Sunday April 1, 2007
Contentious vaccine?
A vaccine to protect women against cervical cancer is now available in Malaysia. CHIN MUI YOON discovers contentious issues amidst the celebrations.
OF all the viruses out there waiting to attack us, perhaps none could strike more fear in women than those that infect our most private areas – the vulnerable, physical parts so intrinsic to our idea of femininity.
Now, a vaccine has been created to help us prevent cervical cancer, a disease caused almost exclusively by the sexually transmitted virus called the human papillomavirus (HPV).
The Quadrivalent Human Papillomavirus Recombinant Vaccine protects against four of the most prevalent strains of HPV that can lead to cervical cancer – types 6, 11, 16 and 18. Some 70% of cervical cancer cases are caused by HPV types 16 and 18 alone, while types 6 and 11 cause 90% of genital warts cases.
HPV is so easily spread that half of all sexually active women and men acquire genital HPV infection at some point of their lives. While our immune systems can overcome many of the infections, some will lead to the development of cervical cancer.
Cervical cancer is the second leading cause of cancer deaths among women around the world. The World Health Organisation (WHO) reported nearly 500,000 new cases of cervical cancer in 2002 alone. The United States’ Centers for Disease Control and Prevention (CDC) states that some 80% of women will become infected by the age of 50.
Against such statistics, there is little doubt why gynaecologists and parents hail the new hero for women’s health.
“[This vaccine] is a major advancement in the prevention of cancer and we support any measure to prevent more women from dying from the disease,” said gynaecological cancer specialist Dr Suresh Kumarasamy, who is chairman of the Gynaecological Oncology Sub-committee of the Obstetrical and Gynaecological Society of Malaysia (OGSM), who was invited to speak at the media launch in Kuala Lumpur on March 27.
OGSM president Dr Abdul Aziz Yahya, also a guest speaker, pointed out that the 2003 National Cancer Registry for Peninsular Malaysia has shown some 1,300 women diagnosed with cervical cancer, with over 750 deaths.
“Women need to be proactive in taking measures to protect themselves,” he said.
“Precancerous changes and early cancers of the cervix generally do not cause pain or other symptoms. Regular Pap screenings are vital to help detect these changes in the cervix. Yet only some 33% of Malaysian women are going for regular checks.”
The new approach to tackling cancer is exciting because it prevents the disease from developing instead of destroying it through chemotherapy or radiation treatments after it is detected.
But in the midst of the euphoria surrounding this medical breakthrough, some uncomfortable questions are being raised.
Protection for the privileged?
Introduced in 2006, the new vaccine has swiftly won approval in over 40 countries today. The Drug Control Authority of Malaysia approved the vaccine last October.
The vaccine is administered as a series of three injections in the arm over six months. One shot starts from RM450. That means complete dosage comes at a minimum price of RM1,350. And don’t forget the consultation and administration fees. But it is still less costly than the average RM16,000 for a hysterectomy to tackle cervical cancer.
“Some of the women who bring their daughters to us for vaccination are cancer survivors. They have experienced the trauma of cancer and they don’t wish their daughters to go through the same thing,” said Dr Abdul Aziz.
The vaccine’s cost means those who can afford it will be protected. What about girls and women in the lower income bracket, especially those whose monthly earnings can’t even pay for one injection?
“The cost of the vaccine will deter poorer families from benefiting from it,” said Fong Kui Lun, MP for Bukit Bintang, Kuala Lumpur, whose constituency is packed with luxury condominiums, government flats and squatter settlements alike.
“And how about those who are uneducated, illiterate and have no clue as to what the vaccine is all about? Cancer is, after all, a major killer disease. If the vaccine can truly benefit the people, the government can certainly consider how it can make it affordable and available for all citizens.”
It would seem the answer is to make the vaccine mandatory at schools or offered at government-subsidised rates. But that solution comes with contentious issues on parental rights.
A question of necessity
Another unsettling factor for concerned parents is the vaccine’s recommendation for girls as young as nine. Even the CDC states that HPV vaccine is routinely recommended for girls 11-12 years of age and works best for those up to 26 years old.
The vaccine’s manufacturer (Merck, Sharpe & Dohme) points out that the vaccine works only for girls and women who are not sexually active or are already infected with the four types of HPV the vaccine protects against. Also, it does not protect against other types of HPV outside those four strains.
Mothers we spoke to have bubbled with indignation at the thought of their daughters being guinea pigs or having big companies benefiting from health scares.
America’s oldest weekly magazine, The Nation, notes that Merck stands to make US$4bil (RM14bil) annually from the vaccine in America. Bloomberg carried in its Feb 20, 2007 report that starting from 2008, girls ages 11 and 12 in Texas, US, will be required to have the vaccine before sixth grade. The shots will cost the state US$50mil (RM175mil) the first year.
The National Vaccine Information Center (NVIC) in the US is vocal on the issue of safety and parental rights, especially as more states are making the vaccine mandatory for 11-year-olds.
In a press release issued in February, NVIC president Barbara Loe Fisher points out that the HPV vaccine “appears to have been studied in fewer than 2,000 girls between nine and 15, and it is unclear how long they were followed up.”
“There is a serious absence of scientific evidence that the vaccine is safe to give to young girls entering puberty, who are biologically different from older women,” she adds in a March 8 statement.
“An analysis of reports made to the federal Vaccine Adverse Event Reporting System (VAERS) indicates that doctors are administering the HPV vaccine to girls and women at the same time with other vaccines, despite the product insert stating that, Co-administration with other vaccines has not been studied with the exception of hepatitis B vaccine.”
In March 2006, Loe Fisher said, “There is too little long-term safety and efficacy data, especially in young girls, and too little labelling information on contraindications for the CDC to recommend the vaccine for universal use.
“This is not just about teenagers having sex; it is also about whether the HPV vaccine has been proven safe and effective for little girls.”
Safe sex, more sex?
Unlike contagious diseases like polio, chickenpox or tuberculosis, cervical cancer and genital warts are mainly a result of personal, lifestyle decisions.
And so the question of the “undeserving ill” arises. The risk of HPV infection is increased by the number of sexual partners we have. The vaccine raises a concern that it indirectly encourages sexual promiscuity by reducing the health risks of sex.
“Many youths at 13 have said they have already experimented with casual sex,” said Pastor Mike Kunaseelan, a social worker with Grace Community Services and committee member of Focus on the Family’s No Apologies programme (to counsel youths between 12 and 24 on sexual responsibility).
Some parents, especially conservative ones, are uncomfortable with the idea of confronting matters on their daughters’ sexuality.
“But the issue is not in whether the vaccine encourages sexual promiscuity or on the sexual aspect. The vaccine prevents cervical cancer,” said Dr Suresh. “After all, when we offer rubella vaccination, we don’t ask each girl, are you planning to get pregnant? Vaccines are just to offer immunisation.”
National Cancer Society of Malaysia executive director Dr Saunthari Somasundaram told The Star that cervical cancer is more prevalent among Malaysian women than most people realise. “It is just something that women don’t talk about because it is intrinsic to femininity,” she said.
“Over 1,500 women develop cervical cancer and 700 die of it every year. That translates to four new cases a day and two deaths daily. Yet cervical cancer is also the most preventable cancer today.
“Pap smear tests, which start at the cost of RM5 or RM10 from government clinics to below RM100 in private hospitals, are readily available. Yet most women just don’t take it.
“While the Pap tests can reveal changes in the cells, that if left unchecked, could lead to cancer, the vaccine goes one step further in prevention.”
It seems logical then, to expect more education and awareness on the risks of cervical cancer and Pap smears than on the vaccine itself. Merck has repeatedly urged girls to continue taking Pap tests even after receiving the vaccine.
Dr Saunthari emphasised, “HPV is a prevalent, sexually transmitted disease, but it is not indicative of sexual promiscuity.
“Even if the woman is a virgin, she can still contract the disease from her husband who has already been infected. The safeguarding of morality starts with the family, but it is also a community issue. Morality differs between person and families.”
Maggie Chan, a 52-year-old cancer survivor and mother of two girls ages 18 and 25, added, “Vaccines offer a good degree of protection although it cannot guarantee complete coverage. Our children still need to be taught the responsibilities of caring for their health and of having sex.
“At the end of the day, it is just a vaccine.”
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