Does cost effectiveness underestimate the impact of meningitis?

The MenB vaccine, Bexsero, was licensed in Europe in January 2013. For vaccines to be made available freely on the NHS an expert government advisory body, the Joint Committee on Vaccination and Immunisation (JCVI), must recommend the vaccine.

Recommendation is based on how well the vaccine is likely to work, the safety profile of the vaccine and whether the vaccine is likely to be cost effective (is likely to be value for money).

The vaccine had already received its licence on the basis that the vaccine was safe and that it was likely to work. However in July 2013, the JCVI published an interim statement which concluded that “on the basis of the available evidence, routine infant or toddler immunisation using Bexsero is highly unlikely to be cost effective”. We were immediately concerned that the burden of disease must have been underestimated in the cost effectiveness model used by the JCVI.

The JCVI were clear that this was an interim opinion and they called for stakeholders to respond and submit any available evidence.

We wrote to the Lancet in August 2013 in response to a comment about the negative interim statement making it clear that we thought that the burden of this disease had been underrepresented and that we intended to provide the JCVI with further evidence about disease burden.

After reviewing our and other new evidence, the JCVI reran their cost effectiveness model and recommended that the vaccine be routinely given to UK infants at 2, 4 and 12 months as long as it could be purchased at a price “low enough to be cost effective”.

We responded to a negative editorial in the BMJ at the time that the amended decision was transparent and based on strong evidence submitted by stakeholders.

The re-evaluation of the cost effectiveness of Bexsero which underpinned the JCVI’s recommendation was published in the BMJ in October 2014. It recommended that the vaccine would only be cost effective at a low price ranging from £3 to £22 per dose.

We are delighted that the JCVI took account of new evidence from stakeholders and re-evaluated the cost effectiveness of the vaccine. Many improvements were made, but we remain concerned that some of the model parameters still underestimate disease burden. We also believe that the cost effectiveness framework that the JCVI have to work with is unfair for the evaluation of vaccines that prevent rare and serious illness in children.

We responded to the BMJ’s publication of the re-evaluation to raise these concerns and we publicised our concerns about the fairness of the framework in a piece in the Nursing Times whilst the JCVI reconsidered their interim statement.

Now, months on from the JCVI’s recommendation we are still no further forward in seeing children protected against this deadly disease and price negotiations between the department of health and the manufacturer have stalled.

In the UK right now we are seeing an exponential rise in a deadly ST-11 strain which the vaccine Bexsero would protect against. Consideration of this in the cost effectiveness analysis would certainly increase the value of the vaccine.

We highlight these concerns in our recent letter to Jeremy Hunt. We hope that consideration of this will help conclude price negotiations swiftly and that we can start seeing lives saved.

Leo Steel
Meningococcal disease
Meningococcal disease at 0

It felt like the life I had woken up to in the morning was distant dream.

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