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Why I support the HPV vaccine

I just got off the phone with an old friend, a dad of two teenager daugthers. One of his daugthers this year is set to receive the mass immunization taking place in Grade 9 girls in BC. The mom, a close friend, signed the permission form, but the dad was hesitant.

"Call Anne", the mom said, "She will convince you."

He called me up tonight, all worry and concern about unnecessary vaccinations and immune modulations, risks and benefits. And this is what I told him in a 30 minute conversation:

Back in 2002 I was ghost writing a massive provincial health document - The Health and Wellbeing of People in British Columbia -- for Provincial Health Officer Dr. Perry Kendall, a doctor and epidemiologist whom I know very well.  Perry is the best of public health officials, firmly committed to the principles of pubic health, constantly weighing the pros and cons of intervention versus the cost of doing nothing, assessing the evidence and formulating a reasoned, safe, proactive response to keep BC on the cutting edge of health protection.

 We were finishing this 245 page tome about how to improve the health of British Columbians when a study in the New England Journal of Medicine reported amazing findings of a new vaccine. It was one of those situations were researchers prematurely broke the anonymous code in a double blind study because one arm had such unamimous results that it was unethical to continue. The results were this: 0f 768 women who received the HPV vaccine, none developed any cervical changes nor even had any HPV-16 residing in their genital tract where it could infect new sexual partners. Not one! ( Koutsky et al, 2002; Crum, 2002) The placebo group had 16 infections, three of which had already developed cervical lesions. The trial had run 17 months.

We knew the results were highly preliminary. We knew there were almost 70 different strains of HPV and this vaccine only protected for the two most virulent strains, HPV-16 and HPV-18. But those two strains alone were responsible for more than 50 per cent of all cervical cancer. This was an amazing result - 100 per cent effectiveness in the vaccine group.  It is estimated that 50 per cent of all seuxally active men and women will have an HPV infection at some point in their sexual lives and while 90 per cent clear, it is now known that HPV is not only behind all cervical cancer, it is also a cause of anal, rectal, oral, penile, vulvular and vaginal cancer.

BC had an important history in the cervical cancer story. In the 1950s this province was the first in the world to institute the PAP screen and make it a part of necessary pro-active health care for all sexually active women. Over the last 4 decades, because of PAP screening, cervical cancer has fallen by 85 per cent. Cervical cancer used to be much more common than breast cancer and was a horrible cancer to get. Its dramatic reduction was a true success story.

But here is what frustrates public health and cancer officials: while 50 per cent of women who get cervical cancer have not had a PAP test in the previous 7 years, the other 50 per cent have had regular tests like clock work. They have been coming, year after year, for their PAP test, and they still get it. That 50 per cent has stuck in the craw of cancer prevention officials for years. ( They always focus on the 50 per cent who don't have the tests. "If only we could increase the participation of Aboriginal and immigrant women in the provincial screening program," they say, not mentioning the diligent compliant gals who put their feet in the stirrups year after year to no avail.)

Some HPV viruses are so virulent the can take hold and destroy in less than a year. Researchers do know that the younger the age at first intercourse the faster the advance to cervical cancer. In Canada about 1400 cases of cervical cancer are diagnosed each year and 400 women die from it.  What is not stated is how many thousands of women get the call that unusual cells were found on the PAP test and they need to come back, or they need a cone biopsy, or an cryro-ablation for pre-cancerous cells. The impact of HPV is much, much greater than that 1,400 number of cervical cancer cases. I bet that the majority of sexually active woman in Canada will have in her life time at least one of her PAPs come back with unusual cells, prompting worry and follow up tests, even invasive therapy.

Was this new vaccine a potential cure? Perry and I carefully selected our words for the report and I inserted a special text box in the 11th hour: "Although results are very preliminary and the length of protection is not known, research on expanding the vaccine to protect against more strains of HPV continues. While experts predict PAP smears will still be needed to screen women in conjunction with the vaccine, over the next decade we may see widespread adoption of the HPV vaccine to help further reduce the toll of cervical cancer."

Those words stand up remarkably well 7 years later. I have followed the debate about HPV ever since. I've seen all the various research studies, read all the articles of pros and cons.

Of course, there are some who are against all vaccinations in general.  That is their choice to make - but only because the vast majority chooses vaccination. By doing so, by us absorbing the risk, the  nay-sayer's children are kept safe - lucky for them. We give them herd immunity. They don't have their children die in their arms, like my grandmother did. My paternal grandmother at the beginning of the 20th century lost five of her 11 children to vaccine-preventable illnesses - whooping cough, diptheria, meningitis. In my family, vaccines are seen as one of the greatest advances of medical science. To reject vaccination for the serious childhood illnesses, in the eyes of my father, who became a doctor, is an abroggation of your societal duty. 

All vaccines, of course, must be weighed for their pros and cons, their risks and benefits. For me the pros of the HPV vaccine vastly outweigh the cons. I had a girlfriend die of cervical cancer in her 30s. I had a Pap test come back with concerning cells.  My girls are too old for the first mass innoculation. I had them vaccinated at my own expense ( $400!! each.) I felt it was a must and they both wanted it.

Some parents recoil that the vaccine is to be given in Grade 9. "They are still such little girls. Couldn't they give it when they are more obviously sexually mature?"

But here is the problem: we know that in grade 9 more than 90 per cent of the girls are still virgins; by Grade 12, some 50 per cent, or more, are not. How can we determine the right age for each girl? A vaccine program must get them well before they need it.

Here are the things we do know:

  • Women will still need regular pap tests.  It is just one more arrow in the quiver. They will have to have their partners still wear condoms. It does not allow complacency.
  • The protection may wear off in the girl's 20s. To me that is understandable -- it gives them protection in the early years when they are most likley to be exposed for the first time. By the 20s it is likely most girls are in more stable relationships. Koutsky et al has now followed more than 200 of the original women who got the shot in 1998 and 1999 in Seattle -- the vast majority still remain negative for HPV. The protection is lasting for most women at least 8 to 9 years or more.
  • Research has shown the teenage cervix is more susceptible to infection and HPV infections in those years can be particularly virulent and advance more rapidly to cancer. The need for innoculation is in the teen years.
  • With mass innoculations, bad side effects will arise. It is sheer statistics. The media will focus on this: " High school girl has fatal reaction!" if and when it occurs. Rare reactions don't happen among just 768 women. But as thousands and then hundreds of thousands and then millions get innoculated it is inevitable that some rare reaction will occur. So far the efficacy and safety of the vaccine has been remarkably good, with very few side effects. But it is certain that a 1 in 100,000 or a 1 in a million occurence of anaphylaxis will happen. That risk ratio exists in all medical care.  I accept and live with that risk. Alas many people don't understand it. 1 in 100,000 is a reasonable risk. But if you are that unlucky 1, I am truly sorry.
  • The viral connection to cancer, that has been revealed by HPV will lead to huge gains in cancer understanding in the coming decade. This HPV vaccine is the cusp of very exciting medicine. We may finally  understand the origin of some of the common cancers in our life because of what HPV teaches us.

I believe that all young boys should also get the HPV vaccine -- that way the transmission of this nasty virus would truly stop. But the expense of the vaccine program is such they will only target the girls. That's because it is girls and women who bear the brunt of its impact.

And that's the way it has always been, whether fair or not. Contraception has significant risks - women bear the brunt of it. Pregnancy has even more risks -- all on women's shoulders.

HPV vaccine has risks. But the risks are far greater without it.  I accept those risks for my charges. And we have to ask, what would our daughters want as sexually active adult women? My daughters would want this vaccine. And I want it for them.


Posted on Thursday, October 8, 2009 at 01:01AM by Registered CommenterAnne | Comments1 Comment

Reader Comments (1)

no matter how awful gonna be the news I will not never make a vaccine
I saw clearly that swine flu was a big deal...
June 29, 2010 | Unregistered Commentergerovital h3

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