Business without Debate

Delegated Legislation

Motion made, and Question put forthwith (Standing Order No. 118(6)),


That the draft Education (Amendment of the Curriculum Requirements) (England) Order 2013, which was laid before this House on 10 June, be approved.—(Mr Swayne.)

Question agreed to.

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HPV Vaccine

Motion made, and Question proposed, That this House do now adjourn.—(Mr Swayne.)

8.58 pm

Mike Freer (Finchley and Golders Green) (Con): I am grateful to Mr. Speaker for granting me this debate on vaccinations against the human papillomavirus, otherwise known as HPV. My main aim is to raise the issue of the inherent inequality of the vaccination programme, which excludes men.

Discussing this issue involves raising topics that people often do not want to talk about, but such discussion is easier than having to deal with the illnesses and diseases that arise from not vaccinating. Embarrassment is preferable to the many cancers that are associated with HPV.

Let me begin by saying that it is important to acknowledge the success of the programme. Since its launch in 2008-09, it has successfully screened and vaccinated more than 80% of applicable girls. Last year the original HPV vaccine was replaced with the quadrivalent HPV vaccine, which provides protection against the two strains of HPV that cause at least nine in 10 cases of genital warts. Of course this added protection is above the primary purpose of the vaccination programme—to bring down rates of cervical and vaginal cancer in women. Men are, however, up to six times more likely than women to have oral HPV infection, thereby increasing the risk of cancers of the throat, neck and head.

Mr Mark Spencer (Sherwood) (Con): I am pleased to hear my hon. Friend mention throat cancers in men. Will he address how much the treatment of such diseases would cost compared with the cost of the vaccine?

Mike Freer: Yes, I will raise the cost-effectiveness of the vaccine as compared with the treatment costs of many cancers, including oral or pharyngeal cancer, which is throat cancer.

In 2009, just after the HPV vaccination programme started, there were over 6,500 cases of these cancers, with 47% of penile cancers and 16% of head and neck cancers thought to be HPV-related. Today, however, overall rates of HPV-related cancer and warts should—should, I stress—subsequently come down in heterosexual men, because of so-called herd immunity.

Herd immunity is where men have sex with vaccinated women and thereby get protection against warts, as well as other cancers including penile, anal, oral and pharyngeal cancers. However, they get such protection only if they have sexual contact with UK-born women who have been vaccinated, or with Australian women or those of the very few countries that have had a mass vaccination programme.

Jim Shannon (Strangford) (DUP): I congratulate the hon. Gentleman on securing this debate. Does he agree it might be better if we had a regional vaccination programme not only for England and Wales, but for Scotland and Northern Ireland as well, so we can address issues of education and intervention UK-wide first, and also globally?

Mike Freer: The hon. Gentleman makes a good point. On a small island such as ours it is important that men who are having sex with women, or men having sex with

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men, are having sex with partners who are vaccinated, and I believe that is a matter not just for England and Wales, but for the whole of the United Kingdom, and we would also then be setting an example for the rest of the world.

Herd immunity is valuable, but it is not foolproof for heterosexual men. I have mentioned that it is valuable where heterosexual men are having sex with vaccinated women, but men who have sex with men are not subject to herd immunity, and that is another element of inequality. Evidence from other countries suggests herd immunity will eventually prevent most, but not all, cases of HPV-related cancer in heterosexual men. There is still work to be done, therefore, on all men having vaccinations against HPV-related cancers.

Some HPV-related cancers are on the rise in the UK, despite the vaccination programme. Throat cancer has overtaken cervical cancer as the leading HPV-related cancer in the UK. Men who have sex with women who are not vaccinated remain at risk. This is of concern to men who, for example, have sex while on holiday or while living outside the UK, or who have sex with unvaccinated migrants to the UK—but men, straight or gay, remain at risk.

The current programme is inequitable, as those men who “stray from the herd” by having sex with unvaccinated women or men will remain at risk. That is why I am seeking a commitment for the HPV vaccination programme to be widened.

The key issue I wish to press is the health inequality in respect of gay men and anal cancer, an inequality perpetuated by the current vaccination policy. Gay men already experience poorer sexual health as a group; they are at an increasing and far higher risk of HIV and other sexually transmitted infections compared with the wider population. Rates of anal cancer in gay men are now equivalent to those for cervical cancer in women before the cervical cancer screening programme was introduced in 1988. HPV is associated with 80% to 85% of anal cancer in men, yet it is not yet possible to screen for or effectively treat anal pre-cancer, as it is for cervical cancer; HPV vaccination is the only effective form of prevention, and it is being denied to men.

Gay men with HIV are particularly susceptible to HPV-related anal cancer and as the number of gay men with HIV continues to rise year on year, so will cases of anal cancer, other HPV-related cancers and warts. In addition to having a disproportionate effect in HIV-positive men, HPV can increase the risk of HIV transmission. HPV can increase skin fragility and overt anal warts can bleed, which enhances the risks of acquisition or transmission of HIV infection. This health inequality between gay men and the general population will continue to widen as long as gay men remain unprotected against HPV. I stress this point as it relates to gay men, but it also affects heterosexual men who are equally unprotected.

Pamela Nash (Airdrie and Shotts) (Lab): I congratulate the hon. Gentleman on making a powerful argument on a difficult subject. Michael Douglas, the actor, was given much criticism in the press recently for talking about these difficult issues. I know about this, because I had the HPV vaccine as a 17-year-old, so I am glad the hon. Gentleman has brought the matter to the Floor of the House. I just want to highlight the fact that this is an issue not only for homosexual men in terms of the vast

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health inequalities they have here in the UK, but for heterosexual men. Although we have a successful HPV vaccination programme for young women, we by no means have the whole herd vaccinated just yet.

Mike Freer: The hon. Lady makes a good point. Herd immunity is valuable only for those who are sleeping within the herd. Those who have sex outside the herd are at risk, and that inequality needs to be addressed.

The best way to protect all males against HPV-related cancers and warts would be to offer the vaccine to all boys aged 12 to 13, as well as girls, as part of the school-based immunisation programme. The vaccine is most effective when given at this younger age, before people start having sex and before exposure to the strains of HPV. Other countries are starting to do that; the vaccine is available for boys in a number of other countries, including Australia and the United States. I firmly believe that we should follow suit.

If we do not have a widespread vaccination programme for boys, at least, and as a bare minimum, gay men should be offered the vaccine when they first present at a sexual health clinic as men who have sex with men. That would match the current policy on offering hepatitis B vaccinations to gay men. Given the expense of treating HPV-related cancers and warts, there is a strong cost-effectiveness argument for extending the availability of the HPV vaccine. If the inequality is not a powerful argument, the cost savings to the Department of Health must be.

The Joint Committee on Vaccination and Immunisation inquiry that began last year is welcome, although little is known of the progress it is making. If the JCVI looks into the cost-effectiveness of vaccination initiatives, it will find that the case to extend the programme to boys is irrefutable.

Each HPV vaccination for the three-dose programme costs £260. Compare that with the lifetime treatment and care cost of an HIV-positive man or woman at £280,000 a year, the £13,000 cost of treating anal cancer, the £11,500 cost of treating penile cancer, the £15,000 cost of treating for oropharyngeal cancer or the £13,600 cost of treating vulval and vaginal cancer transmitted by an infected male. In 2010, the cost of treating anogenital warts was £52.4 million.

Mr Pat McFadden (Wolverhampton South East) (Lab): I congratulate the hon. Gentleman on securing the debate. If the Minister and the Department are considering reviewing the vaccine in the light of his speech, may I ask the Minister whether she will also consider another aspect of this—that is, the number of young women who have had a severe adverse reaction to the vaccine? My constituent, Stacey Jones, received the vaccine five years ago and since then she has struggled with memory loss, loss of concentration, mood swings and a need for continuing treatment by the neurology department at the Queen Elizabeth hospital in Birmingham. Does the Minister accept that it cannot be an acceptable price to pay for what might be an otherwise beneficial vaccine programme if some young women undergo such a severe reaction? Will the Minister and her officials look into this to see how many other young women are in

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that position and whether changes can be made to reduce the number of young women who have had such a reaction or even stop it altogether?

Mike Freer: I am grateful to the right hon. Gentleman for intervening on me to ask the Minister a question and I am sure that she will answer it in due course. He makes a valuable point, however. I, too, have a constituent who had an adverse reaction to the vaccine and who is believed to have myalgic encephalomyelitis as a result. Statistically, such reactions might only be small in number compared with the benefits of the widespread vaccination programme, but he makes a good point in that it is important that the Department of Health tracks them to see whether a pattern emerges over time.

Mr Spencer: My hon. Friend is being very generous with his time. Is screening available on the NHS to prove whether someone is a carrier of HPV? If I presented myself to my local GP and asked to be screened, would such screening be readily available?

Mike Freer: To be honest, I am not sure that I can answer the question. I suspect, however, that if my hon. Friend presented at a sexual health clinic, the staff might be able to advise on what screening or tests were available to identify whether he is a carrier of HPV. It is quite common in men, so in all probability he is. He might want to visit a sexual health clinic tomorrow—if I have not frightened him too much.

I understand that the JCVI inquiry is limited to considering cervical cancer, which restricts the review to women and girls. I press my hon. Friend the Minister to confirm that the JCVI’s scope will be extended to include all HPV cancers so that we can look at how best to vaccinate boys, girls, women and men. The Department of Health must redefine the formal aim of the programme, because if it does not it will be compounding inequality and cost-ineffectiveness.

Males must be protected against the four strains of HPV. The herd immunity that will potentially result from the current programme is often used as a defence for not vaccinating boys, but that implicit intention of excluding men who have sex with men or men who have sex with women who are not vaccinated is simply not sustainable.

The inequality of health protection is obvious and so are the cost savings that I have identified. I know that the Minister will be as concerned as I am that that cost-ineffectiveness and inequality cannot be allowed to continue, and I look forward to hearing her confirmation that the scope of the review will be widened.

9.13 pm

The Parliamentary Under-Secretary of State for Health (Anna Soubry): I congratulate my hon. Friend the Member for Finchley and Golders Green (Mike Freer) on securing the debate and bringing this important subject before the House. He speaks, as ever, with considerable knowledge and makes a powerful argument. I would not expect anything other than that from my hon. Friend.

I shall not rehearse the statistics on vaccination— they were well explained by my hon. Friend—and the success that it has had in its take-up among young women. It has been a success. Seven million doses have

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been given so far in the United Kingdom, and we have achieved one of the highest rates of HPV vaccine coverage in the world, with 87% of the routine cohort of girls completing the three-dose course in the 2011-12 academic year. That contrasts with 35% take-up in America. The very low take-up in America explains why America has extended the vaccination to boys as well as girls; it is only 35% in girls.

As my hon. Friend explained most ably, because of the high uptake of HPV vaccine among girls, it is argued correctly that many boys are indirectly protected against HPV-associated cancers, such as anal cancer and head and neck cancers, as transmission of the virus between girls and boys should be substantially lowered. But of course, my hon. Friend is making the point that it does not protect men who have sex with men, and men who have sex with women who have not had the vaccine.

Jim Shannon: In my intervention on the hon. Member for Finchley and Golders Green (Mike Freer), I made the point about conducting campaigns regionally and UK-wide. Has the Minister had any discussions with the Health Minister in Northern Ireland, for instance, or the Health Minister in Scotland to ensure that we have a UK-wide strategy to address this issue?

Anna Soubry: I am going to repeat everything that has been said, and I agree; that is a very important point. As my hon. Friend the Member for Finchley and Golders Green argues, the vaccine does not protect men who have sex with women who have not been vaccinated, because they may have been in a country where the vaccine was not available to them. So I completely take the point, which is well made, and ask my officials to take it back to the Department.

As hon. Members know, the Department of Health is advised on all immunisation matters by the Joint Committee on Vaccination and Immunisation—an independent expert advisory committee—and our HPV vaccination policies are accordingly based on the advice of the JCVI. When the committee considered the introduction of the HPV vaccine in relation to cervical cancer, it did not recommend the vaccination of boys because with high vaccine uptake among girls, as is the case in the UK, it is judged that there would be little benefit in vaccinating boys. With the high uptake of HPV vaccine among girls, we would expect many boys to be indirectly protected against vaccine-type HPV infections and associated diseases, including anal cancer, head and neck cancers and penile cancers. However, the JCVI recognises that under the current programme, the same protection may not be provided to men who have sex with men, and of course men who have sex with women who have not had the vaccination.

Mr Spencer: I hope the Minister would recognise that, obviously, ideally we should be vaccinating boys who are pre-puberty, and at that stage we have no idea of their sexual orientation or whether they may fulfil their career abroad or in the UK, so we have no way to identify whether they are at risk.

Anna Soubry: I am going to struggle, because that is another good point. I always try to be honest when I come to the Dispatch Box and when hon. Members

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make good points—points that were made not only by my hon. Friend, but by the hon. Member for Airdrie and Shotts (Pamela Nash).

The point raised by the right hon. Member for Wolverhampton South East (Mr McFadden) is related to the actual vaccine, and I am more than happy to discuss that case, or any other adverse reactions of young women to the vaccine, with him. I am very sorry for his constituent, and I am more than happy to have that discussion with him and help in any way I can. He raises an important point.

As we have heard, in June 2012 the JCVI was presented with data on HPV infections and it noted that there is early evidence to suggest that the HPV immunisation programme in England is lowering the number of HPV 16 and 18 infections—the strains of HPV that are linked to these unpleasant cancers—in females in birth cohorts that have been eligible for vaccination.

I accept that the data are very limited on the prevalence of HPV infections among men who have sex with men, but we hope that research under way at University College London will provide more data and an age profile of HPV prevalence. HPVs, particularly types 16 and 18, are associated with the majority of anal cancers as well as cervical cancers, and to a lesser degree with penile, vaginal, vulval and head and neck cancers, but HPV types 16 and 18 predominate in cancers at those sites that are HPV-related. Data on the impact of HPV vaccination on infection at some of these non-cervical sites are limited.

The JCVI noted that the potential impact of HPV vaccination on non-cervical cancers would make the current HPV immunisation programme even more cost-effective, but it would remain the case that, given the expected effects of immunisation on HPV transmission and the indirect protection of boys that accrues from high coverage of HPV vaccination in girls, vaccination of boys in addition to girls was unlikely to be cost-effective. That argument, which we know is advanced, is combated by all that has been said by my hon. Friends the Members for Sherwood (Mr Spencer) and for Finchley and Golders Green, who urge us to consider the cost of treating someone who has one of these cancers.

Evidence for indirect protection would continue to be evaluated by the ongoing HPV surveillance programme at the former Health Protection Agency, now part of Public Health England, but the JCVI agreed that there may be little indirect protection of men who have sex with men from the current immunisation programme. Therefore, the impact and cost-effectiveness of vaccination strategies for men who have sex with men, with the offer of vaccination through general practice and/or at genito-urinary medicine clinics, needed to be assessed. In addition, data on the prevalence by age of HPV infections in men who have sex with men and in the settings where vaccination could be offered to them were needed to determine the potential effectiveness and cost-effectiveness of HPV vaccination of men who have sex with men. It would also be important to understand better the rates of HPV-related disease in men who have sex with men and the influence of HPV on HIV infection.

As we have heard, in August 2012, the JCVI issued a call for evidence from interested parties, including for information to inform a study on the impact and cost-effectiveness of HPV vaccination of men who have sex with men. Any new proposals for the vaccination of

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additional groups will require supporting evidence to show that this would be a cost-effective use of resources. The JCVI also asked the HPA, now part of PHE, to undertake that study. The study is under way and, once completed, will be considered by the JCVI, at the earliest in 2014. The Department will consider carefully the advice from JCVI, once the committee has completed its assessment.

Pamela Nash: May I reiterate the point the hon. Member for Strangford (Jim Shannon) made about the need to have conversations with ministerial colleagues in Scotland, Wales and Northern Ireland? As the hon. Member for Finchley and Golders Green (Mike Freer) argued powerfully, this is about homosexual men and men who have sex with men, but also about men who have sex with women who have not been vaccinated. It is important to have those conversations with the other nations.

Anna Soubry: I am grateful for that intervention. I was about to conclude by saying that it is only fair and right to acknowledge the powerful arguments that have been advanced by a number of hon. Members this evening. They have certainly caused me to take the view that I will not hesitate to contact the JCVI, as a matter of urgency, to raise all these important points with them. The committee is an independent expert body, and when it gives its advice to the Government, the Government are—quite rightly—bound to accept that advice.

Mike Freer: I am grateful to my hon. Friend for the commitment and the confirmation that the JCVI is now looking at this, but while we are waiting for 2014 and the results, can my hon. Friend confirm, if not tonight then in writing, that the Department of Health will give some guidance that sexual health clinics and GUM clinics can offer the vaccinations as an option before that becomes mandatory, should the JCVI recommend that?

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Anna Soubry: I had thought that that was already the situation; but if I am wrong, I will not hesitate to agree to a quite proper, reasonable request. I think that I am wrong.

Mike Freer: My hon. Friend is being very generous. May I confirm that the vaccination is available only to men on private health schemes and that they have to pay for it?

Anna Soubry: Forgive me—it is available, but people have to pay for it. The point being made is that they should not have to pay for it. It should be available, like any other vaccination. That is a good point, and one that I am more than happy to take up.

These are all important and powerful arguments, especially when they are advanced on the basis of inequality, which should concern us all, wherever it may lie, and a good argument has been made that it is simply not fair on men who have sex with men that they should not have the same sort of protection as heterosexual men. If for no other reason, that demands that I make further inquiry.

I repeat—I am sorry to have to repeat it—the committee is an independent body, but it has such force and power that when it makes a recommendation, there is no debate or argument about it: the Government follow its recommendation. I am more than happy to take the matter forward and to make sure also, which is very important, that the committee’s recommendations and findings are made as soon as possible. At present, I am told that that will be in 2014 at the earliest, but it seems to be the sort of matter that requires everybody’s most urgent attention. I hope that is a positive note on which to finish.

Question put and agreed to.

9.26 pm

House adjourned.