The HPV Debate Needs an Injection of Reality
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.