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The recent announcement by the Department of Health to introduce routine vaccination, in England and Wales, against human papilloma virus (HPV) for girls aged 12 to 13 years from September 2008 brings new opportunity for improving public health as well as challenges for health professionals and policy makers. HPV vaccination has previously been available in the US and Australia. It is also available in UK in private clinics at a
cost of around £450.
Generally speaking, pharmacists are the first point of call for medicines
and health information by the public. As one of the most trusted professional,
pharmacists have to be well informed and up to date with new developments
in health services.
One of the questions pharmacists may be asked by parents or public may
concern the safety of the vaccines. Bearing in mind the issues surrounding
MMR (measles, mumps and rubella) vaccination, safety is bound to be a
major concern.
With about five years’ experience globally, the
European Medicines Agency (EMEA) and the US Food and Drug Administration
(FDA) consider the vaccines to be safe with no major adverse effects.
The
recent rise of the legal debate in the US linking thiomersal (organomercury,
used as preservatives in vaccines) with autism could provoke serious
anxiety in parents. The good news is that HPV vaccines do not contain
thiomersal or mercury. Another question pharmacists might be asked is
whether girls still need cervical screening once vaccinated. The answer
is “yes” because these vaccines do not protect against all
genotypes of HPV. So regular screening must be carried out in addition
to vaccination.
Pharmacists might also be asked whether vaccinated girls
are safe from all STIs. The answer is “no”, because it does
not protect against bacterial or fungal infections or other viral infections.
One of the critical messages is that HPV vaccination is not a substitute
for cervical screening and HPV vaccination does not protect against all
STIs. This may appear to be a rather simple message to pass on but in
practice it is not an easy task.
All health care professionals, governments
and allied organisations (including cancer, sexual and reproductive health
and health promotion groups) must act together to plan successful communication
strategies.
Pharmacists can play a crucial role in this ambitious plan. In my view,
innovative and daring pharmacists can grab this opportunity to raise
their professional profile. Pharmacists can promote the vaccine, provide
information and education to public, make referrals or even vaccinate
people, either in schools or in pharmacies.
Vaccination coverage in target
populations will be crucial if maximum benefit from any vaccination programme
is to be achieved. For this reason, all available and competent resources,
including pharmacists, must be utilised.
“Public health”, one of the essential services in the new community
pharmacy contract, presented pharmacists with opportunities and challenges.
No doubt pharmacists have been playing major roles in promoting public
health through many endeavours such as stop smoking services, blood pressure
monitoring, diabetes screening, cholesterol testing, chlamydia screening,
advising on healthy lifestyles and so on.
Pharmacists are competent and
confident in providing new services and deserve their fare share of
any reward system.
The Joint Committee on Vaccination and Immunisation has advised that
HPV vaccination would be most efficiently delivered through schools.
Nonetheless, the decision on how to deliver vaccination programmes
locally has been left to individual primary care organisations.
So
now is a good
time for pharmacists and professional bodies to approach PCOs, local
pharmaceutical committees, schools and surgeries at this early stage
of the HPV vaccination programme when decisions on how it will be
delivered have still to be made.
I believe the vaccination programme is an excellent opportunity for
the profession to be involved in the decision-making process.
ACKNOWLEDGEMENT I thank “doctor of public health” trainees
at Brunel University for thoughtful discussion.
Human papilloma virus: genotypes,
incidence and available vaccines
HPV is a member of papilloma family of viruses. It
was first isolated from rabbits by Richard Shope in 1933. A papilloma
is a small benign epithelial tumour, such as a wart.
HPV is linked
to nearly all cervical cancer cases. HPV is transmitted through
skin to skin contact during sexual activity. Out of 40 different
genotypes of HPV that can infect the genital areas of men and women,
HPV types 16 and 18 are sometimes referred to as “high risk” genotypes
because these are responsible for approximately 70 per cent of
cervical cancers (but in Europe it can be as high as 85 per cent)
and 80–90 per cent of anal cancers.
The other two genotypes,
HPV 6 and 11, are designated “low-risk” because they
cause relatively benign cervical dysplasia. Nonetheless, HPV 6
and 11 are causally related to 90 per cent of genital warts.
The peak incidence of HPV infection occurs between 16 and 20 years
of age. In UK, cervical cancer has an annual incidence of 3,320
cases and causes 1,330 deaths. Globally, there are around 510,000
new cervical cancer cases and around 288,000 deaths each year.
Currently there are two brands of HPV vaccines licensed in the
EU — Gardasil and Cervarix. Gardasil protects against HPV
types 6, 11, 16 and 18 whereas Cervarix protects against HPV types
16 and 18. Both vaccines have been shown to be almost 100 per cent
effective against HPV-related cervical intraepithelial neoplasia
(CIN).
Gardasil is licensed to be used from nine years of
age and Cervarix from 10 years of age. Each vaccine needs to be
given three
times over six months: months 0, 1 and 6 for Cervarix and months
0, 2 and 6 for Gardasil. The relative prices of these vaccines
will have major impact on decision makers to choose particular
brands.
The introduction of HPV vaccination in England and Wales is in
line with the global immunisation vision and strategy of the
World Health Organization and UNICEF. The chief aim is to reduce
illness
and death due to vaccine-preventable diseases globally by at
least two thirds by 2015 compared with 2000.
According to the Department of Health the current target population
is 12- to 13-year-old girls, one reason being cost effectiveness.
HPV vaccination is most effective in people who have not previously
been infected with HPV. Ideally, therefore, it should be given
to girls before their sexual debut.
HPV vaccination will prevent
almost 70 per cent of cervical cancers and it is expected that
introduction of HPV vaccination will save around 400 lives
per year. Gardasil, but not Cervarix, will also prevent almost
90
per cent of genital warts, currently the most frequently diagnosed
viral sexually transmitted infection in the UK. |
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The
Pharmaceutical Journal