HPV Vaccines: Cervarix vs Gardasil
Before launching into this I want to preface what I say with this: Public health is a complex issue; there is a finite amount of money to be allocated and the long term cost/benefit analyses are by no means straightforward. Organisations like NICE have to make some occasionally very tough decisions, and sometimes good treatments have to be left out of guidelines because they would deprive other areas of resources judged to have a greater beneficial impact. With that said, on to an issue of current importance, in which NHS guidelines may well be letting a lot of people down.
Gardasil vial, via Wikimedia Commons. This is what we
Human Papillomavirus (HPV) is one of the most common sexually transmitted infections. HPV symptoms include outbreaks of genital warts, and several of the strains (primarily types 16 and 18, which account for roughly 1 in 20 infections according to CDC statistic) are responsible for the majority of cervical cancer cases. Cervical cancer is the second leading cause of cancer deaths amongst women worldwide, particularly in developing nations.
So when vaccines that protect against the high-risk strains of HPV became available in 2008 it was a good thing, yes? A concerted vaccination program would reduce new infections, see a decrease in cervical cancer diagnoses over the next 15-20 years, and save millions of pounds in public health spending on pap smears, right? Well, sort of. The issue here is that there are two vaccines available, Gardasil from Merck and Cervarix from GlaxoSmithKline. Whilst both protect against strains 16 and 18, Cervarix does not provide any protection against the non-cancerous strains responsible for genital warts. Gardasil, by contrast, also protects against strains 6 and 11, which cause 90% of genital wart cases. Gardasil also has a rather high list price of £240 per person, whereas the makers of Cervarix have significantly undercut their list price in an unreleased contract with the NHS.
In countries such as Australia, that have taken up Gardasil, there has been a 75% decrease in new cases of genital warts over the last three years; the UK, over the same period, has seen no difference in the number of new cases. Whilst women aged 16-19 are the group most affected by this, the issue is one that matters to everybody: greater uptake of the vaccine increases herd immunity, protecting those who haven’t been vaccinated as well (for the same time period cases in unvaccinated heterosexual males fell by one third in countries using Gardasil).
So, and this is the problem, we’re now offered a vaccine that provides no protection against genital warts, and almost no information about the alternative (I could find just one mention of Gardasil on the NHS’s HPV vaccination page here ). Those in the know are seeking out Gardasil through private clinics, whilst the majority, arguably including those most at risk of infection, are left in the dark.
“We, as consultants in sexual health, have been told to say nothing publicly that would damage the current vaccine programme, as the Cervarix vaccine has already been purchased. We have had to be circumspect in public but in private we have all purchased Gardasil for our own children and advised colleagues to do the same.” – Dr. Colm O’Mahony and Dr. Steve Taylor
This is leading us into a split system whereby those who can are taking the greater protection of Gardasil, and everyone else is getting Cervarix. This is, I think, neither a reasonable nor efficient use of NHS funding, and somewhat gives the lie to health secretary Andrew Lansley’s promise of “no decision about you without you.”
Treatment of genital warts costs the NHS £31 million annually and takes trained staff away from time that could be spent on other serious conditions. It is difficult to gauge how this balances against the savings from sticking with the cheaper Cervarix, because the NHS will not release the details of their contract with GSK. With the contract coming up for renewal now is the time when Lansley needs to reveal the details of the contract, involve the public in the decision, and provide more accessible information regarding Gardasil.
Why is this relevant on a feminist blog? Fair access to this information (and related sexual health matters) is vitally important to women (and indeed to men). We all need to be equipped to not only make the best decisions for our own sexual health but also to campaign for those in the most at risk groups — who are currently being let down by the lack of information provided by the NHS. The choice of vaccine is an important issue that will effect tens of thousands of lives every year, and it is one the public needs to be involved in.
(Here’s the British Association for Sexual Health and HIV’s press release on the issue, which has links to some relevant papers.)
Hope I’m not going too tangential here…
The thing that always bugs me whenever any new vaccine that will prevent sexually transmitted disease, no matter how vital or lifesaving it may be, is that there is always someone out there saying it will encourage underage sex if we give it to kids. I just wonder to what extent the potential to avoid this odd moral/political point might factor into the NHS’ decision? “Oh no, we’re not giving them drugs to prevent genital warts, we’re giving them drugs to prevent cancer, it’s fine!” Might be the easier defence.
I expect the cost is more important, but it’s always struck me as somewhere between odd and despicable that people who claim to be speaking from a moral point of view are in fact encouraging the suffering of others through disease.
I may also be on a complete tangent.
I did a project on HPV for the Global Alliance of Vaccination and Immunisation a few years ago, and came up against this problem. Gardasil was developed for a specific reason; the strains that cause genital warts also effect men, where as they can only carry the HPV virus and display no symptoms. Gardasil was developed for areas of the world where vaccinating women against STIs is considered unacceptable because of cultural norms, whereas if you go to the men “hey do you want to not get warts on your old man” you get a higher pick up and decrease infection rates accross the population.
Because this isn’t the case in the UK I suspect that the cost of Gardasil out weighed the benefits. There are lots of drugs that aren’t NICE reccommended for precisely this reason, and whilst its tough, its also necessary for the NHS to work.
Thanks for this comment, it really made me think. Interesting stuff.
Marketing sexual health awareness is a tricky business. There’s this whole emphasis on birth control in a lot of sex ed (at least, in my experience!) without looking at STIs as a real issue – for me, at school they were a half-hour “add on” in which we learned that “gonorrhoea” was a word, along with some other words. And that condoms were the way to avoid these words. But nothing about HPV whatsoever.
I think the London chlamydia awareness campaign CheckUrself (https://www.checkurself.org.uk/) was the best SH awareness campaign I’ve seen yet.
Isn’t the real issue that the vaccine doesn’t reduce incidence of cervical cancer any better than annual screening via PAP smear from the age of 20? And that annual screening programs plus condom use can reduce both cervical cancer AND other STIs far better than a vaccine?
In developing countries, a case might be made because of high rates of HIV-associated cervical cancers and the difficulties with rolling out an annual screening program for women, say, in rural Africa. You don’t have the lab facilities, the technology to detect is inappropriate for rural clinics, the clinics themselves are inaccessible, there are cultural prohibitions that would deem PAPs invasive at best, immoral at worse.
But in developed countries, what is the need, really? When there are better measures – more feminist measures, measures that encourage being empowered to take care of your body?
I don’t know. But I have serious doubts that these vaccines rolled out in developed countries have anything to with anything besides making as much money as possible for GSK and Pfizer. They have to give these vaccines out at low or subsidized cost to African countries. The profit exists entirely in the developed world market. Hence, “a vaccine that prevents cancer!!!” for first world women. But we can really do better with what we already have…National public health systems should AUTOMATICALLY do annual screening because this detects a number of other reproductive health problems besides cancer. Because women, in fact, pay taxes or health insurance fees for this kind of work to be done. And insisting on protected sex is, indeed, an important part of taking back control of our bodies.
A vaccine is a band-aid, a quick fix. And a sure way to enrich big Pharma. But it doesn’t get at the root of the problem. And it doesn’t actually do a better job than what we already have got.
I think these are all good points, but I also think that Herpes/warts are actually one of the more difficult STIs to control with “protected sex” – what do we mean when we say that? Condoms? Warts are a difficult thing to completely protect yourself from even when using condoms, because they affect whole areas that a condom won’t cover – and what about when they are passed between women, who may not particularly have a use for condoms (depending on what they’re doing, of course)?
Personally, although I do take your point about big pharmas and the importance of education, I’d still welcome a vaccine. Dental dams for oral sex are an unglamorous ‘mare, and much more difficult to sell as useful and enjoyable than condoms. Genital-to-genital contact between someone who has dormant HSV (and may not even know it!) is also one of those things where even if you’re very careful, you run risks, and it’d be nice to cut those risks down.
In a world free of all kinds of expense limits, of course. Which isn’t this one. But I don’t think that vaccines are “less feminist”, necessarily – or that they would downsize the need for good sex ed in this country.
I do get the impression that Gardasil *and* Cervarix are being marketed out of all proportion as a “vaccine for cancer”. Which it isn’t, of course, there being no such thing. It seems to be being marketed more for this than for the much less marketable issue of warts, which while not life threatening, are really contagious, really unpleasant, and not curable on a viral level once contracted, only managed.
@Anne – I take your point about vaccination being no more effective than cervical smears in preventing cancer (this is undoubtedly true based on the currently published evidence) but I would make two points about your mail –
a) Vaccination renders you immune to the viruses that cause cervical cancer and prevent you being infected in the first place – this is no ‘band-aid’. If we had an effective vaccine for HIV it would solve the problem, and possibly put us in a position to eradicate transmission of the virus altogether. In many cases vaccination is a one-off event (ok, an initial course of jabs anyway) and then the recipient is immune for life – cheaper, more convenient, and much more comfortable than a lifetime of cervical smears.
b) Cervical smears only work as surveillance if you attend for your appointments (as poor Jade Goody discovered) and even then there are interval cancers that can develop between smears. And this strategy effectively means monitoring a disease-in-evolution with regular smears and burning or chopping the offending bits out if they become too nasty – I would argue that preventing the disease in the first place is a much better strategy – and avoids nasties like cone biopsy and colposcopy as treatments.
Just a thought anyway.
These decisions are always difficult, and the maths involved is highly complex statistics which are influenced by the frequency of the disease in the population. I don’t know if anybody knows whether NICE made the right decision with the public purse. Shame they can’t reveal the costs – surely a FoI application should deal with that.
P
It’s not just about warts and cervical cancer. HPV16 also causes oropharangeal cancers in men. Having undergone treatment for this my sons are getting Gardasil. Many specialists in the field argue that boys should be vaccinated too; the Government’s line appears to be that this is unecessary as boys will be protected by herd immunity.
This is true – provided one makes some pretty sweeping assumptions about pre-teens’ future sexual conduct…