To Vaccinate or Not to Vaccinate…

By Ronald C. Strickler, M.D.

World-wide, cervical cancer is the leading gynecologic malignancy. In North American, 50 years of Pap smear cervical screening and hence early detection with treatment have dramatically changed our statistics. Nonetheless, we expect that there will be 13,000 new cases and cervical cancer will kill 4,500 women this year.

In parallel with the detection success story, 30 years of search has convincingly linked cervical cancer to a virus that also causes genital warts, the human papilloma virus (HPV.) Although there are tens of viral genetic variations, only a few have been found to cause human disease. Four of these serotypes, including #16 and #18 which are high probability cancer-causing infections, have been attenuated to make the newly available (since June 2006) vaccine, Gardasil® manufactured by Merck Pharmaceutical. A second vaccine which is bivalent (against 2 serotypes, #16 and #18) is expected to receive approval in 2007 (Cervarix®, Galaxo-Smith-Kline.)

Vaccines protect because the attenuated virus can not cause disease, but it does stimulate the immune system to form antibodies. When the wild virus is encountered, these antibodies inactive it before infection can cause disease. Thus, immunization is needed before one is exposed to HPV, most commonly by sexual activity.

United States secondary school student statistics shock most parents: 25% of freshmen and 75% of seniors have been sexually active in the last 3 months. These average numbers are higher for boys than for girls. These statistics have proven remarkably consistent in urban poor and suburban rich, public and private, secular and faith-based, city and rural, single gender versus gender mixed class surveys. University freshmen who are sexually active most often report 2-5 partners in their beginning lives.

These facts are shared to support three arguments:

  1. This vaccine released in 2006 will not promote sexual activity because the practice is historic and already happening. Those who make the argument that vaccination gives license to young women have chosen to ignore or to disbelieve the studies.
  2. Offering the vaccine to primary school girls (age 9 years) is not too early. The vaccine is prevention: once one is inoculated by wild-type virus, the opportunity for benefi t has been lost.
  3. Your daughter may “say no to sex.” However, if their eventual one-and-only husbands had even one indiscretion, they may silently bring the virus to the marriage bed. (Currently, there are no plans to vaccinate boys.)

HPV vaccine is recommended for all women ages 9-26 years. There are currently no screening tests to know whether one has already been infected by specifi c viral serotypes. The immunization is a series of three (3) injections (now, after 2 months, and after 6 months.) A full series gives maximal protection but immunity begins with the fi rst dose. There are few contra-indications: pregnancy, allergy to other vaccines, reaction to a dose of this vaccine, and altered immunity due to disease or medications. Side-effects such as local soreness at the injection site and mild fl u-like symptoms are similar to other vaccines. Serious reactions to vaccines occur in about 1/750,000 recipients. Insurance coverage often lags introduction of vaccines by 6-12 months: check with your insurance carrier patient representative. Ask if they will pay for one or both of: (a) the vaccine; (b) the offi ce visit for vaccination. The Michigan legislature is debating a bill that will mandate vaccination to attend public school. Perhaps this will stimulate wider availability of vaccination without personal expense.

I titled this article as a question because every scientifi c “advance” creates uncertainty and controversy. The “break-through” here is the fi rst vaccine to prevent a type of cancer. The uncertainty is whether “my daughter” needs the protection because the controversy is fueled by emotions tied to sexual transmission. Parenting is preparing the child for the potholes that we and they can neither predict nor patch along the road of life. That preparation comes in many fl avors: education, advice, role-modeling, rules, restrictions, praised-decisions, rewards. We parent to prevent harm, sadness, disappointment. We parent to promote health, joy, and good outcomes. An action that prevents inoculation by a cancer-causing virus following a personal or partner baddecision seems to me a good parenting decision, a good answer to the question, “To Vaccinate…”

Dr. Strickler is the chairperson of Women’s Health at Henry Ford Health System.

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