UPDATED: The HPV Vaccine for Boys?


For an excellent and thorough review of HPV in the United States, please see this article by Sharon Phillips, MD., originally published by RH Reality Check.  Please also see this excellent article on HPV in men and boys by Pamela Merritt.

This post has been updated, Thursday, September 16, 2010, 2:30pm EST

I took my 11-year-old son (we’ll call him “E” out of protection for his future teen self who may or may not read this) for a back-to-school check-up recently. He’s in need of a Tdap vaccine, apparently (clearly, I’m less than on-point about keeping up with the vaccine schedule – and somewhat cautious about which vaccines are necessary and which aren’t). After undergoing his first official “pre-teen” health exam while I was in the room with him, E. turned to me slightly red-faced and sighed, obviously thrilled at its completion. It was at that moment his pediatrician addressed me, “Okay, Mom (why are we all the monolithically named, Stepford wife-esque “Mom?”),  he looks great.”

“Just one more thing…”

He glances sidelong, ever so briefly, at E. and looks back to me.

“Have you thought at all about the HPV vaccine?”

Now, as a reproductive and sexual health advocate and writer I’m always quick to jump in ever-so-proudly when conversation turns to these issues – like a fourth-grade know-it-all who can’t wait to show off her knowledge: oooh! oooh! I know this! I know this!

But, I admit that his question caught me off guard. I’d read very little, to be honest, about the pros and cons of the HPV vaccine for boys and young men.

There are currently two HPV vaccines on the market: Cervarix and Gardasil. Both prevent against the most prevalent strains of HPV known to cause cervical cancer, but Gardasil also protects against the strains that cause genital warts. The price tags for both are hefty – anywhere between $120 – $260 per dose. And you need three shots over a period of nine months. Most private insurers cover it, however, and it’s also covered by the federal government’s Vaccines for Children program. Still, for those without private insurance it can certainly be prohibitively expensive.

In 2006, amidst growing concern over the prevalence of HPV – it’s the most common sexually transmitted infection in the United States – Gardasil was approved by the U.S. Food and Drug Administration (FDA) for girls and women ages 9 to 26 years old. But, as with everything else related to female sexuality, it wasn’t without its share of controversy. Anti-sex ed, anti-choice Conservatives screamed that vaccinating girls and young women would give them license to become sexually active sooner – even “promiscuous.”

In October 2009, the use of Gardasil was approved for males in the same age range, to protect against the two strains of HPV which cause genital warts. Strangely, this approval process did not engender the heated debate over a potential sexuality “apocalypse” it did for females. But the reality of its importance still stands – at least half of all sexually active adults in the United States will become infected with HPV at some point in their lives; over twenty million Americans are currently infected.

It’s no surprise that the vaccine is now suggested for males as well. Gardasil is extremely effective in protecting against genital warts in males. In a study of males betwen the ages of 16 and 26, who were not infected with the strains of HPV which cause genital warts, the vaccine was 90 percent effective at preventing infection.

Dr. Doug Lowry is the co-creator of Gardasil. In a story on NPR, he argues that vaccinating boys against HPV provides “herd immunity”, since boys can reduce the number of people transmitting the HPV infection,

He says that since just 11 percent of girls now get all three doses of the vaccine and less than half get even one dose, rates of HPV in the U.S. are unlikely to come down very much.

So, he says, let’s offer the vaccine to boys as well.

“When the percentage of girls getting vaccinated are in the 30 to 40 percent range, vaccinating boys is suggested to have a substantial enhancing impact on trying to protect those girls who are not vaccinated,” Lowy says.

Some are not convinced, however, citing the fact that it will take a much longer time for the vaccine to “catch on” for girls. Vaccinating boys is not the answer.

Dr. Diane Solomon, with the National Cancer Institute says it’s also about cost effectiveness.

“The greatest benefit in terms of health care costs is with decreasing cervical cancer and cervical abnormalities,” Solomon says. “Men don’t have a cervix.”

Even though the HPV vaccine protects against anal cancer and genital warts in men as well, she says vaccinating boys still doesn’t bring down the cost of health care enough.

For me and my son?

He’s certainly not at the age, yet, where this is an issue. His doctor told me he was planting the seed since he believes if it can help prevent genital warts in males and help stem the spread of HPV in both males and females, it’s worth it. As with all issues surrounding the health of my children, I include them in the discussion process. This is about my son’s body, health and life. When he becomes sexually active or he reaches an age where I think we need to realistically address sexual activity and talk more in-depth about it, we’ll do so. We’ve already talked about birth control, sexuality, and pregnancy and infection protection. To me, this is one more area of discussion he has a right to be a part of. Until then, I have time to consider whether another vaccine is the right way to go.

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  • saltyc

    Why not?

     

    I think the controversy was not all conservative, and it was around the mandatory vaccination for girls in places like Texas. I mean, mandatory vaccinations are for trying to eradicate a disease from a population, right? So how can that be done if only girls are vaccinated?

  • hmprescott

    SaltyC is right — the controversy went beyond the anti-sex ed conservative crowd but also included various political constituencies who oppose childhood vaccines more generally.   Your doubts about which childhood vaccines are “necessary” concerns me.  The short answer is the all are if you want to ensure herd immunity and prevent epidemics of various diseases.  In states like Colorado where vaccine rates are below the recommended level for herd immunity, there have been outbreaks of pertussis and measles. 

     

    Also, HPV has been linked to  number of types of cancers, not just cervical cancer.   This includes anal cancer, penile cancer, and oral cancers.

  • beenthere72

    I didn’t know how prevalent HPV was, or even that it existed, until I contracted it over 10 years ago.    And then, when I’d bring it up in conversation with my friends, I learned that most every woman I know had also had it at some point in their lives.   My cousin had very serious complications from it.  

     

    I took my 15 year old step daughter to get her first shot just 2 weeks ago.    The information her doctor gave me says they recommend administering the vaccine at 11 years old!   I was surprised at that. 

     

    I’m glad to hear it’s being recommended to boys as well.    HPV can spread even when condoms are used. 

  • jodi-jacobson

    For an excellent and thorough review of HPV in the United States, please see this article by Sharon Phillips, MD., originally published by RH Reality Check:

    “The Human Papillomavirus: What You Need to Know”

     

    Please also keep in mind there are many strains of HPV but only a few are responsible for cervical cancers. Those that are related to cervical cancer, however, have been found to be responsible for virtually all cervical cancers that occur (well over 95 percent).  HPV can cause genital warts and also other forms of cancers, such as those cited by another commenter.

     

    At any given time, 26.8 percent of women between ages 14 and 59 have an active HPV infection, and approximately 75 percent of all sexually active individuals will contract HPV at some time in their lives.  Most people that contract HPV clear it by themselves.  The point of a vaccine for girls/women is to eliminate/dramatically reduce the chance of developing cervical cancer.  Pediatricians often base their administration of the vaccine on various factors, but I, for example, have been advised to have my daughter vaccinated at age 15 or so, thereby ensuring that should she become sexually active sometime between the ages of 16 and 22, she will be protected from most forms of HPV that may lead to cervical cancer.

     

    Suggestions of the age range at which it is suggeted girls receive HPV vaccines are often based on the general population in a specific catchment area and the general ages at which teens are becoming sexually active.  This may or may not apply to your teen.

     

     

     

     

  • beenthere72

    I’m really happy they came up with a vaccine for HPV, if only for the fact that people are talking about it openly now.    I’m amazed that I didn’t know about it until my mid-20s, unless I was completely tuning out my OB/GYN’s growing up.  

     

    My concern now is with the new recommendations of frequency, or lack thereof, of pap smears.   When I contracted HPV, they recommended pap smears every 6 months.   Sure, I haven’t had it for over 10 years now, but I’m still worried about it and now they tell us to get pap smears every 3 years?   Makes me very uncomfortable.    

  • squirrely-girl

    Vaccinating half the population (theoretically) results in something referred to as “herd immunity.” However, this takes MUCH longer than it would if we were immunizing everybody and would only generally benefit those men who have sex with women. 

  • jodi-jacobson

    I believe that the reasons for HPV vaccination have less to do with herd immunity in the traditional sense than it does with ensuring that individuals don’t develop cervical cancer.

     

    While HPV is obviously “communicable,” I am not sure it is akin to measles, chicken pox, small pox in the same way, in part because there are so many strains. The Department of Health and Human Services for example points out that while HPV infections leading to genital warts can be eradicated by the body’s immune system in some people, there is no treatment available to eradicate strains that cause warts. 

    Likewise HHS and others point out that the outcome of HPV vaccines for girls is to eradicate cervical cancers not necessarily HPV per se.

     

    Obviously if we could effectuate herd immunity by vaccinating everyone against the strains of HPV that do lead to cancers we might eventually eradicate the virus altogether, but I’m not sure that is the current goal or an achievable so much as it is to prevent the adverse outcomes.

     

    best wishes, Jodi

  • amie-newman

    Thanks for commenting! The controversy was not only amongst those who were/are anti-sex ed and anti-vaccine but also those who feared that reported side effects warranted extra investigation. However, I am referring above to the fabricated notion that vaccinating teen girls against HPV encourages them be sexually active before they would have anyway.

    I understand – and I agree wholeheartedly! – that vaccines are necessary to ensure herd immunity but, for example, I did not receive – nor did I have my children receive – the vaccine for the swine flu. It turned out that warnings of a swine flu pandemic were severely exaggerated. It was my pediatrician, in fact, who calmly explained last year to me that he did not feel that the swine flu vaccine was necessary for my children. I agreed. And we both feel good about that decision, in retrospect.

    Thanks for commenting!

    Amie

  • kevin-rahe

    I would never vaccinate my child against bad behavior.

  • crowepps

    I’m not sure I understand your comment.  Is your position that if your child has sex at some time in their life it serves them right to get cancer? 

  • carolyninthecity

    You daughter can choose to abstain from sex until she’s married, but if her partner doesn’t, there’s a very real chance he may have HPV- even if he’s only had one other partner. It really isn’t all that far fetched (75% of adults will contract it at some point in their life). 

    you can control your own sex life, but not other peoples. What would be easier- vaccinating your daughter, or ensuring she marries a virgin? 

  • squirrely-girl

    … you’d be okay with her contracting HPV on her wedding night and developing cervical cancer? In other words, you’d punish her with cancer or genital warts for ever having sex? You do realize there are still plenty of other, non cancer causing STDs for her to punished with, right?

     

    If your child stepped on a rusty nail would you also refuse to vaccinate against tetanus?

     

    Way to be a great parent there, Kevin. Seriously.

     

  • kevin-rahe

    … you’d be okay with her contracting HPV on her wedding night and developing cervical cancer? In other words, you’d punish her with cancer or genital warts for ever having sex?

     

    You daughter can choose to abstain from sex until she’s married, but if her partner doesn’t, there’s a very real chance he may have HPV- even if he’s only had one other partner.

     

    The article is about vaccinating boys against HPV, but as soon as you want to defend the practice, you justify it in terms of its effect on girls.  Interesting.

     

    I expect my children to hold themselves to high standards of conduct, and I hope they expect the same of their potential spouses.  If nothing else, this whole thing with HPV shows that very few if any of the people who have premarital sex actually appreciate the seriousness and possible long-term effects of what they’re doing, not only on themselves but on others, even some they don’t yet know but will someday care deeply about.  (And some thought the only issue was the effect it has on one’s soul.)

  • mechashiva

    I’m still not seeing a good argument against vaccination here. I mean, if it isn’t neccessary because you (and they) are absolutely certain that they will only have sex with one person who has never (and will never) have sex with anyone else for the rest of their lives, that’s your family’s perrogative. However, I see no reason not to get vaccinated just in case something happens that causes an uncontrollable deviation from your plan.

     

    Like… your child’s spouse dies, and they don’t wish to be alone and celibate for the rest of their life. If they re-marry, it’s unlikely they’ll be re-marrying a virgin. I know, it’s unlikely… but so is the likelihood of your child and their spouse living up to your standard of sexual morality. I mean, it isn’t like getting vaccinated is harmful or guarantees/encourages your child to have sex with multiple people. It’s the sex with multiple people (in your mind) that is bad, not the vaccine. So… why not just vaccinate to be on the safe side?

     

    I know I make a lot of veterinary analogies (my best friend is a vet), but bear with me here… I’d keep my indoor-cat up-to-date on its vaccinations, not because I plan on it running away and coming into contact with infected animals… but because it could happen, and I don’t want my cat to suffer anything worse than confusion and homesickness if it gets lost.

  • jodi-jacobson

    This discussion is assuming sexual activity of what kind?

     

    Mr. Rahe keeps referring to “premarital sex.”  Intercourse is not the only means through which HPV is transmitted.  It can be transmitted through any kind of genital contact (including genital touching), oral sex, and intercourse, and mouth to mouth contact cannot be excluded as a possible means of transmission.

     

    This is a conversation about public health, not Mr. Rahe’s “family values,” which he is free to impose on his children, however unfortunate the outcome of such thinking may appear to be or may in fact be in sheer consequences for his children.

     

    Since 75 percent of ALL adults will contract at least one of the 200-odd HPV viruses in their lifetimes (many of which are completely harmless and/or cleared by the immune systems of most healthy bodies) and since in any case the vast majority of people in the United States do have sex before they are married, it might be helpful to deal in the realities at hand and not for the benefit of a minority who apparently think sex is shameful and those who engage in it should “pay for it.”

     

    Let’s face it: There has never really been a time when a significant share of people, if not the majority, did not engage in sex before marriage.  I don’t particularly see it as a “goal,” but for those who do, it is one that has never even been closely achieved, unless we are talking about women living in purda.

     

    One the share having sex before marriage, from Guttmacher:

    The vast majority of Americans have sex before marriage, including those who abstained from sex during their teenage years, according to “Trends in Premarital Sex in the United States, 1954–2003,” by Lawrence B. Finer, published in the January/February 2007 issue of Public Health Reports. Further, contrary to the public perception that premarital sex is much more common now than in the past, the study shows that even among women who were born in the 1940s, nearly nine in 10 had sex before marriage.

    No matter my own family values, I would never subject either my son or my daughter to a potentially avoidable cancer by trying to predict or decide what they “will do” at a later age, when I can protect them at an earlier age.  That is not the same as saying that the HPV vaccine is right for boys per se, or that there are not discussions to be had about the vaccine for either sex/any gender.  It is however a point of fact that people have sex.

  • kevin-rahe

    it might be helpful to deal in the realities at hand and not for the benefit of a minority who apparently think sex is shameful and those who engage in it should “pay for it.”

     

    I would never suggest such a broad thing as “sex is shameful,” though I do believe that, like everything else, it has its proper place.

     

    “contrary to the public perception that premarital sex is much more common now than in the past, the study shows that even among women who were born in the 1940s, nearly nine in 10 had sex before marriage.”

     

    Most women born in the 1940s were born in the late 1940s thanks to the baby boom, which would put most of them in their teens and early 20s in the 1960s, and we all know what happened in the ’60s.  That hardly makes it a convincing statistic.  In fact, the oldest people in the study you linked to turned 20 in 1958.  Even with the changing attitudes toward sex that started in the 1960’s, however, as late as 1969 75% of American adults with an opinion on the matter said that premarital sex was wrong.

     

    There has never really been a time when a significant share of people, if not the majority, did not engage in sex before marriage.

     

    There has also never been a time when there were so many reasons (or at least so many that we’re aware of) not to engage in sex before marriage as there are now.  Thankfully (given where we’re at anyway), history shows that social mores and permissiveness tend to wobble back and forth rather than move continuously in one direction.  We can only hope that it’s getting close the point where they start moving back from the brink we’ve brought ourselves to.

  • kevin-rahe

    So… why not just vaccinate to be on the safe side?

     

    There were 53.9 adverse effects reported for every 100,000 girls/women vaccinated with Gardasil, of which 6.2% were serious and 32 of them were deaths (that’s according to the ABC News article linked to below, which was published in August 2009; there have now been 53 deaths according to the CDC).  According to the ABC News article, “Dr. Jacques Moritz, director of gynecology at St. Luke’s-Roosevelt Hospital, said he would not offer the Gardasil vaccine to patients when good cervical cancer screening techniques and treatments exist. He has also chosen not to have his 11-year-old daughter get the HPV shot because of his concerns.  ‘I’m pro preventing cervical cancer and HPV,’ Moritz said. ‘I’m not pro that the physicians don’t know the risks and side effects.'”

     

    It doesn’t sound very “safe” to me, especially when the benefits are dubious at best.

     

    http://cogforlife.org/gardasilMerckAdmits.htm

    http://abcnews.go.com/Health/CancerPreventionAndTreatment/gardasil-hpv-vaccine-faces-safety-questions/story?id=8356717

    http://www.cdc.gov/vaccinesafety/Vaccines/HPV/gardasil.html

  • mechashiva

    54/100,000 = 0.000054, meaning 0.0054% of women experienced some sort of complication.

    6.4% of 0.0054% (that’s 0.064 x 0.000054)= 0.000003456, meaning 0.0003456% of the women experienced a serious complication.

     

    Seems like good odds to me (and the vast majority of medical professionals), but you go ahead and fear-monger.

  • squirrely-girl

    The article is about vaccinating boys against HPV, but as soon as you want to defend the practice, you justify it in terms of its effect on girls.

     

    The push medically is still to vaccinate girls, but my bad. Let me rephrase. 

     

    So instead, you’d be okay with him contracting HPV and (assuming heterosexuality) giving it to his unsuspecting virgin wife on their wedding night and letting her develop cervical cancer? In other words, you’d punish her with cancer or genital warts for ever having sex with your son?

     

    Way to screw the lives of two children there, Kevin. Great parenting skills!

  • squirrely-girl

    What many people consistently refuse/fail to acknowledge is that ALL vaccines carry those risks of reactions and FAR more often those reactions are to the enzymes used to create the vaccines, rather than the vaccines themselves. 

     

  • colleen

    Why not just deal with the bug like I did, it would be much cheaper,

    Here’s what these folks say:
    http://www.cancer.gov/aboutnci/servingpeople/snapshots/cervical.pdf

    Although cervical cancer incidence and mortality rates have declined approximately 50 percent in the United States over the past three decades, the disease remains a serious health threat. Incidence rates for Hispanic women are higher than those for non-Hispanic women. Even though the mortality rate for African American women has declined more rapidly than the rate for white women, the African American mortality rate continues to be at least double that of whites. Geographic and socioeconomic disparities in cervical cancer mortality also exist

  • saltyc

    Fear mongering

    I don’t know, I have seen plenty of fear-mongering pushing parents to vaccinate their daughters for something that is curable. I had it, had cryosurgery, it was gone. No, parents don’t want to punish their children with cancer, I mean come on.

     I think the fact that it’s a bigger stigma for a girl to have an STI than it is for a boy is playing into this. Girls and women were always seen as vectors. Vectors. That’s playing into this.

    I mean, vaccinate a girl when she’s 15, acording to the scarleteen article, it’s most effective the year after then wears off until it’s useless in 5 years, so she’s totally susceptible at 23, so then she gets another vaccine, and she could still get it at 28, etc. Why not just deal with the bug like I did, it would be much cheaper,

    and they’re saying it’s not worth the money for boys, even though they can get and cause cancer too?

    I can understand getting it to prevent dealing with the bug, but seems like it should be voluntary which is why fear-mongering is totally out of place here.

    I’m sorry, but the cervical cancer on the wedding night thing is fear mongering.

    There are what like 4000 deaths in the US a year from cervical cancer, is that from a population that is getting pap smears and going to the gyno or urologist, or is that from the disenfranchised population? I’m saying, the people who can’t afford a gyno/urologist visit to cure the warts can’t afford the 1000 for the gardasil either, amirite? So will it really impact on the # of deaths as much as better screening would? Cost-benefit anyone?

    This is a conversation about public health, not Mr. Rahe’s “family values,” which he is free to impose on his children, however unfortunate the outcome of such thinking may appear to be or may in fact be in sheer consequences for his children.

    I’m in no hurry to vaccinate my daughter. Go ahead and question my parenting skills, has anyone questioned why Aimee hasn’t gotten it for her son? She already explained the good reasons why she didn’t, which is exactly the same reason I don’t want it for my daughter.

  • saltyc

    I edited my post after your post, and I wondered: (repost)

    is that from a population that is getting pap smears and going to the gyno or urologist, or is that from the disenfranchised population? The people who can’t afford a gyno/urologist visit to cure the warts can’t afford the 1000 for the gardasil every 5 years either, amirite? So will it really impact on the # of deaths as much as better screening would?

  • sharonmd

    It’s also important to remember that adverse effects include ANY serious or lethal event after the vaccination.  This would include a diagnosis of cancer that was made 2 days after getting the vaccine, a seizure that happened a week later, or a blood clot in the lungs.  Since we don’t have a comparison group of people who did not get the vaccine (we do have such a group in the clinical trials that shows no difference in adverse events, but that group is much too small to see any event that happens only 1 time in 500,000 doses; this is why we have an adverse events reporting system for vaccinations), we can’t make any causal inferences.  It’s the same as saying that out of 10 million people who watched a football game on TV, 30 died in the 2 months afterwards.  Would you blame the football game for every incidence of pneumonia, suicide, or meningitis?  Probably not.  Because the reported adverse events were all entirely different, we can’t conclude that the vaccine caused them, and because the rates of these events were no different from the rate in the general population, the logical conclusion is that these effects are not due to the vaccine.

  • sharonmd

    Unfortunately, vaccinating only half the population won’t get you anywhere near herd immunity.  Generally 80-90% saturation is needed for herd immunity; when you get to this level, you get what’s called herd effect, or decreased prevalence of an infectious disease (ie measles) or consequence of an infectious disease (ie death from measles).

     

    These definitions are actually quite important.  Right now the program really benefits girls only, and protects them only partially from various strains of HPV that can cause cervical dysplasia that can cause cancer.  There are lots of steps along the way.  We are making assumptions that vaccinating against HPV –> decreased cervical cancer in the entire population, but that’s actually not data that we have yet.  All we know for sure is that vaccinating against HPV –> fewer abnormal pap smears and fewer episodes of vaginal warts in the 5-10 years after vaccination.  Another assumption being made here is that vaccinating boys against HPV –> decreased risk of transmission to female partners –> decreased incidence of genital warts and cervical cancer.

     

    I am a big fan of these vaccines, but I really think their effect has been oversold.  We aren’t vaccinating nearly enough people to get herd immunity, and given the cost of the vaccine and the fact that the vaccine decreases in efficacy with time it would be quite an endeavor to get there.  We know that the vaccine decreases genital warts and pre-cancerous lesions, but not if it decreases incidence of cancer or rate of mortality from cervical cancer, or other HPV-related cancers.  We don’t even know if we can decrease frequency of pap smears.  We have absolutely no data on the effect of the HPV vaccine on the partners of the recipients.

     

    This is an example of using proxy markers for real outcomes.  In other words, we are assuming that decreased HPV incidence will decrease cervical cancer incidence, but in medicine we’ve been fooled by this kind of assumption over and over again.

     

    I highly recommend vaccinating your children if you can afford it.  Although it’s recommended at 11, I usually recommend waiting until teens are thinking about starting to date since we know the efficacy decreases somewhat with time and we don’t yet have any information on re-vaccination.  But it’s definitely important to have the series before sexual contact if possible.

  • jodi-jacobson

    I want to be clear that I am not questioning anyone’s parenting skills based on their decision whether or not to have their child vaccinated with Gardisil.  My point was to the issue of making the decision based on assuming that two persons will absolutely remain virgins until they marry.  Even if that were my own desire for my children (which it is not; it is not a guidepost for them that I aim for necessarily), I would not be making medical decisions based on their willingness to engage in “good behavior” as defined by Mr. Rahe. That was my point.

     

    I have a 14-year old daughter who has not yet been vaccinated.  I have weighed this issue very carefully for her and continue to, and will continue to, discuss this with health professionals until we decide what path to take.  I will not make the decision based on my assumption that she “might remain a virgin til marriage and might marry a virgin,” if she chooses to marry at all.

     

    That all being said, every pediatrician and medical professional I’ve spoken to so far has recommended it.  Even my own ob-gyn, who does not see my daughter, recommended it for her when I asked her about it.  I need to double-check data and notes I have, but in fact, the reason for getting the vaccination early is to have the immunity before/at the time in our life you are most likely to contract the form(s) of HPV that are linked to cervical cancer, and then your body later takes over that role.  I will check on this and reply once I have.

     

    Jodi

  • sharonmd

    You’re right, getting the vaccine (all three shots) before first having sex is the best idea; otherwise you may already have contracted the virus.  It’s still worth getting even if you’re had sex because it covers several strains and may confer at least partial immunity to some of the strains it doesn’t cover.

     

    Also, younger women, due to progressive changes in the way the cervical cells are distributed during puberty, may be more susceptible to contracting HPV and other STIs than older women.

  • kristin

    Vaccines are always a question of risks versus rewards. With, say, the polio vaccine, the ‘rewards’ of the vaccine and the necessity for herd immunity were overwhelming. With Gardasil, there are a whole lot more questions.

     

    One of those questions is whether this isn’t just yet another a quick-fix that covers for unhealthy behavior and may bring unanticipated side effects. I’m not remotely anti-sex, nor am I naïve about the fact that my kids are as unlikely to wait for marriage as I was.

     

    But we do have to be honest about the lifestyle risks that lead to persistent HPV infections (and it’s only the relatively rare persistent ones that need concern us). You don’t hear doctors telling your son that smoking will increase the chance of a persistent infection by up to 2,600 percent, or that not eating his veggies increases the risk by a good 50 percent; you don’t hear rational discussions about the effect of inadequate sleep on the immune system. And although anyone who thinks that premarital sex hasn’t always been fairly common is crazy, teens these days are far more likely to have many partners for oral sex and often for regular sex too—and each partner raises risks exponentially.

     

    So do we say hey, go ahead and be as reckless as you like; just get the shot? Or do we say, hey, here are the facts. If you’re going to choose an unhealthy lifestyle that will raise your risk for MANY diseases, not just HPV, and ignore regular checkups, then the potential rewards of the vaccine probably outweigh the risks. If you are more careful, and if you have certain iffy factors (like a family history of autoimmune disease), maybe you’ll think of this more like a statin—something that has risks (like the unanticipated increased risk of diabetes) and can be avoided if you care properly for your body. As JAMA said, Merck’s ads (and most doctors) maximize the risk of HPV while minimizing potential unintended consequences of the vaccine.

     

    Good for you, Ms Newman, for including your son in the discussion. Most of us treat our kids like idiots and send them out into the world expecting them to behave like idiots. So they do. Sadly, most of the discussion about Gardasil has deteriorated into “you’re a prudish dinosaur if you don’t give it unquestioningly to your kid” versus “you’re going to die/fall prey to a pharma conspiracy if you do.” There is rarely an honest discussion of the pros and cons.

     

  • sharonmd

    Cervical cancer (in advanced stages) is undoubtedly linked with poverty and other factors that have been shown to be associated with worse health outcomes (such as being black or latina).  Increasing access to screening is definitely another strategy we should continue to pursue. 

     

    Given how effective pap smears are, the vaccine is less likely to be a lifesaver than an illness reducer (in medical speak, it reduces morbidity much more than mortality).  It looks like it will decrease the number of abnormal pap smears, thereby decreasing the number of colposcopies women must undergo, which saves time, money, and the pain and anxiety that goes with it.  It will probably also decrease the need for minor surgical procedures to remove precancerous lesions and early cancers.  This again saves money, time, pain, and anxiety, as well as saving women from the slightly increased risk of cervical incompetence and preterm labor in future pregnancies.  It also decreases the need for visits to doctors, treatment and discomfort of genital warts for both men and women.

     

    This vaccine appears to be cost-effective, even though it’s quite expensive, because of the decreased numbers of minor procedures that will be required.  It’s probably not life-saving, except maybe for the people who tend to be quite disenfranchised from medical care as adults but who may have medicaid or another subsidized insurance plan that pays for vaccines when they are children.

  • sharonmd

    You don’t hear doctors telling your son that smoking will increase the chance of a persistent infection by up to 2,600 percent, or that not eating his veggies increases the risk by a good 50 percent

    I’m really interested to know where you got this information.  Women who are smokers are more likely to suffer from cervical cancer, but there are many confounding factors that probably explain most of that difference.  Similarly, women who eat more fruits and vegetables often have lower incidence of many kinds of cancer, but the extent to which that is because of the fruits and vegetables as opposed to other factors (such as poverty, smoking, lack of exercise, and other dietary factors) is not clear.

  • beenthere72

    Y’all keep mentioning how expensive this vaccine is and now I feel like an idiot for not double checking that my weak insurance coverage covers the vaccine for my step daughter – who just got her first shot a couple of weeks ago.  I work for a company for whom entire TV networks are dedicated to and is in the news on a daily weekday basis.    If my insurance doesn’t cover this (and I’ve had serious conflicts with them in the past over necessary blood tests and mammograms), I am going to go hellcat on their ass! 

     

    Hate Cigna. 

  • kristin

    For smoking: http://news.healingwell.com/index.php?p=news1&id=536167 (sorry, I didn’t remember accurately: heavy smoking is associated with a 2,700 percent, not 2,600 percent, higher risk of precancerous lesions).

     

    For veggies: http://cebp.aacrjournals.org/content/11/9/876.full

     

    I think these were the studies I was looking at originally, although, to be honest, it’s a while since I’ve researched this and had these discussions with my children, and I didn’t keep notes of my sources.

     

    I fully take your point: disease is complex. Poverty is certainly a big issue (often resulting in worse health care, lower fruit and vegetable consumption, and sometimes associated with higher cigarette consumption, but that only underlines my point).

     

    However, I think we’re doing our children a real disservice when we teach them that we can go our merry way and pop a pill–or a vaccine–to enable us to live carelessly. Our diet and lifestyle really does affect our future health: those pills and vaccines have consequences and should be used wisely and sparingly. I also think it’s a disservice to our kids when we consider it “judgmental,” religiously motivated, whatever, to say that we need to look at our sexual habits. It reminds me of when a whole generation of women howled because they couldn’t get pregnant in their 40s and were bitter that feminism, in their view, had said they could have it all. I’d count myself as a feminist, but there’s just a certain reality to biology.

  • kristin

    In response to the two posts before mine, there have been several articles about the fact that the kids who could most benefit from Gardasil (those who don’t have access to regular healthcare and often eat a poor diet) aren’t getting it, while those who would least benefit from it are getting it. Another crazy side effect of our health care system.

  • sharonmd

    Thank you for the link.  It brings up a few good questions. 

    Current smokers who had signs of HPV infection at the time of their first Pap smear were more than 14 times more likely to show signs of precancerous lesions than current smokers who weren’t infected.

    And heavy smokers who had high levels of HPV when first tested were 27 times more likely to have precancerous lesions. Among nonsmokers, however, high HPV levels only raised their risk by six times.

    This is actually a very well-done study.  By looking at smokers with HPV and those without HPV we have a good comparison group, and they also looked at higher levels of the virus versus lower and found a correlation (in practice we don’t look at the level of the virus).  We also know that smoking causes some changes in other kinds of cells that make them more susceptible to cancer so there’s biological plausibility.

     

    Because they looked at a relatively small number of women, their confidence intervals are quite wide (these are statistical estimates that take into account random variation, so there is a range within which we think the true answer lies).  For instance, smokers with HPV were anywhere from 5 to 37 times more likely to have pre-cancerous cells.  Regardless, it’s striking no matter what.

     

    Moral of the story?  Quitting smoking (or better, never starting smoking) is far more beneficial than the HPV vaccine.  I completely agree with you Kristen that we spend far too little on preventive measures, such as diet, exercise, and smoking sensation, and tend to over-emphasize medical interventions with far less benefit.  Although Gardasil will probably save us money over the long term, if we invested that money in helping people change their lifestyle we might see much greater benefits.  It’s good to keep that in perspective.

     

     

     

  • kristin

    Glad you thought the study was well done. My kids seem to pay more attention when I put the facts on the table and say, it’s your body, your future, it’s up to you, rather than haranguing them and moralizing.

     

    Incidentally, I’ve only known two women who’ve suffered from pre-cervical cancer. One smokes like a chimney and the other apparently thinks that green M&Ms count as a vegetable. No kidding; even my kids comment about how bad her diet is.

     

    What are your thoughts on Merck’s ongoing results study? I keep wondering if I’m reading it correctly as an overall 17-45 percent reduction in cervical abnormalities doesn’t seem worth the cost and potential side effects of Gardasil. I have asked a couple of scientists I know and they think I’m reading it correctly, but they’re not MDs and may not be getting the full implications.

     

    http://www.merck.com/newsroom/news-release-archive/research-and-development/2009_0508.html

     

    I have to reiterate that I’m not anti-vaccine. But as more and more vaccines and accompanying adjuvants pile up in our kids’ bodies, I’m getting choosier about which ones are worth it.

    Thanks.

  • nina

    This is an excellent discussion.  For my part, I regret vaccinating my daughter with Merck’s HPV Vaccine, Gardasil, as she has developed epilepsy since being vaccinated.  She received two of the three shots and experienced seizures 5 and 20 days after each shot respectively.  To date, she is under the care of a neurologist and takes 2000mlg of anti-seizure medication daily. 

    Most people disregard her situation and claim the vaccine is not the culprit but there are far too many girls just like my daughter who became seriously ill after the vaccinations began.  Sadly, some girls and young women are far more ill and some have died. 

     

    To those considering vaccinating your son or daughter, please look beyond the slick marketing campaigns of both HPV vaccines.  If you can avoid them—they are everywhere.   I would encourage you to find and read the articles and editorial in the 08/19/2009 Issue of JAMA; search the New York Times online (it’s free) as it has many good articles regarding the vaccine. 

    Looking back I can’t believe I ever thought my daughter’s risk for getting cervical cancer was so great, she needed to be vaccinated against it.  Furthermore, Gardasil’s efficacy has yet to be established and no one knows how many booster shots a person will need after the initial 3 shot series.  The post-licensure initiatives are going on as we ‘speak’.  And although this might be the standard protocol for most vaccines and/or drugs, it is very creepy considering how hard this vaccine was marketed.  I would have preferred it be more completely researched before being so strongly recommended.