Equity and consent
FOR THE last three years, the field of cervical cancer treatment has been rocked by the introduction of a prophylactic vaccine that protects against the human papilloma virus or HPV, which causes about 80 percent of cervical cancer cases.
The vaccine protects against the most common types of HPV linked to cervical cancer and genital warts, but it does not cure anyone who is already infected or has been exposed to HPV. And because a person’s immune system works best when one is young, HPV vaccination is recommended for people from age 9 to 26, preferably before one becomes sexually active.
At the recent biennial meeting of AOGIN-Philippines, the local research organization on health issues surrounding cervical cancer and genital infections, the HPV vaccine was the subject of many presentations, some of them concerning the issue of parental consent for vaccinations for young people, others on expanding coverage to boys and men and “special groups,” and community support for both vaccination and screening.
In her talk on “KAP (Knowledge, Attitudes and Practice) Studies on HPV Vaccination in the Local Setting,” Dr. Ma. Julieta Germar presented previous studies measuring public awareness and attitudes towards HPV vaccination before and after the introduction and marketing of the vaccines. As expected, public knowledge about the HPV vaccine increased after the marketing efforts were launched, and when asked if they would themselves get vaccinated or bring their daughters for vaccination, most of the women (about 60-80 percent) said they would, saying that the vaccine would protect against cervical cancer. But the numbers dropped when told that the vaccine, at the time of the study, would cost about P15,000 for all three shots. Asked how much they would be willing to pay for vaccination, women respondents at the waiting room of Medical City said they would pay no more than P5,000.
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“COST is a big factor” said Germar, in influencing a person’s decision to go for vaccination or not. But also important, she said, is “belief in the effectiveness of the vaccine,” and this is best influenced, she said, by “doctors’ endorsement,” which means that physicians themselves have to believe in the vaccine and the good it holds for their patients.
One problem that arises, though, is parental consent for younger patients.
As a general rule, say Dr. Rosa Marie Nancho and doctor-lawyer Antonio Reboso, a doctor should protect himself or herself by securing written consent before vaccinating a minor. But for every patient, said Nancho, doctors should make sure they provide proper counseling and full information not just on vaccination, but also on responsible sexual behavior. To be sure, she said, “parents with previous experience of cervical cancer tend to encourage vaccination” for their children. Also to keep in mind, she added, are adolescents’ right to confidentiality and privacy. In certain cases, she said, “the principle of the best interests of the child can apply.”
Nancho cited the guidelines issued by the international Catholic Medical Association which emphasizes that the vaccine provides a moral good, and that even if HPV infection is sexually transmitted, it does not mean that vaccination against it is immoral.
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AT PRESENT, the situation of HPV vaccination mimics that of screening, which aims for early detection of signs of cervical cancer through a pap smear or the simpler and much cheaper VIA or visual inspection with acetic acid.
The main problem is the narrow reach of both vaccination and screening programs, with a limited number of women reached due mainly to cost but also because of other factors like the lack of skilled health personnel, facilities and equipment.
With JHPIEGO and MSD, a drug company, the Cervical Cancer Prevention Program, a multi-sector endeavor, recently launched the “Mother-Daughter Initiative,” which seeks, said Dr. Cecilia Llave of CECAP, “to incorporate vaccination in a screening program.”
A program launched in both Thailand and the Philippines, the initiative is in three sites here: Pagbilao, Quezon, Los Baños, Laguna and Minglanilla, Cebu. It involves working with the community to encourage mothers who come to health centers for screening to bring their young daughters with them so the girls can be vaccinated. This follows on work done in pilot sites (three at first and now expanded to 10) where a coordinated, comprehensive effort to promote screening (using VIA) has been carried out. From a narrow slice of the “universe” of targeted women, in certain sites such as Minglanilla, said Llave, coverage is as much as 90 percent.
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BUT even as efforts to scale up vaccination and screening coverage go on, studies are even now being conducted on expanding the target audience, mainly by providing vaccination to boys and men.
Although the effort to eradicate cervical cancer must continue, said Dr. Efren Domingo, the quadrivalent vaccine, which offers protection against genital warts, has recently been approved for use on males. This is because HPV has also been linked to diseases in males, such as anal and penile cancer, cancers of the head and neck, and genital warts. “There has been an increase in the incidence of anal and penile cancer,” noted Dr. Domingo, while genital warts can also result in the creation of “stigma, worry and anxiety” in infected patients.
Another reason to promote vaccination among men, said Domingo, is that HPV infection in men also increases the risk of infection for women partners, while cross-infection between two infected partners is also common.
“Vaccination for both men and women is a more equitable public health policy,” declared Domingo.
