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Home HPV Vaccines HPV Vaccines The HPV Vaccine Controversy: Sex, Cancer, God, and Politics Interview with Shobha Krishnan, M.D.

The HPV Vaccine Controversy: Sex, Cancer, God, and Politics Interview with Shobha Krishnan, M.D.

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Much has shifted with the HPV vaccine market in the United States over the last six months and as our understanding of these vaccines increases, more change seems inevitable. To gain perspective HPV News recently chatted with Shobha Krishnan, M.D., a gynecologist and family physician at Barnard College Health Services, Columbia University in New York. Dr. Krishnan, who has also worked with the Centers for Disease Control and Prevention (CDC) and has spent more than a decade in private practice, is author of The HPV Vaccine Controversy: Sex, Cancer, God, and Politics (Praeger Publishers, 2008).

HPV News: Since your book was published in 2008 we’ve seen a couple of developments with HPV vaccines in the U.S.: GlaxoSmithKline’s vaccine was approved, and the indication of Merck’s vaccine was expanded to include boys and young men. Do you perceive any advantage to having two vaccines on the market?
SK: I think it’s good having two products on the market because a little bit of healthy competition is good for the consumer, even though the vaccines are currently priced similarly. Each vaccine has its own advantages: the Merck vaccine covers HPV types 16 and 18 -which together are found in about 70% of cervical cancers worldwide – along with HPV 6 and 11, the types found in nearly 90% of cases of genital warts. 

The GSK vaccine covers HPV 16 and 18 and has shown higher cross-protection against other “high-risk” types of HPV, particularly HPV 31.

What do you think about including men in HPV vaccine programs?

Even though the cost effectiveness of vaccinating men isn’t compelling at present, the public health benefits of including men are very clear. The evidence shows the Merck vaccine to be effective against the HPV types that cause 90% of genital warts in men. No studies done to date have confirmed the value of the vaccine against HPV-related cancers in men – including those of the penis, anus, head and neck- but research here is ongoing and of course there may be benefit in preventing HPV-associated cancers in men, too. I’m hopeful the private and public sectors can come together to work with manufacturers in getting the price of the vaccine down. If so, we’ll see better cost effectiveness numbers. 

Another reason I think it’s good to include men in HPV vaccine programs is because doing so means that HPV isn’t seen as only a woman’s infection, so women alone don’t bear all the stigma. Particularly in conservative areas of the world, women often take a back seat to men and have much less power, and there is also a tendency to blame women for sexually transmitted infections.

What about the potential benefit of HPV vaccines with gay men?
Just as is true with the cervix, vulva, vagina, and penis, the anal canal is also a reservoir for HPV and if someone is immunocompromised then HPV has a tendency to persist and cause diseases, including anal cancers HPV vaccines can be very beneficial in men who have sex with men, even though the best time to vaccinate is around the age of 11 or 12 (because the vaccines are preventive in nature). By the time a man is sexually active with other men - or even a heterosexual relationship, for that matter- you lose the full advantage of the vaccine because by then the person may be exposed to one or more HPV types. Of course, they can still be protected against other HPV types they don’t have that the vaccine covers. 

Since the best time to vaccinate is adolescence, let’s talk a bit about parents. What kinds of questions and concerns do parents bring to you about the vaccine?

When you tell them HPV is sexually transmitted and we recommend vaccinating kids between the ages of 11 and 12, some parents are naturally uneasy. They also worry about side effects, and whether or not their insurance will cover the cost of the vaccines. 

How do you address the issue of side effects? There has been a great deal of discussion about that.
I start by saying that several million doses of the vaccine have been given, and when you give so many doses you’re bound to see a few things come up, often effects that might occur in the general population even if you didn’t administer the vaccine! It’s important to distinguish between a “side effect” and an “adverse effect.” A side effect is something we know is directly related to a vaccine, whereas an adverse effect is something that may or may not be caused by a vaccine, and typically adverse effects can take as long as six weeks to occur. 

If you look at the side effect profile with the Merck vaccine, swelling and pain at the site of injection are by far the most commonly observed; these are local reactions that last about 24 hours and resolve on their own. If you look at the adverse effects that might occur a few weeks after administration of the vaccine - and may or may not be related - the three most often talked about are fainting spells, blood clots and muscular weakness [known as Guillain-Barré Syndrome, an autoimmune disorder that can lead to paralysis]. Both CDC and the Food and Drug Administration (FDA) have looked at all this really closely and terms of fainting, half of kids in the age group we’re vaccinating have a fainting spell at some point anyway. They may be dehydrated, have needle phobia, and so on, so the recommendation is that anyone who receives an HPV vaccine sit upright in the waiting room for about 15 minutes, because most of those fainting spells occur fairly soon after the vaccine is given.

CDC and FDA found the number of blood clots in those who’ve been vaccinated is roughly the same as found in those who take birth control pills, 1 to 2 per 100,000. With the progressive muscular weakness, in the general population the incidence is about 1-2 per 100,000 and that’s what you find with the vaccine.

Scientists are still looking at this, though, to see if there might be relationship between the environment and the genetics of some people that make them react that way. The bottom line is both CDC and FDA say the vaccines is safe and effective, and strongly recommend it between ages of 11-12.

In the book you write, “The single most important factor to prevent HPV is education.” Where do we need to do a better job?
I’ll repeat that our efforts here should not focus on women alone; men should be included in the education process. 

To cover the main issues around HPV prevention, especially with young people, I point to the “A,B,C,D,E” model: “A” is for abstinence, “B” is for being monogamous, “C” is for consistent condom use, “D” is for delayed sexual activity (because it’s been shown if a person is sexually active in early adolescence the anatomy of the cervix is such that HPV infections are more likely to gain hold), and “E” is for education, including transmission and risk factors. Also, we must stress the importance of continued cervical cancer screening with those who are vaccinated against HPV, as there are cancer-associated types of the virus not covered by the vaccines.

About 90% of HPV infections clear naturally, but the 10% that persist have the potential to progress to cause diseases that, if not caught early, can cause cancer. Other factors that can play a role in this include a weakened immune system, stress, poor nutrition (particularly folic acid deficiency), smoking, and long-term use (more than five years) of birth control pills. I have to make clear the risk of HPV persistence and cervical cancer due to use of the birth control pills is extremely small, and should not be a source of great anxiety.

Details of the book, her cervical cancer projects in India and her contact information can be found on Dr. Krisnan's website. Her book is available at amazon.com and Barnes and Noble.