While everyone is on the subject of HPV…
It is distasteful to see a number of anti-vax headlines (which have subsequently been taken down) reporting the tragic death of a 15 year-old girl after she had received the cervical cancer jab. Of course we learnt soon after that Natalie Morton had a malignant chest tumour but that was after the vaccination programme had taken a hit.
None of this furore really leads to a conducive atmosphere in which we can talk about possibly extending the vaccination to boys, but I’ll give it a go.
This week the British Medical Journal published a study into the cost-effectiveness (or not) of extending the HPV vaccine programme to boys as well as girls. Of course, cervical cancer is not the only cancer associated with HPV 16 and 18, which the Cervarix vaccine covers, but also vulvar, vaginal, and oropharyngeal, anal, and oral cancers.
The vaccine would therefore not only have direct health benefits for males but also to indirect health benefits (for sexual partners) through reduced transmission of HPV.
To be clear (unlike the Sunday Express) this was research done in the US on Gardasil not on Cervarix which is being rolled out in the UK. There has however, been similar research in the UK by the Joint Committee on Vaccination and Immunisation which lead to the current recommendation that the vaccination programme should only cover girls (cost-effectiveness of vaccine to girls here).
The BMJ research continued that:
Given currently available information, including boys in an HPV vaccination programme generally exceeds conventional thresholds of good value for money, even under favourable conditions of vaccine protection and health benefits.
Put simply, there would not be enough benefit from boys being vaccinated to make the extension to the programme value for money. What is interesting is that it does highlight where a pure cost-effectiveness analysis can miss important social policy aspects.
The British Medical Association voted at its last Annual Representative Meeting (ARM) for the vaccine to be rolled out to boys as well as girls. The arguments did not rest only on the effectiveness of the extended coverage but also on the impact that limiting the vaccine to girls – namely, that both men and women should take responsibility for eradicating HPV from the population rather than women taking sole responsibility.
This is not just a political point or an abstract notion of ‘fairness’, it is also a public health one. Due largely to the risk of pregnancy, women routinely take more responsibility for sexual health then men (I won’t go into it here but this still has implications for lesbian and gay people). Therefore, gender discrimination and inequality impacts on sexually transmitted infections when for example, women are not in a position to insist on condom use. This is not just the role of sexual or public health education, our systems and programmes need to support the principle of men and women taking responsibility for sexual health matters.
This is why the 1994 International Conference on Population and Development in Cairo spawned the ‘Cairo Consensus‘ which acknowledged the need to increase male responsibility for family planning and recommended expanding services in ways that protect the reproductive health of both men and women. However, cost is always going to be a barrier.
Before I’m accused of being in the pocket of Big Pharma on this one (er, unlikely) it is important to acknowledge the well-founded concerns regarding Merck’s aggressive marketing of Gardasil in the US and the suspicion that Merck would be behind any extension to the vaccination programme. Believe me the last thing I want to do is contribute to Merck’s profits.
I am not arguing that Cervarix should definitely be rolled out to boys as well as girls, simply that (rather ironically) focusing on evidence-based medicine can be overly simplistic if it fails to take into account important social factors and the cumulative impact of focusing sexual health interventions on women and girls. I also acknowledge the economic need to ration health care and that cost-benefit analyses are important but necessarily cannot factor in every eventuality.
Vaccine policy based on QALYs alone? Unfortunately society’s a bit more complicated than that.
This is cross-posted on The Lay Scientist.