HPV Vaccination

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: G-politik in Industrieländern 10

Abstract

A vaccine has recently become available that may protect women against HPV infection and subsequent cervical cancer. The vaccine was licensed in New Zealand in July 2006. Immunisation interest groups and professional organisations representing obstetricians and gynaecologists bodies have recommended the introduction of this vaccine to the national schedule. However the Ministry of Health has so far not committed to a decision to fund the vaccine and include it on the immunisation schedule.

Purpose of health policy or idea

Human papilloma virus (HPV) is a common sexually transmitted infection (STI) that is also responsible for most cervical cancer. Cervical cancer is the 8th most common cancer in New Zealand, with rates for Pacific and Maori women being twice that of all New Zealand women. There are more than 30 HPV types that can be transmitted sexually and although most do not cause symptoms, others can have significant long term effects for some people. The highest infection rates are amongst people aged 15 - 24 years. The latest (2006) STI survey for New Zealand shows a 3.6% presentation rate for HPV infection.

In July 2006, a vaccine that protects against certain types of HPV, Gardasil, manaufactured worldwide by the pharmaceutical company Merck and by CSL Biotherapies in Australasia was licensed in New Zealand. The vaccine has shown significant efficacy against anogenital and cervical lesions related to vaccine type in women with no evidence of previous exposure to vaccine specific types.

These findings have led to aggressive marketing from Pharma to fast track this vaccine into the national immunisation schedule for girls aged 11 - 15, so as to reduce the spread of HPV infection and decrease the burden of cerival cancer. Meanwhile, the Ministry of Health which funds the immunisation programmes has not yet seen a rigorous cost benefit analysis of the inclusion of this vaccine in the context of national immunisation. The Ministry is therefore reluctant to commit significant funds until such an analyis is provided.

Main points

Main objectives

A vaccine that protects against certain types of HPV was licensed in New Zealand in 2006. However the Ministry of Health has not yet made any commitment to include the vaccine in the national immunisaton programme. The aims of such a programme would be to:

• reduce the incidence of HPV infection
• reduce the incidence of cervical cancer

Groups affected

Ministry of Health, families with school age children, pharma producing the vaccine

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Political and economic background

The New Zealand Ministry of Health produced a cancer control strategy in March 2005. Objective 5 in this plan has the aim of reducing the number of people developing infectious disease related cancers. Specifically this document goes on to say … 'a vaccine to prevent human papilloma virus is currently under development and this has the significant potential to reduce cervical cancer'. It recommends that we … 'monitor and assess developments in HPV screening and potential vaccination and implement as appropriate when evidence shows these to be effective and feasible'.

The Ministry of Health takes advice on what should be included in the National Immunisation Schedule from its Technical Working Group. In November 2006 this group recommended to the Minister Of Health that HPV vaccine using Gardasil should be included as a primary immunisation series of 3 doses to girls of age 15 if no 'catch up vaccination' was planned, or to girls aged 11 or 13 if a catch up to age 15 was allowed. They noted that... "The catch up for new vaccines was of lower priority than implementation of new vaccines to the appropriate age cohort."

Also in November 2006, The Royal Australian and New Zealand College of Obstetricians and Gynaecologists produced a position statement on HPV vaccination. This statement called for the "vaccination of all females aged 9-26 years with the initial vaccination of girls aged 11 or 12". This is similar to the program of vaccination that has been introduced in Australia in 2007 and funded by the Federal Government.

Political pressure to introduce HPV vaccination has also come from various other groups in the New Zealand health scene, other than the College of Obstetricians and Gynaecologists. Various medical specialties including paediatrics, sexual health, primary care and the Immunisation Advisory Centre at the University of Auckland have produced letters and articles supporting the introduction of HPV vaccination in New Zealand.

Change based on an overall national health policy statement

Cancer Control Strategy

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

The national and international scientific consensus is that immunisation is one of the most cost effective means of preventing disease and improving health, and that risks associated with vaccines are rare. Many countries have rapidly approved and legislated for the introduction of this vaccine, including Australia, many states in the USA, the NHS in the UK and various EU countries such as Germany and France. The driving force for introduction of this vaccine has been players from the fields of paediatrics, gynaecology, sexual health, public health and education.

Initiators of idea/main actors

• Regierung

• Leistungserbringer

• Kostenträger

• Bürgergesellschaft

• Privatwirtschaft, privater Sektor

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

Supporters :  

1. The Immunisation Technical Working Group - this group advises the Minister of Health. They recommended in November 2006 that this vaccine be included in the 2008 immunisation schedule either at age 15 if no catch up program is planned or at age 11 or 13 if catch up vaccination is to occur.

2. The New Zealand College of Obsetricians and Gynaecologists recommened the vaccination of all girls and young women from ages 9-26.

3.  Medical advisors from The Immunisation Advisory Center at the University of Auckland - This group could be seen as a pressure group for advancing understanding around vaccinations.

4. Other medical specialists involved in public health, sexual health, paediatrics immunisation etc.

5. Companies producing the vaccine.

6. The Private HPV Project - Supposedly an independant information and education group for virally transmitted infection. Historically closely aligned with Pharma.

7. NGOs such as Family Planning, The New Zealand Sexual Health Society and the Aids Foundation.  

Opponents:  

1. Social conservative groups that advocate 'abstinence only' approaches or so called family value groups. An example is Family First which republishes articles from mainly right wing conservative christian groups in the United States that question the need for and the safety of HPV vaccination. This vaccine they argue is not necessary until 6 months before sexual activity commences. They go to say that vaccination could then be planned for in an enviroment that condones any sexual activity before marrriage.

2. The Immunisation Awareness Society - This group opposes medical immunisation on various grounds, under the guise of informed choice for parents.  

Undecided:  

1. The National Cervical Screening Programme is part of the Ministry of Healths National Screening Unit. The leader of this group, Dr Hazel Lewis, published an article in July 2007 questioning whether the time was right to introduce mass vaccination programmes for HPV. She argued that there were a number of questions to be answered about the vacciantion itself and its introduction. Her implied suggestion was that delaying implementation was sensible at present. This opinion is obviously one that reflects current Ministry of Health opinion as well, as this Ministry is well known for its tight control over policy opinion.

2. As suggested above, the funder of immunisation programmes the Ministry of Health seems undecided as to when to introduce this programme and is looking for longer term data re efficacy and cost benefit. 

Actors and positions

Regierung
Minister of Health	sehr unterstützend		stark dagegen
Leistungserbringer
Primary care and public health	sehr unterstützend		stark dagegen
NZ College of Obstetricians and Gynaecologists	sehr unterstützend		stark dagegen
Kostenträger
Ministry of Health	sehr unterstützend		stark dagegen
Bürgergesellschaft
Immunisation Technical Working Group	sehr unterstützend		stark dagegen
Privatwirtschaft, privater Sektor
Pharmaceutical suppliers	sehr unterstützend		stark dagegen

Influences in policy making and legislation

No formal legislation is required to introduce new vaccine programmes in New Zealand.

Actors and influence

Regierung
Minister of Health	sehr groß		kein
Leistungserbringer
Primary care and public health	sehr groß		kein
NZ College of Obstetricians and Gynaecologists	sehr groß		kein
Kostenträger
Ministry of Health	sehr groß		kein
Bürgergesellschaft
Immunisation Technical Working Group	sehr groß		kein
Privatwirtschaft, privater Sektor
Pharmaceutical suppliers	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

The New Zealand situation has not yet led to a position of adoption and implementation for vaccination. The issue at hand is how to introduce the vaccination into the landscape of cervical screening presently in place. New Zealand has had a comprehensive and free nationally coordinated cervical screening programme in place since 1990. Overall this achieves a 70 % uptake rate for cervical screening. Since implementation there has been a 50% reduction in the incidence of cervical cancer and a 65% reduction in mortality. Obviously this programme is effective, but it suffers from a poor uptake amongst Maori and Pacific women with 50 % and 45 % uptake respectively for these groups. A successful implementation of a vaccine programme for HPV needs to consider some of the following issues

• What age group will be vaccinated and will there be a catch up programme? - at present, estimates are that the cost of vaccination will be NZ $10m per age cohort vaccinated.
• What will be the optimum cervical screening regimen for vaccinated cohorts? Does it differ from that currently in place and are there cost savings?
• The cost of vaccination should include the cost of education for girls and their parents - what is the best operational structure to implement this at a school level?
• Initially vaccination may lead to increasing social inequality in cervical cancer incidence/mortality if the vaccine is not effectively promoted to Maori and Pacific women who already have lower rates of uptake of cervical screening and higher incidences of cervical cancer than other women.
• Should young boys also be offered vaccination in an effort to reduce the transmission of HPV?

Expected outcome

The introduction of this vaccine poses a number of interesting issues around screening and vaccination. In the context of a succesful effort to reduce cervical cancer (the National Cervical Screening Programme) we now have an added tool that could reduce the rate of this disease even futher. However the cost of vaccination is not small and the added value over the present system is unclear. The oppotunity cost of spending additional money on cervical cancer prevention, which is now relatively rare and continuing to decline, needs to be considered, especially if catch up programmes are contemplated. The overall cost of the cervical cancer prevention programme will initially rise, and ways of reducing cost in the longer term, such as altering the time frames for Pap smears need to be considered.

There is inequality in the present system with a lower uptake of screening in certain ethnic or socioeconomic groups. It is unclear yet how a vaccine programme will address these issues. It would be undesirable if those already well represented in screening cohorts became the main recipients of vaccination. This could actually lead to incresed inequality in burden of cervical disease at a later date.

The long term efficacy of vaccination is still unclear, as is the need for possible booster vaccination. One unintended outcome could be a reduced awarness of the ongoing need for cervical screening amongst women. If this was to be combined with a waning protection from vaccination, or a increase in cervical disease from other types of HPV then cervical disease could in fact rise.  

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

The introduction of HPV vaccination should increase the quality of the screening programme for cervical disease. However there a number of issues that need to be considered which will may impact on both the present and future quality, cost efficiency and equity of this programme

• Which age groups to vaccinate?
• How will the programme be marketed to target groups?
• How will uptake of vaccination be measured and what methods will be used to reduce social and ethnic inequality in its uptake?
• What affect may vaccination have on the current screening system?
• How will we follow the effectiveness in our vaccinated cohorts?

References

Sources of Information

• Raffles, Angela E. Challenges of implementing human papilloma virus vaccination policy. British Medical Journal 335 (7616): 373, Aug 25th 2007.
• National Screening Unit. Screening Matters - newsletter of the National Screening Unit. Issue 10, July 2007. www.nsu.govt.nz/News  
• McConnell, Dynes, Stewart Reid, Nikki Turner et al. Criticism of the decision not to fund the HPV vaccine for pre-adolescent females in New Zealand, and Response. New Zealand Medical Journal (120) 1259,  Aug 2007.
• Ministry of Health. The New Zealand Cancer Control Strategy: Action plan 2005-2010. Wellington: Ministry of Health. www.moh.govt.nz/moh.nsf/49ba80c00757b8804c256673001d47d0/abed0ba681a637e1cc256fbc006f22d7?OpenDocument
• Lo, Bernard. Human Papillomavirus vaccination programmes - Editorial. British Medical Journal (335) 7616: 357,  Aug 25th 2007.
• Sawaya, G.F. and K. Smith-McCune. HPV vaccine - more answers more questions. Editorial. New England Journal of Medicine (356)19: 1991-1993. May 2007.

Author/s and/or contributors to this survey

Franklin, Rick

Auckland District Health Board

Empfohlene Zitierweise für diesen Online-Artikel:

Franklin, Rick. "HPV Vaccination". Health Policy Monitor, October 2007. Available at http://www.hpm.org/survey/nz/a10/2