HPV vaccines: peering through the fog.

©FSRH J Fam Plann Reprod Health Care 2008: 34(4) Background The UK’s human papillomavirus (HPV) vaccination programme should now be underway: vaccination of 12–13year-old girls against HPV was due to begin in September 2008, with a recent announcement that 17–18-year-olds will also be vaccinated in this academic year.1 From September 2009, a further catch-up programme for girls up to the age of 18 years will commence. The Department of Health (DH) has decided that the HPV vaccine to be used for the programme will be Cervarix® (GlaxoSmithKline), which is the bivalent vaccine against the cervical cancer-causing HPV types 16 and 18. This decision has surprised many, in view of the fact that the other available vaccine, Gardasil® (Merck), would protect against genital warts (HPV types 6 and 11) as well as cervical cancer. It is unfortunate that there has not been a proper disclosure of the factors that led to the decision, resulting in widespread speculation amongst health professionals and the media, particularly relating to the cost of the vaccine. A list of the pre-agreed evaluation criteria against which the bids were evaluated has recently been released (Table 1), and includes many factors, which have been weighted, though details of cost are still not given. When questioned, the Secretary of State for Health stated that both published and unpublished data were considered.2 The suggestion in the media that girls in the UK will receive an inferior vaccine may undermine the success of the vaccination programme, as parents become unsure whether it is worth vaccinating their daughter with such a product.3,4 Adding fuel to this debate is a mathematical model published in the BMJ, which was considered by the DH when making its decision.5 This suggests that Cervarix must be £13–£21 cheaper than Gardasil in order to be cost effective. However, it should be noted that a number of assumptions were made in this model; it was assumed both vaccines were identical in terms of efficacy, duration of immunity, cross-protection against nonvaccine HPV types, and that uptake amongst girls would be at least 80%. This last assumption is the least likely to be correct; a pilot study in a primary care trust (PCT) in Manchester found uptake was only 70% overall, and significantly lower in schools with a greater proportion of girls from ethnic minority groups and poorer families. In addition, the Catholic schools in the PCT refused to participate in the pilot.6 One could speculate that another factor influencing the DH decision might have been the possibility of greater acceptability of a ‘cervical cancer vaccine’ (without the need to mention genital warts) in certain ethnic and religious groups.7