Women's & Children's Hospital February 22, 2012

HPV Prevention and Policy

By Jeff Webb

Don’t let vaccination controversy impede progress, expert says

Following an early debate among Republican presidential candidates, Rep. Michele Bachmann, R- Minn., blurted out on national television that she thought the vaccine used to ward off cancer-causing human papillomavirus (HPV) posed a physical threat to the pre-teen girls for whom it is intended.

Her comments have since drawn widespread criticism from the medical community, which sees the vaccine, GARDASIL®, as a paradigm-changer in occurrences of cervical, anal, penile and oropharyngeal cancers.

Anna Giuliano, PhD, an international authority on HPV, has come up against this sort of misinformation before, and the result usually is not good. “In general, whenever there is media attention (about the vaccine), it is negative. It often is false reporting about an adverse event that has very little validity. Afterward, we actually see a decline in vaccine rates,” she said.

But this time, Giuliano thinks the backlash against such comments may have been helpful. “In this setting, (Bachmann’s comments) are so stupid and so bizarre, it may have a positive effect” in raising awareness about the HPV epidemic, she said.

Giuliano is chairwoman of the Department of Cancer Epidemiology at Moffitt Cancer Center in Tampa, Florida. In that capacity she has secured tens of millions of dollars in grants, including $10-million from the National Institutes of Health to study males’ roles in the spread of HPV. It is the largest sum ever granted to a cancer control and prevention researcher at Moffitt.

Giuliano would like to see the debate about HPV shift from political rhetoric to public education. Just as former U.S. Surgeon General C. Everett Koop “brought it home to Americans that we needed to stop smoking, we need to solidify in Americans’ minds that there is a vaccine available to prevent multiple cancers,” Giuliano said.

Such an educational campaign would need to be launched within the “context of vaccines in general,” she said. “Americans are so far removed from infections that cause disease that we think we are no longer susceptible. In fact, our overall rate of complete vaccinations for childhood immunizations is lower than in many other countries. We get a push-back from Americans (who say) ‘I won’t get that because I live in America,’” said Giuliano. “We cannot let down our guard. We live in a global society, which is all the more reason to be vigilant about vaccinations, in general.”

And physicians should be at the head of the class for that education, says Giuliano. “Most physicians don’t even know that HPV causes cancer in men, too. (Physicians) are the starting point of an education campaign.”

The inclusion of boys in the Centers for Disease Control’s recommendation for the HPV vaccine is a huge step forward in dispelling the myths about the spread of HPV according to Giuliano. Most people thought “men were the evildoers, that they carry the infection and transmit it, but never develop the disease. That is just rubbish,” she said, adding that her 12-year-old son has been vaccinated.

Five years ago, Merck, the pharmaceutical maker of GARDASIL®, launched its “I’m going to be one less” advertising campaign.  “At that time, most women didn’t understand that HPV causes cervical cancer,” Giuliano said. “The GARDASIL® campaign did pretty well with cervical cancer education. But when people started saying it causes cancer in men, the problem was so tied to female cancer that the very thought it could cause cancer in men was beyond anyone’s belief.”

“Our first hurdle is that HPV is asymptomatic in both sexes and, as the most common sexually transmitted infection, it is an equal opportunity infection. HPV is not gonorrhea or syphilis, where you have a core sexual group” with which you can identify it. There are more than 100 types of the HPV virus, explained Giuliano. “It is an infection where everyone, at some point, is exposed and most are infected. In the course of their lives, 80 percent of people will have been infected with one or more types of HPV.”

Dr. Donald Mickal, longtime OB-GYN and the newly appointed Chief Medical Officer for The Regional Health System of Acadiana, is on the front lines of women’s healthcare, and he wholly endorses vaccination against HPV.

“When you consider that 75-80 percent of the female population could have some form of this virus, and we know that 98 percent or greater of cervical cancer comes from it, vaccination against the virus will significantly lower the risk of cancer,” Mickal said.

“We have been vaccinating for hepatitis B for years, and it is a sexually transmitted disease, so this is no different,” he said. Unfortunately, Mickal said, when people hear about HPV, “they think of an STD, and they forget we are trying to prevent or eradicate cervical cancer. They sort of lose the big picture.  We have a great chance at knocking out cancer, especially if boys are vaccinated.”

Also, Mickal stressed, “It should be understood at this time that this vaccination is not meant to take the place of a regularly scheduled pap smear.” Should politics or religion have any role in defining health policy? Giuliano stops short of making HPV vaccination mandatory. “That was the whole hoopla with Rick Perry,” the Texas governor who was Bachmann’s primary target in this controversy, said Giuliano.  Perry had supported mandatory HPV vaccinations as a school-entry requirement for eligible girls. “In terms of politics he made a mistake. The American public was not ready to have a brand-new vaccine legislated to them. It was really bad timing. But the policy itself is very sound in terms of the mechanism we need to ensure broad dissemination of the vaccine,” said Giuliano.

Giuliano concludes, “I have a philosophy that I don’t want to make people do something they don’t want to do. If I could do anything it would be to change the way people think about vaccines in general, and specifically about the HPV vaccine. If we can accomplish that, I think many of the health policy issues we face will be easier to implement. We need the public to support it without shoving it down their throats.”