February 19, 2007
The HPV Vaccine Backlash
A national backlash is brewing against Merck's campaign to make the cervical cancer vaccine mandatory for teenage girls. I'm not surprised. I have a 13-year old daughter. After she watched one of Merck's ubiquitous commercials on television, she asked me when she was going to get hers. I replied that it really wasn't necessary until she became sexually active with someone who had already had at least one sexual partner, to which she said "yuck" and decided she could wait.
A lot of basic information has been overlooked by public health officials pushing this national vaccination campaign on behalf of Merck. First, cervical cancer has been sharply reduced in the U.S. We're down to under 12,000 cases a year, with fewer than a quarter of them fatal. Even those could be wiped out if the health care system targeted regular pap smears (the long-standing test for the disease) at the women who are most at risk: women who've had multiple sexual partners, especially if they were uncircumcised males; women who have co-infections like veneral diseases, HIV or hepatitis; smokers; and women of lower socio-economic status.
By insisting that all young women get this vaccine, public health officials (the Centers for Disease Control last June endorsed universal vaccination, although its recommendations are not binding on the states, which carry out public health policy in the U.S.) are in essence saying it is impossible for the health care system to identify and treat older women who have already become infected and are at risk of getting cervical cancer.
You know who really needs this vaccine? Poor women in the developing world. There are nearly a half million deaths a year from cervical cancer around the world. But the women in Africa or south Asia who might suffer that fate don't have the $400 for the three-shot course. Although no one will say so, I suspect Merck will make this vaccine available at low cost in the developing world once they've got a routine market in the U.S. (About a million girls turn 11 every year; at $400 a tri-pop, that's about a $440 million-a-year market.)
Since we don't yet know the long term risks, if any, from this vaccine, from a medical point of view it makes the most sense to give it to young women who are most at risk from the disease, for whom the reward-risk ratio is highest. That's not upper-middle class kids in the U.S., whose parents' health insurance will pay for the vaccine. A better strategy would be to have the U.S. and donor countries buy Merck's vaccine for the developing world in sufficient quantities to make a major dent on the disease, which will simultaneously guarantee Merck a fair return on its investment.
There another downside to this misguided lobbying campaign by Merck and its allies in the public health establishment. The backlash will further undermine the public's willingness to go along with vaccination campaigns when they really become necessary. It's the old story of the little boy who cried wolf.
My daughter can't catch the human papillomavirus while sitting next to someone on a bus or train who has the infection. But she can catch the flu that way. What will happen if bird flu becomes transmissible between humans? Will people respond to public health pleas that everyone get the vaccine?
Posted by gooznews at February 19, 2007 09:11 AM I couldn't agree more.
This is not a story about Merck savings tens of thousands of women's lives in the U.S. This is a story about Merck needing a block-buster drug to make up for the loss of Vioxx.
Rather than spending billions to vaccine pre-teens, we might better put a part of that money into a camnpaign to make sure that teen-agers get in the habit of having regular Pap Smears. Thanks to Pap smears, cervical cancer will account for less than 1 percent of cancer deaths in the U.S. this year. And almost all of the women who die could have been saved if they had Pap smears.
Finally, although most media reports describe Merck's product as a vaccine that immunizes against "most" of the viruses that cause cervical cancer, the fact is that it protects against just 70% of the viruses associated with cervical cancer. . Okay,70% is more than 50%--so technically, that's most. But even Merck acknowledges that girls who are vaccinated will still need regular Pap smears.
But will go for Pap smears? Bloomberg News recently reported that some health experts in the U.K. have expressed concern that once girls are vaccinated, they will feel that they are "safe" and thus maybe less likely to go for Pap smears. . . A week or so ago, I saw a young girl in Texas tell NBC News how happy she was that she had been vaccinated. "Now this is one cancer I don't have to worry about fighting." No one corrected her.
great post- Merrill
Be Well
Dr. Rick Lippin
Posted by: Dr. Rick Lippin at February 19, 2007 05:05 PMI couldn't have said it better myself. Thank you for so accurately framing what appears to be yet another issue that will be fought with the paintbrushes of black and white, with neither side admitting that there is an entire palette filled with shades of gray that would so much better illustrate the matter.
Posted by: Melody at February 19, 2007 05:08 PMSending this vaccine to the developing world would prevent a lot of deaths.
It has the potential to save a lot of morbidity here in the U.S. Cervical cancer is not prevented by PAP smears. If an abnormality is found, women have to go through procedures (surgical excisions) that cost a lot of time, discomfort, and money. The vaccine could prevent a lot of women from having to go through this.
We can't target this vaccine to "high risk" women. By the time they are "high risk" it is too late, they might already have the virus. It's also a lot easier to vaccinate children who you know will go to the doctor, and not older teenagers. Second, this virus really has nothing to do with sexual promiscuity. It is VERY common and you can get it from just touching.
This vaccine has the potential to reduce a lot of morbidity and mortality, here and abroad, just like most other vaccines.
We need to promote PAP smears, but we also need to use this vaccine.
Bravo Gooz!!!!
Posted by: Les at February 19, 2007 07:13 PMBravo!! My sentiments exactly!
Posted by: Delin at February 19, 2007 08:43 PMI just brought my 17-year-old daughter to get her first HPV vaccination yesterday. She is not sexually active and doesn't intend to be in the near future. Although I do not have insurance coverage for either the doctor's visit or the vaccine, giving the "rent check to the Merck cats" was money well spent in my estimation.
The name of the game here is prevention. There is no guarantee that this vaccine will have any beneficial effect once exposure to the virus has occurred. Unfortunately, having sex is not always a lifestyle choice for women - even in developed countries.
As for pap smears, they are quite unpleasant, may pose a risk of other infection, especially in the third world, and are not always accurately read even in the West.
While I agree with you that this vaccine should not be mandatory in the US, and that its use in third-world countries would be money well spent, I think it is dangerous to use statistics to identify "high risk" individuals. Rather than to roll the dice, it is better to be out of the game to the greatest extent possible. This means getting the vaccine at a younger age rather than an older one. Since the vaccine must be given over a 6-month period, it's important that some parental control be exerted to improve compliance with the regimen.
I believe this vaccine represents one of the more valuable public health advancements to come down the pike in a while. Merck may have taken a calculated risk in advocating for mandatory vaccination knowing the polarized political climate in the US at present. Anyway, even if they've gotten the meme out there in a sneaky way, I support it.
Posted by: Kirsten at February 21, 2007 10:25 AM