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The 2006 launch of a HPV (Human Papilloma Virus) vaccine aimed at protecting girls and women against cervical cancer provoked a lot of debate. Debate is good because it is the catalyst of mass information and information is the truest form of empowerment.  

Cervical Cancer: The Facts:

Cervical cancer accounts for 1% of all cancers in the UK causing over 1100 deaths every year. In the United States in 2002, over 12,000 women were diagnosed with cervical cancer and nearly 4000 women died of the disease that year. About 3700 women were expected to die of the disease in 2006.

World-wide, over 270,000 women die of cervical cancer each year and it accounts for 9% of all female cancer deaths annually with women in the developing world bearing the brunt of this disease. Cervical cancer is the commonest diagnosed cancer among women in Central America and Southern Africa.

With the introduction of regular cervical cancer screening using smears, the rate of the disease and death from it in western countries has fallen steadily over the years. In the United States, the annual rate of fall has been around 4.5% but it is still a significant cause of morbidity and mortality among women of all age groups.

The HPV Vaccine

The
Human Papilloma Virus (HPV) infection is known to be the leading predisposing factor to cervical changes which lead to cervical cancer. The infection accounts for almost all cervical cancers. It is also responsible for genital warts.

HPV is the commonest sexually transmitted infection in the United States and quite possibly the world. Crucially it is almost always symptom-less at the time of transmission.

There are over 100 strains or subtypes of the Human Papilloma Virus (HPV), a third of which are sexually transmitted. The other non-sexually transmitted strains are dubbed low-risk and possibly clinically insignificant.

The strains that are known to predispose to cervical cancer are subtypes 16, 18, 31, 33 and a few others.

Subtypes 16 and 18 are by far the most important accounting for 70% of cervical cancers.

Subtypes 6 and 11 are the strains most responsible for genital warts (90%).

The  HPV vaccine (Gardasil®) protects against subtypes 6, 11, 16 and 18. These as shown above, are responsible for the vast majority of genital warts and cervical cancer cases. What’s more, studies have shown the vaccine to be almost 100% effective in preventing cervical cancer and other diseases, including dysplasia (pre-cancer) of the cervix, vulva and vagina, and genital warts, caused by the four HPV strains . That is so
if given to girls and women who have not been exposed to the virus. With that logic, it has been recommended that it be made available to girls and young women from the age of 9 to 26 years. With universal coverage, such a program has the potential of dramatically cutting down the rate of cervical cancer and save millions of lives. With universal vaccination, it is estimated that such a program could cut cervical cancer deaths by as much as 75%.

Gardasil® and Cervarix®

By summer 2007, over 75 countries had approved Gardasil® which is by the drug company Merck and Sanofi Pasteur. Another vaccine, Cervarix® by another drug firm (GSK) protecting against HPV subtypes 16 and 18 (the strains responsible for cervical cancer) was  approved in Europe  in late 2007. It is already licensed for use in Australia and was adopted in Britain as the vaccine of choice. In November 2011, Britain switched to Gardasil.

A study carried out by Harvard researchers in the United States had its results published  in the New England Journal of Medicine in August 2008. This showed conclusively that vaccinating 12 year old girls would be cost-effective. This also recommended that a catch-up vaccination of girls under 21 would also be cost-effective.

In the United States, Indiana became the first state in January 2007 to legislate for this vaccine. The bill required girls to be vaccinated against HPV before the start of sixth grade. Texas followed soon after, via an executive order in February 2007, launching the vaccination program starting with girls entering the 6th grade in 2008. The order also made the vaccine available free to uninsured girls aged 9 to 18. This is an example of bold political foresight and decision making. However, like all political acts, some of the more right wing players in the 2012 Republican primary campaigns tried to turn this healthcare issue into an ideological subject making some outlandish claims. Mercifully, these claims never got any traction and were soon forgotten.

In Britain, the vaccination program started in 2008 using Cervarix® switching to Gardasil in early 2012. The vaccine is also available privately for parents who want it for their children who may fall outside the target group such as young teenagers at 13 -15. The cost is between £300 and 600 for a full course of three jabs. This may be partly an acknowledgement of the fact that data show that 10% of girls are sexually active at 14 and by the age of 16, 50% of girls are.

When to Start Vaccinating.

While in the UK the adopted age is a reasonable and understandable compromise, it is clear why the recommended start age is 9 years. It is to ensure girls are protected well before they become sexually active. HPV is largely sexually transmitted and the whole process starts there. For some, that process inexorably leads to pre-cancer (dysplasia) changes and then cancer. This is a very distressing disease which might eliminate the woman’s fertility, lead to premature menopause and for some, tragically, death. The issue of age has exercised many a mind and has been one of the main areas of contention in this debate.

There is a school of thought that argues that giving this vaccine to such youngcervical cancer vaccine girls is giving them a greenlight to be sexually active without worrying about consequences. Personally, this is a track of reasoning that I find absurd. This is similar to the mainly religious lobby which frowns upon the availability of condoms. Only it is worse. Unfortunately, this anti-vaccine lobby is quite powerful and voluble and sadly the most vulnerable members of our societies are the most susceptible to this self-righteous pious posturing. Encouragingly, in a recent study by Cancer Research UK, most (75%) mothers were in favour of having their daughters vaccinated and 80% of them felt 10-14 years will be the appropriate age.

Young girls grow into young women and most young women, sooner or later, become sexually active. The sexual activity involves another individual
(usually) which means it removes the absolute control the individual might want to have about its consequences. This is regardless of whether the sexual activity is in a religiously acceptable context or not. It follows, therefore, that any reasonable individual will applaud the availability of this protection for our children and young women against one of these perennial scourges.

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Vaccine against cancer of the cervix