The HPV De­bate Needs an In­jec­tion of Re­al­ity

The Washington Post Sunday - - Outlook - By Arthur Allen

The rec­om­men­da­tion was that all chil­dren be given a vac­cine for a car­cino­genic virus whose spread is as­so­ci­ated, in many minds, with sin­ful ac­tiv­i­ties. Here’s what some lead­ing pe­di­a­tri­cians had to say about it: “We are no­tably poor sooth­say­ers in pre­dict­ing which child will be put at high risk by fu­ture be­hav­ior. Pe­di­a­tri­cians must ini­ti­ate, then, an in­sur­ance pol­icy for young pa­tients that ma­tures in adult­hood.”

That state­ment was made in 1992. Its au­thors were Neal Halsey and Caro­line Breese Hall of the Amer­i­can Academy of Pe­di­atrics’ in­fec­tious-dis­ease com­mit­tee. They called for uni­ver­sal vac­ci­na­tion of new­borns and ado­les­cents against hep­ati­tis B, a dis­ease that, in the United States, spreads mainly through sex and shared hy­po­der­mic nee­dles. Halsey and Hall were push­ing uni­ver­sal vac­ci­na­tion be­cause ear­lier pro­grams to im­mu­nize at-risk groups — drug users, pros­ti­tutes, pris­on­ers, gay males — had been a mis­er­able fail­ure.

The choice to vac­ci­nate in­fants was con­tro­ver­sial, but the virus is a deadly one. In the early 1990s, about 250,000 Amer­i­cans were in­fected with hep­ati­tis B each year. About a fifth would be­come chronic car­ri­ers and suf­fer, in some cases, scar­ring of the liver. About 6,000 died each year of liver can­cer as­so­ci­ated with hep­ati­tis B. And al­though chil­dren rep­re­sented a small per­cent­age of those in­fected, they were more likely to be­come chronic hep­ati­tis B car­ri­ers.

There was con­tro­versy in the med­i­cal com­mu­nity over the hep­ati­tis B vac­ci­na­tion pro­gram, but it was im­ple­mented, in that pre-In­ter­net era, with min­i­mal pub­lic fret­ting. Nearly ev­ery state now re­quires the vac­ci­na­tion for en­try to pri­mary school.

Now there are ques­tions about manda­tory vac­ci­na­tion of girls for the hu­man pa­pil­loma virus, which can cause cer­vi­cal can­cer. This vac­cine of­fers sim­i­lar, if slightly less dra­matic, hope to a large pop­u­la­tion of ne­glected Amer­i­cans. But po­lit­i­cally, it’s a very dif­fer­ent story this time. A pow­er­ful move­ment has sprung up to op­pose manda­tory HPV im­mu­niza­tion. Much of this re­sis­tance is, I be­lieve, mis­guided. Yet I have my own reser­va­tions about man­dat­ing the HPV vac­cine at this time.

The re­sults of the hep­ati­tis B vac­ci­na­tion pro­gram that be­gan in the 1990s have been dra­matic. In the Mor­bid­ity and Mor­tal­ity Weekly Re­port of March 16, the Cen­ters for Dis­ease Con­trol and Pre­ven­tion re­ported that the num­ber of new cases had fallen to about 50,000 in 2005. New in­fec­tions were most re­duced in the vac­ci­nated groups — 98 per­cent among el­e­men­tary-school chil­dren and young teenagers, and 90 per­cent among 15- to 24-year-olds.

Sim­i­larly, in tri­als com­pleted last year, the HPV vac­cine was shown to pre­vent 70 per­cent of the growths that lead to cer­vi­cal can­cer, which strikes 14,000 Amer­i­can women each year, killing one-fourth of them. The 20,000 women who re­ceived the vac­cine in tri­als by Merck, the man­u­fac­turer, ex­pe­ri­enced no ma­jor side ef­fects. By pre­vent­ing pre­can­cer­ous growths, the vac­cine also can re­duce the need for ex­tra gy­ne­co­log­i­cal vis­its and painful pro­ce­dures.

This all sounds good. It helps ex­plain why lib­eral groups such as Women in Gov­ern­ment ac­cepted fund­ing from Merck this year to help the drug firm lobby state leg­is­la­tures to make the HPV vac­cine manda­tory for sixth-grade girls.

So what’s wrong with or­der­ing par­ents to get their chil­dren im­mu­nized by a prod­uct that has the power, like the hep­ati­tis B vac­cine, to help pre­vent a deadly dis­ease?

Plenty, ac­cord­ing to the many ac­tivists who have whipped up a firestorm on the is­sue in places from Cal­i­for­nia to Mary­land and the Dis­trict, where the city coun­cil last week took the first step to­ward re­quir­ing HPV vac­ci­na­tion. (Vir­ginia acted this year to re­quire the im­mu­niza­tions but made it fairly easy for par­ents to opt out.)

In my view, the fact that HPV is sex­u­ally trans­mit­ted is no rea­son to keep chil­dren from be­ing vac­ci­nated against it. Im­mu­niz­ing in­fants against hep­ati­tis B has clearly shown that pub­lic health cam­paigns can pre­vent dis­ease with­out caus­ing moral turpi­tude. In any case, HPV’s spread is not linked to risky sex­ual be­hav­ior. The virus is as com­mon as in­fluenza: About 80 per­cent of women will be ex­posed to it at some point.

When the CDC led a drive to en­force manda­tory vac­ci­na­tion against measles in the 1970s, it dis­cov­ered that im­mu­niza­tion rates in­creased by as much as 20 per­cent. The par­ents who had their kids vac­ci­nated only when their schools re­quired it of­ten had been un­aware of the vac­cine, un­able to af­ford it, or too over­whelmed to get their chil­dren to a clinic. Those who strongly op­posed the vac­ci­na­tion could usu­ally opt out un­der state laws. The same would be true of the HPV vac­cine.

Most cer­vi­cal can­cers can be pre­vented with reg­u­lar pap smear tests, which find pre­can­cer­ous growths that can be ex­cised. Most of the women who get cer­vi­cal can­cer haven’t had the test done in at least three years. It stands to rea­son that, with­out a manda­tory vac­ci­na­tion, many of the girls who don’t get vac­ci­nated will be­long to the same groups that fall through the cracks of the patchy U.S. health-care sys­tem.

Dur­ing a re­cent ra­dio in­ter­view about this is­sue, I was dis­mayed to hear call­ers claim that pro­posed HPV man­dates would make their chil­dren “guinea pigs” in a con­tem­po­rary Tuskegee — a ref­er­ence to the no­to­ri­ous ex­per­i­ments in which black men with syphilis were stud­ied but not given peni­cillin. I re­sponded by ask­ing whether it was bet­ter to be ne­glected by the med­i­cal main­stream than to be en­rolled in a mea­sure that cov­ers all girls — rich, poor, black, white, His­panic and Asian.

Sadly, as long as the HPV vac­cine is not re­quired, the peo­ple who need it most prob­a­bly won’t get it. “Those who are well-in­formed with good fam­i­lies, par­ents in­volved with their chil­dren, will go ahead,” said Hall, who is with the Univer­sity of Rochester Med­i­cal Cen­ter in New York. “Those who are not as well in­formed or in­volved in the care of their chil­dren will not get the vac­cine.”

So why, given all th­ese ar­gu­ments, do I think that re­quir­ing HPV vac­ci­na­tion for school-age girls is a mis­take at the present time? The most ob­vi­ous rea­son is that when a vac­cine is man­dated, it must be avail­able for free to those who can’t af­ford it. But state health of­fi­cials are al­ready strug­gling to pro­vide for ex­ist­ing man­dated vac­cines such as DTP (diph­the­ria, tet- anus and per­tus­sis), MMR (measles, mumps and rubella) and chick­en­pox. They sim­ply don’t have the money to buy the HPV im­mu­niza­tion for girls whose fam­i­lies can’t af­ford it.

Sec­ond, the vac­cine, while promis­ing, has no track record. Merck’s hep­ati­tis B vac­cine was li­censed in 1986, which al­lowed plenty of time to ob­serve its ef­fi­cacy and safety be­fore it be­came manda­tory — and fore­stalled the “guinea pig” ar­gu­ment. While the hep­ati­tis B vac­cine proved quite safe, there’s no guar­an­tee that the HPV im­mu­niza­tion won’t pro­voke a rare side ef­fect.

But there is a third, less tan­gi­ble rea­son for hold­ing off — one that has to do with the kind of pub­lic per­cep­tions that are es­sen­tial to suc­cess­ful vac­ci­na­tion pro­grams and are mag­ni­fied in this era of in­stant blog­ging.

With only Merck and a few ac­tivists push­ing the HPV vac­cine, it lacks cred­i­bil­ity. This has opened the door to crit­ics of im­mu­niza­tion in gen­eral, who are gain­ing sup­port among peo­ple who fear an HPV-vac­cine man­date.

Our rick­ety pe­di­atric vac­ci­na­tion sys­tem is a three­legged stool whose sta­bil­ity re­lies on the par­tic­i­pa­tion of drug com­pa­nies, which need a profit in­cen­tive; the gov­ern­ment, which buys about half of all child­hood vac­cines; and par­ents, who are called on to sub­mit their chil­dren to vac­ci­na­tion not only to pro­tect them but to di­min­ish the spread of dis­ease.

In fail­ing to in­clude two legs of the sys­tem, those push­ing for im­me­di­ate manda­tory vac­ci­na­tion are risk­ing its col­lapse. The HPV vac­cine may do great things, but we shouldn’t rush it.



A shot in the dark: Man­dat­ing the HPV vac­cine against cer­vi­cal can­cer is a good idea whose time has not yet come.

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