Vac­cines: what you need to know

Who should get them? Why? And what are the risks if we don’t get them? Or the side ef­fects if we do?

The Irish Times - Tuesday - Health - - Front Page - Liz Farsaci

In­for­ma­tion and ar­gu­ments sur­round­ing vac­ci­na­tions for teenagers and adults seem to be ev­ery­where these days. Two in par­tic­u­lar – the HPV vac­cine for teenage girls and the flu vac­cine for adults – are con­tin­u­ously men­tioned in the me­dia, on posters in the chemist and in on­line fo­rums, while the per­tus­sis vac­cine for preg­nant women is in­creas­ingly a part of pub­lic dis­course.

The Cer­vi­cal-Check scan­dal, with cer­vi­cal can­cer’s link to hu­man pa­pil­lo­mavirus (HPV), the late Emma Mhic Mhathúna’s par­tic­i­pa­tion in the Health Ser­vice Ex­ec­u­tive’s cam­paign for the vac­cine and Min­is­ter for Health Si­mon Har­ris’s an­nounce­ment that money from the new bud­get will help fund gen­der-neu­tral vac­ci­na­tion, have all brought dis­cus­sions re­gard­ing the HPV vac­cine to the fore.

Mean­while, the up­take for the an­nual flu vac­cines has in­creased over the years, and the on­set of the colder weather means that the pub­lic are once again en­cour­aged to get it.

A lesser dis­cussed but none-the-less cru­cial vac­cine is the one for per­tus­sis, or whoop­ing cough. Although this is part of rou­tine child­hood vac­ci­na­tions, preg­nant women are now be­ing en­cour­aged to get this vac­cine again dur­ing their sec­ond or third trimesters in or­der to pro­tect their ba­bies from in­fec­tion – although it is not al­ways read­ily avail­able.

But amidst all the dis­cus­sions and buzz­words and Face­book posts, de­ter­min­ing the ba­sic in­for­ma­tion one needs to know can prove dif­fi­cult – what are the vac­cines and what are their links to the dis­eases they are de­signed to pre­vent?

Who should get them? Why? And what are the risks if we don’t get them? Or the side ef­fects if we do?

(HPV) Hu­man pa­pil­lo­mavirus

Be­fore we ex­am­ine the HPV vac­cine, it is help­ful to take a step back and look at the in­for­ma­tion about HPV, the virus that the vac­cine tar­gets.

HPV in­fec­tion is the most com­mon sex­u­ally trans­mit­ted in­fec­tion – in fact, 90 per cent of us will ac­quire a HPV in­fec­tion at some point in our lives, ac­cord­ing to Dr Máirín Ryan, Hiqa’s deputy chief ex­ec­u­tive and di­rec­tor of health tech­nol­ogy as­sess­ment. Most of us will clear the in­fec­tion spon­ta­neously, but the con­cern for the 5-10 per cent of us who do not, is its link with can­cer, as a sus­tained HPV in­fec­tion is as­so­ci­ated with a range of can­cers.

Dr Ryan says women carry the great­est bur­den in re­la­tion to HPV, as the most com­monly as­so­ci­ated can­cer with the virus is cer­vi­cal can­cer.

Ac­cord­ing to the HSE, more than 6,500 women need hospi­tal treat­ment for pre-can­cer of the cervix ev­ery year in Ire­land, while 300 get cer­vi­cal can­cer, and 90 women die from it an­nu­ally.

Other types of can­cer as­so­ci­ated with the in­fec­tion in­clude vul­val, rec­tal, pe­nal and head and neck can­cers – in 2011, Michael Dou­glas no­to­ri­ously at­trib­uted his throat can­cer to hav­ing oral sex with his wife, Cather­ine Zeta Jones (he has since apol­o­gised for the in­ac­cu­rate – and mor­ti­fy­ing – com­ments).

Along with these types of can­cer, the HPV virus also causes anal and gen­i­tal warts, of which there are about 3,500 cases di­ag­nosed per year in Ire­land.

Ben­e­fits of the HPV vac­cine

Ac­cord­ing to Dr Ryan, stud­ies show the HPV vac­cine is 80-98 per cent ef­fec­tive in pre­vent­ing HPV in­fec­tion and HPV-re­lated dis­eases. How­ever, data on ac­tual cases of cer­vi­cal can­cer are not yet avail­able, as most na­tional vac­ci­na­tion pro­grammes are about 10 years old (ours be­gan eight years ago) and the pe­riod be­tween in­fec­tion and pre­sent­ing with cer­vi­cal can­cer can be up to 20 years.

There are both in­di­vid­ual ben­e­fits and larger, pop­u­la­tion-wide ben­e­fits to HPV vac­ci­na­tion, ac­cord­ing to Dr Ryan: “When you vac­ci­nate a per­son, they them­selves are pro­tected, but when you vac­ci­nate a sub­stan­tial pro­por­tion of the pop­u­la­tion, the lev­els of cir­cu­lat­ing virus in the pop­u­la­tion de­creases to such a level that ev­ery­body gets the ben­e­fit.”

Prof Mary Hor­gan, a con­sul­tant physi­cian in in­fec­tious dis­eases and in­ter­nal medicine at Cork Uni­ver­sity Hospi­tal, con­curs: “If some­one told us we could take a tablet to pre­vent can­cer, no­body would have an is­sue. The HPV vac­cine has a long track record. It’s proven to be safe, and it’s proven to be ef­fec­tive.”

The HPV na­tional vac­ci­na­tion pro­gramme for girls

A rou­tine HSE school HPV vac­ci­na­tion pro­gramme be­gan in May 2010, for girls in their first year of se­condary school (or those who were 12 years old and in spe­cial schools or home­schooled). The vac­cine, which pro­tects against seven out of 10 cer­vi­cal can­cers, is pro­vided free of charge to the pupils by teams from the lo­cal health of­fices, who visit the schools.

In Septem­ber 2018, the HSE re­ported an in­crease in HPV vac­ci­na­tion rates, with pro­vi­sional na­tional up­take lev­els at 65 per cent. This fig­ure rep­re­sented a sig­nif­i­cant in­crease in up­take, as the na­tional up­take dropped to 51 per cent in the 2016/2017 aca­demic year, due in part to neg­a­tive on­line com­ments and cam­paigns from anti-vac­ci­na­tors. How­ever, the lat­est fig­ure still falls well un­der the HSE’s tar­get for the up­take of at least 80 per cent.

Gen­der-neu­tral HPV vac­ci­na­tion On Oc­to­ber 9th, Mr Har­ris an­nounced that some of the new fund­ing al­lot­ted to the De­part­ment of Health in this year’s bud­get will go to­wards ex­tend­ing the HPV vac­cine to boys. This an­nounce­ment comes on foot of Mr Har­ris’s re­quest that Hiqa con­duct a health tech­nol­ogy as­sess­ment (HTA) into the ev­i­dence and cost-ef­fec­tive­ness re­lat­ing to the pro­vi­sion of gen­der-neu­tral HPV vac­ci­na­tions. The Min­is­ter re­quested this HTA on foot of rec­om­men­da­tions from the Na­tional Im­mu­ni­sa­tion Ad­vi­sory Com­mit­tee that boys be in­cluded in the HPV vac­ci­na­tion pro­gramme. With the pub­lic con­sul­ta­tion com­plete, Hiqa is ex­pected to sub­mit its fi­nal rec­om­men­da­tion to the de­part­ment in Novem­ber.

Mr Har­ris has in­di­cated that, sub­ject to a favourable rec­om­men­da­tion from Hiqa, the Gov­ern­ment will seek to ex­tend this vac­cine to boys as well as girls as a pri­or­ity, and the new fund­ing will help to fa­cil­i­tate this in 2019.

Dr Ryan says, while pro­vid­ing boys with the HPV vac­ci­na­tion will ob­vi­ously help them on an in­di­vid­ual level, it will also ben­e­fit women later in life by boost­ing the im­mu­nity of the pop­u­la­tion as a whole.

Hiqa’s re­view also eval­u­ated the safety of the HPV vac­cine, and found that while mild side ef­fects such as red­ness and sore­ness at the site of in­jec­tion are com­mon, there are no se­ri­ous neg­a­tive side ef­fects. Women who did not re­ceive the HPV vac­cine in school can get it through one of the Dublin Well Woman Cen­tre clin­ics or through their GP.

Dr Shirley McQuade, med­i­cal di­rec­tor of the Dublin Well Woman Cen­tre, said they of­fer women the HPV 9 vac­cine. This is sim­i­lar to the vac­cine pro­vided through the HSE school pro­gramme, but has been avail­able in Ire­land for just 18 months, and of­fers pro­tec­tion against 90 per cent of cer­vi­cal can­cers. There’s also no up­per age limit, so women of any age can get it and ben­e­fit from the pro­tec­tion it pro­vides.

There’s a catch, though. There is cur­rently no pro­gramme in place en­abling women to get the vac­cine, which means we must pay for it our­selves. Each jab costs ¤200, and you get three jabs over the course of six months, mean­ing a woman must pay ¤600 out of pocket, plus the costs to ad­min­is­ter the jabs.

Women in Ire­land get their first smear test at the age of 25. As the school HPV vac­ci­na­tion pro­gramme be­gan only eight years ago, Dr McQuade and her col­leagues are still see­ing women who have not yet ben­e­fited from the vac­cine – but that will change in a few years.

“I see the other end of things, where the 25- to 29-year-olds are com­ing in for their first smear test, and many have high-grade changes go­ing on [with their cer­vi­cal tis­sue],” says Dr McQuade. “In the next cou­ple of years, we’re go­ing to start meet­ing the 25-year-olds hav­ing their first smear tests who’ve been vac­ci­nated for HPV. Hope­fully, we’ll start see­ing a dif­fer­ence.”

Long-term in­vest­ment in health­care

Con­sul­tant physi­cian Prof Mary Hor­gan, who is also pres­i­dent of the Royal Col­lege of Physi­cians Ire­land, said the HPV vac­ci­na­tion is a cru­cial part of long-term in­vest­ment in women’s health­care.

“The HPV vac­cine pre­vents some­thing that may hap­pen in 10 or 20 years’ time, which will avoid an over­stretched health­care sys­tem, and peo­ple be­com­ing ill in the fu­ture,” said Prof Hor­gan.

“That’s how we should be run­ning our health ser­vices – we should not be think­ing about putting ban­dages on prob­lems that hap­pen now, but think­ing long term, hav­ing a vi­sion for women’s health, and think­ing about the long-term gain. In­vest­ing now in HPV vac­ci­na­tion will be hugely ben­e­fi­cial to our pop­u­la­tion in the fu­ture.”

When you vac­ci­nate a sub­stan­tial pro­por­tion of the pop­u­la­tion, the lev­els of cir­cu­lat­ing virus in the pop­u­la­tion de­creases to such a level that ev­ery­body gets the ben­e­fit

Flu­vac­ci­na­tion

An­other vac­cine that re­ceives a great deal of at­ten­tion, par­tic­u­larly around this time of year, is the flu jab which chil­dren and adults alike can get.

Many em­ploy­ers are now recog­nis­ing the neg­a­tive ef­fect that ill­ness, par­tic­u­larly in the win­ter months, has on their work­forces and are pro­vid­ing the flu vac­cine to their em­ploy­ees.

And although the vac­ci­na­tion can­not al­ways pre­vent some­one from get­ting in­fluenza – due to the con­stant mu­ta­tions of the dis­ease – it can go a long way to­wards both preven­tion and pro­tec­tion, ac­cord­ing to Prof Ka­rina But­ler, con­sul­tant pae­di­a­tri­cian and chair of the Na­tional Im­mu­ni­sa­tion Ad­vi­sory Com­mit­tee.

She warns that the flu vac­cine specif­i­cal-

ly tar­gets in­fluenza, whose on­set is swift and whose symp­toms in­clude aches through­out the body, fever and the feel­ing of be­ing com­pletely wiped out. It does not ward off ill­nesses which might be com­monly re­ferred to as the flu, such as head colds.

On foot of pre­dic­tions from the World Health Or­gan­i­sa­tion, this win­ter’s flu vac­cine con­tains pro­tec­tion against three strains of flu virus. The flu vac­cine is not a live virus, which means it stim­u­lates your im­mune sys­tem with­out giv­ing you the flu, although peo­ple can ex­pe­ri­ence some sore­ness in their arms just af­ter they get their jab.

“The in­fluenza virus is a par­tic­u­larly chal­leng­ing virus to de­velop a vac­cine for, be­cause it’s a virus that has the ca­pac­ity to drift and shift, in that it can change its ge­netic ma­te­rial from year to year,” says Prof But­ler, who is also UCD clin­i­cal pro­fes­sor of pae­di­atrics and in­fec­tious dis­eases spe­cial­ist at Our Lady’s Chil­dren’s Hospi­tal Crum­lin and Tem­ple Street hospi­tal.

“What you’re try­ing to do is to get what might be a pro­tec­tive re­sponse against what is a com­mon part of the virus that will be less likely to shift, but you are also try­ing to an­tic­i­pate which of the strains are the ones that are go­ing to be cir­cu­lat­ing in any given year, and to try to pro­tect against that.”

Who should get the flu vac­cine?

While the HSE rec­om­mends that ev­ery­one gets the flu vac­cine, vul­ner­a­ble groups are par­tic­u­larly en­cour­aged to do so. These groups in­clude peo­ple who are 65 years or older, those liv­ing with a long-term health con­di­tion, women who are preg­nant, health­care work­ers and car­ers, those liv­ing in a long-term res­i­den­tial care and those who reg­u­larly come into con­tact with pigs, poul­try or wa­ter­fowl.

Peo­ple within these high-risk cat­e­gories, as well as those with Med­i­cal or GP visit cards, can get the flu vac­cine free of charge, although there may be a con­sul­ta­tion fee. Adults can get the vac­cine through a phar­ma­cist, GP or oc­cu­pa­tional health cen­tre, while chil­dren should get them through their GP.

Pre­vent­ing other dis­eases

Get­ting the flu vac­cine can not only pro­tect you from in­fluenza, it can also pro­tect you, your chil­dren and other peo­ple in your life from other bac­te­rial in­fec­tions, in­clud­ing menin­gi­tis.

“You might get the flu, and get over it, but the flu makes you more sus­cep­ti­ble then to get­ting a se­ri­ous bac­te­rial in­fec­tion,” says Prof But­ler. “So we of­ten see the flu as the fore­run­ner to pneu­mo­nia, and the same with menin­gi­tis. Ev­ery time we get a series of flu, we see an up­surge in meningo­coc­cal in­fec­tion.”

Per­tus­sis vac­cine

In line with HSE rec­om­men­da­tions, Prof But­ler says women who get the per­tus­sis (whoop­ing cough) vac­ci­na­tion dur­ing preg­nancy can pro­tect their new­borns from the dis­ease. Although ba­bies re­ceive the jab them­selves at two, four and six months of age, con­tract­ing the dis­ease be­fore they are fully im­mu­nised can have very se­ri­ous con­se­quences.

Although whoop­ing cough has been largely ir­ra­di­ated thanks to im­mu­ni­sa­tion, there are still sev­eral dozen cases each year, mostly in ba­bies less than six months of age, ac­cord­ing to the HSE. In 2015, there were 117 cases of per­tus­sis, up from 73 cases in 2014. In 2012, two ba­bies died as a re­sult of the dis­ease. The way to pro­tect young ba­bies from this is for preg­nant moth­ers to get im­mu­nised dur­ing the lat­ter part of the sec­ond trimester or the early part of the third, says Prof But­ler.

“Per­tus­sis is dif­fer­ent to flu, in that it is a bac­te­rial in­fec­tion,” she says. “It used to be called the 100 days cough be­cause when you got it, it stuck around. For ev­ery­one who is beyond the first year of life, it’s un­pleas­ant and un­com­fort­able, and can cause sig­nif­i­cant lung dam­age, but, in gen­eral, it’s not life threat­en­ing. But where it does threaten life is for young ba­bies, par­tic­u­larly in the first six months of life.”

Ev­ery­one in Ire­land is vac­ci­nated for the whoop­ing cough as ba­bies, but adults can still con­tract the dis­ease, even if it man­i­fests it­self as a mild cough – but then we can pass it on to oth­ers, in­clud­ing new­borns who have not yet had their vac­cines.

“For young ba­bies, per­tus­sis can cause them to stop breath­ing, and it can cause very se­vere pneu­mo­nia that re­ally doesn’t re­spond that well to treat­ment at all,” said Prof But­ler. “The way to pro­tect these in­fants is to vac­ci­nate the moth­ers, to boost the im­mu­nity that they have, so they will have their an­ti­body lev­els that are passed with all their other an­ti­bod­ies to the ba­bies, so that the ba­bies are pro­tected.”

Prob­lems with pro­vi­sion

But ac­cord­ing to Prof But­ler, get­ting the per­tus­sis vac­cine, or Tdap, may not be as easy as one would think. “The vac­cine is pro­vided by the Na­tional Vac­ci­na­tion Of­fice,” she says. “But there has been no agreed path­way for how the vac­cine is to be de­liv­ered, so there’s been no agree­ment with the GPs to de­liver it, or con­tract ar­range­ments made. And tra­di­tion­ally, ob­ste­tri­cians don’t see it as their role, or the ma­ter­nity ser­vices, to of­fer vac­cines. And therein lies the rub.”

A spokes­woman for the De­part­ment of Health said that, since Septem­ber 2013, the HSE has pro­vided the Tdap vac­cine to GPs for preg­nant women free of charge. How­ever, ad­min­is­tra­tion fees have not been agreed, which means that women are li­able for the ad­min­is­tra­tion fee.

HPV vac­cine for women

PHO­TOGRAPHS: COLLINS COURTS AND DARA MAC DÓNAILL

The late Emma Mhic Mhathúna par­tic­i­pated in the HSE’s cam­paign for the HPV vac­cine; Min­is­ter for Health Si­mon with Laura Bren­nan, HPV vac­cine ad­vo­cate; and graphic show­ing the de­vel­op­ment of cer­vi­cal can­cer.

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