The HPV Vaccine: A No-Brainer?

Last year the U.S. Food and Drug Administration approved Gardasil for the prevention of cervical cancer caused by certain strains of the human papillomavirus (HPV). The vaccine has been hailed as a major public health breakthrough, prompting a number of states — including Massachusetts — to introduce legislation that would make it available for girls 9 to 12 years old. However, opponents of the legislation fear that it will encourage risky sexual behavior among adolescents.

The BU School of Public Health’s annual two-day William J. Bicknell Lectureship in Public Health, being held this year on September 27 and 28, will look beyond the initial hype over Gardasil and ask the question: The HPV Vaccine: Is It Really a Public Health No-Brainer? Susan Weller, a professor of sociomedical sciences and director of research at the department of family medicine at the University of Texas Medical Branch, Galveston, is the 2007 lecturer. The event is free and open to the public.

The William J. Bicknell Lectureship in Public Health, named in honor of William J. Bicknell, chair emeritus and professor of international health at SPH and professor of sociomedical sciences and community medicine at the School of Medicine, was established in 1999 to showcase new ideas and approaches to pressing public health concerns, with presentations by leading scholars and practitioners and a panel discussion to consider questions specific to public health policy and practice.

Deborah Maine, an SPH professor of international health, who teaches reproductive health, will serve as moderator for Friday’s panel discussion. She spoke with BU Today about the HPV virus, the new vaccine, and some of the many issues that need to be considered about administering Gardasil on a large scale.

BU Today: What is HPV, and what risks does it pose?
Maine: HPV is a collection of different subtypes of virus, of which there are about 100, and 30 or 40 of these cause disease in humans. HPV types 16 and 18 are associated with about 70 percent of cervical cancers worldwide; HPV 6 and 11 cause genital warts.

Is it a common virus?
HPV is the most widely sexually transmitted infection in the United States, affecting both men and women, but more women suffer serious health consequences from contracting high-risk types of the virus. There is some controversy about estimates of prevalence in the United States, which Susan Weller will address in her lecture, but the Centers for Disease Control has estimated that 20 million people are currently infected in this country. It most commonly affects people in their late teens and 20s, and by the time women are 50, it is estimated that 80 percent contract at least one strain of HPV.

How many women get cervical cancer?
In the United States, about 10,000 cases of cervical cancer will be diagnosed this year, and about 3,600 women will die from it. Worldwide, especially in resource-poor countries where screening is not done, cervical cancer kills nearly a quarter of a million women every year. It is the leading cause of life-years lost due to a cancer in the world, because it strikes relatively young women.

Does the new HPV vaccine mean we can now prevent cervical cancer?
The idea of preventing cancer instead of treating it is very appealing and is potentially cost-effective. It’s certainly a wonderful tool in the public health toolbox. But there is a danger in people and policymakers thinking the vaccine solves the problem of cervical cancer. It does not. This vaccine will not be effective in preventing about 30 percent of cervical cancers, so women will still need to get Pap smears. And while the vaccine will reduce cancer among today’s girls, and young women 20 to 30 years from now, two generations of women who are already sexually active will not be helped by this. The vaccine will also prevent genital warts and other kinds of cancer caused by HPV — such as anal cancer, which is less common, but not insignificant — and esophageal cancer. The cost of the vaccine — $350 for three shots, plus doctor’s visits — is a prohibitive factor for many people.

Even so, doesn’t it make sense to try to immunize eligible girls and young women?
Well, the response depends upon who is answering the question. The CDC recommends girls and young women be immunized. And many parents will understandably be eager to immunize their girls to protect them from a disease they could get later in life. But the public health community looks at health from a population perspective. If our goal really is to reduce deaths from cervical cancer, then we must do a better job of making sure poor women get Pap smears. This is a disease of poor women and minorities. The Department of Health and Human Services has a map of cervical cancer that shows the U.S. counties in which cervical cancer is most common: along the Mexican border, in Appalachia, among Native American populations, and in certain rural areas, including in the Northeast. If you detect and treat precancerous lesions, cancer survival is close to 100 percent; with treatment after early detection, there is still a five-year survival rate as high as 92 percent. Yet in the United States, half of the women who are diagnosed with cervical cancer have never had a Pap smear. We could reduce deaths in these communities in the next few years.

Some people have expressed reservations about giving a vaccine that prevents a sexually transmitted infection to young girls. Can you comment?
Many people just don’t want to think of their nine-year-old daughter as a soon-to-be-sexual person. That accounts for some of the objections. But other people have suggested that having the vaccine will lead girls to have sex at a younger age. These kinds of fears are not well-supported by the literature. For example, similar claims about contraception and sex education have been shown not to be true.

Will the vaccine be helpful in the developing world?
Theoretically, it could be. In Kenya and India, for example, only one percent of women have had a Pap smear, and rates of cervical cancer are high. Immunizing a generation of girls would help reduce this significantly in the future, even without the availability of Pap smears. But the vaccine is costly, needs to be refrigerated, and must be given in three separate doses over six months. This would be a massive task. Consider the fact that only half of children in India today get standard childhood immunizations, which speaks to the difficulty of delivering vaccines.

There is already a simple screening and treatment method, known as visual inspection with acetic acid (VIA), that could have an immediate effect in resource-poor countries and that does not require the level of technological development that Pap smears do. With some training, nurses or medical staff can learn to visually inspect the cervix with a solution containing acetic acid, better known as vinegar. This solution makes cervical lesions show up as white spots. These can be treated rather simply with cryotherapy, the way dermatologists here freeze warts and suspicious moles. This method is 85 percent effective in treating precancerous lesions, can be done in a single visit, and has great benefit, even if women are screened only once or twice in their lifetime at 30 to 40 years of age.

When we begin to discuss the HPV vaccine in the developing world, we should consider a variety of approaches toward reducing cervical cancer deaths. We can’t forget about the generations who are already sexually active and for whom the vaccine is too late.

The HPV Vaccine: Is It Really a Public Health No-Brainer? begins at 4 p.m. on Thursday, September 27, with a lecture by Susan Weller; the panel discussion begins at 9 a.m. on Friday, September 28. Both the lecture and the panel discussion will be held on the Medical Campus, at 670 Albany St.

Should HPV vaccinations be mandatory? Vote now. Sharon Britton can be reached at sbritton@bu.edu.