Life saving treatment or giant experiment?

Abstract

Global reachIn Australia, the vaccine has had an easier ride. The first government funded vaccination campaign started there this year, targeting all 12-13 year girls. For the first two years there is also a free “catch up” programme for women up to 26. Ian Frazer, the immunologist who created Gardasil and director of the department of medicine at Princess Alexandra Hospital, Brisbane, told the BMJ that objection had been “minimal.”“Senator Barnaby Joyce implied that the vaccine should not be given to under 18 year olds because it encouraged promiscuity. However, he rapidly changed his mind in the face of public opinion,” he said.Elsewhere, Canada's latest federal budget includes $C300m (£130m; €190m; $260m) for the vaccine. In the UK, Gardasil is licensed for use in girls as young as 9 and can be bought from private clinics. The NHS has yet to provide the vaccination for free—leading to claims that the government is dragging its feet. Minutes of the Joint Committee on Vaccination and Immunisation show that it is in favour of “vaccination of girls at the age of 11 or 12 years with HPV vaccine.”8 The minutes also reveal that cost implications are stalling a final decision. In the developing world—which has much of the burden of cervical cancer disease and practically no screening programmes—there are hopeful signs that the vaccine will be widely introduced. Professor Frazer said: “The offer of vaccine at cost from the two major manufacturers and support from the Bill and Melinda Gates Foundation, together with imminent endorsement by UICC [International Union against Cancer] and WHO for global immunisation should help.” He is involved in plans to introduce the vaccine on the south Pacific island of Vanuatu, to test the feasibility of immunising pre-teens in the developing world.But there is concern for less poor countries that don't qualify for funding from the GAVI Alliance, which supports childhood vaccination programmes. Eduardo Franco, director of the division of cancer epidemiology at McGill University, Montreal, has spent 20 years studying the causes of cervical cancer. He told the BMJ: “HPV vaccines will not be subsidized in the ‘middle resource' countries, such as Brazil, Mexico, Argentina, and India. They do have the required training and screening infrastructures in place. Yet these countries continue to experience high morbidity and mortality because one or more items in the chain of resources needed for effective screening have failed.”Professor Franco said that the “cruel logic” was that the women who stood to benefit from the vaccine—and pass the message on to their daughters—were those who can afford high quality private health care and already get regular smear tests. “But those women who cannot afford private health care and thus have to depend on the public system (which has low quality, spotty, or non-existent screening) are not being screened adequately or at all. They do not know about HPV vaccines; nor will their daughters be offered vaccination. These are women who, today, develop invasive cervical cancer in these countries.”