The Magazine

A Merck-y Business

The case against mandatory HPV vaccinations.

Mar 12, 2007, Vol. 12, No. 25 • By MICHAEL FUMENTO
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Legislators in some 20 states are considering making mandatory Merck & Co.'s Gardasil vaccination for the human papillomavirus. In Texas, Republican governor Rick Perry bypassed the legislature and ordered it on his own. The requirement there applies to 11- and 12-year-old girls entering 6th grade.

The benefits seem clear. FDA-approved for females age 9 to 26, the vaccine has been shown to be 100 percent effective at preventing disease from the two HPV strains that account for 70 percent of all cervical cancers. Government estimates are that there will be 11,150 cases and 3,670 deaths from cervical cancer in 2007. So what's not to like?

Plenty.

One argument is that a mandate removes parental authority. Which it does, but so do all mandatory vaccinations. The difference here is that while Perry claims the HPV vaccine is no different from the polio vaccine, polio is transmitted through the breath, while HPV is transmitted by sexual intercourse.

As Robert Zavoski, physician and president of the Connecticut chapter of the American Academy of Pediatrics, explained to the Hartford Courant, "Vaccines previously mandated for universal use are those which protect the public's health against agents easily communicated, responsible for epidemics, or causing significant morbidity or mortality among those passively exposed to the illness." He added, "HPV is not an agent of this sort."

The other argument, which many Christian groups have made in addition to the one about parental authority, is that a mandatory vaccination will encourage promiscuity. This idea has been mocked. District of Columbia councilman David Catania, sponsor of a mandatory HPV vaccine bill, for example, insists, "This vaccine no more encourages sexual activity than a tetanus shot encourages you to step on a rusty nail."

But again, the analogy is faulty. There is no biological urge to step on rusty nails. There is, however, a powerful urge to have sexual intercourse that begins at puberty. It's an urge that nations and religions throughout history have sought to control in various ways because sexual intercourse, while pleasurable to the participants at the time, can have consequences that are deleterious to the individuals later as well as to society as a whole.

When you insist that 11-year-old girls receive shots to protect them from dangers attending sexual intercourse, you are sending them a message. In fact, you're even sending their male peers a message. And it is one that conflicts with the message that sexual activity is best left to people who are more mature.

Still, what about those preventable infections and cancers? HPV infection is usually fairly benign; in fact, a study just released by the CDC says about 27 percent of U.S. females aged 14 to 59 years have it. Importantly, only 2.2 percent of those women are carrying one of the two virus strains most likely to lead to cervical cancer. Usually infection is asymptomatic; but in a minority of cases it leads to tiny cauliflower-like bumps on the genitalia (or anus) that will disappear on their own or be zapped off by a doctor. And in a much smaller minority of cases, infection leads to cell irregularities that become cervical cancer.

The 3,670 deaths from cervical cancer expected this year are a tiny fraction of the 270,100 projected female deaths from all cancers. Further, both the incidence and the death rate for cervical cancer are dropping. The incidence was 14.8 per 100,000 women in 1973 according to federal data, but down to 7.1 per 100,000 by 2003. Meanwhile, the incidence of cancer generally increased. "Cervical cancer was the only cancer among the top 15 cancers that decreased in women of all races and ethnicities," according to the American Cancer Society. Cervical cancer death rates declined steadily from 5.6 per 100,000 in 1975 to 2.5 in 2003.

The main reason for the declines in both incidence and death is the Pap test or Pap smear. Public health campaigns and individual physicians have sought to convince women to get these tests, in which tiny samples are scraped from the opening of the cervix. Moreover, computer imaging has improved the reading of these smears, leading to fewer false results. Early treatment has also improved, with the use of a laser to vaporize cells showing abnormal growth.

Pap smears are not 100 percent effective at finding cells before they become cancerous, but they have the added benefit of detecting pre-cancerous cells with causes other than HPV. These include other sexually transmitted diseases. Remember, too, that Gardasil prevents only 70 percent of HPV infections that lead to cervical cancer. Thus, even women who have been vaccinated must still be encouraged to get Pap smears every three years.