Highlights:
- Andhra Government approves 47 screening tests: What about pitfall of false positive?
- Nutritional Support for TB patient: shutting the stable door after the horse has bolted.
- Mathematical models project high Cervical Cancer in Low and Middle Income Countries while developed countries will eliminate it by 2048 – promoting HPV vaccine?
Website: https://uho.org.in
By Dr. Amitav Banerjee, Chairperson of the Universal Health Organisation (UHO)
Andhra Government approves 47 screening tests: What about pitfall of false positive?
Andhra Pradesh Health Minister Satya Kumar Yadav, announced a program of 47 screenings tests for every individual to ensure early detection and treatment of chronic diseases. The state government will spend Rupees 162 crores for this program every year.
These tests will be conducted through 104 medical mobile units. The scheme will cover 56.4 lakhs including those identified under non-communicable disease (NCD), survey and students residing in welfare hostels.
The 47 tests will include 11 categories such as liver function tests, urine analysis, lipid profile, blood counts, electrolytes, renal assessments, glucose levels, coagulation parameters, erythrocyte sedimentation rates (ESR) and other diagnostic categories.
UHO has some concerns, based on available scientific literature, about mass screening programs with 47 screening tests, a huge number. There are advantages as well as disadvantages, in equal number.
Advantages
- They can prevent a disease (preventive testing): This is true of bowel or cervical cancer screening, which look for benign (non-cancerous) early signs of cancer. If it finds any and they’re remedied, the cancer can be prevented. So the screening means you don‘t suffer the mental stress of being diagnosed with cancer and you don‘t receive treatment that can sometimes have severe side effects.
- Although the tests can‘t prevent the disease, they can improve your chances of only needing low-impact treatment and of recovering. One example is breast cancer screening, which can detect breast cancer before it spreads to other parts of the body.
Disadvantages
- The screening test can have side effects or cause complications like injuries.
- The test delivers an incorrect abnormal result (false positive result). This can cause unnecessary worry and stress.
- The test detects the disease but the person’s chance of recovery doesn’t improve as a result.
- There hasn’t been much research on the method concerned so it’s not clear whether it offers any advantages and whether they outweigh the potential disadvantages.
UHO is of the opinion, that more resources should be devoted to the first step, i.e. health promotion and primary prevention by way of promoting healthy lifestyle, restriction on ultra-processed foods, ensuring safe water supply, food, sanitation instead of going for the second step, i.e. early diagnosis and treatment by way of mass screening which may not be cost-effective and would facilitate profits by market forces promoting testing kits, and curative services. If screening has to be done at the population level, it should focus on high risk people instead of mass and indiscriminate screenings which will generate large number of false positives leading to further tests, anxiety, and sometimes unnecessary interventions or medications.
While in theory mass screenings with large number of test looks appealing, in practice it only increases ambiguities due to large number of false positives which increases with the number of tests administered and number of people screened.
Nutritional Support for TB patient: shutting the stable door after the horse has bolted.
According to a study published in BMJ Global Health published in BMJ Global Health and reported by ETHealthworld, nutritional support to TB patients, would avert 120,000 deaths annually. According to the study authors this would be more cost-effective than many biomedical interventions. While UHO concurs with the study recommendation for nutritional support for TB patients, we we would like to add that that this is not a novel concept. TB is a disease of poverty. Developed countries in the West eliminated tuberculosis as a public health problem before the discovery of antibiotics and vaccines for the disease.
This historical context is why many global health experts argue that we cannot “medicate our way out” of TB in developing nations today. Even with modern antibiotics, if the underlying conditions—malnutrition, smoky indoor environments, and extreme poverty—remain, the disease persists.
It’s a powerful reminder that public policy and economic stability are often the best “medicines” we have.
If we put more resources in improving nutrition of the whole population instead of experimenting with newer and newer vaccines against TB, we may control the disease far more effectively. Good nutrition for the whole population, should be a primary prevention strategy for control of TB and not limited to secondary prevention, i.e. only when the patient has been diagnosed as having TB. The latter is akin to shutting the stable door after the horse has bolted.
Mathematical models project high Cervical Cancer in Low and Middle Income Countries while developed countries will eliminate it by 2048 – promoting HPV vaccine?
Mathematical models published in The Lancet, estimating millions of deaths prevented by Covid Vaccine, were used to promote the jabs, ignoring real world data, which showed rising Covid-19 cases and deaths after mass vaccination rollout. Real world data clearly demonstrated that the vaccine neither prevented transmission nor deaths as claimed initially by the authorities and vaccine manufacturers. On ground the effect of the covid jabs did not last beyond 6 months and booster after booster was recommended.
The same mathematical models are out again, this time to promote the HPV vaccine against cervical cancer. The claims, once again published in the Lancet, are far more ambitious. The projection is that the HPV vaccine will eliminate cervical cancer by 2048, while the low and middle income countries will keep having a public health burden from if they do not promote uptake of HPV vaccine in pre-teen girls.
The assurance given is that the HPV vaccine given in 9-15 year girls will prevent them getting the cancer in their fifties, i.e. almost 4 decades later. One marvels at the audacity of the experts, when they failed to predict the efficacy of the Covid jabs beyond six months, how they can predict the efficacy of a vaccine against a virus covering 4-9 serotypes out of over 200 serotypes of the HPV giving lasting protection for 40 years?
The mathematical models to predict the efficacy of HPV vaccine conveniently overlooks the fact that the rates of cervical cancer are falling in most countries, particularly in India over the past three decades without any vaccine, or even mass scale cervical cancer screening with PAP smear. In fact the latter should be promoted more vigorously, but would require availability of gynecological and pathological facilities across the country.
Another nuance in the report by ETHealthWorld quoting the WHO, is that 99% of the cervical cancer is related to high risk Human Papilloma Virus (HPV). Gardasil 4, and Cervarix rolled out in India covers only 4 of the 200 serotypes of the HPV, while Gardasil 9, covers only 9 serotypes missing out the bulk of the large number of HPV serotypes, many of which have also shown cancer causing potential. Even if 99% of cervical cancer is due to high risk HPV, the vaccine does not cover 99% of the serotypes. About 12 HPV serotypes (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59) have been identified as oncogenic. Gardasil 4, rolled out in India, covers only two of these 16 & 18.
We have also reservations about the statement by WHO that HPV is responsible for 99% of cervical cancers as about 3-8% of cervical cancer cases are truly HPV-negative. Cervical cancer cases that are HPV-independent are being reported steadily in clinical practice. In the background of all these uncertainties, and also due to misadventure during unethical HPV vaccine trials in 2009-10, during which 7 tribal girls died in Andhra Pradesh and Gujarat, we should be cautious about the first aspect of the recommended 90-70-90 goals by the WHO i.e., first 90% HPV vaccination among girls 9-14 years; second, 70% cervical cancer screening by PAP smear of eligible women; and thirdly, 90% treatment of woman with early cancer. While UHO agrees with the second and third recommendation, we recommend extreme caution in mass rollout of HPV vaccines among young girls given the gaps in evidence and uncertainties.
Responsible sexual behavior, genital hygiene, improving standards of living are the other factors which would bring down the mortality from cervical cancer.
The weekly newsletters bring the updates on the science, battered and bruised during the pandemic, legal updates and impact of activism for a just society, across the world. These are small steps to promote Transparency, Empowerment and Accountability – the ethos of the UHO.
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