Vicky Phelan (guest editor): Why it’s essential children get the HPV jab

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The HPV vaccine is safe, effective and helps prevent many types of cancer, not just cervical. That’s why it’s now being rolled out to boys, writes Helen O’Callaghan.

It’s a compelling statistic that would make you glad the HPV vaccine will be offered to teen boys as well as girls in Irish schools from this September.

A comparison between the rates of throat cancer in 2009-2013 and 2014-2018 in eight cancer centres around Ireland found a 37% increase in this cancer type. “Of that 37%, 50% is directly related to HPV infection and of that 50%, 78% are male,” says James Paul O’Neill, professor of otolaryngology, head and neck surgery at Royal College of Surgeons in Ireland and Beaumont Hospital.

These statistics emphasise the importance of the vaccine for boys, says O’Neill. “We presented the results to Hiqa, which ultimately recommended boys be included in the vaccination schedule and thankfully the Government agreed.” HPV infection doesn’t discriminate between boys and girls — 85% of women and 91% of men with at least one heterosexual partner will contract a HPV infection during their lifetime.

“Most healthy people with a normal, healthy sex life will be exposed to HPV at some stage,” says O’Neill, who confirms most common transmission is through vaginal and anal sex — and oral sex is “also a way in”.

While most people spontaneously clear HPV infections, there’s no way to know who won’t — some HPV infections can persist for years. And the trouble with HPV infections is about half of them — according to US-based Centers for Disease Control and Prevention (CDC) — are with a high-risk HPV strain that can cause cancer. Persistent infections with these HPV types can lead to cell changes, which, if left untreated, may progress to cancer.

HPV is responsible for about one in every 20 cases of cancer worldwide. HPV strains 16 and 18 are the big players — implicated in 70% of cervical cancers, 95% of anal cancers, 75% of throat cancers, 75% of vaginal cancers, 70% of vulval cancers and 60% of penile cancers.

Last December, Hiqa said it had advised the National Immunisation Schedule to switch from the 4-valent vaccine — which protects against four HPV types and which has been available to first-year secondary school girls for some years — to the 9-valent vaccine, which protects against another five HPV types, as part of a gender-neutral vaccination programme (extended to boys as well as girls).

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Hiqa director of health technology assessment and deputy chief executive Dr Máirín Ryan said extending the HPV vaccine to boys will provide “direct protection against HPV-related disease to boys, indirect protection to girls who have not been vaccinated and would reduce HPV-related disease and mortality in Ireland”.

She predicted that over 20 years, a gender-neutral 9-valent programme will prevent an estimated 101 additional cases of cervical cancer compared with the current girls-only 4-valent programme.

The HPV link with cervical cancer is now lodged pretty firmly in the public consciousness, but its connection to other cancers is less well known, says Prof Mark Lawler, dean of education at the Faculty of Medicine, Health and Life Sciences, as well as Chair in Translational Cancer Genomics, at Queen’s University Belfast.

“Certainly, the majority of people would know there’s some connection between HPV and cervical cancer.

But what a lot of people don’t know is that HPV causes other cancers that occur in both males and females, particularly oropharyngeal (throat) cancer and anal cancer. In Britain, oropharyngeal cancer is the fastest-growing cancer.

O’Neill points to a similar trend in the US, where throat cancer incidence has surpassed that of cervical cancer — 2018 saw 18,226 cases of throat compared with 11,866 of cervical cancer.

“And the majority of oropharyngeal cancer is in males,” he says.

By extending the HPV vaccine programme to boys, Ireland has now joined the ranks of countries offering gender-neutral HPV vaccination: Australia, Austria, Bermuda, Brazil, Canada, Croatia, Germany, Israel, regions of Italy, Liechtenstein, New Zealand, Serbia, and the US.

“It never really made sense to only vaccinate girls,” says Dr Phil Kieran — Cork GP and star of RTÉ’s You Should Really See a Doctor. “Vaccinating half of the population means there’s a reservoir of HPV left in the community — vaccination programmes are most effective when more than 80% of the population are vaccinated.”

Back in the 2013/2014 academic year, average HPV vaccine uptake among first-year secondary school girls was almost 84%. Following anti-HPV vaccine publicity — fear was sparked by claims girls became very ill after getting the vaccine — it dropped to about 50% in 2015/2016, but by last September the HSE confirmed provisional uptake rate for the vaccine had risen again to 65%.

Responding to the rise, Minister for Health Simon Harris said the “very welcome increase reflected huge amount of work done across the medical community, including school vaccination teams, GPs and pharmacists, to provide accurate and trusted information”. He said he wanted to be “unequivocal in saying the HPV vaccine protects young people’s lives”.

The HSE points out that all national and international regulatory bodies have stated HPV vaccines are safe. It cites an endorsement of HPV vaccination issued in January 2017 from all 69 US National Cancer Institute-designated Cancer Centers: “We are compelled to collectively call upon parents and health care providers to increase vaccination rates so our nation’s children don’t grow up to become cancer patients.”

Most recently on February 4, World Cancer Day, the International Agency for Research on Cancer stated the HPV vaccine is “safe, effective and critical for eliminating cervical cancer”.

“The jury is not out on the safety of the HPV vaccine. The jury is very much in. The vaccine is safe — we’ve known that for a long time,” says O’Neill, adding that most parents who decided not to vaccinate their daughters were “good parents” taking the decision out of concern.

“They wanted to do the right thing. They decided not to vaccinate but it was because of the scaremongering, lies and mistruths being spread about [the vaccine]. What’s important is to reassure parents that the absolute correct thing to do is to vaccinate their boys and their girls.”

Co Clare cervical cancer patient Laura Brennan, a HPV vaccine advocate, has been pivotal to achieving higher vaccine uptake rates. In July 2018, she was invited to Copenhagen by the World Health Organisation to consult about HPV advocacy.

“My only reason for getting involved in this campaign was to save other families going through what mine is going through, to save other parents watching their child suffer from a preventable illness, caused by a virus which the majority of people have had or will have at some point in their life.

I was just unlucky that I caught a cancer-causing strain of the virus and my body couldn’t fight it off. That’s why I got cervical cancer.

Her stark message is encapsulated in her words: “I’m facing my death and the reason is a virus that your child doesn’t have to get.”

If evidence from any country shines a spotlight on the absolute importance of cervical cancer screening, data from Romania does. Cervical cancer rates there are four times higher than the European averagem — 13.5% compared to 3% generally in the rest of Europe. The reason: low participation in the free national cervical cancer-screening programme which has been in operation in Romania since 2012.

But screening programmes, even with high participation, are not foolproof, as highlighted by the CervicalCheck controversy. “This proves the old adage that prevention is better than cure — or indeed treatment,” says Kieran.

“The HPV vaccine will not do away with the need for cervical screening completely — but it will reduce risk of the cancer overall, making the chances of missed abnormalities on a screening programme much lower.”

Vaccination’s also important because — apart from cervical cancer — screening isn’t “available or feasible for almost all HPV-associated cancers”, says O’Neill.

And throat cancers, for example, are difficult cancers, often presenting at an advanced stage. In the case of penile cancer, Kieran has seen just three cases in 12 years, but says “it’s devastating when it occurs”.

With the HPV vaccine also set to be rolled out to young boys in England, Scotland and Wales this autumn, Lawler points to the health-economic benefits. Cost of HPV vaccination for boys there will be £20-22m. “Treating three things caused by HPV — genital warts in both sexes at £58.5m, HPV-related oropharyngeal cancer at over £21m and HPV-related anal cancer at £7m — comes to an overall cost of £86m. So there are significant cost savings.”

These ratios will also bear out in Ireland, with similar savings for the health service. “There’s potential for a four-fold saving by rolling out the HPV vaccine programme to boys in Ireland.”

The big message, says Lawler, is that HPV disease is preventable because of the HPV vaccine. “We have the tools at our disposal to eliminate it so that’s what we should be doing — eradicating it as a disease.”

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