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Press releases Monday 30 June - Friday 4 July 2008

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(1) Multiple vaccinations have not caused ill health in UK soldiers in Iraq
(2) Potential solutions to the copayment dilemma
(3) Malaria on the increase in the UK
(4) Screening for heart disorders in competitive athletes would save lives

(1) Multiple vaccinations have not caused ill health in UK soldiers in Iraq
(Multiple vaccinations, health, and recall bias within UK armed forces deployed to Iraq: cohort study)
http://www.bmj.com/cgi/content/short/337/jun30_1/a220

Multiple vaccinations have not been a cause of ill health in UK service personnel deployed to Iraq, finds a study published on bmj.com today.

The report from researchers at Kings College London says "recall bias" is to blame, when people link a perception of ill health with their memory of having had multiple vaccinations.

The findings add to the ongoing debate surrounding the impact multiple vaccinations may have had on the health of Gulf war veterans after the 1991 war. Several studies have found an association between self-reported multiple vaccinations in service personnel deployed to the Gulf war and later ill-health. However, other studies have not found these associations.

Dominic Murphy and colleagues randomly selected 4882 military personnel with a median age of 32 who had all been to Iraq since 2003. Before being deployed to Iraq, tetanus, typhoid and yellow fever were all routinely administered to service personnel, and anthrax was offered to individuals who had to sign a consent form.

With the use of detailed questionnaires they asked them about the maximum number of vaccinations they had received in any one day in preparation for deployment. They then randomly selected and assessed the medical health records of 10% of the group in order to see if multiple vaccinations had resulted in any adverse health effects being reported at the time.

They found "significant associations" between service personnel recalling two or more vaccinations in one day and complaints of fatigue, common mental disorders and a variety of physical symptoms.

However, when they looked at the medical records of 10% of the group they found, without exception, that there were no health differences in those who had received one vaccination and those who had received multiple vaccinations. Significantly this 10% had, like the entire group, also been more likely to report ill health if they recalled having had two or more vaccinations in one day.

The researchers say that military personnel's memories of the number of vaccinations received in a day "cannot be considered reliable," unless they had only one vaccination, which they remembered correctly.

In view of these findings and the impact of "recall bias" the researchers say "there is no evidence that receiving multiple vaccinations has resulted in adverse health for UK service personnel deployed to Iraq since 2003."

Contact:
Dominic Murphy, King's Centre for Military Health Research, King's College London, UK
Email: dominic.murphy@iop.kcl.ac.uk

(2) Potential solutions to the copayment dilemma
(Editorial: Cancer drugs and co-payments)
www.bmj.com/cgi/content/extract/337/jun30_2/a527
(Personal View: Top-ups for cancer drugs: can we kill the zombie for good ?)
www.bmj.com/cgi/content/extract/337/jun30_1/a578

A general policy of copayments or top-ups, allowing patients to pay privately for drugs, would be counter to the principles of the NHS and grossly unfair to desperately sick people, say experts on BMJ.com today.

"Once a policy is introduced for one disease, where will the process stop? It could come in for equally unproved dementia drugs" and would be "disastrous", writes Cam Donaldson, Director of the Institute of Health and Society at Newcastle University in a Personal View. This would led to escalating costs and threaten the equity of healthcare delivery.

Professor Ilora Finlay and Professor Nigel Crisp, both independent members of the House of Lords suggest that one solution may be to produce a definitive list of drugs for which copayments would be permitted, recognising that the National Institute of Clinical Excellence (NICE) cannot always produce a quick or definitive response.

They point out that other health systems have experienced problems with copayments. For example, data published in 2004, showed that in the US, where there is widespread use of copayments, 40% of patients did not seek medical attention when they needed it because of the potential costs involved. In contrast to the UK, where the figure was just 9%, the lowest in the study.

In the UK, NICE was created to evaluate the evidence of drugs and treatments from clinical trials and decide on their use in the NHS. This takes time, and patients are increasing faced with the dilemma that despite evidence that a licensed drug has a benefit, it has not yet been appraised or funded by NICE, and if they purchase it privately, they will be excluded from NHS care.

But according to the Finlay and Crisp, in practice, the number of patients wanting to pay for additional drugs is small and most are drugs that have yet to be reviewed by NICE, or for which there is insufficient evidence of a benefit to patients.

They suggest accelerating the NICE process as much as possible and compiling a definitive list of drugs for which copayments would be sanctioned on the basis of four criteria:
1. The drug or device is one for which copayment is allowed.
2. The patient has discussed the risks and likelihood of failure as well as success with their doctor.
3. The doctor believes that the anticipated benefits of the unfunded drug for the patient outweigh the benefits of other treatment.
4. Patients who are unwilling or unable to participate in a clinical trial should be willing for their treatment and its outcomes to be recorded on a register to monitor adverse incidents and to be used in subsequent reviews by NICE.

A government review of whether patients should be able to remain NHS patients if they pay privately for drugs is due to report in October this year. This will not be an easy task, say the authors, it will have to tackle some difficult issues including whether copayments should cover the cost of administering drugs and any complications arising from private treatment as well as the cost of the drug itself.

Donaldson believes that to control healthcare costs and address the dilemmas posed by "budget-busting" cancer drugs, governments need to target the supply side of the market and not try to limit patient access by ineffective and unfair "user fees" that do nothing to increase access.

It is vital that patients and the public continue to be involved in making decisions about health and healthcare, says Donaldson. But, "If we want to raise money in a way that is consistent with what we want to achieve in health care, there is another way - it's called taxation", he concludes.

Contacts:
Ilora Finlay, House of Lords, Westminster, London, UK
Email: finlayi@parliament.uk
Cam Donaldson, Director, Institute of Health and Society, Newcastle University, Newcastle, UK
Email: cam.donaldson@ncl.ac.uk

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