Vaccination against human papilloma virus in the light of quaternary prevention

1 Departamento de Medicina Familiar y Comunitaria, Facultad de Medicina, Universidad de la República (UdelaR). Uruguay. 2 Grupo de trabajo en Prevención Cuaternaria de Uruguay. Uruguay. 3 Grupo de Prevención Cuaternaria y Sobremedicalizacion de WONCA. 4 Proyecto NotasL@cas. Uruguay. 5 Chercheur associé D2IM, Université de Rouen. France. 6 Scientific collaborator, Clinical sciences department, University of Liège. Belgium.


Immunization and trust
The question of vaccination against the papilloma virus is for the moment the subject of intense discussions.One might think at first sight that this is a purely medical, and thus, a scientific question.
However, it's not.We will see that the question or problem is first sociological, then economic, political and finally scientific.This question is so acute that is called the first vaccine war. 1,2The aim is not to detail the recent history of the vaccine, but to recall some interesting facts.
The individual and population protection has always been one of the concerns of medicine.As doctors grapple mainly with fighting time, arriving before an event is the object of prevention, even though patients are not yet sick or are not yet affected by potential harm.We are talking about primary prevention.Vaccinations and the discovery of water hygiene have been among the most important historical discoveries against events that have disrupted the life expectancy of humans.However, it is the medical nature of vaccinations, their protective and preventive aspects what have affected the population the most.In turn, this kind of mass population requires significant coverage rates.The question was to protect a group of people, not necessarily individuals.Therefore, we were focusing on protection from a public health perspective.The disappearance of smallpox, the control of poliomyelitis or whooping cough was remarkable events, and the term vaccination was passed in culture under the symbolic equivalent of protection.
Vaccination does not concern disease treatment but instead aims to protect against the risk of disease before fruition.Controlled risk protection is a secular human symbolic activity 3 and for people, beliefs are often more important than facts.Risk and trust are relatives in the symbolic field, and it is not surprising to find that confidence in immunization varies related to the educational background of populations. 4

What is at stake for humans in HPV issues?
In a meta-analysis realized in 2010 5 shows that the HPV prevalence was higher in less developed countries (42.2%) than in more developed regions (22.6%) with HPV 16 (9.5%)and 18 (6.2%) to be the prevalent type, regardless of the region of study.In Argentina, nearly one in three women (27%) are infected.
Human papillomavirus (HPV) infection is now recognized as the leading cause, but not the only cause, for the development of cervical cancer.However, not all infected women are affected.Most HPV infections in young people are of short-lived, less than 9 months. 6We are addressing here the problem of Papillomavirus Vaccines of which the Medical subject heading scope in Medline note: Vaccines or candidate vaccines used to prevent papillomavirus infections.These vaccines, which aim to reduce the incidence of uterine cervical neoplasms, are therefore often considered cancer vaccines, not infection vaccines.This semantic shift towards cancer vaccine is unexpected, as nobody has been able to verify the suggested capacity of the HPV vaccine to protect against cervical cancer so far.A cohort study with 14 years of follow-up in the Netherlands shows safety and efficiency in applying screenings programs with new techniques for cervical cancer and HPV detection, with intervals even greater than 5 years, when risk stratification strategies are implemented. 7In this way all cervical or other cancers, related to infections by HPV: i) is linked to HPV infections that often show spontaneous resolution ii) screening techniques every five years, along with HPV detection are very efficient if high-risk populations are selected.

New strategies in health care market
In the fifties, the clinical trial appeared.Clinical trials have been important for the drug industry because for the first-time drugs could be paired with risk factors. 8The rise of the pharmaceutical industry cannot be understood without taking into account the profound transformation it has achieved; turning risk into disease meant opening the symbolic world of protection.At the same time, we have seen the throbbing question of lipid "diseases", of hypertension "disease", of osteoporosis "disease", as well as the transformation of a public health problem into an individual health problem.Vaccination was no longer a matter of population but of the individual to be protected.In the case of HPV, the symbolic cocktail is particularly powerful.As the claim is that HPV vaccine protects against cancer -fact still unproven -, the protection against a ubiquitous virus almost saprophyte of the man but potentially dangerous, is now becoming a mix between protection, sex, risk and death-themes of the greatest dramas of humanity.
An important fact is that the two vaccines are extremely expensive and their use implies severe cuts in other health budgets for low economic profile countries.Glaxo Smith Kline (GSK) produces Cervarix.Merck Sharp & Dohme (MSD), known as Merck & Co. in the United States, produces Gardasil.It is worth noting that those two firms are in good ranking in the list of the largest pharmaceutical settlements-including both civil settlement and criminal fines in the US. 9 In this case, criminal means Off-label promotion or failure to disclose safety data. 10
The means implemented are now well known; information retention, ghostwriting, paid publications, fake publications, data manipulation, no reporting of serious adverse effects, pressure on physicians and prescribers, manipulation of patient associations, etc.The implications on confidence, as value, are so severe that the very concept of vaccination has been seriously distorted in the general population.
Based on the truncated analysis anti-vaccination movements have emerged.Since the population does not differentiate between conventional vaccines and new marketing products, outbreaks of highly transmissible disease epidemics such as polio or diphtheria can be expected.Moreover, it seems obvious that the pressures and political lobbying are considerable as some countries have even made HPV vaccination mandatory.Finally, many adverse effects have been suspected and are suspected in the post-marketing data available. 17[20]

A new network of knowledge dissemination
Faced with this large-scale manipulation of information, family and community (MFC) general practitioners (GPs), sometimes referred to as referring physicians, have organized to fight this.Quaternary prevention, a concept endorsed by the World Organization of Family Physicians (http://www.globalfamilydoctor. com/), advocates the application of ethically acceptable procedures in health care. 21e quaternary prevention movement has organized to gather the information material to share in its network of dedicated professionals.Members of the WONCA quaternary prevention special interest group are often digital natives, and use electronic media for quick exchanges, emails, mailing lists, and WhatsApp.
When intense discussions arise on sensitive topics that give rise to relevant questions, this information is collected, organized, classified, published and updated on the websites such as NotasL@cas/M@dNotes, which is edited by one of the authors (MP). 22In this way, GPs, often on the forefront of advising patients, can easily obtain the precise information that allows them to make a decision guided by knowledge rather than decisions manipulated by biased information.
We will not rewrite the numerous, easily readable files available online over this HPV issue on https://tinyurl.com/notaslocas-HPV. 23 From our point of view, the question of vaccination against the papillomavirus is, for the time being, subject of intense discussions and controversies.
You can think in a simple way, that it is a purely medical and therefore scientific issue.However, it's not.In this discussion, a number of levels and possible points of analysis are overlapped: sociological, economic, political and finally scientific.Our recommendations on vaccination against HPV are in line with those of the Cochrane Nordic Center (2016). 24Whether at the individual or population level, the usefulness of the vaccine against the papillomavirus is questionable, its relative effectiveness, its minimum efficiency and, above all, the trust of people and many professionals, has been betrayed by non-transparent practices linked to the commercialization of drugs.Investing funds to address health inequalities is a potentially preferable, ethically advisable and socially respectful way of proceeding.Scientific societies and family and community physicians 25 must inform in a responsible manner so that users are in a better position to make decisions according to their knowledge and understanding and within the framework of their scale of values and that of the society to which they belong.
Palabras clave: Vacunas contra Papillomavirus; Prevención Primaria; Ética Clínica; Prevención Cuaternaria Resumo Palavras-chave: Vacinas contra Papillomavirus; Prevenção Primária; Ética Clínica; Prevenção Quaternária the beginning of the twentieth century began to consolidate confidence in vaccines sustained by the practice of mass vaccination against communicable diseases with immediate and visible effects on population health.