by Dr Sam Merriel
GP and Honorary Lecturer
Centre for Academic Primary Care
Dr Joanna Kesten
Senior Research Associate
NIHR Health Protection Research Unit in Evaluation of Interventions
Researchers from the Centre for Academic Primary Care and Population Health Sciences, Bristol Medical School, with colleagues from Queens University Belfast, Ulster University, and Southampton University, have published an editorial in the British Journal of General Practice (BJGP) in response to Public Health England’s (PHE) recommendation to roll out a targeted Human papillomavirus (HPV) vaccination programme for men who have sex with men (MSM) through genitourinary medicine (GUM) and HIV clinics across England.
The editorial argues that although this announcement is a positive step, it would be more effective to follow more recent recommendations to introduce gender neutral HPV vaccination to achieve total elimination of HPV, rather than a reduction. The PHE proposal means MSM who do not attend sexual health clinics, unvaccinated women and heterosexual men who have sex abroad would continue to suffer from HPV-related genital warts and cancers.
The incidence of HPV-related cancers, particularly oropharyngeal cancers, has risen in recent decades. Preventive measures to reduce the burden of HPV-related diseases include safe sex practices, regular cervical smears for women, and HPV vaccination programmes. However, the optimal approach for the reduction and prevention of HPV-related diseases is yet to be determined.
The HPV vaccine was introduced in 2006 and has been adopted in a number of countries worldwide. There are three types of HPV vaccine; the bivalent vaccine (covering HPV sub types 16 and 18); the quadrivalent vaccine (covering HPV sub-types 6, 11, 16 and 18); and the 9-valent vaccine (covering HPV sub-types 6, 11, 16, 18, 31, 33, 45, 52, and 58). The current recommendation in the UK is for two doses to be given, based on evidence that the effectiveness is comparable to a three dose schedule.
Optimal coverage for HPV vaccination programmes targeting adolescent females is at least 70%, which is being achieved in the UK and Australia, but not in other high-income countries such as France, Italy, Germany, The Netherlands, and the USA.
Female-only HPV vaccination programmes theoretically protect heterosexual males if optimal coverage is reached. However, this herd immunity does not extend to men who have sex with men (MSM) and heterosexual males who are sexually active overseas, exacerbating health inequities, particularly for MSM who are at increased risk of HPV-related diseases.
Extending HPV vaccination to men who have sex with men
Currently, the four nations of the UK have HPV vaccination programmes only for adolescent females based on the original recommendations of the UK Joint Committee on Vaccination and Immunisation (JCVI). Public Health England recently endorsed adding a targeted HPV vaccination programme for MSM after running a pilot programme for MSM through sexual health clinics in 2016/17.
Before the PHE recommendation could be implemented, the JCVI re-evaluated the available evidence for HPV vaccination and recommended that current UK vaccination programmes be extended to adolescent males as well. All four nations have accepted the recommendation. However, there has been no timeline or details about implementation, and no discussion about catch-up programmes for young adult males.
Testing through cervical screening
Cervical screening (formally known as pap smears or cervical smears) aims to detect abnormal cells in the cervix. Recently HPV testing has been added to cervical screening programmes, as most cervical cancers are caused by HPV infection. Women with abnormal cervical cells detected on screening need to undergo further diagnostic testing to determine if the changes are pre-cancerous or if cervical cancer is present and, if necessary, to receive appropriate treatment.
Optimal cervical screening coverage to reduce cervical cancer rates is at least 80% of all eligible women. As of 31 March 2017, 72.0% of women in England had been screened adequately, and coverage in England and other UK nations has been falling in recent years.
No single approach
It is likely that no single approach will achieve the aims of the International Papillomavirus Societyto ‘move towards eliminating HPV as a public health problem’. Cervical screening coverage is sub-optimal in the UK and trending downwards, and public health teams will have to work hard to maintain current HPV vaccination coverage.
HPV vaccination also does not protect against all cervical cancer in women, so the extent of the anticipated reduction in cervical cancer rates will be interesting to follow in the coming years. A robust gender-neutral HPV vaccination programme, in combination with cervical screening and safe sex campaigns might help in reducing the burden of HPV-related disease.
Read the BJGP editorial by Merriel S. et al “’Jabs for the boys’:time to deliver on HPV vaccination recommendations.