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(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

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Vaccination for genital warts to prevent cervical cancer: principles first, please, before details

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

Kwegyir Aggrey Distinguished Professor of Human Genetics and Consultant
Physician Genetic Counsellor in Haemoglobinopathies, 10 Harley Street,
London, W1G 9PF

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/art...

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

Competing interests: No competing interests

12 November 2008
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