Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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HPV vaccination in younger pre-adolescents?
- Fergus Maher, Ioannis Mammas (13 September 2007)
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Challenges of implementing human papillomavirus (HPV) vaccination policy
- Nick F Hallam (17 September 2007)
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HPV education is not an ‘add-on’
- Alison M. Gehring (21 September 2007)
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Challenges of implementing human papillomavirus (HPV) policy
- Angela E Raffle (25 September 2007)
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Challenges of implementing human papillomavirus (HPV) vaccination policy
- Nick F Hallam (16 October 2007)
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Fergus Maher, F2 SHO Whiston Hospital, Warrington Road, Prescot, Merseyside, L35 5DR, Ioannis Mammas
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Raffle (1) comprehensively points out in her article that there are many challenges to be overcome if an effective Human Papillomavirus (HPV) vaccine programme is to be successfully introduced into the UK. However the decision of the age at which the vaccine is given to girls is an issue that Raffle mentions only briefly. Several European countries have already decided to introduce vaccination programmes to girls aged 12 and above and the UK seems likely to follow suit. However, given that the recent UNICEF Inocenti Report (2) highlighted that the UK has far higher rates of sexual activity in teenagers under the age of 15 than the rest of Europe, perhaps consideration should be given to introducing the HPV vaccination programme in younger children in this country. The published studies investigating the effectiveness of the quadrivalent vaccine have been carried out in HPV naïve subjects, and the effectiveness of the vaccine has thus only been demonstrated in non- infected individuals (3). To optimize the efficacy and thus cost- effectiveness of the vaccination it will be necessary for it to be given at an age when the greatest possible proportion of vaccinated individuals have not been exposed to HPV. Reisinger et al (4) demonstrated in a randomized, controlled, double blind trial that vaccine administration is safe and effective in children as young as nine years of age. Further research needs to be carried out to confirm Reisinger’s findings and to establish the duration of immunity when younger children are vaccinated. Cost-effectiveness is of particular importance in the UK and this surely necessitates that we consider changing the imminent vaccination programme to include pre-adolescent children when more evidence is available. 1. Raffle AE. Challenges of implementing human papillomavirus (HPV) vaccination policy. BMJ 2007;335:375-7. 2. UNICEF. Child poverty in perspective: An overview of child well-being in rich countries. Inocenti Report Card 7, 2007. www.unicef- icdc.org/publications/pdf/rcf_eng.pdf. 3. The FUTURE II Study Group. Quadrivalent Vaccine against Human Papillomavirus to prevent high-grade cervical cervical lesions. N Engl J Med 2007;356:1915-26. 4. Reisinger KS, Block SL, Lazcano-Ponce E, Samakoses R, Esser MT, Erick J, et al. Safety and persistent immunogenicity of a quidrivalent human papillomavirus types 6, 11, 16, 18 L1 virus-like particle vaccine in preadolescents and adolescents: a randomized controlled trial. Pediatr Infect Dis J 2007;26:201-9. Competing interests: None declared |
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Nick F Hallam, Clinical Virologist Royal Preston Hospital PR2 9HT
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There are a few points I would like to query in Angela Raffle's helpful paper. Firstly, I believe that the Texas Governor's executive order in February 2007, which made HPV vaccination mandatory for girls entering the sixth grade, was legally blocked three months later,(1) and that Virginia is the only American state to have such legislation in place at present. Secondly, Raffle says that cervical screening gives 80% protection against cervical intraepithelial neoplasia. What is the evidence for this? Finally, she describes cervical intraepithelial neoplasia 2 as a low grade abnormality. This is at variance with professional guidelines.(2) 1. http://www.msnbc.msn.com/id/18575675. 2. Colposcopy and Programme Management. Guidelines for the NHS Cervical Screening Programme. NHS Cancer Screening Programmes No. 20, 2004. Competing interests: Adviser to Sanofi Pasteur MSD |
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Alison M. Gehring, Senior Policy Officer The Royal Society of Health, London, SW1V 4BH
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The inadequate education provision in the UK in relation to human papillomavirus (HPV) is almost certainly a major reason why the vast majority of women do not know that cervical cancer is caused by a sexually transmitted infection, one of the findings of a recent public awareness survey conducted by Cancer Research UK. With nearly 3000 cases of cervical cancer per year these findings are deeply worrying, if people don’t know about it then how can they make an informed choice? Clearly this situation needs to be addressed in the interests of public health. An integrated education programme, designed, implemented and evaluated in line with contemporary best practice in health promotion, is essential if any HPV vaccination programme is to be successful. The need for “adequate education” was articulated in the article (1) but the question this raises is “whose responsibility is it to provide this education?” Presumably the options are either the pharma companies themselves, public sector bodies, or independent third parties, such as health charities. The Royal Society of Health (RSH), a major public health charity, has already brought together health and education experts, young people and industry representatives from across the country to develop an education programme for HPV. This will be rolled out nationally over the next two years, designed to raise public understanding about HPV. We are engaging with key stakeholders now to ensure health professionals and the public are equipped with the skills and knowledge to realise the benefits of a future HPV vaccination programme. The precise value of this health promotion work will clearly be dependent on future decisions by the Department of Health, following recommendations by the Joint Committee on Vaccination & Immunisation. The RSH strongly supports the introduction of a comprehensive HPV vaccination programme. However, the efficacy of any such programme will be strongly influenced by the impact of public education, not least in relation to disadvantaged social groups. The first cancer vaccine might be ready but the public are not. HPV should be viewed in the wider sexual health context. The general poor state of sexual health in the UK is clearly illustrated by a recent Health Protection Agency report that found the number of new sexually transmitted infections is on the increase, yet again, standing at 376,508 cases in 2006 (2). Although this is not surprising, when one considers the findings of the UK Youth Parliament report that sex and relationship education is too little too late. 40% of the 20 000 young people surveyed rated sex and relationship education as poor or very poor (3). If politicians, educationalists, and health professionals want to improve the public’s sexual health we need to get the message right. Development of NICE guidance on health promotion in schools and colleges is a significant step forward and the RSH will be working with the health promotion workforce to push forward this agenda. The inclusion of immunisation take-up as a priority for the Department of Health is a welcome recognition of the importance of immunisation in promoting better public health. The RSH takes the view that recent scientific and technological developments will reinvigorate vaccination as a key public health intervention over the coming years. But success will be predicated on sound public education. No longer should children and young people be expected to put out their arm unsure of what the syringe contains. Immunisation and vaccination provide an essential tool in improving public health. However, success requires an investment not just in vaccine delivery, but also in the health promotion measures necessary to create a supportive educational and organizational environment. Adequate education is at the heart of a successful vaccination programme and to achieve this we need to have all stakeholders sitting around the table as it is all our responsibility. Education is not an ‘add-on’, but a pre-requisite. agehring@rsph.org 1. Raffle AE. Challenges of implementing human papillomavirus (HPV) vaccination policy. BMJ 2007;335:375-7. 2. Health Protection Agency. STI data 2006 http://www.hpa.org.uk/infections/topics_az/hiv_and_sti/epidemiology/datatables2006.htm 3. UK Youth Parliament. Sex Relationships Education: Are your getting it. 2007 http://www.ukyouthparliament.org.uk/174737/195488.html Competing interests: The Royal Society of Health is developing an HPV education programme with support from Sanofi Pasteur MSD, guided by an independent advisory board. |
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Angela E Raffle, Consultant in Public Health Bristol Primary Care Trust , King Square, Bristol BS2 8EE
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Many thanks to Nick Hallam for the three points raised. First - yes it is absolutely right that the unilateral executive order used by Texas governor Rick Perry to make HPV vaccination mandatory for sixth grade girls provoked considerable publicity and a challenge from legislators to override the order. Vaccination programmes as we know them in the UK do not really exist in the USA. The onus is on each individual to procure vaccination from their preferred healthcare provider. Therefore, in order to ensure widespread coverage, each State legislates to require vaccination as a condition of school attendance. The conditions for allowing parental opt out vary from State to State. Many States are proceeding with legislation relating to HPV vaccination. Second – it is entirely legitimate to ask what evidence supports my assertion that the current England and Wales cervical screening programme provides an 80% lifelong risk reduction from cervical cancer in women who participate. Cervical screening was introduced without any randomised controlled trial evidence. Some case-control studies were published, but these can be an unreliable source of evidence for the impact of screening[1]. This leaves only time trends in incidence and mortality as a means of attempting to work out what impact screening is having. The problem, of course, is that you can never say with certainty what the trends would have been had screening not been introduced. In 1995 Sasieni and colleagues published an important analysis of death trends by birth cohort for women born since 1910[2]. This showed that for women born from the 1930s a new phenomenon was occurring. Previously, deaths had risen up to age 60. In cohorts born since 1930, the deaths were now declining as the cohort aged, and in each cohort the start of the downturn was in the late 1980s, coinciding with the launch of our national quality assured cervical screening programme for the NHS. This provides the strongest evidence that we have for the impact of screening. More detailed statistical analyses were subsequently published, both by Sasieni and Adams[3], and independently by Quinn et al[4] that confirmed these findings. Subsequent analyses have updated these data[5], and have examined the impact according to age and frequency[6]. It is true that from all these analyses of observed mortality trends one derives only estimates, not absolute certainty, but this is where the 80% lifetime risk reduction estimate comes from. Comparison of mortality rates for different countries in Europe lends further support, since countries that lack screening are seeing a rise in death rates from cervical cancer[7]. For a complete and accessible treatment of the vexed question of how to measure the impact of screening I would refer readers to a book that will be published next month[8]. Thirdly – yes, my sentence is misleading as CIN2 is not low grade. I should have simply said “over 70% of CIN1 and CIN2”. References 1 Raffle AE. Commentary: Case-control studies of screening should carry a health warning. Int.J.Epidemiol. 2003;32:577-8. 2 Sasieni P, Cuzick J, Farmery E. Accelerated decline in cervical cancer mortality in England and Wales. Lancet 1995;346:1566-7. 3 Sasieni P,.Adams J. Effect of screening on cervical cancer mortality in England and Wales: analysis of trends with an age period cohort model. BMJ 1999;318:1244-5. 4 Quinn M, Babb P, Jones J, Allen E. Effect of screening on incidence of and mortality from cancer of cervix in England: evaluation based on routinely collected statistics. BMJ 1999;318:904-8. 5 Peto J, Gilham C, Fletcher O, Matthews FE. The cervical cancer epidemic that screening has prevented in the UK. Lancet 2004;364:249-56. 6 Sasieni P, Adams J, Cuzick J. Benefit of cervical screening at different ages: evidence from the UK audit of screening histories. Br.J.Cancer 2003;89:88-93. 7 Levi F, Lucchini F, Negri E, Franceschi S, la Vecchia C. Cervical cancer mortality in young women in Europe: patterns and trends. Eur.J Cancer 2000;36:2266-71. 8 Raffle AE, Gray JAM. Screening: evidence and practice. Oxford: Oxford University Press, 2007. Competing interests: None declared |
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Nick F Hallam, Clinical Virologist Royal Preston Hospital PR2 9HT
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I'm very grateful to Angela Raffle for responding (25 Sept) to the three points I raised about her paper. In fact my second point questioned the implied assertion that cervical screening protects against 80% of cervical intraepithelial neoplasia, rather than against 80% of cervical cancer. Her paper says "Vaccination at age 16-26 in the future II study gave only 17% overall protection against cervical intraepithelial neoplasia. Screening, which gives 80% protection, is more effective so is the policy of choice for females 16 and over." Competing interests: Adviser to Sanofi Pasteur MSD |
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