Health: Human Papilloma Virus

Lord Patel of Bradford Excerpts

Tuesday 20th January 2015 Lords Chamber

Asked by

[Lord Patel of Bradford]

To ask Her Majesty’s Government what action they are taking to include all adolescent boys in the national vaccination programme for human papilloma virus.

[Lord Patel of Bradford (Lab)]

My Lords, I am most grateful for the opportunity to discuss the very important issue of whether adolescent boys as well as girls should be included in the national vaccination programme for HPV—human papilloma virus. I thank all noble Lords who will be speaking in this short but important debate, and express my gratitude to Peter Baker, former chief executive of the Men’s Health Forum and the current campaign director of HPV Action, for all his expert advice and guidance.

This debate is particularly timely because the Joint Committee on Vaccination and Immunisation—JCVI—is currently looking at whether the national HPV vaccination programme should include boys. I have a particular interest in the outcome through my role as chair of the All-Party Parliamentary Group on Men’s Health. Some two years ago, the all-party group held a meeting jointly with the All-Party Group on Sexual and Reproductive Health in the UK. The chair of that group, my noble friend Lady Gould of Potternewton, and I heard evidence from two distinguished speakers—Professor Margaret Stanley from Cambridge University and Mr Peter Greenhouse, a consultant in sexual health from Bristol—which absolutely opened my eyes to the avoidable risks to the health of men caused by HPV infection.

I realised that HPV is not just a problem for women. It does not cause just cervical cancer but other cancers in women and a wide range of cancers in men as well. We know that HPV can cause, in men and women, cancers in the head and neck, as well as anal cancer. In women it can cause vaginal and vulval cancer, and in men penile cancer. In fact, worldwide HPV is understood to cause 5% of all cancers and is thought to be behind the steep rise in oral cancers in the past 20 years.

Unfortunately, HPV is a very common and easily acquired sexually transmitted infection. The majority of people—probably over 80%—will be infected with HPV at some stage in their lives. The good news is that most people’s bodies clear the virus naturally and it causes no lasting damage. But in others it can persist, especially if they have weakened immune systems, and can lead to potentially life-threatening problems. HPV is not just a cause of cancer; it is also responsible for genital warts and a very unpleasant but fortunately much rarer condition called RRP—recurrent respiratory papillomatosis. This can cause serious breathing problems and is very difficult to treat.

Thirty-six organisations have come together as HPV Action to make the case for gender-neutral vaccination; in other words, protecting both males and females from the consequences of HPV infection. These 36 organisations are major names in the fields of cancer, sexual health, men’s health, oral health and public health; in fact, one of them is the Royal Society for Public Health, of which I happen to be a vice-president. HPV Action has informed me that some 2,000 cases of cancer in men are caused each year in the UK by HPV. Around 48,000 men also develop genital warts as a result of HPV infection, and about 600 men and boys live with RRP. This is a huge burden for the individuals affected and their families, and a significant issue for the NHS, which has to find the resources to treat and care for them.

It seems patently unfair that we exclude boys from a vaccination programme that can easily prevent a wide range of diseases, including several types of cancer. This makes no sense on the grounds of equity or public health. I also wonder if it might even be unlawful to exclude boys from this programme under our current equality legislation. I would be very interested to hear from the Minister whether this is the case and whether an equality impact assessment has been undertaken on this issue.

With regard to the JCVI’s timescale for a decision on adolescent boys, in 2014 it stated that it would be in a position to make a recommendation later this year. Unfortunately, in the past few weeks we have heard that the JCVI will not be taking a view until early 2017. Given the facts and figures that I have just presented, this delay is totally unacceptable. I ask the Minister to meet the JCVI urgently to discuss how the decision-making process can be accelerated. Any continued delay is causing many, many more people to suffer avoidable ill health. In fact, I believe that the case for vaccinating boys is already proven and that Ministers should make a decision now to vaccinate boys as soon as possible.

Of course, as always, there are arguments put forward that seek to justify excluding boys. I will briefly address a couple of these. First, it has been argued that the current vaccination programme for girls is so good that it protects males as well. It is true that the programme reaches over 80% of girls; 80% is the level at which the population as a whole is believed to be well protected. The UK HPV vaccination programme is without doubt one of the best programmes in the world for girls. But it is not perfect. There are some areas, notably in London, where vaccination rates in girls are well below 80%. The latest data for Enfield, for example, show that just 67% of girls received all the doses they needed. A recent study by University College London also found that girls from black or other ethnic minority backgrounds were less likely to have been vaccinated than girls from white or Asian ethnic backgrounds. These shortfalls leave large numbers of unvaccinated girls and women at risk of contracting HPV and limit the efficacy of the wider vaccination programme.

Evidence from Denmark clearly shows that while HPV vaccination for girls is reducing the incidence of genital warts in girls, it is not reducing the incidence of warts in boys. This suggests very strongly that boys are continuing to be infected with HPV, either by unvaccinated Danish girls or by girls from countries without a vaccination programme. Men in the UK, as in Denmark, do not conveniently have sexual contact just with women brought up in their own country. It is also the case that not all men have sexual contact with women of their own age group. For those men who have partners who are older than the first female cohort to receive the vaccination, the risk of HPV infection and disease will remain.

Secondly, there are some who believe that the problem with not vaccinating males is largely confined to those who have sex not only with women but also—or instead—with men. It is true that men who have sex with men are, in general, more seriously affected by HPV. Rates of anal cancer in this group have risen sharply in recent years, and anal cancer rates are even higher in men who have sex with men who are HIV positive. It has been suggested that the solution to this problem could be to offer HPV vaccinations to men who have sex with men, on attendance at a GUM clinic. Indeed, this step was recently recommended by the JCVI. In my view, and in the view of HPV Action and other experts, this is a useful but certainly nowhere near a sufficient response. It might be of some help to individuals who receive the vaccine, but it is not an effective solution for all men, or indeed for all men who have sex with men.

That is because we know that people generally become infected with HPV very soon after their first sexual experiences. That is why it is best to vaccinate before a person begins sexual activity. It is also best because the body’s immune response is greater if the vaccine is administered before the age of 16. But if we wait until men who have sex with men turn up at GUM clinics, they are likely already to have had sex with one or more sexual partners. There is lots of evidence to prove that the median age of men approaching GUM clinics is their late 20s and early 30s.

As we cannot practically or ethically identify and vaccinate the 12 and 13 year-old boys who will in their adult lives go on to have sexual activity with other men, the only effective way to protect men who have sex with men is to vaccinate all boys. This would, of course, also protect all other men and increase the level of protection for unvaccinated girls, especially in those areas where, as I have just mentioned, vaccination rates are below 80%.

The proposal to vaccinate all boys has far-reaching support. In fact, it is now hard to find anyone in the field of public health in the UK who does not support gender-neutral vaccination. Significantly, other countries are already vaccinating their boys. Australia, several Canadian provinces and Austria have already introduced gender-neutral vaccination programmes, and the United States is recommending vaccination for both sexes.

I want briefly to mention the issue of cost. HPV Action estimates that the additional cost of extending the HPV vaccination programme to boys in the UK would be in the region of £20 million to £22 million. This relatively small cost has to be set against the economic impact of HPV-related disease. In England, the cost of treating genital warts alone is estimated to be more than £52 million a year. The cost of treating RRP has been estimated at £4 million a year and there are the costs of treating a rising number of HPV-related cancers.

I serve as chairman of Bradford Teaching Hospitals NHS Foundation Trust, so noble Lords will appreciate that I am very interested in health interventions that are cost-effective, as this one clearly would be. But, ultimately, any decision about whether to vaccinate boys should not be made solely on a financial basis, although that is very clear cut. I believe that public health, equity and, above all, the human costs of HPV-related disease for both sexes must be the primary considerations. I would be grateful if the Minister could assure the House that the Government will act quickly to vaccinate both boys and girls in the UK.