posted on Introibo ad altare Dei 5 December 2006
Human papilloma virus, or HPV, is a virus which causes cancer of the cervix in women. The only way HPV is transmitted is by sexual intercourse, one doesn't get it from a toilet seat or by shaking hands. Since virtually all cervical cancers are related to HPV infection, it is correct to say that cervical cancer is a sexually transmitted disease. Interestingly, those of us who used to put it in those terms were pooh-pooh'd not infrequently. Now, however, with the advent of Merk's Gardasil HPV vaccine, everybody is talking about HPV, cervical cancer, and the vaccine. Let's flesh in some details.
There are over a hundred subtypes of HPV, and over thirty of these are associated with cervical diseases including genital warts ("condylomata") in both ladies and gentlemen, cervical dysplasia (pre-cancerous cervical changes) and frank, invasive cancer. The viruses don’t cause cancer directly, they cause dysplasia. The dysplasia may, in turn, progress to cervical cancer if left untreated. The dysplasia is detected by the Pap smear and its more modern derivatives. If the Pap smear detects dysplasia, especially of the high grade variety, a biopsy of the cervix is recommended. If the biopsy confirms the high grade dysplasia, a LEEP (loop electrosurgical excision procedure) is usually performed, where a thin strip of the cervix containing the abnormal tissue is removed. This is frequently, but not always, curative. Here are some important points: first, dysplasia is not invasive cancer. It is a precursor to cancer. Secondly, a lot of dysplasia spontaneously regresses without further treatment. Thirdly, some cervical dysplasia, if untreated, progresses. Progresses to what? Invasive cervical cancer. But the important thing is this: the progression is slow, orderly, and well understood. That's why the Pap smear works so well as a screening tool for cervical cancer: it detects the precursor lesions before they become cancer. HPV infection is the most common sexually transmitted disease in the world, and prior to the widespread use of the Pap smear in the 1950's, cervical cancer was the most common cancer killer of women worldwide. It still is in parts of the world where Pap screening is not done. In the U.S., cervical dysplasia is very common. LEEP’s for high grade cervical dysplasia are very common (this procedure is done several times per day in my hospital). Cervical cancer, however, is relatively uncommon, due to the Pap smear (5000-7000 cases in the U.S. annually). Wouldn’t it be nice if there were a vaccine that would prevent all this?
Enter Merck and Gardasil. Approved for use by the FDA in June, 2006, it protects against the four most common types of high risk HPV, which account for 70% of cervical cancers, and 90% of genital warts. It’s a three shot series given at 0, 2 and six months, and need for a booster is unknown at this time. A second vaccine is under development by GlaxoSmithKline. On June 29, 2006, the Advisory Council on Vaccine Practices (ACIP - the group which formulates vaccine recommendations for the CDC) voted to “recommend” universal vaccination with the HPV vaccine for all girls age 11-12, but beginning as early as age 9. ACIP recommendations, once accepted by the CDC, take the de facto force of law, as local school boards and others turn the recommendations into requirements. The ACIP recommendations that all adult nonpregnant women (>19 years old) be vaccinated were published in the CDC’s publication, Mortality and Morbidity Weekly Reports (MMWR) on 13 October 2006. The recommendations for the universal childhood vaccinations are scheduled to be published in November, but are unavailable as of this writing. Not too surprisingly, the medical machine, as represented by the New England Journal of Medicine, is all for this, and well funded pro-teenage contraception organs like Advocates for Youth are simply livid that those religious conservatives might not think universal HPV vaccination for children is such a swell idea.
Why isn’t it a swell idea? First. The vaccine does not remove the need for Pap smears nor will it do anything for a lady already infected. Second, it doesn’t do anything about other sexually transmitted diseases, although it’s easy to imagine a 12 year old (remember, that’s the target audience) who thinks it does. For that matter, I can easily imagine a 20 year old who might think it does, but that’s neither here nor there. Thirdly, there are concerns that the FDA has "fast-tracked" licensure of Gardasil, without adequate study of its safety in little girls. Fourth, and most importantly, no one knows what effect universal vaccination of 9 year olds might have on adolescent tendency to have sex. However, the data of the past forty years of social experimentation suggest that it would tend to increase sexual activity. That’s been the outcome of all the other experiments on early immersion of young children into the fetid world of “sex ed” and teenage contraception, and there’s no reason this should have a different effect. Regarding the morality of the vaccine itself, its manufacture does not involve aborted babies. So the moral problems attached to, say varicella or rubella vaccines do not apply here.
HPV is a sexually transmitted disease. You don’t get it if the person next to you coughs, and you don’t get it from a water fountain or a toilet seat. Requiring HPV immunizations for young girls (and that is what ACIP “recommendations” amount to: requirements) is, in my view, no different from requiring that all school age girls be put on contraception. The decision to vaccinate one's little girl with Gardasil should reside strictly within the family. Legislating its use is inappropriately paternalistic. The National Catholic Bioethics Center has summarized it appropriately:
“The NCBC considers HPV vaccination to be a morally acceptable method of protecting against this disease, but asks that civil authorities leave this decision to parents and not make such immunization mandatory.”
 “HPV and HPV Vaccine: Information for Healthcare Providers” Centers for Disease Control, August, 2006. www.cdc.gov/std/healthcomm/fact_sheets.html
 “ACIP Provisional Recommendations for the Use of Quadrivalent HPV Vaccine”. available at www.cdc.gov
 Steinbrook, R. “The Potential of Human Papillomavirus Vaccines.” NEJM 354(11):1109-1112; 16 March 2006.
 “Will the Politics of Teen Sex Stop a Cancer Vaccine?” Advocates for Youth Media Brief, www.advocatesforyouth.org
 "Merck's Gardasil vaccine not proven safe for little girls." National Vaccine Information Center, Press Release, 27 June 2006. www.909shot.com/PressReleases/pr62706gardasil.htm
 Gardasil package insert, Merck & Co., 2006. Available at Institue for Vaccine Safety, www.vaccinesafety.edu/package_inserts.htm
 NCBC Statement on Vaccination against Human Papilloma Virus (HPV). National Catholic Bioethics Center, 11 July 2006. www.ncbcenter.org/06-07-11-hpv_vaccine.asp