Human papillomavirus vaccination: stabbing in the dark?

Human papillomavirus vaccination: stabbing in the dark?

Comment Human papillomavirus vaccination: stabbing in the dark? In September, the human papillomavirus (HPV) vaccine will become part of the UK’s imm...

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Human papillomavirus vaccination: stabbing in the dark? In September, the human papillomavirus (HPV) vaccine will become part of the UK’s immunisation programme. Initially, 12–13-year-old girls and a catch-up group of 17–18-year-old girls will be targeted in schools,1 with a three-dose vaccination schedule at 0, 1, and 6 months.2 Cervarix, a bivalent vaccine developed by GlaxoSmithKline, has been chosen in favour of Merck’s quadrivalent Gardasil.1 This vaccination programme could prevent 70–80% of cases of cervical cancer and over 90% of cases of genital warts,3 but its potential success depends on uptake. In a pilot study of just over 2800 schoolgirls in Manchester aged 12–13 years, overall uptake was 71% for the first dose and 69% for the second.4 Uptake was lower among girls from less affluent backgrounds and minority groups, and results from the third dose were not reported.5 Cancer Research UK reports these results as “encouraging”,6 but higher uptake would be desirable, particularly as cost-effectiveness models assume uptake greater than 80%.5 There are many possible explanations for poor uptake: first, the logistical difficulty of administering three doses of vaccine at specific times. Second, fears of the girls, their parents, and perhaps even teachers that the vaccination is dangerous. Third, concerns on moral or religious grounds that use of the HPV vaccine will promote sexual promiscuity. Fourth, girls, parents, and teachers lacking awareness of the advantages of immunity to HPV.

Awareness is necessary for informed consent, which is a prerequisite for vaccination. However, a recent study reported that only 23% of 1348 Italian 14–24-year-old women knew that HPV can infect genital mucosa and had heard about cervical cancer.7 If these results can be extrapolated, it is worrying that most girls being offered vaccination against HPV might have no concept of what the virus does, and certainly therefore no understanding of the benefits of immunity. If the programme is extended to include boys, conveying the value of herd immunity will be an even greater challenge than promoting individual immunity. Raising awareness of the link between HPV and cancer of the male genital tract, oral cavity, oropharynx, and larynx8 may be a more successful route for encouraging vaccination. The Department of Health has planned an advertising campaign, directed at young girls and their parents, to coincide with the first injections.9 Hopefully, the multimedia messages will illuminate all those who are in the dark about the benefits of vaccination. Elizabeth Leyland University of Leeds School of Medicine, University of Leeds, Leeds LS2 9JT, UK [email protected] I declare that I have no conflict of interest. 1

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Department of Health. Introduction of HPV vaccination into the national immunisation programme: vaccination of 17- to 18-year-old young women in 2008/09. July 25, 2008. http://www.dh.gov.uk/en/Publications andstatistics/Lettersandcirculars/Dearcolleagueletters/DH_086515 (accessed Aug 16, 2008). Department of Health. Immunisation against infectious disease—’The Green Book’. Chapter 18a: human papillomavirus (HPV). May 20, 2008. http://www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/ Greenbook/DH_4097254 (accessed Aug 16, 2008). Kane M. Human papillomaviruses (HPV) vaccines: implementation and communication issues. J Fam Plann Reprod Health Care 2008; 34: 3–4. Brabin L, Roberts SA, Stretch R, et al. Uptake of first two doses of human papillomavirus vaccine by adolescent schoolgirls in Manchester: prospective cohort study. BMJ 2008; 336: 1056–58. Kim J. Human papillomavirus vaccination in the UK. BMJ 2008; 337: 303–04. Cancer Research UK. ‘Encouraging’ uptake in HPV vaccination trial. April 29, 2008. http://info.cancerresearchuk.org/news/archive/ newsarchive/2008/april/18571762 (accessed Aug 16, 2008). Giuseppe GD, Abbate R, Liguori G, Albano L, Angelillo IF. Human papillomavirus and vaccination: knowledge, attitudes, and behavioural intention in adolescents and young women in Italy. Br J Cancer 2008; 99: 225–29. Bosch FX. HPV vaccines and cervical cancer. Ann Oncol 2008; 19 (suppl 5): v48–v51. Department of Health. Introduction of human papillomavirus vaccine into the national immunisation programme: guidance on programme implementation. May 2, 2008. www.immunisation.nhs.uk/files/HPV_ DSletter020508.pdf (accessed Aug 16, 2008).

www.thelancet.com Vol 372 August 23, 2008