We are now in public session. We have apologies from Senator Nicole Ryan and Senator Maria Byrne.

I remind members of the constitutional requirement that members must be physically present in the confines of Leinster House in order to participate in public meetings. I will not permit a member to participate when they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside of the precinct will be asked to leave the meeting. In this regard, I ask any member participating via MS Teams that prior to making their contribution to the meeting, they confirm they are on the grounds of the Leinster House complex.

Today's meeting will consider issues relating to vaccines policy, availability and uptake, with a particular focus on adult vaccination, which has not received the attention it deserves. The State has made great strides in terms of childhood vaccination but less progress when it comes to older adults. The consequences of overlooking the vaccination of older adults include the increased risk of ill health and death, a diminishing quality of life and greater strain on our health services. The committee is eager to put a focus on the secondary benefits of vaccination, with emerging evidence showing the shingles and RSV vaccinations may reduce the risk of dementia and cardiovascular disease.

To assist the committee today, I welcome Professor Rónán Collins, consultant geriatrician and stroke physician. Hopefully, joining us online, if we can get the technology working, will be Professor Luke O'Neill from the biomedical sciences institute in Trinity College Dublin, TCD, who is joining us from the US very early in the morning. I thank him for doing so. We also have Ms Alison Bough from Active Retirement Ireland, who is head of policy and programmes.

Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that may be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be asked to discontinue their remarks. It is imperative that they comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person or an entity outside the Houses or an official either by name or in such a way as to make him, her or it identifiable.

To commence today's proceedings, I will invite Professor Rónán Collins to make his opening remarks.

I thank the Cathaoirleach and the committee for the invitation to come to talk about vaccination. As a clinical lead for the national stroke programme, I am increasingly interested in vaccination as an important measure for the prevention of stroke.

In the 1700s, smallpox killed about 10% of the world’s population. Since Edward Jenner developed the smallpox vaccine in 1796, vaccination has been the single greatest medical advance in history. Harnessing and stimulating our own immune system to protect against or fight diseases has led to the saving of hundreds of millions of lives. The WHO Lancet paper of 2024 estimated that, through vaccination, almost 155 million children’s lives had been saved between 1974 and 2024. That would be the equivalent of six lives being saved every minute for 50 years, which is really quite astonishing. Many debilitating and fatal diseases such as polio and the aforementioned smallpox have been, effectively, eradicated from our society by effective vaccination programmes, and vaccine technology is now being used to prevent and, indeed, treat cancer.

We naturally understand from this experience the importance of childhood vaccination programmes in protecting our population and we have all been familiar ourselves with the vaccination booklets we got as children updating us on our immunisation status. Those of us from Cork will remember queuing as children for the sugar cube oral polio vaccine as outbreaks threatened to re-emerge in the 1960s and early 1970s. As parents, many of us will remember bringing our own children to be vaccinated against the threatened avian flu pandemic in 2009. However, our approach to adult vaccination has been less robust, more reactive at times and probably more motivated by urgencies affecting our health service capacity, such as the Covid pandemic or the annual winter flu crises, rather than focusing more on the individual and public health benefits. There is both a strong individual and systems rationale for an organised effective programme of vaccination for adults, not only to prevent our healthcare systems from being overwhelmed with the seasonal outbreaks of respiratory disease such as flu or respiratory syncytial virus, RSV, but also in preventing cardiovascular disease and longer term cognitive decline.

Death from cardiovascular disease is our single greatest cause of death and respiratory infection, coincidentally, is probably the most commonly reported actual death certification and the background of that disease. In the 2023-24 season, we had an estimated 35,000 to 55,000 cases of RSV and there were 17,000 cases of laboratory-confirmed flu, which is likely to be an underestimate. Even within that cohort, we had 4,000 hospitalisations and 220 deaths. Vaccines exist against these infections, but the variation in the availability and effectiveness of the vaccine type being used can influence its impact in public health campaigns.

Two to three people per 1,000 of the population, eight to 12 per 1,000 of those over 70, and a lifetime risk of one-in-three get shingles every year. Some 10% to 20% of those will develop a painful chronic syndrome, which we know as post-herpetic neuralgia. Vaccination is 90% effective against this disease reducing GP visits, post-herpetic pain and hospitalisation.

What I want to concentrate on in addition to that compelling evidence is that we have added years to life, but if we are serious about adding life to those years, we have to focus on the broader healthy ageing aspect as we move forward.

One in four of us in this room as it currently stands will get a stroke, and the members will not like to hear that. One in four of us will also get dementia, and the members may particularly not like to hear that either. The Interstroke and other population studies have demonstrated that systematic vaccination against flu is one of the single greatest and cheapest public health measures we can take to reduce the relative risk of stroke by up to 25% in vaccinated populations.

In addition to flu, we also know that the RSV and shingles viruses also increase the risk of stroke, heart attack and heart failure in the months following infection. Collectively, these illnesses increase your relative risk of stroke, cardiovascular disease by a factor of between two and eight depending on the circumstances.

It does not stop there. These viral illnesses, as the witnesses may have witnessed with their loved ones and I certainly witness very regularly in the hospital, are frequently associated with acute confusional states, medically known as delirium, in older people. This is a very distressing condition, both if you ever witnessed it and certainly if you have talked to people who have survived it. It is also, of course, associated with prolonged hospital stays and very often ends up with the need for nursing home care. It also has an appreciable in-hospital morality.

Delirium in itself, while a very significant illness, is the harbinger of dementia in many cases. About 50% of people who have a delirium episode in hospital will be diagnosed with dementia within 12 months. We now know and have growing evidence that vaccination against viral infections, such as flu and RSV, reduces the risk of developing dementia by as much as 20%, which is quite compelling.

The members are probably wondering how the hell are these respiratory viruses associated with cardiovascular events and brain failure. Broadly speaking, viral infections such as flu, Covid-19 ad RSV - and we have an immunologist online, so I am not going to steal his thunder - cause the release of cytokines and inflammation and these molecules circulating in our system do a couple of things. Number one, they increase the platelet activity. These are the building blocks that form clots. They cause instability in any existing limescale you may have along your arterial wall, so it is more likely to break off and go down the circulation and cause a clot. It also causes dysfunction of the normal elastic function of the arterial wall, so it becomes more stiff. All of these events lead that you are more likely to form a clot which can cause strokes and heart attacks.

In addition, that whole inflammatory response in temperature causes increased circulating adrenaline and is much more likely to cause cardiac arrhythmias, in particular atrial fibrillation. I say atrial fibrillation because atrial fibrillation causes one in three of all our strokes in Ireland. It is a very common cardiac dysfunction rhythm. About 10% of people over the age of 75 have it and most of the people do not know they have it. In addition to the irregular heart rhythm, the inflammation causes stress in the heart wall, so you are more likely to develop heart failure.

The members can probably understand how viral infections can cause clots and heart dysfunction, why then would it cause confusion and dementia? We know that these circulating cytokines and inflammation during an acute viral illness affects a very important structure that we all have, the blood-brain barrier, which prevents toxic chemicals from crossing from the blood stream into the brain circulation. We know that these cytokines affect the function of this barrier, so it is much more likely to let toxic molecules through to the brain causing delirium and very often leading to the accumulation of things like amyloid plaque precipitating dementia.

As a gerontologist and a man who has spent most of his life looking after people and hopefully advocating for a healthier ageing policy in Ireland, and the current national clinical lead for the stroke programme, I would say that vaccination is an important pillar of healthcare to ensure healthy ageing and the prevention of cardiovascular disease, stroke and dementia. We have compelling and growing evidence. It is vital component to any national health strategy that seeks to be age-friendly, promote healthy ageing in adding life to years and very importantly, that seeks to address the rising rates of stroke and dementia in our society.

I thank the members for the invitation to appear before the committee. I am the head of policy and advocacy at Active Retirement Ireland, the largest membership organisation for older people in the country. We represent over 24,000 members nationwide.

In May 2025, our members mandated this issue at our national AGM as a major policy priority for them. This is not an abstract issue for us. It is one that comes directly from the lived experience and concerns of older people across the country. I welcome the opportunity to speak with the committee today about shingles vaccination from the perspective of older people, public policy and equitable access to preventative healthcare.

In less than two weeks, more than 20,000 primarily older people – as of today, 21,000 people - have signed our petition calling for fair, State-supported access to the shingles vaccine. That is a clear signal that older people expect equitable access to preventative healthcare.

At the outset, I want to be clear about the issue before us. A recombinant shingles vaccine is available in Ireland. The national immunisation advisory committee, NIAC, recommends it for all adults aged 65 years and over, as well as for certain immunocompromised groups. However, in Ireland, it is not currently available through a publicly funded programme. The HSE states that it is available privately only and is not covered under the medical card or the drug payment scheme. That means that access depends on the ability to pay.

In practical terms, current listed prices from named pharmacies all over the country place the cost of the two-dose course at approximately €450 to €487, meaning a typical cost of around €480. The maximum contributory State pension is currently just under €300 per week. This means that the vaccine costs the equivalent of around one and a half weeks' income for someone who is relying on the State pension. These are citizens who have contributed throughout their lives to the Irish economy and society through both paid work and unpaid roles such as caring, volunteering and supporting families and communities. For many older people, this cost represents a significant financial barrier.

This inequity is particularly stark in border regions. An older person living in the Republic of Ireland may have to pay close to €500 for this vaccine, while a short journey across the Border to Northern Ireland would allow access through a publicly funded programme. That contrast highlights the extent to which access in Ireland currently depends on ability to pay rather than need. From the perspective of Active Retirement Ireland, that is the central policy issue.

A recommended vaccine is available, but access is not equitable. Shingles is not simply an acute condition that resolves quickly. For many older people, it can have lasting and significant consequences. The most common complication mentioned previously, post-herpetic neuralgia, is persistent and often severe nerve pain that can last for months or even years. This affects sleep, mobility, concentration and the ability to carry out everyday activities. From the perspective of older people, the impact is not just clinical, it is functional. People reduce their movement because of pain. They stop attending social activities and withdraw from community life. Older people are also carers, volunteers and childminders. When shingles limits their ability to participate, there is a real human cost, not only to the individual but also to families, communities and wider society. That impact is not fully captured when focus is limited to cost-effectiveness alone. Over time, that can lead to increased social isolation, and we know that social isolation is associated with poorer physical health, poorer mental health outcomes and increased risk of decline.

The impact of shingles does not end with the infection. It can trigger a cascade of effects that undermine independence and well-being. There is also a clear impact on the health service. Shingles leads to GP consultations, repeat visits, pain management and, in some cases, hospitalisation. Where complications such as post-herpetic neuralgia develop, this can require ongoing treatment and engagement with services over a prolonged period. From a policy perspective, these are not one-off costs. They are ongoing and, in many cases, avoidable. Current valuation too often focuses only on health service cost savings. That payer lens misses the broad, tangible benefits that matter to people. These include preserved independence, fewer months of disability and better day-to-day functioning. These are outcomes that resonate with the public, older people and policymakers alike. They should be central to implementation decisions. As a health psychologist, I would emphasise that prevention plays a critical role in supporting healthy ageing. When we prevent conditions that lead to pain, withdrawal and loss of independence, we are not just avoiding illness; we are supporting people to remain active, engaged, and connected in their communities.

It is also important to be clear about the evidence base. NIAC has made a clear recommendation for vaccination of adults aged 65 and over. HIQA found that the vaccine is safe and effective but that at the price used in its model, it is not considered to be cost-effective. The issue is not, therefore, a lack of clinical recommendation, and it is not a question of efficacy. The issue is that there is currently a gap between the recommendations and access.

Ireland is not starting from a blank page internationally on this issue. Comparable European countries, including the UK, Germany, France and Italy, have already established public or publicly supported shingles vaccination pathways for older adults, although the specific models differ from country to country. In Ireland, older people are still required to pay privately. From the perspective of Active Retirement Ireland, this raises a clear issue of equity. Older people have contributed to building modern Ireland. Offering recommended vaccines to everyone aged 65 and over recognises that contribution and protects people irrespective of their income. Older people are being encouraged to prioritise prevention and healthy ageing, but in this case access to a recommended preventative measure depends on their income and that is not equitable.

In practical terms, Active Retirement Ireland is asking for three things. We ask: for recognition that shingles vaccination for older people is an issue of prevention, equity and healthy ageing; that Government actively examine pathways to enable publicly funded or State-supported access in line with NIAC recommendations, including engagement on pricing and implementation; and that the position of older people on fixed incomes is explicitly considered in decision-making. A recommended vaccine that is available only to those who can afford to pay privately is not equitable access. The policy pathway is clear. The need is very clear. What is required now is a decision on access.

I thank the committee members and, on behalf of the 24,000 older people who Active Retirement Ireland represents and the families and communities it supports, welcome any questions they have.

I thank Ms Bough. We will try Professor Luke O'Neill again. Hopefully, it will be a case of third-time lucky with the technology. It seems like the technology is failing us. I apologise to Professor O'Neill. I hope we can engage him again when he is back. I know he is in the US and has got up very early in the morning to be with us. I apologise that the technology is not working on this occasion, but, hopefully, we will have an opportunity to engage with him when he is back. We can continue this discussion at that point. I thank him for the presentation and the opening statement he submitted in advance, which members have considered. I apologise for the technology failure on this occasion.

We will now move to questions from members.

I thank Professor Ronan Collins and Professor Luke O'Neill. We got Professor O'Neill's statement, which is important. I also thank Ms Alison Bough for coming in and presenting on this matter.

I am delighted that Professor Collins reflected on the powerful role of vaccination in the reduction of both mobility and mortality right across the population and across all age groups. We need to restate that because we are living in an age of vaccine hesitancy and false messaging by people in very powerful positions in governments right across the western hemisphere who should know better. We know who we are talking about. When vaccine hesitancy lies at the heart of one of the most powerful governments in the world, namely the US Government, it is difficult to get that message out. We have to reach beyond the public understanding of a simple prevention of disease process rather as distinct from the wider benefits that appeal.

The shingles vaccine issue is a matter of equity. As a GP, I have patients who have means and who will fund their own vaccination. The poorest, the sickest and those who need it most and who are most at risk are unable to afford this vaccine. That is what is really regrettable. We had a HIQA report into the cost-effectiveness of the vaccine. The study was set up in the context of the vaccination of those in the population who are over 50. In Professor Collins' view, would there be increased cost-effectiveness if we were to target an older population, either those over 65 or over 70? Would this have significant benefit, not just for those people but also for our health service?

That is a very interesting question. The short answer is "Yes". The longer answer is that all these vaccines are not just the same in some respects. Shingles is a particularly interesting illness. You are unlikely to get shingles when you are younger. You can get it, but most people do not get it when they are younger.

Even younger people who get shingles have cardiovascular events after it. The reason 50 was picked is probably because some of the evidence produced for shingles placed the population in cohorts of older than 18 and older than 50. It was a very blunt study in that regard. In the context of almost all the other vaccine schedules, for example, the enhanced flu vaccine, which was a NIAC recommendation and which the State stopped a tender on, the evidence and recommendation are that vaccination should be focused on a cohort that is older. The line was drawn at 65. As I told Senator Clonan, that age of, which sticks with us all our lives, comes from Bismarck's pension age. The Deputy is right. The most at-risk groups are probably those who are over 65 and other cohorts, including people with chronic respiratory diseases and immunodeficiencies. In that model, there will probably be much more cost-effectiveness.

The Cardiff study with Stanford, which showed for the first time ever the connection between viral infection and the onset of Alzheimer's, is extremely important. I do not think that has been fully factored into this understanding.

I agree. I am not a health economist, but it is easier for health economists to cost discrete episodes like heart attack and stroke. It is much more difficult for them to factor in the lifetime cost of dementia. That is the problem with that type of model. Nobody did a health economic model in the context of, for example, immunising children against diphtheria or whooping cough, but we all agree that it is a good idea because it gives a child a healthier life and less risk of mortality. Health economics have to be borne in mind as one criterion in looking at the whole issue. Who is not going to vote for prevention of stroke or dementia? It has to be costed in reasonably, but the focus should be that we want people to have a healthier and active later life.

People's understanding of vaccination and that of medical and nursing professionals is that it is very much isolated to the prevention of specific diseases, namely a chest infection or the onset of flu or pneumonia. The case Dr. Collins has laid out is the need for much wider promotion of vaccines to prevent heart disease and stroke, which are the biggest killers in our society. There needs to be a refocusing when it comes to the education of medical, nursing and healthcare professionals and in the context of the prevention many other diseases. I do not think there is a connection in the public's mind between the flu vaccine and heart disease and stroke or the RSV vaccine and dementia. Does Ms Bough think there needs to be a refocusing?

I agree with Dr. Collins. Looking at cost-effectiveness and quality-adjusted life years, QALYs, in a HTA and health economics assessment of a vaccine does not take into account the potential need for long-term care, the removal of individuals from communities and the activities older people in particular take part in. Many grandparents are now primary caregivers for their grandchildren while the parents are at work. On public understanding, it has been our experience in recent months that this is an issue that is driven by older people. Our members mandated this at their national AGM. They wanted us to lobby for this vaccination in particular because they are aware of the long-term impacts on their health.

I am on the clock. I just want to reflect that it was suggested in the HIQA report that it there would need to be an 80% reduction in the price of the vaccine, even if over-65s were targeted. That is the health economics part. I urge pharma companies to look at recalibrating their negotiations with the Government in order to provide this really useful vaccine to our older people.

I thank our guests. They make a compelling case not only from a health perspective but also the quality of life someone can have from vaccines. I was aware of the ancillary benefits of some vaccines, but even I was not aware of the depth. This committee and the population are aware that there are certainly some negative actors in the area of vaccines. They are anti-vaccination. There are also other people who are vaccine hesitant. How do we manage communication in this regard? People should be told to get their flu jabs because it will stop you getting the flu, but it there are also those other aspects to which I refer. We all have a role to play in that communication part. I spoke to quite a few older people prior to this meeting. They told me that they look at what has happened in other areas and feel their needs are not being addressed because they have seen it happen in other places, some in their countries of origin. If they still lived in those countries, they could have got this vaccine. How many of Active Retirement Ireland's members could afford to get this vaccine privately?

We hear time and again exactly about what the Deputy described. There is a feeling of unfairness. For example, if you leave in Omeath, County Louth, you are entitled but may not be financially able to access this vaccine but a short drive over the Border into Newry and you would be able to access it free of charge. There is a feeling of significant unfairness on this issue.

How many would be in a position today of one were to do a straw poll?

We have approximately 800,000 people over the magical age of 65 in this country of 5.4 million people. When it comes to the health economic breakdown, the number of people entirely dependent on the State contributory pension is a number you have to look at. There is anecdotal evidence that uptake of the privately paid for shingles vaccine at around €500 is predominantly in quite wealthy socioeconomic areas.

Does that not then further embed health inequality?

It absolutely does. If someone cannot access a recommended necessary vaccine whether they are immunocompromised or just an older person who is more likely to get shingles because of their inability to pay a large sum of money for that vaccine, that is absolutely health inequality.

I do not believe we should look at health only from an economic standpoint. If one takes the number of people today over 65 who would benefit from the shingles vaccine in particular, the cost of treating other illnesses that may be prevented by the shingles vaccine would cost a certain amount of money. As the population continues to age, the cost of treating those other conditions will also rise in the absence of the shingles vaccine.

Would Dr. Collins agree with a statement like that?

Yes, I would. I will go back to vaccine hesitancy because I think I should say something on it. This is not a modern phenomenon. When Jenner introduced the smallpox vaccine, he faced quite considerable resistance in Victorian England for many decades. There were advertising campaigns, some of them led by church groups, saying, "Do not vaccinate your children". It was seen as interfering with what God had ordained for you. This is not a new kind of phenomenon. It has always been with us. You cannot, obviously, rough-ride people's independent voices but at times I find a lot of the debates about vaccine hesitancy challenge the anti-vaxxers by stating, "That is nonsense", when really what we should be teasing out in the debate is where they have formed that opinion, or what the basis of the evidence is, for example, "That is an interesting thought. How have you formed that opinion?" Let us get the debate going because once you get a person into the arena of debating, at least you begin to shine light and change the minds of a lot of the people who are moderate and who are not, if you like, irrationally held to a belief. You will never convert the people who irrationally hold to a belief, but a lot of the followers of the movements are people who are swayed by arguments that need to be teased out in a public forum so more light is shone on them.

I also believe in the power of education and public awareness. As we have all talked about this morning, I think people who get vaccinated do not want to get the flu, feel unwell or get into hospital if they have a bad chest, etc. They are less aware of the issues of stroke, heart attack, delirium and dementia. That needs a whole public health campaign. If I reflect on the stroke programme, ten years ago not many people knew the signs of a stroke, which was astonishing to me, but I live in the ivory tower of medicine where I think everybody understands everything. Medics can be guilty of that at times as well. We saw the effectiveness of the awareness campaign. Almost everybody knows face, arms, speech and time, FAST, now. Most people have the face, arms and speech thing and they know to ring an ambulance. We have seen huge improvements in stroke care on the back of that.

On what Members of the Oireachtas need to consider, while individual vaccines are important - I very much agree with Deputy Daly - the pharma companies cannot be given a free ride on this either. We are putting ourselves in a position where we can be bargained out of it. Deputy Burke explained to me the cost of the health budget this morning and it made my eyes water. However, what we need to realise ourselves is whether we are going to have a public health policy on vaccination in older people or not, in the same ways we approach children.

I have an eye on the clock.

Apologies.

I have one comment and one quick question to ask Dr. Collins. My comment is that I was very glad to hear him mention whooping cough in children. One of my children was hospitalised at five weeks old with whooping cough. It is an absolutely-----

Horrendous, yes.

-----horrific condition for any child to have.

If there is one ask the witnesses have of us as a health committee today, what is it?

A policy that says older people will get a vaccination schedule just like children that is paid for by the State. There will be a record of it and it will improve everybody's health. The Deputy is absolutely right. The downward rise in stroke and dementia is going to be enormous and we have to start investing more in the preventative measures.

I am going to put two sentences into one ask. I ask that the position of older people on fixed incomes is explicitly considered in the Government's decision-making in the budget around preventative healthcare. I also ask that a shingles vaccine, in particular, be added to the vaccination schedule free of charge at the point of delivery for those aged 65 and over.

I thank both witnesses for coming in here this morning and giving a very detailed analysis of what we need to do. Dr. Collins referred to the health budget. The health budget this year is €27.4 billion. That includes paying for the employment of over 130,000 people but also paying for the roll-out of vaccine programmes. It is about value for money as well in regard to trying to keep people out of hospital.

On the shingles issue, have we any idea of the number of people who have been admitted to hospital in the last 12 months as a result of having shingles that then leads on to other complications thereafter? The big issue is when you weigh that up as regards the long-term consequences from a health point of view, there is a real cost to the health services. If a vaccine programme is introduced, where would we start? The big argument at the moment is the cost of it but what age group should we start with? Should we start with over-70s, just to get the programme up and running, and then try and get the message out there about the importance of it?

The other issue I want to raise is about the vaccination programme, for instance, the flu vaccine. A low percentage of HSE employees took up the opportunity to get the flu vaccine. Do we need to do a campaign on that simple issue alone, where people who are employed by the HSE are reluctant to take that vaccine?

That is one for me. The over-70s might not be an unreasonable age at which to start but there is a natural target at retirement age. If I were introducing a public health campaign for a vaccination programme to increase the uptake, it would be focused around the time people retire so they start focusing on it. In the four or five years after retirement, when you are enjoying your retirement, it is not going to suddenly come at you at 70 that you have to think about vaccination. Increasingly, of course, the age of retirement may rise to that level as we are all going to live longer. Most of our children are going to live well into their late 90s if not hitting 100 on average. Life expectancy is improving and, as I said, we have added years to life and we want to add life to those years. It is not unreasonable to get the thing going but we also need to give consideration to whether we can introduce the concept of vaccination in people's minds allied with another life event like retirement, so they start doing it as part of their planning. That is just a thought I have.

Health workers and vaccine uptake is a very complicated issue. I do not think there is huge hesitancy among healthcare workers themselves, although there are some people who have the belief that their immune system has been well-tutored by working in a hospital for the last ten years. There are several steps that need to be taken. You could view the issue as whether it should be mandatory, as it is in some countries, where you have to be mandatorily vaccinated to continue working. I prefer to use the carrot approach but that approach must also have very visible leadership campaigns within healthcare institutions, where senior clinicians and nursing, medicine and allied health professionals are seen to be vaccinated. We need to make vaccination access very mobile so it reaches towards people who are working shifts and on different time patterns. One of the things we have done in our own hospital is have mobile vaccinations units, like the trolley going round to the wards. I find that most healthcare staff will take up the vaccine if it is easy for them in what are very busy working lives. We need to be looking at things around senior leadership and campaigns within the healthcare institutions, so it is visible for people on their computer screens and in the reception areas. It is where people are reminded of their - if not moral then ethical - duty to prevent passing infection to others and also being fit for work at a key time of pressure on the health service. We also need, as I said, to make those vaccines very mobile and available to the workforce working various shifts.

I raise the issue that the National Immunisation Advisory Committee, NIAC, for instance, has recommended in relation to the respiratory syncytial virus, RSV, vaccine. It has been introduced in Scotland, for instance, where it has proved to be effective in decreasing the number of hospitalisations as a result. What is Dr. Collins's view on that?

The Scotland study was very impressive evidence for reducing the amount of hospitalisations through the campaign led out of Aberdeen, if I am not mistaken. It is definitely going to have a huge impact. RSV, in itself, might seem like a self-limiting respiratory virus, but anyone who has had it will realise they will be coughing and quite miserable for about three or four weeks on average.

It is quite a nasty illness in itself. As I said, the downstream risk of stroke, heart attack and heart failure as a result of it is appreciable as well. I am supportive of the NIAC. If we look at 2023-24, as I said in my statement, we had a very bad year for RSV. The estimates range but it was probably somewhere around 40,000 cases. It is quite an appreciable burden of illness. One of the things about being a clinical lead is, although I am employed by the HSE, I always say I am the RCPI clinical lead because there has to be a difference and a separation from the clinical advice and the commissioning of that advice because otherwise one ends up in a biased position. Notwithstanding the economics that need to be gone through, as a clinician looking at the UK, which tends to be economically conservative when it comes to healthcare, it recommended the RSV vaccine. I think we are behind the curve.

Coming back to the vaccine and getting the message out there for older people, looking back over the last three to four years where various programmes were put in place, does Ms Bough think we now need to change the approach around getting older people to take up vaccines in various areas? Is enough being done to get that marketing done and get across the message of the importance and benefits of vaccines?

As I said in my opening statement, as of this morning we have 21,000 signatories on our petition which has been entirely led by older people. I do not think there will be a problem in older people coming forward to access this vaccine. The preventative-----

Ms Bough referred earlier to the people who are paying for the shingles vaccine at the moment. Do we also have a problem in the lower economic social group being slower to take on vaccines as well? Does a lot more need to be done with regard to marketing for that group?

I ask for it to be a brief answer because we are over time.

I am only going to speak for older people today and on behalf of our membership. When it comes to different socioeconomic groups, different age groups, between 2013 and 2022 there were 54 deaths in acute hospitals in Ireland where shingles was the primary diagnosis. Of those, 85% occurred in adults over the age of 75. I ask that, when it comes to age groups, the committee not look at pushing it to people aged 70 to 75. I agree with Dr. Collins that we should really look at this at the point of retirement at 65 years of age.

I have a number of questions. I probably should have said at the start that this is the first of two sessions we are going to have on vaccines. Next week we will have the HSE and the Department of Health in. This is a very useful opening to that and to bring us up to speed on it. It is also an issue we have been engaging with the Department of Health and the HSE on, particularly on the shingles vaccine. Back in February the Department of Health provided this committee with a briefing note on the shingles vaccine and it said that HIQA was aware of new studies published since the 2024 health technology assessment which said that providing the shingles vaccine free of charge to all adults aged 65 or over would not be cost-effective. The note said that HIQA is considering the implications, if any, of the advice provided in relation to the cost effectiveness of shingles vaccines. I would be interested to know if the witnesses have had any engagement from HIQA about that update or any of the ongoing consultations on that.

Similarly in March, the Minister for Health said in reply to a parliamentary question that the introduction of the shingles vaccine to the immunisation scheme in Ireland is being actively considered for a cohort of immunocompromised individuals. Do the witnesses have a view on this being reviewed again but only for immunocompromised individuals and do they believe the decision to exclude over 65-year-olds from this latest review is purely on the basis of cost or are there other factors?

As a geriatrician and a gerontologist, I believe that we should have a public health vaccination policy for older people that looks at the evidence of all these vaccines and comes up with an agreed schedule. However, to respond to the specific entity of the shingles vaccine, people who are immunocompromised are at very high risk and anyone who has seen disseminated shingles in someone who is immunocompromised will not forget it. It really is a devastating condition. There is the issue of people who are extraordinarily high risk. They should certainly have it.

I would prefer to not limit my comments to an individual vaccine. My real message here is that we should have a comprehensive programme of evidence-based vaccination that improves older people's quality of life and prevents stroke, heart disease and dementia. That is my message.

In Ms Bough's opening statement she spoke about the need for equitable access to the shingles vaccine. Her third call is that the position of older people on fixed incomes be explicitly considered in decision-making. Has she had any engagement with the Minister for Health on that or has the Department of Health engaged with her on that call?

We have had a series of engagements with Government. I am delighted to see Senator Conway here. We have had a Commencement matter raised in the Seanad on this issue. We have had a Private Members' motion raised in the Seanad. I am delighted we have been asked here today to discuss this. We have had parliamentary questions raised by a variety of Deputies, including Catherine Callaghan, William Aird and John Connolly. We have had responses in that sense to the Topical Issue debates. We have had responses to the parliamentary questions raised and we had a unanimous, cross-party approval of the Private Members' motion in the Seanad. The support is there. However, we are battling through this issue of cost-effectiveness which I see as masking a level of structural ageism in looking at vaccination for adults as opposed to it being taken for granted that we will vaccinate children and not vaccinate people who are older or later in life. Longevity should be our greatest social success but it is being seen as an economic burden at the moment. I very much welcome further interaction with the Minister and the Department of Health.

We can follow up with the Department in our next session as well and put some of those questions and points to them.

In Dr. Collins' opening statement he says the State's approach to adult vaccination is reactive at times "motivated by urgencies affecting our health service capacity, such as the COVID pandemic or winter flu." In his view, why is the vaccination programme for older adults much less robust that the approach for childhood vaccinations?

If we look at childhood vaccination, it is very much a set schedule. Everybody knows when they are getting their vaccines, at what age and when they get the boosters. It is laid out like almost a formal policy and every adult is aware about the vaccine schedule for their child and their GP teaches them if they are not. I am not aware of a similar approach in older adults. We see older adults coming in and they are a bit hesitant at times, asking whether the should get a certain vaccine this year or another type this year. People are not empowered and then they are not sure whether they are paying for it or if it is free. We just do not have the same approach towards adults and I think we should learn from what we did with children and apply it to older adults.

There is a degree of selfishness in this as well. We are all getting older and it is in everybody's interest to keep an eye on that. Health is a continuum. It is not something we end when someone is aged 70 and we stop worrying about their health concerns or they are not as important. Health is a continuum through all our lives and we should be trying to maximise everybody's health at all stages of life.

I agree with Ms Bough. There is an element - going back to statements I have made about cocooning during the Covid-19 pandemic - of ageism in our society that needs to be tackled a little bit.

In relation to the schedule of vaccines for older adults, does Dr. Collins have thoughts on what vaccines to include, such as RSV and shingles? Are there other ones we should-----

RSV is one and I would also argue that we should have followed NIAC's advice and had an enhanced flu vaccine. I think we would have reaped benefits from it. It is a lot more efficacious than using standard flu vaccine. The shingles vaccine is a no-brainer. Then we might start looking at things like norovirus, at least for people who are living in community settings where infection is likely to spread.

There are other nuanced approaches to it as well.

I thank Dr. Collins. Professor O'Neill has joined us on another device so we might try that, take some opening remarks from him and then go to Deputy Sherlock. Would you like to try again, Professor O'Neill? The issue might be on our end, I suppose. We are just not able to get the audio to the room. Apologies again about that. I hope we will be able to engage with him at a future date. Thanks very much for giving your time as I know it is early in the morning there. That is frustrating all right, but thanks again.

I thank Professor O'Neill and Ms Bough. Even though we do not have the benefits of Professor O'Neill's comments, we have the benefit of his contribution, which is quite powerful. I am really glad we are having this conversation. My observation over the years is that the proactive approach to ageing has been very inconsistent and patchy. Some things are done well and then obviously others are very much behind the curve. It is also striking that while we have seen a significant increase in life expectancy, which Dr. Collins spoke about, the last time I looked at the data we had seen a plateauing of the healthy life expectancy. That is something to be very seriously concerned about, not just in terms of the economics, but also with respect to quality of life for older people.

Dr. Collins has presented very compelling medical opinion on why there should be a public scheme for the shingles and RSV vaccines. However, I want to understand the process. If he is a clinical lead for stroke and dementia and able to point to the very clear causation between shingles, flu and RSV and those, will he talk to me about his involvement in the NIAC process or, indeed, the Department or HSE? We have the NIAC process, it made its recommendations and the economics were very much in play there. HIQA also made its recommendation and the Department says it is reconsidering but where does Dr. Collins come into it as clinical lead? His voice is obviously very important and of course we need to look at the economics, but will he just talk to me about the process?

Yes. It is not really a joined-up process like that. I am the clinical lead for the stroke programme and my colleague, Dr. Seán O’Dowd, is clinical lead for the dementia programme. Then there is a clinical lead for important issues like chronic disease management. We meet regularly. For example, we have a brain health forum. My other colleagues in cardiology also meet regularly and we try to ensure that the strategy documents we put forward are consistent, especially on important areas of prevention. If you read, for example, the dementia brain health strategy or the new stroke strategy - or step 2 of it that has been written - you will find consistency across the board, taking in the messages we have garnered from recent-enough evidence on the beneficial effects of vaccines on heart disease, stroke and dementia. That is all great and everyone is consistent but the Deputy was asking how that feeds up the chain. We have a gerontological representative on NIAC and we feed in through that mechanism. The interesting thing you find is we are all on the same page. All the clinicians from the various programmes who are analysing the data and involved in the care of older people have this view. NIAC also has this view.

The bit where it is not coming across is the barrier between that and the health economic assessment. I am not a health economist and obviously there has to be budgetary constraint on this as well. Let us say we reach our desired goal of having a public access vaccine for older people. There is then the issue of how we administer it. General practice has been fairly successful in administering our vaccine programmes across the country and I have faith in GPs' ability to do this as well. However, we are facing a crisis in general practice because of the number of GPs we have. Anyone who has had cause to try to get an appointment with their GP will see how short we are in general practice capacity. As such, we would need to speak to the Irish College of General Practitioners, ICGP, and also the Irish Pharmacy Union. Then there are the congregated settings like nursing homes, etc. Please let us not forget people in nursing homes like we forgot them during Covid. We need to have engagement with public health nurses on how that might work.

As a country, we should also recognise that when we introduce the schemes, we are pretty successful at delivering vaccinations and most of the public are pro vaccine and pro investing in their health. They still trust the medical advice that comes down, as long as that medical advice is always seen to be open and transparent. People lose faith in something if they feel the debate has not been open and transparent and in the early days of Covid when, for obvious reasons, the debate was less open and public, people began to become a little distrustful of it. That was an emergency situation and you always have to limit that openness and transparency when you are in an emergency situation.

That point about access to GPs is a crucial one because there are significant regional variations in access to GPs. The HSE or the Department is not willing to take that on because of how general practice is organised at the moment.

I want to go back to the point about the economics. This is maybe a comment rather a question but when we look at the HIQA assessment, we do not see the broader economics of the bed days and the private purchase of surge capacity. I am thinking in particular of the conversation about the enhanced flu vaccine. The economics of rejecting the enhanced flu vaccine last winter seemed completely bananas when you take into account the bed days and the surge capacity.

I have a separate question about vaccine fatigue. It has already been covered somewhat, but the take-up of the flu vaccine among the older population is relatively high, certainly compared with healthcare workers or children. However, as older people had to take more Covid vaccines relative to the general population, is there any vaccine fatigue there now? Maybe that is something I am picking up anecdotally that is not being matched by what the witnesses are hearing. Is it a factor at all?

It is certainly not what I am hearing.

Okay.

As I have stated a number of times, this campaign has been very much mandated by our members and is being led by them. There are thousands of older people all over the country writing to their public representatives and going to clinics in their constituencies asking for this repeatedly. We had 21,000 signatories on a petition. It is certainly not what I am hearing.

To briefly touch on the recommendations of NIAC and HIQA, NIAC recommended the shingles vaccination for those aged 65-plus but HIQA modelled a cohort of 50-plus. To my mind, the real cost-effectiveness and the public health benefit for the most at-risk group has not been fully captured in that HTA. When we are looking at that HTA or revisiting it, that needs to be kept in mind.

I agree with Deputy Sherlock in the context of dementia, delirium and nursing home care. None of those things is in that economic model. She may have missed the comment on this earlier, but no one did an economic model on whooping cough. It was just recognised that it was a nasty illness to get as a child and involved significant health concerns. There was no hoo-ha about having an economic analysis of it. I agree that we have to be prudent in terms of our budgets, but I do not think it is using the same level of concern for the health of older people.

And at a time when we see growing inequality in parts of our health service, the cost, at €500, is obviously prohibitive.

Professor Collins has to leave in the next couple of minutes. If any of the members have a quick question for him, they may ask it. We will then continue with the rota. He has just a couple of minutes left, and then we will continue.

If the Chair does not mind, perhaps I could have my time, because-----

It is just that Professor Collins has to leave within the next five minutes.

Yes, but I want to address him specifically.

I will hang on.

Deputy Cullinane has indicated that he wants to come in at some point as well.

Can we not just go by the rota?

It is just that we will be down to just one witness when Professor Collins leaves. If members want to continue, we can continue with Senator Clonan.

I thank the Chair. I welcome Ms Bough and Professor Collins and thank them for coming here. The evidence has been compelling and fascinating. I thank Professor Luke O'Neill, particularly as he got up at, I imagine, 3 a.m or 4 a.m. I acknowledge the efforts on the part of the secretariat to get him online.

I will declare a conflict of interest. Professor Collins and I go back a long way. He may be a candidate in the new university constituency for the Seanad. I can think of no finer candidate. It kills me to say it, but I wanted to put that on the record as well.

I was very proud to co-sponsor Senator Joe Conway's Private Members' Bill on the shingles question. There was a debate on that. My dad was a member of An Garda Síochána. He was a big, invincible guy. He got shingles when he was in his late 60s, and the outcome for him was damage to his eyes. Before he joined the Garda he was a carpenter. After that bout of illness he could not use his tools any more. To Ms Bough's point about social participation and inclusion, it had a devastating outcome for him.

I have a couple of questions for Ms Bough and Professor Collins. I live in the eircode A94 area. It is one of the most socially advantaged and wealthy areas in the country. I spoke to one of my local pharmacists recently. She told me that there are hundreds of people in the area who are in their 90s and who live very high-quality lives, so there is definitely a link between socio-economic advantage and being able to take up all these things. As regards the link between inflammation and the blood-brain barrier, I know there is now increasing research on depression, that people who suffer from depression and low mood also have an increased risk for this.

We had representatives of the National Centre for Pharmacoeconomics in here before Christmas. I asked them very carefully about the methodology the centre employs in the context of arriving at its conclusions. Those who work at the centre are predominantly statisticians. The centre does not have any ethicists. It relies entirely on the natural sciences to get its positivistic, deterministic outcomes. It does not incorporate any of the human sciences or any phenomenological approach. I have therefore come to the conclusion that its methodology is unethical. To Professor Collins's point about whooping cough, we do not incorporate that kind of thinking. It is self-evident and manifestly the ethical and correct thing to do, and that is definitely the case with shingles. In Professor Collins's capacity with the RCPI and his colleagues across the different specialties, is there any mechanism by which they can advocate and lobby for some sort of a review of or change in the way in which the National Centre for Pharmacoeconomics conducts its research?

As complete laypeople, we read that the vaccine that was chosen last year for the winter flu viruses and Covid was a suboptimal choice based on cost. Who signs off on that? Is it a clinician or a non-clinical person in the HSE?

My final question is for both Ms Bough and Professor Collins. I would have seen a terrible model of ageing with my parents, and I would have been fearful of getting older. As I get older, however, I am aware that there are actually hundreds of thousands of Irish people who are older whose value is diminished somewhat in our popular culture. That is a matter for another day, but how do we communicate that? As Professor Collins says about the advantages of taking a vaccine, it is not just for your heart or your lungs but for adding years of quality to your life.

Senator Clonan and I do indeed go back a long way. I am not sure if my short-lived political career is over, but I enjoy the process and I thank him for saying-----

I was afraid Professor Collins would say that.

The main reason I ran for the Seanad at the time was allied to what we are discussing. It was solely in relation to an age-friendly Ireland. I was concerned after the experiences during the Covid pandemic that we were not really becoming an age-friendly society. Having a voice for older people and having people advocating for older people - and, increasingly, hopefully, more older people themselves doing that - is a very important thing to have in society.

I address the questions in reverse order. How do you educate older people? I find older people generally are hungry for health knowledge and really engage. Traditional methods of media are still working in that cohort. It is very much television and radio, for example, in the context of our stroke campaigns, but we are also aware that the generational shift is changing. In that regard, some of our stroke awareness campaigns, to use that as an example, use Facebook more and are beginning to venture into TikTok because, of course, very often younger people witness their older relatives having strokes. We are trying to be aware of that as well. I find in general that older people are receptive to and hungry for and take up healthcare messaging.

With regard to the issue of the National Centre for Pharmacoeconomics, I do not want to say too much. In a previous world, when I was having the debate about anticoagulation for prevention of stroke and atrial fibrillation, a very strange analysis happened whereby it did reach the pre-specified QALYs, so it met the centre's pre-specified predetermination, but then it added a comment that it still did not think it was value for money. I just could not understand that. I am aware the current head of the National Centre for Pharmacoeconomics has a very difficult job to do - he is a clinical pharmacologist - but I agree with the Senator that having a wider approach to the evaluation of something needs that broader input. I will take his message back to the council of the RCPI to ask if we have really engaged to try to influence this process more meaningfully. The answer to the question is that I am not aware that we are meaningfully engaging. The Senator's suggestion is a really important one and I will bring it back to the council of the RCPI. There will be a change of leadership shortly and naturally anyway in the National Centre for Pharmacoeconomics. That would be a time maybe to engage and to reset the parameters.

I will start with the definition of a QALY. A QALY combines the quantity and quality of life where one year in perfect health equals one QALY. I will use that sentence to answer the rest of the Senator's question. I am not a health economist, a doctor or a clinician; I am a health psychologist. Taking the policy hat off and putting the psychologist's hat on, I have to say, when we look at something like one year in perfect health, if you have even a short-term health condition that leaves you in pain and you withdraw from your family, your family activities, your community, your volunteering activities, whatever those activities may be, and from having to care for grandchildren and you have to withdraw, like Senator Clonan's father, that really begs the question.

Social isolation leads to poorer health outcomes of both cognitive and physical decline. One inevitably leads to the other and we cannot continue to look at them separately.

I thank both of the witnesses.

I would have stayed a bit longer and apologise. Unfortunately, the notice was a bit short. I have clinical commitments and must arrange a bit of cover but I will certainly stay and if you can make the questions maybe appointed for me. I apologise to the committee as I do not want members to think that I am not treating the opportunity to talk as important.

Not at all. It was very short notice. Last week, a meeting to discuss a Bill was cancelled at very short notice by the Minister so we had an opportunity and wanted to engage. We appreciate Dr. Collins and the other witnesses attending at very short notice. Senator Costello is next.

I thank all of the witnesses for attending. As I am from Tallaght, I know that Dr. Collins does brilliant work in Tallaght Hospital.

I thank the Senator.

My colleague Senator Joe Conway raised the issue of the shingles vaccination in the Seanad and I learned so much that day. Even though I know people who have had shingles I was not aware of its connection to heart issues and dementia. I was impressed by the striking statistic in Dr. Collins's opening statement that a vaccine can reduce the incidence of dementia by 20%, which is an opportunity that we should grab with both hands because there is nobody here who does not somebody who is affected by dementia. It is an awful illness.

The word "ageism" has been mentioned. I totally disagree with it. Decisions about the availability of a vaccine do not have anything to do with ageism. I am a member of a Government party, and I care and respect deeply about the ageing population. I would love to see everybody get the vaccine for free. When there is a HTA negotiation, if a pharmaceutical company comes in with a high-ball figure and we take the first price point, other people will miss out. Price negotiations are therefore so important. I would be the first one banging the drum for people to receive medications that improve the quality of their life. I am interested to see in the HTA an emphasis and focus on the additional costs when a person has shingles, including the hospital visits and the knock-on effects on their health. Those are all valid things to incorporate. Everything should not be monetary either. People are living longer but there is no point in living longer yet suffer every day. I watched my own father pass away over two years. Dr. Collins cared for him at one point. My father's experience of living those two years was not living. If there was a vaccine that could prevent people from getting dementia then I would be front and centre in support of that.

Senator Conway educated me about shingles during that debate in the Seanad. He spoke about his outgoing uncle. He said that his uncle was a nice, quiet man who had his life but shingles took away so much. There are studies that say a vaccine has positive effects and I urge the continuation of the negotiations. I ask that the pharmaceutical company does not propose a price that is 80% over the cost. I urge people to meet in the middle. Nobody here would be opposed to the older generation having access to such as brilliant medication, especially with its added benefits.

In other European countries, the vaccine is either publically funded or has supported access. Can Dr. Collins tell me what "supported access" would look like?

I imagine it would be a contribution that is in some form means-tested. To address the "supported access" question, in chronic disease programmes in Ireland, the stroke programme put most of its budget last year into primary care, into chronic disease management for the management and detection of blood pressure because blood pressure is probably the single greatest entity that will make people age badly - damaging the brain, eyes, heart and kidneys. That programme is not going to cover the two thirds of people who do not have a medical card so you have to ask yourself the question because it is a two-way sword: when investing in a public health strategy, are you investing in the population or a section of the population? Lots of us would have life experiences as well where you realise that people who are just above thresholds are often the people who are squeezed the most. I personally think that public health is just that. It is the health of our public. Once you start nuancing that, you start things and undermining what you are trying to achieve.

I thank the Senator for her kind comments about Tallaght. I know she knows well the subject matter of ageing. I hope that I did not use the term "ageism" in my document. I prefer to be more positive and say "age-friendly" because using the term "ageist" at times implies that somebody is purposefully set out to be anti-later life but most ageism occurs from a lack of thought.

Does Dr. Collins think that the health landscape has changed?

It has improved, yes.

Maybe it is because my family experienced dementia but it feels like everybody has dementia. I hear about loads of people having dementia but ten or 15 years ago dementia really was not a thing. It was not a case of people not being switched on. Newborns receive vaccines. There was no education about dementia when decisions were made on childhood vaccines. As we evolve, that is where we have to go. There are people like the witnesses who educate all of us on how people are ageing, the knock-on effects and all of the stuff that is happening. I totally agree with them on the vaccine programme and protecting older people as much as possible to make sure that they live their best lives. Rather than it being ageism is it that things have changed and we need to catch up?

I will clarify because I mentioned structural ageism. When I talk about structural ageism in healthcare or elsewhere, in our policymaking, I am talking about the fact that very often our policymakers in government and health service can be very focused on youth and childhood vaccines. I am not bringing it down to being reductionist about the price being charged by the pharmaceutical company for the vaccine. I am talking about structural ageism within policymaking and healthcare structures. That tends to be very focused on younger people.

The Senator asked whether it is getting better. The narrative has changed towards being a care-based narrative when we are talking about older people. Within the past five to six years we have stopped talking as much about positive and health ageing, and there has been a lot of talk about care.

We should focus on preventative medication.

Exactly, and preventative health. We all require care at some time in the life course and ageing is not necessarily synonymous with care.

I thank the witnesses.

I welcome the witnesses. Seeing Dr. Collins reminds me of Covid. We were on many television programmes during that period and he brings to mind not great memories but it is good to see him again.

What a compliment and it is good to see the Deputy too.

I thank Dr. Collins and Ms Bough for their attendance. I also thank Professor O'Neill for his opening statement.

I support the provision of a State-funded shingles vaccine.

I have raised this in the Dáil with the Minister for Health and I also raised it directly with the head of the Department and the former head of the HSE. There is an incoming head, as people know. There did not seem to be any opposition to this matter. From what I could gather, the issue was down to cost and cost effectiveness. I accept that we have to have some process to evaluate new vaccines, drugs and so on, but I am trying to tease out how we evaluate the cost effectiveness. Obviously, prevention is really important. I know family members who have had shingles. These are people in their 50s and 60s who contracted shingles. It is really painful. It can have long-lasting consequences, as has been outlined clearly already. If we can put in place a publicly funded vaccination programme, that would make sense. It is also one of the areas where universality and having a programme really works. We have seen it with old people with flu, for example. I got the flu vaccine myself in the last number of years and I have not had any flu whereas in previous years I did. Vaccines do work, as we know, and the more publicly available, they are the better.

My understanding of where things are at the moment is that an offer from a company that manufactures the shingles vaccine was for a programme for over-75s and some patients who were immunocompromised. The cost of that is €5 million, which to me does not seem like a huge amount of money. That can be extended out in time to more people. I think we should make a start and that would be a good start. Will both witnesses give their views on that cost effectiveness model, the process and if we are sufficiently factoring in prevention in relation to the cost effectiveness evaluation process?

I am not going to repeat myself about the economic cost effectiveness versus quality of life versus long-term impacts on social isolation because I have said quite a bit about that. We have a really significant issue with short-termism, particularly in our health policy nationally. We need to move towards a model of preventative health for longevity. People are already living longer but let us look towards the long-term impact for the economy, society and our country as a whole and look towards preventative health and public health messaging about positive healthy ageing, because we are all ageing. I think it was Groucho Marx who said it was always better than the alternative. Let us look towards a life-course approach in terms of preventative health rather than looking at the cost effectiveness to deal with this issue in later life. I plead with our policy makers to look more towards preventative health measures and having more of a conversation about preventative health than long-term care.

I suppose my question was exactly that. Are we putting enough emphasis on prevention when cost evaluation comes back to us? We make representations. We raise these issues in the Dáil. As I said, I spoke to the head of the Department and the head of the HSE directly because I saw the benefit of this and I did not seem to get any pushback on the health benefits. The only pushback was cost – that this was going to cost money. It seems to me that €5 million starting for those over 75 in the context of a health budget of €24 billion is not huge but that is what comes back to us. We need to be armed with the facts to go back and say, hang on, prevention is really important, this can actually save us money and it will certainly save people pain and suffering. That is the issue. I fear when they look at the cost effectiveness, they are not looking at it through the lens of prevention, and that is a mistake.

I thank the Deputy for the kind comments again. We did share many an evening during Covid. I would agree with him. A lot of modern economic modelling throws in factors about increased lifetime risk of developing heart failure and dementia and stuff like that into technologies. We probably look chiefly at QALYs, hospitalisations and mortality as the chief outcomes. Modern health economists have far more sophisticated models, so you can create a number of scenarios. If I ask a different question, you get a different model out. However, having worked in and possessing a reasonable knowledge of health services across Europe, I would say that the health service that is most like ours is that of the UK. Having worked there for six years, they tend to be very economically conservative with any new advent that comes along, yet they have approved this. I wonder whether the price of the drug is that different in the UK. I know there is a bigger population so-----

What would be the cost of it if somebody was to get it privately?

I am not sure, actually.

For the shingles vaccine, it ranges between €470 and €500 nationwide.

That would be prohibitive for a lot of people.

For most people.

It is one and a half times. If you were reliant on your State contributory pension, where the maximum amount you would be on was €299, it is one and a half weeks.

I find it incredible. It seems to be an unassailable argument. I am not coming in here to make any pitch for any pharmaceutical company. My only concern is that people who might contract shingles and go through the pain of that could be protected if we put in place a vaccine programme. We went through Covid - we just talked about that - and the vaccine was the saviour. There are lots of other illnesses where vaccines are a real breakthrough. It seems to me the arguments are unassailable, as are the public health benefits and the prevention benefits. We will hear from the Department in due course and we will have to put it under pressure. It does not make sense to me that this is not being done. I hope that, because it has been raised today and with our collective influences, we can get this over the line. I will leave it at that.

We can put it to the Department and the HSE next week when they are before us.

Cuirim fáilte roimh an mbeirt finné ar maidin. Tá a fhios agam go bhfuil Gaeilge ag an Dr. Collins so cuirfidh mé ceist amháin air i nGaeilge mar gheall ar vaccine hesitancy agus seandaoine ach go háirithe. An gceapann sé go bhfuil seandaoine fós sásta vacsaíní a fháil? An féidir linn níos mó a dhéanamh chun a chinntiú go bhfuil siad sásta iad a fháil sa todhchaí?

Tá, gan dabht. Is annamh i ndáiríre a thagann cás chugam áit nach bhfuil daoine sásta an vacsaín a fháil nó go mbeadh eagla orthu mar gheall ar vacsaín. Is annamh a fheicim sin. I mo thaithí féin, bíonn an chuid is mó do na daoine atá ag dul in aois ag lorg na vacsaíní. Bíonn siad ag cur ceisteanna orm faoi aon rud nua atá ag teacht sa todhchaí a thabharfadh níos mó sláinte dóibh. Déarfainn nach bhfuil an rud sin fíor in aon chor ach a mhalairt. Bíonn na daoine atá ag dul in aois ag lorg na vacsaíní agus ag lorg a thuilleadh eolais mar gheall orthu chomh maith.

Níl aon éifeachtaí diúltacha ó thaobh post Covid de?

A mhalairt atá fíor, arís. Bhí sé an-suimiúil tar éis Covid. Bhí daoine níos sásta vacsaíní a thógáil i ndáiríre. An rud a tharla ná nuair a fuaireadar an vacsaín do Covid, bhí siad in ann dul amach. Thug an vacsaín saoirse dóibh. Roimhe sin bhíomar ag labhairt mar gheall ar cocooning agus a leithéid. Bhí mise i gcoinne an ruda sin ar fad ach thug na vacsaíní saoire do dhaoine so bhí níos mó muiníne acu as na vacsaíní tar éis na taithí a bhí acu le linn Covid. Tá sé sin ag leanúint ar aghaidh anois. Bíonn siad do mo cheistiú mar gheall ar vacsaíní le fáil amach an bhfuil rudaí nua ag teacht nó an bhfuil níos mó le déanamh acu ó thaobh a gcuid sláinte féin.

Gabhaim buíochas leis an Dr. Collins as sin. Following on from what Deputy Cullinane said, I would like to ask about vaccination in terms of Government and HSE spending. I have tabled a variety of parliamentary questions on how much we are spending on vaccines per annum. It is quite difficult to get a round figure. Do the witnesses have any idea what we are investing in vaccines per annum?

The short answer is that I do not. Again, I hasten to add that I am not a health economist. I am not involved in budgetary discussions. My big message is to say to people that we should have the exact same strategic approach to the health of older people with regard to vaccination that we do to the health of our children when it comes to vaccination. The other message is that rather than being reactive all of the time and talking about the effect it is going to have on hospital beds, we should be talking about the health of older people and also that this prevents stroke, heart attack and dementia. It will have a knock-on effect on hospital beds, but the main reason for buying a vaccine should not be the crisis that will happen with regard to our hospital beds if we do not do so. The main reason should be because this is going to improve the health of our population. That should be the starting point.

The reason I asked that question is that I have long been an advocate for an overhaul of our assessment process for drugs reimbursement and the HTAs that are undertaken. The Covid situation was a crisis that needed to be dealt with quickly. Does Dr. Collins think it is appropriate that a vaccination, for example, for Covid, in an emergency situation, would still have to undertake the same HTA process that applies to conventional drugs or should there be a bespoke process?

Ní doigh liom é. I do not think so agus aontíom leat. I do not think so either because vaccines are a public health measure and they probably should not be subject to the same type of process. That said, is dócha go bhfuil ríalach ann, and we have committed to rules about evaluating health technologies. These are public health measures, but, of course, that is not to say that there is not a proper economic discussion. I agree with the previous speaker that the pharmaceutical companies cannot have free rein and be allowed to come in high-rolling on the price. What I am curious about is the fact that the English are very conservative economically in the area of healthcare, but what is the differential between the price they are getting the vaccine for and what we are buying it for? What are the reasons for that? Then there is the mysterious mechanism, of which the Deputy may be aware, of the basket price in Europe trading. Again, I can never figure out how that works, but the price of drugs does seem to be much higher here than in other countries. There needs to be an open discussion about that in order to understand the reasons for it. I realise that if goods are coming into a smaller market, there might be an added premium because there is less of a market. The bigger the market, the lower the price can be dropped for certain things. There are probably variations like that but our starting point, going back to my original message, is that we should have the same approach to the public health value of vaccinating older people as we have to children.

I have spent five years up here advocating for a bespoke way to treat vaccines and for a review of the reimbursement process. Dr. Collins put it better than I ever have in the past five years in terms of approaching this from a public health angle rather than it just being about price.

We have four remaining speakers. Do the witnesses need a break?

I only have about five minutes left. I apologise again to the committee, but I have someone covering for me because I could not take the whole day off work.

We appreciate that. What we can do is take a break and then resume with Ms Bough, if that is okay?

It might be easier for Dr. Collins to carry on.

I do want to give members a chance if they have something pressing they want to ask. Again, I apologise to the committee.

I do not need a break.

There are several members remaining on the list. Dr. Collins is free to leave at any point. The next speaker is Senator Boyle.

I thank the witnesses for being here. I am sorry that I had to step out earlier to attend another meeting. I was listening in to the proceedings which were very interesting.

Dr. Collins is 100% right that it needs to rolled out the same for the older people as the children. If this vaccine is good then it is a matter of urgency that we get it out there. We talk about the shingles vaccine, but only between 10% and 20% of people have got it so far. I know that the price is a problem, but does Dr. Collins think that if we got the price of it down, there would be no hesitancy there from older people to take it?

Not in my opinion. As I was saying, and apologies Senator Boyle, but I answered that question as Gaeilge because Deputy O'Sullivan asked me as Gaeilge. It is rare in my experience that older people have vaccine hesitancy. It is quite rare, particularly after the Covid experience. The Covid vaccine freed older people from the misery of cocooning, and the mistake we made around that. It gave people freedom. Older people have lifelong experience of vaccination. They have seen what it has done for their own children, and they probably have more trust in vaccines than any other sector of our society. Older people actually come to me asking if there are any new vaccines coming that they should be getting this winter. They are actually proactive about it. They are asking what they should be doing and whether there is anything else they should take this year to prevent them from getting sick. Each year and each Christmas, life becomes a lot more valuable as people get older, and they certainly want to be healthy during it. I find quite the opposite. It would only be the odd or rare occasion that one would come across an older person who is vaccine hesitant.

The short answer, as Ms Bough has illustrated, is that cost is the factor there. It is an expensive vaccine. As Ms Bough indicated, it costs between €400 and €500. Very few retired people have €400 or €500 to spend on a single vaccine. I go back to the point that vaccination is a public health issue. It is not a purchase it as one can issue.

I know people who had shingles, and the pain and suffering they went through for a week was intense. It is a very intense illness in older people, and it takes them a long time to recover because their immune system is so weak after it. If there is something there, it definitely should be rolled out. I think Ms Bough said that it is freely available across the Border.

Yes, it is. The current status in the UK is that it is free for eligible cohorts under the national immunisation programme. It is routinely given to people aged between 70 and 79, and they have phased that expansion now. It is given to immunocompromised adults aged 18 and over. They are also eligible.

Are there any side effects to this vaccine?

No, apart from the usual bit of pain in the arm and local reactions, which are the common ones. Most of the vaccines are very well tolerated. There is no serious safety signal, if that is what the Senator is asking. There is no serious safety signal with this vaccine.

I will leave it there in order to allow other colleagues to ask questions, to be fair.

I have to leave now. Deputy Burke will take the chair.

I thank the Cathaoirleach, the Leas-Chathaoirleach and the members of the committee for facilitating me this morning. I am not a member of the committee. I deeply appreciate the opportunity to attend the meeting and listen to a very intriguing series of contributions from members and our visiting experts.

I record my absolute astonishment and congratulate Active Retirement Ireland on collecting so many signatures in such a short while for its petition. Ms Bough circulated it to me and the office. It is a measure of the efficiency of the office that we have not got around to signing her petition yet, but we will. I am delighted that it is so successful. It underscores the great joy we had in the Seanad when we tabled that Private Members' motion. On the morning it was tabled, we were a little tentative and apprehensive as to whether it would be opposed and the signally good news came back that the Government was not going to oppose it. People would cynically say that does not mean a whole lot but it does because it does not signal any entrenched opposition to it, which is very important.

On foot of our attendance here this morning, I am convinced that in the next couple of years, we will obtain the shingles vaccine across the board for the older cohort. In addition to what we are doing here this morning and in the Seanad, I hope the Minister of State with responsibility for older people will meet with Active Retirement Ireland to discuss it further, so that we can just keep chipping away at it.

I do not want to take up time unduly but there is evidence that the Government and the Minister for Health are coming together. The pharmacy industry is eager and desirous of people getting the shingles vaccine. Cynics would say they would say that because they make them but GSK in Ireland does not want Ireland to be an outlier and a country that is not providing this when, as I said in the debate in the Seanad, if I was living in Tandragee as opposed to Tramore, County Waterford, I would have had the vaccine free last August whereas as I ended up paying €500 for it. I could afford it but there are 800,000 people out there who may not. We mentioned means-testing. From my experience of 20-odd years as a councillor, when talking to the older cohort about means-testing, a lot of anxiety is raised among the people on the margins who do not like the Government looking into the few bob they have here and there. If the vaccine is means-tested, it will rule a lot of people out. It needs to be universally available. I thank the witnesses very much. I really enjoyed the meeting. When I was asked to pick the Oireachtas committees I wanted to join, I picked the wrong ones. I much prefer the interaction in this one. It is not the last committee members will see of me.

I thank the Senator Conway much. He has been a driving force behind this in the Seanad. I remind him to sign the petition today.

Done.

I am not a member of the committee either. I was next door at a meeting of the disability matters committee. I apologise, as I am coming in blind but I saw the agenda in advance.

I am coming from a context where I was a community pharmacist. I was practising for 36 years up to last summer. I am interested in where improvements can be made in funding, budgeting and pharmacoeconomics that can then enable further roll-out of the shingles vaccine or any other new drugs for rare diseases whereby a new medicines optimisation service will be available. By properly sitting down with patients, for want of a better word, and going through the regimen of what people are on, what it is for, etc., and if people are having side effects from products, community pharmacists can provide a bespoke service and savings can be made because it can be identified where there are products that may be contraindicated or disagree with people over time. In particular as people age, their physiology and biochemistry changes so drugs affect the body differently, as well as a change in diet. All of that can be considered.

That leads me on more specifically to shingles vaccination. It is so important that post-marketing surveillance is carried out because as people get older their physiology changes. A polypharmacy situation arises where they are on multiple drugs and there can be interactions. Hesitancy has crept in. The tagline "safe and effective" was previously attached to the SARS-CoV-2 vaccination but that has not been everybody's experience and therefore hesitancy has crept in. Going back to the economics of this, looking at each patient on a case-by-case basis in conjunction with a community pharmacy can result in savings being made that can then be ring-fenced for new treatments. Hopefully, we would not then have to go the route of means-testing. I hope that makes sense. I apologise for coming here totally blind.

Deputy Toole is very welcome.

It was only when I saw the subject matter on the screen that I came to say there are opportunities there. I am happy to collaborate.

I thank the Deputy. That all sounds absolutely relevant. I am not a health economist but from my point of view as head of policy in Active Retirement Ireland, I would very much love to be in the situation where we are talking about those stages because at the moment it is the financial barrier and the cost of access to the vaccine that is preventing us from even getting to that stage of the conversation. If we had an equitable cost or it was free of charge at the point of delivery, it would be fantastic to look at issues like that with pharmacists. A lot of older people in the country have a really positive relationship with their community pharmacist and their practice nurse because it is becoming increasingly difficult to access a general practitioner.

It would be remiss of me not to voice something that I will not even call a concern, but in the time that I have been practising, shingles was never a thing. It came up maybe after Christmas where people had to take multiple courses of antibiotics or whatever for respiratory infections, but I am surprised at the prevalence of it in recent years. I am just flagging it, but Professor Collins made the point about childhood vaccination. Shingles is listed as a side effect of chickenpox vaccination. The post-marketing piece has to be looked at. I am not saying that to cast doubt but, again, we do have a developing hesitancy and there very much needs to be a 360° view of everything so that ultimately the best decision is made for the person. In particular for older people, we want that quality of life. We want people to age well at home. We do not want neuropathic pain, but we also have to balance all of the variables and make sure that the best outcome happens. I accept that cost does come into it, but I would flag that we have to look at things in the round. Whether it is an inactive virus or bacteria or the newer therapies, nothing is in its unique little box, there is a crossover in human beings. That is purely a side piece but I make the point for information.

I thank the Deputy very much. Her experience of dealing with the public in the area of medication is evident. Does Ms Bough want to respond?

I agree but I reiterate that an informed choice is better than no choice, which is the situation at the moment.

I thank Ms Bough for her contribution, for making time available and for the work she is doing in the area of the older population. We have a growing elderly population. There are now approximately 865,000 people over the age of 65, and there will be 1 million within three years. It was brought home to me when my mother-in-law died recently. She was 102 and fully competent up until the day she died in the sense that she understood everything that was going on around her. People are living longer, so it is important now that we have the necessary medical support available for people who require it. The whole issue of vaccines is so important in dealing with that growing population.

I thank Professor Collins for coming here, for taking the time out of his busy schedule to be here and for the contribution he made. I also thank Professor O'Neill. It is disappointing that we were unable to set up the link for him to make a contribution, but I thank him for the paper he submitted and for the work that he is doing in this area. I thank all the medical people who work in this area. I also thank all the people who are working with people who are retired and with people who require support and care.

The committee will reflect on today's very helpful proceedings. We will meet again next week to further consider the issue with the HSE and the Department of Health.

I thank Senator Conway and Deputy Toole for coming in, taking time out of their busy schedules and contributing to the meeting.