Genital warts
The whole of Western Europe, the United States, Australia, New Zealand and Canada have decided to use the Garadasil vaccine to protect their teenagers against cervical cancer and a variety of genital warts. The whole of Western Europe that is except for the United Kingdom. Our government has decided to purchase the cheaper and less effective Cervarix which protects against a narrower spectrum of HPV infections.
So when British teenagers start to suffer from these (warning : graphic pictures) we will know who to blame.
My children will be having Gardisil, and I shall be prescribing it on demand to any one who wants it unless or until someone stops me. Then I shall advise “topping up” your second rate health care by buying it privately.
And why are we not giving it to the boys as well?
Labels: cheapo cheapo productions, gardasil
35 Comments:
What's the difference in price between the two vaccines in the UK?
Good point about boys! Why only vaccinate half the susceptible population?? As your link shows, boys get them too! Makes no sense at all - unless you're Gordo!
I think the problem with using the vaccine in boys is that while a few were included in the trial, there was only sufficient data to approve it in females.
Both Gardasil and Cervarix protect against the 9 most common types of genital warts as well as the most prevalent HPV's, but not all of them. The important factor is to marry the vaccine with the Pap smear. The Pap smear is a test that must not be overlooked and forgotten, and it should start earlier than the 25 years in this country. Condom use is also vital.
Both drugs have not been approved for use on boys, though it's expected to happen around 2010.
A few points. I don't pretend to be an expert but as a reflective GP that was caught out not knowing much about this a few months ago by a young lady and her mother, I thought I would learn more, mainly through the BMJ learning website.
A reduction of disease in women has not been demonstrated following vaccinating men. Oncological HPV disease in men is rare.
There are 2 vaccines licensed in the UK;
GARDASIL - this contains protection against HPV 16+18 (both oncogenic) and 6+11 (genital warts).
CERVARIX - this contains protection against HPV 16+18 only.
HPV 16+18 is known to be responsible for 70% of cervcal cancer cases.
A further 6 HPV types would need to be included to reach 90%.
Being protected against one type of HPV does not protect against other types (type replacement).
The vaccine efficacy lasts at least 5 years. Maximal benefit is given before the first episode of sexual intercourse.
The vaccine should be postponed until after pregancy but is ok if breast-feeding.
The regimen is 3 doses over 6 months.
THE CERVICAL SCREENING PROGRAMME IS STILL IMPORTANT.
Please see my blog entry;
http://dens2.wordpress.com/2008/05/09/prophylactic-hpv-vaccination/
It would still seem logical to immunise boys if trying to eliminate/reduce virus in the community. This will help reduce risk in non vaccinated females. Are other countries just vaccinating females? Seems illogical.
Dr C is it just a question of cost, then?
I thought it was because there had been a handful of deaths from Gardisil vaccinations, or is that just government spin?
Interestingly, we were told at med school that Gay males have been requesting the vaccine, there is a transitional cell zone in the rectum just like there is on the cervix - so could possibly prevent some rectal ca too.
1) Yes THe HPV vaccine could indeed prevent ANAL cancer which has HPV16/18 as a root cause of >40% of cases.
2) THe comment about "The Pap smear is a test that must not be overlooked and forgotten, and it should start earlier than the 25 years in this country." is half right.
Yes Pap smears will continue to be important and it must be stressed to those vaccinated they have reduced risk, not no risk, however There is little evidence to show real benefit in screening the under 25 yo age group.
I found Dr Dino through you, and found his posts on the Gardasil vaccine quite persuasive.
http://dinosaurmusings.blogspot.com/2007/02/my-blood-is-boiling.html
http://dinosaurmusings.blogspot.com/2007/02/gardasil-analogy-killer-salmonella.html
http://dinosaurmusings.blogspot.com/2006/08/gardasil-argument-against.html
re screening for the under 25s.
http://eurpub.oxfordjournals.org/cgi/content/full/15/1/70
The differences in social classes is interesting. Those women in a higher socio economic group start the pap smear test younger.
Gardasil costs around $500 per shot as opposed to $150 for Cervarix. Many women believe it will protect them against cancer. It has to be used in conjunction with the smear test. In the USA the general rule of thumb is a smear test three years post first sexual intercourse, but then the recommendation is to have it yearly (far too often imho).
I have just checked on a phamaceutical wholesaler's website, and the cost for a single dose of Cervarix is £80.50. The cost of a single dose of Gardasil is also £80.50. (I know, what a coincidence, who would have thought it, etc.)
Now I know that the DoH will bulk buy and get discounts, and they may be offered a better deal by one of the manufacturers that the other, but I think that your claim that the choice was made on cost grounds needs some referencing
In Portugal only women will be vaccinated too. The vaccine hasn't been chosen, but I certainly hope gardasil will be the one.
As too not vaccinating boys, not only it would not be a smart public health move (cervical cancer is the second most frequent cancer in women, not comparing to the numbers of penile cancer in men...), but it is also expected that a crossed immunity phenomenon will happen, between men and women. There are other vaccines in Portugal given only to women for the same reason (crossed immunity).
Love reading your blog.
Ines
(medical student in portugal)
As a CNM in a Women's Health Center in Jerusalem, I've been getting a lot of questions about the HPV vaccine, which is 40%subsidized by the various Health Funds, which is a quasi-governmental health system. Each shot, with the discount, is about $125, which is a LOT of money here.
Not all the OB/GYNs are wildly enthusiastic by any means. Many point out that the marketing campaign, by the drug reps, is very aggressive and Merck, at least, needs a cash cow to compensate for the Vioxx claims it has been stuck with. The reps visit at least once a week, and buttonhole women in my clinic, to my intense annoyance, telling them to demand the vaccine from their doctors.
There is no evidence currently that it has any efficacy after 5 years. Since it is being advised to inoculate girls as young as 12 or 13, they might well not be protected by the time they are sexually active. Israel is rather more sexually conservative than the US or UK [btw, the rate of cervical cancer is not high here]. Parents tend to worry what their girls will do when they go to the army at age 18, but not much before, and most girls do not have many partners. Word gets around in a small country like ours, and most girls are a bit cautious as a result.
There have been a number of significant side effects, including a number of instances of Guillan-Barre Syndrome. There have also been questions raised about why it isn't being marketed to men, especially homosexual men.
The protection, as noted, is only partial, and can give a false sense of security and women can be lax about doing regular Pap smears as a result.
Finally, one doctor, who has teenage daughters himself, says he tells mothers who call him, to buy their daughters a package of condoms and make sure the girls know how and why to use them. "It's a fraction of the cost", he says, "and it protects against EVERYTHING".
IMHO, I wouldn't rush to inoculate your daughters, Dr. Crippen. I expect they understand and know how to say "no" with you for a father.
"Finally, one doctor, who has teenage daughters himself, says he tells mothers who call him, to buy their daughters a package of condoms and make sure the girls know how and why to use them. "It's a fraction of the cost", he says, "and it protects against EVERYTHING"."
The doctor is an idiot. HPV is sexually transmitted. Condoms will help protect, but it is rather contagious. You can have a multitiude of 'sins' without full unprotected sex which can spread the HPV virus. Mutual masturbation for isntance could spread the virus.
[As credentials go I'm an ex-cambridge grad whose specialty who studied virology and whose dissertation was on cervical cancer/hpv)
With regards to the young age - it is the young people having sex more than any others who are at high risk. During puberty especially the cervix is absolutely primed for HPV to take root. THe transitional zone is at its most exposed, osetrogen levels are booming, and compliance (good compliance that is) with condoms is poor.
Of the two Gardasil is by far and away best.
But at the end of the day, from a virology point of view its all a bit of a hash job anyway. Because as soon as you protect against the two most common DEVELOPED WORLD strains then the other strains - many just as nasty as 16/18 will increase prevalence.
Not sure I agree with you there with regards prevalence, 12.13 Anon. Has the amount of meningococcal meningitis increased to compensate for the vaccination preventing other types? I think not.
And as for buying the crappest of the 2 vaccines? Well, this is typical NHS practice.
NHSpenpusher will pop up soon saying how this has saved the NHS tons of money which would have been spent by muppet clinicians if it wasn't for the superhuman massively qualified NHS procurement (piss) artists. In reality, it exemplifies how bastard managers and admin knobends run the show in the NHS. Kick them out!
Thanks for the links to those pictures John. I really must stop surfing whilst eating my lunch.
I agree that both sexes should be vaccinated against HPV. What age are you recommending the vaccine be given? Some are pushing for as early as 9-12 over here across the pond. I'm not so sure that's appropriate and am still waiting more research as we go along.
Anon 1.04am: I note your jibes at NHSpenpusher, just a quick question for you - if Purchasing Specialists are so useless and unnecessary, whay are they a feature of all successful large businesses? Would these businesses really employ these people if there was no benefit to them?
"Not sure I agree with you there with regards prevalence, 12.13 Anon. Has the amount of meningococcal meningitis increased to compensate for the vaccination preventing other types? I think not"
Meningococcal is a whole different bacteria to those vaccinated agaisnt Haemophilus influenza B.
I'm talking about different HPV serotypes.
Some HPV serotypes that a have a low carcinogenic rating have actually been found to be somewhat protective if you are ifnected with them against contracting a more carcinogenic HPV strain.
But what do I know, you 'think not'.
antigonas said:
"Finally, one doctor, who has teenage daughters himself, says he tells mothers who call him, to buy their daughters a package of condoms and make sure the girls know how and why to use them. "It's a fraction of the cost", he says, "and it protects against EVERYTHING"."
Including HIV and AIDS......something the vaccine will not protect your precious teenage daughters against, Dr C.
Hi Dr C,
I got my twin daughters vaccinated against this last year when they were just 16. I had to pay over £600 each for the course of 3 injections. They had to be done by our GP because the practice nurses refused to do it as they hadn't been trained!! I had to pay £45 on top for the GPs time to do it instead 3 times.
I understand the vaccination is to be made available to 13 yr old girls this year or has that changed?
I really like my GP but the practice management sucks.
Jane
Warning: LONG comment!
Gardasil has been out in Canada for about a year. It occurred to me that it would make more sense to administer it to boys too - the chain of transmission can be broken in two places, and this would double the opportunities to do so. Furthermore, males get genital warts (and no doubt don't enjoy them) and I do have two patients in my practice with penile amputations for cancer, which as you will know is also HPV related. So I asked the drug rep about this, and was told that in some countries (I believe Australia was given as an example) it is being given to both sexes. Apparently, the manufacturer has not applied for a license in Canada for administration to boys, feeling more sure of a successful application restricted to girls only. Perhaps you have read of the opposition to this vaccine in the US, where for example a group of parents in Texas have sued the governor for issuing an order to give it to girls at state expense, on the grounds that it will encourage their daughters to be promiscuous.
So I pondered this and thought that perhaps there might be an ethical objection to giving a vaccine to boys when the primary benefit is for girls. I dismissed the mildly paranoid idea that Harper and Co. wouldn't approve something that might offend their masters in the US. Perhaps the manufacturer was aware that the government would soon see that this vaccine would be cheaper than paying for cervical cancer treatment, and would be happier to only pay for half as many doses. It would halve sales, but a bird in the hand is better than two in the bush - well, perhaps that isn't quite the metaphor we want here! As things stand, girls will get protection against cancer soon if their parents buy the vaccine, and a younger cohort will get protection when provinces decide to give it to them at age 10 or so. Boys will eventually get the benefits when there are no girls from whom to catch HPV. Someone out to portray this for maximum political effect could describe it as discrimination against poor versus rich, or as the politically sexy furthering of a women's health issue over that of a boring masculine one.
Now follow me one stage further: there are a group of males who will never benefit from not being able to contract HPV from vaccinated women. There is no protection, ever, for gay men under the current licensure for Gardasil. Men who not only can suffer from warts, but have a high risk of anorectal carcinoma related to HPV, and some at a vastly higher risk if they also have HIV. There is a really important issue for gay men here - especially as the vaccine is known to offer benefits even to individuals after infection with HPV. Perhaps I am way behind the times and this is already a known problem that is being debated or pushed forward by gay health advocates, but if it isn't it certainly should be. I have a feeling that if licensure of Gardasil for males was a gay health issue it might even move forward faster than if it was seen as merely a problem of genital warts in boys and the exceedingly rare penile carcinomas. In fact, HPV related anorectal cancer in gays might outnumber penile cancers in heterosexuals quite handily, for all I know. It seems crazy that I can explain all this as much as I like to a young man with his first genital warts, or to a gay teenager, but I can't then give them the vaccine if they want it without all the risks of 'off label' usage. I would like to be able to do this, and I can see no downside to doing so.
To add fuel to the fire, I am now aware of a paper that states the risk of oral carcinomas is increased 32x with HPV, versus only 7x with smoking. "Syphilis, smoking and spices" indeed! This would make a pressing reason to administer the vaccine to both sexes - many more Canadians die of oral carcinomas each year than die of cervical cancer.
I got a letter saying our GPs' practice wouldn't be vaccinating any girl over the age of 16, and so would I like to pay £300 or so for them to vaccinate my 16 year old daughter. All her friends' parents got the same letter. I had no idea the doctor could choose the cut off age for vaccination, I thought it was Govt mandated.
So the wholesale price of both drugs in the UK is the same, £80.50, which is what I thought when I researched it.
Therefore, doctors are charging different amounts for the actual vaccinations, despite Gardasil protecting from genital warts and Cervarix doesn't.
Interesting.
"Including HIV and AIDS......something the vaccine will not protect your precious teenage daughters against, Dr C."
Protect against HIV and AIDS?
Phew, I thought condoms only protected agaisnt one or the other.
Silyl Billy
"So I pondered this and thought that perhaps there might be an ethical objection to giving a vaccine to boys when the primary benefit is for girls."
Same as the Rubella part of the MMR. Primary reason is to reduce the risk of problems with the foetus in pregnant women.
"So I pondered this and thought that perhaps there might be an ethical objection to giving a vaccine to boys when the primary benefit is for girls."
Its silly to think ont he indivdual basis in vaccination programmes. You must think in terms of herd immunity primarily.
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Cervarix vs. Gardasil? Well, one is made by a UK company with a big HQ in West London, and one isn't.
Actually, while Gardasil has the breadth benefit I think I recall Cervarix achieved a higher response rate and may be showing less drop-off in protection over time.
The focus on women's health my be an issue, but if you actually look at the logistics of adding another standard vaccination at 13 and organizing a catch up programme for older children there is rather a lot to be getting on with.
And while it makes economic sense long-term it is on a time-scale that has no benefit to current post holders. The good news is that the NHS is actually going ahead rather than dragging its feet.
An interesting question would be if a gay man turned up at his GPs and explained why he wanted the vaccine... would he get it.
I know this won't be of much interest to many (as most of you i suspect aren't GAY) but being a man and gay I'm tottaly paranoid about infections that are easy to transmit, HIV can be prevented for all gender preferances along with most other STI's, warts on the other hand are probably one of the most easy virus infections to pick up with minimum effort, and quite possibly without direct contact so it might seem, if the vaccine is good enough to give to girls/women to prevent cancer, than why discriminated/omit bi and gay men, who lets face it - are probably at a much more significant risk than herosexuals due to the prevalence of the disease within the gay community. welcome any thoughts and opinions on this people.
just a point to note on my last comment, i think to omit boys from the vaccine and just give it to the girls is akin to half closing the stable door - so to speak, i think i understand that there was the subject of cross vaccine problems if both sexes were vaccinated, presumably this reffers to new strains of HPV emmerging when the known ones die out, but won't that happen anyway? ermm... how many HPV strains are there? ermm, point made i think, new ones will appear i'm sure, and it will be decade before theres enough of 'em about before the scientists identify them as a problem.
as with most viral infections they mutate and or hide over the course of time, medicine will always be playing a game of catch-up. Plug the holes (vaccinate) where you can against viruses you have vaccines for, worry about new strains when or IF they appear, the ideal soulution would be to try and irradicate the knowns HPV strains off the face of the planet with vaccinations for all, that would be a good start, but you can't do that unless everybody get the vaccine in the first place. i think the silly people who say "this vaccine will increase risky behaviour and condoms are the only protection" well i say this, {to get a woman or man ready for intercourse it involves fore play}, thats when HPV more or likely could be transmitted, what bloody use is a condom gona be then? well it might stop other nasty sti's but not warts!!
and at the end of the day i think most people know to use condoms if not to prevent pregnancy - Sti's too, there are alot of people out there not using condoms anyway, so goes the proverb "you can lead a horse to water...." if a section of the comunity don't like condoms a wana put their health at risk without the HPV vaccine then i don't think its going to make much difference in peoples habits if they are vaccinated or not. people who use condoms use them to prevent STI's and or babies, i really don't think responsible people are going to think "oh! i won't get warts and cancer now, i'll ditch the condoms!" this was the knee jerk reaction from the catholic church, who don't like condoms anyway (yes i'm catholic so i can say this) were worried that thier young children would start to experiment in sex if they had the vaccine. now i'm not going to get into a fight with God on this, but i'm sure the warts was sent by the devil, so by all account "God helps thou's who help themselves" surely the vaccine is a good thing? right?
Very good info, some people will definitely get a false sense of safety with this vaccine. Still safe sex should be practiced, there are other std's that may not be cured by the vaccine.
Really I don't believe sexual preference should be an issue. The way I see it we have a few options. We can treat the problem with the proverbial band-aid by offering the vaccine to only woman or we can look to eradicate the virus and make it a mandatory vaccine given at a certain age to both genders. It simply doesn't make sense to only vaccinate half the population from a virus which has no gender preference.
I tested wartrol and it worked and all those urgly warts were gone within days.. and yes.. we should get vaccinated..
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