The Point of a Shot in the Wallet.
By Dr. Peter W. Kujtan, B.Sc., M.D., Ph.D.
The rapid introduction of the most expensive vaccine for public use in Canadian history has sparked a great deal of debate. Safety, effectiveness and moral debates about Gardasil are popping up everywhere. Mothers are worried, trustees are worried, clergy are worried and even us doctors were caught off guard with how quickly this program was launched, paid for and shipped off to our schools.
Human Papillomavirus (HPV) has been around for eons, and 96% of the varieties are harmless. It is spread by close intimate contact of mucus membranes. There are over a hundred varieties of HPV. To acquire a genital subtype, you need susceptibility and intimate contact with a carrier(s). Now, if you are only fishing for types 16 or 18, then statistically you need a lot of “bites”, meaning multiple partners. This is the basis of moral arguments. Like many other things we humans carry, sometimes HPV is invisible making those carriers hard to spot. Other times it may result in the growth of a fleshy wart. These warts are caused by HPV types 6 and 11, and are not linked to cancer. But types 16 and 18 have been linked to some types of cervical cancer. Gardasil targets these 4 HPV types. In Ontario, cervical cancer has fallen to 11th place as a cause of death. It is a cancer that PAP screening has dealt a mighty blow to. Theoretically, it is almost totally preventable if all women participated in regular PAP screening, since precancerous stages can be identified and destroyed. Gardasil will not eliminate or cure cervical cancer, but it may further lower the number of cases we see 25 years from now. When Health Canada approved it for use in 2006, the selling rhetoric was that it might eliminate the need for PAP tests. That is not true, and even the manufacturer stresses the need to continue PAP testing.
One company with no market competition makes Gardisil. The market price is close to $500 for all 3 shots. The National Advisory Council on Immunization (NACI) is the body of experts that evaluates vaccines. They make general recommendations, and leave it up to governments of how best to implement them. Their mandate is scientific and noble, but some members do make ethical disclosures regarding funding from pharmaceuticals. It is a part of survival in academic life. NACI rates Gardasil as a safe vaccine with side effects comparable to other routine vaccines and only released its recommendations in February 2007. Monies were dangled from federal coffers to entice provinces to spend vast more quantities purchasing vaccine and duplicating administration structures. In a few short months, the provincial government scrambled to buy and launch a program aimed at all grade eight girls. There was little forewarning or feedback sought from family doctors, and the uncanny timing just before an election is a little suspect. I have no idea of what this program costs, and am concerned for the great number of young women in my practice that it excludes. If handed $500 for healthcare, many young women would prioritize it to other health concerns. Many of my own colleagues would also apply it to multitudes of more pressing health matters, like updating 50-year-old equipment or training hundreds of more doctors. Who is going to do all the PAP monitoring after the vaccine?
I am not anti-vaccination by any means. I have a visit to Dr.Medhat Gindi’s travel clinic and two sore arms to prove it. I made an informed decision about vaccination, which did not burden the taxpayer, in preparation for my trek to the Andes. There is also nothing wrong with giving Gardasil to young men. They may not have a cervix, but they are an integral part of transmission. Not all vaccines need a massive immunization strategy to be effective. It worked with smallpox, and the results were stunning. Rabies, Hepatitis A, typhoid are examples of educated choice being effective alternatives. Avoidance of HPV or any sexually acquired infection is a topic worth discussing with young people. Morality is an integral part in this type of discussion. In the case of HPV, I suppose advocating moral ideals may be an alternative to vaccination. More importantly, I believe that in a social based health care system, noble causes and economic realities need to find an acceptable balance that involves personal choice. With the advent of recombinant DNA technology, we can expect a plethora of other vaccines such as Zostavax for shingles to soon appear (same company oddly enough), and using the “it does some good” argument, we have raised the bar to suggest the tax-payer will be saddled with every top-priced market new-comer. We need to make some hard choices about how best to devout our limited resources. The Gardasil program is a done deal, bought and paid for. Few doctors will advocate against it at this point. At this juncture I encourage open discussion, even though this program will continue to confound my ability to maintain accurate vaccination records. It is a voluntary immunization and grade eights and their parents are scrambling for opinions to make the choice. The true sadness is that in third world countries where cervical cancer is much more abundant, there is no hope of mass immunization at our prices!