The main question of prevention of a disease is complex. Especially those sexually transmitted. Some one asks a toughie of the proponents of cervical cancer vaccination
It was one of those classic tropical days in Malaysia. A sudden shower had washed the streets clean. The sky was a maudlin grey, and the Petronas Towers greyer in the sky.
It has nothing to do with what was happening inside the vast rooms of the Kuala Lumpur Convention Centre. But we’re setting the atmosphere, the play of cosmic forces. Erm. For inside, matters of great import were unravelling themselves, and little storms raining themselves out.
Inside the KLCC, there was a galaxy of important people, representing that slice of fairly influential institutions and governments from across the world, discussing intently, a virus. As a run up to the global conference Women Deliver, calling for investments in girls and women, the Global Forum on Cervical Cancer Prevention (GFCC) had organised a meeting on tackling Cervical Cancer.
The Life and Times of a Virus
The virus under the scanner was the Human Papilloma Virus. Yes, you have heard that before, recently too: When the once handsome Michael Douglas, the guy with the drawl that is alternately fascinating and irritating reportedly told newspapers that his throat cancer had been caused by oral sex. It is quite possible: Oral sex can cause the transmission of the Human Papilloma virus that causes cervical cancer in women, to the mouth or throat, where it nestles, to cause cancer.
So what is this HPV? It is a DNA virus that infects epithelial cells (cells that line the cavities and flat surfaces of the body. There are at least 100 known HPV genotypes, of which 13 are said to cause cancer. The two most common types associated with cervical cancer are genotypes 16 and 18.
Yes, it spreads during sexual contact, not penetrative sex only, but mere skin to skin contact is sufficient. In a woman, it seeks and settles the mouth of the uterus, the cervix. Most adults are said to have HPV infections some time during their life, but the infection usually clears up on its own. If a person has a type of HPV that causes cancer and remains untreated for many years, then cancer might occur.
The risk factors that contribute to development of cancer after HPV infection include smoking, early age at first delivery, smoking, long term use of hormonal contraceptives, multiple child births, and or co-infection with Herpes Simplex virus.
Show me your cervix; I'll give the cancer a fix
A Pap Smear test can indicate any activity, cancerous or precancerous in the cervix. This test is widely used in the private health care sector, whereas the public sector relies heavily on a simpler technique: visual inspection with acetic acid (VIA) and Visual Inspection with Lugol’s Iodine (VILI). Smearing the cervix with the acetic acid or iodine reveals white lesions or marks, that can be treated with cryotherapy, in other words, by freezing them to hell.
Jab we must take
Two vaccines are today available to prevent HPV infection, and the idea is to get the public health care system take them to the target group - adolescent girls. This is because the risk of infection is highest soon after sexual activity begins; and there is said to be another peak among women during menopause. It must be administered before exposure to the virus, or, beginning of sexual activity.
Numerous tools and technologies exist to prevent cervical cancer, but these interventions remain inaccessible to the vast majority of girls and women in the world. For instance, the market price of the Cervical Cancer Vaccine is as high as $ 130 for a single dose; three doses are required to provide protection. In India, one dose costs about Rs. 2500, gynaecologists say. The GAVI Alliance recently negotiated to bring the price per dose down to $ 4.50, and has urged nations to apply for support.
Mamma Mia, look at the boys
But let’s get into that auditorium again. Important questions are being asked. A young reporter from one of the African nations says, “So, you tell me the boys can give it to us. So why can’t you give the boys the vaccine too, so they don’t give us the virus in the first place. Isn’t this practical?” The most simple, pertinent questions get the loudest titters in the room.
Seth Berkley, the CEO of GAVI, who speaks with evangelical zeal about the virtues of vaccination, took her question after the titters died down. He explained that with the available resources it was important to tackle prevention for the group that the virus most affects – women. One had to work out how best to take the vaccine to the target group. But sure, one day, he hoped, HPV vaccination would be offered to the boys as well.
A point recently reinforced by experts in their article in the British Medical Journal as experts recommended that young gay men should be vaccinated against HPV infection, because their risk of developing anal cancer is more than 15 times higher than it is in straight men. They also added that doing so would be cost effective for the NHS; the challenge being in identification of young men before they become sexually active.
The challenge, however, as Mr. Berkley subtly indicated, and was evident at GFCC and Women Deliver, is to get governments to bring HPV vaccination into their schedule – at least for the women. India, for instance, has among the highest number of deaths (over 72,000) globally from Cervical Cancer, and there are an estimated 2,75,000 deaths of cervical cancer every year.
Similar statistics are not available for incidence of other forms of cancer that HPV causes, among women and/or men. But once we’ve thrashed out that massively challenging issue of taking HPV vaccination into government strategies, we could look at expanding the target group eligible for protection. Because, clearly in this case, what’s good for the goose, is good for that gander too.
*The author was at the GFCC to speak at a media session on cervical cancer, at the invitation of Global Health Strategies.