HPV Vaccination for Boys

Steve Brine Excerpts

Wednesday 2nd May 2018 Westminster Hall

[Sir Roger Gale (North Thanet) (Con)]

I beg to move,

That this House has considered the case for HPV vaccination for boys.

I am delighted to find you in the Chair, Sir Henry. Before I start the substance of my speech, I want to place on the record my appreciation for the help I have received from a number of people, most notably Professor Christopher Nutting, one of the country’s most eminent oncologists specialising in throat and thyroid cancers, and Peter Baker, the campaign director for HPV Action. I am grateful to them both for educating me. I am also indebted to Stephen Bergman and Jamie Rae, two sufferers from the condition we are going to discuss—I shall say more about them later. Finally, I place on record my appreciation of the work done by my hon. Friend the Member for Finchley and Golders Green (Mike Freer). The Minister will understand that he cannot be here this morning; he has Government duties and a vow of Trappist silence as a Government Whip.

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

I have been there.

[Sir Roger Gale]

My hon. Friend the Minister indicates that he knows the problem only too well. My hon. Friend the Member for Finchley and Golders Green has done a significant amount of work in achieving the provision of human papillomavirus vaccine for gay men—a small but significant step in the direction in which I hope we may travel further this morning.

Until a relatively few weeks ago, I knew very little about this issue. I concede that entirely. Unlike one of my colleagues who was here in this Chamber yesterday morning while I was in the Chair listening to the debate, who had a relative who had died of bowel cancer, I have no personal experience. However, when I met Professor Nutting and Peter Baker, I was astonished at the speed with which they convinced me of the argument—and I am not a pushover when it comes to spending taxpayers’ money. I think it is a no-brainer, and I hope to persuade my hon. Friend the Minister, and others, on this cause.

The human papillomavirus causes, among other things, cervical cancer, throat cancer, anal and penile cancers, and cancer of the back of the tongue. The virus is carried by about 80% of the population, which means somebody in this room is a carrier; it is not uncommon. I would like everybody to take that on board. Go on the tube in the morning and there will be dozens of people carrying the virus—most of it dormant, and a lot of it non-malignant. It is contracted in sexually active youth and, for men, usually in their teens or 20s.

The point is that it is a slow-burn issue. Its effects are not experienced overnight. A condition contracted as a teenager or at university may not rear its head for 30 years. We are talking about men now in their 50s and 60s, who some of the eminent people sitting behind me in the Public Gallery are treating, waiting that length of time without realising that they have anything wrong with them at all, because there is no screening process for men, unlike the screening process for cervical cancer.

I spoke yesterday to two people, Jamie Rae and Stephen Bergman—both sufferers, and both in their mid-50s—who described their experiences to me. I will not go into too much of the gory detail. I heard again this morning of another experience: somebody’s colleague, himself an eminent surgeon, who had throat cancer and suffered many months out of work, which was a loss to the health service, damage to his family and, of course, the treatment. The treatment involves chemotherapy and radiotherapy; it may involve a tracheostomy; and it inevitably damages the saliva glands in the mouth, leaving the patient who survives with permanent dryness, considerable pain and ongoing discomfort. As I have indicated, there is also the social damage. Both Jamie Rae and Stephen Bergman described to me in graphic detail the processes they have been through and the discomfort—I use that word very modestly indeed—they have experienced. They described themselves as the lucky ones, because both those gentlemen have come through it relatively unharmed, but of course there are many others who do not.

The HPV vaccine has been available to adolescent girls since 2008. A pubescent girl of 12 or 13 is offered the opportunity to be vaccinated in school. The parents, quite properly, have a right to refuse that vaccine. Just in case anybody has any doubt, I am aware that there are a small number of cases where parents believe that things have gone wrong and that children have suffered as a result of the vaccination. That is medically unproven, but we have to recognise that the parents believe it. Parental choice is vital, and in the case of pubescent girls there is parental choice.

The process ties in directly with the Department of Health and Social Care’s cancer strategy, which of course is about prevention. The Department has done significant work on preventing or seeking to prevent other prominent cancers. Lung cancer is the obvious one, and the anti-smoking campaign is highly relevant in this context. Melanoma is another; something that people of a certain age, such as myself, probably did not bother with at all has suddenly become prominent as the realisation of the damage that the sun’s rays can do to the skin and the cancers that can arise from that has dawned on the population. Any responsible parent or grandparent now takes the trouble to ensure that their children have appropriate sunscreens at all times when enjoying the sun. HPV vaccine falls directly into that category. It is usable for prevention and, used properly, it works. That is proven. As I said, this has been available to adolescent girls since 2008.

We now come to the hard bit of the argument, because up until now I think everybody would probably agree that we are on a winner in using HPV vaccine, but of course there is the question of cost and efficacy. The argument has been deployed that herd immunity, to use the colloquial phrase, will mean it is not necessary to vaccinate boys, because if we eliminate the infection in girls, boys will not catch it from the girls. That is nice in theory, but wrong in practice.

I am told by those who know better than I do that the average young male has at least 10 sexual partners. The Minister might find that surprising; I did myself, but it is so. It depends whom we believe, but in the United Kingdom the vaccine has an uptake of between 70% and 83%, although in some parts of the country it is as low as 50%. A young man embarking on an exciting night out with his girlfriend therefore has a very high risk of contracting HPV from a girl who has not been vaccinated, and that is just in the UK. We overlay on that the foreign travel that many young people are now happily able to enjoy. Sometimes, with sun, sea and sand goes sex, and the risk of exposure to HPV in those circumstances can be even greater. Therefore, the idea that herd immunity will in time address the problem is fallacious, and this is where I have to accuse those who are responsible for taking the decisions—that is not the Minister—of short-termism.

I can see the attraction of the argument that extending vaccination would not be cost-effective and that herd immunity is coming downstream. Yes, the cases coming through now are historical, in the sense that the disease was contracted 20 or 30 years ago, so well before any immunisation. If we want to save money and damage health at the same time, that is quite a good way of going about it. I am seeking to persuade the Minister of the real value of having the courage—he is not lacking in courage—to take a long-term decision now.

The cost of immunising every adolescent boy within the relevant range in the UK is estimated to be, at the top end—this includes the purchase of the vaccine, which of course has to be negotiated by the health service, and its application—about £22 million a year. That is a lot of money, but in health service terms it is almost a bagatelle. Set against that, I am told by those with real experience, some of whom are sitting behind me in the Public Gallery, that there are about 2,000 patients a year—men in their 50s and 60s—who have developed throat, penile or anal cancers. The cost of treating those is about £21 million a year. Of course, that takes no account of the social costs and the other damage that can be done. In the case described to me this morning, of a surgeon who was taken out of play for a considerable time, the cost of treatment—of a replacement jaw, as well as the chemotherapy, radiotherapy, hospitalisation and everything else that goes with it—is looking like being somewhere between £50,000 and £100,000, and that is just one case.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

It is a pleasure to serve under your chairmanship, Sir Henry, I think for the first time. I congratulate my hon. Friend the Member for North Thanet (Sir Roger Gale) on securing the debate and bringing this important subject to the House. He was in the Chair the last time I was in Westminster Hall, which was just yesterday. I am surprised that so few Members are present for the debate. As the shadow Minister suggested, perhaps matters elsewhere in the House and outside are occupying their minds.

As my hon. Friend the Member for North Thanet mentioned, our expert group, the Joint Committee on Vaccination and Immunisation, is considering this matter, and it is important that I do not pre-empt its final advice, as he rightly said. That does make the timing of the debate challenging, but I will respond as fully as I can and give as much context as possible.

I will first set out some of the context. In 2008—before I was even a Member of the House—on the advice of the JCVI, an HPV vaccination programme for girls was introduced. The primary objective was to protect against cervical cancer. As the hon. Member for Washington and Sunderland West (Mrs Hodgson) kindly said, my mission in life—not just in my job—is to challenge and beat that dreadful disease. While I am on the subject, I pay tribute to Jo’s Cervical Cancer Trust and the brilliant Rob Music, who leads it—I know that the hon. Lady knows them well. The trust’s work in this area over many years, including with me as Minister, has been truly transformative for many women’s lives.

The HPV vaccine that is used in the UK offers protection against the two types of HPV that are responsible for about 70% of cervical cancers, and since the introduction of our vaccination programme the number of young women infected with HPV has fallen dramatically. Protection is expected to be long-term, eventually saving hundreds of lives each year, which I am sure we all agree is very welcome. Today, however, our focus is on boys and men.

[Jim Shannon (Strangford) (DUP)]

Is the Minister aware of the paper on this subject by Dr Gillian Prue of Queen’s University Belfast? Dr Prue’s six recommendations are very similar to what the hon. Member for North Thanet (Sir Roger Gale) and others have put forward today. They include: first, that both men and women should be vaccinated against HPV-related diseases; and secondly, and more importantly, that the significant human cost of HPV-related diseases should be the primary consideration for including boys in vaccination programmes. If the Minister has not been made aware of the paper, I am happy to furnish him with the copy. Its recommendations are integral to moving forward on the issue.

[Steve Brine]

Not wishing to mislead the House, my honest answer is that I am not aware of that paper. Whether my officials are aware of it is another matter—I will ask them. I know that the hon. Gentleman will not be shy about putting a copy in my hand after the debate.

The good news is that HPV vaccination of girls also provides some—I emphasise “some”—indirect protection for boys. When the vaccination uptake rates are high, as they are in England, there are fewer HPV infections in heterosexual males, because the spread of HPV infection between girls and boys is reduced. There is evidence to back that up; it is not just words. For instance, diagnosis of first-episode genital warts in young heterosexual men between the ages of 15 and 17 declined by 62% between 2009 and 2016. That suggests that there is some—again, I emphasise “some”—herd protection from the existing HPV vaccination programme. However, that is not the start of the story, and neither is it the end, and I have to put it on the record that nobody in Government has ever said that it was. Nevertheless, I take the points that have been made today about herd immunity; it is only part of the story.

Of course, it will take much longer to see the impact that the girls programme has on HPV-related cancers, but we should not wait for those results before considering whether more needs to be done now for boys. As my hon. Friend the Member for North Thanet said, this is a slow-burn problem.

[Sir Peter Bottomley]

It is just a matter of pure mathematics. If 100%, or nearly 100%, of any age cohort —male and female—gets the vaccination, the herd immunity develops much faster than just relying on vaccinating up to 50% of that cohort.

[Steve Brine]

I think that my hon. Friend is stating facts, and I know that the JCVI officials who are here today will have heard him.

The JCVI keeps all vaccination programmes under review, as it should, and it keeps Ministers informed of any reviews. As my hon. Friend the Member for North Thanet is aware, given the increasing evidence about the link between HPV infection and oral, throat, anal and penile cancers, alongside the incidence of genital warts, the JCVI has considered whether HPV vaccination is now needed for males.

I understand the point that the hon. Member for West Dunbartonshire (Martin Docherty-Hughes) made about the surprise about penile cancer. He has more experience of the subject than I do, but it is not a surprise to me. I work with a very good charity called Orchid Cancer, some of whose staff attend my cancer roundtable regularly. It deals with male cancers and is trying to raise awareness of penile cancer as a challenge in society today. It is an issue that is difficult for society, let alone for men, to talk about. I thank the hon. Gentleman for what he has said today.

The JCVI considered its current piece of work in two parts: first, whether the HPV vaccination should be introduced for men who have sex with men—MSM—and secondly, whether it should be introduced for adolescent boys. MSM, as we know, are a group at high risk of HPV infection. Unlike heterosexual men, of course, they are unlikely to receive much, if any, indirect protection from the HPV vaccination programme for girls. The JCVI advised us that a targeted HPV vaccination programme should be introduced for MSM up to the age of 45 who attend genitourinary medicine clinics or HIV clinics. Following a successful pilot in 42 clinics that was led by Public Health England, we announced in February that the programme would roll out across the country from April, and it is now being rolled out. That programme is welcome, but again I fully appreciate that it is not the start and it is certainly not the end of the story, for some of the reasons that the hon. Member for Washington and Sunderland West set out in her very coherent remarks.

Let me turn to the issue of adolescent boys. Of the non-cervical HPV-associated cancers, not all cases are caused by HPV—indeed, the percentage of cases that are attributable to HPV is widely debated. My hon. Friend the Member for North Thanet mentioned The Swallows, which I do not have much contact with, although I have heard of it. I passed a note to my officials asking them to get in touch with the charity as a result of this debate, so it should look out for that. For head and neck cancers, alcohol is an important risk factor to take into account, but HPV does play a role, and that is why the JCVI is considering whether vaccination for boys should be introduced.

The JCVI issued interim advice on HPV last July. As Members know, that was subject to consultation. It is reviewing the evidence ahead of finalising its advice to Ministers. Its members are the experts, and they are best placed to consider the evidence and provide advice to Ministers. That is the system that Parliament has mandated. Parliament could change it, but that is our system.

[Sir Peter Bottomley]

When the Minister sends a report of this debate to the JCVI, it might be worth him respectfully saying that some of us here are aware of how long it took it to agree to bring in HPV protection even for females. It might want to consider whether postponing that decision was right or wrong. In my view, it was wrong. The people at the British Association for Sexual Health and HIV knew that it was wrong, and it took an awfully long time for them to change their minds. Can we please ask them respectfully not to make the same mistake again?

[Steve Brine]

Those people are nearer to my hon. Friend than he knows, and they will have heard his point.

In his opening remarks, my hon. Friend the Member for North Thanet asked the JCVI to take the long view, and I hope that I can reassure him somewhat on that point. Some examples of what the JCVI is taking into account in its considerations include: the projected future number of HPV cancers resulting from the current incidence of HPV infection; the potential savings as a result of preventing future cancers, which a number of Members have mentioned; the potential savings from preventing genital warts; and, crucially for my hon. Friend’s point, the long-term impact of HPV infection up to 100 years into the future, which will outlive even him.

The JCVI’s interim advice indicated that to vaccinate boys would be

“highly unlikely to be cost-effective in the UK, where uptake in adolescent girls is consistently high”.

It is true that the UK has achieved high uptake for the girls HPV immunisation programme for the past 10 years. In 2016-17, 83.1% of girls completed the current two-dose course, including the daughter of the hon. Member for Washington and Sunderland West. I have two young children—one of each—and of course those of us who are parents want what is best for our children. Somehow arguments about cost-effectiveness do not feel right. Cost-effectiveness is important, however, because it is about how to fairly, consistently and robustly assess which interventions and treatments should be funded in what we must remember is a publicly funded health system. We need to deliver value for money for the taxpayer and deliver the most health benefit possible to all patients. That is our system.

[Mrs Hodgson]

I take on board what the Minister is saying for areas where uptake is high but, as I cited earlier, there are parts of the country where uptake is nowhere near high enough, such as Stockton, where it is 48%. How does that work? How does that argument stand up for those parts of the country?

[Steve Brine]

The hon. Lady makes a very good point. I was hoping to have a note to respond on that specific point about regional inequalities, but I will have to write to her. Perhaps it is something we can discuss offline. That very good point has not been raised with me recently, but I will take it away and follow it up.

My hon. Friend the Member for North Thanet did not mention discrimination and equality, but other Members certainly did. I accept that equality needs consideration in this case, and I confirm that the Department is carrying out an equality analysis. That cannot be completed until we have received the JCVI’s final advice and we know what it is advising and why, but I can confirm that officials will make contact with key organisations such as HPV Action—I met members of it recently at a roundtable I held on cost-effectiveness methodology for immunisation programmes and procurement, and I know that some of them are here today—as they progress the equality analysis to ensure that such views are taken into account. I confirm that the equality analysis will be published, and I will make the House aware when it is.

There have been a number of threats of judicial review related to equality and sex discrimination in relation to HPV vaccination. I do not think it would be appropriate to say more at this stage, but the House will have heard those two commitments.

[Mrs Hodgson]

On the equality point and the herd immunity point, may I raise the issue of men who have sex with men and the fact that their first presentation at a sexual health clinic could be at the age of 32? Again, there is no way for there to be herd immunity or even for us to extend the vaccination, as we have done in the pilot, to men who have sex with men. There will still be huge numbers of people not covered. Does the Minister agree, and what is he going to do about that?

[Steve Brine]

The hon. Lady makes her point, and it is not one that I miss, I assure her. That issue forms part of the ongoing deliberations. She has made that point twice, and it is a good point.

I know there are concerns, to put it mildly. My hon. Friend the Member for North Thanet set out the timeline of how long it is taking the JCVI to finalise its advice. However, the consultation raised some important, complex issues around the cost-effectiveness model, and it would be remiss of the JCVI not to ask for those issues to be addressed before it puts the matter on its agenda and makes its final decision. I appreciate that my hon. Friend and other Members want the advice quickly—believe me, so do I—but I cannot advocate asking the JCVI to cut corners, which would call into question the quality and robustness of its advice and undermine an internationally respected organisation. The JCVI will get its advice on boys to me as soon as it can, and I am certainly expecting it this year. As soon as I have it, we will turn it around as quickly as we can.

I am totally committed to our world-leading vaccination programme. It is an area where this country leads the world. I am as keen as my hon. Friend and other Members present to hear the JCVI’s final advice on HPV vaccination for boys as soon as possible. The JCVI has helped successive generations of Ministers and, as my hon. Friend said, it will help those who come after me—there will be many, and maybe sooner than we think. It has helped Ministers make decisions that are fair and justifiable, and we need to allow it to complete its advice without too many distractions that could slow it down even further, which no one wants.

We have heard an impassioned case for an HPV vaccination programme for boys from, among others, the hon. Member for Washington and Sunderland West, for whom I have so much respect. As my hon. Friend the Member for Worthing West (Sir Peter Bottomley) suggested, I will send a transcript of the debate to the JCVI to ensure that in the unlikely event there are any issues it was not aware of, that can be reflected in its final advice. It is listening to the debate today. For the reasons I gave at the start of my remarks, I cannot give the House an indication of when exactly a decision will be made, or what that decision might be—trust me, I would love to—but I can say that I will prioritise consideration of the JCVI’s final advice as soon as I receive it.