Talk:HPV vaccine

Intellectual History

Someone from the University of Rochester has been posting the following text repeatedly:

"The key initial discovery leading to the development of preventive HPV vaccines was the demonstration that it was possible to block the infectivity of authentic virions of genital HPV type 11 (HPV11) with antibodies raised against the native HPV11 virions. This achievement was reported at the International Papillomavirus Workshop held in 1990 in Heidelberg, Germany, by a group of investigators from the University of Rochester (see external link below: "A Cancer Vaccine is Born"). The same group then developed a method for recreating the three-dimensional structure of the HPV11 viral outer shell, or capsid, in a non-infectious form, and demonstrated that HPV11 "virus-like particles" (VLPs) were capable of efficiently inducing HPV11 virus-neutralizing antibodies. Following this, the Rochester group generated VLPs of the two most prevalent cancer-causing HPVs, i.e., HPV types 16 and 18, and showed that they too were highly immunogenic and, importantly, were also antigenically distinct from one another, and from VLPs of HPV11. The new HPV vaccines thus consist of non-infectious VLPs, produced from multiple genital HPV strains, that replicate the immunologic properties of native virions, including the ability to induce conformationally dependent capsid-specific virus-neutralizing antibodies."

In truth, the development of the HPV vaccine was a incremental effort by laboratories based in the United States and Australia, with input from laboratories around the world. Pharmaceutical companies have also played a major role in developing methods to manufacture the HPV vaccine. IMO, the above posting is a biased viewpoint that doesn't reflect the more complicated origins of the HPV vaccine. The McNeil article listed on the main page gives an overview of the key published research underlying the vaccine's development. Chackerman

Controversy?

Is there a real scientific, medical controversy, or is it just hype? I would consider is controversial if a scientist had evidence that it didn't work or caused problems, but not if a PAC representative rants about it. Could someone shed light on this?

The only controversy is of a moral nature. I actually cannot imagine the mindset that finds even that controversial, but I'll spare you the rant. --Suttkus 00:53, 14 June 2006 (UTC)

My problem with the Bambenak article is that is just presents the viewpoint of a single (and IMO misinformed individual). I think a better reference that reflects the viewpoint of the "mainstream" christian conservative movement is the the Washington Post opinion piece that I've inserted. While I don't agree with the viewpoint, I think it presents a reasonable discussion of the viewpoints of this community. --Chackerman

I agree with Chackerman - the article should use the Washington Post ref. The clinical trial data clearly shows that vacinated women are 100% protected against the development of high-grade cervical dysplasias caused by the HPV types in the vaccine. Since high-grade dysplasia is a required step in the development of full-blown cervical cancer, it is logical to say that the vaccine offers at least some protection against cervical cancer. By mis-characterizing the views of "medical community elites," the Bambenak article is using a straw-man fallacy to manufacture controversy where none actually exists. Retroid 20:22, 13 August 2006 (UTC)

The Washington Post has a bias, FYI - Anonymous —Preceding unsigned comment added by 75.185.32.240 (talk) 22:15, 1 June 2008 (UTC)

The article doesn't talk about what kinds of clinical trials there were and for how long. Can anyone add this information? —pfahlstrom 06:25, 20 January 2007 (UTC)

I attended a lecture by one of the doctors in charge of University of New Mexico Hospital's clinical trial. She said she was afraid that the vaccine would have the opposite effect through social factors. The vaccine works, she said, but only on women who never had sex before. She feared that marketing it to the public would have a series of disastrous side effects:

• Women who have already had sex and who are misinformed would have the vaccination ineffectively, either as a "cure" or because they think it'll still work.
• Women who had it would avoid pap smears and cervical screenings, thinking they were completely safe.
• Women who took it might have more sex, or unprotected sex, thinking it was safe.
• Parents might deny the vaccine to their daughters, thinking it promotes early, promiscuous, or extramarital sex.

She is also worried about the (currently stable) sexually transmitted HPV ecology; if these strains are wiped out or minimalized, other strains will take their place. She did advocate a government program to vaccinate all girls by age 10 (!), because that's the only way to be sure they're not sexually active yet. However, she had little hope of that happening.

After hearing her speak, I agree with all of her positions, because they seem to me to be well-reasoned. --BlueNight 17:28, 7 February 2007 (UTC)

BlueNight, what makes you say that the vaccine only works on women who hadn't had sex before? That statement doesn't seem very plausible, only in magic spells does the virginal quality of a woman have an absolute block on the nature of their immune system. Moreover, HPV is one of the lesser known sexually transmitted diseases among laypeople. Women might have more or unprotected sex if they had a vaccine for Syphilis, or Chlymidia, but most HPV infections don't even lead to a problem. 66.41.66.213 04:01, 23 February 2007 (UTC)

Concerned Women For America, has a video on their website about the use of this vaccine maybe we should have a link to it.

BlueNight, I suspect that there was a subtle misunderstanding about what the UNM doctor was saying. Probably she was making the point that only someone who had never had sex before can know that she is not already infected with a high risk strain of the HPV virus, and once she is infected the vaccine won't help (with that strain). Also, there is reason to believe that the "sexually transmitted HPV ecology" (as you put it) is far from stable. In the U.Wash. study, 82% of new high-risk HPV infections were with strains of HPV other than types 16 & 18. Does that means that the HPV vaccines can only prevent 18% (rather than 70%) of future cervical cancer cases? (If you know the answer to that question, please answer it here!) If so, then even very small social effects of the sorts that your UNM doctor mentioned could exceed the preventive effect of the HPV, leading to a net increase in cervical cancer. NCdave 14:20, 29 June 2007 (UTC)

I have heard the arguments that BlueNight pointed out before. It seems like there was some news story I saw on it once. That would actually be a good item to add to the controversy section for informative purposes; of course, it should properly source a person or group who is raising these concerns and, assuming it is necessary, a properly sourced disclaimer. Here's a site I found containing a bit of information on this issue of having the vaccine before becoming sexually active. [1]Bradkoch2007 04:14, 8 October 2007 (UTC)

Strains 6 and 11

This is expected to help market the vaccine to men, who may otherwise have no interest in taking a drug that doesn't benefit them directly.

While this undoubtedly has some truth to it, isn't it a little crass to write this off as a mere "marketing feature"? Genital warts are a legitimate medical malady by any definition. It's not as though vaccinating against these strains is a purely cosmetic afterthought. --Peter Farago 16:52, 31 January 2006 (UTC)

Please change "that doesn't benefit them directly" to something more sensible. --JWSchmidt 16:55, 31 January 2006 (UTC)

I've replaced it with a relevant quote from a Merck spokesman. --Peter Farago 03:39, 16 February 2006 (UTC)

The significant feature to adding the non-cancer strains to the HPV vaccine (6 & 11) maybe going unnoticed here. Adding protection against these two commonly found strains of the virus will have the added benefit of reducing the incidence of mis-read or false positive Pap smears. This will reduce the need for costly retesting and will no doubt reduce the anxiety factor many wonen experience when recieving a 'positive' pap result.--BeohBe 16:42, 22 September 2006 (UTC)

Contraction after marriage

Some people oppose the vaccine because they think that it will encourage women to have sexual activity before marriage. However, a woman can contract the virus from her husband. They might counter this by saying that you should not marry someone who has sex before marriage, but it only takes a single exposure to get it and a person can usually conceal their sexual history, especially when it is limited. Also, some people get the disease from their mother, so they cannot be blamed for getting it (it is rare and a vaccine won't help them, but it would have prevented their mother from getting it). They can also pass it on to their husband or wife, with neither one of them having sex before marriage.

Also, I don't think that fear of cervical cancer is a major concern for women when deciding to engage in sexual relations. Pregnancy and AIDS are probably the most important concerns. Other diseases might cause concern, but they are not usually considered individually. People are usually only concerned with an individual disease when they have personal experience with it, such as getting it before (for bacterial diseases and crabs, which can be cured), knowing someone who had/has it or exposure to detailed information about it. Even if someone is concerned with an individual disease, it might not be HPV. Even if they are concerned about HPV, they are probably concerned about getting genital warts, not cervical cancer.

Should the article mention any of this? The first point is rather obvious, except the part about the ease of concealing past sexual activity, so I would not consider it original research. The second one is just speculation and should not be used, though it might be good to check if someone has made such an argument before. -- Kjkolb 21:34, 19 March 2006 (UTC)

NPOV

Extremists of the religios right? That isn't NPOV. I am going to change it. The entire contrversy section has the same problem.

Not so much controversy anymore

The lack of major public objections at the CDC's Advisory Committee on Immunization Practices hearings demonstrates that a broad consensus has been reached. Conservative religious groups appear to have realized that blanket opposition to a vaccine against cancer is bad PR, and public health officials appear to have conceded that mandatory vaccination is not likely to be feasible in the near future. Discussion of the RU486 debate in Australia seems somewhat off topic for an article about HPV vaccines. I streamlined the section, reflecting the fact that some initial controversy over the vaccine seems to have pretty much faded. Retroid 20:52, 4 August 2006 (UTC)

It doesn't matter if it's faded; we'd still report on what was present in the beginning, but I think you're basically right; there really wasn't that much opposition in the first place. — Omegatron 23:10, 4 August 2006 (UTC)

Most of the conservative religious folks now publicly say that they were mis-quoted back in the beginning. Which seems plausible given the media's tendency to accentuate conflict where little may really exist. So I'm especially uncomfortable with the hear-say quote about "going to sabotage our abstinence message." In this case it would be particularly important to use actual quotes from the original people. Retroid 14:29, 5 August 2006 (UTC)

More about the controversy

I don't want to play up the controversy, but it seems to me like there's precious little about it, considering how much of a big deal it was. I'm a very new Wiki editor and I don't want to go this alone, but I went to this article expecting to find more information than I did, as well as almost no citations. Can't we do better? Kagechikara 20:46, 6 October 2006 (UTC)

I don't think it was ever controversial among Christian conservatives. However, the price (and the inconvenience of having to get a series of three injections) have caused some complaints[2].

Also, there is some reason to believe that the vaccine's protective benefits are overstated. The Winer / U. Washington study[3] found that only 14 of 78 infections with high-risk types of HPV were types 16 and 18, the two high-risk types prevented by the vaccine. The other 64 high-risk infections were with 16 other high-risk types of HPV. NCdave 19:32, 24 November 2006 (UTC)

The new section on adverse reactions used tertiary reports going back to a download from the VAERS database by judicialwatch.org. I have replaced the "sources" by the VAERS downloads available on judicialwatch.org, and included some words of caution from the VAERS site. I have also removed the heading "Vaccine killed a 12-year-old girl" which seems over-assertive in view of the cautious words on the VAERS site, and replaced it with "Possible adverse reactions". Richard Keatinge 23:53, 26 May 2007 (UTC)

Number of sexually transmitted types of HPV

The article said that 30 strains are adapted for transmission by sexual contact. However, the Winer / U. Washington study (in the NEJM last June)[4] checked for 37 such strains, not just 30[5]. So I've changed the article to say 37.

The article also said that about a dozen types put women at risk of cancer; however, the Winer / U. Washington study listed 19 high-risk types (18 of which they encountered among the small group of U. Washington students who they studied). So I've changed "about a dozen" in the article to "about 19." That's a kind of funny phrase... does anyone think it should be "about 20," instead?

It is also worth noting that, unfortunately, the 126 new HPV infections detected in the Winer / U. Washington study included infections with 30 different types of HPV, not just 4. Only 21 of the 126 infections were of the 4 HPV types which can be prevented by the Gardasil vaccine. Only 14 of the 78 new infections with "high-risk" types of HPV were types 16 & 18, which can be prevented by the vaccine. 64 of the 78 high-risk infections were with any (or, in some cases several) of 16 other high-risk HPV types. NCdave 19:50, 24 November 2006 (UTC)

I've noted this result from the the U.Wash. study in the article. Also, I've added the word "currently" where the article says that the vaccines are thought to prevent 70% of cervical cancer cases, since the use of the vaccine will presumably reduce the prevalence of types 16 & 18 in the future, relative to the prevalence of other HPV types.

But I also have a question. In the U.Wash. study, only 18% of HPV infections with high-risk types of HPV were types 16 & 18. The other 82% of those infections were other high-risk types (types not protected against by Gardasil). Yet 70% of cervical cancer cases are said to be associated with type 16 or 18 (a statistic which I presume comes from tumor pathology). That seems to indicate that one or both of the following two factors must be at work. Either:

• 1. The "mix" of HPV strains in circulation is changing. 70% of high-risk infections 30-40(?) years ago (when most current cervical cancer victims presumably became infected) were types 16 & 18, but now other high-risk strains predominate. And/or,
• 2. The carcinogenicity of types 16 & 18 is higher than most of the other high-risk strains of HPV. The reason most cervical cancer victims have types 16 & 18 is that the other high-risk strains are less likely to cause cervical cancer than are types 16 & 18, or when other types of HPV cause cancer it develops later or more slowly than does cancer caused by types 16 & 18.

Does anyone know which of these two hypotheses is correct? Or is there another explanation that I've not thought of?

The answer to that question has important health and public policy consequences. If the carcinogenicity of the other 17 known & suspected "high-risk" strains is similar to that of types 16 & 18, but the mix of HPV strains in general circulation has changed, then the advertised 70% effectiveness of these vaccines is wrong. If that is the case, and the U.Washington numbers are typical, then the vaccines will probably only prevent about 18% of potential cervical cancer cases, rather than 70%, like getting a flu shot with last year's flu vaccine. Worse yet, if the vaccines turn out to be drastically less than 70% effective, then it is quite possible that a false sense of security from vaccination could cause behavioral changes (e.g., fewer PAP smears and/or riskier sexual behavior) that would actually increase the incidence of cervical cancer. NCdave 10:14, 22 June 2007 (UTC)

The lecture I attended by a researcher who worked on it said she foresaw riskier behavior due to misinformation and misunderstanding; non-virgins getting vaccinated, more unprotected sex, fewer pap smears, etc. The questions were raised of the other strains taking the place of the ones vaccinated against, and of new mutations / genetic drift making the vaccines obsolete. The impression I got from her response was that continued research and continued refinement were the main goals, with behavioral awareness an equal partner in reducing or eliminating the threat. She also stated point blank that the strains being vaccinated against were the most the most important to eliminate; I don't remember if they were most virulent or most prevalent, or both. Sorry I wasn't much help, I haven't read any literature on it lately. --BlueNight 05:30, 30 June 2007 (UTC)

I thank you, BlueNight. Thus far, you are the only person to attempt an answer, though I sent direct messages soliciting responses to several Wikipedia editors whom I thought might know something about this. It certainly seems an important question: it is the difference between 70% protection and 18% protection from cervical cancer.

Are you in contact with the researcher whose lecture you attended? If so, would you mind posing this question to her? NCdave 08:28, 1 July 2007 (UTC)

I think the question is what study came up with the 70 percent figure. I looked at the cited reference, which states "HPV16 and HPV18 predominate, accounting for about 50% and 20% of cervical cancer, respectively " The reference for this was given as PMID 15197783, a 2004 study involving about 3600 samples from 25 countries. The University of Washington study only used 82 women, all from the U of W. I'm sure there are also a lot of differences regarding the type of study and the type of analysis used, which I am no good at interpreting (you may want to ask over at WP:MED), but it seems that the 2004 study was broader in scope and designed to identify the most high risk virus strains, while the U of W study looked at the ability of condoms to prevent HPV infections. --Joelmills 14:50, 1 July 2007 (UTC)

NCdave asked me for some comments with regards to the above. First, I'd like to say that you should be cautious about relying on one source, even if it is peer-reviewed and even if it is in a top medical journal (e.g. NEJM, JAMA, Lancet, BMJ, CMAJ). Medical opinion is usually based on several studies.

Whether it is 19 or 20 strains... probably isn't that important. That said, I think referencing the numbers is a good thing-- 'cause the previous ones may have just been made-up. Any case, the key is-- what's the risk-benefit relationship and the cost-benefit relationship. I think for both there is broad consensus that a HPV vaccine is a good thing-- good risk to benefit... good cost to benefit.

Specifics -

As far as I know the carcinogenicity of types 16 & 18 are higher than that of the other types-- this is what I remember from med school. Here is a ref. from a review paper: PMID 17366752. Expanding a bit on what I wrote above-- it is probably better to work from review articles than primary studies, if you don't have a good overview of the literature.

As for risky behaviour increasing due to HPV vaccines, I think it is just speculation. Besides, for any one that has had basic sex ed-- there is still AIDS, chlamydia, syphilis, gonorrhea, PID and pregnancy. Also, I don't think sexual behaviour got more careless with the introduction of the hepatitis B vaccine. Beyond that, a classmate of mine did a survey of why pap tests are done-- most women didn't know pap tests are cervical cancer screening. Nephron  T|C 05:48, 2 July 2007 (UTC)

NCdave asked me for some comments as well. I agree with Nephron, the higher rate of cancer associated with 16 and 18 is related to the fact that these strains are more oncogenic. Chackerman 15:57, 28 September 2007 (UTC)

Only for young women--WHY?

Young bisexual males are at increased risk for HPV (increased prevalence among gay men).

They can also pass that virus along to women.

WHY is it that no doctor or clinic will administer the vaccine to young men??

This makes NO SENSE in addition to being sexually discrimatory.

Why is a heterosexual woman's risk for cervical cancer more important than a bisexual male's risk for colon cancer??

As far as I can tell there is no shortage or harm in allowing young men to be vaccinated.

I'm really curious why this hasn't been proposed. Epidemiologically, it makes as much sense (or more) to vaccinate the potential carriers as to vaccinate those at most risk of being significantly harmed. Especially as one infected male can expose numerous females to the virus. Similar to a test they did a few years back in a small town on the winter flu shots where, instead of vaccinating the elderly (at greatest risk of harm), they vaccinated all the schoolkids, the primary transmission vector. Fan-1967 18:30, 3 January 2007 (UTC)

In Australia, the vaccine is licensed for boys and girls. The FDA is currently working on licensing the Gardasil for both sexes but there is a shortage of research to back up the green light for universal vaccination. —Preceding unsigned comment added by 65.189.39.96 (talk) 03:37, 13 December 2007 (UTC)

HPV is a risk for Colon Cancer in Gay/Bisexual Men

Why is this not mentioned anywhere on this page?

It is important that the vaccine be offered to young men as well (if not the entire population).

HPV is a risk factor for the development of anal cancer, not colon cancer.64.234.168.255 21:40, 10 April 2007 (UTC)

Lifetime or booster?

Is this a one time only vaccine, or should you get one every ten years or five years to get the full benefit? And while we're at it, will its' effectiveness be such that women who have had the vaccine can stop having pap smears? 66.41.66.213 04:06, 23 February 2007 (UTC)

We don't know how long the vaccine lasts just yet. That's one of its critics' key arguments. Since the vaccine blocks only two of the about ten strains of HPV that cause cervical cancer (albeit the two that cause about 70% of the trouble), it is recommended that women NEVER stop seeking Pap smears. Most of this can be referenced on cancer.org.Darkfrog24 17:06, 2 May 2007 (UTC)

Addendum. One source (see article) now says that we can expect the effects to last at least four and a half years. Darkfrog24 15:24, 15 May 2007 (UTC)

The Winer/U.Washington (NEJM) study tested for 19 different high-risk types of HPV, which are known or suspected to cause cancer. They encountered new infections with 18 of the 19 high-risk types. NCdave 10:23, 22 June 2007 (UTC)

Have there been any studies that show the long term side effects of the vaccine (e.g. 10-50 years after initial dosing) and when it's administered more than once for a booster? —Preceding unsigned comment added by 75.185.32.240 (talk) 22:25, 1 June 2008 (UTC)

Since the vaccine is a recent development, probably not, though research is underway. Since the vaccine contains no active or self-replicating components, can expect that it will be cleared from the body fairly rapidly (e.g. in days to weeks). In the absence of immunization, high risk HPV viri, on the otherhand, may take years to clear the symptoms of infection, and the virus itself might never be cleared from the body (it isn't known at this point whether it is cleared or not). So long term side effects are much more likely with the HPV virus (which might be around long term) than they are with the vaccine (which is only present for a short time). Zodon (talk) 22:00, 3 June 2008 (UTC)

No really good evidence of just how effective cervical/Pap smears are

I've changed the text to reflect the fact that nobody ever did a randomized trial to find out if cervical screening actually prevented cervical cancer. I assume that the programme does prevent some cases, it certainly vaporizes a good many abnormal cervices, but cervical cancer is a disease of poverty and was declining from way before smears were invented. This page isn't the right place for discussing that issue, which is complicated, difficult, controversial, and inconclusive, with poor evidence and many "experts" with a stake in perceiving the programme to be effective and successful, but I have changed the text to something defensible. —The preceding unsigned comment was added by Richard Keatinge (talk • contribs) 10:06, 24 April 2007 (UTC).

I think you need to cite the literature to back up this controversial statement.Chackerman 21:38, 25 April 2007 (UTC)

Fair comment. Here we go, some items from the British Medical Journal, not in any way a systematic search but illustrating the point that an academic and well-respected professor of surgery (he specializes in breast surgery and screening) can seriously suggest that screening is not particularly useful, that the evidence for usefulness - there is some, the present UK program probably does have a useful effect- is based on disputable evidence, cohort analysis rather than trials, and that some "experts" do overstate what evidence there is:

"BMJ 1999;319:642 ( 4 September ) Letters

EDITOR---We were rather non-plussed to read that the conclusion of the paper by Quinn et al on screening for cervical cancer1 is not supported by their data, and we wonder whether so called political correctness had anything to do with it. The statement "800 deaths might have been prevented in 1997" is based on a projected mortality of a completely arbitrarily (alas, not randomly) selected part of a subset of graphs showing trends in mortality. (snip) Jayant S Vaidya, honorary lecturer in surgery. j.vaidya@ucl.ac.uk

Michael Baum, professor of surgery. Department of Surgery, Royal Free and University College Medical School, University College London, London W1P 7LD

Authors' reply

EDITOR---The conclusions in our paper are not based solely on the analysis of mortality. We presented strong evidence that the introduction of national call and recall and of incentive payments to general practitioners led to a dramatic fall in the incidence of cervical cancer in women in all age groups from 30 to 74 and in all regions of England. (snip) We remain deeply concerned about the many well known problems with cervical screening which we mentioned in our paper: cervical cancer is a comparatively rare disease and its natural course is not well understood; the smear test has both low sensitivity and low specificity; many tests are technically unsatisfactory and the proportion of such tests varies widely across the country; the mix of three and five year screening intervals is inequitable; too many smear tests are opportunistic; and the programme costs four times as much as breast screening. Nevertheless, there is now conclusive evidence that cervical screening has markedly reduced both incidence and mortality.

M J Quinn, director, National Cancer Registration Bureau. P J Babb, senior cancer epidemiologist. J Jones, cancer epidemiologist. Office for National Statistics, London SW1V 2QQ"

And, earlier:

"BMJ 1997;315:953-954 (11 October) Letters (snip) A fall in the number of deaths from cervical cancer occurred in each successive cohort this century. This trend predated screening.

(snip about overstated claims for effectiveness) It may be that deaths from cervical cancer in women born since 1930 are being halved by screening. If so, then the number of deaths in 1995 would have been 2000 in the absence of screening instead of 1339 (which would represent a doubling of the observed 661 deaths in women born since 1930). This saving of hundreds of lives comes at a high cost. Department of Health statistics show that in England and Wales each year about 800 000 women have abnormal smears; 166 000 of these abnormalities are severe enough to warrant referral for investigation and treatment. A tiny minority of these women are actually helped.

The NHS cervical screening programme is among the best in the world, and 30 years' experience has shown much about the inherent complexities and limitations of early detection as an approach to preventing cancer. It is easy to make simplistic claims about screening. In the long term we will do more for the public by being honest.

A E Raffle, Consultant in public health medicine a

a Avon Health Authority, Bristol BS2 8EE "

I hope this helps. As I say, this page isn't really the place for a long argument about a different subject. Richard Keatinge 09:35, 26 April 2007 (UTC)

I don't think that a couple of letters to the editor in the BMJ really constitutes much evidence. Here's what the US National Cancer Institute has to say on the matter (see http://www.cancer.gov/cancertopics/pdq/screening/cervical/HealthProfessional/page3 for references)

"The Papanicolaou (Pap) test has never been examined in a randomized controlled trial. A large body of consistent observational data, however, supports its effectiveness in reducing mortality from cervical cancer. Both incidence and mortality from cervical cancer have sharply decreased in a number of large populations following the introduction of well-run screening programs.[1-4] In Iceland, the mortality rate declined by 80% over 20 years, and in Finland and Sweden by 50% and 34%, respectively.[1,5] Similar reductions have been observed in large populations in the United States and Canada. Reductions in cervical cancer incidence and mortality were proportional to the intensity of screening.[1,5] Mortality in the Canadian provinces was reduced most remarkably in British Columbia, which had screening rates 2 to 5 times those of the other provinces.[6]

Case-control studies have found that the risk of developing invasive cervical cancer is 3 to 10 times greater in women who have not been screened.[7-10] Risk also increases with long duration following the last normal Pap test, or similarly, with decreasing frequency of screening.[11,12] Screening every 2 to 3 years, however, has not been found to increase significantly the risk of finding invasive cervical cancer above the risk expected with annual screening.[12,13]"

64.234.168.255 22:42, 26 April 2007 (UTC)

Thanks, I've reworded the paragraph to give what I hope is a more NPOV on the subject. I really don't want to involve this page in a long and peripheral argument, but if you really want a full literature search I'll do one! I do think it's worth making the point that HPV vaccines probably offer even better protection than screening at the moment, and the two programs can be combined. Richard Keatinge 09:10, 27 April 2007 (UTC)

I think the new wording is fair and supported by the data. Chackerman 16:43, 27 April 2007 (UTC)

speaking of NPOV, has anyone taken a look at the 2 may revision? It seems like a rather clumsy politically motivated revision.

I found a source on Pap smears. The American Cancer Society credits them with the drop in cervical cancer rates since 1955: http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Cervical_Cancer_Rates_Continue_to_Drop.asp

EDIT: The actual link is a discussion of an article that appeared in Obstetrics & Gynecology.

Darkfrog24 14:05, 17 May 2007 (UTC)

I'm confused, Darkfrog24. The 2 May version was your own, and it was just a tiny wording improvement. Are you referring to something that was still in the 2 May version, but was left over from an earlier version? Like maybe this 21 February, 2007 zing by Kalmia against Gov. Perry? If so, then I agree with you, that was pretty blatant. But it appears that the worst of it, at least, has already been cleaned up. NCdave 10:48, 22 June 2007 (UTC)

I was not talking about the May 2 revision at all. My comment, made on May 17, starts with "I found a source on Pap smears." Darkfrog24 18:03, 22 June 2007 (UTC)

Merger proposal

The vaccination schedule & policy stuff really does not belong in the product articles (like Gardasil, Cervarix) but should be moved here instead - at least the Gardasil article still has stuff which would belong here instead. --Jkpjkp 21:13, 25 August 2007 (UTC)

agreed--IronAngelAlice (talk) 18:30, 12 December 2007 (UTC)

Agree - a lot of the policy etc material seems to be dupliated in the Gardail article. Material that applies to HPV vaccines in general should go to the HPV vaccine article instead. Zodon (talk) 18:34, 19 May 2008 (UTC)

Prevalence section

The HPV prevalence section doesn't belong in this article. The prevalence of HPV has (as it very well should) a section in the HPV article. But this article is about the vaccine. Except for what information has been written that pertains to the vaccine itself, there is no need to fork content over from the main article. Such information may provide a useful background for the need of a vaccine, but lengthy discourse should be forgone for a brief summary and link back to the main article. If a reader wants to know about the virus that this vaccine prevents, he can follow the handy link in the introduction. Someguy1221 (talk) 02:00, 28 December 2007 (UTC)

I cut down the HPV Prevalence section, creating a more succinct summary. I also added references and information about how HPV prevalence is pertinent to the discussion of the HPV vaccine.--IronAngelAlice (talk) 02:14, 28 December 2007 (UTC)

Religious Right and Conservative Groups Section

Previous description of FOF and FRC position was somewhat ambiguous. "Expressed concerns about this." I clarified their actual positions with links to policy statements from each organization. Both "support widespread (universal) availability of HPV vaccines but oppose mandatory HPV vaccinations for entry to public school." The FRC is even more adamant on it's page: http://www.frc.org/get.cfm?i=IF07B01

Q: Does the Family Research Council oppose development and distribution of an HPV vaccine?

A: No, FRC believes that Gardasil and other HPV vaccines represent a tremendous advance in preventative medicine. FRC advocates for widespread availability and distribution of the vaccine to both girls and young women. Forms of primary prevention and medical advances in this area hold potential for helping to protect the health of millions of Americans and helping to preserve the lives of thousands of American women who currently die of cervical cancer each year as a result of HPV infection.

Q: Would vaccinating individuals against a sexually transmitted disease lead them to be more sexually active?

A: Not necessarily. If vaccination is handled properly, accompanied by medically accurate information and the right message, it could even have the opposite effect. Vaccination at the beginning of adolescence may provide a unique opportunity for both health care providers and parents to discuss with young people the full range of issues related to sexual health. FRC has recommended that policy-making bodies, such as the American Academy of Pediatrics, should develop and formalize clinical counseling interventions directed toward sexual risk avoidance (also known as abstinence) strategies for adolescents. Such strategies mirror the risk avoidance messages presented to adolescents regarding tobacco, alcohol, and drug usage, and youth violence prevention. The sexual risk avoidance/abstinence message is the best form of primary prevention youth can receive to prevent HPV infection, as well as the wide range of sexually transmitted diseases and associated physical, emotional, and social consequences. The adolescent sexual risk avoidance/abstinence strategy is also the best form of prevention to protect a female's future fertility.Ghostmonkey57 (talk) 01:11, 4 January 2008 (UTC)Ghostmonkey57

I am confused as to why the "Response" section immediately succeeds the section referencing the policy of FOF and FRC. The response seems to address concerns about availability of the vaccine leading to increased promiscuity. The FRC position specifically states that vaccines would not necessarily lead to increased sexual activity. Why is the response directed at the FRC when the FRC doesn't hold that position? Ghostmonkey57 (talk) 01:14, 4 January 2008 (UTC)Ghostmonkey57

Excellent catch Ghostmonkey. I like the edit you already made regarding this topic. I did some additional research on this topic and found the following:

• Tony Perkins, President of the Family Research Council - ""Our concern is that this vaccine will be marketed to a segment of the population that should be getting a message about abstinence,” said Tony Perkins of the Family Research Council. He would not inoculate his own daughter, because she would be more inclined to have sex outside marriage. “It sends the wrong message.” (Fortune Magazine, October 17, 2005, Guyon J, Cancer and the culture wars: the coming storm over a cancer vaccine.)
• Leslie Unruh, Executive Director of the National Abstinence Clearinghouse - “I personally object to vaccinating children against a disease that is 100 percent preventable with proper sexual behavior.” (http://www.nam.org.uk/en/news/3429199D-5FE5-4795-B0E6-CD957617C160.asp)
• State Sen. George Runner of California - "State Sen. George Runner of California told the Los Angeles Times that American money would be much better spent on other types of vaccines, since cervical cancer is a result of lifestyle choices, rather than bad genetic luck." (http://www.slate.com/id/2174850/)
• Andy Schlafly of the Conservative "Eagle Forum" - "This vaccine is a loser. Imagine a vaccine that told young teenagers that if they took this vaccine, they would be protected against getting lung cancer, so they can go out and smoke. It's not true. It's not true of lung cancer, it hasn't been shown with this vaccine. The average age of diagnosis for cervical cancer is 48 years old. But they propose to give this vaccine to 11-year-old girls. Not even Merck says the vaccine will last nearly that long. Merck says they don't know how long the vaccine will last." (http://mediamatters.org/items/200702050010)
• "A Vital Discussion, Clouded" NYTimes.com - "Cervical cancer is caused by a sexually transmitted virus, and the message from some quarters is that a decent young woman shouldn’t need this vaccine... For example, Focus on the Family, a Christian advocacy group in Colorado Springs, says that instead, a woman should simply avoid the virus by not having sex before marriage. Even some who think that abstinence is unrealistic still imagine that this kind of disease does not happen to a girl who’s had only a boyfriend or two."

With regards to the question of an increase in promiscuity following vaccination, I found the following articles:

• "HPV Vaccine Unlikely To Increase Teen Sexual Behavior, Researcher Says" MedicalNewsToday.com
• "Defusing the War Over the 'Promiscuity' Vaccine" Time.com
• "Catholic schools okay HPV vaccine" The Toronto Star

--IronAngelAlice (talk) 06:13, 4 January 2008 (UTC)

I'm not saying that some groups might have suggested that the vaccine would increase sexual activity, but only that the official policy of the Family Research Council is that the vaccine would NOT necessarily increase sexual activity, and if handled properly, might have the effect of DECREASING activity. With the response section immediately following the section after the FRC and FOF, it makes it seem like the response was to a position that the FRC doesn't hold. Perhaps rewording the intro to that section to something along the lines of: "In response to the suggestion that the vaccine would increase sexual activity..." This doesn't make it seem like it's directed at the FRC, but rather other groups who might have suggested such a thing.Ghostmonkey57 (talk) 13:35, 4 January 2008 (UTC)Ghostmonkey57

I agree. The section needs a revamp.--IronAngelAlice (talk) 01:06, 5 January 2008 (UTC)

The first sentence of this paragraph gave undue weight to Judicial Watch's inference regarding the meaning of Vaccine Adverse Event Reporting System reports, without making it clear their opinion was their interpretation of VAERS reports. The FDA statement which followed the Judicial Watch statement did not sufficiently offset the initial statement to create a NPOV.

VAERS reports include any and all reports, including duplicate reports from more than one reporter on the same patient, reports which made by someone who 'was told by a friend' (per one VAERS report I looked at, or, in other words, unverified gossip) regarding a death, etc. VAERS accepts ALL reports, whether thought to be related or not, to better detect possible trends for investigation. Judicial Watch places undue weight on these reports, counted every duplicate report, and infer by their statement of opinion that all VAERS reports were actually adverse events of the HPV vaccine.

I have modified the text in this section to quote their statement in an attempt to create a better NPOV from the originally linked Judicial Watch article at their site. As their view is biased and creates a false inference regarding VAERS reports, to better establish a NPOV, I then added further FDA language with links to the FDA VAERS website. The previous section also covers VAERS reports fairly well, I wonder about merging the Judicial Watch section into the "Anti-vaccination groups" above? I'm a little concerned that to create a NPOV, these two sections are being forced to focus on what VAERS reports actually mean.

Though I have amended the Judicial Watch sentence, still I wonder whether including their opinion statement is appropriate/needed. While the links to the VAERS reports available through Judicial Watch are nice, their decidedly biased views skews the NPOV of the section. Isn't this group, though well funded, something of a 'fringe group' per the Wiki definition? They list 28 people in their staff directory and appear to be primarily funded by one person through a couple of foundations. I hadn't heard of them before - does this group represent large numbers of people, or is it a group serving primarily the opinions of their one major funder? Perhaps a brief mention of their opposition similar to the stance of the two groups in the last paragraph, "Family Research Council" and the group "Focus on the Family", would be sufficient, as quotes from these groups aren't included here. If Judicial Watch quotes were omitted, VAERS information could then be cut back as well. Surely the later two groups might have a wider membership than Judicial Watch, quoting the later may give undue credence to their views.

Thoughts? If there is agreement in cutting back the focus on Judicial Watch here, feel free to amend this section further. Lcph88 (talk) 05:06, 10 March 2008 (UTC)

I personally appreciated the coverage of the Judicial Watch controversy. For one thing, it makes wikipedia distinct from government or medical association sites that are colored by policy - there are already plenty of those. This page is one of the few (at least among those with a high google ranking) that provides broad coverage and tries to place everything in perspective. Perhaps a less defensive stance and less text would be OK. It is clear however that there is a lot of sensationalism in the many web sites that contain judicial watch information, and as correctly noted in this page, an incorrect and inappropriate interpretation of the VAERS reports. Wikipedia should at least point this out in a cool and rational way. Citation 35 however (as noted below) should be revised as it could fuel further controversy simply because the cited article doesn't directly support the statement it is associated with in the text.

:::Hmmm, when I edited this section, I definitely should have checked the reference attributed by a previous editor for the FDA statement "However, an FDA spokesperson stated that these deaths are not related to the vaccine, and occurred independently of vaccination.[34]" (Note that the citation reference numbers change as other citations are added or removed). I entirely agree that the Citation attached to the FDA statement was not appropriate and will replace it with "Citation needed". Lcph88 (talk) 02:21, 30 March 2008 (UTC)

Still considering a re-write of my previous edit to create a better NPOV (the editor for the previous section above did well there). Though I don't have alternate language yet, I also linked Vaccine Adverse Event Reporting System in this section, as I hadn't noticed the earlier internal link myself. However, since both sections are short and close to each other, would this be considered overlinked? If there is a concensus that this may overlink the subject on VAERS, perhaps the extra link I added to the VAERS article within this section should be removed. I'm thinking though, perhaps I can add more the the Wiki VAERS article instead and then be able to cut back in this section on the VAERS focus. I also haven't been able to find info on any FDA statement to the effect "However, an FDA spokesperson stated that these deaths are not related to the vaccine, and occurred independently of vaccination."[citation needed} so cannot provide/find a citation to attach to this statement added by an earlier editor. Perhaps in light of this, the statement attributed to the FDA by that editor should be removed, which may help in creating better NPOV and a less defensive stance, as noted by the unsigned commentor above. If there are no objections, and no one else removes the statement or can attach a proper citation, I'll probably delete the FDA attributed statement later this week. Lcph88 (talk) 02:55, 31 March 2008 (UTC)

Incorrect Information

Editors should be aware that the user Drsavard (and apparently 71.224.215.219) who proposed these changes does consulting work for QIAGEN pharmaceutical company, which is the owner of Digene, maker of the HPV test. Therefore they have a potential WP:COI regarding HPV testing. Zodon (talk) 05:59, 11 May 2008 (UTC)

I am a medical doctor specializing in internal medicine with 25 years of experience. I found the following information in this article to be incorrect and I’d like to update it to include the correct information. If no one protests the updates below within 48 hours, I’d like to go ahead and make these edits to ensure that Wikipedians receive the correct information as soon as possible. All references are included below.

Existing Text
In developed countries, the widespread use of good-quality cervical “Pap smear” screening programs has reduced the incidence of invasive cervical cancer, by 50% or more. The current generation of preventive vaccines offers protection against the two HPV types (16 & 18) that currently cause about 70% of cervical cancer cases. Therefore, experts recommend that women combine the benefits of both programs by seeking regular Pap smear screening even after vaccination.

Updated Text
In developed countries, the widespread use of quality Pap testing programs has reduced the incidence of invasive cervical cancer by 70% or more. The current generation of preventive vaccines offer protection against the two HPV types (16&18) that currently cause about 70% of cervical cancer cases. Therefore, since about 30% of cervical cancers are caused by other types of HPV, experts recommend that women continue to get regular Pap tests even after vaccination. In addition, since the Pap can fail to detect some abnormal cells, many experts now recommend that women age 30 and older get an HPV test along with the Pap.

Drsavard (talk) 14:21, 10 March 2008 (UTC)

Not quite sure what information you are saying is incorrect? Much of your addition here seems to be sources for existing material. (i.e. you seem to be supporting it, rather than changing it). Good to get it sourced, just not sure what saying is incorrect?

Mostly seems good (though I haven't checked the the sources). Might want to refrain from the 30% figure (cases caused by other types). I assume it is just 100%-70%? As this gets edited/etc. the two figures may get separated, or somebody might update one, but not the other. Not hard for people to do the math themselves if they want. As vaccination becomes more prevalent the proportions will likely change (and that 30% will grow). Just removing that parenthetical part (or saying still at risk of cervical ca, but without a number) would be fine, and probably easier to maintain.

The last sentence needs balance (lacks NPOV - many experts recommend against it also, other factors, etc.). Suggest leave it out here (since this article is about HPV vaccine), and deal with elsewhere (e.g. cervical ca. prevention, or HPV).

Apart from those two things, looks good. Hope this helps. Zodon (talk) 07:21, 11 March 2008 (UTC)

My main purpose in editing this section is to more clearly explain the need for continued screening despite vaccination (something that is commonly misunderstood amidst all of the publicity), and the potential value of including HPV testing along with the Pap for screening women age 30+. Although it is true that many community doctors have not yet adopted routine HPV screening, the preponderance of experts are now in favor of it. Below is just a sampling of the accumulating studies, beginning with the most recent: • Study results suggest that, in women aged 30 + years, co-testing with a Pap smear and HPV DNA test was more sensitive than reflex HPV testing for the detection of high-grade cervical lesions (91% vs. 54%), provided women with a positive hc2 test and negative Pap were referred to colposcopy and biopsy. Janet G. Baseman, Ph.D., Department of Epidemiology, University of Washington (American Journal of Obstetrics & Gynecology, March 2008)

• For both vaccinated and unvaccinated women, age-based screening by use of HPV DNA testing as a triage test for equivocal results in younger women and as a primary screening test in older women is expected to be more cost-effective than current screening recommendations. Sue J. Goldie MD, MPH, Department of Health Policy and Management, Harvard School of Public Health (Journal of the National Cancer Institute, Feb. 26, 2008)  Compared with cytology, HPV testing has greater sensitivity for the detection of cervical intraepithelial neoplasia. The sensitivity of HPV testing for CIN grade 2 or 3 was 94.6%, whereas the sensitivity of cytology alone was 55.4%. The sensitivity of both tests used together was 100%, and the specificity was 92.5%. Franco, E. et al. Human Papillomavirus DNA versus Papanicolaou Screening Tests for Cervical Cancer. New England Journal of Medicine 2007; 357: 1579-1588.

 Implementation of HPV DNA testing in cervical screening led to a substantial increase in the number of CIN 2/3+ lesions detected at the baseline screening round. At the subsequent round, combined HPV DNA and cytological testing was used in both study groups and significantly fewer CIN 2/3+ lesions were seen in the women who received both tests at the baseline round than in the control group. Therefore, the results show that implementation of HPV DNA testing in cervical screening leads to earlier detection of clinically relevant cervical lesions. Meijer, C. et al. Human papillomavirus DNA testing for the detection of cervical intraepithelial neoplasia grade 3 and cancer: 5-year follow-up of a randomized controlled implementation trial. The Lancet 2007; DOI:10.1016/S0140-6736(07)61450-0.

 HPV testing in primary screening and HPV vaccination against the most common types have the potential to reduce the incidence of invasive adenocarcinoma. Castellsague, X. et al. Worldwide Human Papillomavirus Etiology of Cervical Adenocarcinoma and Its Cofactors: Implications for Screening and Prevention. Journal of the National Cancer Institute 2006; 98: 303-315.  HPV testing is substantially more sensitive in detecting CIN 2+ than cytology (96.1% vs. 53%) but is less specific (90.7% vs.96.3%). In this analysis, the sensitivity of HPV testing was similar in all studies carried out in different areas of Europe and North America, whereas the sensitivity of cytology was highly variable. These results support the use of HPV testing as the sole primary screening test, with cytology reserved for women who test HPV-positive. Cuzick, J. et al. Overview of the European and North American studies on HPV testing in primary cervical cancer screening. International Journal of Cancer 2006; 119: 000-000.  HPV testing alone was more sensitive than conventional cytology among women 35- 60 years old. Adding liquid-based cytology improved sensitivity only marginally, while increasing false-positives. HPV testing using Hybrid Capture 2 with a 2 pg/mL cutoff may be more appropriate than a 1 pg/mL cutoff for primary cervical cancer screening. Ronco, G. et al. Human Papillomavirus Testing and Liquid-Based Cytology: Results at Recruitment From the New Technologies for Cervical Cancer Randomized Controlled Trial. Journal of the National Cancer Institute 2006; 98: 765 – 74.

 Because HPV DNA testing is more sensitive than cervical cytology in detecting CIN 2 and CIN 3, women with negative concurrent test results can be reassured that their risk of unidentified CIN 2 and CIN 3 or cervical cancer is approximately 1 in 1,000. ACOG Practice Bulletin No. 61, "Human Papillomavirus. Clinical Management Guidelines for Obstetrician-Gynecologists." April 2005.  The negative predictive value of combined HPV/Pap testing is 99.21% for CIN 3. Sherman M.E., et al. Human Papillomavirus Testing, and Risk for Cervical Neoplasia: A 10-Year Cohort Analysis. Journal of the National Cancer Institute, 2003;95:46-52.

 In another study of more than 11,000 women, the digene HPV Test was shown to be 97% sensitive for CIN 2+, compared to 77% for conventional Paps resulting in ASC-US or abnormal results. The study also documented that women infected with high-risk HPV and who have normal or borderline cytology can be managed as effectively with repeat testing after 12 months with immediate colposcopy. Cuzick, J. et al. Management of women who test positive for high-risk types of human papillomavirus: the HART study. The Lancet 2003;362:1871-76.  Still another study demonstrated that HPV testing is a more sensitive indicator of high-grade CIN than either conventional or liquid cytology alone. Screening with both an HPV and Pap test offered a sensitivity and negative predictive value of almost 100%. Twenty-one percent of women who were persistently positive for high-risk HPV DNA types when tested with hc2 were diagnosed with CIN 2/3 within 36 months, compared to only 0.08% of women who were initially HPV-negative. Lorincz, A., Richart, R. Human Papillomavirus DNA Testing As An Adjunct To Cytology In Cervical Screening Programs. APLM 2003;127:959-968.  A study of 8,466 women undergoing routine cervical cancer screening showed that when used in conjunction with a Pap, the sensitivity of the digene HPV Test test was 100% for detection of CIN 2+, while that of the Pap alone was 43.5%. Petry K., et al. Inclusion of HPV testing in routine cervical cancer screening for women above 29 years in Germany: results for 8,466 patients, British Journal of Cancer,2003;88:1570-1577.  Women with persistent HPV infection are more than 300 times more likely than HPV-negative women to develop high-grade cervical disease. Bory J., et al. Recurrent Human Papillomavirus Infection Detected with the Hybrid Capture 2 Assay Selects Women with Normal Cervical Smears at Risk for Developing High Grade Cervical Lesions: A Longitudinal Study of 3,091 Women. Int. J. Cancer, 2002;102:519-525.  In an ASC-US population, the sensitivity of the digene HPV Test for detecting high-grade precursors and cervical cancer is 96%, compared to 85% for a repeat liquid-based Pap test. Solomon D., et al. Comparison of Three Management Strategies for Patients with Atypical Squamous Cells of Undetermined Significance: Baseline Results from a Randomized Trial, J. Nat Cancer Inst, 2001; 93:293-299.  A cohort analysis of 5,671 women older than 30 (conducted within a larger study of 7,932 women) showed that conventional cytology was 57% sensitive for HSIL; liquid cytology was 84% sensitive, and the digene HPV Test was 100% sensitive. Clavel C., et al. Human Papillomavirus Testing in Primary Screening for the Detection of High-Grade Cervical Lesions: A Study of 7,932 Women. Brit J Cancer, 2001; 89 (12):1616-1623.  High-risk HPV types have been detected in 99.7% of cases of cervical cancer, confirming that the virus must be present for cervical cancer to develop. Walboomers J.M.M., et al. Human Papillomavirus is a Necessary Cause of Invasive Cervical Cancer Worldwide. Journal of Pathology 1999;189:12-19. However, I agree that the edit could be more concise and to the point, given that this section is focused on the vaccine. Thus, I will change my edit to read:

The current generation of preventive HPV vaccines offers protection against the two virus types (16 & 18) that currently cause about three-quarters of cervical cancer cases. That means about a third of cervical cancers are caused by other types of HPV. In addition, even when infection with HPV 16 and/or 18 are involved, the vaccine only appears to be fully effective prior to exposure and protection may not last a lifetime. Therefore, experts recommend that women continue to be screened regularly, even after vaccination. This includes a Pap smear and – for maximum protection, if they are 30 or over – an HPV test. 71.224.215.219 (talk) 20:03, 28 April 2008 (UTC)

Bad citation

In the section discussing "Religious right and conservative groups" the following statement is made

"However, an FDA spokesperson stated that these deaths are not related to the vaccine, and occurred independently of vaccination.[35]"

This citation does not point to a statement but a A MEDWATCH CONTINUING EDUCATION ARTICLE dated 1998 that (naturally enough) makes no specific reference to HPV vaccine. As the purpose of this citation is clearly to provide credibility to the statment it should be corrected or replaced with a "citation required" marker. —Preceding unsigned comment added by 203.12.172.254 (talk) 05:55, 11 March 2008 (UTC)

• I double checked the cited reference linked by a previous editor and you're right. I've replaced the incorrect citation with "Citation Needed".

Lcph88 (talk) 02:51, 30 March 2008 (UTC)

Prevalence of genital HPV

I have moved the statement “Both sexes are urged to get the vaccine to this discussion page, along with it’s referenced internet article. Reviewing the reference, one finds this is a statement of opinion of one person, but seems to imply otherwise. While the opinion may appear (or may even be) logical, this opinion does not represent current general consensus, either in the U.S. or abroad, and the vaccine is not presently covered by insurances or by the U.S. Vaccines for Children Program for men or boys, and does not contribute to NPOV for this section. Therefore, I have removed the statement along with it's reference from the main article. An excerpt of the person interviewed for the referenced Post article is below for interest:

“Bradley Monk, associate professor in gynecologic oncology at the University of California at Irvine, said the best use of the vaccine would include giving it to girls and boys and all women and men, regardless of individual risk factors. "We need to move toward a paradigm where this is a universal vaccine," he said in a commentary published in the latest issue of the journal Obstetrics & Gynecology.”

One last note, per my review of so far on this subject, official recommendations so far appear to be based on cost/benefits for this vaccine, along with a current assumption that vaccination of young women will eventually also protect men and boys, due to "herd immunity". Lcph88 (talk) 21:17, 29 March 2008 (UTC)

Implied racism

Doesn't the long list of the legislatiive progress (sic) in the several US states imply a certain racism since it highlights the stupidity of a people who seem unable to implement even the simplest of public health measures for the greater good Albatross2147 (talk) 04:17, 5 May 2008 (UTC)

Not sure how this is racism. Perhaps you mean cheauvanism/nationalism? Not clear how it is that either, it just reports what is being done. There are countries/populations where regular Pap smear screening, or even more basic public health measures, like routine hand washing with soap is prohibitively expensive. Different governments have different resources/priorities/cultural limitations. So far not enough data here to even determine if US response is atypical, much less whether it is better/worse than most. Zodon (talk) 18:03, 19 May 2008 (UTC)

Ian Frazer

I believe Ian Frazer should be mentioned in this article. He won an Australian of the year award for helping develop this vaccine, and although I'm aware many laboratories collaborated in making this vaccine his contributions have been well recognised. Then again, I'm from Australia and his contributions may be out of proportion from this side of the globe. Drippingmintleaves (talk) 10:26, 14 June 2008 (UTC)

I believe that his contribution may be a bit overstated. Frazer did make a contribution, but it's far from clear that his was the most important breakthrough in the development of the vaccine. Certainly all four groups mentioned on the main page (as well as the pharmaceutical companies) made contributions that led to the development of the vaccine. Of course, there's nothing wrong with a little local boosterism! 64.234.168.129 (talk) 22:56, 19 June 2008 (UTC)

Lead - HPV prevalence

Please discuss rather than continuing to make edit to remove the HPV prevalence information from the lead. I couldn't find anything in the cited reference http://www.medicalnewstoday.com/articles/64137.php, or in the Dunne article (upon which the reference is based) that obviously contradicts the 80% lifetime chance of HPV infection in sexually active Americans. If there is a concern, please explain further. Since leaving the 80% figure with note of needing citation was questioned, I revised the 80% figure to 50% (which have a current CDC citation for) until citation for the 80% (or a better figure) can be found. Perhaps that will be more satisfactory. I also didn't find where the medicalnewstoday or linked articles dealt with worldwide HPV prevalence, so removed the use of that source for that sentence. Zodon (talk) 20:42, 29 June 2008 (UTC)

I have no idea what you think there is to talk about. The text made a statistical claim and cited a source for that claim. I read the source and found that it made no such claim. You can not just randomly generate numbers, throw them into articles, provide false citations, and then rationalize retaining this WP:OR by adding a tag. Please see WP:RS and WP:OR Best Regards, Doright (talk) 02:23, 30 June 2008 (UTC)

In one of the edit summaries the assertion was made that the medicalnewstoday reference contradicted the material in the article. It is not obvious that this is the case, therefore, it seems reasonable to discuss to find out more specifically what the difficulty is.

As the 80% number is not unreasonable (it is close the ASHA estimate of 75%), it seemed more courteous to try to fix it and request a source, rather than to summarily delete.

As to the assertions of randomly generating data and providing false citations, I did not add any of the content in question, please see Wikipedia:EQ and Wikipedia:CIVIL. Zodon (talk) 04:18, 30 June 2008 (UTC)

Zodon, I now see that I am not the first to recognize this problem and point it out to you. User:Nbauman had previously (over a week ago) and explicitly asked you: "Zodon, I'd like to know your source for that figure of 80% of the population having HPV" [6] . There seems to be a pattern developing here. Please make sure your cited references actually say what you claim. Also, you may again want to review WP:OR. I don't think you will find that your criterion for inclusion (i.e., if statistical material in your personal judgment is "not unreasonable," then it should not be deleted) is consistent with WP policies. Also, WP may be better served by thinking more of our users (i.e., those people that come to WP as a source of reliable information) rather than crying wolf about civility. Doright (talk) 21:32, 30 June 2008 (UTC)

Zodon, your reference [7] that your edit [8] cites makes no such claim. It makes no mention of your claim that "by the age of 50 more than 50% of American women will have contracted at least one strain of HPV." Doright (talk) 19:51, 30 June 2008 (UTC)

If you will observe the update date on the CDC page, it was just changed in the last few days. When I checked it, it said that sexually active adults had 50% chance. See for instance the version on the internet archive. http://web.archive.org/web/20070718122117/http://www.cdc.gov/std/hpv/STDFact-HPV-vaccine.htm

So this is just a case of unfortunate timing - I added the reference when it said something, you checked it after it had been changed.

I assume other's additions were made in good faith and am careful about checking facts before editing. Zodon (talk) 00:41, 1 July 2008 (UTC)

If you look around a little on the CDC website you can find the same information is still there, e.g. http://www.cdc.gov/std/hpv/STDFact-HPV.htm under HPV infection (version of 10 April 2008). Zodon (talk) 01:30, 1 July 2008 (UTC)

The CDC page does say

HPV infection. Approximately 20 million Americans are currently infected with HPV, and another 6.2 million people become newly infected each year. At least 50% of sexually active men and women acquire genital HPV infection at some point in their lives.

Unfortunately it doesn't give a supporting citation, just a list of general references at the bottom. I'd guess that was seropositivity in older adults, but a guess isn't good enough. It also doesn't say whether those are HPV infections that persist forever, or HPV infections that are cleared by the immune system and no longer present. It also doesn't give the date, so that number may have been superseeded by a later, more accurate figure.

I think the best figure is the 2007 NHNES study with PCR, which reported 26.8%, as we were discussing in Human papillomavirus.

I'd like to get a doctor or two who really understands epidemiology for an opinion. Nbauman (talk) 02:01, 1 July 2008 (UTC)

I agree that given the nature of the subject and related anxieties of the public, that it is essential that any editor contributing statistical information ensure that they understand its meaning and context so that the article is coherent and concise and does not unduly alarm or mislead the reader. For example, IMHO, the way the article was written bordered on unconscionable when its lead nakedly stated, "by the age of 50 more than 80% of American women will have contracted at least one strain of HPV." There is no definition of "contracted." There is no mention that the overwhelming majority of the cases are cleared by the body's immune system ... often before any symptom manifests (i.e., its often cleared before the patient even knew they had been exposed to it). Also, providing the stats only for total HPV's when the vaccine addresses only certain HPVs (which are a rather small subset of all HPVs) is likely to mislead and violate WP:Weight. Doright (talk) 04:56, 1 July 2008 (UTC)

Here is one source that reflects an aspect of one of the concerns I've expressed above: " Most people more than 50% of males and females will be infected with at least one type of HPV at some time in their life. But remember that most people clear HPV infection from their body without any symptoms or health problems. " [9] Doright (talk) 05:36, 1 July 2008 (UTC)

There are newer studies. Take a look at the article refs now.--IronAngelAlice (talk) 06:23, 1 July 2008 (UTC)

Thanks for finding the other ASHA reference, it made me look around their site some more. Would their HPV factsheet be a little more accessible as a reference. (Gives the estimated lifetime risk, but don't have to plow through as much unrelated material to find it.)"American Social Health Association - National HPV and Cervical Cancer Prevention Resource Center". Retrieved 2008-07-01. Zodon (talk) 01:04, 2 July 2008 (UTC)

IMO, the 2nd paragraph of the lead has the wrong focus. The article is about the vaccines which target a subset of all HPV strains. Yet, the paragraph emphasizes prevalence stats for all strains in total, while the vaccines only target certain strains. Please consider:

"Two studies have reported prevalence in representative, population-based samples. In a study of sexually active women aged 18--25 years, prevalence of any HPV was 26.9% (33). Prevalence of types 6 or 11 was 2.2%, and prevalence of types 16 or 18 was 7.8%. In a study of females aged 14--59 years during 2003--2004, the prevalence of any HPV was 26.8% (61). Prevalence was highest among women aged 20--24 years (44.8%). Overall, prevalence of types 6, 11, 16, and 18 was 1.3%, 0.1%, 1.5%, and 0.8%, respectively. " [10]- emphasis added for WP discussion

Gardasil is designed to prevent infection with HPV types 16, 18, 6, and 11. HPV types 16 and 18 cause about 70% of cervical cancer cases. In addition, some types of HPV, particularly type 16, have been found to be associated with oropharyngeal squamous-cell carcinoma, a form of throat cancer.[1] HPV types 6 and 11 cause about 90% of genital wart cases. Human papillomavirus (HPV) infection causes nearly all cases of cervical cancer.

Cervarix is designed to prevent infection from HPV types 16 and 18.

Therefore the prevalence stats that we should be emphasizing in the lead should be related to the prevalence of types 6, 11, 16, and 18 respectively.

Also please consider:

The vaccines are highly effective in preventing certain types of HPV. The vaccines are less effective in preventing HPV-related disease in women who have already been exposed to one or more HPV types. The vaccine does not protect against all types of HPV— so it will not prevent all cases of cervical cancer. About 30% of cervical cancers will not be prevented by the vaccine.

Gardasil is designed to prevent infection with HPV types 16, 18, 6, and 11. HPV types 16 and 18 cause about 70% of cervical cancer cases. In addition, some types of HPV, particularly type 16, have been found to be associated with oropharyngeal squamous-cell carcinoma, a form of throat cancer.[1] HPV types 6 and 11 cause about 90% of genital wart cases. Human papillomavirus (HPV) infection causes nearly all cases of cervical cancer. Doright (talk) 19:57, 2 July 2008 (UTC)

The article is about HPV vaccines, not specifically about Gardasil or Cervarix. Just because the currently available vaccines target specific types doesn't mean that all vaccines do/will. (I believe vaccines that cover other types are in development, so would be covered by this article in the research section when that gets written.)

The raw prevalence data is a bit harder to interpret, so I think lifetime risk makes more sense in intro. (If we have lifetime risk estimates for types 16, 18 that might be reasonable to put in intro.) Including detail on prevalence for the specific strains involved in particular vaccines makes sense, in the body of the article. At the moment I think there may be too much detail about US HPV prevalence in the lead. (Most of the prevalence information should be in the HPV article, with only enough here to support information about the vaccines.) Zodon (talk) 06:32, 3 July 2008 (UTC)

Please see my reply in the below subsection titled Intro. Doright (talk) 21:25, 3 July 2008 (UTC)

Intro

I agree the article is about "HPV Vaccine." In any case, that's it title. Therefore, although I believe it is proper for the article to give appropriate weight WP:Weight to the vaccines that are currently on the market, I also agree that their is no need to exclude a discussion of other potential HPV vaccines, if sources exist. However, the first two sentences of the intro states:

Human papillomavirus (HPV) vaccine is a vaccine that targets certain sexually transmitted strains of human papillomavirus associated with the development of cervical cancer and genital warts.[1] Two HPV vaccines are currently on the market: Gardasil and Cervarix.[2]

I think it is less than helpful to the reader to then focus on statistical information for HPV types that are not targeted by the existing vaccines.

It would help if you can explain why you think the "prevalence data is a bit harder to interpret, so I think lifetime risk makes more sense in intro."

I agree that most of the prevalence info should be in the HPV article. However, I do think it is essential to provide a statistical context for the reader. For example:

Although W% of women are are likely to be infected at least once with at least one of the 100+ strains of HPV, Most women will naturally clear the infection without symptoms or disease. A much smaller percent of women (X%) are likely to be infected with an oncogenic strain of HPV. Even among those, most women will naturally clear the infection without symptoms or disease. However, approximately 10??% of them are likely to experience a "persistent infection." A persistent infection by an oncogenic strain of HPV is a risk factor for dysplasia and cancer. Cervical dysplasia is a precancerous change that may be identified by a pap smear. If not treated there is a Z% chance of developing cervical cancer. Current vaccines target HPV strains that lead to 70??% of the cervical cancers and one of the vaccines also target strains that lead to 90??% of the cases of genital warts.

Doright (talk) 21:25, 3 July 2008 (UTC)

Specific notes on the above suggestion: the ASHA 80% figure is for sexually transmitted (genital) HPVs, so can simplify the first bit by ignoring the "100+" non-STI strains of HPV. If we have well sourced figure for percent likely to be infected by high-risk HPV (X% above), great, I haven't seen it so that why use the 80% figure. (Can't really say if X% if much less than W% until we have figure for X.)

But I think the whole suggestion above focuses too much on numbers and gives too much detail. Lots of folks aren't comfy with lots of numbers, so throwing a lot of percentages at them right off may be off-putting, and obscure the points. For the lead, I think it better to keep it short and simple. Perhaps something along the lines of:

Infection with sexually transmitted HPVs is very common. There are about 40 HPV types known to be transmitted through sexual contact, of which about a dozen "high risk" types can cause cancer. Although most women who are infected with high risk HPV types will not develop cancer, it is estimated that worldwide every year there are 473,000 cases of cervical cancer, resulting in 250,000 deaths per year.

Gardasil and Cervarix prevent infection with two high risk HPV types which are estimated to cause about 70% of cervical cancer cases. In addition, Gardasil prevents infection with HPV types that are estimated to cause 90% of genital warts. The vaccines are most effective if administered before initiation of sexual contact. Since vaccines don't cover all the HPV types that can cause cervical cancer, experts recommend that women get regular Pap smear screening, even after vaccination.

Then delve into the details of the development of HPV infections, CIN, etc. in the body of the article (or just refer them to article on HPV and/or cervical CA).

Above is still a bit rough, the cervical cancer incidence might be better replaced by the ranking (nth largest cause of cancer death in women..., killing 250,000/year).

First sentence of the above could be strengthened to say that majority of sexually active people have been exposed to HPV. (Would need to get a reference for that of course.) Zodon (talk) 06:54, 9 July 2008 (UTC)

As far as what I mean by the prevalence being harder to understand.

• If you say that there is z% lifetime chance that an individual will get an infection - that makes it personal - something that relates to "me" (if I am an American who has sex, these are my chances).
• If say that at a given time p% of the population has a condition, what does that mean for the individual? You need to know more information, like how long the condition lasts, can you be reinfected, etc. (e.g. If condition lasts a lifetime, than you can figure that only about p% of the population will get the condition, if the condition lasts 2 weeks, like a cold, and anyone can catch the condition, you can figure that to maintain that p%, lots of people will probably get it). There are probably standard models you can plug the prevalence, duration, etc. numbers into to calculate lifetime risk, but point is it takes extra bother to make it something that relates to an individual ("me"). Zodon (talk) 06:54, 9 July 2008 (UTC)

Lifetime risk - sources

I am curious about the origins of the ASHA vs the CDC estimates of lifetime chance of getting HPV. Where did the estimates come from? When were they made? This isn't obvious looking at the CDC or ASHA websites. Zodon (talk) 01:04, 2 July 2008 (UTC)

For that reason I don't think the CDC or ASHA web sites are WP:RS. These are actually "patient pages". You have to find the professional pages that are written for doctors and have the supporting footnotes.

One of the problems with such sources is that they may be using numbers which go back 10 or even 20 years. That often happens in medical statistics, if you look at the footnotes in journal articles.

You can't just quote CDC or ASHA as an authority. You have to find recent research, and you have to figure it out and understand it. There's no way out of it.

As I said above, I think the best figure is the 2007 NHNES study with PCR, which reported 26.8%. Nbauman (talk) 16:45, 9 July 2008 (UTC)

Nbauman, do you have a way of assessing if the NHNES study is an outlier?--IronAngelAlice (talk) 22:35, 9 July 2008 (UTC)

Why can't one cite the CDC or ASHA as authorities? They are prominent authorities within their fields. Government statements, like those made by the CDC, are generally subjected to a review process before publication. More context and background would be helpful, but in terms of WP:RS, it isn't clear why you think these don't qualify.

In terms of the >50% lifetime risk estimate, one might guess some of the possible background of that by checking some of the other HPV references, e.g. Baseman and Koutsky 2005.

We don't seem to have a reliable source (review/meta-analysis/etc.) that says that NHNES is more reliable than any of the other estimates. (Or even one that interprets it in terms comparable to the CDC or ASHA estimates.) Lacking that we can form our own opinions about such, but, as a primary source, it must be used with considerable care; we can't say that it is better than other sources. Zodon (talk) 06:29, 10 July 2008 (UTC)

A source is reliable (in the medical sense) if you can track the data back to an original source. It's not reliable if it's nothing more than a "patient page" that gives data without giving original sources. Some of the CDC and ASHA pages are written down to readers ("patient pages") and don't give sources. Some CDC and ASHA pages give very reliable well-sourced data. There is no ultimate source of that 80% figure. As you can see from reading the abstracts, the incidence varies widely and you have to know how the number was obtained in order to make any sense out of it. If you test patients in STD clinics you have unrepresentatively high numbers.

This is what I think is the most reliable information. I think we should use this:

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr56e312a1.htm

Two studies have reported prevalence in representative, population-based samples. In a study of sexually active women aged 18--25 years, prevalence of any HPV was 26.9% (33). Prevalence of types 6 or 11 was 2.2%, and prevalence of types 16 or 18 was 7.8%. In a study of females aged 14--59 years during 2003--2004, the prevalence of any HPV was 26.8% (61). Prevalence was highest among women aged 20--24 years (44.8%). Overall, prevalence of types 6, 11, 16, and 18 was 1.3%, 0.1%, 1.5%, and 0.8%, respectively.

33. Manhart LE, Holmes KK, Koutsky LA, et al. Human papillomavirus infection among sexually active young women in the United States: implications for developing a vaccination strategy. Sex Transm Dis 2006;33:502--8.

34. Dunne EF, Unger ER, Sternberg M, et al. Prevalence of HPV infection among females in the US; National health and nutrition examination survey (NHANES), 2003--2004. JAMA 2007;297:813--9. Nbauman (talk) 13:41, 10 July 2008 (UTC)

Nbaumen, the paragraph you reference looks at a very narrow age group. If you go on to read the statistics of HPV infection among a broader age group on the same page ("HPV Prevalence and Incidence in the United States"), it is clear the statistic quoted in our article that around 80% of American women will have contracted HPV at one time in their lives is supported, and is not refuted. --IronAngelAlice (talk) 17:36, 10 July 2008 (UTC)

Poor grammar in anti vaccination section

Although it is a quotation, the sentence "two thirds of the 385 adverse incidents are related to Gardasil injections required secondary medical treatment." does not make sense. Is there a comma and an and missing? Judging from the origin of the quote I'd imagine a "sic" insertion might be warranted, although since the sentence contains proportions and references to numbers it is not advisable to leave such an obfuscated judgment about ill-effects in its current form. Nina137.111.47.29 (talk) 08:04, 14 July 2008 (UTC)

Upon reflection it might even be correct to say "Gardasil injections-required medical treatment, in which case the entire sentence changes meaning. Nina137.111.47.29 (talk) 08:06, 14 July 2008 (UTC)

The section has several grammar problems, (e.g. the quotation starting "new analysis ..." also doesn't make much sense.) The whole business could use more concise coverage, also note that almost the same material was put into the Gardasil article, and should be cleaned up there as well (and duplication removed - one way or another). Zodon (talk) 19:35, 20 July 2008 (UTC)

Media Coverage

I find it odd that this page has no information on the extensive media coverage of Gardasil and it's reported side-effects. I realise that there is not solid scientific evidence that the HPV vaccine is dangerous, but I would expect this article to provide information on the huge media controversy that a number of deaths in the US and Europe has caused. —Preceding unsigned comment added by 122.108.240.89 (talk) 14:58, 20 July 2008 (UTC)

Most vaccinations cause at least some cases of complications and death, whether through their actual action, administration or health of recipients. In the area of the HPV vaccination these cases (which are generally understood to be acceptable by the health and drug agencies) has been used as a way to attack the administration of the drug to children by people who view the process through their own specific ideology. Nina137.111.47.29 (talk) 09:11, 21 July 2008 (UTC)

I recently updated the information on safety on the Gardasil page, including coverage of US events. (So far they are unrelated to the vaccine.) Haven't seen much about Cervarix, or references on European cases. The safety on this page should probably just be a summary and leave the details to the sub-pages. (Since vaccines use different Adjuvants) Zodon (talk) 07:45, 25 August 2008 (UTC)

Cervical dysplasia in lead

I removed the cervical dysplasia (CIN) material in the lead because:

• The dysplasia data was USA only (trying for a more worldwide view, hence using numbers like cervical cancers which more likely to have global data available).
• While dysplasia is a step in the whole HPV, ... Cancer story, it is not an essential detail (i.e. one can explain the basics without it, and then give the full details in the body).
• The information as presented was misleading because it sounded like treatment with LEEP, etc. was typical for dysplasia, and it didn't indicate what severity of dysplasia talking about mild (CIN 1) and more severe (CIN 2/3). Since there are a lot more cases of CIN 1, but it is much less likely to develop into anything (and should not be treated), to pair numbers which looked like probably number of CIN 1 cases (certainly not clear that they are number of CIN 2/3), with a list of treatments for CIN 2/3 is misleading.

Since the dysplasia was put back, I attempted to fix it up a bit. If CIN is going to be in the lead, then need to make it clear what level of severity of dysplasia numbers are for (the reference used at the moment doesn't say, and the margin of error in the number is so huge as to make it not clear how useful the number is), and the followup mentioned needs to be appropriate to the severity. But I still think it would be clearer to just give the basics in the lead - HPV is widespread and it causes Cervical cancer (here is problem, here is result we care about), and cover the details of the path along the way (persistent HPV infection/dysplasia(CIN)/treatments/etc.) to the body of the article. Zodon (talk) 07:37, 25 August 2008 (UTC)