Editorial
The HPV Vaccine: Promises, Questions, and Controversies
Sheetal Sharma, MD
Editor-in-Chief 2007-08
One of the new features we are bringing to our housestaff is a periodic special topic review, the first of which is Dr Tracey Jablonkski’s review on cervical human papilloma virus (see Dr. Jablonski’s article in this issue). HPV, of which there are currently more than 90 identified types, has been implicated in the oncogenic development of laryngeal papillomas, genital warts, vulvar neoplasia, and most well known, cervical neoplasias. The newly approved FDA HPV vaccinations, a set of three injections, are the first vaccinations with the explicit purpose to prevent cancer. The HPV vaccination has an enormous potential to decrease cervical cancer, both here and abroad. The HPV vaccination targets 2 particular subtypes of HPV, 16 and 18, that are responsible for approximately 70% of cervical cancers. Two vaccinations, one by Merck and the other by GlaxoSmithKline, both have limited long-term data, but preliminary results are highly encouraging in both efficacy and safety profiles, with the major side effect being injection site irritation.
In the Female United to Unilaterally Reduce Endo/Ectocervical disease (FUTURE) I and II trials, the HPV vaccination demonstrated lower rates of cervical intraepithelial neoplasia or adenocarcinoma. Current recommendations by the Centers for Disease Control (CDC) based on the FUTURE I and II data, recommend early vaccination of girls and young women, prior to the age of sexual activity. Preliminary data presented to the Advisory Committee on Immunization Practices (ACIP) on the vaccine’s efficacy, demonstrated that those vaccinated at an early age have the most success. Cervical screening guidelines, however, have remained relatively unchanged, given the current lack of data regarding durability of the vaccination beyond the current study parameters.
Other questions also remain to be answered, including the importance and safety of vaccinating males, a known carrier. Herd immunity has been held as the mainstay for most mandatory vaccinations, and vaccinating males seems a logical next step, however, studies are still ongoing as to the best time for inoculation and overall safety profiles. The CDC position for mandatory vaccination, however, is only a recommendation, as individual states set their own mandatory vaccination requirements.
Controversies have arisen since the vaccines have been approved, stemming between societies’ need in preventing transmission of a known disease and the social mores and religious convictions. However, many states are in the process of mandating vaccinations, as in Texas. Texas Governor Rick Perry’s attempt to mandate vaccination of girls has come under significant fire by those suggesting it will increase the rate of teenage sexual activity. Only Virginia thus far has mandated vaccination of all those entering the sixth grade, though parents can opt out of the vaccination attempt. Other states, such as New Hampshire, have made Merck’s vaccination, Gardasil, free to all young girls, while quietly educating the populous to the potential benefits of early vaccination of young girls. As controversy continues, and regardless of one’s stand, the potential of this new class of vaccinations, unlike those of the past, will surely change the face of preventing both transmitted infections as well as possible new cancers now and into the future.