Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Not for the boys either!
- Tim J Harrison (24 October 2008)
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Over optimistic view
- Patrick Silvestre (26 October 2008)
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Important to take into consideration all scientific data on both vaccines
- Pim Kon (26 October 2008)
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Controlling Information Controls Budgets
- Graham M Kyle (28 October 2008)
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HPV and the larynx
- Peter D Bull (28 October 2008)
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Gardasil: warts and everything else ...
- Mark Struthers (28 October 2008)
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Cervical cancer vaccine in developing countries: hype or hope?
- Joseph L. Mathew, Chandigarh, India 160012 (1 November 2008)
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Who’s mad?
- Veerle Piessens, Jan De Maeseneer (4 November 2008)
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Phil Hammond, you need more adjectives
- Hanmant Ganpati Varudkar (4 November 2008)
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warts and other nonsense
- Richard J. stockley (6 November 2008)
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Full consideration of HPV vaccine
- David M Salisbury (6 November 2008)
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Genital warts - annoying? Really?
- Colm O'Mahony (6 November 2008)
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Cervical cancer and melanoma interventions contrasted
- Stephen F Hayes (7 November 2008)
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Vaccination for genital warts to prevent cervical cancer: principles first, please, before details
- Felix ID Konotey-Ahulu (12 November 2008)
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Ethical issues as well
- Paquita C. de Zulueta (9 December 2008)
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Tim J Harrison, Reader in Molecular Virology Windeyer Institute UCL, 46 Cleveland Street, London W1T 4JF
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Well said Phil! But the other side of the coin is that this typical, penny-pinching approach means that only (up to) half of the population will be protected and HPV 16 and 18 will remain in circulation. Who do the bean-counters think most females acquire their HPV infections from? Presumably, they have not heard of ano-genital carcinoma in males. The pre -MMR policy of vaccinating only pubescent girls against rubella is a paradigm for the failure of this approach to immunisation. Competing interests: None declared |
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Patrick Silvestre, General practitionner 60590 FRANCE
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Our dear colleague is surely right about the effectiveness of Gardasil in preventing warts. Nevertheless declare that these vaccines prevent 70% of cervical cancer seems quite questionable, all published study suggest the best 20 to 30%. In Gardasil ITT sudy demonstrated a percent reduction of CIN2/3 of only 12.2% As for the overall cost, it neglects the urgent need for continuing vigilance by cervical cytology, for several decades Also most cervical cancer occur in poor countries or resource–poor population of women where several hundred dollars or pounds or euros are an annual income American Cancer Society Guideline Human Papillomavirus Vaccine Use to Prevent Cervical Cancer and its Precursors HPVaccines:Today and in theFuture Anna-BarbaraMoscicki,M.D Journal of adolescent Health 43 (2008) S26-S40 Competing interests: None declared |
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Pim Kon, Medical Director GlaxoSmithKline UK UB11 1BT
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While we appreciate Dr Hammond's expertise in sexual health and his concerns regarding the burden of genital warts, his comments do not take into consideration all the scientific data for the two vaccines evaluated by the Department of Health. The Government chose GSK’s HPV vaccine following a rigorous evaluation process considering quality and duration of protection against cancer-causing HPV strains 16 and 18 and HPV strains 6 and 11 (which cause genital warts). Quality of protection against HPV strains not included in the vaccine formulation, as well as price and the manufacturing and supply of the vaccine were also evaluated. The Government's decision was based on a comprehensive review of published and unpublished clinical efficacy and safety data, some of which was not available at the time of the JCVI cost efficacy evaluation. New data for GSK's cervical cancer vaccine submitted to the Government included the demonstration of high protection against HPV 16/18 for over 6.4 years, which is the longest duration of protection reported from any cervical cancer vaccine to date. As long-term protection is an important consideration when vaccinating 12 year old girls, GSK is extending this study for up to 9.5 years in a subset of women. Since launch, Cervarix has been selected as the HPV vaccine of choice in nearly two-thirds of eligible tenders. In the UK, an average of 3,000 women are diagnosed with cervical cancer and approximately 1,000 die from the disease each year. In the UK the ongoing HPV immunisation programme will see more than 600,000 girls offered the vaccine this year and we believe the benefits of this programme will be felt by women and their families for generations to come. Competing interests: Medical Director, GlaxoSmithKline UK |
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Graham M Kyle, Consultant Ophthalmologist 86 Rodney Street, Liverpool, L1 9AR
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Dr Hammond gives a good example of the Government's plans to contain healthcare costs by controlling information, and thereby restricting choice; 'The NHS website..restricts information about treatments it doesn't wish to fund'. Suspicions had been raised when it was announced that the National Library for Health was to be subsumed into a new body 'NHS Evidence', effectively controlled by NICE (National Institute for Clinical Excellence and Health). The choice of title for the new body is worrying, given the history of NHS neologisms (or Newspeak, as George Orwell would say(1)). We already have 'NHS Trusts' and 'NHS Contracts' in an attempt to persuade the public that the NHS was business-like, although neither term comes within the proper legal definition of a trust or contract. Especially when tainted with the 'NICE' brand name, the public are likely to see through 'NHS Evidence' as an attempt at political justification for rationing which, presumably, is the real reason for the changes. Reference: Orwell G. Nineteen Eighty Four, A Novel. London: Secker and Warburg, 1949. Competing interests: GMK is a member of the External Reference Group of the Eyes and Vision Specialist Library, National Library for Health |
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Peter D Bull, retired paediatric otolaryngologist sheffield Children's Hospital S10 2TH
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Dr Hammond correctly draws attention to the decision to use the bivalent vaccine against HPV16 & 18 in the NHS. Sadly, this choice has missed the opportunity to protect against HPV 6 & 11 which are the cause not only of genital warts but of recurrent respiratory papillomatosis. This is a terrible and life-threatening disease which commonly presents in infancy and which in at least 50% of cases is associated with maternal genital warts during pregnancy. The children require regular and sometimes frequent treatment under general anaesthesia and suffer considerable morbidity. Immunisation with the quadrivalent vaccine held the promise of a reduction in the incidence of RRP, an opportunity now lost. It has been estimated that the cost to the US of treating RRP amounts to $150million per annum (Derkay 1995)and there will be a proportionate cost in the UK which does not seem to have been considered when making the choice of vaccine for use in the NHS. Peter Bull Competing interests: I have been funded by Sanofi Pasteur MSD to attend two meetings in 2007 to consider the development of a European database of cases of recurrent respiratory papillomatosis. |
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Mark Struthers, General Practitioner Bedfordshire, UK
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Judicial Watch is a non-partisan educational foundation based in Washington, DC. [1] In June this year, the organisation produced a special report on Gardasil after examining the FDA's HPV vaccine records obtained under Freedom of Information Act (FOIA). [2] I do not believe that Phil Hammond can have read this report. Having read it, I can not believe that he'd have been mad enough to inject his daughter with Gardasil, warts and all, whatever the cost. Far from protecting against genital warts, it appears that the vaccine may actually induce them in some children. In the Vaccine Adverse Event Reporting System (VAERS) reports obtained by Judicial Watch there were 78 separate cases where, after receiving the vaccine, patients experienced outbreaks of warts. Here are two excerpts from the VAERS reports, "Two days after receiving the first dose of Gardasil, the patient developed groin warts. There is no known history of these warts. The patient came back in about a month later and was given the second dose of Gardasil. A few days after receiving the second dose, the patient had a huge outbreak of warts. VAERS ID: 292052-1" "Information has been received from a consumer concerning her 17-year -old daughter with no medical history and an allergy to sulfa, who on 28- SEP-2007 was vaccinated with a first dose of Gardasil . . . Prior to being vaccinated with Gardasil the patient was tested for HPV and genital warts and all her test came back negative. On 15-OCT-2007 the patient experienced a fever, and broke out with white bumps that were diagnosed as genital warts. VAERS ID: 301339-115" And outbreaks were not limited to genital warts; some patients experienced outbreaks of warts on the face, hands, and feet. Go figure! [1] http://www.judicialwatch.org/about.shtml [2] A Judicial Watch Special Report. Examining the FDA’s HPV Vaccine Records.Detailing the Approval Process, Side-Effects, Safety Concerns and Marketing Practices of a Large-Scale Public Health Experiment. June 30, 2008 http://www.judicialwatch.org/documents/2008/JWReportFDAhpvVaccineRecords.pdf Competing interests: None declared |
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Joseph L. Mathew, Assistant Professor Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India 160012
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Recently, there has been aggresive marketing and promotion of cervical cancer vaccines in India. This has taken two forms viz academic and commercial. The former is done through numerous national, regional and local sponsored presentations by eminent national and sometimes international experts, usually for a fee. The latter is through press conferences, public 'education', setting up an 'information help-line' and widespread adversting and promotional campaigns. Against this backdrop, the Indian Academy of Pediatrics (IAP) recently published their recommendation to include HPV vaccine for routine use in all girls at the age of 10-12 years (1). The 'scientific basis' for this was stated to be: (i) cervical cancer is the most common cancer and cancer related cause of death in Indian women as per India's national cancer registry; (ii) it is responsible for 132000 cases and 74000 deaths as per the same data source, (iii) compliance with annual Pap smear screening is low, and (iv) the currently available vaccines are safe and efficacious. In response to these statements, I dashed off a letter to the Editor of the journal to try and set the record straight, but this was rejected for publication. Some of the relevant issues have been highlighted in the current correspondence in the BMJ. Some others also merit attention. These are given below. A) Data from the Indian National Cancer Registry(2,3) show that (i) cervical cancer is the second most frequent malignancy in women after breast cancer, (ii) the total number of cases recorded is 7012, (iii) mortality is around 20%, unlike 56% suggested, and (iv) incidence is maximal beyond the fifth decade and not in younger age-groups. Therefore, HPV vaccination must guarantee protection for at least 3-4 decades after primary immunization in order to be a useful public health intervention. Of course, it may be argued that certain extrapolations were made to arrive at the high estimate of disease burden, but the fact is that the data quoted does not match the source. B) The IAP recommended that the vaccine be administered only to those who can afford to pay for it. This statement appears to be intended primarily to boost vaccine sales; if HPV vaccine has scientific merit suggesting benefit for women at high(er) risk of cervical cancer, it must be recommended for those who need it, rather than only those who can afford it. C) The critical issue of effectiveness (does the vaccine do what it is supposed to?) is confused with efficacy (what is the immune response to vaccination?). Not surprisingly, the following additional issues have been missed altogether: (i) the lack of practical experience in prevention programmes world-wide, (ii) questionable acceptance of a vaccine to prevent a sexually acquired infection that can sometimes (but not always) cause cancer, and that too only if vaccination is completed before exposure, (iii) the vaccine does not protect against all causes of cervical cancer, hence HPV vaccine is not synonymous with cervical cancer vaccine, (iv) the fact that it cannot replace annual screening programmes for cervical intra-epithelial neoplasia and (v) some developed countries have rejected a vaccination programme on these grounds (4). These facts suggest that currently, there is more hype than hope with available HPV vaccines; in the context of developing countries. References 1. Indian Academy of Pediatrics Committee on Immunization (IAPCOI). Consensus recommendations on immunization, 2008. Indian Pediatr 2008; 45: 635-648. 2. Indian Council of Medical Research. National Cancer Registry Programme. Consolidated Report of Population Based Cancer Registries 2001- 2004, December 2006 3. Indian Council of Medical Research. National Cancer Registry Programme. Consolidated Report of the Hospital Based Cancer Registries: 2001-2003, December 2006. 4. Reduction in the risk of cervical cancer by vaccination against human papillomavirus (HPV) - a health technology assessment. Copenhagen: National Board of Health, Danish Centre for Health Technology Assessment, 2007; 9(1): 1-14. Accessed from www.dacehta.dk Competing interests: None declared |
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Veerle Piessens, General Practioner 9000 Ghent, Jan De Maeseneer
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Who’s mad not to protect his daughter against genital warts if he can afford to? The real parent who should pay an extra £350 instead of accepting the public funded bivalent vaccine or the government as the symbolic parent who’s mad not to pay for the more expensive option of the quadrivalent vaccine. It may be clear that the main objective is to prevent cervical cancer and deaths from CC. The prevention of genital warts is not on the prevention priority list, not because it’s not an annoying problem, but mainly because it’s not a major health problem and of all the health problems public health has to deal with (and has to save resources for), genital warts are probably rather low on the priority list. Although some will invest a lot of money and energy to make us believe- apparently with great success– that genital warts are a major health problem. The symbolic parent has already spent a lot of money for a preventive intervention that eventually might be effective, but that lacks until now reassuring evidence that the protection will last without need for boosters and other vaccines to deal with shifts to other HPV-types.1,2 So, if this parent can offer the same protection against the relevant health problem cervical cancer with the bivalent vaccine at a lower cost, it seems not to be a sign of madness but of good sense. The same applies tot the real life parent. The yearly risk your child gets a genital wart is 0,3%3. The quadrivalent vaccine lowers the risk, but for how long? So, are you mad not to spend £350 to lower this low risk of this not extremely important health problem? Perhaps it might be interesting to imagine what other preventive things you could offer your child for £350: a bicycle helmet, a nice box of condoms, a smoke-free-house-sticker, a good filled fruit basket on the kitchen table, … . Veerle Piessens, MD, Jan De Maeseneer, PhD, MD. Dpt. of General Practice and Primary Health Care, Ghent University, Belgium. Conflicts of interests: none. 1. La Revue Prescrire Février 2007/ TOME 27 N° 280, p89-93. 2. La Revue Prescrire Février 2008/ TOME 28 N° 292, p91. 3. http://www.thehpvtest.com/About-HPV/Genital-Warts-FAQs.html Competing interests: None declared |
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Hanmant Ganpati Varudkar, Professor and Head, Department ofPulmonary Medicine,Mamata Medical College, Khammam, A.P.India,
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I am a pulmonologist and therefore I am at the receiving end in this subject.Without studying the original article of Dr. Phil Hammond about vaccination against genital warts I gathered following impressions.
Phil has probably worked and studied this subject in depth and therefore he is biased. As common reader I would like to ask these question
If we could consider these questions the picture will be clear. Either this concept is not acceptable or it may applicable to many other conditions Competing interests: None declared |
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Richard J. stockley, G.P. Kampala. Uganda
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Blogs abvout the HPV vaccine simply reinforce my view that an awful lot of nonsense is found on the web. Warts appearing 2 or 3 days after a vaccine blamed on the vaccine? Give us a break! Competing interests: None declared |
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David M Salisbury, Director of Immunisation Department of Health SW1A 2NS
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Sir, It was unfortunate that Dr. Hammond wrote his piece without asking us for the basis on which the choice of HPV vaccine was made - we would have been delighted to give him the information. We gave full consideration to all of the issues raised by Dr. Hammond and much more that was scientific, logistic and economic. We used the cost-effectiveness analysis (Jit et al BMJ 2008) to allocate points for quality of scientific information on protection against cervical cancer, protection against warts, logistic details such as stability out of the cold chain and only after the scoring was completed were the prices revealed. Again using the Jit et al analysis, the prices were scored for cost-effectiveness in balance with the other factors. The scoring system had been shared in advance with the manufacturers. In central contracts, the price offered by manufacturers can differ considerably between products and against the list price. We took full account of the burden of genital warts and the benefits that might come from vaccinating males. Perhaps Dr. Hammond might have asked himself how much he was prepared to pay to prevent genital warts; I assume that even he must have a figure in mind beyond which it would not be cost-effective to use a quadrivalent vaccine. Professor David M Salisbury CB FRCP FRCPCH FFPH
Competing interests: None declared |
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Colm O'Mahony, Consultant in Sexual Health Countess Of Chester Hospital Chester CH2 3AF
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I can't believe the naievity of anyone dismissing genital warts as annoying. Ask any of the 800 new patients who come through my clinic each year or indeed any of the 100,000 UK new cases if they consider it annoying. as Phil Hammond said, take as look at my website www.chestersexualhealth.co.uk in the wart section and tell me you still think it's just an annoying nuisance. Both vaccines are so far equally effective for HPV 16 and 18. It will be many years before we know if one has longer efficacy then the other. The DoH estimated the cost of wart treatment at an all time low of £134 per patient. The cost here in my clinic is aprox £423 per patient. Even first visit PBR at my hospital is £153 and follow up is £90. Most warts need a few visits - do the maths! Despite GSK's assertion of winning eligible contracts I am not aware of ANY country that has chosen Cervarix as the national vaccine? Also what is the issue with Cervarix and the USA? Why won't the FDA approve it? Have they concerns that the Briish don't know about? Now that top up payments are in the clear can parents top up and but Gardasil? The NHS price of both vaccines is £80 per shot, 3 shots are needed. Competing interests: I've recieved lecture fees from GSK and Sanolf Pasteur MSD |
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Stephen F Hayes, GPwSI in dermatology The Canute surgery, 66A Portsmouth road, Southampton SO19 9AL
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Dear Sir I would like to contrast the introduction of an expensive new vaccine to further reduce cervical cancer mortality with the failure to address the problem of poor skin lesion recognition skills of British GPs. Intervention to improve those skills could reduce skin cancer mortality, which exceeds that from cervical cancer. Melanoma mortality could probably be significantly reduced by targeted education and the use of new technology. In 2006 malignant melanoma skin cancer killed 1,852 UK citizens (1) versus 949 for cervical cancer (2). Clearly great strides have been made in protecting women from this important disease, and the introduction of HPV vaccine should reduce mortality further, but women also die from skin cancer, as do men, and we are not doing enough about it. Universal screening and now a very costly new vaccine are deployed against cervical cancer, but there is no programme to reduce the greater mortality from skin cancer. Early diagnosis saves lives, but this depends on patients presenting early, and excellent GPs lesion recognition skills, which continue to be inadequate, as a Parliamentary enquiry found. (3) The NICE guidance on skin cancer has encouraged GPs to refer more patients to hospitals but has done nothing to improve their skills, and by banning most GPs from doing any skin cancer work may even lead to loss of skills. Furthermore, QOF payments in the new GP contract inevitably divert limited resources away from areas which they do not reward, which includes the whole area of skin disease. We have too few dermatologists (420 for the UK against 2,300 in Spain, 3,000 in Italy and 8,000 in France). This is not due to a lack of bright young doctors who wish to train in the specialty, but to centrally imposed limits on trainee numbers. One consequence of this is too little dermatologist time for teaching medical undergraduates, GPs and other health workers.(3) The new diagnostic technique of dermoscopy has been shown by numerous international studies to improve lesion recognition in trained hands (4), but it is not being rolled out into the community. The private sector offers anxious patients mole screening using modern dermoscopic technology. Many GPs are interested in the technique but courses and mentoring are hard to come by and there are no incentives. While much new money is being directed to further reduce a falling annual mortality due to one specific cancer, there are no plans to deploy evidence based interventions against another specific cancer which kills twice as many and is on the increase. Is this another example of resources being determined more through special interest lobbying rather than equitable and evidence based planning? (1) http://info.cancerresearchuk.org/cancerstats/types/skin/mortality/?a=5441 (2) http://info.cancerresearchuk.org/cancerstats/types/cervix/mortality/?a=5441 (3) http://www.skincarecampaign.org/docs/APPGS/New%20APPG%20on%20Skin%20calls%20for%20reforms.doc (4) http://www.library.nhs.uk/Cancer/ViewResource.aspx?resID=282773 Competing interests: SH uses and teaches dermoscopy, works in a skin cancer clinic and is a trustee of the Primary Care Dermatology Society |
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Felix ID Konotey-Ahulu, Kwegyir Aggrey Dsitinguished Professor of Human Genetics, University of Cape Coast, Ghana Consultant Physician Genetic Counsellor in Haemoglobinopathies, 10 Harley Street, London W1G 9FJ
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Vaccination for genital warts to prevent cervical cancer: principles first, please, before details There are at least 3 interlinked perspectives from which vaccination against cervical cancer can be looked at by someone: (a) As a public health measure (b) As a vaccine manufacturer (c) As a parent of daughters. Dr Phil Hammond (26 Oct) has done very well to discuss all these to some degree [1]. VACCINATION AS A PUBLIC HEALTH MATTER With “100,000 new cases in England each year “ [1] “the current estimate of treating genital warts in England every year is £23 million …” [1]. Any responsible government would want to do something about the problem. But is vaccinating every 12 year old girl the best antidote to this problem? Especially when Dr Patrick Silvestre says all published study suggest the cancer preventing efficacy of vaccination is just “20 to 30” [2]? VACCINATION FROM PERSPECTIVE OF MANUFACTURERS Manufacturers are in the business of selling drugs and vaccines. Their products need careful probing to verify claims of efficacy and safety. One of the 2 vaccines under discussion is effective for only HPV strains 16 & 18, while the other that covers HPV strains 6 & 11 has been known (perversely) to proliferate warts all over the body [3]. Moreover, the government preferred option does not afford protection against recurrent respiratory papillomatosis (RRP). These HPV 6 & 11 strains are “the cause not only of genital warts, but of recurrent respiratory papillomatosis” [4]. VACCINATION FROM PERSPECTIVE OF A PARENT Phil Hammond quotes “a sexual health consultant” as saying “You would be mad not to protect your daughter against genital warts if you can afford to” [1]. The way he would protect his 12 year old daughter would be by taking the government’s advice and vaccinating her with a vaccine that is not only NOT fool proof, but also could be hazardous. Some other parents, including myself “would be mad” to choose that method to protect our 12 year olds for the future, reminding me of what a chief in my Manya Krobo tribe in Ghana once articulated. THE TRIBAL CHIEF’S PRIORITIES During a trip around sub-Saharan African countries studying AIDS at the grass roots [5], I mentioned in a Public Lecture that the Europeans and Americans were in the process of producing a vaccine for HIV/AIDS. “What?” exclaimed one tribal chief sitting in the front row “You mean they are going to prick us with needles so we can do what we like?” [6]. I thoroughly identify with this fellow tribesman. Do I teach my 12 year old daughter the ethics of sexual discipline, or do I ask her to go with the crowd to be pricked with needles so she can do what she likes? And that brings me to government diktats and fiats in areas of parental responsibility. GOVERNMENT INVADING PARENTAL TURF WITH SEX EDUCATION Of course, responsible parents are entitled to choose what they consider to be best for their daughters: Go with government recommendation, however inadequate, or take their own parental initiatives in the interest of their child’s health. I for one shall go along with my tribal chief. But what does one do when the content of government education material on sex education for children leaves a lot to be desired? Take this headline in the Daily Telegraph: “Children aged five to get sex education” [7], the first paragraph of which article begins: “Children as young as five will be given sex education under Government plans to cut teenage pregnancy and sexually transmitted diseases” [7]. Another “Government” initiative headlined “Oral sex lessons to cut rates of teenage pregnancy” [8], which elaborated: “Encouraging schoolchildren to experiment with oral sex could prove the most effective way of curbing teenage pregnancy rates, a government study has found” [8]. CONTENT OF THE SEX EDUCATION PROGRAMME Would the sex education material include information on gonorrhoea of the throat? Would the children be told of the risks to which phallic bruising of the palate exposes them with oral sex? [9] Would they be informed that HIV/AIDS has been known to be contracted through oral sex? [10 11 12]. Would the advisers of government, namely Chief Medical Officer and National Institute of Clinical Excellence (NICE) make sure that this information was also included in the planned sex education for school children? Dr Tom Stuttaford, the very experienced Health Expert of The London Times wrote on Monday 10 November 2008: “As 99.7% of cases of cervical cancer can be shown to have resulted from HPV infection, and more than 75 per cent of sexually active women have at some time been infected by HPV, the search for a vaccine that would spare women this hazard was intense” [13] He went further: “Vaccination is offered early to girls at about 12 or 13, as by that age 10% of them are sexually active”. But the question worrying some parents is this: “Why should, for the sake of 10% who are sexually active, Government recommend that 100% of girls at 12 be vaccinated?” If the answer is “we do not know which 10% of these 12 year- olds are sexually active”, the retort naturally becomes: “Do you therefore introduce sex education in the kindergarten to increase the proportion of sexually active children from 10%?” You see, when you teach little children Geography, they have an intense desire to travel. When you teach them about sex, what stops them rushing out to do it? Dr Stuttaford’s article in The Times warning people to take care over the Christmas Season is accompanied by a picture of a couple passionately locked in kissing, oblivious of the fact that people who do different things with their mouth can pass on Chlamydia through a harmless pastime like French kissing. Passing from the UK scene to what I have seen overseas, there is risk taking and risk taking. Those who take obvious risks, as described below, will welcome anything to help them prevent diseases. But those African parents who teach their children to behave themselves are paranoid about new vaccines especially when they have read that population control agencies have sometimes laced vaccines with contraceptives [14]. BY ALL MEANS VACCINATE RISK TAKERS During my fact finding tour of African countries studying AIDS [5 15 16 17] I interviewed no less than 125 international prostitutes on duty. The East/Central Africans were more independent than the West Africans which latter were usually controlled by treacherous pimps and unscrupulous Madames. Some of these West African prostitutes who travelled to Abidjan for sex were subjected to on average of 20 coital acts in a day by sailors and tourists for between 50 to 100 dollars per act. I learnt from some of the girls that, Tafracher, [18] they allowed both anterior and posterior (vaginal & anal) intercourse depending on client requests, while the pimps collected the money [19 20]. When they became ill and were repatriated home to Ghana to die, I visited and examined some of them at home [19 20 (page 106) 21 22 23] and treated their infections including genital warts “that allow AIDS virus to invade the body” [20 page 91]. The state of the perineum of some of these girls was such that I described it as “perineal devastation” [21 22]. Indeed, visiting their homes as I did with a local team [23 24] one could easily identify those girls with disintegrated perineum by how they sat. They would never sit on a chair, but always on the open end of a bucket – the so-called “Matekole sign” [21]. Examining them indoors with a female chaperone, those accompanying me often could not bear the sight of the grotesque genital warts and asked permission to get out of the room [24]. Photographs I took can never be shown in a public lecture. But the point of all this is as follows: These girls received less than 50 pence per coital act in Ghana in the sex business, while crossing the national border to Ivory Coast fetches nearly 100 times that amount per act. One lady I treated in the tribe not only returned in less than a year to go to Abidjan again for foreign exchange, but when she later died from AIDS, her younger sister who had just come out of school was lured by pimps to go to Abidjan for foreign exchange, at the expense of her health. “O Dorkita” her mother said to me in the tribal language when she saw my sheer astonishment: “O Dorkita, Wa be noko!” (O Doctor, we have nothing!) [20 page 43]. So even with a 20 to 30 percent success rate of a vaccine doing any good, I would recommend vaccination for these risk takers. We had tried to get light industries for them in my tribe to stop them traveling abroad in the sex trade [17], but the control of the pimps and Madames proved far too strong. In any case, as Joseph Matthew has just pointed out [25], in the developing countries the cervical cancer vaccination drive “is more hype than hope with the available HPV vaccines” SEX AND ETHICS FOR OUR SCHOOL CHILDREN The principle of parental instruction of our 12 year olds about sex requiring discipline with an ethical dimension is a far more important priority than assuming that what these girls need for their future good is pricking them with needles so they can do whatever pleases them. Felix I D Konotey-Ahulu MD(Lond) FRCP DTMH FGA FGCP FAAS FTWAS FWACP
felix@konotey-ahulu,com Conflict of Interest: None declared 1 Hammond P. (Not) warts and all. BMJ 2008; 337:a2186 2 Silvestre P. Over optimistic view. BMJ Rapid Response Oct 26 2008 http://www.bmj.com/cgi/eletters/337/oct23_1/a2186#203716 3 Struthers M.Gardasil: warts and everything else …BMJ Rapid Response 28 Oct 2008 http://www.bmj.com/cgi/eletters/337/oct23_1/a2186#203842 4 Bull Peter. HPV and the larynx. BMJ Rapid Response 28 Oct 2008. http://www.bmj.com/cgi/eletters/337/oct23_1/a2186#203800 5 Konotey-Ahulu FID. Clinical epidemiology, not epidemiology, is the answer to Africa’s AIDS problem BMJ 1987; 294: 1593-1594. 6 Konotey-Ahulu FID. AIDS in Africa. Lancet 2002; 360: 1424 (2 November) 7 Paton Graeme. Children aged five to get sex education. Daily Telegraph, London Thursday October 23 2008. 8 Townsend Mark. Oral sex lessons to cut rates of teenage pregnancy http://www.guardian.co.uk/uk/2004/may/09/society.schools - 72k The Guardian/ The Observer Sunday 9 May 2004 9 Konotey-Ahulu FID. Extensive palatal echymosis from felatio – a note of caution with AIDS at large. British Journal of Sexual Medicine 1987; 14: 286-287. 10 Goldberg DJ, Green ST, Kennedy DH, Emslie JAN, Black JD. HIV and orogenital transmission. Lancet 1988; ii; 1368. 11 Rozenbaum W, Gharakahanian S, Cardon B, et al. HIV transmission by oral sex. Lancet 1988; i: 1395. 12 Spitzer PG, Weiner NJ. Transmission of HIV infection from a woman to a man by oral sex. New England Journal of Medicine 1989; 320: 251. 13 Stuttaford Tom. HPV: An unwanted gift at Christmas. The Times, 10 Nov 2008 http://www.timesonline.co.uk/tol/life_and_style/health/expert_advice/article5109830.ece 14 Miller, James A. Are new vaccines laced with birth control drugs? HLI Reports 1995; Human Life International, Vol 13: Number 2. 15 Konotey-Ahulu FID. Slowing HIV contagion among Africans. International Journal of STD & AIDS 1991; 2: 139 16 Konotey-Ahulu FID. AIDS in Africa: Another perspective. International Pharmacy Journal 1992; 6: 92-99 (English & French – Invited Paper) 17 Konotey-Ahulu FID. An African on AIDS in Africa (Guest Editorial). The AIDS Letter – Royal Society of Medicine 1989, No 11, Feb- March 1989, 1-3. 18 Konotey-Ahulu FID. Tafracher – Personal View. An invaluable Ghanaian devulgarizing word. BMJ 1975; 1: 329. 19 Konotey-Ahulu FID. The AIDS crisis in Africa: a survey. In Appropriate Technologies for AIDS Management in Africa: Editor Kihumbu Thairu, 3-7 September 1990 Kenya Medical Research Institute, Nairobi. Commonwealth Secretariat, London pages 42-44. 20 Konotey-Ahulu FID. What Is AIDS? Tetteh-A’Domeno Company, Watford, England 1989 [ISBN: 0 9515442 0 9] 21 Konotey-Ahulu FID. Some thirty features of AIDS in Africa. Annales Universitaires des Sciences de la Sante 1987; 4: 541-544 22 Konotey-Ahulu FID. Origin and transmission of AIDS. Journal of Royal Society of Medicine 1987; 80: 720. 23 Quartey JKM, Konotey-Ahulu FID. The domiciliary management of AIDS in a rural community in Africa. In: Appropriate Technologies for AIDS Management in Africa, 3-7 September 1990, Kenya Medical Research Institute, Nairobi. Commonwealth Secretariat London pages 42-44. 24 Quartey JKM, Konotey-Ahulu FID, Bentsi Cecilia, Antwi Phyllis, Gboloo D, Ofori Monica, Ofei Beatrice, Amegayao Gertrude. Domiciliary management and prognosis of AIDS in the Krobo tribal region of Ghana. In: The Global Impact of AIDS, First International Conference, London 8-10 March 1988 (Abstract W28) 25 Matthew L J. Cervical cancer vaccine in developing countries: hype or hope? BMJ Rapid Response http://www.bmj.com/cgi/eletters/337/oct23_1/a2186#204027 (Nov 1) Competing interests: None declared |
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Paquita C. de Zulueta, GP/Hon Senior lecturer Dept Primary Care and Social Medicine. Imperial College, Charing Cross Campus.W6 8 RP
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Phil Hammond makes a compelling case for vaccinating daughters with Gardesil rather than Cervarix although I know that this has been contested by the latter's manufacturers. Incidentally Gardesil appears to have fewer side effects as well. But there are other ethical issues at stake here. Of great concern is that the age groups at particularly high risk of HPV infection (and subsequent cervical dysplasia) are not being offered protection until too late i.e 14-16 year olds. Since the figures show that around 40% of fifteen year old girls are sexually active in the UK, waiting until 2009/10 for their first vaccine is not much use. The Health Protection Agency is not forthcoming for advice regarding this age group. Even more troubling is that the postponement till 25years for the first smear test means that some young women may be harbouring carcinogenic strains of HPV for at least ten years at the time of their first test. These policies represent covert rationing, but since it involves teenage sexuality, there is little fuss. This is typical of the unhelpful stance taken towards young people in this country. We seem to be incapable of helping teenagers from (unplanned) early pregnancies and we now abandon them to preventable diseases. Take the case of the sensible well informed fifteen year old in a stable relationship. She seeks contraceptive advice from her GP. She is duly given the contraceptive pill. She then asks for the vaccine as she knows that it will confer protection against a carcinogenic virus. She has an older sister who had to have unpleasant treatments for cervical dysplasia and she particularly wants to avoid this risk. Her GP refuses to supply her with the vaccine or provide a private prescription or even give her advice as to where she could obtain it. Is this ethical? There is a clear duty of care here and an ethical responsibility towards vulnerable patients which is being ignored. Imagine if someone was going to a malarious area and needed a doctor's prescription for the appropriate anti -malarial. The GP refuses to supply the patient with a script or provide advice, even though she will be at significant risk of becoming infected. Would that be ethically or legally acceptable? Both Gardesil and Cervarix are licensed as prophylaxis for 15 and 16 year olds. Simply saying 'we don't do it here' is not good enough. Competing interests: None declared |
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