SECOND OPINION:HPV vaccination programme makes no economic sense, writes JACKY JONES
THE HSE is offering a new human papilloma virus (HPV) vaccination programme to young girls in first and second year at secondary school. The organisation plans to immunise more than 46,000 girls in 2011, at a cost of €4 million. Does this represent value for money? HPV is a common virus: it is estimated that about 80 per cent of sexually active people will contract it at some stage in their lives.
The virus is passed on via skin-to-skin contact during sexual activity, not just intercourse. It is often referred to as the common cold of sexually transmitted infections (STIs) and can cause genital warts, although many people have no symptoms.
Cervical cancer occurs in only a small number of those infected by HPV and takes many years to develop. In Ireland, fewer than 80 women die from cervical cancer each year, whereas more than 600 die from breast cancer and more than 500 of lung cancer. Does the number of women with cervical cancer justify a nationwide vaccination programme?
Two things have to happen before a woman develops cervical cancer. First, she has to contract the HPV virus. Second, her cervical cells need to be vulnerable to the effects of this virus. No one knows why so few women go on to develop cervical cancer given that so many are exposed to the HPV virus. Risk factors we know about are: having sex at an early age before the cervix is fully developed, having children very young, having large numbers of children, smoking, contracting other STIs such as chlamydia, and anything that makes the cervix more vulnerable to the effects of HPV.
Statistically, having a large number of partners increases your risk as you are more likely to meet someone who already has HPV. Sometimes people are afraid to mention numbers of partners because of fears of labelling people “promiscuous”. This is ridiculous as, theoretically, you can have as many partners as you like without contracting HPV if you practise safe sex, whereas you might become infected after your first sexual encounter if you don’t. A virgin will never get HPV or cervical cancer but that is not a realistic scenario for 99.9 per cent of the population. The best protection involves using a condom correctly, delaying sex until 17 years of age and negotiating safe sex.
Although cervical cancer is thus preventable through modifying sexual behaviour, the emphasis in Ireland to date has been on screening for the disease through smear tests, and now providing the vaccine. Educational materials available from the HSE and other organisations do not mention safe sex or make vague references to sexual activity. People then get confused between morality and science, which is no help to anyone.
The WHO recommends that any HPV immunisation programme be part of a co-ordinated strategy that includes education about safe sex. This should include assertiveness training on saying yes and no to the kind of sex you want to engage in. We are not there yet in Ireland. I can’t imagine teachers discussing how to use condoms properly or how to ask for what you want in sexual relationships. Most schools, if they offer sex education at all, focus on health risks, STIs, unwanted pregnancy: all the bad things and none of the good things associated with sex.
Focusing on vaccination as the main way of preventing cervical cancer can have negative consequences. Young women may assume they are fully protected: they are not. The vaccine protects against only HPV strains 16 and 18 which cause 70 per cent of cervical cancer. Girls still have to practise safe sex to prevent this and all other STIs.
So why bother with expensive mass vaccination which is pretty well useless without sex education? Vaccination might make economic sense in countries where the incidence of cervical cancer is six times higher than in Ireland, where people do not have easy access to condoms, where women are not in a position to negotiate the kind of sex they want, but in Ireland it doesn’t. The cost of the vaccination programme means we can’t afford a sex education programme. Health promotion in the HSE has lost 43 staff over the past few years and €3.3 million has been cut from its budget so we have nobody to organise sex education even if we wanted to. Now can anyone say this makes economic sense?
Jacky Jones has recently retired as a regional manager of health promotion with the HSE