Injections sought as protection against cancer

This year, Beijing resident Chen Chu finally received her first injection of a vaccine that protects against nine types of HPV, a virus that can cause several types of cancer.

It was late April, and she had been waiting for several years to be administered the 9-valent human papillomavirus vaccine, marketed under the name Gardasil 9.

The HPV vaccine is the world's first aimed at preventing cancer. Multiple valent vaccines are prepared from two or more strains of the same microorganism.

Industry experts attribute the demand for Gardasil 9 to women's fear of HPV-related diseases, especially cervical cancer, but also to the increasing affordability of health services and products.

On the Chinese mainland, the 9-valent vaccine is recommended only for women ages 16 to 26, and Chen said, "I feel very lucky to be able to receive the vaccinations before I became too old."

The vaccine she was given, from United States pharmaceutical company Merck & Co, was made available on the Chinese mainland in May of last year. Outside the US and Canada, the company is known as Merck Sharp& Dohme.

In July 2016, Chinese authorities approved a 2-valent HPV vaccine, from GlaxoSmithKline, for use on the mainland, while in May 2017, they approved a 4-valent vaccine, from Merck.

The 2-valent vaccine, which protects against two types of HPV, is recommended for females ages 9 to 45 on the mainland, while the 4-valent, which protects against four types of HPV, is for females ages 20 to 45.

All three types require three shots over a period of six months.

However, since the 9-valent type became available, it has become the most popular and sought-after HPV vaccine in China, despite not being included in the country's free and compulsory vaccination program.

Under the public healthcare system, each vaccination usually costs about 1,300 yuan ($188), while in private facilities, the cost is typically at least 1,000 yuan more for three doses.

However, because demand heavily outstrips supply, successfully making an appointment with either public or private service providers to receive the 9-valent vaccine can be compared to winning a lottery.

In fact, in Shenzhen, Guangdong province, health authorities have been relying on a lottery system since November to fairly decide reservations for the vaccine.

When the city's health authority opened online reservations in September, the website received more than 3 million daily page views, with the number rising to 9 million in October, while only 600 to 1,000 doses were available every month.

There have been media reports of customers lining up to be placed on a waiting list when supplies run out in a particular area, or paying large amounts to agencies at home and overseas to get the vaccine, only to end up with smuggled or counterfeit supplies.

For Chen, it took less than five minutes for a nurse to administer the vaccine, but the process involved in reaching that stage took considerably longer.

She searched online for advice on how to increase the chance of a successful appointment, and then spent an afternoon in March trying to secure a reservation at community medical centers and hospitals providing the vaccination service.

She received constant rejections for more than an hour because the centers and hospitals had run out of supplies. Finally, a community medical center far from her home placed her on a shortlist.

Some two weeks later, she received a phone call asking her to come in for a vaccination at her convenience.

"I had expected to wait even longer, or go to Hong Kong for the vaccination, because I was about to turn 26," she said.

As women resort to a number of measures to receive the 9-valent vaccine, they neglect the other two types available to protect against HPV.

There are more than 100 types of HPV, and some that are closely related to the development of malignant tumors are categorized as high-risk.

The chances of a sexually active woman contracting at least one type of HPV are estimated to be as high as 40 to 80 percent, according to an article on the National Medical Products Administration's website on the granting of conditional approval for the 9-valent vaccine. This approval includes requirements for additional studies and post-marketing surveillance.

Some 80 percent of HPV infections clear up within eight months. Only consistent infection for more than two years from just a few types of high-risk HPV may result in cancers, and only a very few people consistently infected by HPV will eventually develop cervical cancer, the article said.

The 2-and 4-valent vaccines can lower the risk of developing cervical cancer by 84.5 percent, while the 9-valent version can reduce the risk by 92.1 percent, the article said.

It advised people to choose the type of vaccine based on their age and income. On the mainland, the 2-and 4-valent types are cheaper than the 9-valent, costing about 600 yuan and 800 yuan a dose, respectively.

In addition to cervical cancer, HPV infection is closely related to 90 percent of anal cancers, 40 percent of vulvar or vaginal cancer, and 12 percent of head and neck cancers, according to an article on the online health platform DXY.

In China, cervical cancer is one of the most common and lethal forms of the disease.

Each year, some 131,500 new cervical cancer cases are reported in the country, and about 53,000 patients die from the disease, accounting for 18.4 percent of the deaths caused by malignant tumors among women in China, according to an article in the Chinese Journal of Practical Gynecology and Obstetrics last year.

Moreover, HPV vaccines have been introduced in China about 10 years later than in some other countries.

However, conditional approval for the 9-valent vaccine was granted on April 29 last year, just nine days into a fast-track review, and the medicine was officially available in Hainan province one month later.

The world's first HPV vaccine－the 4-valent－was approved in the United States in 2006. The 9-valent was approved in the US in 2014, before China approved the 2-and 4-valent versions.

Chen Qiulin, deputy director of the Health Industry Development Research Center at the Chinese Academy of Social Sciences, said, "It is all about fear of cervical cancer, and the huge demand accumulated in all the past years.

"People have known about the vaccines for years, but they were not able to access them in the past. Since they are available now, it is only natural that demand has boomed."

He added that previously, many people traveled overseas to be vaccinated against HPV.

Demand has also increased as incomes have risen, and more people can now afford to spend money on such services as health awareness increases, Chen said.

Once people can acquire the vaccination on a regular basis, the balance between supply and demand will be gradually restored, he said.

According to a report released earlier this year by Horizon Insights, a consultancy in Shanghai, some 300 million Chinese are in the recommended age group for the 2-valent vaccine, 130 million for the 4-valent, and 90 million for the 9-valent. Every year, 8 million people fall into the recommended age group for each vaccine.

Last year, 300,000 people were vaccinated with the 2-valent type, 1.1 million with the 4-valent, and only 100,000 with the 9-valent, resulting in market values of 500 million yuan, 2.7 billion yuan and 400 million yuan, the report said.

About 833,300 doses of the 2-valent vaccine, 3.41 million of the 4-valent and 1.22 million of the 9-valent were released on the market last year, according to the report.

It estimated that the market value for the 2-, 4-and 9-valent vaccines would reach 1 billion yuan, 7.2 billion yuan and 10 billion in times of peak demand.

There will continue to be a shortage of all three types until next year, as the huge demand that exists now cannot be met in a short period, the report said.

Zhao Heng, founder of consulting company Latitude Health, said the shortage could be resolved through increased production and distribution, but as the three types of vaccine are not on the national compulsory vaccination program, it is difficult for the authorities to order pharmaceutical companies to increase supplies.

However, more than a dozen Chinese pharmaceutical companies are developing HPV vaccines ranging from 2-valent to 14-valent, and some have started phase-3 clinical trials while others have only just received approval for such trials, according to the Horizon Insights report.