HPV Vaccine, Not Immune To Controversy

International Journal of Gynecology and Obstetrics (2008) 101, 123–124
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
w w w. e l s e v i e r. c o m / l o c a t e / i j g o
SPECIAL EDITORIAL
HPV vaccine: Not immune to controversy

recipient of many teaching awards including the APGO
Excellence in Teaching Award. In addition, she developed
and directed the Middle Eastern Women's Health Program at
the Center of Excellence for Women's Health at the
University of Michigan. In recognition of her contributions,
in 2005 Dr Hammoud was awarded the Arab American and
Chaldean Council's Excellence in Health Care Award.
The introduction of Gardasil (Merck & Co, Whitehouse

Station, NJ, USA) as a vaccine to the human papillomavirus
(HPV) has received much media attention worldwide since its
approval by the US Food and Drug Administration in 2006.
From the United States to the United Kingdom, New Zealand,
and Malaysia, news headlines have highlighted various issues
and controversies surrounding the HPV vaccine.
ʻʻOuch! Cervical cancer shots painful” [1] released by the
Associated Press in January 2008 outlines the most recent
complaint about the vaccine; the shot seems to cause more
pain than other vaccines. In the United Kingdom, more
controversial discussion appeared in The Times in ʻʻIs it time
for a cancer jab?” [2], where two opposing answers to the
question: ʻʻMy daughter is 12 and not yet sexually active.
Should I arrange for her to have the cervical cancer jab?”
posed by a British parent were presented. On the supporting
side, the parent is encouraged to obtain the vaccine for
Maya Hammoud, M.D.
protection; while on the opposing side, testing of the vaccine
Weill Cornell Medical College, Qatar
mainly on adult women, nonprotection against other sexually
transmitted diseases, and side effects—including some
Maya Hammoud is Associate Professor of Obstetrics and serious ones such as blood clots—were presented as reasons
Gynecology and Senior Associate Dean for Education at Weill for not obtaining the vaccine. From New Zealand, the article
Cornell Medical College in Qatar. She is a fellow of the ʻʻHPV vaccine—why are we waiting?” [3] criticizes the
American College of Obstetrics and Gynecology and current government for not funding or prioritizing the HPV vaccine,
Chair of the Undergraduate Medical Education Committee of despite the prime minister calling it an ʻʻinternational
the Association of Professors of Gynecology and Obstetrics breakthrough.” The article highlights public misconceptions
(APGO). Dr Hammoud is a United States citizen of Lebanese about fears that vaccination might promote sexual promis-
origin. She completed her medical degree and residency cuity and erode family values. In Malaysia, similar issues
training at the University of Michigan, where she joined the were raised in the article ʻʻTo vaccinate or not?” [4] following
faculty and became Director of the Obstetrics and Gynecol- concerns that ʻʻgiving the vaccination to young girls is like
ogy clerkship. She was the Interim Associate Dean for giving these girls permission to have sex.”
Student Programs before relocating to Qatar. Dr Hammoud Are these controversies misperceptions underscored by
introduced many innovations to the third year medical the media or are they evidence-based? A review of the recent
student curriculum including technology and simulations. literature on the issues surrounding the HPV vaccine has
She has run many teaching workshops for faculty develop- shown similar controversies and additional concerns that do
ment and in training residents how to teach. She is the not seem to draw as much media attention.
0020-7292/$ - see front matter © 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd.
All rights reserved.
doi:10.1016/j.ijgo.2008.01.009
124 SPECIAL EDITORIAL
The 2007 Advisory Committee on Immunization Practices' two most common high-risk HPV genotypes, which cause 70%
recommendation report on the quadrivalent HPV vaccine [5] of all cervical cancer.
summarized the studies evaluating its efficacy and con- FIGO's President, Professor Dorothy Shaw, has highlighted
cluded that the vaccine has high efficacy in preventing the major programs and priorities endorsed by FIGO's
persistent HPV infection, cervical cancer precursor lesions, Executive Board [10]. Saving women's lives through fighting
vaginal and vulvar cancer precursor lesions, and genital cervical cancer was identified as one of the high priority
warts caused by HPV types 6, 11, 16, or 18 among females action areas for FIGO. With the introduction of the HPV
who have not already been infected with the respective HPV vaccine it is important to develop effective plans that
type. The report recommended vaccination of females aged integrate immunization with appropriate cervical screening
11–12 years based on several considerations, including programs. Continuing data collection about the efficacy and
studies showing high antibody titers achieved after vaccina- safety of the vaccine, educating healthcare providers and
tion at that age, and data on HPV epidemiology and age of the public, documenting cost-effectiveness, and improving
sexual debut in the United States. The vaccine has been vaccine delivery—especially in low-income countries—are all
demonstrated to provide protection for at least 5 years with important elements for effective strategies toward imple-
no evidence of waning protection. Long-term follow-up menting appropriate programs and reducing cervical cancer
studies are underway to determine duration of protection. worldwide.
The recommendation also considered cost-effectiveness
evaluations and the established young adolescent healthcare
visit at age 11–12 years recommended by several profes- References
sional organizations. Therefore, concerns regarding the
study population are not totally unfounded, as most of the [1] Stobbe M. Ouch! Cervical cancer shots painful. Associated Press;
studies were indeed done on adult women, and the age January 3 2008. http://ap.google.com/article/ALeqM5h
recommendation was based mostly on assumptions and huO4x2Hjvo2Y-NJXxMPQpfpGYRwD8TULMF80. Accessed January
convenience. In addition, basing the age recommendation 5, 2008.
on the girls' age of sexual debut in the United States is not [2] Stuttaford T, Godson S. Is it time for a cancer jab? The Times;
necessarily applicable to other countries and cultures. December 29 2000. http://www.timesonline.co.uk/tol/life_and_
style/health/our_experts/article3103543.ece. Accessed January
As for the safety of the vaccine, which some have
5, 2008.
questioned, information is available on the Centers for [3] Azariah S. HPV vaccine — why are we waiting? New Zealand
Disease Control and Prevention website [6]. Since May 8, Doctor Online; December 19 2007. http://www.nzdoctor.co.nz/
2007, the site has received a total of 1763 reports of news?article=6d18bff6-fabf-4bff-91b2-b23d32ca087b. Accessed
potential side effects following HPV vaccination, of which 94 January 5, 2008.
(5%) are defined as serious. They include 13 unconfirmed [4] Mokhtar NA. To vaccinate or not? The Star; December 16 2007.
reports of Guillain–Barré syndrome and 4 deaths: 1 involving http://thestar.com.my/health/story.asp?file=/2007/12/16/
a pulmonary embolism, 1 involving deep venous thrombosis health/19746501&sec=health. Accessed January 5, 2008.
(both in women on birth control pills), and 2 reportedly [5] Markowitz LE, Dunne EF, Saraiya M, Lawson H, Chesson H, Unger
caused by influenza unrelated to vaccination. Therefore, ER. Quadrivalent human papillomavirus vaccine: recommenda-
tions of the Advisory Committee on Immunization Practices
none of the 4 deaths appears to be caused by the
(ACIP). MMWR Recomm Rep 2007;56:1–24. http://www.cdc.
vaccination. Such reports of serious adverse reactions gov/mmwr/preview/mmwrhtml/rr5602a1.htm. Accessed Jan-
cause fear among parents who are trying to make the uary 5, 2008.
decision of whether to administer a vaccine to their daughter [6] HPV vaccine — questions and answers for the public. Centers for
or not. Obviously, as with any other drug or vaccine, years of Disease Control and Prevention; June 28 2007. http://www.cdc.
postmarketing surveillance are required to confirm initial gov/vaccines/vpd-vac/hpv/hpv-vacsafe-effic.htm. Accessed
efficacy and safety estimates based on premarketing trials. January 5, 2008.
Additional issues that have received just as much media [7] Wright TC, Bosch FX, Franco EL, Cuzick J, Schiller JT, Garnett
attention include defining the optimal age for vaccination, GP, et al. HPV vaccines and screening in the prevention of
vaccination of males, the need for boosters, introduction of cervical cancer. Vaccine 2006;24(Suppl 3):S251—61.
[8] Newall AT, Beutels P, Wood JG, Edmunds WJ, MacIntyre CR.
the vaccine in low-income countries, and the impact of
Cost-effectiveness analyses of human papillomavirus vaccination.
vaccination on screening programs [7]. Furthermore, the Lancet Infect Dis 2007;7:289—96.
cost-effectiveness of the HPV vaccine has not been clearly [9] Kulasingam S, Connelly L, Conway E, Hocking JS, Myers E, Regan
outlined. Although the studies suggest that the introduction DG, et al. A cost-effectiveness analysis of adding a human
of the HPV vaccine could be cost-effective in certain papillomavirus vaccine to the Australian National Cervical
countries [8,9], the key variables regarding its introduction Cancer Screening Program. Sex Health 2007;4:165—75.
worldwide have not been well addressed. The vaccine is [10] Shaw D. A vision for FIGO. Int J Gynecol Obstet 2007;97:82—5.
expensive, and it will be challenging to get it to where it is
needed most to have the most significant impact. However, Maya Hammoud
the facts remain that cervical cancer is the leading cause of Weill Cornell Medical College, Qatar
death in women in low-income countries and that HPV E-mail address: mmh2004@qatar-med.cornell.edu.
vaccines are very effective in preventing the infection of the

HPV Vaccine, Not Immune To Controversy

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International Journal of Gynecology and Obstetrics (2008) 101, 123–124

HPV vaccine: Not immune to controversy

The introduction of Gardasil (Merck & Co, Whitehouse

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