Gardasil

[jonb12997]

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So, what do we think about making Gardasil, the new HPV vaccine required for school aged girls?

Here's my feeling: It seems like Merck is getting a little too cozy with the government and until the evidence based medicine that comes out proves it, we shouldn't listen to what Merck has to say about it. They stand to make too much money to have a say in requiring the vaccine... I'm not saying that we shouldn't use it, it just seems like Merck should stay out of it and let evidence based medicine decide. Maybe we will eventually require it, but i don't like the fact that Merck has influence over this. Also, i don't remember the science that well, but yes Gardasil does cover the 4 big strains, but it seems like if we eliminate these 4 strains that others are going to cause more cases eventually. How about, will this cause women to stop getting pap smears? "Well, I got that vaccine, I don't need to worry about pap smears"...

Thoughts?

 

[crazy_cavalier]

It seems to me that most parents detest the idea of vaccinating their 12 year old child against a virus that gets transmitted sexually. If Merck had any brains, they'd come up with a better marketing scheme. Either require this vaccine along with the Hep B vaccine when kids go off to college, or give it to 'em while they're still pups.

 

[Wizard of Oz]

I commented on the thread with the referenced quote as such, but I didn't get any love.

As far as parents not wanting their children to have the vaccine, I'm not sure that will be a big issue. There will always be some parents distrustful of all vaccinations, probably no more so for HPV vaccine. As far as it being a vaccine for a STD, we already provide Hep B vaccine (Hep B being a bloodborne pathogen historically primarily transmitted through sexual contact and IV drug use) without much fanfare.

Coming from one of the biggest Bush-supporting states in the union, conservative groups will find any reason (however absurd it sounds) to try to promote abstinence only. They've already been saying that HPV transmission appears unaffected by condom use (so what, now you're telling people not to use condoms?), so I guess this vaccine would destroy their standpoint. It stands to reason that my state is second to Nevada in divorce and remains a hotbed for teenage pregnancy. Yeah, abstinence only, don't get me started.

We also have an education issue on our hands with HPV--warts vs. cervical CA, what it means to be seropositive, the fact that you can clear the virus, etc. I'm afraid that in my over-educated mind, I can't really accept HPV as a traditional STD (or perhaps more appropriately sexually-transmitted or associated infection) since the letters "STD" have such a negative stigma. To me, the virus family in itself is really just a marker for sexual activity.

I'm behind the vaccine 100% Cervical CA is a life/death matter. We don't have time to stand behind a pulpit on our moral high ground with this issue.

 

[JonnyG]

Vaccines are not very profitable to begin with so they will not be making tons of money even if everyone is vaccinated (they wont be hurting either). Fact is the four types of HPV it covers against cause cervical cancer. If it can be prevented why not.

 

[njaqua]

Also, i don't remember the science that well, but yes Gardasil does cover the 4 big strains, but it seems like if we eliminate these 4 strains that others are going to cause more cases eventually.

This is one of your arguments? Why do we treat/cure anything then?

 

[SteveUTexas]

Hooray for Texas being the first state to require the HPV vaccine for school girls.

 

[hyperbaric]

Hooray for Texas being the first state to require the HPV vaccine for school girls.

Texas governor orders STD vaccine for all girls
http://www.msnbc.msn.com/id/16948093/wid/11915773?GT1=9033

 

[BozoSparky]

Vaccines are not very profitable to begin with so they will not be making tons of money even if everyone is vaccinated (they wont be hurting either). Fact is the four types of HPV it covers against cause cervical cancer. If it can be prevented why not.

aren't they (merck) charging quite a bit, though?

 

[beefballs]

My argument with this being a mandatory vaccine is that it is only spread through sexual contact, it isn't like airborne pathogens where the infected is a risk to those around them. Would I want my daughter to get it-Yes. Do I think it should be required for everybody-no people should make their own choice. As for the argument that we are required to have the Hep B vaccine-Well we are at risk of accidental needle sticks, but it isn't like I am just going to randomly beefpoke girls transmitting the HPV virus.

 

[beefballs]

I'm behind the vaccine 100% Cervical CA is a life/death matter. We don't have time to stand behind a pulpit on our moral high ground with this issue.[/QUOTE]


It isn't about being on a pulpit it is about an indivduals right to make their own choices in regards to their health. This isn't a disease whose method of transmission provides a threat to those around them, so the argument that it is a matter of public health isn't accurate. If you were to argue about making the vaccine more readily available or increasing sex education I would support what you are saying entirely. The mode of transmission should seperate this vaccine from the mandatory ones that are a matter of public health.

 

[JonnyG]

aren't they (merck) charging quite a bit, though?

wouldn't really matter because the person recieves one vaccine and thats it. there arent monthly refills that continue to generate income. Vaccines are the least profitable pharmaceutical sector. Vaccines are cures and drug companies are really only into treatments.

 

[Tired]

It seems to me that most parents detest the idea of vaccinating their 12 year old child against a virus that gets transmitted sexually. If Merck had any brains, they'd come up with a better marketing scheme. Either require this vaccine along with the Hep B vaccine when kids go off to college, or give it to 'em while they're still pups.

I've read two of the studies on these vaccines (in addition to Merck, I believe GSW also has one in the works). The data is pretty dramatic; if I recall correctly, the cervical cancer rate fell something on the order of 80%.

The problem is, you pretty much have to do it during the 10-12yo age range. If you do it early (as children) you risk the antibody levels falling off by the time the kid is actually exposed. If you wait until college, a whole bunch of girls will get cancer because they were doing their boyfriend while a freshman in high school. You vaccinate them at 12 because that's a little bit before the average age that a girl will start having sex. The vaccine administration has to be near the time of exposure in order to be effective.

Personally, I'd like it if it were mandatory, but unfortunately that's just not very American. We require compulsory vaccination for most childhood illnesses because of the relative ease of transmission (droplet, aerosol, contact). But HPV doesn't transmit by any of those routes, so the chances of random contact resulting in infection is essentially nil. Thus we can't really frame this as a compelling public health interest, and it shouldn't be mandatory.

I just hope that all the parents who turn down the vaccine for their daughters will be around to nurse them through surgery and chemo . . .

 

[beefballs]

I've read two of the studies on these vaccines (in addition to Merck, I believe GSW also has one in the works). The data is pretty dramatic; if I recall correctly, the cervical cancer rate fell something on the order of 80%.

The problem is, you pretty much have to do it during the 10-12yo age range. If you do it early (as children) you risk the antibody levels falling off by the time the kid is actually exposed. If you wait until college, a whole bunch of girls will get cancer because they were doing their boyfriend while a freshman in high school. You vaccinate them at 12 because that's a little bit before the average age that a girl will start having sex. The vaccine administration has to be near the time of exposure in order to be effective.

Personally, I'd like it if it were mandatory, but unfortunately that's just not very American. We require compulsory vaccination for most childhood illnesses because of the relative ease of transmission (droplet, aerosol, contact). But HPV doesn't transmit by any of those routes, so the chances of random contact resulting in infection is essentially nil. Thus we can't really frame this as a compelling public health interest, and it shouldn't be mandatory.

I just hope that all the parents who turn down the vaccine for their daughters will be around to nurse them through surgery and chemo . . .

totally agree with you-way more eloquent than I said it. Although if you worked in a few beefpole references or sweaty clam jokes I would like you more

 

[Wizard of Oz]

aren't they (merck) charging quite a bit, though?

Methinks that the vaccine is a 3 shot sequence that runs about $340. Good insurance should cover it.

Texas governor orders STD vaccine for all girls
http://www.msnbc.msn.com/id/16948093/wid/11915773?GT1=9033

I have a problem with calling it an STD vaccine. We should remember that there is a difference between a disease and an infection. HPV most often does not cause disease. It arrives, replicates, and gets defeated leaving an antibody marker behind. The wart that comes most often from 6 and 11 is the "disease" or visible pathology, but they tacked on those strains to help them sell the vaccine since genital warts are cosmetic and typically treated topically and/or regress themselves. Save for the sexual contact that got them the warts, those strains in and of themselves are associated with cancer extremely rarely if at all.

If you look at the commercials, however, they are calling it more appropriately a vaccine to protect against cancer, namely 16 and 18 which are linked to 70% of all cervical CA cases.

Regarding the other strains, if you cut out 70% of cervical CA, sure the others will look like they are causing a greater percentage, but they do not contain the most potent oncogenes (let's not get into the molecular biology here though). Only a few of the other HPV strains cause cancer.

BTW if women start ignoring regular Pap's, then their docs aren't educating them properly.

It isn't about being on a pulpit it is about an indivduals right to make their own choices in regards to their health. This isn't a disease whose method of transmission provides a threat to those around them, so the argument that it is a matter of public health isn't accurate. If you were to argue about making the vaccine more readily available or increasing sex education I would support what you are saying entirely. The mode of transmission should seperate this vaccine from the mandatory ones that are a matter of public health.

I didn't mean to imply that it should be mandatory, but I think that women need to know that dudes carry HPV's, and condoms hardly reduce the skin-to-skin transmission mode. I don't see the virus as an STD but rather a marker for sexual activity in general. To say that you can control whether you are exposed to it or not is to say that you know for sure that the only initial sexual contact you'll ever have is with virgins, and you'll have to guarantee their monogamy after that.

 

[OncoCaP]

Good luck with getting that vaccine. Many physicians are refusing to stock it because they would provide it at a loss. Some are offering it for $450 cash up front: http://www.cnn.com/2007/HEALTH/conditions/02/02/cancer.vaccine.ap/index.html

 

[beefballs]

Methinks that the vaccine is a 3 shot sequence that runs about $340. Good insurance should cover it.



I have a problem with calling it an STD vaccine. We should remember that there is a difference between a disease and an infection. HPV most often does not cause disease. It arrives, replicates, and gets defeated leaving an antibody marker behind. The wart that comes most often from 6 and 11 is the "disease" or visible pathology, but they tacked on those strains to help them sell the vaccine since genital warts are cosmetic and typically treated topically and/or regress themselves. Save for the sexual contact that got them the warts, those strains in and of themselves are associated with cancer extremely rarely if at all.

If you look at the commercials, however, they are calling it more appropriately a vaccine to protect against cancer, namely 16 and 18 which are linked to 70% of all cervical CA cases.

Regarding the other strains, if you cut out 70% of cervical CA, sure the others will look like they are causing a greater percentage, but they do not contain the most potent oncogenes (let's not get into the molecular biology here though). Only a few of the other HPV strains cause cancer.

BTW if women start ignoring regular Pap's, then their docs aren't educating them properly.



I didn't mean to imply that it should be mandatory, but I think that women need to know that dudes carry HPV's, and condoms hardly reduce the skin-to-skin transmission mode. I don't see the virus as an STD but rather a marker for sexual activity in general. To say that you can control whether you are exposed to it or not is to say that you know for sure that the only initial sexual contact you'll ever have is with virgins, and you'll have to guarantee their monogamy after that.

then we have no argument and I can return to looking at porn-my job here is done

 

[Wizard of Oz]

then we have no argument and I can return to looking at porn-my job here is done

👍

 

[Doctor Bagel]

I've read two of the studies on these vaccines (in addition to Merck, I believe GSW also has one in the works). The data is pretty dramatic; if I recall correctly, the cervical cancer rate fell something on the order of 80%.

The problem is, you pretty much have to do it during the 10-12yo age range. If you do it early (as children) you risk the antibody levels falling off by the time the kid is actually exposed. If you wait until college, a whole bunch of girls will get cancer because they were doing their boyfriend while a freshman in high school. You vaccinate them at 12 because that's a little bit before the average age that a girl will start having sex. The vaccine administration has to be near the time of exposure in order to be effective.

Personally, I'd like it if it were mandatory, but unfortunately that's just not very American. We require compulsory vaccination for most childhood illnesses because of the relative ease of transmission (droplet, aerosol, contact). But HPV doesn't transmit by any of those routes, so the chances of random contact resulting in infection is essentially nil. Thus we can't really frame this as a compelling public health interest, and it shouldn't be mandatory.

I just hope that all the parents who turn down the vaccine for their daughters will be around to nurse them through surgery and chemo . . .

On your point about contamination, one could argue that HPV does have great ease of transmission because it's not necessarily linked with sexual promiscuity. Sexual activity (and I don't just mean intercourse) period puts you at risk because it's so easy to get. People who have been relatively chaste and have followed conservative religious guidelines regarding sexuality can still get it and not in freakishly low amounts either. Nuns are about the only adults who probably aren't at risk. 🙂

As for your last point, so agree. It's sad to think that people might essentially kill their children because of bs religious grandstanding.

 

[Doctor Bagel]

To say that you can control whether you are exposed to it or not is to say that you know for sure that the only initial sexual contact you'll ever have is with virgins, and you'll have to guarantee their monogamy after that.

Requiring that your mate is a virgin isn't enough because you can get it without penetration. Now I grew up in the Bible Belt around lots of religious people who thought you should wait until marriage to have sex, but pretty much none of them held off on all sexual activity meaning your nice religious virgin fiance can still be a carrier. 😱 IMO, one essentially has no realistic power in preventing exposure unless again you're entirely celibate.

 

[Wizard of Oz]

Requiring that your mate is a virgin isn't enough because you can get it without penetration. Now I grew up in the Bible Belt around lots of religious people who thought you should wait until marriage to have sex, but pretty much none of them held off on all sexual activity meaning your nice religious virgin fiance can still be a carrier. 😱 IMO, one essentially has no realistic power in preventing exposure unless again you're entirely celibate.

Good point. I've read that the virus is even stable enough to go from hand to infected area and back. 👍

And I thought that I was the clinical micro studboy...

 

[Doctor Bagel]

Good point. I've read that the virus is stable enough to go from hand to infected area and back. 👍

And I thought that I was the clinical micro studboy...

You are. 🙂 I'm just interested in bible belt sexual hypocrisy. Speaking of which, I actually did know girls who would have anal sex but not vaginal sex because they thought god was more okay with that. I had a friend in Oregon who took a human sexuality class and learned about that in class. He was amazed, but I already knew it from going to high school in Oklahoma.

 

[Wizard of Oz]

You are. 🙂 I'm just interested in bible belt sexual hypocrisy. Speaking of which, I actually did know girls who would have anal sex but not vaginal sex because they thought god was more okay with that. I had a friend in Oregon who took a human sexuality class and learned about that in class. He was amazed, but I already knew it from going to high school in Oklahoma.

😱 That can't be comfortable. Is there just some feeling that you need to please the guy that much that you need to offer your body in some way? Seems pretty demeaning to me. I hope that they at least use condoms.

Yeah there was a rumor in my school that a preacher's daughter was the same way.

I saw on the news last night that legislature similar to the Texas law is circulating in the Oklahoma congress.

 

[cfdavid]

Good luck with getting that vaccine. Many physicians are refusing to stock it because they would provide it at a loss. Some are offering it for $450 cash up front: http://www.cnn.com/2007/HEALTH/conditions/02/02/cancer.vaccine.ap/index.html

Yep, I read a similar article in the Detroit News just this morning. Reimbursements are b/t $2-15 above cost. Yet, overhead to stock, insure, and keep track of inventories would allow for a break even, AT BEST. So, until doctors start drawing more lines in the sand, reimbursements for potentially life saving treatments will continue to decline (and thus, the use of such treatments). That's not in anyones best interest.

 

[Wizard of Oz]

Yep, I read a similar article in the Detroit News just this morning. Reimbursements are b/t $2-15 above cost. Yet, overhead to stock, insure, and keep track of inventories would allow for a break even, AT BEST. So, until doctors start drawing more lines in the sand, reimbursements for potentially life saving treatments will continue to decline (and thus, the use of such treatments). That's not in anyones best interest.

We needed to get one of those overseas flu shot companies to make 'em. 😀 Too bad you can't just grow attenuated HPV in chicken eggs.

 

[hyperbaric]

I have a problem with calling it an STD vaccine. We should remember that there is a difference between a disease and an infection. HPV most often does not cause disease. It arrives, replicates, and gets defeated leaving an antibody marker behind. The wart that comes most often from 6 and 11 is the "disease" or visible pathology, but they tacked on those strains to help them sell the vaccine since genital warts are cosmetic and typically treated topically and/or regress themselves. Save for the sexual contact that got them the warts, those strains in and of themselves are associated with cancer extremely rarely if at all.

If you look at the commercials, however, they are calling it more appropriately a vaccine to protect against cancer, namely 16 and 18 which are linked to 70% of all cervical CA cases.

I agree with your concern regarding the nomenclature (I copied the article title so those weren't my words). I think that in the case of that article 'STD vaccine' was an attempt to sensationalize the story. Stir up the conservatives if you will.

 

[potato51]

I believe you're allowed to opt out for philosophical or religious reasons. Also, won't making it state-mandated compel insurance companies to cover the vaccine?

 

[Jwax]

"...overall HR-HPV prevalence of 22.5%. Prevalence in STD clinics was 28%, 24% in Family Planning clinics, and 16% in Primary Care clinics. Prevalence by age group was: 14-19 years 35%; 20-29 years 29%; 30-39 years 14%; 40-49 years 12%; and 50-65 years 6%" from: http://www.cdc.gov/std/stats/otherstds.htm

I don't know about you guys, but a prevalence of ~1 out 4 people is pretty high. High enough to say that transmission is a matter of public health IMHO. I found another CDC quote that says prevalence of Hep-B is 1 in 181... hmmm 1 in 4 vs 1 in 181?? Of course that has to do with the fact that Hep-B has a vac. for it now. My point is that I strongly feel that this should be required for all 10-12 yr old girls (and maybe boys, too, why should they be spared? They pass HPV on, too). If 1 in 4 people get HPV, and ~70% of cervical cancer cases result from the two strains that are prevented by Gardasil (with ~80% efficiency)... those are enough stats for me to feel this is not a black & white issue. Yes, people should get to make choices about their health. Yes, people can choose who they sleep with. But, if you note from above, the age population group with the largest prevalence of HPV (35%) was ages 14-19. These are ages in which people certainly aren't about to ask questions like, "Did you get vaccinated for HPV?" These are people that need public protection. They need to have more educated people determine what is best for them, just like we've done with other issues like Hep-B.

Hopefully this was well-written enough that it at least makes sense...

 

[Wizard of Oz]

I'm thinking that the vaccine isn't approved for dudes. The statistics didn't quite confirm its efficacy.

If somebody knows better, sign me up! I'll take some of that. If I can cut my chances of having a wife with cervical CA by 70% someday as well as reduce my chances of getting genital warts by 90%, I'll gladly pay the price. 👍

I'm thinking that the way the right tries to prevent people from protecting themselves is to keep calling it an STD vaccine (a title perhaps equally or moreso applicable to HBV).

 

[hyperbaric]

I *think* it is protective against 4 strains HPV. For now, use in males is off-label. Once the data for males is in, I would assume/hope that Texas will require all children to get the vaccine. W of Z, you would have some protection against warts as well as the dreaded penile cancer.

 

[turkleton]

I'm glad someone started this thread. I think the OP makes a valid point regarding the intimacy between Merck and the government. It shouldn't be Merck trying to sell the impact of the drug to the goverment- they quite obviously have a huge vested interest. It should be the data- which I have to say is very impressive thus far. As for profitability, Merck certainly stands to generate tremendous amount of revenues- they're not foolish enough to undertake unprofitable ventures. When you say vaccines aren't profitable, I think its to the overall healthcare picture in the sense that physicians will see less business. However, the cost savings to the total equation by eliminating cervical cancer is staggaring. As one Ob put it, we could make it a disease like polio- you study it because it existed, but don't expect to see it.

The view of conservative states on this is difficult to digest. What, if by some miraculous genius, someone someone came out with an HIV vaccine? Because its sexually transmitted you don't dispense it? I agree that the thought of administering to 12 year old girls is a little unsettling for whatever reason, but just look at the upside. Incidentally, I was wondering how cervical cancer was carved up demographically- because I imagine that the largest impact this vaccine can make is probably in a population segment which will have minimal access to it.

Oz, I'm pretty sure you're right- the vaccine doesn't work for those carrying a phallus. Glove up brother.

 

[bjackrian]

I'm thinking that the vaccine isn't approved for dudes. The statistics didn't quite confirm its efficacy.

I think the issue with guys is just that the study was just started later, so the data don't exist yet, but the prelim data suggest that it helps prevent HPV causes anal and penile cancers (which are much rarer than cervical cancer in the general population).

On the issue of cost, making it mandatory would not require insurances to cover it, but it would almost certainly be added to the vaccines that are subsidized through county health departments giving more poor/uninsured people access to the vaccine.

And on the crazy end, there's a Washington Post metro columnist who has taken on Gardasil as a pet cause and has decided that mandatory vaccination policies are akin to Tuskeegee or slavery. They're fun reads, and fairly short:

Jan 10: http://www.washingtonpost.com/wp-dyn/content/article/2007/01/09/AR2007010901780_pf.html
Jan 24: http://www.washingtonpost.com/wp-dyn/content/article/2007/01/23/AR2007012301502_pf.html

 

[Instatewaiter]

it is about an indivduals right to make their own choices in regards to their health. This isn't a disease whose method of transmission provides a threat to those around them, so the argument that it is a matter of public health isn't accurate. If you were to argue about making the vaccine more readily available or increasing sex education I would support what you are saying entirely. The mode of transmission should seperate this vaccine from the mandatory ones that are a matter of public health.

Don't forget about the idea of herd immunity. For those of you who aren't familiar with the idea of 'herd immunity' basically when a certain percentage of the population is vaccinated or carries enough memory cells to fight a subsequent infection the pathogen will be unable to survive. This is the reason we don't have polio any more, even when someone brings the disease into the country it cant infect enough people to self-stain. So forcing enough people to get the vaccine just may erradicate the most pathogenic strains of HPV. Screw the mode of transmission, this is about helping people.

It is precisely for the reason of herd immunity that people feel safe not vaccinating their kids. Now as to the individual's rights thing goes people do not realize the danger or prevalence of HPV nor do they realize just how easy it would be to protect their kids. I am a staunch believer in individual rights but realize too by not vaccinating your kids you are potentially hurting others by being a potential host for the virus.

 

[Tired]

Screw the mode of transmission, this is about helping people.

As sympathetic as I am to your position, unfortunately it just doesn't fly in the United States.

1) Medicine is not divorced from politics. As long as HPV is considered a "sexually-transmitted disease", medicine will be forced to confront the sociologic and political implications of the mode of transmission. Unfortunately there is a grain of truth in the argument that, "If they don't have sex, they won't get the disease." Unless we actively address this line of argument (and acknowledge its truth) we will be unable to sway people towards getting the vaccine.

2) Most Americans believe that a person has the right to refuse medical care, and that parents (with a few exceptions) have the right to refuse treatments for their children. Forcing vaccinations is a big step, and one that needs to have solid public health reasons behind it (see next point).

3) HPV is not a public health issue, at least not on the scale that other vaccine-preventable illnesses are. Schools simply do not feel the effects of "HPV epidemics" in the way that Pertussis, diphtheria, and mumps once were. The public saw "otherwise innocent" children afflicted with illnesses that had immediate, dramatic effects, and so accented to mandatory vaccination for Polio, measles, etc. HPV has no such effect, and only afflicts segments of the population engaging in certain behavior. It is understandable, then, that the public would be reluctant to mandate this invasive treatment for all its children.

Personally, I think that so far the advertising for Gardasil has been pretty on target, playing up the risk of cancer for young women, without mentioning sexual behavior. I imagine that, with time, it will become a more socially acceptable vaccine. For the time being though, I find it unlikely that trying to force the issue will see any results.