Speaker 0 00:00:01 Hello and welcome to our Wonder Care podcast. I'm Sheena Mitchell, pharmacist and mom of three. I combine healthcare and practical advice to support you on your parenting journey. This week I'm chatting all about the publication of Hick's Health Technology Assessment on the addition of the chickenpox vaccine to the Childhood Immunization Program. This document was published on the 13th of July this year. Since then, I've had a flurry of queries on the topic, so I decided to deep dive into the 417 page document to try and get the answers to as many of your questions as possible. If you would like to get involved in this podcast, then follow at Wonder Care underscore i r l on Insta, where I regularly pop up question boxes on upcoming topics. I've done previous episodes on the management of Chicken Box and also the pros and cons of vaccination, so I won't go into that fully right now. Speaker 0 00:00:55 However, it is important to say that I have remained firmly on the fence about the chickenpox vaccination to date and the reasons for that were as follows. The chickenpox vaccine has not previously been on the childhood schedule, and as a result, people who wanted to get it had to pay privately. It's expensive. The impact of that means that very few children have actually been vaccinated, meaning that chickenpox is spreading widely in our communities. I'd safely say I've heard of more cases this year than I ever remember hearing about in previous years. Like all infections, this is probably a pandemic hangover. The reality is that the chickenpox vaccine only has evidence of immunity for 10 to 15 years. We know that older children and adults suffer from more severe disease, and we also know that contracting it while pregnant can be dangerous. So in my head, I was imagining a four or five year old getting the vaccine on my advice, and then suddenly in 15 to 20 years there have childbearing age and potentially at serious risk if they catched the chickenpox. Speaker 0 00:01:54 I couldn't personally find ease with that scenario. I recorded an episode with the wonderful Dr. Neve Lynch who gave her view that people should get the vaccine as, although it's normally more of a nuisance than a serious disease, it can indeed cause hospitalization of a small minority. She made exceptional informed points, which left me further conflicted on my own opinion. For me, I felt that unless everyone was getting vaccinated, then all we were doing by encouraging a small minority of people who could afford and wanted their kids to be vaccinated, all we were doing was potentially putting those kids at serious increased risk in later life as chickenpox would still remain rife within our communities. And of course their vaccinations could potentially be waning. However, national free vaccination is a completely different story. If the vast majority of children get vaccinated, there are some who can't due to medical reasons like immunocompromised. Speaker 0 00:02:49 But if the vast majority get vaccinated, then herd immunity can be achieved over time. We know the vaccine lasts for 10 years at least, and we also know that the majority of children contract chickenpox by their 10th birthday vaccinating at least 80% of all children will reduce or eliminate the virus and thus reduce the risk at least of any adults or older kids who haven't had it of contracting it in addition to those who are unable to receive the vaccine due to immunocompromised. So in summary, I am completely delighted and excited that this recommendation has been made to the Minister for Health and the Department of Health by hwa. So now let me explain the findings of the 417 page health technology assessment and what it could potentially mean for you. A health technology assessment is where every study and detailed analysis is done to provide the pros and cons on every aspect from societal aspects to wellbeing, economic, the whole spectrum, ethical risks, everything. Speaker 0 00:03:52 Actually, it was a really, really interesting read and I just want to commend Hira because I'm sure they do that all the time, but I don't often dive into HTAs and I found it fascinating, although I'd hate hate to have to do that level of research <laugh>. So by reading it and understanding it, I feel like I'm now in a position to be able to explain what the story is and what the report actually means. On a practical level, the first question that I want to answer is one that I got asked a lot, and that is when will this vaccine be introduced? The long and short of it is I don't know, the Department of Health and the minister now need to analyze the report as there are practical, economical and social considerations to be taken into account. They might decide that they can't afford it at all. Speaker 0 00:04:43 However, HERA have recommended it as they say it is economically worthwhile. Anyway, you know me, never want to encourage the dilly ding of our health minister. So of course I've written to him asking him for potential timelines and decisions raised by the report in Hira, even I as an impatient person, <laugh> do understand that it won't be instant though. A few more key points and then I will answer lots of more questions. HIA examined different vaccination schedules. So they were mainly debating three things. The first one was whether one dose would be enough to give to every child or if they should give two doses. The second one was if they give two doses, how far apart should those doses be? And the third one was whether they use a varicella. So varicella is the name of the virus which causes chicken pox. So whether they use a varicella only vaccine or they use a quadrivalent vaccine, which means it would be in combo with the mm or they established that one dose will decrease severe disease including hospitalizations and the overall occurrences of chickenpox. Speaker 0 00:05:54 However, two doses would further decrease the number of cases and potentially eliminate chicken pox. In essence, one dose just helps to keep kids outta hospital, but children will still be getting chicken pox and will still need time off school, et cetera, et cetera. Two doses does give us the potential, the real potential to eliminate chickenpox. For me, that's a no-brainer. Surely we want to achieve elimination to protect children as they enter adulthood. Two doses has been shown to reduce the effect of immunity waning, but of course I don't have to balance the budget and our ability as a nation to pay is finite. One dose would cost 13 million over the first five years. Two doses would cost 28 million over the first five years. On the other side of that argument, societal cost will be greatly reduced. We've all heard of a family with three kids and one got it, and then the next 10 days later, and then the next two weeks after that resulting in a parent having to take five to six weeks off work to care for their kids. The flip side to that is that with a healthcare budget so tight, are we going to be taking money from other important causes like oncology mental health support or neurodiversity assessments? I don't have the whole budget in front of me, so I can't comment on that, but the HT A that's hick was report found that the two dose short interval strategy was the least costly and most effective. Speaker 1 00:07:25 I just want to interrupt this episode for one little second. Speaker 0 00:07:28 Okay, more than one Speaker 1 00:07:29 Little second, but not a lot of seconds. Summer is here and it's definitely my favorite season. The only downside is all of the circulating dust spores and pollen that can make life miserable by affecting your sleep and respiratory health. That's why I'm so delighted that Salon Plus are supporting this season of Wonder Care podcast as the Saam plus device filters these Dustin pollen particles out of the air when used every night in your bedroom and circulates fresh clean air for improved sleep and comfortable airways. Speaker 0 00:07:59 I cannot believe Speaker 1 00:07:59 We're on season five. Where is the time going anyway? Back to the pot Speaker 0 00:08:04 For short intervals, they looked at the first dose being given at 12 months and the second dose at 15 months for long intervals. They looked at the first dose at 12 months and the second dose at five. So when your child is in junior infants, they also said that there's still uncertainty around how long immunity would be boosted for if a second dose is given, but that it is clear that two doses do provide longer immunity. And remember, if we are vaccinating ongoing, it means that waning immunity won't matter significantly as chicken pox won't be circulating for anyone to catch it. So in essence, if we only give one dose, we won't stop chickenpox circulating. We'll just reduce the severity and number of cases of hospitalizations. If we give two doses, we can aim to eradicate chickenpox and that protects all of these kids when their vaccines wan in the future. Speaker 0 00:09:00 On a practical level, as a parent, a two dose short interval means an extra GP visit. At the moment, a parent will bring their baby for their routine childhood scheduled vaccines at 12 months, so that appointment is fine, but with the short interval, they'd have to go back again at 15 months. Now, I don't know about you, but I think that is a barrier that in the current landscape of GP shortages and an overburdened primary care system, I think it's just a barrier to great, too great to climb a two dose long interval means no extra appointments because they'd get it at 12 months with the rest of their vaccines and then they'd get it in school the same day as they get their other vaccines. For me, any rollout should be as practical as possible. A short interval is hard to see working in my view because gps are already overworked and overburdened. Speaker 0 00:09:53 In addition, parents are also overworked and overburdened. Another point that I've been asked a lot of questions about is a catch-up plan. HIA did not recommend a catch-up plan, meaning that whenever this is brought in, it'll only be applied to children who are 12 months old at that age. So older kids will have to pay for it privately if they want to get it. This happened to me in the meningitis B vaccine. I really felt strongly about getting it, but it is a significant financial burden on families. There is also a possibility that whilst 85% of children get chicken pox by 10 years of age, the introduction of a vaccination program may shift infection into older age groups where there is a higher risk of disease. Now, I looked into this a little and in America a two dose schedule has virtually eliminated the disease in the space of a generation. Speaker 0 00:10:44 They use a long interval schedule at 12 months and five years as I described earlier, and they actually, in addition to that, offer it to all ages. Now if you've never had the virus, and that includes kids, teenagers, and adults, they go as far as to have state laws in all 50 states which require chickenpox vaccination for entering childcare school or college or university. HIA have not recommended that here because in my opinion it would drain a huge proportion of the health budget and unfortunately we have more than one disease state that we need to consider in terms of public expenditure. It does bring me to another question though. Should I get my older child vaccinated before now? I would've brought it back to my previous point that vaccinations will wane. However, if the Department of Health do decide to take hwi advice and do go with the two dose schedule, then we are aiming to eliminate the virus. Speaker 0 00:11:40 And so it won't matter if your child's immunity wanes in 10 to 15 years time. I also had a lot of questions about shingles and if the introduction of this vaccine would impact levels. Shingles also known as herpes zoster is the reactivation of the varicella virus, so the chickenpox virus, and it occurs in 30% of people who had chicken pox. There has been a long existing theory that if you as an adult had chickenpox as a child and then as an adult have exposure to chickenpox, you get a little boost of immunity, which helps to prevent the reactivation of the latent virus in the form of shingles. So for example, I had chickenpox as a child, so when my children each had chickenpox, that would've given me a little boost of immunity against shingles. So if we adopt this theory, then we are getting rid of that natural immunity boost to shingles as chickenpox won't be circulating anymore. Speaker 0 00:12:36 However, long-term follow-up data from the US has shown that in reality this predicted rise in shingles infections simply has not materialized. They actually now think that shingle cases will reduce as vaccinated children age at this point. There is insufficient evidence to rule it out as a mild concern, but there's certainly enough positive outcomes and evidence from the US to make it a fairly redundant argument against vaccine introduction. Some other questions I got were, is it safe for an immunocompromised person to come in contact with a child who was recently vaccinated for chickenpox? The chickenpox vaccine is a live vaccine and whilst it's rare transmission may occur to susceptible contacts including healthy or high risk individuals who have not previously had the chickenpox. The vaccine manufacturer of varivax recommends avoiding close contact with susceptible high risk individuals for up to six weeks following vaccination. If it's a household member, you need to weigh up the risk of getting the vaccine versus the risk of acquiring the wild type virus. Speaker 0 00:13:43 High risk individuals include immunocompromised people, pregnant women who have not had chicken pox before, and newborns of mothers who did not have the chicken pox before. So that means their mother didn't have the chicken pox. Obviously a newborn's not gonna have had it. Another question, A child that received the vaccine at four, should they receive another before 12 years? Okay, so I would recommend that any child not included in the childhood schedule should receive two doses where financially possible children from 12 months to 12 years can have a second dose one month after the first children from 13 years and up should have four to eight weeks a minimum between doses. But I do think it's really important to add here that this vaccine is quite expensive to get privately somewhere around 120 to 130 euro per dose. For the vast majority of children who get chicken pox, it will be a mild disease, which can be managed well at home. Speaker 0 00:14:42 I have an episode on how to do that, so check that out if you need to. The point is that while getting everyone vaccinated would be lovely, it's simply not practical for many families with multiple children. It's my view that unless you have disposable income and really want to get them vaccinated, then you can wait a few years and see if they have caught up by the age of 10. At that point, you can then review your decision. I want to make it very clear that for many households it's just not affordable and you may well be right to prioritize other household expenses over varice vaccination. Some families will have their own reasons for feeling the need to get it done, but just knowing that this rollout on the childhood schedule will benefit everyone in the future who is susceptible means that whether you pay for vaccination privately now or don't, the future will definitely be brighter. Speaker 0 00:15:30 Another person asked if you can take nuen post vaccination. So we know that nuen has been found to increase the likelihood of skin complications from the chickenpox rash. So you definitely do not give your child nuen when they have the chickenpox. Paracetamol will be the first line for vaccine related fever and other illness for a few weeks post chickenpox vaccination. However, it's just a caution. An ibuprofen can be given if paracetamol alone is not alleviating symptoms after the vaccine, only 4% of people will get a rash after vaccination. So if there is no rash, I can't see why there would be a risk of skin complications if a rash does occur. Speak to your GP before giving rine. Generally, if a rash happens, it's only a very small number of spots and often they occur around the vaccination site. It's worth saying that if your child does get a few spots after vaccination, it is possible that they're contagious. Speaker 0 00:16:28 So I'd keep them home from school childcare, et cetera, until the spots have scabbed over. But do remember and be reassured by the fact it's only a 4% chance of getting spots after vaccination compared with a hundred percent chance of when you catch it wildly in the community. Another question was, I'm not sure if my three-year-old had chicken pox, but I'd like to get them vaccinated. If not, is there any way to check? Yes there is. Ask your GP to do a chicken pox antibody blood test. That'll give you a definitive answer on whether they have immunity or not. A few other people asked, will the vaccine be free? And the good news is yes, if it's covered under the childhood schedule, it will be free, but only for those in the correct eight cohort at the time it's rolled out and HEA have not recommended a catch-up program. Speaker 0 00:17:14 So at the moment, the decision hasn't been made, whether it's gonna be one single dose at 12 months, two doses at 12 months and 15 months or two doses at 12 months and five years, I really hope it's the third option there, 12 months and five years. Someone else asked, why bother get it? Does it not normally just cause mild disease? I really, really understand that question and it's one that's circulated fastly in America before the introduction for time and time again, it came back to the same thing. The best way for me to explain this is to urge you to listen to my episode with Dr. Neve Lynch, the pediatrician. She outlines a very strong argument for vaccination. Ultimately, it comes down to the fact that there's an average of 226 hospital admissions per year in Ireland and 161 I C U bed days all as a result of chickenpox as a parent, if my children hadn't had chicken pox, personally, I would get it if offered because I don't want one of those ICU bed days to involve my children. Speaker 0 00:18:14 Two of my children had mild doses and one of them wasn't so great and had significant scarring. It also had them miserable and it involved me having to take about six weeks off work from the pharmacy over their young years. Next question is, should you avoid trying to conceive for a few months if your child is getting vaccinated? If you've had chicken pox yourself as a child, then there's no need to delay the trying to conceive journey. Another question, do they need the chicken pox vaccine if they've had the chicken pox? No. So if you're assured that they've had chicken pox, then they have immunity, they don't need vaccination. And another question, my child was exposed to chicken pox and had then only one spot can they get the vaccine. So if you're uncertain whether they have immunity from chicken pox, then you could ask your GP for an immunity check to confirm. Speaker 0 00:19:04 Okay, I think that answers pretty much all of the questions. In summary, I think it's good to know that while obviously this report made the headlines and you kind of think, whoa, they're bringing in the chickenpox vaccine, amazing. Actually all that's happened is the health technology assessment has been completed by hwa and they have found after, to be fair to them, amazing research and consideration that it is beneficial on an economic, social, ethical, and practical level to recommend vaccination to the Department of Health on the childhood immunization schedule, what the Department of Health and our Minister for Health do with that information. I don't know. Personally I'd like to see the vaccine rollout happen at 12 months and five years. I don't think that there is any benefit to dragging parents back into overburdened busy GP centers at 15 months when it's no more effective to do so. Speaker 0 00:20:04 I can understand that we can't afford a mass rollout to anyone who hasn't had chicken p. Maybe things will change down the road, but currently that is not the plan. So I just wanted to make that clear for anyone who was homing and horn about getting vaccinated. If your child's over 12 months before, I would probably would've sat in the fence and not given you a direct answer about whether or not to get it. And that's because in 10 to 15 years you have no guarantee of immunity and they're more susceptible to severe disease if they catch it. But now, if the government do decide to go forward with the childhood schedule vaccination, then there isn't going to be a lot of chicken px circulating. And so we all benefit and that reduces my concerns about contracting it in later life. Another thing to reassure people is that if you come into contact with chicken pox and you haven't had it and you're in a vulnerable health group, you can actually go and get vaccinated within five days of exposure, and that will reduce the severity of disease that you experience. Anyway, I hope all of this gives you some clarity on the headlines and that I've answered all of your questions throughout that episode. Thank you so much for listening, and if you found this episode helpful, I would really, really appreciate a review or follow on Apple, Spotify or any podcast streaming platform. And if you could share it with your friends, that would be great. Thanks so much for supporting this podcast. I absolutely love answering all your questions. Talk to you.