The Republic is awaiting the go-ahead for a school-based cervical cancer vaccine programme that could save many lives every year
FROM SEPTEMBER, all schoolgirls aged 12 and 13 living in the North will be offered a free vaccine against cervical cancer. But their counterparts in the Republic - more than 52,000 of them - would have to pay about €600 each for the same medical procedure.
The UK programme, which is aimed at preventing most cases of the disease in women by vaccinating girls against the sexually-transmitted virus that triggers it, is predicted to save at least 400 lives a year in the future.
Studies have shown that the vaccine, which is given in three injections over six months, is most effective in girls before they become sexually active. The British government has not yet decided whether to provide the vaccine to older women on the National Health Service.
While other European countries are introducing national vaccination programmes, the Republic has been slower to address the idea. Cervical cancer is the second most common cancer in women under 45 worldwide, claiming 70 lives a year in the Republic. Some 180 new cases are diagnosed each year.
A cost-benefit analysis of a vaccination programme has just been completed by the Health Information and Quality Authority (HIQA) and is with the Minister for Health, Mary Harney. It is expected to be published shortly.
Fianna Fáil and the Green Party promised in their Programme for Government to introduce the vaccine as a universal health measure if it was recommended by experts. The Minister for Health asked the board of the National Cancer Screening Service and the National Immunisation Advisory Committee (NIAC) to examine the issue, and last autumn they requested HIQA to compile a health technology report.
The chief executive of the Dublin Well Woman Centre, Alison Begas, says she is "reasonably confident" that a programme will be announced within weeks. She sees it as an essential part of the cervical cancer screening programme which the Government is committed to implementing this year.
Cervical cancer is primarily caused by the human papilloma virus (HPV), a sexually-transmitted infection. It is estimated that 80 per cent of sexually active women get an HPV infection at some stage in their lives.
For most people, HPV does not cause a problem and goes away on its own. However, in some cases, if left untreated, certain high-risk types of HPV can lead to cervical cancer. The vaccine protects against the virus and therefore reduces the risk of developing cancer.
The vaccine was licensed for use by GPs and clinics in the Republic 16 months ago but there has been a very low uptake so far. Dublin Well Woman, for instance, has vaccinated only about 100 women. At €600 for a course of three injections over six months, the cost is prohibitive. There is also a lack of public awareness.
"The sooner we have a decision on a school-based vaccine programme the better," says Begas. Without it, "we are leaving it open for people to be exploited" by some having to pay an exorbitant price for the injections.
She says she was disturbed to get a phone call from a woman in her late 30s who had cervical cancer and whose mother had had cervical cancer. Because of the family history, she wanted her teenage daughter vaccinated. "The GP had charged her €250 per injection, a total of €750 for the course."
Two drug companies, Merck and GlaxoSmithKline, market HPV vaccines under the trade names Gardasil and Cervarix respectively. Both protect against the two most common cancer-causing HPV types, numbers 16 and 18, responsible for 70 per cent of cervical cancer cases.
Gardasil also provides immunity against two other strains, numbers six and 11, which cause 90 per cent of genital warts.
The medical director of Dublin Well Woman Centre, Dr Shirley McQuade, says that even if the go-ahead for national immunisation is imminent, it is highly unlikely it could be up and running by the beginning of the new school year in September, when it will start in the North.
So what is her advice to parents in the Republic in the meantime? "For parents who have a child in the six to 10 age group, just hold on. The vaccine is likely to become available. The difficulty I see is the older teenager. In other countries they have started with a particular age group, such as 12-year-olds. So 15-year-olds onwards might not get caught in the net," she says.
She thinks it unlikely that we would follow the lead of Australia, which is vaccinating up to 26 years of age. There, she explains, a standard programme has been introduced for 12- to 14-year-olds, a catch-up scheme for 14- to 18-year-olds, also through schools, while those aged 18 to 26 can go to their GP.
"I would say to parents of 15-year-olds upwards, they will probably be missed out so they should be considering the vaccine, but cost is an issue," says McQuade.
The least the Government could do is remove the 21 per cent VAT on the vaccine, she suggests. The three doses cost about €140 each, including VAT, and there's doctor's fees on top of that. The vaccine has not been approved for use within the GMS.
"If anybody is sexually active at all, she is likely to get the virus," explains McQuade. "Skin-to-skin genital contact is enough to transmit the virus, it doesn't have to be full intercourse."
There is some public confusion about cervical cancer. "It is sexually transmitted, but lifestyle is not a problem. You don't pick out people to be vaccinated." And she suggests that vaccinating at age 12 takes the stigma out of it.
The immunisation scheme has caused controversy, particularly in the United States, where critics argue that providing it for 12-year-olds gives tacit approval to underage sex. But supporters point out that this is simply the age at which it is most effective to administer it and is not a judgment about what any girl does or doesn't do.
"It's a fact of life: HPV is everywhere," says McQuade. "If we did blood tests on any group of people, at least 80 per cent of them would have markers showing that they have been in contact with HPVs at some time."
And that includes both genders.
Although boys transmit the virus they usually do not suffer symptoms and health officials in other countries have decided it would not be cost effective to include them in their vaccination programmes.
It is considered cost effective to vaccinate girls up to 18. Britain plans to introduce catch-up programmes from next year.
A spokesman for the Department of Health and Social Services in Belfast explains that while they are starting with 12- and 13-year-olds this autumn, they will catch up with 16- to 18-year-olds the following autumn and 15- to 17-year-olds in 2010.
Once these are finished, all girls in secondary school, apart from in the final year, will have been offered the vaccine free.
It is estimated that the vaccination scheme for 12-year-olds will cost the NHS £100 million (€130 million), plus a further £400 million (€520 million) to implement the catch-up programme.
Parents should welcome a vaccination programme if it is introduced here, McQuade says.
It is not just about cutting your daughter's risk of cancer, it also reduces the chance that in the future her smear tests will come back with even minor abnormalities.
While many of these abnormalities indicated in cervical cells revert to normal by themselves, they have to be monitored and that can cause a lot of upset and hassle.
"The decision to have your daughter vaccinated is a medical one," she adds, "and it should not be an emotive issue."
The National Cancer helpline is at free phone 1800-200700 and is open Monday to Thursday, 9am-7pm and Friday, 9am-5pm.
Do you think that girls as young as 12 should be vaccinated against cervical cancer? E-mail your views to healthsupplement@irish-times.ie.
A selection of your views will be published in a future issue.
Case study: 'I have not yet decided to have my daughter vaccinated'
Susan is well informed on the benefits of the cervical cancer vaccine but has not yet decided if she will bring her 15-year-old daughter, Christine, to their GP to get it privately.
"The price is one thing," she says. "I'm also a bit reluctant to go looking for a vaccine which hasn't officially been taken on yet.
"I haven't discussed it with Christine. She doesn't like injections for a start - and this is a course of three. It would also be easier for her to accept it if everybody else in school was getting the vaccine. But of course the longer you wait, the more you risk your daughter being exposed to the virus."
In another year, Christine will be 16 and at the age of consent for medical matters. "It would be more up to her to decide then," says Susan.
She is finding it a difficult issue to address with her daughter, "because of the implications of sexual activity. She's at the in-between age - at a later age it's more acceptable and at an earlier age you don't have to explain fully the reasons for the vaccine.
"I do want her to be vaccinated before any sexual activity and it's unlikely she will be covered by any new vaccination programme.
"I just keep putting it off - partly because it is difficult to discuss what she's up to after the discos, and there is also the possibility that we would be spending quite a lot of money which may not be necessary in a few months' time, if they do start to offer it free."
She also doubts she can convince Christine of the benefits - that not only would it greatly reduce her risk of cervical cancer, but also make it much less likely that she would have an abnormal smear test some time in the future.
"At this age they live for the day, and have little concept of serious illness."
Reasons to: vaccinate at 12
It cuts the risk of developing cervical cancer by at least 70 per cent.
The vaccine is much more effective before any sexual activity.
The immune system of a child reacts better to a vaccine than that of an adult.
It will help prevent even minor changes of cervical cells, so will reduce the chance of an abnormal smear test later in life and all the upset and hassle that goes with it.
