A well-considered position against universal HPV vaccination in Canada has been published in the Canadian Journal of Medicine. The authors, who are part of the Canadian Women’s Health Network, argue the following:
- Cervical cancer is far from epidemic in their country, with only 400 deaths yearly, a rate that has been steadily declining;
- Most HPV infections resolve spontaneously;
- The vaccine was not trialed sufficiently in adolescents, the group being targeted for univeral vaccination;
- The long-term efficacy of the vaccine against cervical cancer in the population has yet to be proven, in light of the fact that it protects against only two of the subtypes that cause cervical cancer and its duration of effect is not known;
- The vaccine is too new and the clinical trials were all industry-sponsored;
- The true costs are not determined.
The Canadian Government apparently had a different opinion on the matter – they recently allocated $300 million for HPV vacination. The Canadian health service is rolling out a mass HPV innoculation campaign with the beginning of this year’s school year, the first such innoculation campaign since the polio vaccine in the 1950’s. (CBC.Canada has a very well-done segment on the vaccine initiative.)
Opponents of universal HPV vaccination in both Canada and the United States are focusing on reports of Guillain Barre syndrome occuring after Gardasil administration, expecially when administered along with the meningococcal vacine Menactra. This is typical of anti-vaccine strategies – to focus on rare adverse events that are unlikely to be caused by a vaccine. Similar publicity around a since-debunked theory that the MMR vaccine causes autism has been blamed for recent outbreaks of measles in Britian.
Here in America, the lawyers are already jumping into the Gardasil fray.
Basically, here is the situation – Merck is frightening women about cervical cancer, then using slick marketing campaigns to sell them their vaccine. The anti-vaccine folks are frightening the public that this vaccine has severe side effects, an approach they basically take with all vaccines.
But well-reasoned and informed views such as those expressed by the Canadian Women’s Health Network deserve attention and discussion. Unfortunately, such views do not lend themselves to catchy slogans or soundbites, and don’t frighten anyone. Which makes it unlikely that anyone will hear them.
My position? (Like I haven’t beat this drum enough already…) I pretty much agree with the position of the Canadian Women’s Health Network. I believe that the HPV vaccine is safe, but not yet appropriate for universal vaccination. Like all new pharmaceuticals, only time will tell if there are rare effects not found in clinical trials. I do offer the vaccine to patients who express interest in it and who understand its limitations, mostly adult women who are having multiple partners over time. I am opposed to universal or mandatory vaccination in young adolescents, and abhor the marketing and lobbying tactics being used to promote this vaccine.
I think that the HPV vaccine would be great if it could be distributed in developing nations where cervical cancer is a real problem and women don’t have access to routine pap smears. But we already know that the women who get cervical cancer that’s HPV related are women who don’t get pap smears regularly. If I remember correctly, the average cervical squamous cell cancer patient has gone more than 10 years since her last pap smear at the time of diagnosis.
It would be interesting to see a study to see if it would really reduce the number of LEEPs and colposcopies done for high grade dysplasia. Maybe that study’s been done and I haven’t seen it…
Great post. I agree. I think this is a very effective vaccine. But, to make it mandatory at this time is not a good idea. I have a long conversation with patients/parents as well to try to filter through the hype and the marketing.
We have sparred on this issue before, and I fear are about to do so again.
Let’s start with our mutual agreement that universal vaccination is not appropriate.
Now that that is out of the way…I am not in agreement that the pharma organizations are inappropriately selling fear – shouldn’t we be a bit fearful of HPV? Shouldn’t we know more? It has been a great service to the community to know that HPV is the driver behind cervical cancer – something NOT discussed in general until recently, but something that has been clinically known for a long time. Parents should know more about the virus, how (easily) it is spread, and that there is potentially a medical prevention available should they collectively decide it is appropriate for them?
Tell me something of importance that doesn’t use fear? Just take a look at the Republican platform…Rudy Guiliani is totally selling fear – fear that the Democrats are not adequate to do the job, fear of security, fear of everything.
I also don’t believe that the medical community itself is not immune from selling fear. Can you say elective/preventative surgery? My father is about to undertake radiation therapy for early prostate cancer because one doctor has him scared to death. We have visited many doctors who mostly recommend that he wait and see how things progress, but the fear has him sold. Should we hate the selling of fear? Not so sure. My father will have a cure to his prostate cancer, but he needs to not make the decision out of fear, but more out of risk/benefit analysis. Same is true for the HPV vaccine.
I hope that the clinical trials continue for the vaccine so that the long term efficacy question is answered with more certainty as well as the indication for men. Seems as though there is an uptick in the occurance of throat cancer that is linked to the same strains of HPV. It would be great to know if there is a risk of oral cancers from HPV that can be prevented by the vaccine as well.
Last point. If the marketing camapign gets parents and teens talking to each other and their doctors, how is that bad – particularly around a taboo topic such as sexual behavior? Let’s face it, this is not something as ridiculous as the ad campaigns for Restless Leg Syndrome! This will at least make sure that sexual behavior and reproductive issues are talked about more easily than in the past since now it is so much more a part of the main stream of topics in the media.
As a mom, and not a medical professional,I see no reason to offer this vaccine to my teenage daughter.
That being said, this vaccine definitely has had a real benefit in our house and in the homes of her peers. It has certainly opened up the lines of communication and allowed conversations among my daughter, her friends and I. Just for that it is valuable.
Nice post. Wish “reason” was always enough and that “fear” was never needed to “sell” anything.
MWAK:
The studies show a reduction in HGSIL lesions, whether that will translate to a reduction in the poulation as a whole in these procedures is yet to be shown…
Dr A:
Agree, and hope that the vaccine proves to have some cross-protection against other subtypes over time. But time only will tell…
Schruggling:
Here we go again…
There is a huge difference between informing women and frightening.
The sense of urgency with which this vaccine is being marketed has created a culture of fear around HPV that is out of proportion to the fact that the overwhelming majority of HPV infections resolve without treatment and that highly effective screening for cervical cnacer has been around for decades.
Heard the pool is done – can’t wait to hang out in the Jacuzzi…
Carrie – Agree. Neither of my girls has had the vaccine yet, although some of my patients who are teens have.
RL:
Reason should be all we ever need, yet it is just ignored.
I agree that the HPV universal vaccination is not necessary, especially in Canada. However, it is a plus that it has sparked debate and initiated communication between parents and teens.
Midwife with a knife made a good point that if women get regular pap smear tests, there is not as great a need for the vaccination. I would focus more on having teens get regular check-ups than pushing gardasil, (especially till long term affects are better documented)
http://www.youtube.com/watch?v=wtaXjzQQGE8
THIS is selling fear. Yet VW has gotten numerous awards for it’s realistic portrayal of accidents.
The pharma world could be going down a much more fearful path for sure.
Are they trying to make money? Yep! Not sure why it is bad. They aren’t non-profit organizations. Not sure why people think they ought to be.
When it comes to this vaccine, I agree that mandate is too far. I also think that some pharma ads sell fear worse than HPV…look at Lipitor with the inventor of the artifical heart, Dr. Jarvic. It is offensive. Also the ad with the older couple reading the news paper and see an ad about PAD, and that the wife is in immediate danger, so they call for the brochure. Horrible! Then again, so is Evertt Koop with the medical alert – “I’ve fallen and I can’t get up!” That isn’t selling fear? That isn’t the former head of human health policy? THAT isn’t offensive?
The idea of a cancer preventitive is exciting in the pharma world where so many products that are coming out are just “me too”s. Gardasil can and will make big differences in people’s lives without them even knowing it.
While there may be very few cases of cervical cancer in the USA, I bet there are a whole lot of LEEP procedures done. If this can prevent the fear of the unknown and the discomfort of the procedure, isn’t that a good thing?
For the crowd that thinks that the vaccine doesn’t save lives compared to the pap smear, where is the lobby from the medical community to have the pap smear made more available in Africa? Who is going to fund that? Who is going to do all of the LEEP procedures for free afterwards also?
It’s easy to hate the pharma companies, but it’s hard to go beyond criticism and enact real change like they have.
TBTAM – pool is done. Was in the hot tub on Saturday night where the water was 98 and the air temp was 59. It was GLORIOUS! When are you coming over?
As a layperson, I find it really hard to get a good sense of the risk/benefits balance of a lot of medical stuff I read about in the press. Gardisil is no different.
What do you see as the primary risks for this vaccine? How does cost figure in?
I’m interested in why those of you who’ve chosen not to vaccinate your daughters (or not to offer them the vaccine?) made that choice. Were your daughters involved in the choice? At what age would it be appropriate to include one’s daughter in that decision, or to leave it completely to her? (18 seems potentially late, if the statistics on sexual activity in teens I’ve seen are anything like accurate.)
Bardiac:
I actually think the HPV vaccine itslef has few risks, although it is too new to be 100% sure. (Which is one reason why it is too soon for universal vaccination)
The biggest risk, I believe, comes from the aggressive marketing of the vaccine, marketing that has engendered fear in women, and conversely, led many to believe that if they get this vaccine they won’t get cervical cancer. And that’s just not true – the vaccine only protects against two of the HPV subtypes that cause cervical cancer.
I don’t think I’m overstating the problem – See my previous post on the HPV panties. http://theblogthatatemanhattan.blogspot.com/2007/08/hpv-vaccine-defining-limits.html
I have not yet vaccinated my daughters (ages 11 and 16) because they are not yet sexually active (or even dating). We don’t even know yet how long immunity lasts, if boosters will be needed and how often, or if other subtypes will “step in” and replace types 16 and 18 in causing cervical cancer.
So many unanswered questions. All we need is a little time to answer them. But time is something Merck’s stockholders don’t have.
It’s great to read opinions like this coming from a knowledgeable source. Food for thought. Thanks for sharing!!
Great post, TBTAM. My daughters have both had 2 of the 3 injections, will get the third in a few months. I did not push it on them. I told them about it and we discussed the pros and cons, just as we did about birth control, becoming sexually active, and getting gyn care. This was their decision entirely. I would have accepted them getting it or not getting it.
That being said, I might have had more to say financially if the vaccine hadn’t been covered by our insurance plan…it’s VERY expensive for a vaccine…but may be cheap compared to LEEPs, etc done in the future if one of them should acquire HPV that could have been prevented by the vaccine.
Thanks for the interesting blog. I’m leery of newly introduced products in general. I don’t give my kids vaccines that haven’t been around AT LEAST 20 years. Neither did my mother. I need to see the how the first round of people are doing 20 years down the line.
I find myself avoiding new medications until they’ve been around 10+ years and are established.
My Grandmother refused to take Thalidomide with during 2 pregnancies after they were prescribed to her before adverse effects were known. There has been a history in my family of refusing drugs when they first come out and the drugs later coming under heat. Frankly, I don’t trust a drug until I’ve seen it doesn’t have long term consequences.
Here in Israel the vaccine is being very aggressively marketed by the drug company. The various Sick Funds (our semi-national HMOs) have had no option but to discount the vaccine, but it is still extremely expensive. I must get several queries a day, mostly from half-hysterical mothers who think the vaccine is 100% effective against all forms of cervical cancer, and that waiting even a week to begin injections is like condemning their daughters to a certain and lingering death in the future. This is rather odd, because certain parts of Israeli society are VERY sexually conservative (with considerable emphasis on being virgin at marriage) and even the “wilder” teens are more conservative than their US counterparts (has to do with Israel’s smallness: the guy you sleep with today could be a pal of the guy you decide to marry later, oops. There also are a lot fewer places with adequate privacy. This is a country where discharged soldiers live at home with parents for lack of cheap rentals)
A yearly Pap smear, btw, is free to all women in Israel.