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BMJ 2013;346:f2184 doi: 10.1136/bmj.f2184 (Published 19 April 2013) EDITORIALS
HPV vaccination—reaping the rewards of the appliance
of science
National programmes could virtually eliminate certain diseases and substantially reduce costs Simon Barton clinical director 1, Colm O’Mahony consultant in sexual health and HIV 2 1Department of Sexual Health and HIV, Chelsea and Westminster Foundation Trust, London SW10 9TH, UK; 2Countess of Chester NHS Trust, The optimism generated by scientific breakthroughs often turns vaccination programme. This was judged the best option on to disappointment when applied to the real world of clinical economic grounds—economic analyses during the tendering care. It is therefore worth celebrating the extraordinary success process found that the bivalent vaccine was substantially cheaper of Australia’s national human papillomavirus (HPV) vaccination than the quadrivalent one. At the time, there was much debate programme, which was implemented five years ago, as reported about whether the benefits of preventing genital warts had been in the linked paper by Ali and colleagues (doi:10.1136/bmj.
properly assessed, given the current high rate of new and f2032).1 This analysis of data on 85 770 new patients from six recurrent genital warts—more than 150 000 cases a year—in
Australian sexual health clinics shows a remarkable reduction the UK, which cost more than £50m (€59m; $76m) to manage.2 in the proportion of women under 21 years of age presenting This seemingly short sighted policy decision caused with genital warts—from 11.5% in 2007 to 0.85% in 2011 consternation among experts in sexual health services.3 4 (P<0.001). Only 13 cases of genital warts were diagnosed in However, in September 2012, the UK national programme began women under the age of 21 across all six health clinics in 2011.
to use the quadrivalent vaccine. Given Ali and colleagues’ Such a reduction in this distressing disease caused by a sexually findings, the number of young women presenting with genital transmitted virus is a major public health achievement.
warts to sexual health services should drop substantially in five Furthermore, the near eradication of genital warts in young to nine years’ time, reducing the workload in sexual health Australian women will probably have a major impact on the What about including boys in the national vaccination In 2007, Australia became one of the first countries to implement programme in the UK? In 2013 the Australian government began a nationally funded HPV vaccination programme for girls and a publicly funded HPV vaccination programme for 12-13 year young women with the quadrivalent vaccine. It started with the old boys, with a catch-up for 14-15 year old boys. This decision vaccination of girls aged 12 years in schools and a catch-up was prompted by two important considerations. The first was programme for girls and women aged 13-26 years. Quadrivalent the increasing incidence of HPV related oropharyngeal cancers vaccine protects against HPV types 6 and 11, which cause more in men.5 The second was the realisation that young men who than 90% of genital warts, in addition to HPV types 16 and 18, have sex with men, who would not benefit from heterosexual which cause cervical cancer. Vaccination coverage rates were herd immunity, would be unfairly discriminated against under exemplary, averaging almost 80% for all three doses.
a vaccination programme targeted only at girls. Ali and Ali and colleagues also found a significant decline in the colleagues state that, in addition to helping prevent genital warts proportion of women aged 21-30 years presenting with genital and anal, penile, and oropharyngeal cancers in men, “the warts—from 11.3% in 2007 to 3.1% in 2011 (P<0.001). As vaccination programme is expected to increase herd immunity might be expected, the rate of diagnoses of genital warts in and provide further indirect protection to unvaccinated women.” women over 30 did not drop. The proportion of men under 21 They comment that this may lead to control, if not elimination, years presenting with genital warts also decreased sharply, from 12.1% in 2007 to 2.2% in 2011 (P<0.001). From 2007 to 2011, Throughout Europe, there has been regional tendering to use there was no significant decrease in the prevalence of genital quadrivalent or bivalent vaccines in young women only. Doctors warts in heterosexual men over 21 years or in men who have in sexual health would obviously favour the quadrivalent vaccine because new and recurrent genital warts are the most common In the United Kingdom, policy makers chose a bivalent HPV sexually transmitted diseases managed in clinics.
vaccine (effective against HPV types 16 and 18) for the national For personal use only: See rights and repr BMJ 2013;346:f2184 doi: 10.1136/bmj.f2184 (Published 19 April 2013) It remains to be seen whether we will see similar dramatic savings. Countries should consider these data seriously and act reductions in HPV-16 and HPV-18 associated diseases, such as cervical cancer, vulval cancer, other anogenital cancers, and head and neck tumours as a result of national vaccination Competing interests: We have read and understood the BMJ Group programmes. This is likely given the reported evidence for the policy on declaration of interests and declare the following interests: efficacy of the vaccines. It is hoped that future vaccines will both authors have received lecture fees from GSK and SPMSD.
protect against other HPV types, such as types 31 and 45, which Provenance and peer review: Commissioned; not externally peer are also involved in the genesis of genital cancer. Countries should carefully explore whether it is economically feasible to Ali H, Donovan B, Wand H, Read TRH, Regan DG, Grulich AE, et al. Genital warts in Do HPV vaccines have a role to play in treatment? It is young Australians five years into national human papillomavirus vaccination programme: national surveillance data. BMJ 2013;346:f2032.
scientifically plausible that they do, because wart virus infection Lanitis T, Carroll S, O’Mahony C, Charman F, Khalid JM, Griffiths V, et al. The cost of and recurrence are caused by failure of immune recognition.
managing genital warts in the UK. Int J STD AIDS 2012;23:189-94.
The immunity induced by vaccination is four or five times O’Mahony C. Government decision on national human papillomavirus vaccine programme is a sad day for sexual health. Sex Transm Infect 2008;84:251.
greater than that induced by natural infection. Recent treatment Hammond P. (Not) warts and all. BMJ 2008;337:a2186.
D’Souza G, Kreimer AR, Viscidi, R, Pawlita M, Fakhry C, Koch WM, et al. Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med 2007;356:1944-56.
These are exciting times in the science of HPV and the world Joura EA, Garland SM, Paavonen J, Ferris DG, Perez G, Ault KA, et al. Effect of the human papillomavirus (HPV) quadrivalent vaccine in a subgroup of women with cervical can confidently look forward to the virtual elimination of genital and vulvar disease: retrospective pooled analysis of trial data. BMJ 2012;344:e1401.
warts, recurrent laryngeal papilloma, most genital cancers, and Daayana S, Elkord E, Winters U, Pawlita M, Roden R, Stern PL, et al. Phase II trial of imiquimod and HPV therapeutic vaccination in patients with vulval intraepithelial neoplasia.
some 60% of head and neck cancers. The interruption of Br J Cancer 2010;102:1129-36.
transmission of a major sexually transmitted infection through a public health initiative offers the prospect of substantial cost Cite this as: BMJ 2013;346:f2184 BMJ Publishing Group Ltd 2013 For personal use only: See rights and repr

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