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Views & Reviews Personal View

(Not) warts and all

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2186 (Published 23 October 2008) Cite this as: BMJ 2008;337:a2186
  1. Phil Hammond, general practitioner, writer, and broadcaster
  1. hamm82{at}msn.com

    “You’d be mad not to protect your daughter against genital warts if you can afford to.” So advised Peter Greenhouse, a sexual health consultant in Bristol, when I asked him which human papillomavirus vaccine I should choose for my daughter. The NHS vaccination programme may have opted for the bivalent vaccine (Cervarix) to concentrate resources on preventing cervical cancer, but every doctor I’ve spoken to has chosen the quadrivalent vaccine (Gardasil) for their own daughters (and the odd son, though of course this is off licence).

    Genital warts are common (100 000 new cases in England each year), and the condition is on the rise, particularly among young people: in women 60% of cases occur in the 16-24 years age group. They don’t kill you, but they can kill your sex life, and in some people they can be recurrent and extensive. The health minister Dawn Primarolo claims that warts are “preventable,” but meticulous condom use cuts transmission of the human papillomavirus by only 50%. A far safer option is to vaccinate.

    The NHS Choices website (www.nhs.uk) promotes Cervarix but doesn’t return a single hit for Gardasil. Having chosen one vaccine for us, the government has decided we don’t need information about another that could prevent 90% of warts (as well as 70% of cervical cancer). Those administering Cervarix at my daughter’s school offer no information about Gardasil. Whatever happened to informed choice?

    The NHS vaccination site (www.immunisation.nhs.uk) is also a Gardasil free zone. An editorial in Sexually Transmitted Infections (2008;84:251, doi:10.1136/sti.2008.032755) describes the government’s decision as “a sad day for sexual health.” The decision also doesn’t seem to make long term economic sense. Within three or four years, the editorial says, the use of Gardasil “would begin to have a big financial payback, as the current estimate of treating genital warts in England every year is £23 million [€30m; $40m].”

    So why did the government opt for Cervarix? The Joint Committee on Vaccination and Immunisation is most illuminating. “If the vaccines were offered at similar prices, then the committee recommended choosing the quadrivalent vaccine, which would protect against cervical cancer and genital warts,” said a committee statement (www.advisorybodies.doh.gov.uk/jcvi/HPV_JCVI_report_18_07_2008.pdf). The British National Formulary gives exactly the same price (£80.50 for each of three injections) for the two vaccines, so GlaxoSmithKline (GSK), which makes Cervarix, offered a discount to undercut Gardasil’s manufacturer, Sanofi Pasteur.

    I have no issue with this. New drugs are ludicrously expensive, and the NHS deserves credit for beating GSK down. Or perhaps GSK was desperate to break into a market dominated in most other developed countries by Sanofi Pasteur. The size of the discount is “commercially confidential,” said my MP, Dan Norris. I asked him about this because I wanted to “top up” the difference so that my daughter can have Gardasil with her classmates, within the NHS programme. But this choice, apparently, is not allowed.

    Parents who choose Gardasil will almost certainly have to pay privately for it. The going rate in local general practices seems to be £350 to £400. We can (reluctantly) afford this, but many parents can’t. My primary care trust allows those in the vaccine programme to have Gardasil if there is “a specific clinical need,” without defining what this means. For girls who are particularly at risk of genital warts (for example, those with type I diabetes or extensive verrucas or hand warts) or skin conditions that make genital warts particularly unpleasant (such as extensive psoriasis or eczema), it seems unethical not to offer them Gardasil. And how long will it take for a woman with warts to sue the NHS for not offering her the choice? Doctors are supposed to use clinical judgment in individual cases, but the pressure to reduce prescribing costs is relentless.

    The cheap GSK deal for Cervarix applies only to vaccines in the programme. Outside the programme many doctors will recommend Gardasil, because of the extra protection it offers, so we may end up with all women in the programme getting Cervarix and most outside it getting Gardasil. This clearly has the potential to undermine the programme (or at least it would if anyone was brave enough to shout about genital warts).

    For any licensed treatment, the public (and NHS staff) need quick and easy access to unbiased data on efficacy and safety, updated as it emerges. The NHS website would seem to be a logical gateway for this, but it currently restricts information about treatments it doesn’t wish to fund. Vaccination programmes have a coercive flavour, but some parents, quite legitimately, may want to delay vaccination until more comprehensive safety and efficacy data emerge (http://content.nejm.org/cgi/content/full/359/8/861). Others simply don’t trust data presented and controlled by drug companies. They should not be made to feel guilty if they decide against vaccination.

    I have worked in sexual health and seen plenty of people whose warts have been successfully treated. I’ve seen others with extensive, recurrent warts that need prolonged and fiddly treatment and florid anogenital warts that resisted just about every treatment. We’ve opted to pay for Gardasil. Unlike the Blairs I’m happy to go public about vaccination of my children. I tell parents what vaccine we’ve chosen if they ask me, and I’ve written about it in Private Eye. If it was breast cancer, there would doubtless be an industry supported march on Downing Street, but the genital warts lobby is largely under cover. There are no letters to the Times, and warts have never made it to the cover of the Mail. But go to www.chestersexualhealth.co.uk/genitalwarts.htm to see what we could be preventing.

    Notes

    Cite this as: BMJ 2008;337:a2186

    Footnotes

    • Competing interest: PH has been paid to speak at dinners by many drug companies (including GSK and Sanofi Pasteur) and NICE.

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