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HPV Vaccine: The Science Behind The Controversy

Experts disagree about whether girls as young as 11 should get the HPV vaccine. (iStockphoto.com)

The first vaccine against human papillomavirus, or HPV, which causes cervical cancer, came out five years ago. But now it has become a hot political topic, thanks to a Republican presidential debate in which candidate Michele Bachmann inveighed against "innocent little 12-year-old girls" being "forced to have a government injection."

Behind the political fireworks is a quieter backlash against a public health strategy that has won powerful advocates in the medical and public health community.

It appears this vaccine gets people riled up because it involves sex and 11-year-old girls.

The two approved vaccines, Gardasil and Cervarix, are designed to protect against a sexually transmitted virus. That's why Julie Stewart was shocked when the pediatrician said her 11-year-old Sophie should get it.

"My daughter is so not sexually active that it seems very premature to even think about protecting her from cervical cancer," Stewart says.

Ninety-five percent of women who are infected with HPV never, ever get cervical cancer. It seemed very odd to be mandating something for which 95 percent of infections never amount to anything.
Dr. Diane Harper, professor at the University of Missouri-Kansas City School of Medicine

Stewart says she tends to have faith in doctors, so she pondered why she reacted that way.

"I realize it's probably more about my squeamishness with the thought of her becoming sexually active than the vaccination itself," she says. "It's not the science. I think it's my own issues around her developing sexually."

Stewart lives in Washington, D.C., which requires the vaccine for middle-school girls. Virginia is the only other place to mandate it. Both allow opting out with a doctor's note. Dozens of other states are debating whether to mandate the vaccine.

The Case For Fighting Cervical Cancer

Many find the public health case for HPV vaccination compelling. Cervical cancer strikes about 12,000 U.S. women a year and kills around 4,000. Strong backers of the vaccine include the American Academy of Pediatrics, the American Academy of Family Physicians and the Centers for Disease Control and Prevention.

The vaccine requires three shots over six months and costs upwards of $400, which is not always covered by insurers or government agencies.

Milwaukee pediatrician Rodney Willoughby, a designated spokesman for the American Academy of Pediatrics, says there's a very good reason for the big push to get preteen girls vaccinated. The idea is to get it done well before their first sexual encounter.

"This is being timed just before you start to have those discussions about the birds and the bees," Willoughby says.

Studies done before widespread HPV vaccination show that by the time they're 15, nearly 10 percent of American girls are infected with HPV. By age 17, that has doubled to nearly 20 percent.

Some research also indicates that many parents are clueless about when their children start having sex.

"Ideally none of our children is going to be sexually active until they meet Mr. Right or Mr. Wrong, and that's the end of the story," Willoughby says. "But it happens, and sometimes you're not aware of it. And we can't prevent [HPV infection] once that exposure's occurred."

Willoughby says his daughter will get the vaccine next year, when she turns 11.

A Lobbying Effort From Manufacturers

But Dr. Diane Harper, a professor at the University of Missouri-Kansas City School of Medicine, says the vaccine is being way oversold.

That's pretty striking, because Harper worked on studies that got the vaccines approved. And she has accepted grants from the manufacturers, although she says she doesn't any longer.

Harper changed her mind when the vaccine makers started lobbying state legislatures to require schoolkids to get vaccinated.

"Ninety-five percent of women who are infected with HPV never, ever get cervical cancer," she says. "It seemed very odd to be mandating something for which 95 percent of infections never amount to anything."

By Harper's calculations, the tried-and-true method of regular Pap smears is a more effective way to prevent cervical cancer than the vaccines. "Pap smear screening is far and away the biggest thing a woman can do to protect herself, to prevent cervical cancer," she says.

Of course, cervical exams and Pap smears are not universally done, they're invasive, and when the test comes up abnormal, the woman faces further diagnostic tests and possibly a procedure to obliterate precancerous growths.

Apart from the comparative advantages of vaccine versus Pap smears, Harper has another objection to mandating early vaccination at this point. She points out that studies so far show the vaccines protect for four or five years. Scientists hope protection will last for 10 years or more, but it's possible young women may need a booster shot later.

As it stands now, Harper says, vaccinating an 11-year-old girl might not protect her when she needs it most — in her most sexually active years.

A Dangerous Vaccine?

There's another reason parents balk. Some worry that the vaccine could be dangerous.

Two children have died of a rare neurological disorder — an early and accelerated form of ALS, or Lou Gehrig's disease — after getting the vaccine.

Last month, the independent Institute of Medicine found no good evidence that these deaths, or any other serious side effects, were caused by the vaccine.

The CDC has examined 35 deaths that occurred among 35 million young people who received the vaccine. It also concluded there is no evidence of cause and effect.

"We have not identified a significant likelihood of serious adverse events following vaccine," says Dr. Joseph Bocchini, chairman of pediatrics at Louisiana State University in Shreveport, who leads the CDC's working group on HPV vaccines. "This is a very safe vaccine."

But as much as he believes in the vaccine, Bocchini doesn't think the government should require kids to get it yet.

"We want to get some experience with it," he says. "We want to educate physicians and other providers about the benefits of the vaccine. We want to educate the public about the infection and its consequences."

So for now, the CDC's lead adviser thinks the decision should be left to parents.

Some parents, like Willoughby, will go ahead and get it. "If in 20 years time, my daughter, with two children at home, develops cervical cancer, and I didn't give her the vaccine, I'm going to be looking pretty hard in the mirror at myself," he says.

And some parents, like Julie Stewart, will think about it some more.

"Our doctor plans to talk to us about it at my daughter's 12-year wellness visit," Stewart says. "So, you know, maybe we'll do it then."

For her, it's not really a question of whether. It's a question of when.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.

Transcript

DAVID GREENE, host: This is MORNING EDITION from NPR News. Good morning. I'm David Greene.

STEVE INSKEEP, host: And I'm Steve Inskeep. Good morning.

Today in "Your Health," we're going to talk about teens and vaccines. First, we'll talk about a controversial vaccine against HPV, a virus that causes cervical cancer. It's become a hot topic again after it came up in a Republican presidential debate. NPR's Richard Knox looks at what the scientists say.

RICHARD KNOX: This vaccine gets people riled up because it has to do with sex and 11-year-old girls. It protects against a sexually transmitted virus. That's why Julie Stewart was shocked when the pediatrician said her 11-year-old should get it.

JULIE STEWART: My daughter is so not sexually active that it seems very premature to even think about protecting her from cervical cancer.

KNOX: Now, Stewart tends to have faith in doctors. So she thought about why she reacted that way.

STEWART: I realize it's probably more about my squeamishness with the thought of her becoming sexually active than the vaccination itself. It's not the science. I think it's my own issues around, you know, her developing sexually.

KNOX: Stewart lives in Washington, D.C., which requires the vaccine for middle-school girls. Virginia is the only other place to mandate it. Both let you opt out with a doctor's note.

Cervical cancer kills 4,000 women a year. And the American Academy of Pediatrics is backing the vaccine. So is the Academy of Family Practitioners, and the Centers for Disease Control and Prevention. Milwaukee pediatrician Rodney Willoughby says there's a very good reason for this big push.

Dr. RODNEY WILLOUGHBY: This vaccine is aimed at a transmissible disease. It's sexually transmitted. In some sense, it's just the timing. This is being timed just before you start to have those discussions about the birds and the bees.

KNOX: The idea is to vaccinate girls well before their first sexual encounter. Studies show that by the time they're 15, nearly 10 percent of American girls are infected with HPV. Studies also show that many parents are clueless about when their children start having sex.

WILLOUGHBY: Ideally, none of our children is going to be sexually active until they meet Mr. Right or Mr. Wrong and that's the end of the story. But it happens and sometimes, you're not aware of it. And we can't prevent it once that exposure's occurred.

KNOX: Willoughby says his daughter will get the vaccine next year, when she turns 11. But Dr. Diane Harper, of the University of Missouri at Kansas City, says the vaccine is being way over-sold. That's pretty striking because she worked on the original vaccine studies. And she accepted grants from the manufacturers, although not anymore. Harper changed her mind when the manufacturers lobbied to require school kids to get vaccinated.

Dr. DIANE HARPER: Ninety-five percent of women who are infected with HPV never, ever get cervical cancer. And it seemed very odd to be mandating something for which 95 percent of infections never amount to anything.

KNOX: That's not her only objection. Studies so far show the vaccines protect for four or five years. Scientists hope protection will last 10 years or more, but young women may need a booster shot later. Harper says vaccinating an 11-year-old girl might not protect her when she needs it most.

HARPER: It may actually wear off before she's finished her most sexual-active years.

KNOX: And the vaccine can be expensive - three shots costing several hundred dollars, and not all insurers cover it. Another reason parents balk is worry the vaccine could be dangerous. Two children have died of a rare neurological disorder after getting the vaccine. Last month, the independent Institute of Medicine found no good evidence the deaths, or any other serious side effects, were caused by the vaccine.

Dr. JOSEPH BOCCHINI: This is a very safe vaccine.

KNOX: That's Dr. Joseph Bocchini of Louisiana State University, who chairs the CDC's working group on HPV vaccines. But as much as he believes in the vaccine, Bocchini doesn't think the government should require kids to get it yet.

BOCCHINI: We want to get some experience with it. We want to educate physicians and other providers about the benefits of the vaccine. We want to educate the public about the infection and its consequences.

KNOX: So for now, the lead CDC adviser thinks the decision should be left to parents. Some parents, like Dr. Willoughby, will go ahead and get it.

WILLOUGHBY: If in 20 years' time my daughter, with two children at home, develops cervical cancer and I didn't give her the vaccine, I'm going to be looking pretty hard in the mirror at myself.

KNOX: And some parents, like Julie Stewart, will think about it some more.

STEWART: Our doctor plans to talk to us about it at my daughter's 12-year wellness visit. So, you know, maybe we'll do it then.

KNOX: For her, it's not really a question of whether. It's a question of when.

Richard Knox, NPR News. Transcript provided by NPR, Copyright NPR.

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