it's the 95% target has been removed. But if I say some of the positive things about the vaccine strategy, I think it's positive that it has expanded the number of vaccines that children are getting and including chicken pox on the schedule. I think it's positive that we're looking at some different ways of delivering care, including health visitor pilots.

So I'll say something about that at the moment. And I think it's positive around ICB devolution, though I think as we go on with our evidence, that's also got some problems associated with it. And I also think it's very positive that the ten year plan talks about the treatment to prevention. I think that is that's really important. So but now for some of the problems, I think the the strategy, uh, doesn't deal with the fundamental issues, which I think are deprivation, inequalities and poverty.

And I know that the first thousand days has also stressed that and dealing with vaccine in isolation, I think completely misses the point. I think the strategy completely misses the issue around workforce, in particular, the first day of public health, which was GPS health visitors and district nurses. And whilst the district nurse pilots are good, we're just robbing Peter to pay Paul because we know, and I'm sure you've heard, we're about 5000 health visitors short. And put that in context, that's nearly one health visitor per practice.

If they were still attached to practices, which they're not, I don't think we also know that though. They're dealing with the strategy does deal with deprivation. We're seeing inequalities widen. And I think many of the recommendations, including the issue about using a digital solution. We know and I know that my patients cannot afford to have data. Uh, they might be able to use their phone as a phone, but they can't use their phone unless they're connected to external Wi-Fi for data.

And I think we forget that the privileged positions that we're in, that we can just download the news at any time. So I think using a digital solution, as we'll talk about. And finally, I think that one of the issues is around the the massive reorganisation. I know the professor, Andrew, is probably going to talk. Andrew is probably going to talk about that. The Icbs, uh, whilst I. Think it's good to devolve it to Icbs.

I think that we are at risk and I don't think the strategy talks about that of replicating some of the terrible consequences of the 2012 act, and most of my email traffic or a lot of my email traffic is goodbye emails from staff that I've known working within the different health system. Uh, and so we're losing yet again, an enormous corporate memory, etc., etc.. So I'll stop there.
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None Portrait Speaker 4
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Thank you. Um, my name is Andrew Furber. I'm the regional director of public health for the North West of England. And as regional director of public health, we work across the Department of Health and Social Care, where we lead the department's health improvement and public health interests in our regions. But also we have a role with NHS England, where we oversee NHS England's Prevention and Inequalities programme, amongst other things. And it's that latter capacity that I'm speaking to you, to to you today.

I think you've had colleagues from the Department earlier in your inquiry, and I think you have our minister coming later on to talk about the department's position. Uh, I'm really pleased that you're having this inquiry. I think the fact that Ukhsa have reported two measles deaths this year is truly heartbreaking and very much welcome. The focus that you're bringing on this topic, and I think that's one of the strengths, if you can call it that, of the current position, that there is recognition that we are facing a major public health challenge.

And so your recommendations will be very, very important to that. I agree with all that my colleagues have said, and I think this focus on inequalities is going to be fundamentally important. That's unquestionable correlation between vaccine uptake and and deprivation, I think, needs to be a core part of our thinking. So the immunisation equity strategy, I think, is really helpful in framing some of that. But putting it into practice is clearly a challenge. I think those three shifts within the ten year plan give us hooks on which we can take some of this forward.

That shift to prevention, uh, that shift to neighbourhood health and increasing use of digital and a focus on data again, which I'm sure will come up later in our conversation. Uh, I think there is something about how we embed vaccination programmes within a broader portfolio of prevention work and of our engagement with communities so that they're not standalone programmes, but they're integrated into a number of other activities that we have around early years around family hubs, around maternity pathways and so on. I think that gives it more resilience.

Um. In terms of, um. Coherence with the wider prevention programme, um. Yeah, now I think I've made those points. I'll stop there. Thank you.
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None Portrait Speaker 4
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I start with that one. Thank you. All change is disruptive. We know that. So, um, mindful of the change that colleagues are going through at the moment, but I think in principle there's some real opportunities here. So I think the role of regions where I sit, um, is going to be an increasingly powerful one. And we've seen this over recent months as we've held organisations to account for delivery on urgent and emergency care recovery, elective recovery.

And we've begun to see some progress on that. And I think the challenge going forward is how do we bring similar scrutiny onto the prevention agenda?And obviously, in the case of your inquiry today, in terms of Icbs role as strategic commissioners around commissioning immunisation services, and I think there's an opportunity for icbs in the North West. Their combined budget is in excess of £6 billion. So it's a lot of public money that they have direction over. And I think to, um, get them to think about how that they can commission immunisation services within that quantum of resource shifting resource from towards.

Health towards communities, integrating vaccination services with other services that they commission will be, I think it will be an opportunity. It does need that um national direction, standard setting target setting from from the national level for us then to carry out regulatory role, assure assurance role around both icbs as strategic commissioners, but also provider organisations to ensure that delivery continues to improve.
14:31
None Portrait Speaker 1
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I mean, I'll be brief because I absolutely agree with everything that's been said, except for the caveat that I said at the start. I think we lost ten years of work with the 2012. And whilst the NHS Confederation says that the knowledge for Icbs that they did a big survey, the actual readiness to take on these responsibilities, I think we have to be very careful whether they are ready and whilst. And strategic commissioning is very difficult, we think of commissioning as as just buying something, but it requires a tremendous amount of public health involvement, a tremendous amount of knowledge at the grassroot level.

So I agree, but I have a sort of caveat with that. I would say there are clearly some advantages of the ICB you can do. You can flex how you spend your money depending on the local population. And you can also, much more importantly, integrate with your population health. But I think unless we have accountability at national level with a national statutory body that is responsible for vaccination, responsible for that 95% target and all the other targets, I think we're just going to diversify responsibility.

And when you diversify responsibility, you get no responsibility. I think at regional level, we need some really skilled pan regional commissioning, whether these are clusters of icbs or whatever you call them. And at local level, we we have to have local vaccine coordinators, which I know is one of the issues that you've discussed. And that has to be somebody that has a paid role that is there. That's not an add on to to the rest of their role that actually is able to link in with the various parts of the system.

So again, I'll just there.
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None Portrait Speaker 7
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Um.
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None Portrait Speaker 1
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Slightly muffled. But what I understand your question is, are there other any public health places that you can deliver vaccines?And. Yes, of course there are. But I want to backpedal a little bit. I think that, uh, I think that the problem we're trying to solve is the problem of strengthening the public health space that already exists, already did exist, which is primary care, uh, reaching out to, to its community. And I think we're at risk.

And dare I disagree with Professor Furber of creating innovative, short term, evidence based solutions, uh, which then get dropped that are not that don't go, that aren't sustainable, that don't understand the local community, that don't use the voluntary sector. Uh, whereas if we start to build on what we've already got, rather than trying to split it apart. And when we talk about family centres, so of course, family centres sounds like a good idea. They were what I provided 15 years ago with bolt on social workers, debt advisers, housing officers, knowing the family, knowing their community, not just removing children and mothers away.

We're now going to have women's hubs removing women away. We've got mental health hubs removing mental health patients away. We'll soon have men's hubs. So what we've then got left is a transactional space where it isn't a public health space. So I think this is this is the sort of my sense is we're looking at it through the wrong lens. Now, of course, we have to learn from Covid. GPS were able to engage local communities, go to mosques, go to rabbis, start talking to people, go to local schools, weren't open to the places where patients were.

But I will still fundamentally say that what we're trying to do is to create solutions rather than build on the solution. That has been the jewel in the crown of the NHS for, for for decades.
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None Portrait Speaker 7
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Well.
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None Portrait Speaker 4
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Uh, well, I don't think I'd disagree at all with anything that Claire has said. The the mainstay of childhood vaccination delivery is now and will always be through general practice. And it's important that we make sure that that GP system is as strong as possible to continue to deliver as effectively as possible. I think I'll go back to my point about sort of inequalities, and I think the the data shows us that there's a small proportion of the population, but nevertheless significant that for whatever reason, the GP system isn't working.

And it might be. Though we've got a spectrum of general practice quality and the majority is very good. But there is a small proportion that's perhaps less effective. We've also got characteristics of local communities that perhaps mean they don't engage with general practice in the way that the majority of the population do. So I think it's in those circumstances that we need to think about. What are the other touch points for these parts of our population?And as I said, it might be family hubs, it might be sort of health visiting early years, um, where I think we need to think a bit more creatively, but there's a number of kind of good case studies.

I was kind of looking before I came Bolton, Wigan, Trafford, just within the Greater Manchester area. I know you've heard from Liverpool as well, but again, completely agree with Claire that the um the problem with some of these initiatives is that they come in response to cases of measles or an outbreak of some sort, and they're very effective in the short term in terms of increasing vaccination uptake, but they're not effective in the long term. And I think we need to move from that to doing things which are sustainable, are long term, do engage communities in a more meaningful way, make sure that we develop those relationships with community leaders and community voices.

Um, for the long term, not just for the short term and make sure that we deal, deal with those things in a more sustainable way.
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None Portrait Speaker 1
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I start with that. So let's just and you've got my evidence. And I have read the evidence from your previous witnesses, and I slightly disagree with some of their, their points. For example, one witness said that a young person came to the practice for a vaccine was turned away. That is very unusual to do that. Okay, we'd like to grab them in. But let me start with some figures which I have given you. So we've had 120% increase in the number of hospital consultants over the last decade, and a -5% decrease in the number of GP principals, people like myself, we've seen a fall of 40% in health visitors.

We've seen now that about 80% of all nurses and doctors reside in hospitals, whereas, however you measure the activity, we know that 30 million contacts per month are in primary care, 30 million. So that's half the population of Britain, more or less every month. And I know probably none of you do, but this is on average. We've also seen a formula for deprivation, which is now 30 years old. That doesn't wait. Complexity. What it waits is basically age, age and sex with with extremes of age.

So if you're an elderly person in Bournemouth, you're you have to reach a person. In my practice at 55 has the same morbidity as an elderly person in Bournemouth if you take the morbidity, whereas we get no deprivation because they're not 75 yet. So we've got these downward spiral of general practice. And meanwhile we've got removal of more of the workforce to go into these other spaces. So we have a downward spiral. We've also got moving general practice from a relational activity, knowing the patient and the context of their family and their community to a transactional one, giving repeat prescriptions, uh, giving jabs, if you like, rather than knowing the whole person.

So that is what is decreasing. And I would argue that much of the evidence you've had around access and hesitancy, I would personally say is not correct. I think you cannot argue that we have no access when we have 30 million people, 30 million contacts per month accessing. You just can't argue. And in terms of hesitancy, we've always had hesitancy. I've worked post Wakefield. When you want to see hesitancy, that was hesitancy. But we addressed that and my partners are still addressing it.

I spoke to one today in order to bring someone who is hesitant, you need 2 or 3 consultations. That's 30 minutes of time. When we get £150 per patient per year in order to do innovative solutions, we have to have time to consult with the local community. So my sense of the we want to do more, but we we. Our biggest constraint is time.
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None Portrait Speaker 2
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Yeah, so, so I think the Association of Directors of Public Health are completely agree with some of the points Claire has made about resourcing that we know the current formula does not help. Um, practices in areas of deprivation. And that has all the knock on consequences that Claire has just described. And I'd also agree that general practice is absolutely the backlog of vaccination provision. Um, I think there have been some good steps to sort of nuance some of the payment mechanisms.

And of course, it's not all about payment, but the quality outcomes framework has now been changed. So actually it rewards improvement rather than hitting a very challenging target, which is incredibly difficult in a deprived area. So some steps that are being taken. Um, I think what I would say is I'm certainly seeing a local level positive developments around the family hubs actually. And you know, there's clearly a way of looking at these. Um, so for example, where I work, we have family hubs and areas of deprivation.

You have co-location of social workers, debt advice, domestic abuse advisors, health visitors do certain clinics there, but not all. And we have antenatal appointments now and we're seeing successes through that model. And that's absolutely not taking it away from the vital connections with primary care. But what we are seeing is people who may come in with something completely different. They may be coming in because they can pick up, um, you know, get go to the free school uniform stand where there's then an opportunity to engage in conversation, including about vaccinations.

And my view would be we want all those contacts to be working because we know for some parents, they need, as Claire said, they need that conversation to say, I'm a little bit worried about vaccination. Can I talk it through?And actually, they want a trusted person to do that with. So I think it's really important that we mobilise all these resources to kind of get us, um, get us to the end result. I know one thing is an association we're interested in is the whole call recall.

Um, and this is a bedrock, that ability to phone people up who haven't been vaccinated and said, we've noticed you've not been in, um, can we, you know, what could we do to get you in there?And that's something that would be really interested in looking at how we could develop that. It's very resource intensive. I know when we've done it, it takes a lot of time, but actually people who really, really, really need those hard yards to build confidence and build trust, that's the sort of thing we really need to do to get into our more deprived communities.
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None Portrait Speaker 5
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Indeed.
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None Portrait Speaker 9
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Thank you very much.
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None Portrait Speaker 2
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I'm happy to start. And then Professor Fairborne may want to come in. So, um, we know I think there is consensus across the system that we need a national data set for childhood vaccinations with live, real time data. I think we've got some good developments in training around the childhood programme. Um, so I don't know if colleagues have heard about the Mavis programme, which is attempting to bring in a single system for schools. Now that's the, the school age vaccination, but there are things like that that will be a real step forward if we can get that.

So, um, at the moment it's, it is difficult to see live real time accurate data for a number of reasons that I'm sure you've, you've had from, from other experts. So I think in order to really get to that granular, where do we have a problem?Which community we really need that data to really drive those, particularly those bespoke solutions and also for surveillance purposes, I think it's really important that we can build confidence that things are getting better and that we can make a difference. So again, having really good data so we can say we are seeing the impacts of what we've done is is really, really important.

And that is where I think a national data solution is, is really critical with the right people able to see that data. So we've talked about how complex this system is. You need the icbs, you need general practice. So we need to have the right permissions. Um, you know, including local directors of public health who have teams who can analyze this data to really make sure that what we're doing is really targeted and solutions focused. So I think, you know, really important part of the work you're doing to look at, are we doing enough and what more we could do around that?
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None Portrait Speaker 10
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Thank you, thank you.
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None Portrait Speaker 1
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A GP.
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None Portrait Speaker 5
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You can have two.
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None Portrait Speaker 5
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Brilliant. Thank you so much. Well, thank you all very much indeed. That's been really very helpful, very informative, but particularly useful to us to have your on the ground experience. Uh, so thanking you very much and reminding you that if there's anything further you want to send to us, please, please do that. And with that, I'll close the public session. Welcome back to today's meeting. This is the 14th oral evidence session as part of the committee's inquiry into childhood vaccination rates in England.

And thank you to Professor Sir Andrew Pollard for attending today. The session is open to the public and it's broadcast, and it will subsequently be accessible on the parliamentary website. We will be taking a verbatim transcript today of the evidence, and it will be published again on the parliamentary website a few days after the session. Our witnesses will be sent a copy of the transcript just to check if there are any inaccuracies in there and if there are, we would be most welcome. We would be most grateful if you would send those to us as soon as possible, so we can get it all up onto the website.

If after this evidence session, you wish to clarify or amplify any points you made during your evidence or have anything additional you want to say, you're very welcome to send us supplementary written evidence, and we're grateful to you for the evidence you've already sent to us. So, um, here is the first question, which is a very general one. How safe and effective are the vaccines in the routine childhood vaccination schedule?And what is the evidence on adverse events linked to vaccines in the routine childhood vaccination schedule?And how does the safety of routine childhood vaccinations compare to other medicines or to other vaccines, and also to people who have not been vaccinated?
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None Portrait Speaker 11
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I thank thank you very much. So I'm Andrew Pollard, I'm a professor of infection and immunity at Oxford University, and I've been a paediatrician for 35 years and worked in infectious disease for most of that time. As to seeing the consequences of not being vaccinated and, um. I've been director of the Oxford Vaccine Group, which is a research institute within Oxford University for the last 25 years. I've also been chair of the Joint Committee on Vaccination and Immunisation. I just stepped down at the end of last year after 12 years in that role, advising the government on vaccine policy for the NHS.

And I first started working on vaccines 40 years ago with my first studies, interested in the immune system as an undergraduate. So, um, to come to the not simple question, uh, the rather complex question you asked, perhaps first of all, the right thing to do is to frame what we mean by safety in that part, because it's very difficult when you talk about safety to understand from the perspective of the person who's talking about it and those hearing it what you mean. Um, so you often hear a statement like, um, no, medicines are completely safe.

And in the case of vaccines, that is the right answer. If you're a vaccine developer, because we collect data on tolerability and safety. And as I think most of us who've been vaccinated know, when you've had a vaccine, some people have a sore arm or get a temperature and that's all recorded. And that's part of the safety database. So it's quite right to say that that there are always some safety signals. There are some people have a sore arm or feel a bit woozy for 24 hours after being vaccinated, and to give a sort of a framing of that, um, for an older adult receiving the pneumonia vaccine at the age of.

65 around about 3%, 4% of people may have a low grade temperature. Um, and what's interesting in, in those studies in a control group, people who didn't get vaccinated, about half of the people, half of half the numbers. So instead of 2 or 3%, 1 to 2% will have a fever as well. So even if they've not been vaccinated, so so you do have a signal. There's a bit of a temperature in some older adults who get vaccinated. And that would be a safety signal, but it's not a concern.

So safety doesn't necessarily mean it's a concern. We accept that because that is, um, our immune system recognizing a vaccine given. So it can start the preparation to be able to produce an immune response. That means if we ever get exposed to the pneumonia bug, we're ready to fight it. So it's a natural part of the process, but it is considered part of the safety database. So it's quite right to say that it's not all safe. That same vaccine given to a baby.

It may be as much as 8% of babies will have a bit of a temperature after they've been vaccinated. So but again, that's something self-limiting. It stops usually in a day or so. And without any long term consequences. So that's, that's what really the sorts of things we're talking about in safety for most childhood vaccines. We also, in the clinical trials collect what are called adverse events, serious adverse events. And that would include a broken leg.

It would include someone having their appendix out because there are um it's important in clinical trials to collect all safety events because it could be that something that is happens normally in the population happens more commonly after a vaccine or a medicine is given. So you collect everything. So at the end of it you can analyse to see whether there's an increased rate of that condition in the vaccinated group compared with the non-vaccinated group. And in most clinical trials, we don't find any difference in the serious adverse events, but we report serious adverse events, adverse events in the trial.

There's a lot of misunderstanding about what that means, because it doesn't mean they're caused by the vaccine. Clearly, if you get hit by a car, that's not the vaccine that's caused that, but it would still be recorded in the data. So I think that's that's the second bit. Now, there are some very rare serious adverse events. And we know, for example, with Covid vaccines, there was the very rare condition of blood clots with one of the vaccines, um, heart inflammation with one of the others.

So there can be extremely rare ones, but you can't pick those up in the clinical trials. And so they're so rare that they're not seen in that setting. Um, and you asked how does that compare?With what you see with medicines?Now with medicines, we accept a lot more risk than we do with vaccines. Vaccines were given to healthy population, to healthy children. So whereas we'll accept those tolerability issues that I talked about, we really don't accept any significant rate of anything serious with a childhood vaccine.

But if you have cancer and you've got a treatment that might cure your cancer, you'll accept quite a lot of risk associated with that treatment. And we see that if you look at the clinical trials and the data, we have them. So vaccines are far safer than some drugs that we use simply because we're giving them to healthy population where we don't want to cause harm.
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None Portrait Speaker 11
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Sometimes I was referring there to the clinical trials side, where you have very good data, but obviously it's relatively small numbers that most trials only have thousands of people. And when you get to the safety database before licensure, not millions, um, for obvious reasons. It's just a cost in development. And so at that point, that's, that's what we're dealing with after licensure. And then data are collected by both the regulators across the world, as well as by the companies who are marketing the product to look at all adverse events that get reported.

And there are different systems, as you know, including our yellow card system here for that reporting. And so if, for example, people report high rates of, of a particular condition after vaccination, let's say multiple sclerosis, then it's really important to know whether that high rate is the same as you would see if someone hadn't been vaccinated. Now for a condition like that, we have really good data. There's of course, huge numbers of multiple sclerosis cases identified every year in adults. And so we can quite readily look at whether the rate observed in a trial or actually not in a trial, but after after licensure is similar to the rate that you see in the general population.

But if it's a rare condition that we very often don't have good data on it, we don't have data on how common it happens in the background and what regulators tend to do there is err on the side of caution. And so whether whether there's uncertainty, they will include that condition in the label. Even though we're not really sure. And whether that condition is directly associated with the vaccine. But it means that people are alerted to that possibility.
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None Portrait Speaker 11
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Yes. So first of all, the process of clinical development actually starts in the laboratory in designing a vaccine. And then once there's a design, it's tested in animals quite extensively usually. And the the regulators require that animal data in order to then provide the, the application or approve an application to start clinical trials. And those trials are first done in very small numbers of adults, usually tens of individuals with a specific focus on safety. Obviously, as a developer, you also look at the immune response because there's no point in proceeding if there isn't any immune response to a vaccine.

But the main focus of phase one trials is on safety. The next stage, if that all looks good and there's no safety issue in a few tens of people, is to move on to phase two trials, which tend to be larger numbers and in the target population, that you're aiming to originally initially eventually vaccinate. So for example, if it's a vaccine for babies, the target population may be an age de-escalation. So you've already got some adult data from phase one. And then you work down to babies with sizes of, um, of studies in the hundreds, usually, um, before you then move into babies to see whether there's any signals that are concerning in that age group.

And then moving on to the phase three clinical trials, which are usually in thousands of individuals. And that has both a safety measurements, but also to see that the vaccine actually works. So does it protect individuals?Um, and I've gone blank on the second bit of the question.
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None Portrait Speaker 11
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You also asked about licensing, about licensure. So so the MHRA for licensure has three different components that, that are reviewed. There's the animal studies um are looked at closely by preclinical assessor. And then there's a pharmaceutical assessor who looks at the way it's been manufactured and all the testing to make sure that what's in the vial is what it says it should be, and whether it's safe. And then there's a review of all the clinical evidence that's been accumulated around the product.

And that's true for vaccines and drugs in the same, um, the ethnic minority component is an important question. Uh, most of the vaccines that we use in the childhood schedule are used all over the world, across different ethnicities and with different databases and collating data. And so certainly if you were to look at most routine vaccinations and there are enormous databases of both safety and effectiveness across different ethnicities, the I think the question is more about new vaccines when they're introduced, and that does depend a bit on where the development programmes have happened.

So one of the for example, in the Covid vaccine trials, one of the things that we decided to do for the Oxford University trial was to run them in the UK, but also in Africa and in Latin America to try to get a wide range of ethnicities included, because obviously we have a much smaller proportion of people from ethnic minorities here. So even if you just reflect the national population, um, the numbers are by definition smaller. Um, there is a challenge which I think is being actively worked on is some ethnic minorities are less willing to take part in clinical trials.

And so that needs extra work. I think it's already happening nationally, but particularly by investigators to try and encourage people to take part.
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None Portrait Speaker 11
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I mean, I think it's very rational for all of us to ask questions about our health and how and when we go, and to have our child vaccinated, or we have vaccines ourselves to want to understand what it's about. And often that questioning, um, which I would want to do if I was going to see my GP about something, and is entirely appropriate. That should be what we do as a literate, um, well-educated population is to, to want to understand more. That's often called hesitancy and lack of confidence.

But I, but I think there is in my mind, it's quite an important part of that engagement with the health system. And when we look at the the data about vaccine uptake, and you try and look at where the obstacles are, the vast majority of that, in my view, is about access, and it may be access to the immunisation services. And we certainly see that particularly, um in the more deprived communities. But it's also access to someone to get information about and have those health conversations with and which, as I say, looks like lack of confidence.

But I think it's just normal health behaviour and it's appropriate. And there's an interesting question about how you might change that. Um, which I think you've addressed to some extent with the previous panel, but there's also a question about how you make sure the population going forwards is more confident in understanding what is there. So there doesn't have to be so much engagement with the NHS around that question. And for me, that is an educational question. We should be having school leavers leaving with a good understanding of science and a good understanding of how of how vaccines are used and their importance, um, in, in protecting our children in the future.

It's the wrong moment for a parent to make a decision when someone's coming at their baby with a needle, they should really know before they go in that this is the right thing to do.
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None Portrait Speaker 5
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Thank you.
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None Portrait Speaker 11
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The process for the Jcvi uses for a new vaccine is to look at, first of all, the safety and efficacy data from clinical trials. So there's a the full data package is collected from the published literature from the committee's own analysis around any new vaccine, usually in subcommittee. We also invite the company to come and present their data, which gives us an opportunity to really grill them on things which are not in the public domain. But but the main committee doesn't meet with with industry.

We don't want them to be influenced by that. Um, so that's the around the vaccine. We also need to understand in the UK population whether there's a need. And so the epidemiological information, what the rates of the disease are, what the burden is on the health system and what the mortality rate is, all that information is collated. And the UK Health Security Agency gathers that together. So if there's a good case of need and there is a vaccine that's available that meets those requirements, the final arbiter is really cost effectiveness.

And this flows from the Treasury's Green Book. Um it follows very similar guidelines to the guidelines that nice uses and establishes what threshold of cost for a vaccine would make it cost effective. And that that obviously includes the administration costs as well as the purchase cost. And that assuming we with that analysis that we meet the Treasury's guidance on cost effectiveness, then we would recommend to the Secretary of State that the vaccine is introduced. And I should say that that's separate from the other role of Jcvi, which is overseeing the whole programme.

As new data emerges, which could be on safety, more often it's on efficacy, which might mean that we can withdraw some doses. And a great example of that is the human papillomavirus vaccine for cervical cancer, introduced in 2008. We're looking at the data emerging from around the world. We started with three doses for adolescent girls, and we've now eventually, because of the new data emerging, we only give a single dose and we give it to girls and boys. So that's sort of withdrawing the number of doses because we didn't need more.

And there's no point in giving more if you don't need them. But there are other examples where, for example, with with whooping cough, where just over. In fact, nearly 15 years ago now, we had a number of baby deaths from whooping cough. And it was in the age group before they're vaccinated. And so at that point, we introduced vaccination for the mother because we were able to look at the data emerging and make recommendations about existing vaccines. Again, as long as it's cost effective to add an extra dose.

Um, and the last bit of the question is sort of more around.
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None Portrait Speaker 12
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Thank you.
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None Portrait Speaker 11
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Um, I think my experience of the childhood programme is that changes when they happen are quite difficult to adapt to for the health service, but the public are much more accepting of those changes. And, you know, I think practice nurses are very good at picking up the the rationale for change and the reasons the recent big changes in the infant schedule have been driven largely by the withdrawal of one of the vaccines by the company, which meant that we had to rejig the schedule to to fit that in, um, rather than it being a change because there was any safety or efficacy issue.

So I don't think there's such a big problem with the, with the public, because we've got very good people in the front line in primary care, um, explaining that to them. You made the point about Covid. And I think that's a really good point to make because I think a lot of what we expect in the way that, um, debate is considered really is very much more like the political debate, which might be taken as, as an ideological standpoint. And that's not what we do with science.

We look at emerging evidence and we change our mind as the evidence changes. That's not that's not a failure. That's that's the right thing to do. And I think we saw that very clearly in the pandemic as new evidence emerged on which age groups should be vaccinated. And there was a response to me that gives me confidence as a scientist, but I can see how the communication of that is something we need to do better about with the public.
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None Portrait Speaker 11
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I think that's a very good question. I think one of the things that, um, we don't do very well around the communication is to do enough of it. Um, when you, when you look at communication over many of the vaccine decisions, there's no government announcement about them. It's something which changes in the system over time. And it seems to me that there's, there's often an opportunity missed. To be on the front foot about what we're doing and why we're doing it, and the potential health benefits.

I mean, if you were to frame. Childhood mortality over a few centuries, if we if we look back to the 1700s, nearly half of all children died. Nearly half of all children died. And most of those were from infectious diseases. And that's changed dramatically to now. It's about, um, I know something like 4 in 100,000 in this country will die in the first five years of life. I mean, that's an astonishing impact of public health.

And vaccines have been a really important part of that. It's not the whole story, obviously clean water and so on are also important, but that's a dramatic change that's happened. But with the vaccine story, where most of the vaccines we use have been introduced over the last century, we don't have much of a story about the remarkable impact that they've had and why, when we introduce a new one, we're also aiming for those those enormous impacts. The most recent maternal vaccine, the RSV vaccine, about 3% of babies will end up in hospital every year.

Some of those on intensive care. And we've got an intervention that can completely stop that. So it's it's just not as well communicated and repeated as it should be about the the enormous impact that that vaccination has. I think that does need joining up more. It's great for politicians says something, but perhaps you need to have the right voices that are appropriate for the. The age group and younger adults, usually who are involved in vaccination. Um, you know, we may be listening to, um, the media sources.

Um, that is familiar for, for people over the age of 50 or 60, depending on the age of ages of people in the room, or maybe even more. Um, but certainly people under 35 are not listening to the same media sources. And they also will respond much less favourably to one of us providing that information. So I think we've got to do a lot more about connecting with the right media sources to the people who are the parents of those children today. Um, and obviously that's, that's changing all the time as the type of media changes.
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None Portrait Speaker 11
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So.
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None Portrait Speaker 1
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Okay.
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None Portrait Speaker 3
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I mean, I think the one of the difficulties is that vaccines are phenomenally safe. And so the unsafe question is really hard to answer because you're looking for something which, if it's there at all, is extremely rare. Um. What the regulators do always is a benefit risk calculation. And going back to my point at the beginning that vaccines are given to a healthy population. So safety is absolutely paramount. The benefit risk, particularly for rarer diseases like this awful meningitis disease.

Um, it's a very rare disease. It's dreadful. It kills teenagers and babies. Um but it's very rare. So for most people being vaccinated, they are clearly protected against that disease because we don't know if they might get it, but for most people they won't. So you can't take any risk. Um, for the population with vaccines. So what the MHRA is doing, first of all, and its licensure is assessing that benefit risk. And it has to be near to zero risk and very high benefit for vaccines because of that population.

Um, and then what, after licensure, the yellow card system, another system that are used for monitoring and are trying to pick up signals allowing the public or doctors to report anything that they think might be related to vaccine. And that usually is something which happens sometime after vaccination. And so of course, because stuff happens to all of us all the time, there will be lots of signal that that's being picked up. Um, which is not real. And that's the yellow card system is picking all of that up.

And then the regulator has to wade through that to see whether there's anything which is more common than you would have expected. Um, in an unvaccinated population or by chance. I think what was very interesting in the Covid pandemic. Enormous numbers of yellow card reports because stuff happens to us all the time. And of course, everyone had been recently vaccinated, so everything felt like it might have been related to it. If you developed cancer or if, you know, developed, you've had your first heart attack, all of those things happen normally, but everyone had just been vaccinated.

And then there's this major question of how do you sift through, um, what might be a real signal versus what is just expected anyway?
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