TOPICS > Health

New Study Stirs Debate over Mandatory Cervical Cancer Vaccination

February 27, 2007 at 12:00 AM EDT
By age 24 over one-third of American women contract the human papilloma virus (HPV), which has been linked to cervical cancer, a medical journal reported Tuesday. Following a background report, two guests debate mandatory HPV vaccinations for school-age girls.

JUDY WOODRUFF: Ever since a federal advisory panel recommended vaccinating young girls against a virus associated with cervical cancer, the debate has grown in a number of states about whether the vaccine should be mandatory.

Now, there are new findings about the prevalence of the virus in the U.S. population that may feed into that debate. For some background, we begin with our health correspondent, Susan Dentzer.

Susan, what exactly does this study being released today say about the prevalence of this virus, called HPV?

SUSAN DENTZER, NewsHour Health Correspondent: Well, HPV, human papilloma virus, is actually a family of viruses, more than 100 of them, which cause some very common things, like warts on your hands.

But there’s a group of about 30 of these HPV viruses that are sexually transmitted, transmitted through sex either male to female, female to female, or even male to male. And those can include some that lead to such conditions as genital warts. There are about 20 viruses that are considered high risk and then an additional dozen or so that actually are linked to cervical cancer.

What this study did today — that was announced today did was look at those sexually transmitted HPV viruses, that group of roughly 30 sexually transmitted viruses, and said, how prevalent are these among women aged 14 to 59? It was the largest group of women that had ever been looked at.

What the study said was that, in that group of women, these sexually transmitted infections are about one in every four women, or about 25 million women overall, and that the rate of high-risk types of infections, the high-risk viruses, is as high as one in seven.

And for the two particular types of HPV viruses that have been linked to cervical cancer, 70 percent of cervical cancers, the rate is about one in 50.

JUDY WOODRUFF: One in 50. Is this what the researchers expected to find?

SUSAN DENTZER: More or less. There was an earlier study that looked just at younger women, adolescent women, and the prevalence rates there were lower. But, more or less, the researchers said this is about what they expected to find, in that it shows that these infections are common, they’re commonplace among women.

This is prevalence, which means it’s just a point in time. If you looked at the cumulative infections over a long period of time in all women, the rates would be higher.

But they also went on to say that the rate of infections that are linked to the cervical cancer are, as they used in quotes in the study, put it in quotes, “relatively low.”

JUDY WOODRUFF: And, just to be clear, how is the virus transmitted?

SUSAN DENTZER: Again, the sexually transmitted HPV viruses are transmitted through unprotected sex. Again, that can be female to female, female to male, male to female, or male to male.

Understanding the vaccine debate

JUDY WOODRUFF: And what do you see? I mean, Susan, you've been following the story. What do you think the significance of this survey, this study, is going to be in the growing national debate over whether this vaccine that is now out there should be mandated or not?

SUSAN DENTZER: I don't think we quite know that, although it clearly is going to feed into the debate.

Merck, for example, the manufacturer of the vaccine that is now on the market, Gardasil, says that this just underscores that there are many women out there with these infections.

In fact, roughly three million women at any point in time are going to have the four types of viruses that are protected by this vaccine, specifically two that contribute to genital warts and two that contribute to cervical cancer. So they say this just underscores what we already know.

Others say this is a reason for caution. For example, on the area of cost effectiveness of administering these vaccines on a mass basis, some are saying now we have to take these new prevalence numbers, and look at their estimates again, and see if this is really a cost-effective strategy to massively immunize young women and girls against the risk of cervical cancer.

JUDY WOODRUFF: And just quickly, we know that some types of the virus are protected against with the use of this vaccine, Gardasil, but some are not, is that right?

SUSAN DENTZER: That's correct. Again, there are roughly a dozen or more types of HPV virus that are linked to cervical cancer. The two most common are protected by the vaccine. Those are so-called type 16 and type 18, which account for about 70 percent of all cervical cancers.

JUDY WOODRUFF: And just to set up this discussion that we're going to have right after I speak with you, Susan, tell us who is lined up on each side of this argument.

SUSAN DENTZER: There's really a spectrum of opinion on the vaccines and on the mandates. On the pro-vaccine side, you have the group you mentioned earlier, the advisory committee that recommended routine vaccination for girls 11 to 12 and catch-up vaccinations for girls 13 and all the way up to women of the age of 26. Those recommendations have been taken up by groups like the American Academy of Pediatrics.

So another group of public health people who say, yes, routine vaccination is good, but mandates might be too soon to go there, in part because they want to answer some of these questions about cost effectiveness, about how effective the vaccine is over time, how long a period of time it's effective, et cetera.

Then there's a group that is for the vaccine in principle but very much against the mandates, worried about issues of parental control. Most of the legislation in various states has provisions for parents to opt out of the vaccine, but some people feel that even that is overly burdensome to parents.

And then there's a group that's opposed to the vaccine altogether. And these tend to be the groups that are worried about the effects of vaccines and try to focus on unproven, allegedly deleterious, effects from those vaccines.

JUDY WOODRUFF: And in terms of the time line, decisions being made, what are we looking at here?

SUSAN DENTZER: Well, now this is going to proceed on a state-by-state basis. And there are about 18 states where bills are in the hopper to mandate vaccinations for school-aged girls, girls of 11 or 12. But it's not clear whether that's going to happen or not.

In the one state, Texas, where the governor earlier this month issued an executive order mandating the vaccine for school-aged girls, now there's a bill in the House in Texas which probably will override that decision.

And given that there's additional concern now, specifically about the lobbying push that was made by Merck over this and the connections that the governor and his former chief of staff had to Merck, that slowed things down.

So in many states we'll just have to wait and see whether the legislation continues to move along out of concerns about cervical cancer prevention or whether at this point it's put on hold while we evaluate more of the effects of the lessons from this study and other information.

JUDY WOODRUFF: All right, Susan Dentzer, thank you very much. It's very helpful.

SUSAN DENTZER: Thanks, Judy.

Debating the mandate

Dr. Ralph Anderson
University of North Texas
I do believe that, with the statistics that have been shown earlier, that we can eradicate 90 percent of the venereal warts and approximately 70 percent of the cancers. And with that would go a great deal of morbidity and mortality.

JUDY WOODRUFF: And now, more on the debate to make the vaccine for HPV mandatory for all school-age girls.

And for that, we turn to Dr. Ralph Anderson. He is chair of the obstetrics and gynecology department at the University of North Texas Health Center. For the record, he does not have an affiliation with Merck, the maker of the vaccine.

And Wendy Wright, she is president of Concerned Women for America, a conservative group that focuses on women's issues.

Thank you both for being with us. We appreciate it.

Dr. Anderson, to you first. You believe, as I understand it, that the vaccine is not only necessary, you also believe that it should be mandatory. Am I correct about that?

DR. RALPH ANDERSON, University of North Texas Health Center: Yes. As a gynecologic oncologist, I see the ravaging effects of the HPV virus, both causing the warts and the various problems that that can create in individuals, and in the cancers of the cervix.

We have roughly 10,000 new cases of cancer of the cervix per year in this country, and we have approximately 4,000 deaths from cancer of the cervix.

I believe the medical merits of this vaccine are very real. I do believe that, with the statistics that have been shown earlier, that we can eradicate 90 percent of the venereal warts and approximately 70 percent of the cancers. And with that would go a great deal of morbidity and mortality.

In relation to the mandated portion of it, you can have opt-in and you can have opt-out policies. In using vaccinations in other areas, it is very clear that, when you use an opt-out policy, you get a larger number of people taking the vaccine than if you have an opt-in policy.

JUDY WOODRUFF: An opt-out policy meaning, just to clarify?

DR. RALPH ANDERSON: Meaning that, if parents do not wish their daughter to be vaccinated, then they can make that wish known, and it will be honored.

JUDY WOODRUFF: And just to be clear, again, what age girl, young woman, do you believe should have the vaccine?

DR. RALPH ANDERSON: It should be given prior to any sexual activity, so you can get into a debate on that, but I think the age of 11 to 12 is a very reasonable age. That is what's being recommended, and I would support that.

JUDY WOODRUFF: From 11 to 12.

Wendy Wright with Concerned Women for America, your view of this vaccine?

WENDY WRIGHT, Concerned Women for America: Well, we don't oppose the vaccine. Our problem is with mandating it, requiring that every little girl has to get it before she enters sixth grade.

Now, we are grateful for the attention that's being given to the problem of sexually transmitted diseases. There's a terrible epidemic in our country, and there needs to be more attention on that and how to prevent it.

There's one 100-percent way of preventing getting a sexually transmitted disease, and that's being abstinent outside of marriage and faithful within marriage.

And with this disease of HPV being mandated before entering school, with other kinds of mandated vaccines, it's for diseases that are contracted through the air or through simple touch. This disease is contracted through intimate sexual contact, and so this should be something that should be left up to parents to decide, not requiring that every little girl has to get it.

Safety of the vaccine

JUDY WOODRUFF: But, again, to be perfectly clear about this, you're not saying the vaccine is bad. You're saying it's fine, but...

WENDY WRIGHT: Well, you know, I think, because of these mandates being introduced in states, it's caused us to take a second look at the vaccine itself.

But, first with the mandated vaccines, about a little less than 4,000 women a year die from cervical cancer. About 36,000 people a year die from the flu, but we don't mandate that each person get a flu vaccine.

I think one reason is because the experience we had in 1970s with the swine flu vaccine and many people having complications, serious complications from taking that.

This vaccine has been tested, but in those trials people were pre-screened. People with medical conditions weren't included in it. By mandating it, it requires that the entire population, virtually the entire population of young girls, would have to get it.

That means girls that may have medical conditions that were not included in the trials, and we don't know what kind of effect the vaccine may have on the general population.

JUDY WOODRUFF: Dr. Anderson, what about that, that, in this trial, you hear Ms. Wright saying that these young women, girls, were pre-screened for pre-existing medical conditions? That wouldn't be the case if it were the general population.

DR. RALPH ANDERSON: No, it wouldn't. And you never honestly know the true effects of the side effects of a vaccine until it is tested in a large number of patients, really in the population. However, the studies that have been done demonstrate that we believe it is safe and we believe it is effective.

JUDY WOODRUFF: How confident can you be? I mean, what do you see in those studies that makes you confident?

DR. RALPH ANDERSON: Well, as I said, the Food and Drug Administration has looked at this. They have looked at the side effects, which have been really a low-grade temperature and some nausea that is transient. They have not seen any other major complications.

Now, I think it is fair to say that, whenever you use a new either drug or vaccination, that you can never be 100 percent sure. But I think the Food and Drug Administration feels very confident that, with the information they have, that this is a safe vaccine.

JUDY WOODRUFF: How do you counter that? I mean, the Food and Drug Administration, they don't green-light everything that comes through there.

WENDY WRIGHT: Well, the last time that Merck was in the news like they are now was with the Vioxx. And with Vioxx, it had shown to be safe in trials, but when it was used on a wider...

JUDY WOODRUFF: That's a very different medication.

WENDY WRIGHT: ... when it was used on a wider audience, that's when they saw complications, serious complications. That shows the difference between a trial and using it on a general population. We don't know with the vaccine what will happen with people who have conditions that were not included in the trial.

So I think, before we mandate something, let's do some more research. Let's not jump into this, and especially when you consider that the number of mandated vaccines for children has doubled since the 1980s.

In the 1980s, children were required to get seven vaccines, 23 doses. Now it's 48 doses of 14 vaccines. In that same time period, we've seen an increase in cases of autism. We don't know if there's a connection, but before we require another vaccine on top of all the others, let's do some more research.

JUDY WOODRUFF: What about that point, Dr. Anderson, and also the earlier point that we don't mandate a vaccine against the flu, and she's saying many more people die of that than of cervical cancer?

DR. RALPH ANDERSON: Well, we do know what happens to people who get the disease, who are affected by the virus and get cancer of the cervix. So I think you have to weigh the benefits versus the risk of any procedure or any vaccine that you're going to use.

There comes a time when you have to convince yourself that, yes, this will prevent significant, not only mortality, but also morbidity. One of the things that has been left out of this discussion to a great degree is what the long-term effects of venereal warts are, what that does not only fiscally but mentally to people.

People can be devastated by this. They do recur. They're a major problem. So my point is that we do know what happens if you don't give the vaccine. We don't know exactly what happens if you do get it, but we have a very good idea what happens. And I think we do believe it's safe.

Education and opt-out policies

Wendy Wright
Concerned Women for America
And as the good doctor said, people need to convince themselves. It should be up to each person's decision, a woman, in the case of an adult, or parents, in the case of minor children, whether they want to take this vaccination or not.

JUDY WOODRUFF: Ms. Wright, how much of your concern is your organization's general concern about sexual activity among young women? You included that in part of your first answer. But the fact that this vaccine would be administered to girls as young as, what did we say, 11, 12 years old.

WENDY WRIGHT: Well, the concern is that, if an 11-year-old gets it, right now it's only known to be effective up to five years. So that means, by the time she's 16, or, let's double it, 10 years, she may have to get a booster. In fact, Merck is already saying that boosters may be required.

So that means that a girl may end up having to take it twice, and even before she's sexually active, way even before she would even need it.

So what it goes back to, again, is mandating it. And as the good doctor said, people need to convince themselves. It should be up to each person's decision, a woman, in the case of an adult, or parents, in the case of minor children, whether they want to take this vaccination or not.

JUDY WOODRUFF: And, Dr. Anderson, your concern is that, if it's not mandated, then what?

DR. RALPH ANDERSON: Well, as I said before, if you set up a vaccination policy where you encourage people to opt-in, very few do opt-in, whereas if you opt-out, they don't. They do take the vaccine.

One of the things that I think has been done with this vaccine, as with other studies, is that they have shown that the more people are educated as to the value of this vaccine and to the side effects of this vaccine, the higher the rate of acceptance becomes.

And I think that there is a very good opt-out policy, certainly in the bill in Texas and in other bills across the country. So I believe that, when you're using vaccinations and you use opt-in as opposed to opt-out, you won't affect as many people.

And as far as the...

JUDY WOODRUFF: Let me just stop you there and ask Ms. Wright if that would address your concern.

WENDY WRIGHT: It doesn't, because the opt-out provision requires the parent to have to give an excuse to a government official. And they should not have to have the burden on them to explain themselves to a government official as to what their medical decisions are for their children.

So, in the case of Texas, there are private schools that follow the state's mandated vaccine list but don't accept the opt-out provisions, whether the state allows for it or not. So there are children in private schools that have been expelled from the schools because they didn't get the mandated vaccines as set out by the state.

So, again, it's putting too much of a burden on the parents. And while the public health officials may know that -- may think that they know best for everyone, in a case like this, it should be left up to parents to decide.

JUDY WOODRUFF: All right. We are going to have to leave it there. Wendy Wright with Concerned Women for America, and Dr. Ralph Anderson who's joining us from the University of North Texas Health Center, thank you both.

WENDY WRIGHT: Thank you.