Thinking more about clinical trials.

Helping the over 80s

Thanks to Gemini AI for the pic

Respiratory syncytial virus - a common cause of coughs and colds - kills 8500 people a year, hospitalises almost 10,000 more, and leads to half a million GP appointments. More people visit the doctor for RSV than for flu.

In short, it is a killer, and costs £70m for hospital care for those who die, and a further £31m in other hospital care and £23m in GP visits. Like flu, it is winter-prevalent, when the NHS is most stretched.

Thankfully there is a “take once” vaccine. It is about 80% effective, and better for people in their 70s than 60s, although sample sizes are small.

The vaccine costs £245 privately, so my rule of thumb says about £175 for the NHS. That means protection costs of about £105m a cohort, little than the £124m cost of treating those who would otherwise get ill. (Of course, the financial economics are much worse, since people who survive get their state pension and use the NHS and other services for longer. That is why “it will save the NHS money in the long run” is rarely true, but that doesn’t matter).

NHS rollout began two years ago, for people aged 75-79. This April eligibility was extended to the over 80s.

Many over 80s were very unhappy two years ago. The older people’s magazine Saga reported receiving “a stronger response from readers than any other issue we’ve covered this year.”

One 84 year old, Helen Penney, said “It is the principle that really gets me, that when you turn 80 you are past your sell-by date, of no interest or importance and basically just a nuisance.”

That was not the reason, although I can see why she would think that. Rather, too few over 80s enrolled in the randomised control trials that showed it worked. For example, in one trial there were 23,000 participants in their 60s, 11,000 in their 70s and under 2,000 in their 80s. None of the people over 80 got RSV, whether they had the vaccine or the placebo, so the research could not tell if it worked.

Without efficacy evidence, the Joint Council on Vaccination and Immunisation recommended the vaccine for those aged 75-80, but not for people over 80.

To be honest, I think that was odd even then. After all, we knew the vaccine worked for people in their 60s and 70s, and that the only reason we didn’t know for people in their 80s was too few people in the trial.

I have three policy recommendations.

First, government should work with organisations like Saga, Age Concern so more people over 70 and 80 enrol on medical trials for which older people are key.

Second - and to paraphrase my fellow substacker and economic historian Deirdre McCloskey - , we should stop obsessing about statistical significance, and use some common sense. If it works for people in their 60s, and better still for people in their 70s, it seems pretty darn likely that it will work for people over 80s.

Third, where we have a drug that is known to work for people in their 70s, it will be easy to find people in their 80s willing to be part of a rapid follow up trial. The size of the Saga mailbox shows that! We could also use a quasi-RCT, whereby everyone over 80 is invited to get the vaccine. Not all will accept - and so we have two groups to track over time.

Had we followed these approaches two years we could have rolled out the vaccine for the over 80s then, and saved a significant number of people a lot of suffering. Let’s do better in future.