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HPV VACCINE

Vaccine seems to always provoke controversy, perhaps none so much as the HPV vaccine. Here we have a collision of science, sex, parenting, and money. Welcome to the Clinician's Roundtable.

I am Dr. Leslie Lundt, you host, and with me today is Dr. Gregory Zimet. Dr. Zimet is Professor of Pediatrics and Clinical Psychology at the Indiana University School of Medicine. He is also a faculty member in the Indiana University Cancer Center and holds adjunct appointments in the Department of Psychology at IUPY and in the Indiana University School of Nursing.

DR. LUNDT:

Welcome to ReachMD, Dr. Zimet.

DR. ZIMET:

Thank you. I am very pleased to be here.

DR. LUNDT:

Dr. Zimet, your research focuses on the acceptability of biomedical approaches to the diagnosis and prevention of sexually transmitted infections. What are the potential structural obstacles that may interfere with the widespread acceptance of this relatively new HPV vaccine.

DR. ZIMET:

Well, I think there are a number of structural obstacles, you know the people have talked about quit a bit. So, for instance, this is a relatively costly vaccine, so cost potentially can be an obstacle for those who do not have insurance coverage and are unable to get the vaccine through the Vaccine for Children Program, then that can be a big obstacle. Availability potentially was an obstacle initially when the vaccine was licensed and made available. There are a number of physicians, who were not able to carry it. I think that probably is less of an issue now, but availability of the vaccine may still be an obstacle for some individuals. Another obstacle that as a 3-dose vaccine, it requires young people to return twice for the second and third dose, and that can be difficult especially when you are talking about young people ages 11, 12, 13, 14 where they don't necessarily go to see their family doctor or pediatrician regularly.

DR. LUNDT:

How soon do those doses need be repeated?

DR. ZIMET:

So there is the first dose and then the second dose is given, I believe, 2 months after the first dose and then the final dose is 6 months after the first dose.

DR. LUNDT:

Oh, so really it can be a scheduling problem.

DR. ZIMET:

Yeah, it can be and if there are not other reasons for the young woman to return to see their doctor, it means making an extra trip.

DR. LUNDT:

Now, I assume that there are attitudinal factors that also interfere with this particular vaccine especially.

DR. ZIMET:

Yes, and of course, there are some attitudinal factors that interfere with any vaccine, so there are a relatively small group of parents, but very vocal group of parents, who are opposed to all vaccines, so certainly they will be opposed and are opposed to HPV vaccine. Beyond that, at least in my research and in actually several research projects, there are some parents who express concern that the vaccine may lead to sexual disinhibition, so it may lead to adolescents having sexual activity earlier than they would otherwise. Again, we are talking about a relatively small group of parents here, but parents who have that concern are less interested in having their daughters vaccinated. Some parents who are interested in the vaccine express concerns about safety and will often say that they want to wait a little while before they have their daughters vaccinated.

DR. LUNDT:

Yeah, it's amazing to hear what people have to say about this. I have a mother-daughter book club and we all have preadolescent age girls, really the prime target group for this vaccine, and I brought it up at our last meeting what people's thoughts were about their girls getting the vaccine and they ranged from, oh no! all vaccines are horrible, and you know, potentially lethal to oh my gosh! I would never do that and then one woman already had her 10-year-old vaccinated, so it's a tremendous range of beliefs out there in the public.

DR. ZIMET:

Right. There are, although I think if you're putting aside, you know, questions of parents who want to wait because they want to make sure that it's safe, the large majority of parents across multiple studies have indicated really interest in protecting their daughters from cervical cancer through use of this vaccine. I think we often tend to hear the opposition to the vaccine because it makes it appear controversial and more interesting, but I am not sure it's just widespread as it appears.

DR. LUNDT:

And what about there is some of the other thing I have heard out there is perhaps waiting because may be the vaccine will lose efficacy over time, so if you vaccinate an 11-year-old may be they will have to repeat it at age 17, is there any truth to that?

DR. ZIMET:

I think it's a combination of things. So I think sometimes there is a misinterpretation of the data, so what the research has shown so far is that both HPV vaccines, the one that's currently available in the United States and the one that is still waiting for licensure, that both of these vaccines show pretty impressive efficacy 5 to 6 years and what's happened though as those papers have been published showing efficacy for that long, people have interpreted it as saying it only works for 5 to 6 years and that's not true, it works at least 5 to 6 years. There is some evidence that the vaccines may remain effective for many many years beyond that. Definitively, it's going to be hard to say until, in fact, many years pass. I don't think that's a good reason to delay vaccination because there is every reason to believe that the vaccine will last, again, at least 5 to 6 years and probably at least 10 years, and by vaccinating an 11 and 12-year-old you are probably providing protection again for at least about 10 years, and if a booster is needed, you know, that's something that would be determined in the future.

DR. LUNDT:

If you're just joining us, you are listening to the Clinician's Roundtable on ReachMD XM 157, the Channel for Medical Professionals. I am Dr. Leslie Lundt, your host, and with me today is Dr. Gregory Zimet. We are discussing the HPV vaccine.

Tell us about your research in this area.

DR. ZIMET:

Well, I have done several studies over quite a few years now. Looking at attitudes about vaccination, focusing on several different vaccines, but including the HPV vaccine, so I've been involved in research looking at adolescent's attitudes about vaccination, parental attitudes about vaccination, and physicians and other healthcare providers' attitudes about providing vaccination. So I have been doing that kind of research for about 13 years looking at different kinds of STI vaccines including HPV vaccine. Currently, because now the vaccine is obviously available and being used, I have shifted with some of my colleagues and, you know, we are looking at predicators of actual vaccine acceptance.

DR. LUNDT:

And what is the uptake been for the HPV vaccine, are our people using it?

DR. ZIMET:

I think there is a mixed data on that, so my understanding is I do not have knowledge of sort of a national rates of vaccination, but I think it has been accepted and utilized pretty well for the targeted, you know, the ACIP CDC targeted age group, which is 11 and 12-year-old, that there has been fairly good coverage, probably not as good as public health officials and pharmaceuticals would like, but it is still been a fairly good uptake of vaccine. I think where it hasn't gone well is in the, what they call the catch-up age range, so the 13 to 26-year-old, especially as you get up into the late teens or early 20s that I think that has not been as successful in reaching those individuals.

DR. LUNDT:

Thinking about vaccines in general, why is this such a lightening rod for opinion? What is it about vaccines in general that get people so worked up?

DR. ZIMET:

Part of the issue is you are taking a healthy child and it's something that is to prevent something that may or may not happen in the future, so you are taking a healthy child, putting something inside them with the intent of preventing something that may or may not occur in the future, and I think that process is difficulty for people, not just understand, but also to feel comfortable with. From one perspective, I thought of vaccines, you know, people who are often against vaccines talk about vaccines as being unnatural, and in a certain sense, vaccines are among the most natural pharmaceutical products that we have in that what vaccines essentially do is get the body's immune system to work and it kind of identifies a passage and it says "immune systems, you know, go after this, go after this virus or go after this bacteria," so vaccines really are about getting natural immunity to kick into action in a specific way, but I think, you know, there is a lot of mythology around vaccines, there are also historically times when vaccines have caused problems and people remember that. For those reasons and others probably, vaccines have become a lightening rod in general. This vaccine in particular, I think, also for a couple of reasons, has led to a lot of scrutiny and one is because it prevents a sexually transmitted infection and the second is because of the manufacturer of the current vaccine has been under a lot of scrutiny for other issues and I have a feeling sometimes that there is this sort of desire to go after them on everything because of their problems with some other pharmaceutical products.

DR. LUNDT:

Yeah, I hadn’t thought about the spillover effect. Well tell us…

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