Rapid Responses to:

LETTERS: David M Salisbury Government fully considered HPV vaccine BMJ 2008; 337: a2552 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

HPV is not only about genital warts and cervical cancer.

Desmond A Nunez   (28 November 2008)

The Government's Bottom Line?

Gee Yen Shin   (2 December 2008)

HPV is not only about genital warts and cervical cancer. 28 November 2008
Desmond A Nunez, ENT Director ENT Unit, Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB Send response to journal: Re: HPV is not only about genital warts and cervical cancer.	Dear Sir: Mr Salisbury goes some way to provide assurance that the Government fully weighed up the pros and cons of a bivalent as opposed to a quadrivalent vaccine for cervical cancer prophylaxis but I am concerned that his letter1, Jit et al’s paper2 and Hammond’s response3 all fail to mention that HPV6 and 11 cause not only genital warts but Recurrent Respiratory Papillomatosis (RRP). RRP is a potentially fatal condition presenting between the ages of 3-5 years 231 times more frequently in children born to mothers with genital tract warts4 than in other children. The condition is difficult to control causes airway compromise or dysphonia and requires multiple airway procedures under general anaesthesia per year over the course of several years5. The economic costs of managing a single case of juvenile onset RRP in the USA is estimated at $201,724 USD6. If there were an increase in genital warts secondary to targeting HPV16 and HPV18 with a bivalent vaccine the burden will not only be the discomfort of a proportion of the sexually active population. Desmond A Nunez Chairman European Recurrent Respiratory Papillomatosis Network d.a.nunez@bristol.ac.uk 1. Salisbury DM. Government fully considered HPV vaccine. BMJ 2008;337:a2552. 2. Jit M. Economic evaluation of human papillomavirus vaccination in the United Kingdom. BMJ 2008;337:a769. 3.Hammond P. (Not) warts and all. BMJ 2008;337:a2186. 4. Silverberg MJ, Thorsen P, Lindeberg H, Grant LA, Shah KV. Condyloma in pregnancy is strongly predictive of juvenile-onset recurrent respiratory papillomatosis. Obstet.Gynecol. 2003;101(4):645-52. 5. Nunez DA. Recurrent Respiratory Papillomatosis: case report and literature review. Paediatriki 2008;71:162-164. 6. Bishai D, Kashima H, Shah K. The cost of juvenile-onset recurrent respiratory papillomatosis. Arch Otolaryngol Head Neck Surg. 2000 Aug;126(8):935-9. Competing interests: DAN has provided expert advice to Sanofi Pasteur MSD and GlaxoSmithKline. The European Recurrent Respiratory Papillomatosis Network of which he is chairman recieves research funding from Sanofi Pasteur MSD.
The Government's Bottom Line? 2 December 2008
Gee Yen Shin, Locum Consultant Virologist Directorate of Infection, St Thomas' Hospital, London SE1 7EH Send response to journal: Re: The Government's Bottom Line?	Sir, I note that both the Department of Health[1] and GlaxoSmithKline (GSK)[2] responded to Phil Hammond's recent BMJ article, "(Not) warts and all"[3] on the British Government's choice of the bivalent HPV vaccine, Cervarix (manufactured by GSK) over the quadrivalent HPV vaccine, Gardasil (marketed in Europe by Sanofi-Pasteur MSD). Dr Hammond has obviously touched a raw nerve. As a virologist, I think an opportunity to protect a population against two vaccine-preventable conditions i.e. cervical neoplasia and genital warts as opposed to cervical neoplasia alone has been missed. This missed opportunity cannot be measured in pounds and pence. The cost-effectiveness analysis of the two competing products appears to have clinched the deal for GSK’s product. I do not question the thoroughness or accuracy of the Health Protection Agency's work in this area[4]. However, isn't the real crux of the matter the fact that the cupboard is bare and this country simply cannot afford anything but the cheapest option? According to the Office for National Statistics (ONS), public sector net debt at the end of October 2008 was an eye-watering £640,900,000,000 (£640.9 billion)[5]. That was before the Chancellor of the Exchequer delivered this year’s Pre-Budget Report, which will see Government debt reach £1,000,000,000,000 (£1 trillion) within a few years[6]. The so-called “Credit Crunch” has been brewing since early 2007[7]. A mushrooming of national debt was predictable long before the Government had to choose between the bivalent and the quadrivalent HPV vaccine. It is no wonder the British Government selected the bivalent HPV vaccine. If I had debts of £641 billion and rising, I'd go for the cheaper option too. References [1] Salisbury D. Government fully considered HPV Vaccine BMJ 2008;337:a2552 [2] Kon P. All data on both vaccines must be considered. BMJ 2008;337:a2554 [3] Hammond P. (Not) warts and all. BMJ 2008;337:a2186. (23 October) [4] Jit M, Choi HY, Edmunds WJ. Economic evaluation of human papillomavirus vaccination in the United Kingdom. BMJ 2008;337:a769. (17 July.) [5] Office for National Statistics. Public Sector Finances October 2008 http://www.statistics.gov.uk/pdfdir/psf1108.pdf (accessed 2/12/08) [6] Pre-Budget Report 2008: Tax hit to fund £20 billion fiscal stimulus. Financial Times 24 November 2008 http://www.ft.com/cms/s/0/4a9f5776-ba36-11dd-92c9- 0000779fd18c,dwp_uuid=7cdbbb7e-84aa-11dd-b148- 0000779fd18c.html?nclick_check=1 (accessed 2/12/08) [7] Credit Crunch in U.S. upends global markets. The Washington Post 10 August 2007 http://www.washingtonpost.com/wp- dyn/content/article/2007/08/09/AR2007080900311.html (accessed 2/12/08) Competing interests: I have indirect financial interests in GSK, Sanofi-Pasteur and MSD through listed collective investment vehicles which own shares in these companies.