(Not) Warts and All

 

British Medical Journal  2008  

Phil Hammond

General practitioner, writer, and broadcaster

 

‘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 inBristol, when I asked him which human papilloma virus (HPV) 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 off-licence son).

 

Genital warts genital warts are common (100,000 new cases inEnglandeach year) and they’re on the increase, particularly amongst the young (60% of warts in women occur in the 16-24 year old age group). They don’t kill you, but they can kill your sex life and in some people they can be recurrent and extensive. Health minister Dawn Primarolo claims warts are ‘preventable’ but meticulous condom usage only cuts HPV transmission by 50%. A far safer option is to vaccinate.

 

The NHS Choices (sic) website 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 describes the government’s decision as ‘a sad day for sexual health.’¹ It also doesn’t seem to make long-term economic sense. Within 3 or 4 years, the use of Gardasil ‘would begin to have a big financial payback, as the current estimate of treating genital warts inEngland every year is £23 million.’

 

So why did the government opt for Cervarix? The Joint Committee on Vaccination and Immunisation is most illuminating.² ‘If the vaccines were offered at similar prices, then the committee recommended choosing the quadrivalent vaccine, which protects against cervical cancer and genital warts.’ According to the British National Formulary, the two vaccines are exactly the same price (£80.50 for each of three injections), so GSK (the makers of Cervarix) must have offered a huge discount to undercut Sanofi Pasteur (makers of Gardasil).

 

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’, according to my MP, Dan Norris. I asked him 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. £350-£400 seems to be the going rate in local GP practices. We can (reluctantly) afford this, but many parents can’t. My Primary Care Trust (BANES) allows those in the vaccine programme to have Gardasil if there is ‘a specific clinical need’, without defining what this means. For girls particularly at risk of genital warts (e.g. those with type 1 diabetes or extensive verrucae or hand warts) or skin conditions that make genital warts particularly unpleasant (e.g. extensive psoriasis or eczema), it seems unethical not to offer them Gardasil.³ And how long will it take for a woman with warts to sue the NHS for not offering her the choice? Women who later develop warts or cervical cancer may also sue if they were denied an NHS vaccine because they were ‘outside’ the screening programme. Doctors are supposed to use clinical judgement in individual cases, but the pressure to reduce prescribing costs is relentless.

 

The cheap GSK deal only applies to vaccines used in the programme – the vaccines are the same price when offered outside it. Many doctors will recommend Gardasil in these circumstances, 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 efficacy and safety data, updated as it emerges. The NHS website would seem a logical gateway for this, but 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.⁴ 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’ve worked in sexual health and seen plenty of people whose warts have been successfully treated. I’ve seen others with extensive, recurrent warts requiring prolonged and fiddly treatment, and florid ano-genital 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 (but not point of conception). I tell patients if they ask me, would prescribe it on the NHS 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 undercover. There are no letters to the Times, and warts have never made it to the cover of the Mail. But follow this link⁵ to see what we could be preventing.

 

 

1. O’Mahony C. Government decision on national human papilloma virus vaccine programme is a sad day for sexual health. Sex Transm Infect 2008; 84: 251

 

2 http://www.advisorybodies.doh.gov.uk/jcvi/HPV_JCVI_report_18_07_2008.pdf

 

3 http://sti.bmj.com/cgi/eletters/84/4/251

 

4 http://content.nejm.org/cgi/content/full/359/8/861

 

5 http://www.chestersexualhealth.co.uk/genitalwarts.htm

 

 

November 24, 2011

BASHH welcomes HPV vaccine decision, and calls for vaccination of young homosexual men at sexual health clinics

 

 

 

The British Association for Sexual Health and HIV (BASHH) today welcomed news that the Government are switching to a multi-purpose HPV vaccine.

 

Peter Greenhouse, spokesperson for the British Association of Sexual Health and HIV commented:

 

“All of us atBASHHare delighted by the news that the next generation of teenage girls will receive a multi-purpose HPV vaccine which will protect them against cervical cancer AND genital warts.

 

“The UK-wide school cervical cancer vaccination campaign has produced higher rates of coverage than achieved in any other country – if we can keep this up we should expect to see genital wart infections start to reduce in teenage girls within five years, and slightly later in boys: If we continue to vaccinate just 70% of 12-to-13 year-old girls, we can predict** that genital warts should be eradicated in heterosexual women and men within 20 years, through the herd immunity effect.

 

“We would also want to make sure that the vaccine is made freely available to young homosexual men on their first visit to Sexual Health clinics – along the same lines as the successful Hepatitis B vaccination programme – to make sure that they can also benefit from protection against anal & oral cancer and genital warts.”

 

BASHHhave been making the case for the multi-purpose vaccination since the previous purchasing decision in 2008: A survey conducted earlier this year 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.

 

** Prediction of genital wart eradication – please see reference over page

 

Visit: www.bashh.org

 

 

• The single-purpose vaccine (Cervavix) protects patients against strains 16 and 18 of HPV which are responsible for around 70% of cervical cancer cases.  The multi-purpose vaccine (Gardasil) additionally protects against over 90% of genital warts, minor (non-serious) cervical smear abnormalities, and Juvenile Onset Recurrent Respiratory Papillomatosis (warts on the vocal cords) which is passed from mother to baby.

 

• The British Association for Sexual Health and HIV – BASHH– is the professional organisation for clinical staff and researchers working in the UK’s sexual health clinics. It sets standards for clinical care, training and education, and supports Public Health by treatment and prevention of infections and care of other conditions related to sexual health. For more information please visit www.bashh.org

 

• BASHHmedia spokespersonPeter GreenhouseFRCOG FFSRH, Consultant in Sexual Health at Bristol & Weston, is available for comment via the number above.

 

• Reference for vaccine coverage rates: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_123826.pdf

 

• Reference for prediction of eradication of genital warts in heterosexuals within 20 years:

http://www.ncbi.nlm.nih.gov/pubmed/20924049