- Email: [email protected]
JCVI response on hepatitis B vaccination
Correspondence
Authors’ reply Henri-Jean Aubin and colleagues suggest that the excess relative risk of coronary heart disease (CHD) from smoking that we identified in women might be explained by excesses of depression in smokers and women. However, although depression might thus confound the effect of smoking, given appropriate causal directionality, these observations alone cannot explain a sex–smoking interaction. We agree with Sam Harper and colleagues that changing to risk differences would probably alter the conclusions of our analyses. Indeed, one of us (MW) made the same point, with the same dataset as an illustration, in a textbook1 that we referenced in our paper. However, we do not accept that risk differences are a better way of representing excess risk. Risk is represented as a ratio, rather than a difference, and consequently it seems both consistent and logical to compare risks, and relative risks, through their ratio. Furthermore, when pooling excess risk across studies, two issues generally make the use of the difference metric untenable in practice. First, as Harper and colleagues suggest, few studies publish risk differences with allowance for confounding factors and censoring and reliable measures of variability. In our case, none of the published articles we sourced gave usable data. Second, risk differences for CHD are notoriously variable between studies because background risk depends so much on the level of economic development, health service delivery, and study design, whereas risk ratios are relatively consistent. We contend that an averaged pooled coronary risk difference, smoking minus not smoking (for either sex), and the difference in these differences, would have little practical interpretation; by contrast, our paper shows that the pooled sex-specific relative risks and their ratio are all reasonable summaries of individual outcomes from diverse settings. www.thelancet.com Vol 379 March 3, 2012
Finally, Sonica Singhal and colleagues show that women have a higher relative risk of non-fatal oral cancer when chewing, but not when smoking, tobacco. We cannot reliably speculate on whether this finding has implications for CHD, but would point out the small number of women included in these analyses and the question of whether conclusions would be the same if fatal events were included. We much appreciate the thoughtful comments on our paper and welcome the caveats expressed. Our bottom line, that a female perspective should be included in tobacco control, remains.
Trials are underway to address this. Those at high risk of hepatitis B are not abandoned but receive vaccination through a selective policy. Horton implies that the decision to use a health intervention should not be based on economic criteria such as cost per quality-adjusted life-year gained—but, given a finite financial resource, what he proposes as an alternative is unclear. We declare that we have no conflicts of interest.
Joint Committee on Vaccination and Immunisation [email protected]
We declare that we have no conflicts of interest.
Joint Committee on Vaccination and Immunisation, Department of Health, London SE1 8UG, UK
Mark Woodward, *Rachel R Huxley
1
[email protected] The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia (MW, RRH); Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA (MW); and *Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN 55454, USA (RRH) 1
Woodward M. Epidemiology: study design and data analysis, 2nd edn. Boca Raton: Chapman and Hall/CRC Press, 2005.
JCVI response on hepatitis B vaccination We wish to respond to Richard Horton’s Offline of Nov 26.1 The prevalence and incidence of hepatitis B infection in the UK is more similar to that of Scandinavia (where universal vaccination is not given) than to the parts of Europe to which Horton refers. Additionally, most (>90%) of chronic infection in the UK is a result of transmission outside the country. Despite this, the Joint Committee on Vaccination and Immunisation (JCVI) wishes to recommend universal hepatitis B vaccination. However, policy in relation to vaccines, as for drugs, has to satisfy government costeffectiveness guidance. The use of a combined vaccination appropriate to the UK schedule might be cost effective but we need to be certain that other immunisations in the combination are not compromised.
Horton R. Offline: When should Mr Lansley go? Lancet 2011; 378: 1836.
Who will fear the Commission on Global Governance for Health? The Lancet–University of Oslo Commission on Global Governance for Health, in collaboration with the Harvard Global Health Institute (Nov 5, p 1612),1 must be welcomed. Indeed, scrutiny is mandatory because too many governments exhibit little concern for their citizens’ health. For example, the Netherlands is flying in the face of best evidence for reducing the tobacco burden.2 However, I am surprised to see that The Lancet–University of Oslo initiative is supported in a Comment3 by several ministers of foreign affairs, with those of Brazil and France as first authors. Indeed, Brazil is the third largest producer of tobacco in the world! In France, infant mortality is worsening— an exception among high-income countries. It went down from being ranked 5th in Europe in 1999 to 14th today, behind Greece.4 The French Government is also showing more concern for the profits of the tobacco and alcohol industries than for protecting its citizens from these burdens. A national study in March, 803
Authors’ reply Henri-Jean Aubin and colleagues suggest that the excess relative risk of coronary heart disease (CHD) from smoking that we identified in women might be explained by excesses of depression in smokers and women. However, although depression might thus confound the effect of smoking, given appropriate causal directionality, these observations alone cannot explain a sex–smoking interaction. We agree with Sam Harper and colleagues that changing to risk differences would probably alter the conclusions of our analyses. Indeed, one of us (MW) made the same point, with the same dataset as an illustration, in a textbook1 that we referenced in our paper. However, we do not accept that risk differences are a better way of representing excess risk. Risk is represented as a ratio, rather than a difference, and consequently it seems both consistent and logical to compare risks, and relative risks, through their ratio. Furthermore, when pooling excess risk across studies, two issues generally make the use of the difference metric untenable in practice. First, as Harper and colleagues suggest, few studies publish risk differences with allowance for confounding factors and censoring and reliable measures of variability. In our case, none of the published articles we sourced gave usable data. Second, risk differences for CHD are notoriously variable between studies because background risk depends so much on the level of economic development, health service delivery, and study design, whereas risk ratios are relatively consistent. We contend that an averaged pooled coronary risk difference, smoking minus not smoking (for either sex), and the difference in these differences, would have little practical interpretation; by contrast, our paper shows that the pooled sex-specific relative risks and their ratio are all reasonable summaries of individual outcomes from diverse settings. www.thelancet.com Vol 379 March 3, 2012
Finally, Sonica Singhal and colleagues show that women have a higher relative risk of non-fatal oral cancer when chewing, but not when smoking, tobacco. We cannot reliably speculate on whether this finding has implications for CHD, but would point out the small number of women included in these analyses and the question of whether conclusions would be the same if fatal events were included. We much appreciate the thoughtful comments on our paper and welcome the caveats expressed. Our bottom line, that a female perspective should be included in tobacco control, remains.
Trials are underway to address this. Those at high risk of hepatitis B are not abandoned but receive vaccination through a selective policy. Horton implies that the decision to use a health intervention should not be based on economic criteria such as cost per quality-adjusted life-year gained—but, given a finite financial resource, what he proposes as an alternative is unclear. We declare that we have no conflicts of interest.
Joint Committee on Vaccination and Immunisation [email protected]
We declare that we have no conflicts of interest.
Joint Committee on Vaccination and Immunisation, Department of Health, London SE1 8UG, UK
Mark Woodward, *Rachel R Huxley
1
[email protected] The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia (MW, RRH); Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA (MW); and *Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN 55454, USA (RRH) 1
Woodward M. Epidemiology: study design and data analysis, 2nd edn. Boca Raton: Chapman and Hall/CRC Press, 2005.
JCVI response on hepatitis B vaccination We wish to respond to Richard Horton’s Offline of Nov 26.1 The prevalence and incidence of hepatitis B infection in the UK is more similar to that of Scandinavia (where universal vaccination is not given) than to the parts of Europe to which Horton refers. Additionally, most (>90%) of chronic infection in the UK is a result of transmission outside the country. Despite this, the Joint Committee on Vaccination and Immunisation (JCVI) wishes to recommend universal hepatitis B vaccination. However, policy in relation to vaccines, as for drugs, has to satisfy government costeffectiveness guidance. The use of a combined vaccination appropriate to the UK schedule might be cost effective but we need to be certain that other immunisations in the combination are not compromised.
Horton R. Offline: When should Mr Lansley go? Lancet 2011; 378: 1836.
Who will fear the Commission on Global Governance for Health? The Lancet–University of Oslo Commission on Global Governance for Health, in collaboration with the Harvard Global Health Institute (Nov 5, p 1612),1 must be welcomed. Indeed, scrutiny is mandatory because too many governments exhibit little concern for their citizens’ health. For example, the Netherlands is flying in the face of best evidence for reducing the tobacco burden.2 However, I am surprised to see that The Lancet–University of Oslo initiative is supported in a Comment3 by several ministers of foreign affairs, with those of Brazil and France as first authors. Indeed, Brazil is the third largest producer of tobacco in the world! In France, infant mortality is worsening— an exception among high-income countries. It went down from being ranked 5th in Europe in 1999 to 14th today, behind Greece.4 The French Government is also showing more concern for the profits of the tobacco and alcohol industries than for protecting its citizens from these burdens. A national study in March, 803