Dr. Bow Tie
Human Papillomavirus (HPV) Vaccine
I wrote a post three years ago, about a month prior to the COVID-19 pandemic, about HPV Vaccines. I was just starting to do more health/science communication on Facebook, and a friend had asked about it because she was facing questions about vaccinating her sons. Shortly after she asked that, there were articles circulating about mandating the HPV vaccine for school-age children, and I wrote this to address questions. I've updated it, in light of new rounds of misinformation circulating on Twitter.
WHY GET VACCINATED AGAINST HPV?
Human papillomavirus (HPV) is a DNA virus (as opposed to HIV, which is an RNA virus, or SARS-CoV-2, which is a coronavirus, and many many other viruses) that has a variety of subtypes. According to the CDC, more than 42 million Americans have been infected with HPV (of various subtypes). 13 million get infected with it each year (not all first-time infections). It is estimated that at least 36,000 will develop cancer from it (these cancers are a slowly-developing illness, so this is likely an underestimate). The most common you have probably heard about is cervical cancer (as in the cervix of the uterus), but it can also cause vaginal/vulvar cancer, anal cancer, penile cancer, assorted ear/nose/oral/throat cancers, and genital warts. It's estimated that over 84% of cervical cancers stem from HPV subtypes 16 and 18 alone. Cancer is the 2nd-leading cause of death in women, and cervical cancers are among the top five cancer types.
The HPV vaccine has been extensively studied over the past nearly-20 years. The current U.S. vaccine protects against 9 subtypes of HPV, including 16 and 18 (older HPV vaccines did not protect against this many subtypes). Most recently, a study out of Sweden that enrolled and followed women over the course of 11 years (2006-2017), showed that "the risk of cervical cancer among participants who had initiated vaccination before the age of 17 years was 88% lower than among those who had never been vaccinated." That is consistent with previous studies, which showed 91% efficacy against HPV infection (different measurement). (It also prevents transmission during childbirth, though that's rare.) Cervical cancer, even more than the others mentioned, can be a deadly disease and the fact that we have a vaccine that can prevent it by that margin is HUGE!
WHO IS RECOMMENDED TO GET VACCINATED AGAINST HPV?
Children aged 9-14 should be vaccinated against HPV (two shots intended to be given prior to exposure). If someone did not get their primary series during those ages, they are eligible up to age 26 (3 shots for increased protection in case of exposure). Beyond that, ages 27-45, the decision is between patient and physician. If you or any of your sexual partners have other sexual partners, it is worth the protection.
On TikTok, someone asked me why only up to 45? Shouldn't we prevent cancer at all ages? The answer is yes, but the logic behind this recommendation is somewhat outdated. By age 26, in the past, many folks were expected to be married to one partner, so less exposure to HPV from other sources. However, times have changed and more people are sexually active with more than one partner (or their partner has other partners) throughout their lives, so community-wide vaccination becomes more important for prevention.
Above age 45, you can still request it, but certain insurance companies may not cover it (hopefully that will change as the FDA gets with the times...or insurance companies stop trying to dictate healthcare). That said, it is still worth getting vaccinated for all the reasons I stated above.
WHY THAT YOUNG? WON'T WE JUST ENCOURAGE KIDS TO HAVE SEX?
The earlier we vaccinate, the easier it is to form lasting immunity to protect against the disease, long before exposure. Two or three shots can protect against cervical cancer.
The vaccine does NOT promote promiscuity. That’s a myth that was disproven in studies done in journals of Pediatrics (2012) and the AMA (2015).
And before you start, HPV is a very different virus compared to COVID-19, so immunity from vaccines actually can last.
DOES THE VACCINATION MEAN I DO NOT HAVE TO GET PAP SMEARS?
No. As with COVID-19, vaccines are one layer of protection. HPV is a different virus and its vaccine thankfully sustains immunity (and thankfully it is not spread as easily to create as much evolution/variation), but as with other vaccines, it does not create perfect immunity in everyone, and not everyone's immune system is strong enough to create immunity (remember - still natural, because it's still your own immune system). Therefore, we still rely on community vaccination to prevent spread, and Pap smears are still useful for early detection in case HPV infection does occur. Even if you get HPV and get cervical cancer, once you get treated for that, you are still susceptible to other subtypes which may infect and cause cancer.
BUT NOT ALL HPV INFECTIONS LEAD TO CANCER, JOE.
It’s true – not all HPV infections lead to cancer. But WHY would you take a chance if you can prevent cancer? Vaccination (with Pap smears) and prevention of infection means fewer tests, fewer procedures (like LEEPs) and less healthcare visits. One of the tenets of the oath I took is that prevention is preferable to cure. That’s why vaccines are so important.
BUT WHAT ABOUT THE SIDE EFFECTS?
Yes – there have been reports of side effects. However, beyond the usual arm soreness and mild fevers, a lot of them have been correlation without causation.
(Note, it is advised that after getting vaccinated, people should sit or lay down for 15 minutes after getting the shot if there is any concern about or to preempt fainting. Also hydrate well and eat beforehand!)
Studies looking purposefully for more serious side effects have not been able to establish causality (for example, a mother claimed that her daughter developed chronic fatigue syndrome from the HPV vaccine – they did a huge study in Norway and NO ONE developed chronic fatigue syndrome). There are no studies that show increased promiscuity or decreased fertility, thankfully - these are myths.
Interestingly, three years ago when I first wrote this, I had just learned that the Vaccine Adverse Event Reporting System (VAERS) had no verification process. It’s like Wikipedia – anyone can add anything to it, and there is no burden of proof. There are many reports of side effects, and when there is a "signal" - a pattern or an uptick in a certain side effect - it is investigated. Those investigations do not reveal causality, for which I am grateful, so that I can keep recommending this cancer-preventing vaccine.
Three years ago, my Facebook post on this subject garnered several questions and comments. They brought up some good points, some of which I have addressed in this re-write. The subject of mandates was on people's minds even back then:
I saw plenty of arguments for getting the vaccine. What is your reasoning for the necessity of removing parental, religious and medical choice?
I’m convinced I should vaccinate my children against HPV when the time comes. I’m not convinced it should be mandated in NYS public schools at age 13. I can see the arguments in favor of mandating such as ensuring all kids have their vaccination prioritized regardless of insurance, parental priorities, etc. But I think the burden of proof to mandate any medical care for a child without parental consent should be very high, I’m not yet convinced this threshold has been met.
The last three years have shown us that mandates are not always well-received. Public health has long struggled because when it works well, no one notices, and when we have an issue, public health measures may be resisted. Vaccines are more than just an individual health issue. This next part will sound like a broken record but here we go: We want to prevent disease in individuals, but for those that medically cannot be vaccinated or who, for whatever reason, do not generate the same immunity with vaccination, it’s so important to have herd immunity, which means vaccinating as many people as possible.
If we can prevent an actual cancer from taking hold in our global community, I think that’s important and achievable. It has to be about more than just each individual. The HPV vaccine is worth mandating, if we can just see past the idea of "being told what to do" in the name of cancer prevention and public health.
There are no religions that prevent or forbid vaccination.
Further, no one is removing consent. Mandates can seem difficult, but it's not just about "imposing rules." Mandated health measures help make standardization possible - all cars must come with seatbelts. All busy roads have traffic lights and lanes. Mandating vaccines (like for school) prevents insurance companies from gouging prices (more than they already do) and makes it so we can provide resources to those barriers to healthcare (such as transportation or funds). If we want to participate in public, we need to contribute to public health.
And for all of these, there are stories like this:
alright heres my story. i got the vax the first year it was offered in 06, i was 15. my mother has always encouraged all vaccinations, esp this one even tho it was so new. not bc she was concerned about promiscuity, but bc of the high risk of cervical and reproductive cancer. i will STRONGLY add that she never forced me - we sat with my drs and discussed. together we made the decision to get the vax. bc no one wants to hear that their 20-something year old child has cervical cancer when it could have been prevented. everyone needs their own reasons and motivation. i am protected bc she made a decision, with me, to protect me. as parents should. because science. okay, end rant.
So with that, I welcome questions. I highly recommend that children (and adults!) get vaccinated against HPV. Medicine is not one-size-fits-all, and the patient-physician relationship is one of teamwork. It’s my job as a physician to educate, and to explain why this is a necessity, and why this vaccine is NOT a conspiracy in any way - to convey the evidence and the research to you in a way that best enables you to prevent disease for yourself and your loved ones. Vaccination is vital!
CDC Website: https://www.cdc.gov/hpv/index.html
The Vagina Bible, by Dr. Jen Gunter. Chapter on HPV.