Global aspirations for HPV vaccination See Leading Edge page 141 For more information on guidance for the introduction of HPV vaccines in EU countries see http://ecdc.europa.eu/pdf/ HPV_report.pdf For more information on Gardasil see http://www. gardasil.com/ For more information on the US public’s reaction to the HPV vaccine see World Report Lancet 2007; 369: 979–80 and Lancet Infect Dis 2007; 7: 251 For more information on introducing HPV vaccine in developing countries see N Engl J Med 2007; 356: 1908–10; http://content.nejm.org/cgi/ content/full/356/19/1908
The European Centre for Disease Prevention and Control (ECDC) has published guidance on vaccinating teenage girls across Europe against the human papillomavirus (HPV). Reviewing the scientiﬁc evidence for the eﬃcacy of Gardasil (Sanoﬁ Pasteur MSD, Paris, France) and Cervarix (GlaxoSmithKline Biologicals, Rixensart, Belgium), the expert ECDC scientiﬁc panel has concluded that “both vaccines protect against the high-risk HPV types 16 and 18, responsible for an estimated 73% of cervical cancer cases in Europe”. Globally, cervical cancer aﬀects 500 000 women each year, many under 45 years of age. In Europe 33 500 women are diagnosed every year, and there are 15 000 deaths. Johan Giesecke, Chief Scientist at ECDC (Stockholm, Sweden) said that vaccinating young adolescent girls against HPV is likely to reduce the number of women who develop cervical cancer, but he warned that “cervical cancer screening programmes must be maintained”. In the UK, 12–13-year-old girls should be able to receive their ﬁrst dose of Gardasil in school, starting in September, 2008. A catch-up programme for girls aged up to 18 years will begin in August, 2009. Vaccination is already well underway in other EU member states. By the end of January,
Ian Frazer gives one of the ﬁrst HPV vaccinations in Australia in 2007
around 1·5 million girls in Europe had already received Gardasil. However, possible serious adverse reactions have been reported, including two sudden deaths. Investigations by the European Medicines Agency failed to show any direct link with HPV vaccination, but this is bound to add to parental concerns. “These reports, and others describing the vaccine as a ‘sex vaccine’ that will encourage promiscuity, will do little to allay the worries of parents and school governors in the UK”, commented Rosalind Godson of the Community Practitioners’ and Health Visitors’ Association (London, UK). In the USA in June, 2006, the Advisory Committee on Immunization Practices recommended that 11–12-year-old girls should be routinely vaccinated, and that there should be a catchup programme for 13–26-year-olds. “Despite this, Virginia is the only state that has mandated HPV vaccination for school entry beginning in 2010”, commented Alexandra Stewart (George Washington University, Washington, DC, USA). Currently, this is in place for other childhood vaccinations, and opt out is less than 1%. “Although many groups in the USA claim to support the vaccine, the idea of mandating it is not popular”, she said. Stewart cited the aggressive marketing of the vaccine as a possible cause. “Many consumers are highly suspicious of manufacturers supporting laws that require the use of their products and there has been a considerable backlash”, she added. “The uptake of HPV vaccination in the USA has been patchy to say the least”, agreed Alta Charo (University of WisconsinMadison, Madison, WI, USA). Charo told TLID that health professionals as well as parents are concerned about the HPV vaccine. “The public-health community is cautious about introducing a new vaccine in such a large population, and may prefer to have a more measured introduction with greater opportunity to carry out surveillance for unexpected side-eﬀects”, she said.
In Australia, Gardasil vaccination was introduced in April, 2007. Ian Frazer (University of Queensland, Brisbane, Australia), who spent 15 years developing the vaccine, is conﬁdent that uptake will improve. “Australia has implemented schools programmes for girls aged from 12–17 years. Although the catch-up component has been tackled diﬀerently from state to state, these voluntary programmes have achieved an 80% uptake”, he said. Frazer is now eager to see eﬃcacy data from Gardasil trials in boys. “Globally, if the vaccine works for boys and delivery of vaccine to girls is less than 100% eﬀective, immunising boys will be useful in reducing community prevalence, and also will likely protect men against HPV-associated anogenital and head and neck cancer”, he said. In the developing world, where screening for cervical cancer is virtually non-existent and 90% of HPV-related cervical cancer deaths occur, blanket vaccination could have an even more striking eﬀect. Frazer thinks that widespread delivery of vaccine in the developing world is crucial to the control of cervical cancer globally. “Just now, this will have to depend on demonstration projects and charitable activity from the vaccine companies and others”, he said. Jan Agosti, Senior Program Oﬃcer at the Bill & Melinda Gates Foundation (Seattle, WA, USA) told TLID about plans in place to run demonstration projects in Vietnam, India, Peru, and Uganda, starting in 2008. “The Global Call to Stop Cervical Cancer movement, launched during the World YWCA International Women’s Summit in Nairobi, Kenya, in 2007, is being taken very seriously”, she stressed. Full implementation of HPV vaccination will take time but Agosti is optimistic. “We expect uptake to be brisk and our estimate is that high coverage is possible in 10 years in resource-poor countries”.
Kathryn Senior http://infection.thelancet.com Vol 8 March 2008