現在是普及HPV疫苗接種的時候了

資料來源：剌胳針醫學雜誌，392期，2018/09/15；財團法人台灣紅絲帶基金會編譯

來自英國公共衛生部門的數據，突顯了英國國家子宮頸癌疫苗接種計劃大大降低年輕女性中人類乳突病毒（HPV）的罹患率，為未來子宮頸癌死亡率的降低提供了鼓勵。然而，HPV也牽涉到兩性間其他的癌症（例如，口咽癌和肛門癌），且HPV感染也會導致兩性間的生殖器疣。與HPV相關的口咽癌是英國發病率增長最快速的癌症，並且很快將在美國變得比子宮頸癌更為常見。鑑於英國公共衛生研究的結果，「性別中性」的疫苗接種計劃（即不分性別普遍接種）將為整體英國人口提供實質性的保護。

在越來越多的國家中為男孩和女孩接種疫苗已成為普及策略的一部分，現已包括有澳大利亞、奧地利、百慕達、巴西、加拿大、克羅埃西亞、德國、以色列、義大利、列支敦士登、紐西蘭、塞爾維亞和美國等。

然而，儘管臨床、科學和社區病患倡議者提供了越來越多的證據和支持，但英國在普及HPV疫苗接種方面上的進展仍緩慢。自2013年以來，疫苗接種和免疫聯合委員會（JCVI）一直在考慮普遍接種疫苗的優點，但推定的群體免疫力和成本效益等問題被認為是推遲接種青少年男孩的原因。

男孩的群體免疫力僅發生在女性接種率高的地區（≥80％）。女性疫苗接種率大幅下降已出現在丹麥、日本和最近的愛爾蘭（51％接受），雖然政府令人矚目的催種運動曾讓愛爾蘭的疫苗接種率增加到60％以上。.英國的接種率則因地區而異（例如，在蒂斯河畔斯托克頓的接受率為48％，而英國全國的平均接種率則為83％）。

群體保護並不能保護在國外發生性行為或與年齡較大未接種過疫苗之女性發生性行為的男性。我們的研究結果和其他研究結果顯示，普遍接種疫苗可以帶來巨大的健康經濟效益。一項分析更顯示，支持普及HPV疫苗接種政策建議的數學模型研究可能存在著缺陷，英國每年花在接種男孩的額外費用最多僅為每年2,000至2,200萬英鎊（小於英國國民健康服務年度預算之0.02％）。

然而，這筆費用可被用於治療生殖器疣（約5,850萬英鎊）、HPV相關口咽癌（大於 2,100萬英鎊）和肛門癌（約700萬英鎊）的年度費用所抵消。更廣泛的經濟效益（提高生產力和收入，增強稅收也會隨之而來）。因此，普遍接種疫苗可以挽救生命並為我們的醫療系統節省經濟成本。

越來越多的證據顯示，終於讓疫苗接種和免疫聯合委員會 (JCVI) 推薦了普遍接種HPV疫苗此項策略。雖然是英格蘭、蘇格蘭和威爾斯衛生部門現已表示願意根據JCVI的建議為男孩和女孩接種疫苗，但北愛爾蘭衛生部門則令人失望地迄今為止仍對該問題一直保持沉默。在英國各地迅速公平地實施這項決定至關緊要，可以避免每年大約有40萬遺留未受保護的青少年男孩去對抗因HPV感染所引起的嚴重威脅生命和所引起的疾病導致之健康衰弱。

It is time for universal HPV vaccination

Source: www.thelancet.com Vol 392 September 15, 2018

Data from Public Health England highlight how the UK’s national cervical cancer vaccination programme has greatly reduced the prevalence of human papillomavirus (HPV) in young women, providing encouragement for a future reduction in cervical cancer mortality. HPV, however, is implicated in other cancers in both sexes (eg, oropharyngeal and anal cancer), and HPV infection also causes genital warts in both sexes. HPV-related oropharyngeal cancer is the cancer with the fastest growing incidence in the UK, and is soon to become more common than cervical cancer in the USA. Given the results of the Public Health England study, a genderneutral vaccination programme would provide substantial protection for the overall UK population.

Boys and girls are vaccinated as part of a universal strategy in an increasing number of countries, which now includes Australia, Austria, Bermuda, Brazil, Canada, Croatia, Germany, Israel, Italy, Lichtenstein, New Zealand, Serbia, and the USA.

However, despite mounting evidence and support from clinical, scientific, and patient advocacy communities, the UK has been slow to move towards universal HPV vaccination. The Joint Committee on Vaccination and Immunisation (JCVI) has been considering the merit of a universal vaccination strategy since 2013, but issues such as putative herd immunity and cost-effectiveness were cited as reasons to postpone vaccination of adolescent boys.

Herd immunity for boys will only occur in areas where rates of female vaccination are high (≥80%). Substantial reductions in female vaccination rates have occurred in Denmark, Japan, and, most recently, Ireland (51% uptake), although a highprofile government campaign led to vaccination rates in Ireland increasing to more than 60%. Uptake in the UK varies substantially by region (eg, a 48% uptake in ockton-on-Tees compared with a UK average of 83%).

Herd protection will not protect men who have sex abroad or with older unvaccinated women. Our findings and those of others have indicated that universal vaccination can deliver substantial health economic benefits. An analysis also indicates that the mathematical modelling studies underpinning policy recommendations regarding universal HPV vaccination might have been flawed. The additional cost of vaccinating boys in the UK would be £20–22 million annually at most (<0·02% of the UK National Health Service’s annual budget). However, this cost is offset by the annual costs of treating genital warts (about £58·5 million), HPV-related oropharyngeal cancer (>£21 million), and anal cancer (about £7 million). Wider economic benefits (increased productivity and earnings, enhanced tax revenue) would also ensue. Thus, universal vaccination can save lives and yield economic savings for our healthcare system.

The mounting evidence has led to the JCVI finally recommending a universal HPV vaccination strategy. Although the Departments of Health in England, Scotland, and Wales have now indicated their willingness to vaccinate boys and girls on the basis of the JCVI recommendation,  the Department of Health in Northern Ireland has been disappointingly silent on the issue to date. It is crucial that this decision is implemented rapidly and equitably across the UK to spare the approximately 400 000 adolescent boys each year who are left unprotected against the serious life-threatening and healthdebilitating diseases that result from HPV infection.