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Seattle Takes on the HPV Vaccine
by Tara Hayes

Laura was 20 years old when her annual Pap smear revealed she had abnormal cervical cell growth from contracting the human papillomavirus (HPV), a sexually transmitted disease and cancer-causing virus. “I remember just in my head being ‘Oh my gosh. Cancer. Women can die from this.’” That was five years ago, before the approval of a vaccine for HPV pushed the disease to the media forefront, the pharmaceutical company began direct-marketing educational television ads, and controversy sprouted nationwide over whether to immunize young girls.

In June of 2006 the FDA approved Merck’s HPV vaccine, Gardasil (a set of three shots given over a six-month span), for girls and women aged 9 to 26. There are dozens of types of HPV and this vaccine protects against four strains, two that cause 70 percent of cervical cancers and two others that cause 90 percent of genital warts.

For a disease that most sexually active people — both men and women — will contract in their lifetimes, HPV is not well understood. Most will never know they’ve had the virus because the majority of infections clear up on their own. But there’s no way to know if the virus is gone because HPV can lie dormant for years before causing warts or, in the worst-case scenario, cancer. That’s why, even with the vaccine’s partial protection, women shouldn’t neglect their regular Pap smears.

Laura was lucky: She lived in Seattle, a city rich in medical resources, had the means to be diligent about her annual checkups, and caught the problem early. She had a simple, though very uncomfortable, surgical procedure to burn away the infected cells, took care to get more frequent Pap smears over the next couple of years, and as a result, has a clean bill of health. Her doctors said they couldn’t be 100 percent sure they got everything, but most women are fine when treated so promptly.

If precancerous cervical cells are not caught early by a Pap smear, the disease is free to develop quietly, without pain or other symptoms, until vaginal bleeding indicates its presence, at which point a woman has only a 40 percent chance of survival. Once the cancer invades surrounding tissues, the treatment options range from surgery and possibly hysterectomy to chemotherapy and radiation. HPV causes 95 percent of invasive cervical cancers and every year 3,700 women in the United States die of the disease.

Aside from the very real physical dangers associated with HPV, there’s also a significant social burden. Laura, having since joined a church and become a school counselor, doesn’t want to share her real name because of the stigma attached to sexually transmitted diseases. It’s a stigma that also attaches to the controversy about vaccinating for HPV — especially because it’s indicated for 11- to 12-year-old girls, before they become sexually active.

On Seattle radio talk shows and in local newspapers, people have been weighing in with personal stories and anecdotal evidence: A man whose wife died of cervical cancer wants all women and girls to be vaccinated; the parent of a 15-year-old worries it could be detrimental to her child’s development; a mom bribes her needle-wary teenager to get the shots.

What-ifs and hypothetical circumstances abound in this debate where a variety of concerns cross paths, including fears that the government will mandate the vaccine and intrude in personal health decisions, desires to hold young women to certain moral and religious standards, and uncertainty over the potential long-term dangers of a newly tested vaccine.

When the CDC first recommended the vaccine for 11- and 12-year-old girls last summer, the National Vaccine Information Center was quick to highlight the limitations of Merck’s studies. “There is too little long- term safety and efficacy data, especially in young girls, and too little labeling information on contraindications for the CDC to recommend Gardasil for universal use,” says NVIC president Barbara Loe Fisher.

Known side effects include pain at the injection site, dizziness, nausea, and, in less than one percent of women, vomiting, cough and joint pain. But those critical of Gardasil, and vaccines in general, pose questions about its unstudied and unproven aspects, such as the use of aluminum as an ingredient, possible interactions with other medications, and just how long the vaccination can be expected to last. Currently, the vaccine’s efficacy has only been tested up to five years.

But perhaps the most commonly voiced concern is that the vaccine, particularly if mandatory, will send young girls the message that it’s okay to have sex. Laura can understand the hesitation. “I don’t want it to make people think it’s okay to have unprotected sex,” she says. “I did not make responsible choices. I feel like these are the consequences of my actions.” But, she points out, there are a lot of variables.

“You don’t plan [sex] out six months in advance. It doesn’t work like that.” And, as she tries to be a neutral advocate in the public school system, she knows the risks kids face. “There are kids who are having sex and the parents aren’t always aware of it.” She’s seen gut-wrenching situations involving the rape of a child. “These are little girls,” she says, “You wouldn’t want an innocent little kid to get this.”

As Laura’s experiences highlight, everyone’s sexual history is different, but in every case the vaccine works best when given before that history begins. Given that, Laura is happy the treatment is available as a preventative measure, but wouldn’t want it to be mandatory. “[But] if a girl or woman can make the choice for herself,” she says “then absolutely.”

Dr. Mary Weiss, like many in the medical community, doesn’t see why the controversy exists. “When I vaccinate a child against tetanus,” she says, “I don’t give them a handful of rusty nails.” She’s more concerned about equal access. At the Swedish Physician’s Providence clinic where she works, Dr. Weiss says, “I saw young women coming in, some of whom I could vaccinate and some of whom I couldn’t” because some could pay and others could not. As with any new vaccine, it takes time to sort out distribution and supply, and while the vaccine has been available for a year, it’s not always easy to get.

Until now the vaccine has not been widely available in the public sector. Women and girls could - and still can — get Gardasil by asking their private physician to order it or by going to places like the University of Washington’s Hall Health, Planned Parenthood clinics and Safeway pharmacies — all of which keep it on hand. Safeway pharmacists can prescribe the vaccine, much like a flu shot. But it’s not cheap, no matter where you get it. While insurance companies have begun to cover the shots, for many the only option has been paying cash — if they could afford it. With office and administration fees, each injection costs anywhere from $150 to $175.

Fortunately, as of the first of this month, the vaccine should be universally available to children under age 19 in Washington state. At press time, Governor Chris Gregoire had funding set aside in the state’s proposed annual budget to enable children to get the vaccine, regardless of insurance or income, making it available from any of the 1200 sites and physicians that offer childhood vaccines, including Seattle’s public health clinics.

It’s a different situation for women aged 19 to 26, particularly those without insurance. “We don’t have any funding to purchase vaccines at all for adults,” says Michele Perrin of the Washington State Department of Health. Yet girls and women who have been sexually active can still benefit from the vaccine because even if exposed to one strain of HPV, they can be protected against another.

Although more girls are now able get the shots, they are not required to get them, at least not yet. Governor Gregoire has said that, for the time being, she wants to educate the public about the vaccine, not mandate it. Indeed, a bill before the legislature will require schools to send informational packets to the parents of entering sixth graders making them aware of HPV, the vaccine, and the CDC’s recommendations for 11- and 12-year-olds.

Earlier this year Washington state Senator Jeanne Kohl-Welles, D-Seattle, seriously considered sponsoring a bill for mandatory vaccination, but was convinced there could be a negative reaction from the public — as later evidenced by Gov. Rick Perry’s overturned attempt in Texas. Several other state legislatures have made overtures toward a mandate, aiming at high vaccination rates, but Washington has adopted a wait-and-see stance, punting to the Board of Health for the moment as it looks over its criteria for mandatory vaccinations. But next year could be another story, says Kohl-Welles. She’ll definitely bring the topic up again soon, and it could be an issue in 2008.

As it turns out, what happens with the vaccine here has global import. “The success of the vaccine [in the U.S.] could help increase access worldwide by increasing production capacity,” says Jacqueline Sherris of PATH, a Seattle-based nonprofit dedicated to improving health care around the globe. While the HPV vaccine is creating controversy here at home, 85 percent of women dying from the disease live in the developing world where there is little access to screening and treatment.

Sherris’ two teenage daughters decided to get vaccinated — something Sherris knows will reduce their chances of having to deal with the anxiety and time-consuming treatment that follows an abnormal Pap smear. But in poorer countries, the reality is often harsher, where HPV ends up killing women who’ve never heard of the disease.

Here and abroad, the struggle with HPV and cervical cancer isn’t over, and this vaccine means different things to different people. Perhaps, in a perfect world everyone could (take your pick): be fully vaccinated so the disease couldn’t persist; always practice very safe sex — or abstinence — and never contract an STD; or get regular Pap smears. But, in Washington state, 63 women died of invasive cervical cancer in 2003, and every year 270,000 die worldwide.

Tara Hayes is a freelance writer living in Seattle.

©2007 Caliope Publishing Company