Arguments against widespread HPV vaccination

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Published: 29 Mar 2017
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Dr Sudeep Gupta - Tata Memorial Centre, Mumbai, India

Dr Gupta speaks with ecancer at EBMCI 2017 about HPV vaccination to prevent cervical cancer.

He outlines his opposition to widespread adoption of an HPV vaccine, based on the already-lowering rates of this cancer without use of a vaccine, the population-wide deployment of a vaccine that would benefit a small number of women, and his concerns over adverse effects.

Noting improvements in access to clean water, and therefore improved sanitation and nutrition, Dr Gupta describes environmental and social factors that increase the risk of infection, and how they can be reasonably managed without vaccination.

HPV is a necessary cause of cervix cancer but not a sufficient cause. As evidence of that, millions of women get infected with HPV and in the overwhelming majority of those women the HPV virus clears itself without any intervention. It is only a very, very, very small minority of individuals in which HPV infection progresses to the next stage which is cervical intraepithelial neoplasia, in other words it’s the stage of pre-cancer. In a small minority of women who develop the pre-cancer eventually cancer develops. That is if the pre-cancer is not detected by any screening strategy. So you see, you have to vaccinate a large number of women in order to prevent very few cancers and the prevention of cancers will happen over the next few decades. So you have to vaccinate a thirteen year old girl before the onset of her sexual activity in order to prevent a cancer that might happen when she’s 45 years old or fifty years old. This, of course, assumes that vaccines have 100% effectiveness that will last for another fifty years in terms of the anti-virus immunity that they engender.

There are other data from several Indian cancer registries that shows that the incidence of cervix cancer has declined sharply, both in urban areas of India as well as in the rural areas. There are multiple reasons but definitely this has not happened due to vaccination because vaccination has not existed for the past forty years. So my submission is that we don’t need the vaccine to reduce the rate of cervix cancer. In any case if you vaccinate today you will be affecting the cancer rates thirty years from now or forty years from now by which time the incidence of cervix cancer in India would already be very low.

The other reason that I don’t advocate the vaccines is although several agencies like the Centres for Disease Control, the European Medicine Agency, have certified the safety of this vaccine there are continuing concerns that it does cause a variety of syndromes, for example the chronic regional pain syndrome, the autonomic dysfunction syndrome, the Guillain-Barré syndrome. There are several concerns that have been raised about the safety of the vaccine so you must understand that this vaccine is not like a polio vaccine, it is not like a diphtheria vaccine. When you give a diphtheria vaccine to a six month old child you want to prevent diphtheria in the next three years or in the next three months. That child has a real possibility of suffering from and dying from diphtheria in the next few months. Here you are vaccinating with HPV a twelve year old girl in order to prevent a cancer that might happen after forty years. So the risk and the benefit, in my opinion, is not in favour of benefit, as least as far as the data that I see.

Is there anything that the public should be aware of?

The public should be aware that there are several risk factors for cervix cancer, the most important one is having multiple sexual partners, having unprotected sexual activity, having more children, malnutrition, genital infections and overall hygiene. The fact that the cervix cancer rate has sharply declined in India in almost all regions is because of the effect on some of these risk factors in the India population in the past thirty or forty years. So, for example, the general level of hygiene has improved in India because of the availability of running water, because of the availability of better sanitation in many parts of India. The nutrition levels have improved. The average age at first childbirth for a woman has increased, the number of pregnancies has decreased. The number of sexually transmitted infections has reduced and safe sexual practices have also been adopted, maybe at least in some measure because of the scare about the HIV epidemic that happened about 25-30 years ago. So because of all of these reasons the rate of cervix cancer has already declined and in order to be able to protect oneself from cervix cancer my suggestion would be first of all to be cognisant of all these risk factors and second of all to undergo screening by one of the validated methods of screening such as either the visual inspection with acetic acid or with a Pap smear or with HPV testing for screening. My suggestion to the public is to go for screening after the onset of sexual activity at regular intervals.

What is the general consensus on HPV vaccination?

I don’t think there is a consensus, I don’t think at least if you are talking about the Indian public that the majority of the Indian population knows anything about the HPV vaccine. If you are asking me about the consensus amongst policy-makers, amongst administrators and amongst the government, then I don’t think there is a consensus. So, for example, one state in India, the state of Punjab has already rolled out the HPV vaccination as a population-based strategy in some of its areas but most other Indian states have not. As I have argued here, I don’t think it’s a good idea to roll out mass HPV vaccination as a preventive strategy for cervix cancer in India. So I am one of the individuals who contribute to the lack of consensus.

Does HPV cause cancer in all cases?

Although the HPV virus is found in the tumour of most patients who have cervix cancer, if you look at all the HPV infections only a very, very, very small fraction lead to cancers. So one should not get scared of the possibility of an infection that is so common in the population. One has to try to look at reasons why it gets transmitted, safe sexual practices as well as screening for cervix cancer, I think, is the way to go.