REVIEW ARTICLE

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CURRENT ISSUES FACING THE INTRODUCTION OF HUMAN PAPILLOMAVIRUS VACCINE IN MALAYSIA

Religious issues
Religion plays an important role in our society. It is not known how our society and local religious conservatives would react to vaccinating youngsters against a sexually transmitted virus. In the US, for instance, religious groups oppose HPV vaccination, preferring instead to advocate abstinence for prevention of STIs.³⁵

STRATEGIES FOR FOSTERING HPV VACCINE ACCEPTANCE

Increase awareness of HPV and remove social stigma
In Malaysia, the level of knowledge on HPV is not known, but is not expected to be any higher than reported elsewhere. Education to raise awareness and de-stigmatise HPV may positively influence uptake of vaccine. Following educational intervention, some initially reluctant parents subsequently became willing to have their children vaccinated.³⁶

Secondly, education efforts should target young adults to improve knowledge about HPV and to prevent HPV infection and cervical cancer. Educational programmes should include information on different HPV types, transmission, implications for sexual partners, prevalence, latency and regression of HPV, management options and the risks of anogenital cancers. Such knowledge may provide a stronger motivation to improve safe-sex practices and lead to primary prevention of HPV infection. It has also been shown that informing men about cervical cancer can impact positively on their female partners’ willingness to be vaccinated.³⁶

A universal recommendation for HPV immunisation for children will help remove the social stigma associated with receiving the vaccine. However, advocating mandatory vaccination, which has been controversially carried out in some US states, may be perceived as infringing on parental rights.³⁵

Improve public’s knowledge of HPV and HPV vaccines
It is important that the public should not be coerced or frightened into thinking that HPV vaccine is a “must-have” for themselves or their children without knowing more about the vaccine, what it can and cannot do. On the basis of accurate and appropriate information, a person can then judge whether or not to accept the vaccine. Information for the public should include:

1. HPV is one of the most common sexually transmitted diseases in the world. Some types cause genital warts, while some types are strongly linked to cervical cancer.
2. The new quadrivalent HPV vaccine provides effective protection against four main HPV types that cause genital warts and cervical cancer. However, the vaccine cannot protect females against diseases caused by other HPV types that are not in the vaccines.
3. Ideally, the vaccine should be administered before onset of sexual activity. Sexually active women who receive vaccine may still be partially protected if they have not been exposed to all the vaccine HPV types.
4. The vaccination does not substitute for routine cervical cancer screening. Women who receive the vaccines should continue to undergo cervical cancer screening.
5. Vaccinated women should continue with protective sexual practices since the vaccines will not prevent all cases of HPV or other STIs.

Physician’s recommendations

Health care providers’ recommendations are important in optimising vaccine delivery. Therefore, it is critical to understand predictors of providers’ intentions to recommend immunisation. Patient information should be provided in an individualised fashion to take into account each patient’s social background, knowledge, and attitudes. Health care providers may hold personal views and biases which may make them reluctant to discuss sexual issues with patients or parents. Furthermore, they may hesitate to recommend the vaccine in anticipation of negative parental reaction. Educational initiatives targeting all health care providers involved in patient education can positively influence immunisation recommendation patterns and foster vaccine acceptance.³⁷

The need and the means
The recommended three-dose course, costing approximately USD $360 (RM 1,260), is unaffordable for many patients. Women of lower socioeconomic status have the highest risk of cervical cancer yet often lack access to healthcare services, including screening. These vulnerable women would benefit most, but will be the least likely to receive the vaccine. Therefore, to ensure the widest coverage, the vaccine may need to be subsidised or incorporated into the vaccine programme.

Cost effectiveness

The cost-effectiveness of HPV vaccines must be considered before widespread implementation. Countries with established cervical cancer screening programmes which introduce routine HPV vaccine still need to continue screening, as there will remain many women who are unvaccinated or already infected with HPV.²⁴ Thus, in countries which lack screening programmes, HPV vaccination is likely to be the most cost-effective method of reducing cervical cancer. HPV vaccination has been shown to be most cost-effective for girls aged 11-12, prior to onset of sexual activity, 38 but is less economical for catch-up vaccination of older females.²⁴ Cost-effectiveness was underestimated in these analyses, which did not include benefits of preventing other HPV-associated diseases. In Malaysia, one of the difficulties in assessing cost-effectiveness for subsequent health planning is the lack of accurate, comprehensive medical documentation.⁷ For example, the uneven distribution of diagnostic pathology services may lead to underestimation of the true prevalence of cervical cancer diagnoses and deaths.⁷