Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Monday, April 21, 2008

Promotion of the HPV vaccine as offering total protection from cervical cancer gives a false sense of security- Vanita Tongbram

Human Papilloma Virus, HPV is the most common sexually transmitted infection in the United States of America. 20 million people in the country are estimated to have it according to the National Institute of Allergy and Infectious diseases. The majority of HPV infections are asymptomatic, unrecognized, or sub clinical. Genital HPV infection is common and usually self-limited. Genital HPV infection occurs more frequently than visible genital warts among both men and women and cervical cell changes among women.(5)

Genital HPV infection can cause genital warts, usually associated with HPV types 6 or 11. Other HPV types that infect the anogenital region (e.g., high-risk HPV types 16, 18, 31, 33, and 35) are strongly associated with cervical neoplasia. Persistent infection with high-risk types of HPV is the most important risk factor for cervical neoplasia. (5)

The Pap test is the best way to screen for cervical cancer. Getting regular Pap tests can save a woman’s life. Even women who got the HPV vaccine when they were younger need regular Pap tests, since the vaccine does not protect against all cervical cancers. More than half of the women in the United States who develop cervical cancer have never or rarely been screened with a Pap test.(6)

Another breakthrough effort for the prevention of HPV infection and cervical cancer has been the approval of Merck’s HPV vaccine, Gardasil by FDA for girls of the age group nine to twenty six. The trials showed the vaccine -- given in three injections over six months is 100% effective in preventing HPV strains16 and 18 and 99% effective in preventing infection by strains 6 and 11. Together these strains cause about 90% of genital warts. Gardasil also protects against vaginal and vulvar cancers, two other gynecological cancers that are also linked to HPV, according to a study presented in Atlanta at a meeting of the American Society of Clinical Oncology. An FDA advisory panel in May voted that the vaccine is safe and effective for girls and women ages 9-26. Consequently, CDC Advisory Committee on Immunization Practices now recommends giving the vaccine to girls ages 11 and 12. Gardasil in studies has been shown to be effective for 3 ½ years. It is unclear if people will need a "booster" immunization shots. The full vaccination course will cost $360.(3)

Public Health’s lack of attempts to counter Merck’s marketing of the HPV vaccine as an anti-cancer vaccine delivers the wrong message to young girls that once vaccinated they are safe from cervical cancer
Although HPV is associated with increased risk for cervical cancer, this vaccine does not provide full protection against it. Regular Pap smear screening is required to detect cervical cancer even after vaccinated. Public Heath professionals have failed to put a better message out there for these young girls. Public Heath workers should realize the hazards of such a misleading Health Campaign in popular media. Public Health should be working to correct Merck’s misleading messages by emphasizing that the vaccine can protect against two strains out of a 100 associated with cervical cancer . “Anti Cancer vaccine” may create a stir in the population and have a mass appeal, but the over-reliance on a vaccine and ignoring the importance of routine Pap smears is detrimental to world-wide efforts to prevent HPV and eventually eliminate cervical cancer.

An example of Merck’s irresponsible marketing of Gardisil is the media campaign “One Less”.(2) The campaign uses the following messages “You could become one less life affected by cervical cancer.”, “Your daughter can become one less life affected by cervical cancer.” And “Gardasil-the only cervical cancer vaccine”. This campaign focuses on getting this strong message across that the vaccine is an anti cancer vaccine. Although the one less campaign does gives the message that it is not enough to just vaccinate but also to continue cervical cancer screening, it focuses mainly on young girls screaming “I wanna be one less” but fails to emphasize that the vaccine does not offer full protection against all HPV strain and cervical cancer. At the end of the commercial you are left saying to yourself “ Yes I wanna be one less so I should get vaccinated immediately.” But not “Yes I wanna be one less person so I should get this vaccine and yes, I shouldn’t forget to get screened too.” Yet again these advertisements are reaching these young girls, who probably are hearing about cervical cancer for the first time from such advertisements. Public Health Professionals need to do a better job of reaching the young generations with more comprehensive campaigns to counter the misleading messages sent out by Merck.

CDC’s recommendation to vaccinate a certain age group of girls fails to convince the parents to vaccinate their girls against an STD
In some states there have been talks of making the vaccine mandatory. Using this power coercive approach to get parents to vaccinate their young girls fails to convince many parents(4) HPV infections because of its associated behavioral risk factors (sexual), is a very sensitive topic for many. Recommending the Vaccine be administered to girls in the age groups of 11 and 12 means that the CDC is assuming that these girls will be entering a sexually active phase after this age range. They did not take into account how this will affect the sentiments of many parents. When does a child become sexually active has a lot to do with the upbringing of the child, her cultural background, religious beliefs. Many would be offended if we were to suggest that their daughter will become sexually active at a certain age as those are matters that the parents know best. There is also the fear among parents that vaccinating their young kids will encourage them to enter sexual phase earlier
(7). CDC had not taken into consideration this important aspect of this vaccine, completely ignoring the associated stigma of such an infection. Public Health should use a normative educative approach to first get parents convinced and educated of this vaccine and change the social norms surrounding such a Sexually Transmitted Disease vaccine.
The chance of getting it increases with the sexual behavior listed below:(1)
• having sex at an early age
• having many sexual partners
• having a partner who has had many sex partners
• having sex with uncircumcised males
Most families will not be raising their kids to practice any of the sexual behaviors listed. So, when a recommendation from CDC who absolutely has no clue of the ways of how a mother has raised her child comes and tell her that her 9 year old needs to be protected from a sexually transmitted disease by getting her vaccinated, chances are she will be outraged at the implications being made. The basic human reaction to intrusion of such personal space was not taken into consideration when CDC recommended that young girls of 11 and 12 should be vaccinated. The emotional side of such a sensitive issue is ignored completely by Public Health professionals promoting the vaccine.

Many states are considering making this vaccine mandatory. But will making it mandatory get more parents to vaccinate their kids. In fact, such an extreme step with a vaccine which is associated with certain sexual behavior may back fire and result in many parents reacting to it adversely.

The promotion of the vaccine among adolescent girls ignores other high risk groups
This campaign focuses on vaccinating young girls before they become sexually active. However, studies show that racial/ethnic minorities are at increased risk of getting cervical cancer due to low rates of Pap smear tests.(6) Hispanic and African American women are at increased risk for cervical cancer. African-American women develop this cancer about 50% more often than non-Hispanic white women. Also, a low socioeconomic background serves as a risk factor because of the lack of money for screening tests. The cost of the vaccine is $360 for the entire course. Haitian-American women are three times more likely than other women to develop cervical cancer, according to the Florida Cancer Data System.(3) Haitian-American women often receive health services from nontraditional healers and have other obstacles to health services, including cultural and language barriers, a lack of health insurance and a lack of access to transportation.

Cervical cancer runs in the family. Someone who has a sister or mother who had cervical cancer, the chances of her getting the cancer is increased 2 to 3 times(1). Therefore, public health should not only be focusing on vaccinating girls before they initiate sex but also racial/ethnic minority women who are sexually active and who could still benefit from the vaccine. The vaccine is for girls and women ages 9 to 26. It works when given before girls have any contact with HPV Types 6, 11, 16, and 18. Although the vaccine is most effective in the girls who have not had any sexual contacts, there is proof that it may still be protective in some of the women who have had sexual contacts. Because it is possible that she hasn’t been exposed to some of the HPV strains that cause cancer. We need to emphasize more on getting the right population vaccinated. The cultural, language, psychosocial barriers that exist in the high risk groups need immediate attention. Money should be allocated to these minority groups. A mother from a low socio economic background may be aware of the vaccine but because of the financial restraints may not be able to vaccinate her child. The ultimate goal being reducing cervical cancer incidence, we should resolve to other methods of creating awareness of other means to prevent cancer which are cheaper.

Public Health has failed to address the over hyped Anti Cancer vaccine campaigns which may ultimately put a whole generation of young girls at risk of cervical cancer due to a false sense of safety. Although this popular campaign would motivate a large population of people but without the right and complete information would lead to adverse outcomes. HPV infection comes with a social stigma of reckless sexual behaviors. We have not yet developed the right approach to deal with the complex moral and cultural issues associated with recommending this vaccine to the targeted age groups. And while focusing only on the younger girls, we have completely ignored the high risk population in the society. Public Health professionals should give equal time and money to study the difference of incidence of cervical cancer across different cultures.


1. .
5. .
7. Improving adolescent health:focus on HPV vaccine acceptance.Volume 37, Issue 6 Pages S17-S23.
8. New England Journal of Medicine. Source reference:
The FUTURE II Study Group. "Quadrivalent Vaccine against Human Papillomavirus to Prevent High-Grade Cervical Lesions."

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