Editorial: HPV vaccination: preventing more cancers in future generations
Cancer prevention initiatives have usually been directed towards the adult population. Smoking cessation, breast awareness, sun avoidance, faecal occult blood testing and health advice on food labels are examples of programmes aimed at encouraging individuals to be more in control of their own health, including cancer risk reduction. The availability of the HPV (human papillomavirus) vaccination programme through vaccines (such as Gardasil) is a further important development but one that takes a somewhat different approach as the individual is offered protection from a vaccine that will only have beneficial effects if used prior to the commencement of sexual activity. Once exposed to the HPV, no benefit will be gained. Age, therefore, is a cornerstone concern and has raised ethical debate about whether mandatory vaccination might encourage promiscuous behaviours in young people (Vamos et al. 2008). To date, in the UK at least, the vaccine has been targeted only at young women prior to them (it is assumed) becoming sexually active. In 2012 in Australia, this was extended to include young men. This editorial explores some of the broader issues underpinning the current HPV vaccination programme.
HPV and cancer
The human genital tract is susceptible to infection by different strains of HPV; especially important are high-risk strains, which include HPV 16 and 18 (Cancer Research UK 2008). HPV has also been implicated in promoting vaginal, anal and head and neck cancers in both sexes. However, not all forms of HPV cause cancer, an important point, as 80% of people may be infected with some form of virus during their lives. In some cases, this can cause cellular proteins, produced by the HPV, to promote abnormal cell division that can result in the development of a cancer (Parkin & Bray 2006). It is estimated that the treatment of genital warts alone costs the British National Health Service approximately 17 million pounds per year.
Immunisation against HPV protects by alerting immune defences to the presence of potentially damaging infections, such as viruses. There are different forms of the HPV, and HPV 16 and 18 are thought to be the most important in cancer causation. Vaccines, in addition, can protect against HPV 6 and 11, which are responsible for genital warts. Evidence already is emerging that rates of genital warts are falling after the implementation of HPV vaccination in young women – in one Australian study, this was reported to be up to one quarter (Fairley et al. 2009).
In addition to the vaccination programme, there is also a well-established cervical screening programme that has been thought to reduce overall incidence of this cancer by up to 80% (European Centre for Disease Prevention & Control 2008). The difference with the vaccination approach is that it has been targeted specifically at girls prior to expected age of sexual debut. Apart from concerns about the relative risks associated with immunisation itself, the age of the vaccine's recipients provoked a number of arguments.
The controversies associated with the HPV vaccination programme revolved around concerns that is associated with sexual activities in an age group who are still under the legal age of consent. This is compounded by the concerns of parents, or due to religious or cultural practices, who felt it should not be administered in schools. Instead, those wishing to opt in should be required to approach their family doctor. In the UK, this led to some school governors refusing permission for the vaccination programme to be instigated. Further concerns were also voiced about the use of the vaccine itself, the risks of possible unknown side effects in the longer term and prophylactic exposure to an agent that some parents feel would not occur within the context of a monogamous, long-term, sexual relationship (Vamos et al. 2008). However, evidence from one study in Hungary has indicated that almost 50% of the sample of young people taking part (aged between 14–19 years) were already having unprotected sex and that education about HPV vaccination was effective in changing their awareness of cervical screening and other safer sex choices (Marek et al. 2012).
Across Europe, there appears to be consensus that HPV vaccination should be made available, although the mode of delivery varies in each country (World Health Organisation Europe 2008). In some countries, for instance, there was a catch-up programme for young women up to the age of 18. However, social deprivation and other associated cancer risk factors, such as cigarette smoking, also have to be considered in cervical cancer prevention programmes.
For nurses, this raises a number of issues. Clearly, low-income countries will be disadvantaged and the price of vaccines will determine access to widespread implementation. The will arise to an even greater incidence of HPV-associated cancers in developing countries where the majority of cervical cancers already occur (Agnosti & Goldie 2007).
It is important that nurses are aware of the choice and features of HPV vaccination programme in their own country. By raising awareness of the importance of HPV in relation to cervical and other cancers, nurses working in public health or school settings are likely to have an influential role on young peoples' decision about whether to choose to accept the vaccine as part of safer sex guidance.
In some countries, young men are also being offered the vaccine. HPV is transmitted sexually and including young men is thought to add additional protection as it may also be implicated in other cancers including those arising in the penis, anus and head and neck (Parkin & Bray 2006, Castle & Scarinci 2009). This reinforces the fact that human sexuality involves more than vaginal penetration. Importantly, it also means that it may be possible to screen for head and neck cancers by screening for previous HPV infection – a whole new approach to cancer screening (Kreimer & Chatuverdi 2011).
Less published evidence has been available about its effectiveness in young men but this will start to change as more boys are likely to be included in future programmes. This suggests the need for effective education when vaccination is being promoted and gender-appropriate material will be needed.
However, there are also important ethical and legal concerns about the ability of young people to opt in or out of vaccination programmes against HPV – or for their parents or guardians to do so on their behalf. In the majority of the press coverage in the UK, for example, the voices of young people were not as obvious as those of policy makers, politicians, parents or religious leaders. Whilst consensus is probably the preferred approach in such circumstances, this may not always be possible when the subject of sex and young people is concerned.
There are an increasing number of resources available for those wishing to support young people or parents to learn more about HPV vaccination. This includes a site from the UK with key questions addressed in a tone that is informative and nonjudgemental with links to young people talking about their understanding of the vaccine. It is also possible to download information leaflets across the adolescent age range – as well as information for teachers, parents and health professionals. This can be located at http://www.nhs.uk/Conditions/vaccinations/Pages/hpv-human-papillomavirus-vaccine.aspx.
The HPV vaccine is a significant breakthrough in the prevention of cervical cancer. More than 5 million young women have now been vaccinated in the UK. It is now being adopted in public health campaigns for young women (and increasingly for young men), and nurses need to be aware of the biological, financial, ethical and political dimensions attached to this important public health initiative that goes beyond cervical cancer (Wright et al. 2006). There is also a need for colleagues to share their experiences of education and implementation to ensure they shape ongoing debates about HPV vaccination for other groups who are at risk in a balanced way.
Nurses have long been involved in administering vaccinations; however, HPV vaccines raise new and additional concerns, especially when the risk of cancer in the future is being raised, further complicated by its association with sexual activity and young peoples’ private sexual choices.
There now exist opportunities to influence health policy debates about HPV vaccination across the globe. This is linked with the need to ensure that sexual health, in its widest sense, is seen as a topic that remains relevant to nursing to be involved in to help deal with preventable infections, such as HPV, that can have such a negative impact on people's lives.