Warts and all at last: HPV vaccination

Health campaigning, like much of public health, can be a slow, repetitive business. The media will break a big story once and then tend to lose interest unless a fresh scandal surfaces. But to change culture, opinion, or behaviour the same message may have to be drip fed over many years. And if the story doesn’t lend itself to a cute front page photo the chance of success is remote. Genital warts will never make the headlines in the Daily Mail or indeed any other newspaper—which makes the government’s decision to switch to a multipurpose vaccine against human papillomavirus all the more remarkable.1

The Lancet kicked off the campaign in October 2006, with an editorial titled “Should HPV vaccines be mandatory for all adolescents?”2 It argued that Gardasil, which protects against HPV types 6, 11, 16, and 18, could dramatically reduce not just the incidence of cervical cancer but unpleasant conditions such as genital warts, anal cancer, and other malignancies affecting both sexes. It concluded, “EU member states should lead by making the vaccinations mandatory for all girls aged 11-12 years.”

Australia, the United States, and many European countries promptly introduced vaccination programmes, but the NHS dithered—doubtless taken aback at the cost of £241.50 (€280; $357) for a pack of three doses—and in 2008 went with the bivalent vaccine Cervarix, which protects against cervical cancer only. My daughter was due to join the vaccination programme at the time, but every sexual health consultant I knew recommended the wider coverage offered by Gardasil. Despite the Labour government’s commitment to patient choice, my primary care trust would not provide it or allow me to top up the difference in price. So I paid for it privately and recouped the money by writing a personal view in the BMJ.3 It attracted a surprising number of responses, indicating that the mainstream media’s lack of interest in genital warts had left a large gap in the market. Warts are far more common than cervical cancer, can be devilishly difficult and expensive to treat, and, although they won’t kill you, can destroy your sex life, which seems a compelling reason to prevent them if you can.

In Private Eye magazine I kept drip feeding the same message, often triggered by the excellent campaigning of the British Association for Sexual Health and HIV (BASHH), which—in the run up to the latest tender—conducted a survey that found that “93% of UK sexual health clinicians would advise friends and colleagues to obtain the multi-purpose vaccination for their daughters, and that 63% with teenage daughters had paid privately for the multi-purpose vaccine rather than accept the free single-purpose vaccine provided at schools.”4 This allowed me to be especially pompous: “If Andrew Lansley is to be a credible Secretary of State for Public Health, he must offer all patients the same protection against disease as the daughters of doctors.”4

And what of the evidence? In Australia 70% of women under 28 have been vaccinated with Gardasil. New cases of genital warts among young women started falling after six months, and now, three years into the programme, they have fallen by nearly 75%.5 Even cases among (unvaccinated) heterosexual men fell by one third, because of herd immunity. In contrast, since England’s school based HPV vaccination programme began in 2008 there has been no significant change in numbers of cases of genital warts, with some 91 000 new cases diagnosed each year and a further 70 000 cases undergoing repeat treatments. It costs the NHS £31m a year to treat genital warts, and preventing most of these would free up time for staff to prevent and treat other infections. In addition, Gardasil prevents 30% of minor smear abnormalities and a rarer but often fatal condition called recurrent respiratory papillomatosis, in which babies develop florid warts on the vocal chords and in the throat. Babies who survive face multiple and extremely unpleasant treatments, costing the NHS £4m a year.

As for the economics, BASHH predicts that “if we continue to vaccinate just 70% of 12 to 13 year old girls, genital warts should be eradicated in heterosexual women and men within 20 years, through the herd immunity effect.”6 A health economics analysis in the BMJ was slightly less gushing, concluding that Gardasil may have an advantage over Cervarix in reducing healthcare costs and the number of quality adjusted life years lost but that Cervarix may have an advantage in preventing deaths from cancer.7 It also concluded that significant uncertainty remains about the differential benefits of the two vaccines.

Policy decisions often have to be made against a backdrop of imperfect science and should be changed as the evidence accrues. In a statement GlaxoSmithKline, the manufacturer of Cervarix, said that it chose not to participate in the latest NHS HPV vaccine tender process because the criteria show that “the government’s priorities have shifted from cervical cancer to also incorporate HPV-related non-cervical cancers and an increased focus on protecting young girls against genital warts.”8 However, it’s worth remembering that the UK’s HPV vaccination programme has been a huge success, achieving higher rates of coverage than in any other country. If the same coverage continues, the incidence of cervical cancer and genital warts will be markedly reduced.

This is a time not just for celebration but also to launch the next campaign. We should make the vaccine freely available to young homosexual men, so they can benefit from protection against anal and oral cancer, as well as anogenital warts. Any takers?