Mainstream scaremongering over Gardasil

By Phil Plait | August 20, 2009 7:30 am

Gardasil is the brand name of a vaccination that protects young girls and women against the human papillomavirus (HPV), a virus that has been positively linked with cervical cancer along with other horrible diseases. It also can trigger cancers in men as well.

I’ve written about this topic before; 4000 women in the United States die every year alone from cervical cancer, an appalling 1/3 fatality rate for those diagnosed with the disease. Tens of millions of people — both men and women — carry HPV.

Gardasil protects young women from ever getting HPV. These women have a substantially lower chance of contracting the virus and getting cervical cancer. I consider that a very, very good thing.

But you wouldn’t think so if you read the New York Times, or the (Australian) ABC News. Both posted articles playing up the dangers of Gardasil as revealed by a new government study of the vaccine. That would be fine if it were true, but both reports, in my opinion, unfairly inflate the apparent danger. The ABC article is particularly egregious, with a headline saying "US doctors question Gardasil side effects" when it’s clear from the article that this isn’t really the case.

What are the dangers? The worst one would of course be death. In a study of the vaccine, there were 20 deaths of young girls at some time after they got the shot. Twenty! That sounds like a lot! However, there are two MAJOR problems with that statement:

1) There is no obvious link between the deaths and the vaccination other than in time. One girl died from drug abuse. Another from hepatitis, and others from embolisms, cardiac failure, and other problems. While these are all very sad — and as a father of a young girl at the age to get Gardasil, my heart aches for those families — none of these can be directly tied to the vaccination.

2) There were 20 deaths out of 7 million girls who received the vaccine. Those odds are 1 in 350,000. That’s roughly the same odds as dying from falling off a bed, chair, or other furniture.

I can just imagine the antivaxxers yelling "It’s a BIG FURNITURE CONSPIRACY!" over that one.

In truth, I imagine the antivaxxers are already licking their chops over this news, ready to fold, spindle, and mutilate reality as they oh-so-often do. The last thing we need are misleading articles like these two. It’s like red meat for them.

The New York Times article quotes a doctor who urges caution over giving girls the shots. She says that proper cancer screening will prevent women from getting cervical cancer. That’s true, but misses the point entirely. Not everyone can or does get screened for cancer. If they did, we wouldn’t be losing 4000 women every year to it. I’d rather close the barn door before the horse escapes.

I’m not a doctor, so I can’t tell you to go get your daughters vaccinated with Gardasil. What I will tell you is that your best weapon here is to simply understand the situation, and don’t just believe what you read. Don’t even believe me. Read up on this yourself and talk to your doctor.

Oh, and to the antivaxxers who will no doubt descend on the comments here and try to muddy the situation with distortions and spin, I’ll answer your question before it’s even asked: Yes, The Little Astronomer did get her course of Gardasil vaccinations. And now she gets an even better shot at living a long, long time to talk about it.

Tip o’ the needle to April Gardner and Topher423 for the article leads.

CATEGORIZED UNDER: Alt-Med, Antiscience, Debunking, Skepticism

Comments (181)

  1. Midwestern Gent

    I can’t for the life of me get into the antivaxxer mindset. As the parent of a young child, I want everything that’s best for him. How can I know what that is if I blind myself with ideology instead of looking reality and the facts square in the face, so I can make a truly informed decision. Their passionate pursuit of an agenda, no matter how well intentioned, won’t do squat to keep their kids safe.

  2. *sigh* I guess this means I should finally get off my duff and add info on Gardasil to my site.

    Oh, yeah, before posting about how bad vaccines are, please give my site a read. You can get to it (antiantivax.flurf.net) by clicking on my name.

  3. Joe Meils

    Vaugely reminicent of the scare they tried to whip up over Viagra. (Causes blindness, heart attacks, etc.) Turns out it was like six cases of damage caused by overuse of the drug, out of TENS OF MILLIONS of doses…

    Who out there is the Chicken Little of the media who twists these news stories so out of proportion?

  4. Dave

    I saw a similar story on the local news recently and was very annoyed at how the data was sensationalized. They reported a large absolute number of cases where there were serious side effects to make the story sound scary.

    When I did the mental arithmetic on the numbers they reported I came up with a value of an approximately 0.5% chance of any serious side effect! That’s nothing. The odds of many risks that no one every worries about are much worse.

    I know the news outlets go for the scary, sensational story to get ratings. But in my mind, it is incredibly unethical to not put some kind of context on this kind of data.

  5. Cindy

    I read the NY Times article and was wondering if you were going to blog about it. I do remember seeing some reports about the deaths earlier.

    I do remember that most of the side effects the article mentioned was feeling lightheaded/passing out.

    The issues with this vaccine is not only the usual anti-vax but also social conservatives because it prevents a sexually transmitted disease.

    I remember reading about another study that not only does Gardasil protect against cervical cancer but also throat and anal cancers in men.

    My kids are really young right now, but I plan to get both my daughter and son to get the vaccine.

  6. My daughter has started the vaccine, and we will get the rest of the shots that go with it. Personally, I consider this a step towards vaccinating against cancer! What a concept!

    My grandmother died from cervical cancer early in her life. The treatments they provided in the early 60s, and later again in the 80s, were in the dark ages compared to what doctors can do now. To think that, if she were able to get this vaccine, her story might have been a much different one…

    Not getting this vaccine for my daughter is akin to not making her wear a seatbelt. Such a simple little act that can save so many lives.

  7. Gammidgy

    We can’t get enough pro-vaccination propaganda at the moment, particularly in the UK where our levels of vaccination against common preventable diseases are lamentably so low.
    There is currently a petition on the UK government’s website to get the statue of Edward Jenner restored to London’s Trafalgar Square in time for the 30th anniversary of the eradication of smallpox next year.
    The British public and mainstream media seem obsessed with Trafalgar Square statuary so such a move is sure to get a lot of column inches. It surely can’t fail to highlight vaccination’s greatest success story.
    Sadly only UK citizens or residents can sign the petition, but I know there are a lot of them among this blog’s readership.

  8. Another bit of spin in the NYT article:

    The majority of adverse event reports were filed by Merck & Company, the vaccine’s manufacturer, and most failed to provide enough information for further investigation.

    Suggests that Merck withheld info, when it is more likely that the reports they received were incomplete, since they’re required by law to report as much info as they have.

    Oh, and they also hit the multiple vaccines meme. The antivaxxers will love that.

  9. sisu

    I am not an antivaxxer.

    There are serious questions about the cost-effectiveness of this vaccine.

    http://www.tc3.edu/instruct/sbrown/stat/vaccine.htm

  10. nichole

    These are the people who think AIDS is a good punishment for homos. Abominable behavior.

    Unrelated, except in the ucky feeling it gave me when I heard it, but I heard a guy on NPR talking about the poor, persecuted Tamil Tigers. They have to live in camps! So sad!! And as a side note at the end of the interview, btw, they used to be terrorists and recruit child soldiers and carry out civilian massacres. Invented the suicide bomb belt. Pioneered suicide bombing as a tactic. But they’re a persecuted ethnic minority, feel sad for them.

    Journalists = teh evil.

  11. Roen

    “Don’t even believe me. Read up on this yourself and talk to your doctor.”

    The best possible advice one can give… yet, sadly millions will believe the alarmists. I actually gave my two children similar advice, “be skeptical of everything you hear, even if it comes from me”.

  12. Gadfly

    Wow. The NYT used to be a respected new org. This isn’t the first blatant exageration I’ve heard from them.
    Here’s a thought — compare HPV to smallpox for a moment. If today’s political environment had existed back then we’d still have smallpox outbreaks. If we had BACK the political environment from those days we could, in time, probably erradicate HPV.

  13. rob

    i suspect a lot of the unstated objection to the vaccine is that you are vaccinating young girls for a sexually transmitted disease. seems like antivaxxers would rather imagine their daughters dying of a preventable disease rather than having sex.

  14. ““be skeptical of everything you hear, even if it comes from me”.”

    While I totally agree with this sentiment, my problem is that the 9/11 truthers, birthers, UFO nuts, moon hoaxers, global warming denialists, holocaust denialists, antivaxxers and so on, give the same advice, and in fact call themselves “skeptics”. It requires far far more than just some advice to “be skeptical”. Understanding how to critically think, how to identify evidence from rhetoric and so forth must be taught. There isn’t a trite sentence you can say that will instill this.

  15. Jason

    @ Nichole

    Some Tamil’s are terrorists. Some.
    The majority of people in the camps are civilians and there are serious questions about the Sri Lankan Governments treatment of civilians during this last campaign.

    Your comment is related, it is like saying “Women who get HPV are sexually promiscuous”

  16. COD

    Interestingly, my wife had this conversation with our Internist just yesterday. The doctor’s reply was that he has two daughters in college, and neither has had the vaccine. He is not convinced that there is enough data on the long term effects of the vaccine. He has the same opinion of the Swine Flu vaccine too.

    The doctor is not anti-vaccine, nor are we. He stuck us both with a DPT booster during our appointments this week, and both of my kids, as well as my wife and I, are up to date with the standard battery of vaccines. Our pediatrician is not as concerned as the Internist, although last year she saw no reason to give it to a 12 year old who has shown no interest in boys yet. Her advice was to hold off until our daughter is dating, or at worst make sure she has it before she goes off to college.

  17. OtherRob

    And the next headline will be: “Billions die after injesting dihydrogen monoxide”. Technically, of course, it’s true…

  18. KYW 1060, Philly’s primary all-news radio station, (http://www.kyw1060.com) carried a report about this yesterday. IIRC, they made sure to mention the total amount of recipients (23 million), the amount of those reporting side effects (23,000; mostly fainting), and total amount of deaths (under 50.)

    The thing that stuck with me most was that the report said that all of the ill effects had not so far been linked to the vaccine. The fact they didn’t ring the conspiracy/anit-vax bell right away was interesting.

    I’m trying to find the broadcast itself, but 1060’s website is an abomination, design-wise.

    Also of interest is that KYW is also linking to an AP article which spends half it’s space accusing Merck of questionable marketing.
    (http://hosted.ap.org/dynamic/stories/U/US_MERCK_GARDASIL_STUDIES?SITE=KYWAM&SECTION=HOME&TEMPLATE=DEFAULT)

  19. @ Sisu-

    Yes, it’s cost effective. Because there are 11 types of HPV. Seven of those are linked to cervical cancer. And Gardasil prevents four of those.

    HPV cannot necessarily be prevented with the use of a condom, depending on where the infection is on a certain person (for instance, below where the condom covers on a penis, and where that skin will touch a woman during heterosexual intercourse), so even people who practice safe sex can be at risk.

    And, sure, women are still at risk from the other three cancer-linked HPV strains, but Gardasil dramatically lowers the chances. And, hey, scientists are even working on a booster shot. And testing Gardasil for use on boys/men, so that it’s harder to spread HPV.

    So maybe it is really expensive, given that it doesn’t entirely prevent HPV related cervical cancer, but women who get it, and parents who give it to their daughters, will say that the cost is totally worth their lives.

    My doctor made sure I was well educated before he gave me the shot, so I’m relying on memory for these facts, which I’m fairly confident in, but I also got the shot when it first came out and memory does fade/get confused.

  20. I'd rather be fishin'

    I have 2 teenage daughters. If the vaccine is available where I live, I will get them vaccinated. My mother, father and a couple of aunts had cancer. Anything I can do to lessen my girls’ likelihood of contracting the ‘big C’ is going to get a very serious consideration by my wife and me.

    When this vaccine was 1st reported in the media, a local bishop publically stated that the vaccine would promote promiscuity.

  21. John Keller

    Both my girls have had all three shots. The youngest was 9, and the oldest was 14. Neither one had any reaction from the vaccines.

  22. Adam

    http://www.edmontonjournal.com/health/swine-flu/Should+kids+vaccinated+this+fall/1911234/story.html

    The above is an interview with a former professor of Immunology and Pediatrics at the University of Alberta. In the interview he’s asked a number of common questions relating to the use and safety of vaccines, and answers them all from the perspective of someone who has made a 30+ year career in studying the topics at hand.

  23. Ann

    I loved the comment you mentioned from the doctor who said that no side effects are acceptable in an 11-year-old because, like, NOBODY gets cervical cancer anymore, DUH (as long as you have access to adequate health care, which of course everyone does). So give the girl a shot and take the 0.0539-percent chance that she’ll get woozy or have an owie at the injection site, or don’t give it to her and take the 0.01someodd-percent chance that her uterus will turn to jelly and fall out on the floor. Man, that’s a stumper.

  24. molly

    Making this about who is sexually active and who isn’t is a big part of this problem. Instead of making gardasil an Big Ol Badge that a young woman is Doing It, it really needs to be part of the regular vaccine schedule–yes, even for girls who aren’t “interested in boys”. No good can come from having this CANCER PREVENTING vaccination all tangled up in our social attitudes and fears. Not to mention a young woman should not have to screw up her courage to tell her parents she’s having sex in order to get this lifesaving vaccine.

    Also it’s not nearly as simple as just “getting pap smears regularly” to prevent cervical cancer. It could be too late by the time it’s spotted; and the “preventative” treatments if something is found are totally unpleasant and painful (and it’s SCARY to have to worry for the rest of your life).

  25. SkepDoc

    @ sisu (9)

    Here’s the Cost Effectiveness quote from Up To Date Online (which is a pretty good source of med info):

    “Mathematical models have examined the cost-effectiveness of HPV vaccination [59-62]. One study suggested that vaccination of the entire United States population of 12-year-old girls would prevent more than 200,000 HPV infections, 100,000 abnormal cervical cytology examinations, and 3300 cases of cervical cancer if cervical cancer screening continued as currently recommended [59]. Studies have demonstrated that the effectiveness of HPV vaccination will depend on the duration of vaccine immunity, including one study that supported continued cost-effectiveness when the vaccine was given to 12- to 26-year-old females [63].
    In models, vaccinating both men and women is predicted to be more beneficial in reducing HPV infection and disease than by vaccinating only women, but at a higher cost [64,65]. However, models of cost-effectiveness are plagued by substantial uncertainty regarding major issues such as duration of protection [66], the effect of herd immunity, and the prevalence of vaccine-specific HPV types circulating in age-specific populations [67].” [References Omitted]

    In my opinion the cost effectiveness (for females alone) is not too bad; especially with a Number Needed to Treat of only 18 and the current full course cost for three 0.5 ml shots being roughly $460.

  26. Christina Viering

    I have heard many say they will not have their daughters vaccinated because of fear of vaccines. I agree with molly.

  27. Mike

    Nice article and blog entry. I too had both my daughters vaccinated for HPV a few months ago. I’m as certain as a parent can be that neither are sexually active right now, but someday they will be, whether they wait for marriage or not.

  28. Matt

    Sisu: I’m going to have to read that analysis in more detail, but first of all cost-effectiveness is not the same as “effectiveness”.

    It gives you a better chance of not having cancer than NOT getting the vaccination. My wife got this a few years before we were married before she was outside the optimal vaccination age range (doesn’t do you much good past 23-25 is my understanding).

    It was a pretty expensive course and it wasn’t covered by her insurance. The price will come down substantially once the patent expires and other vaccines besides “gardasil” are available.

  29. Ian

    Honest question. What is the incidence of HPV amongst men and women who have no sexual relations before marriage, or who remain in one sexual relationship?

    I only ask because this figure is never given amongst all the vaccination literature.

  30. Sir Eccles

    I understand there isn’t currently a vaccine for mono or “the kissing disease”. But if there was one, would parents refuse to get their kids vaccinated because it will allow them to kiss the girls and make them cry?

  31. cory

    There is skepticism and there is blindly pushing for vaccines, any vaccine, right away. I thought scientists were supposed to try and be patient and wait for long term results? Like COD, I am all for vaccines that work but i would like to know that we know as much as we can about their long-term effects before they are pushed on the public.

    While the NYTimes article DID seem to be scaremongering, there was some truth in what it was reporting–that a JAMA editorial stated (and this is from the abstract of the editorial, as i do not have access to the full article):

    “The vaccine manufacturer also provided educational grants to professional medical associations (PMAs) concerned with adolescent and women’s health and oncology. The funding encouraged many PMAs to create educational programs and product-specific speakers’ bureaus to promote vaccine use. However, much of the material did not address the full complexity of the issues surrounding the vaccine and did not provide balanced recommendations on risks and benefits.”

    We are not all knee-jerk antivaxer’s. But as a parent the final responsibility on ANY choice I make regarding my child’s health is my own…should anything happen to my kid, I need to feel that I made the most fully informed choice with the most reliable information available to me. The marketing of this particular vaccine does not at the moment instill confidence in me that the best information has been gathered, yet.

    @ ian–I would like that info as well.

  32. @cory

    The marketing of this particular vaccine does not at the moment instill confidence in me that the best information has been gathered, yet.

    Then ignore the marketing and look at the studies that have been done. You can search the FDA site for the approval letter and information on the studies used to support the application for marketing. You can also search PubMed for studies that have been done.

    Gardasil is looking pretty safe, thus far. It’s a bit early, yet, to determine the impact that it is having on HPV, considering it’s short time on the market thus far and low-ish levels of administration.

  33. grrr…tried to link to Science-Based Medicine, but my comment was marked as spam. Phil, I can haz fixing?

  34. Tsk tsk,

    I imagine the antivaxxers are already licking their chops over this news, ready to fold, spindle, and mutilate reality as they oh-so-often do.

    I just used the whole “fold, spindle, mutilate” line as it relates to some journalists. Admit it Phil, you’ve been stealing my material. :-P

    @sisu,

    I think you’ll find that the link you provide doesn’t really present questions that are all that serious. It’s mainly about efficacy and the old (nay- ancient!) argument over what p values are significant. Adverse reactions in vaccines are known, but what Phil was trying to emphasize is that they’re not common. They’re very rare no matter who you are, and shouldn’t be holding anyone back.

    @ Nichole,

    Whoa, I never thought I’d see someone advocate the concentration of an ethnic population on this blog- and based on an absurd generalization about that ethnic group as well. I think you should seriously read up on things like the Second Boer War, the Holocaust, and the history of the Red Cross.

    Also journalists aren’t all evil. They provide a valuable service in informing society when they’re doing their jobs right. Methinks you like extremes too much.

  35. Mal

    I’m glad you commented on this, back in July I mentioned in my blog that the local current affair program commented on Gardasil – and it was very much a scare-mongering campaign. I’m not even sure how I found myself watching the show that night. I reckon it would have put a lot of Aussie girls off the idea, and it’s good to see you put it all into perspective.

  36. John Baxter

    Hmmm. The New York Times was a respected news organization for a long time, and ABC News likewise (but of course for a shorter time). Too bad they’re losing it.

  37. G Williams

    Pet Peeve: “It *also* can trigger cancers in men *as well*.” that’s two ways to say the same thing in one sentence. arrgh.

  38. The Reuters article is more balanced, as I already wrote about.

  39. Incidentally, a lot of the numbers here are wrong.

    @Phil: the strains of HPV that cause cancer account for 70% of the cases of cervical cancer, so that’s more like 2800 lives saved per year. Not that it’s not impressive, but let’s be accurate so as not to give the other side any ammunition.

    It’s also 32 deaths in the most current study, which is out of 23 million doses. Even lower odds than you cite.

    @Dave: you’re talking about mild side-effects (a rash or dizziness) I think, and the incidence is 0.05%, not 0.5%.

    More details are in the numbers on my weblog that I linked to above, and more discussion about methodology in the comments.

  40. Steve

    What I can’t quite figure out with this is why are they only vaccinating women? I mean while yes, women are the ones who suffer the cancer side effects, presumably if men were vaccinated, it would increase herd immunity and prevent it’s spread, helping everybody. As it is now, only a portion of women are immunized, thus allowing HPV to spread pretty readily.

    Is there some reason this can’t be given to men?

  41. Scott B

    Seems like there’s one base contradiction in the NYT article. This quote: “I wouldn’t accept much risk of side effects at all in an 11-year-old girl, because if she gets screened when she’s older, she’ll never get cervical cancer,” compared to this quote: ““Pap screening alone is not the answer,””.

    Is the first quote true? That’s quite a certain statement from a doctor. From what I know of science and life there isn’t much where we can say “will never happen”. Has anyone studied the percent of women that get cervical cancer based on how often they get checked and that trends by age? If never is correct, then I would say, sure don’t require the vaccination and make it available to people that would rather take it and reduce their worry in the future if they don’t have access to exams for a certain time.

    Assuming that never is misused here, I would think almost anyone would accept the 0.18% chance of any side effect (and this is a high estimate, the article said enough doses were given for 3 doses for 7000000 people which is what I used to calculate that, but later said not every subject was given all 3 doses) , the 0.01% chance of a serious event, and the 0.00046% of death (and that percentage assumes all 32 were caused by the vaccine which was not true). I’d also like to see that average death rate for all women in the age group studied compared to that. I’m almost certain this sample was better off than than the average population death rate.

    Basically, a standard NYT article here, sadly. Mostly factual information, but they just include enough info to worry people into continuing reading and possibly causing them to make poor decisions if they don’t think analytically enough.

  42. Submitted to Digg!
    I have 2 daughters (13 & 15 YO) who got all 3 shots.
    I wouldn’t even THINK of not getting them vaccinated.
    Not for a femtosecond.

  43. Amy F.

    What annoys me about the people afraid of the vaccine promoting promiscuity is that they seem to forget that a) some people don’t have a CHOICE about having sex [rape victims] and b) even if your daughter waits til marriage (highly unlikely, but let’s pretend), what is the guarantee that her husband will be faithful?

  44. Randy

    Would the vaccine have prevented all 4,000 cervical cancers? 2/3 survive, so it’s 1,333 deaths per approximately 150,000,000 women.

    1,333 deaths out of 150,000,000 is approximately 0.000009
    20 Deaths out of 7,000,000 is approximately 0.000003

    I’m making many assumptions and I’m sure there are many other factors involved, but it appears that the risk of dying from HPV is approximately the same as from falling off a bed, chair, or other furniture.

    I am not an anti-vaxer. Am I missing something?

    Phil, I am a big fan of yours. Can you provide more science to this? Unfortunately, I am not a scientist.

    Randy

  45. What annoys me are people afraid of promoting promiscuity. They should give it a try some time.

  46. @Steve

    What I can’t quite figure out with this is why are they only vaccinating women?

    My guess is that the initial push for the vaccine was to figure out a way to prevent cervical cancer. So, natural target is women. Because of this, the clinical trials were likely female-only. Doctors could use it off-label, if they so chose, and give it to boys/men, but the additional indication probably won’t appear on there until Merck wants to start marketing it for men or the patent is near expiry, whichever happens first.

  47. “Journalists = teh evil.” – nichole @ 10.

    Thank you nichole, for that idiotic generalization. As a professional journalist, there’s nothing I like better than being told I’m evil. Some journalists are better than others at their jobs. Period. There never was a time when that wasn’t true. If anything, standards have improved quite a lot. Google “journalistic hoaxes” some time and see what things were like in the Victoria era.

    “Honest question. What is the incidence of HPV amongst men and women who have no sexual relations before marriage, or who remain in one sexual relationship? I only ask because this figure is never given amongst all the vaccination literature.” Ian @ 30.

    It could be that the reason the figures are never given is because it has literally nothing to do with anything.

  48. Testing the SBM link – http://tinyurl.com/kwg3mg

    It is written for a non-scientist audience on how to judge the credibility of an information source.

  49. I haven’t read all these comments, so excuse me if I’m repeating someone:)
    I understood that our friends on the Christian right opposed the cervical cancer vaccine since, as “promiscuity” is a factor in the disease, to give girls the vax would enable them to have pre-marital sex. One wonders if they would feel the same way if we were talking about giving a vaccine to boys to prevent something similar.
    Cervical cancer: the sign of a slut.

  50. 41. Steve Says:
    August 20th, 2009 at 9:45 am

    What I can’t quite figure out with this is why are they only vaccinating women? I mean while yes, women are the ones who suffer the cancer side effects, presumably if men were vaccinated, it would increase herd immunity and prevent it’s spread, helping everybody.
    ______________

    I’d chalk this up to society. If it prevented penile cancer instead of cervical cancer, the vaccine would’ve been created 20 years ago and would be given to all children during infancy.

    Remember, boys have a God-stick and girls have a shame-cave. That’s all you need to know.

  51. Seagull

    In addition to the comments already stated, I never hear the argument that HPV was relatively unknown (read that “unmentioned in general conversation about STDs”) to the general public as an STD before Gardasil was being advertised. Why is it that suddenly having a vaccine for HPV (but not, of course, for AIDS, herpes, or any of the other myriad STDs out there) will make girls more promiscuous? How many girls decide their stance on the subject based on whether they’re protected from HPV or not? “Let’s see… I could get AIDS, but I’m protected from HPV, so hey, what the heck?! Let’s do it!”

    Seriously?

  52. @Sarah Trachtenberg

    Oh God forbid us big strong men should have to endure any sort of disease related to our natural promiscuity. Haven’t you heard? Men just can’t help it.

    Y’know though, I really appreciate the folk who think sex should come with dire consequences, people essentially imply my grandmother died because she was a slut. It brings warm feelings. Or maybe it just gets me hot under the collar.

    Edited to add:

    @Toasterhead and Steve

    The vaccine is approved for men who specifically request it from their doctors. I could easily get it just by asking. The health agencies simply don’t have the studies in hand that they needs to recommend that it be given to men. The vaccine was initially only tested on women since they were at greatest risk. The male studies will be forthcoming I’m sure.

    Oh, and can I borrow the “shame-cave” thing?

  53. 54. The Chemist Says:
    August 20th, 2009 at 10:29 am

    Oh, and can I borrow the “shame-cave” thing?
    ______________

    Sure, though I can’t take credit. I’m already borrowing it from Jon Stewart. :)

  54. Bonnie

    Thank you for everyone’s input into this issue. As a mother with a daughter around the age to start getting the vaccine I have been reading as much as I can about it- both pro & against. I am not anti-vaccine. My daughter has had all her shots throughout her life. I am just concerned about this one because it is so new and in my opinion not enough information is out there yet. My other concern is that it only works against a small amount of the virus and there are still some cancer causing strains that it doesn’t cover. I am still on the fence, but am grateful for the open dialague! The more information I can get, the better decision I and my daughter can make. I still don’t know what I am going to do, but have about a year to figure it out. Thank you!

  55. obviouslyanonymous

    i work for an organization which has been behind a lot of the hype around the potential side effects of gardasil and i have to say, i’ve been absolutely sickened by the ignorant reporting of the information by the people i work with and the media that has picked up on our press releases. but then, i’m the only person in the organization with a degree in science, and unfortunately, all i do is maintain the website, so i have to bite my tongue until i get a new job. honestly, in comparison to the stuff that comes out when we put out a press release, the NYT article is the epitome of good reporting.

  56. knobody

    steve:

    my friend’s tweenage son has gotten it (out of pocket, as it’s not approved for boys), and my boys will be getting it, along with my daughter, when they are old enough. afterall, where do girls get HPV? from the boys (and boys get it from the girls, and…)! in fact, it’s even in the process of being approved for boys (http://blogs.wsj.com/health/2009/01/05/merck-seeks-fda-approval-for-gardasil-in-boys/). yes, provided the vaccine shows good efficacy and limited side effects in boys, there’s no reason why they should not also get it, and in some cases, they already are.

  57. @Randy: 4000 is the number of deaths, not the number of cases of cancer.

  58. Catherine

    I got my final dose of Gardasil two years ago. At the same time, I got the Mumps vaccine (there was a mumps outbreak at my university’s residences) – one in each arm. The arm which got the Gardasil felt very stiff compared to the other arm for several hours afterward.

    However, I’m still glad I got it – I’m HPV and Mumps free and I’m still alive!

  59. 56. greg Says:
    August 20th, 2009 at 10:51 am

    i work for an organization which has been behind a lot of the hype around the potential side effects of gardasil and i have to say, i’ve been absolutely sickened by the ignorant reporting of the information by the people i work with and the media that has picked up on our press releases.
    ______________

    Exactly why I got out of public relations. I used to write the press releases for a national medical association, and was amazed by how many clips we received from our clipping service that were almost verbatim from my press release. At most, the wire service moved a few words around and distributed it as news – no commentary, no in-depth discussion, no opposing viewpoints or alternate interpretations of the data – nothing.

  60. Kirk

    @ nichole

    Back off the ad hominem attacks on journalists. It’s too easy a trap that skeptics all too often fall into, even those aware of the logical fallacy. There is plenty of bad journalism out there, but there are also a lot of us in the trenches fighting tooth and nail against bad science, bad statistics and laziness.

    Skeptical groups would do well to seek those people out and ally with them to help disrupt this sort of shoddiness before it sees the screen or page.

  61. Gus Snarp

    Maybe I’m a bit ignorant of the state of medical science on cervical cancer here, but I thought screening detected cancer, not prevented it. How exactly can screening girls for cancer prevent them from getting it?

  62. sisu

    SBents @ #20:
    For an NNT of 18 and a cost of $450 per treatment, it costs $8300 to save one HPV infection. But most HPV infections are benign. Saying HPV is linked to cervical cancer is not enough. How strong is the link, and how many QALYs does an instance of cervical cancer cost? We need an answer to these questions to get the cost per QALY.

    From a utilitarian standpoint, saying “that the cost is totally worth their lives” is false if the same cost applied elsewhere could save, say, ten lives.

    SkepDoc @ #26:
    With those numbers we can do some back-of-the-envelope calculations.
    If the NNT is 18, and vaccinating the entire population of 12yo girls prevents 200,000 HPV infections, we can ballpark the population of 12yo girls at 2,000,000. The cost, at $450 per would be $900M. This saves 3,300 cases of cervical cancer. If we say cervical cancer costs 25 QALYs (is this reasonable?), we’re paying ~$11,000 per QALY saved (not taking into account later herd effects, cytology exams etc).

    The NIH cutoff is something like $40,000 per QALY. If all the numbers are sufficiently sound, then I’m converted – it’s an OK investment.

    Sidenote: I wonder if big pharma companies have considered their own QALY analyses, just so they can set their prices just under the NIH cutoff.

  63. sisu

    Then again…

    http://www.medicalnewstoday.com/articles/119018.php

    “The researchers found that it would cost about $43,600 for each QALY gained for girls who receive Gardasil at age 12. According to the study, the cost effectiveness of Gardasil would cost $97,300 per QALY for women who are vaccinated at age 18, $120,400 per QALY for women vaccinated at age 21 and $152,700 per QALY for women and girls vaccinated up to age 26.”

    And those figures are at a cost of only $360 per treatment. I must backtrack on my backtracks (should have googled it first). I am not convinced this is a cost-effective treatment.

  64. Randy

    @John Armstrong

    Even if it is 4000 deaths, it does not seem significant. Do we know if the vaccine will prevent all 4000 deaths per year?

    Science in this blog seems to be overhyping on the opposite end of the anti-vaxers.

    Am I incorrect in saying so? I’m still a fan of Phil.

    John, you seem to be a scientist. If you can provide a link where we can have a discussion (well, mostly questions from me), it would be nice.

    Randy

  65. @Randy

    Even if it is 4000 deaths, it does not seem significant. Do we know if the vaccine will prevent all 4000 deaths per year?

    One thing that bothers me about people on both sides of the argument on vaccines is that they tend to focus so much on the deaths from diseases. Granted, deaths are a big issue, but also remember that diseases can cause a whole lot of trouble even if they don’t kill a person.

    In the case of cervical cancer, treating the disease may result in inability to bear children (and the emotional/psychological issues with that), the cost of treatment, bleeding and pelvic pain. While none of these are quite as serious as death, they have both a financial and psychological toll.

  66. Randy

    @sisu

    Can you help me understand your $11,000 per QALY? What is a QALY and why 25 QALYs?

    With $900M saving 3,300 cases, I get $272k per save, assuming the vaccine eliminates all 3,300 cervical cancers deaths. That seems outrageously expensive, if the chances are similar to falling and dying.

    Randy

  67. 62. Randy Says:
    August 20th, 2009 at 11:18 am

    Even if it is 4000 deaths, it does not seem significant. Do we know if the vaccine will prevent all 4000 deaths per year?
    ____________

    How do you propose testing this, exactly? Clone the 7 million girls who have received the vaccination, raise them in an alternate, Gardasil-free universe, and see how many of them die of cervical cancer?

  68. Randy

    @Todd W.

    Thanks for the good point.

    It’s difficult to place a value on life or quality of life. I don’t know if it is worth $900M.

    I’m curious if this is out of pocket or insurance pays. If insurance pays, then I think it is part of the problem of out of control health care costs.

    Randy

  69. Randy

    @ toasterhead

    I’m not a scientist. I figure you would have to approximately discount for the uncertainty.

    What is your point? You already know that I am not as intelligent as you.

    Randy

  70. 64. Randy Says:
    August 20th, 2009 at 11:29 am

    With $900M saving 3,300 cases, I get $272k per save, assuming the vaccine eliminates all 3,300 cervical cancers deaths. That seems outrageously expensive, if the chances are similar to falling and dying.
    ______________

    Unless you look at all 7 million girls who received the vaccine as “saved from dying,” rather focus on the 4,000 who actually die or the 12,000 who contract cervical cancer every year. Then the cost is only $128.57 per save. Sounds like a good investment to me.

  71. @Randy

    It’s difficult to place a value on life or quality of life. I don’t know if it is worth $900M.

    I’m curious if this is out of pocket or insurance pays. If insurance pays, then I think it is part of the problem of out of control health care costs.

    Note that besides quality of life issues, I also included the costs of treatment as an issue to consider. There are also potential costs associated with loss of work, depending on the severity of the pain, duration of surgery recovery, etc., which place added burdens on the medical system and economy.

    I believe that insurance would end up paying for the vaccine. However, I think there are other things that contribute more to the high cost of health care (e.g., higher tech equipment, such as beds with all kinds of built in electronics and other palliative care measures, vanity drugs and treatments, addition of woo-woo procedures paid by insurance, etc.).

  72. sisu

    Tired of waiting for my comment with a link to be moderated…

    Google: QALY medicalnewstoday gardasil

    “The researchers found that it would cost about $43,600 for each QALY gained for girls who receive Gardasil at age 12. According to the study, the cost effectiveness of Gardasil would cost $97,300 per QALY for women who are vaccinated at age 18, $120,400 per QALY for women vaccinated at age 21 and $152,700 per QALY for women and girls vaccinated up to age 26.”

    And those figures are at a cost of only $360 per treatment. I must backtrack on my backtracks (should have googled it first). I am not convinced this is a cost-effective treatment.

    edited to add:

    @ Randy:
    QALY = Quality Adjusted Life Years.
    As for the 25, I PIOOMA. Those calculations were pointless anyway, after reading the Harvard study in the NEJM.

  73. 66. Randy Says:
    August 20th, 2009 at 11:37 am

    I’m curious if this is out of pocket or insurance pays. If insurance pays, then I think it is part of the problem of out of control health care costs.

    ______________

    It’s preventative care. Of course insurance should pay. It is much cheaper, on a per-patient basis, to pay $460 for a vaccine now, rather than thousands and thousands of dollars for surgery and chemotherapy and hospital stays and rehabilitation later.

    And yes, one could argue that it’s still cheaper overall to let 12,000 women contract cervical cancer and let 4,000 of them die, rather than vaccinate everybody. But you’d have to be a pretty heartless bastard to make that argument.

  74. bkallee

    My only bias is the commercial advertising of prescription drugs. It bothers me to see TV ads for any drug. Drugs are advertised for marketing and profit purposes. I’d love to see direct drug advertising banned and instead have information commercials with a list of competing drugs available. Levels the playing field.

  75. Randy

    @toasterhead

    Sorry, I don’t understand how you get $128.57?

    $900M/12,000 is still $75k.

    Randy

  76. 73. Randy Says:
    August 20th, 2009 at 11:51 am

    Sorry, I don’t understand how you get $128.57?

    $900M/12,000 is still $75k.
    _______________

    $900 million divided by 7 million.

  77. Randy

    @toasterhead

    According to your statement, until you have contributed all your disposable income to save lives, you are a heartless bastard in my books.

    That also makes me a heartless bastard. I think this is science.

    Randy

  78. Todd, that’s a good point. On my post, I talk more about the other reported “adverse effects following inoculation”. Their numbers are similarly tiny.

    Randy, maybe it’s not clear, but Phil is talking about 4,000 deaths per year, not ever. Similarly, I’m making an educated guess at 2,800 deaths per year. As for being a scientist, I’m actually a mathematician and no more directly involved in this study than Phil is, but I did a little more digging after seeing some terrible televised reports that make the NYT article look absolutely wonderful. I wrote about it on my weblog and there’s been some discussion there.

    Or my standard internet nickname is “DrMathochist” and I do have an account with Google’s mail service. If you’re still interested in asking questions, I’m glad to answer what I honestly can.

  79. comment deleted

    Soooooooo, just running some numbers. 22 million people get vaccinated at $360 a pop. 3000 people don’t get cancer. That comes out to $2.5million cost per prevented case of cancer. Could someone please explain how that is cost effective?

  80. Chris

    Ian:

    Honest question. What is the incidence of HPV amongst men and women who have no sexual relations before marriage, or who remain in one sexual relationship?

    I remember reading somewhere that it was through a study of nuns that made a connection to cervical cancer and a sexually transmitted infection. Unfortunately, I cannot really find any real information.

    I found this paper: J Med Virol. 1993 Apr;39(4):340-4.
    Evolution of the antibody response to human papillomavirus type 11 (HPV-11) in patients with condyloma acuminatum according to treatment response.

    Which says in the abstract: “The sera of 20 nuns with no lifetime sexual exposure served as controls.”

    And then I found out why it is hard to find the research when I stumbled onto a quote in a Naked Science forum (dub dub dub dot thenakedscientists.com/forum/index.php?topic=21377.0), which had a link reference to dub dub dub dot .cancerhelp.org.uk/help/default.asp?page=5391 … that says “Another study done in 1952 of 13,000 nuns found no cases of cervical cancer. These studies and other much more recent studies, all indicate that women are more at risk of developing cervical cancer once they have become sexually active. ”

    The studies were done over fifty years ago, which is why it is hard to find the references. If it truly intrigues you, you’ll need to dig through the basement stacks and microfiche of a research university’s library.

  81. It’s not just an anti-vax issue, it’s a problem with the media reporting statistically insignifigant (and uncertain causality) deaths as though they are a lurking danger.

    Reporters write articles, other people write headlines – and the whole thing’s a recipe for perpetuating the easily misunderstood.

    Blogging aside, lots of “letters to the editor” might be just as effective at getting out the facts, eh?

  82. CJA

    @Randy: 2800 deaths out of 150 million is about 13x more than 32 deaths out of 23 million (using the updated data from John Armstrong—though I’m not sure on the comment that HPV only causes 70% of cervical cancer cases; I thought two types of HPV alone caused cervical cancer??).

    Assuming 50% efficacy at preventing death from cervical cancer, you still have 7 times less deaths caused as a side effect from Gardasil than the amount of deaths Gardasil is preventing. Not sure if 50% efficacy makes sense, but if Gardasil prevents just over half of the cancer-linked HPV strains, it seems to make sense.

    And that’s before correcting some obvious flaws in this study. First, we know that of the 32 deaths of people given Gardasil so far, at least some (and probably most, maybe even all) have nothing at all to do with Gardasil (e.g. the girl who died of a drug overdose). If we cut 32 in half, the 7x ratio improves to 14x.

    Second, we’re comparing the amount of people who die from HPV-linked cervical cancer EACH YEAR, to the amount of people who have died post-Gardasil EVER.

    This is not the exact way to correct for that issue, but consider: Women age 25-49 are the highest risk group for cervical cancer. That’s a 25 year span; so if 2800 women out of 150 million, or 0.002%, die each yr of HPV-linked cervical cancer in the U.S.; then each individual woman who surives from age 25 to age 49 has a 25 x 0.002%, or 0.05%, chance of dying from cervical cancer over that 25 yr period (note, the 150M denominator is now obviously too high given the narrower age group of women at high risk).

    From GSK’s website: Up to 80% of women will acquire HPV by age 50; 50% of those will be cancer-linked strains; 10% of those will develop precancerous lesions; 8% of those will get cancer in the outer cervical cells; and 20% of those will develop invasive cervical cancer. That comes out to 0.064% of all women developing invasive cervical cancer by age 50. So I think we are at least in the right ball bark now. That’s on a worldwide basis, so morbidity is a little skewed relative to the u.s. only; however, it also does not account for non-cervical cancers caused by HPV.

    http://www.gsk.com/media/press-kits/cervical-cancer-key-facts.pdf

    And while i guess this is also flawed because we’re only talking about deaths post-Gardasil, and all potential side-effects, I’m not too worried. You might think, well if invasive cervical cancer costs 25 QALYs (also just pulled out of thin air), and a rash costs 0.001 QALY, then 25k rashes equals one case of cervical cancer. But I’m willing to say that the difference in the QALY cost of cervical cancer and a rash are of such different magnitudes (perhaps different categories), that such an analysis is pointless. Even if those numbers are precisely correct, is the math alone really enough to say that we should prefer to give up a 50-yr old woman’s life just to save 25k teenagers from a rash that lasts a few hours?

  83. Amanda

    While I am by no means anti-vaccination (mother made sure I had all my shots and if I have a child I’ll do the same), I just can’t bring myself to get this shot yet. I also have two younger sisters of the same mindset. Our biggest hangup is that we are hassled to get it each year we visit the OBGYN (the three of us also are very good and get yearly check ups as well). I guess that’s great that they’re pushing it, but we’ve heard very little information about it outside the OBGYN offices and so are a little hesitant. For informations sake, I’m 24 and my sisters are 21 and 19. They have little more time to decide, but next year will be the last time the doctor can push it on me before I’m told the vaccination won’t be covered by my insurance, so we shall see. More time to research.

  84. Randy

    @sisu

    Thank you for the information. Not understanding all the implications, I think I agree that it is not a cost effective treatment.

    So, although the NYT and other articles did injustice to science and rattled anti-antivaxers, I would have to conclude that it may help in eliminating something that is not worth it.

    I’m not sure if I should have my daughters vaccinated for HPV.

    On one hand yes, but on the other hand, I do not want to contribute to rising healthcare costs.

    Can science help me with this?

    Randy

  85. 75. Randy Says:
    August 20th, 2009 at 11:56 am

    According to your statement, until you have contributed all your disposable income to save lives, you are a heartless bastard in my books.
    ______________

    No, you don’t have to contribute all your disposable income. On a per-person basis, that $900 million investment nationwide costs every United Statesian $3. Maybe $18 per household. That ain’t gonna break the bank.

    The issue is whether you view health-care as a financial proposition or as a human right.

    If you start applying pure cost-benefit analysis to the value of a human life, then it doesn’t make sense to fund ANY care. It’s always cheaper to just let everyone die of whatever disease they have, rather than spend thousands of dollars on cures that might not work. And letting people die younger means fewer people in the country – thus less competition over resources, reduced unemployment, reduced inflation, and a better standard-of-living for all. And just think of the savings you’ll receive by burying your child NOW instead of 70 years from now – who knows what funeral costs will be in 2079? It’s win-win!

    Unless, of course, you happen to be one of the ones who lose.

  86. cory

    @ gus Screening for cervical cancer at the moment includes two things: pap smears and HPV testing. IF the pap is normal, great. If the pap is normal but HPV testing comes out positive, then the woman is followed more closely (two years of every 6 months pap smears instead of the current reccommendation, which is one every 3 years ). IF the pap is slightly abnormal (and i don’t remember the grades but i can go look it up if necessary) then screening tests are done and cells are removed, biopsies done, surgeries done to remove abnormal cells, and so on. So technically even an HPV positive woman can have *cervical* cancer prevented with careful watching and painful procedures. Obviously not a best case scenario, but survivable.

    Gardasil prevents the cancer because it prevents the 4 main types of HPV infection that cause most of the cervical cancers out there. The vaccine prevents the infectious agent. The infectious agent causes the cancer. (Oversimplifying, of course) Here is an ok explanation:

    http://search.creativecommons.org/?q=connection+between+hpv+and+cancer&sourceid=Mozilla-search

    Interesting to note that the National Cancer Institute says, “It is important to note, however, that the great majority of high-risk HPV infections go away on their own and do not cause cancer”.

    http://www.cancer.gov/cancertopics/factsheet/risk/HPV

    Just playing devil’s advocate here.

    @toasterhead—gotta love jon stewart

  87. dendromecon

    I recently found out that I have HVP, the most dangerous strain as far as causing cervical cancer goes. Now I am set for a lifetime of cervical cancer screening which involves, yes, exams I would be getting anyway. But at the very least I will also be getting many biopsies that COST A LOT OF MONEY. I have health care. This increases health costs. I would guess that the cost of vaccinating your children once (girls and boys, since it is an STD), is easily less money than all of the health care costs incurred by those who choose not to, or were born too early, to get the vaccine. Get your kids vaccinated.

  88. Randy

    @toasterhead

    We’re not just taking about HPV. We’re talking about making sure no one dies that does not have to. Now are you ready to contribute all your disposable income?

    This leads me to a conclusion that some kind of line has to be drawn. I do not know much about QALY and what sisu says but it sounds like a lot of smart people have already thought about this.

    Randy

  89. sisu

    So, toasterhead, we can assume you’re wearing a toaster-shaped helmet right now. You must be, because it is always safer than not wearing a helmet and human life is more valuable than any cost.

    The truth is, we apply cost-benefit analysis to the value of human life all the time. Read Peter Singer’s recent article “Why We Must Ration Health Care” in the NYT. It may sound cold and crass at first, but it is necessary.

  90. 89. Randy Says:
    August 20th, 2009 at 12:28 pm

    We’re not just taking about HPV. We’re talking about making sure no one dies that does not have to. Now are you ready to contribute all your disposable income?

    This leads me to a conclusion that some kind of line has to be drawn.
    _________________

    It’s a good point. It’s a really good point. I mean, if it were, say, your daughter with, say, leukemia, it’d be a really tough call for me.

    On the one hand, I could give up a minuscule portion of my income to save her life. On the other hand, I could really use one of those new high-definition TVs.

    It’s a tough call. I dunno. What would you chose?

  91. 90. sisu Says:
    August 20th, 2009 at 12:29 pm

    The truth is, we apply cost-benefit analysis to the value of human life all the time. Read Peter Singer’s recent article “Why We Must Ration Health Care” in the NYT. It may sound cold and crass at first, but it is necessary.
    ______________

    Which “we” are you talking about? If “we” are all multi-millionaires, “we” don’t have to do a whole lot of rationing, since “we” can afford to pay whatever we need to pay to save our own lives.

    On the other hand, if “we” are living near the poverty line, our options are limited. Especially if “our” job doesn’t offer health insurance. Is “our” life worth any less than that of a multi-millionaire?

  92. Larry A.

    I would gladly pay any amount for the vaccine if my wife could have had it when she was a child. She was diagnosed with cervical cancer about 12 years ago. She had all the recommended screenings and tests every year and still was diagnosed too late. She died in 2002. The last four terrible months of her life were spent in the hospital fighting for her life. Anyone that chooses to not have their children vaccinated is an idiot!

  93. amphiox

    I think sisu may have a valid point about the cost-effectiveness of gardasil with regards to cervical cancer prevention.

    However, the cost-effectiveness argument really only applies to universal mandatory vaccination. It is not related in any way to arguments regarding effectiveness or safety (except wherein the treatment of complications adds to the cost).

    It also says very little about the targeted use of the vaccine for specific populations, and even less about whether an individual should or should not choose to have it on a voluntary basis.

    Furthermore, for relatively “newer” medications like gardasil, cost-effectiveness tends to increase with time as costs decrease, and more is learned about when and where to most effectively use it (effectively increasing average benefit).

    And we shouldn’t forget that cervical cancer is not the only thing that HPV can cause. (Though it is the most serious)

  94. Gus Snarp

    cory – thanks for clearing that up. So perfect screening and treatment can prevent cervical cancer, but it still requires treatment and associated costs. Still seems like the doctor quoted in the Times was being deceptive, since that level of screening is unlikely in the real world.

    What this really shows is the dismal lack of understanding of statistics in this country, both among the public and among journalists. I just commented on an NPR story about the 28% increase in workplace suicides in the U.S. Of course that 28% consists of 51 suicides out of an employed workforce of 140 million people. But a 28% increase is a better headline than 51 out of 140 million.

  95. Rocketboy

    If someone WANTS to get Gardasil, which prevents against SOME forms of HPV, which are linked to higer rates of cervical cancer, then yes, go ahead. My issue is when there’s a movement to make it mandatory. That’s where I have a problem with it.

  96. @Amanda

    I guess that’s great that they’re pushing it, but we’ve heard very little information about it outside the OBGYN offices and so are a little hesitant.

    Take a look at the info on the FDA’s site: http://tinyurl.com/motck8

    You could also search PubMed for studies on Gardasil.

  97. Freya

    I’m going to encourage my little sister to get it once she’s 18 and our parents won’t be able to stop her (Yeah, they’re part of the “You don’t need it if you’re not sexually active” school of thought). Personally, though, I don’t really know – not only did I have a moderate adverse reaction to every vaccine I can remember getting except for one flu shot a couple years back, I don’t have $360 to spend on food and rent, much less a vaccine for something that could be avoided with routine care.

  98. MartyM

    Nice article. I love the comments. Keep up the promotion.

  99. Randy

    Does anyone know if Gardasil is covered by insurance?

  100. @CJA: From the FDA’s press release when it licensed Gardasil for sale:

    Some HPV types can cause abnormal cells on the lining of the cervix that years later can turn into cancer. Other HPV types can cause genital warts. The vaccine is effective against HPV types 16 and 18, which cause approximately 70 percent of cervical cancers and against HPV types 6 and 11, which cause approximately 90 percent of genital warts.

  101. Randy

    @CJA

    Thanks for being so informative. Do you think $900M is a good investment?

    Actually, wouldn’t it eventually cost approximately 150,000,000 * $450 (or is it $8300) $67,500,000,000 over the next 80 years assuming the population remains constant and average life expectancy is 80 years?

    That’s about $850M a year but of course the cost will come down as the years go by.

    Randy

  102. CJA

    I think >90% of women age 9-26 that are in private insurance plans are covered for gardasil (9-26 is the FDA approved age). Medicaid also covers it for uninsured children (up to age 18), and Merck has a program whereby women over 18 can get it for free (they have that program for other vaccines as well, as the medicaid Vaccines for Children program cuts off coverage at age 18).

    Note, rate of coverage could differ a lot under the different insurance plans (as with most health care).

  103. Torbjörn Larsson, OM

    I’d rather close the barn door before the horse escapes.

    Not to mention that vaccine is one of the few things we know of who actually prevent risks. It’s even better than safety belts because it makes sure the accident never happen in the first place.

  104. Roen

    15. @TechSkeptic
    Too true, this is why I flood them with links to sites like this one. Seriously, I was simply addressing the comment. My daughter visits here now also. she really enjoyed “Shine a light”.

    Additionally, she was quite scared at all the hubub with 2012… until I gave her this site and 2 others.

    But, nice catch anyway. ;)

  105. CJA

    Randy: I would do the analysis two ways. One, compare the chance that my daughter or myself is to get cervical cancer to the all-in costs of the vaccine (including side-effects, but these seem minimal–I’m not giving much credence to the few deaths that happened, but with no necessary connection to the vaccine). Second, what are the costs and benefits of vaccinating every woman who could potentially benefit from the vaccine.

    First, the above math suggests that there is about a 0.06% chance of getting cervical cancer before age 50. The full course of Gardasil costs $360. Assume Gardasil prevents 70% of cervical cancer cases (a look around suggests it’s more than half, given that Gardasil prevents the virus types that cause 70% of cervical cancer cases, 70% looks reasonable). Also assume the median loss of life from cervical cancer is about 1/2 of one’s life. By buying gardasil, I’ve improved the odds of living that 1/2 of my life by 0.042% (0.7×0.0006), for a mere $360. The implied value of my entire life is $1,700,000 ($360/0.00042/2–the math basically says, I pay $360 for 0.042% improved chance at living half my life; now what does that imply I would pay for a 100% improved chance of living my entire life). Do I value my life more than that? Of course I do, so it’s in my best interest to buy gardasil from a pure expected value sense (and if I’m at all risk averse, it makes even more sense).

    Note, I haven’t taken into account what else I might spend the $360 on. That’s fair. But in reality, people spend far more money all of the time on services/objects that increase their likelihood of living by an even smaller amount. Economists try to figure out an implied dollar value of a human life through a similar back of the envelope approach. For instance, how much are people willing to pay for adding airbags in a car, relative to the extra safety that airbags provide? Or if two people have almost identical jobs, but one has a small physical safety risk–how much more does at-risk job have to pay to attract equal talent? Many of these approaches put the dollar value of a life at $1M to $10M, based on our everyday decisions (note the idea that a vaccine should cost no more than $50,000 per QALY uses similar math; $50,000/yr x 80 yrs/life= $4,000,000/life). So buying gardasil makes at least as much economic sense as buying a car with airbags, or accepting lower pay for a safer job. Last I checked no one has a problem with those types of decisions.

    Also, note how much 0.042% of one’s life actually is. If you live to age 80, its 295 hours. Would you pay your employer $360 for 295 hours of vacation time? I think so.

    Analysis 2: Let’s say we vaccinate about 1/3 of American women over the next few years, or 50 million women (on the assumption that those over 30 are too old to benefit—which may or may not be true). At the same time, per my above math, we assume that 0.06% of these women would have devoloped cervical cancer during their life without the vaccine. About 70% of these cases could have been prevented via Gardasil So 0.042% of 50 million lives will be saved, or 21,000. On average, those women will be around 40, so I guess we are saving only a half of a life, or 10,500 total lives.

    However, that will also take 50M courses of Gardasil, at $360 a piece. That’s $180 Billion.

    So the question is, are 10,500 lives worth $180 billion? You get the same value of a human life as before, at $1.7 million, so I don’t know why the answer would be any different.

    Also, one of the problems with this analysis is that we are using $360 per course of Gardasil. That’s the fee you pay if you go to the doctor today and buy yourself some vaccine. But first, not everyone buys it themselves (e.g. the people who get for free from Merck). And two, it’s not like the $360 just goes down the drain. A bunch of it is profit at Merck, who then uses that profit to reinvest R&D that will create future drugs that save future lives. Of course, most people who dislike vaccines also dislike the idea that big pharma co’s make lots of profits; so that part of the analysis probably isn’t that comforting to them. But it’s a necessary part of the analysis. E.g., if the government could seize control of Merck, and reduce the cost of Gardasil to the actual manufacturing cost of, say, $30, wouldn’t we adjust our economic analysis to reduce the cost of saving one life by a factor of ten?

    Also the QALY analysis you gave the link to earlier appears to have been hardly the final word on teh subject (Merck obviously disagreed, and it seems that some objective bystanders might have as well).

  106. I am one of the woman that had to go through a two year ordeal with HPV and a chance at having cervical cancer. Luckily at the time I had health insurance, but lost my health insurance 3/4 of the way through treatment (which cost me an arm and a leg). I had a abnormal pap, was told I had HPV over the phone and that I might have cancer. Had many followup paps and finally a painful biopsy to confirm that I didn’t have cancer. I got the Gardasil vaccine and then was told to wait. The only way I could get rid of the HPV was to wait and hope my body would fight it off. I was engaged at the time and since there is no test for HPV in men we had to just assume that he had HPV as well. It was a very stressful year and getting the vaccine at least meant that once my body finally did fight it off (it did a year later) that I was not going to get it again from my fiance.
    Getting cancer is only one of the many outcomes that can come from HPV. I was also told that I may not be able to have children.
    If you are on the fence about whether or not to get the vaccine – consider the time, money, and emotional rollercoasters that you will have to deal with if you do happen to get HPV (even if you don’t get cancer – would you sleep with someone knowing that you could pass a potentially fatal disease to them?). My doctor also told me that you could look around in a crowded room and expect that pretty much every person in that room has had HPV during some part of their life. There is no cure for it – you just have to live with it until it decides to go away. If I could have gotten the vaccine when I was 14 as opposed to 23 I would have.

  107. Randy

    Can someone please check my math and my logic

    150,000,000 women in the US
    1,875,000 women in each age assuming an even distribution with average life of 80 years
    46,875,000 women in age group 25 – 49
    2800 deaths per year for women 25 – 49 (this may be wrong)
    Rate is 0.00006
    Over 25 years the rate is 0.0015 (should not be a direct multiplication, but for simplicity sake)

    Does that mean 1 in 1,000 women 25-49 now will die from HPV one day?

    Let’s just underestimate and say 1 in 10,000. What is this rate comparable to?

    Randy

  108. Randy

    @CJA

    Thanks again for such an elaborate explanation. It is helpful.

  109. CJA

    @Randy 103: The math indeed says that about 1 in 1,000 women will get invasive cervical cancer from age 25-49. Not sure how many of those die. (worldwide, over half of all women with cervical cancer die–and that includes the non-invasive kind, so I assume fairly high morbidity on the invasive kind).

    Per the GSK link I gave earlier, every two minutes, a woman dies of cervical cancer somewhere in the world. In the U.S., I think it’s like one person dies every 10 minutes from an auto accident (giver or take a few minutes). So every 2 minutes in a population of 3.4 billion women, vs. every 10 minutes for a population of 300 million. Scaled for the respective population, that means people die from auto accidents in the U.S. only a little more than twice as frequently as a women die from cervical cancer around the world.

    Again, that puts the rationality of recommending that girls receive gardasil on par with the rationality of mandating seatbelts in cars.

  110. gss_000

    I think there is some overreaction here about the NYT article. Let’s looks at the first paragraph:

    “The new vaccine designed to protect girls and young women from cervical cancer has a safety record that appears to be in line with that of other vaccines, a government report has found. Some serious complications occurred, including at least 20 deaths and two cases of Lou Gehrig’s disease, but they were not necessarily caused by the vaccine, the study said. ”

    Another segment:
    “But while the tone of the study, published in The Journal of the American Medical Association, was reassuring, the authors noted that the analysis was based on imperfect data”

    Furthermore, it even ends with a statement that one doctor “said the disparate causes of death made it difficult to determine an underlying cause, or to determine if the vaccine played a causal role.”

    I think with that, there’s no hype or over exaggeration here. How is this scaremongering to say the risks are in line with other vaccines? This article would not stop me from giving the vaccine to my daughter if I had one.

  111. BadSeed

    With the caveat that anecdotes aren’t data…I”m with Jaki @102.

    In late 2005, I tested positive for HPV, one of the cancer-linked strains. Had that nasty, awful biopsy. Doc was able to excerpt the entire lesion. Six months later, clear pap test. I’m golden, right? Not so fast. The Ob-Gyn also ran a separate HPV test — which was again positive. This time, it was cryosurgery to excerpt the lesion, which was now larger than the previous. Six months later, there was a new lesion, and it had progressed to CIN-II even though the pap was still clear. Early 2007 I had a hysterectomy. There were a couple of other factors that really made hysterectomy the only viable treatment.

    I am 41. I’ve been in a monogamous relationship since 1998. I’ve had a grand total of three partners in my life. HPV does not give a rat’s ass how you conduct your business. You can live your life pretty conservatively, and you can get your regular checkups, and one day there it is, despite normal paps, and it Won’t. Go. Away.

    So talk all you want about “cost effectiveness.” That was the reality of HPV, and it sucks.
    Get the damn vaccine for your kids.

  112. Keith Harwood

    There was a segment on the radio yesterday morning. A doctor saying, yes, there were complications, he described them and pointed out that the chances of dying from cervical cancer were something like a thousand times higher. No anti-vax scare there.

    Here in Oz the vaccine is free for girls entering high school and women in early twenties (I forget what age exactly). I think the idea is that the provision for this second group will drop out when the first lot of school girls reach that age.

  113. Randy

    Approximate Deaths/year

    Heart Disease: 650,000
    Lung Cancer: 150,000
    Accidents: 120,000 (including Auto Accident)
    Diabetes: 75,000
    Influenza 63,000
    Auto Accident: 35,000
    Aids 35,000
    Homicide 18,000
    Cervical Cancer: 8,000 (2x, adjusted for gender for comparison sake)

    I am leaning towards vaccinating my children now, but they are still young, so I have some more time to wait and see.

    Randy

  114. Grand Lunar

    Does anyone know an age limit for the vaccine?

    I ask, because I think my sister, who is 21, ought to consider the vaccine.
    I think my other sister had some cancer, but caught it early. It was also benign.

  115. Chris

    Grand Lunar, according to dub dub dub dot .cdc.gov/vaccines/vpd-vac/hpv/vac-faqs.htm, it recommended through age 26.

  116. @Grand Lunar

    Gardasil is approved for ages 9-26. In addition to the link Chris provided, you can also go to the FDA web site and search for the info.

  117. In Australia the vaccine is supplied free of charge to girls between 12 and 26. Almost 5 million doses delivered so far.

    I find the discussion on QALY and cost effectiveness very amusing in a most disturbing way. Are you saying the cost of prevention is too great so we should let them die? Nice.

    BTW, HPV has been linked to Penile and anus cancer in men, it is just that there are significantly fewer cases than cervical cancer in women.

  118. PJ

    THANK YOU, THANK YOU, THANK YOU!!! As a 10-year survivor of HPV and cervical cancer, I am excited to see someone stepping up and saying “wait a minute here – these facts don’t make sense.” Too mnay people have bought into the hype out there and jumped on the anti-vaccine bandwagon.

    Now, I am not saying everyone should get vaccinated, but I do encourage people to learn the facts about HPV and its connection to more than just cervical cancer. HPV can cause anal, penile, vaginal, head, neck, throat and even some forms of lung cancer – and I am sure once more research is done, we will find it is a contributor to other forms of cancer as well.

    People need to get educated from reputable sources and then make their own conclusions. Get educated, get screened and do not become one of 6.2 million Americans who contracts HPV each year!!!!

  119. Wow, I have been reading this blog for quite a while, but this is the most comments I have ever seen for a story.

    I am a molecular biologist and one of the things I learnt a long time ago is that the population as a whole do not understand biology AT ALL, however there are individuals who have some understanding of it (think MIB “A person is smart, people are stupid”).

    Take for example the issue of GM (particularly the ‘Salmon gene in a tomato to stop it from freezing’ issue). I once read a survey saying that a large proportion of people (I can’t remember the total number off the top of my head) surveyed in the UK did not agree with putting salmon genes into tomatoes because tomatoes did not have genes naturally. I think everyone who reads this blog can see the problem with that statement.

    People generally do not want to do something that might cause them harm in the short term, even if not doing it will have a higher relative risk of causing them harm in the future.

    Also, in science, it is never possible to say something will NEVER happen, only that the chance of it happening is infinitesimal, which the media will generally see as the scientific community hiding something, as this is what might happen when politicians refuse to rule something out.

    @Roen (Comment 12)

    The best possible advice one can give… yet, sadly millions will believe the alarmists. I actually gave my two children similar advice, “be skeptical of everything you hear, even if it comes from me”.

    Robert Jordan once said “Believe nothing of what you hear, and only half of what you see”. I think this is a very good life lesson.

  120. provax pediatrician

    #89 is correct. It is MUCH cheaper to vaccinate and have cervical cancer disappear than it is to continue to perform endless pap smears (which do get read incorrectly, by the way), biopsies, and culposcopies, not to mention the time the women have to spend away from life to be in the office. We won’t know whether we can stop pap smears, however, until there is a large enough cohort of vaccinated people who grow up and don’t get HPV. Unless there is something special in small protein chunks of HPV (what is actually in the vaccine) there is very little reason to think the vaccine could even theoretically be dangerous – its made the same way most vaccines are made, with proven technology.

  121. Sisu said:
    I am not convinced this is a cost-effective treatment.

    ah, but a $37,000 hysterectomy to removed a diseased uterus and cervix is? Or the hundreds of thousands it costs to do radiation and chemo is cost-effective? when these costs could have prevented by Gardasil shots?

    Remind me not to let YOU cast the odds for other people’s cervixes and uteruses.

    Other commenters here have pointed out their experiences, costs, and emotional toll of the HPV-caused issues — up to and including hysterectomies. I am one of them and I join with my sister above in saying “Get the damned shot for your daughters.”

    While everybody here is arguing facts and figures, actual women are facing this issue — they have skin in the game, so to speak. They are ground truth and all the BS in the news and put out by the antivaxxers and religulous types is just so much fakery designed to influence behavior in the wrong direction.

    Don’t make actual women’s issues go away by flinging around numbers… realize that there are human beings behind those numbers, not just BS about “shame caves” and head-in-the-sand attitudes from parents in denial about their daughter’s sexual lives. It’s not a judgmental virus — it’s a frigging virus that needs to spread in order to live and it strikes a wide range of people with a wide range of sexual behaviors. Leave the judgment and fuzzy thinking behind and just get the damned shots.

  122. Naomi

    Hey, that reminds me, I’m due for my third shot next month. Yay for free vaccines!

    @ Catherine (comment 60)

    I got a Gardasil shot and a flu shot at the same time three months ago – the Gardasil shot was a LITTLE achy, but the flu one was so painful I couldn’t write properly for two days. Guess it just depends on other factors?

  123. @Naomi
    Guess it just depends on other factors?
    Could be. Blood tests and blood donations run the gamut from “OMG my arm is sore and bruised for days” to “What? You’ve done it?”

    My partner had a rubella booster and flu shot yesterday with only minor discomfort at the point of injection. Hurt her more when I punched her in the arm (kidding).

    And a couple of years ago we had the full range of travel vaccinations for a trip to Africa. I don’t recall any discomfort at all apart from the wallet. You just never know I suppose.

    @ccpeterson
    Bravo.

  124. accountant

    @shane & @ccpeterson

    There are implications to the total cost of healthcare to the nation when costly vaccines are provided as a preventative measure by health insurance. One can argue that due to the soaring cost of healthcare, x number of people cannot afford coverage. These people may be undiagnosed for let’s say, heart disease, our number one killer. Sisu is trying to provide sound facts where you provide unintelligent facts and judgment.

    There should be no fear of this vaccine except for the possible rise in healthcare costs that affect many people, which is why a cost benefit analysis is a necessity.

  125. Buzz Parsec

    A lot of the cost analyses here have focused on the value of the lives saved vs. the cost of the vaccine, but what about the cost of treatment both for cervical cancer and for positive pap and HPV tests that don’t result in cancer? Biopsies aren’t cheap, and that seems to be the *minimum* treatment for the thousands of cases that don’t result in cancer. (I’ve had 3 biopsies in the last 2 years for various conditions, all proved negative, but they were all several hundred dollars, or at least, that’s what the pathologists billed the insurance company.) It sounds like HPV results in 10’s or 100’s of thousands of cases of intensive monitoring including many extra doctor visits and biopsies every year ($10-100M/year or more), and thousands of hysterectomies ($40-350M/year) in addition to the 4000 cancer deaths annually ($400-800M?) 2M doses@$360 = $720M/year (to vaccinate all the 12y0 girls.) If that prevents half the HPV cases and half the treatment costs, then it’s a break-even or better. And this ignores all the preventable pain and suffering, just the direct medical costs.

    My estimates of the treatment costs could be way out of line, but I can only imagine them being way too low, not too high. All this talk about the value of a quality life year should only apply to the residual cost (the difference between the cost of vaccinating and the cost of treating the excess cases that result from not vaccinating) and not simply the cost of vaccinating. If it’s small or negative, it should be a no-brainer.

    (Disclaimer: Absolutely no googles were injured or killed during the making of this post. All data gleaned from previous comments and personal experience.)

  126. 121

    What annoys me are people afraid of promoting promiscuity. They should give it a try some time.

    Well, I think sex is healthy and natural and I’m all for Gardasil, but I wouldn’t want to promote promiscuity, either. You sure you have the correct definition in mind? Promiscuous = casual and indiscriminate. Thanks to that sort of activity we now have HIV, drug resistant syphilis and a huge increase in chlamydia cases in the past 20 years.

  127. Marco Langbroek

    So, we all are QUALY’s now, not humans?

    Given the amount of cancers and other discomforts caused by HPV yearly, any sane person can come to only one conclusion: get that shot for your children.

  128. Nigel Depledge

    Jason B (6) said:

    My daughter has started the vaccine, and we will get the rest of the shots that go with it. Personally, I consider this a step towards vaccinating against cancer! What a concept!

    I’ve been working recently on a vaccine that could help with about 12 different types of cancer. I can’t share any details, however, because my employer’s customer owns the IP.

  129. Nigel Depledge

    Cory (32) said:

    There is skepticism and there is blindly pushing for vaccines, any vaccine, right away. I thought scientists were supposed to try and be patient and wait for long term results? Like COD, I am all for vaccines that work but i would like to know that we know as much as we can about their long-term effects before they are pushed on the public.

    This is inflammatory and misleading.

    The manufacturers of vaccines fulfill the requirements of the respective regulatory authorities (in the USA, this is the FDA) when they conduct trials and submit applications for licences. Once a vaccine is licenced, it may be prescribed by physicians, most of whom will follow advice from professional bodies such as the AMA. Long-term data are only available after a vaccine has been in use for several years.

    If you want long-term data before a vaccine is licenced, feel free to fund the large long-term trials needed to acquire such data. BTW, dig deep, as such a trial will cost tens of millions.

    Or are you saying that attempting to prevent a disease (with known effects, as in the case of cervical cancer) should wait until the data demonstrate that the vaccine has passed a certain threshold of safety? If a vaccine has passed its Phase III trial, it is almost certainly a lesser risk than the disease that the vaccine prevents.

  130. Nigel Depledge

    Captain Mike (49) said:

    “Journalists = teh evil.” – nichole @ 10.

    Thank you nichole, for that idiotic generalization. As a professional journalist, there’s nothing I like better than being told I’m evil. Some journalists are better than others at their jobs. Period. There never was a time when that wasn’t true. If anything, standards have improved quite a lot. Google “journalistic hoaxes” some time and see what things were like in the Victoria era.

    Quite right, Mike. If she’d said “newspaper editors”, however, that would have been another matter, right? ;-)

    On a more serious note, I sympathise with Nichole’s obvious frustration at the wanton abuse of science and statistics in nearly all newspapers.

  131. Nigel Depledge

    Gus Snarp (63) said:

    Maybe I’m a bit ignorant of the state of medical science on cervical cancer here, but I thought screening detected cancer, not prevented it. How exactly can screening girls for cancer prevent them from getting it?

    You are quite right to ask this question.

    Screening does not prevent cervical cancer. Screening detects cancer, and screening programmes aim to detect all cancers in a sufficiently early stage that they can be successfully treated.

    Thus, screening can prevent most deaths from cervical cancer, but it does not prevent cancer.

    I think think most young women would rather have the three shots than have to have a cervical smear every few years. I am given to understand that the procedure is very uncomfortable, to say the least.

  132. Mrs. George Kirk

    I always thing the pap smear conversation is interesting. So based on the fact that polio is usually a mild disease, we should have spent more effort on improving the iron lung and making sure it was widely available – instead of that vaccine that Dr. Salk developed.

  133. DanVeteran

    Both my daughter have had the vaccines. The only side effects I have noted are moodiness, not listening to parents and spending too much time on the cell phone. But that could be caused by them being teen age girls.

    What is the cost of watching your child or spouse suffering with cancer? Are we putting a cost on human life? What is the cost of a triple by-pass for an overweight smoker? Isn’t that a self inflicted injury? Should insurance companies pay for it is a self inflicted injury?

    Dan

  134. David D

    @#124ccpeterson–
    ah, but a $37,000 hysterectomy to removed a diseased uterus and cervix is? Or the hundreds of thousands it costs to do radiation and chemo is cost-effective? when these costs could have prevented by Gardasil shots?

    I don’t know where you got those figures from, but they seem wildly inaccurate.

    Down here in the Deep South, where I practice, Medicaid will reimburse you about $5000 for a hysterectomy. That includes hospital costs, anesthesia and doctor fees, and post-op care. The surgeon probably gets less than $1000. I suspect Medicare will pay even less.

    This goes along with Obama’s claim that surgeons get 30k to 50k for a leg amputation. DON’t get involved in a debate about healthcare costs unless you can get your facts straight.

  135. David D

    @132 Nigel Depledge–
    Screening does not prevent cervical cancer. Screening detects cancer, and screening programmes aim to detect all cancers in a sufficiently early stage that they can be successfully treated.

    Wrong. Pap screening is designed to detect precursor lesions or “pre-cancerous” cells. If the smear picks up cancer, it would not be that great of a screening tool. The tremendous success in treating cervical cancer over the last 70 years or so has come from the fact that we are detecting and treating these lesions BEFORE they become cancer.

  136. River Sol

    I am currently recovering from Lyme disease using an antibiotic regimen, and am modestly dismayed that the Lymerix vaccine I had 10 years ago didn’t prevent it. My infection catalyzed me to research and understand better.

    As it turns out the Lymerix vaccine was shown to have a 78% effectiveness, so I belong to the less fortunate 22%. I’ll tell you the wide array of flu and arthritic symptoms I had for 3 weeks were quite severe, so I am glad those who were protected had the chance to avoid these symptoms plus longer term neurogical and autoimmune issues from not having Lyme disease.

    But of course, you cannot get Lymerix any more, it is a victim of the same sensationalized media treatement that Gardasil is getting here. GSK was litiginously coerced to remove it from the market. No scientific basis tied the vaccine to anything.

    I feel the (very profitable) pharmaceutical companies are juicy prey for lawsuits (though vaccines are generally much less profitable than their medicinal product lines). It would seem drug companies need to grow a backbone and stand up for scientific results and keep their vaccines on the market.

    In the end, anecdotal information can pack a punch for journalistic “fear mongering.” Fear sells; somehow journalistic policy needs to be encouraged to sell the complete picture. Perhaps, open source blogging and the like used by level headed minds will help complete that picture for many of us!

  137. Nigel Depledge

    @ David D (135)-

    Ooh, hey, there you go. You learn something new every day.

  138. Nigel Depledge

    David D (134) said:

    This goes along with Obama’s claim that surgeons get 30k to 50k for a leg amputation. DON’t get involved in a debate about healthcare costs unless you can get your facts straight.

    Surgeons get $30k to £50k for a leg amputation? Oh, man, I chose the wrong line of work!

    ;-)

  139. nichole

    You know, guys, I don’t talk words too good sometimes, and I’m sorry I forgot a qualifier. Am I allowed to say that journalists that force balance on issues are evil? Or something? You know, when they make it sound like there are two equally valid points to be considered, when there’s only one valid point and one STUPID point? Is that okay?

    I’m sorry that I don’t have a lot of sympathy with an ethnic group that advocates violence as the route to secession from its nation. I’m sorry they’re a freaking ethnic group, because if they were just a political group, no one would feel bad at all. If I organized a revolt against my government and then lost the war, I wouldn’t expect to be allowed to live there after the war was over.

    That’s what I think. Go ahead and crucify me.

  140. sisu

    People posting histrionics about their personal experiences and the price of a hysterectomy are missing the point entirely.

    Vaccine A costs $40,000 per QALY.
    Vaccine B costs $20,000 per QALY.

    If resources to spend on health care are finite, and if vaccine B is not already maximally provided, then spending money on vaccine A costs lives in a relative sense.

    The sad thing is the number of more effective vaccines out there that are not provided. Spending the equivalent on universal flu vaccines rather than Gardasil would save one metric buttload more lives.

    w w w dot hhs.gov/nvpo/nvac/vaccines21cer.html

    If the concept of cost/benefit analysis of treatments offends your sensibilities, you need to get on the horn to your Congressperson/MP and insist they crank up spending on health care rather than criticize the analyses. Complain a little about patent law, while you’re at it.

    Full disclosure, in case anyone thinks I have a personal grudge against Gardasil: My province is paying for Gardasil for girls in grades 7/8 (12-13 years old). My province has limited money to spend and more cost-effective vaccines are available, so I think this is a bad idea. My objection is not based on religion or sex politics – if Gardasil is no longer provided when my daughter reaches the age of 12, I am prepared to pay for it myself. I can afford it. I am not prepared to ask the taxpayers of my province to pay for this treatment when cheaper and more effective treatments are not provided.

  141. @sisu

    I see what you’re doing. On one hand you have wishful thinking and on the other an existing vaccine. Okay then.

  142. Jefferson

    Here’s another piece on this “hot” topic:

    http://www.cbsnews.com/stories/2009/08/19/cbsnews_investigates/main5253431.shtml

    Some interesting issues raised here.

  143. sisu

    Flu vaccines exist.
    $/QALY is less than Gardasil.

  144. @sisu
    Not an universal flu vaccine.

    If you get the flu chances are you will be sick for a while then get over it (yeah some people die).
    If you get cervical cancer chances are you will not get over it. There is a very good chance you will die or you will suffer life long complications.

  145. Randy

    I agree with sisu.

    The cheaper flu vaccines can possibly save 60,000 lives per year where as the HPV vaccine possibly only saves 4,000. By cheaper, I mean the per dose is cheaper. I do not know if the total cost would be cheaper, but I would imagine so.

    On the other hand, if the HPV vaccine is paid out of pocket, then there’s no issue with me to get both.

  146. David D

    @Jaki #102
    I had a abnormal pap, was told I had HPV over the phone and that I might have cancer. . . .
    Getting cancer is only one of the many outcomes that can come from HPV. I was also told that I may not be able to have children.

    It sounds like you had a difficult time. It also sounds like you were given some wrong information. Having HPV is not at all the same as “might have cancer.” That was a terrible thing to say to a patient, especially over the phone. As far as HPV itself, there is no association between HPV infection and infertility.

    HPV is like many other viral diseases that we acquire–there is no cure for them. Thankfully most of them remain dormant in our bodies and don’t cause any problems at all. It is estimated that in the vast majority of cases, our immune system is able to contain and perhaps eliminate an HPV infection, usually within 2 years.

    . . . (even if you don’t get cancer – would you sleep with someone knowing that you could pass a potentially fatal disease to them?)
    Again, HPV is NOT a fatal disease. Most HPV infections will not result in the development of cervical cancer, even those involving the “high risk ” types of the virus. It is simply inaccurate to think of this infection in this manner.

    BTW–I do promote this vaccine in my practice.

  147. SkepDoc

    @sisu

    I get what you are saying. But your initial statement was about the cost-effectiveness of the vaccine, not whether the tax payers should be funding them. Those are two fundamentally different questions.

    Based on the study that you cite, Gardasil is probably cost effective if given only to 12 years olds now (QALY < $50,000, generally cost effective). Yet it is probably not cost effective if retroactively given to women under the age of 18 (QALY near $100K).

    The problem that you have about limited funds and choosing between two forms of preventative therapy is a different (and very unfortunate) question…But then you also have to look not only at the cost effectiveness, but also the incidence, prevalence, and severity of the diseases in question.

  148. Randy

    @ Shane
    Not an universal HPV vaccine.

  149. Not an universal HPV vaccine? So? I wasn’t trying to compare imaginary vaccines with a jab I could get today.

    So why can’t you have both vaccines? You seem to have a bit of a false dichotomy going here. BTW, in Oz the flu vaccine is about $20 and free if you’re over 65.

  150. sisu

    @Shane

    The $/QALY numbers are for the annual flu vaccine. They also take into account the mortality numbers for both conditions.

    Do you believe Gardasil is the single, cheapest way in existence to save lives and quality of life that is not already 100% utilized? If not, we’re on the same side here.

  151. Randy

    @Shane
    You need to read the entire blog and comments.

  152. @Jefferson

    Interesting article. It takes a “both sides of the issue” stance, which, in the end, I fear, serves to generate fear or mistrust of the vaccine. This could potentially lead to lower vaccination rates.

    I noted this tidbit from one of the docs that worked on the Phase II and III studies:

    She says data available for Gardasil shows that it lasts five years; there is no data showing that it remains effective beyond five years.

    Gardasil was only approved last year. The earliest clinical trials I could find for it at clinicaltrials.gov were from 2001, but those weren’t looking at efficacy. The trials that did look at efficacy were generally 4-year studies. So, while she’s technically right, that there is no data for long-term efficacy, it hasn’t been around long enough to gather that data, and for the amount of time that it’s been in development, my thought is that Merck problem wants to start recouping some of the millions that have already gone into it.

    Be cautious, yes. Ask questions. Get informed. But barring clear evidence that it presents more risk than benefit, go ahead with it.

  153. @Randy
    Been here the whole time.

    @sisu
    Do you believe Gardasil is the single, cheapest way in existence to save lives and quality of life that is not already 100% utilized?
    Again, false dichotomy.

  154. sisu

    @SkepDoc #150

    “But your initial statement was about the cost-effectiveness of the vaccine, not whether the tax payers should be funding them. Those are two fundamentally different questions.”

    I think they are fundamentally the same question. Every health care arrangement in existence draws the line somewhere (perhaps not consistently – they are not perfect, nor is the information available). Tax payers should fund treatments on the right side of that cost-effectiveness line. To deny this is to say the most marginal treatments in existence – even quack treatments that provide a placebo effect – should also be funded.

    “Based on the study that you cite, Gardasil is probably cost effective if given only to 12 years olds now (QALY < $50,000, generally cost effective)."

    Just marginally cost-effective, and I live in a relatively poor jurisdiction. I think the money could be better spent elsewhere.

    “But then you also have to look not only at the cost effectiveness, but also the incidence and prevalence of the diseases in question.”

    It is my understanding that proper cost/benefit analyses do look into the prevalence of diseases. They would have to, or they couldn’t estimate the $/QALY. I’m not saying this to be snarky, but I trust the Harvard Med School to be adequately thorough in deriving the numbers appearing in a peer-reviewed paper.

  155. @sisu

    I trust the Harvard Med School to be adequately thorough in deriving the numbers appearing in a peer-reviewed paper.

    Hopefully you don’t trust them simply because they’re Harvard. They have their share of cranks and quacks, too, who publish articles favoring their chosen woo.

    Not to mention that quality of life isn’t exactly an objective measure.

  156. SkepDoc

    @sisu

    I understand that cost-effectiveness and provision of care are related. What I was saying (poorly) is that I thought you were mixing up two issues:

    “Is the vaccine cost-effective?” is a different question from “In our current health care system should vaccine A or vaccine B be given?”

    Speaking only about Gardasil and asking purely about cost-effectiveness: I think that more study needs to be done, but by most standard convention a QALY < $50K is probably worth it. But you're right, it is on the margin. It looks like Gardasil is leaning towards being cost-effective if only given to females at age 12 (not 18 and under).

    The problem of where to spend your money is a different one, and probably needs a new thread. The issue I was trying to explain about looking at comparing preventative vaccines was simply that you have to look at more than cost effectiveness (or QALY); For example, if you don't have much exposure to a certain disease in your community then the QALY doesn't really matter.

    You're points are very well taken. In your community if you only have a limited amount of funding dollars and there are two vaccines available for different preventions, then going with the one with a lower QALY makes sense (provided that it is something that your community is significantly exposed to). But it doesn't detract from the intrinsic cost-effectiveness of either vaccine.

  157. @sisu
    I think they are fundamentally the same question.
    No they’re not. Cost effectiveness vs taxpayer funding are fundamentally different. A treatment can be cost effective, or not, regardless of who pays.

    Every health care arrangement in existence draws the line somewhere (perhaps not consistently – they are not perfect, nor is the information available). Tax payers should fund treatments on the right side of that cost-effectiveness line. To deny this is to say the most marginal treatments in existence – even quack treatments that provide a placebo effect – should also be funded.
    Cost effectiveness isn’t the only yardstick. Efficacy counts too. As should compassion and societal provision of care.

  158. Randy

    Shane said:

    Not an universal HPV vaccine? So? I wasn’t trying to compare imaginary vaccines with a jab I could get today.

    So why can’t you have both vaccines? You seem to have a bit of a false dichotomy going here. BTW, in Oz the flu vaccine is about $20 and free if you’re over 65.

    —————————————- (how do I indent?)

    I do not understand what you mean here.

    The Influenza vaccine may save 60,000 lives per year.
    The HPV vaccine may save 4,000 lives per year.
    We do not know if the HPV vaccine is a cost effective option.
    Although I do not have the data, I believe that the influenza vaccine is a cost effective option.

    I do not want health insurance premiums to go up. It is not detrimental to me, but it is to the nation as a whole, I believe. If I wanted to keep health insurance premiums constant, I would want more people to get influenza vaccines instead of the HPV, which I believe will save more lives. If the HPV vaccine was paid out of pocket, there would be no issues with me.

    I think I want the HPV vaccine for my daughters, but according to the above, I am thinking twice. On the other hand, it appears that the ship has already sailed and most insurance covers the HPV vaccine. Maybe I will donate $360 x 2 to the influenza vaccine when my two daughters get vaccinated.

    I think I make sense, is there an error in my logic?

  159. @Randy

    I do not want health insurance premiums to go up. It is not detrimental to me, but it is to the nation as a whole, I believe. If I wanted to keep health insurance premiums constant, I would want more people to get influenza vaccines instead of the HPV, which I believe will save more lives.

    Perhaps instead of voicing concern against the HPV vaccine, lobby against insurance coverage of things like acupuncture or other similar CAM treatments. That way, you not only make room in the insurance premiums for HPV vaccines, you also help eliminate from coverage treatments with no science to support their efficacy. Two birds, one stone.

  160. Jefferson

    @Todd

    Thanks for your comments.

    However, I disagree with you about the way you anticipate the outcome of the “both side of the issue” stance, that is it generates fear of the vaccine.

    People need to have as much balanced information as possible if they are to make an informed decision on such a crucial issue. So if one of the docs who worked for Merck on the Phase II and III studies of the vaccine has a caveat about the product she knows a lot more about than probably a lot of people, am I going to take notice? You bet. Does this mean that I have suddenly turned irrational because I am being cautious? I don’t think so.

    Like you said, “Be cautious, yes. Ask questions. Get informed.”

    Agreed.

    You also said : “But barring clear evidence that it presents more risk than benefit, go ahead with it.”

    That’s not quite what I’m hearing from the good doctor. So as long as a reasonable doubt remains about the vaccine’s safety and effectiveness and, especially, that an alternative that appears to be safer and effective in helping not only prevent, but also detect, cervical cancer (Pap screening) already exists, it’s a no go situation with regards to my 25 year old daughter getting the jab.

    So you may be right after all, that balanced information may generate distrust about the vaccine. But in the end, it may well be that such mistrust is justified.

  161. Randy

    @Todd

    That is an excellent point. It is ture, I am not actually against HPV specifically. How can I go about doing that?

    What bothers me most are the advertisements and television commercials on tv. I believe doctors are better suited to recommend treatment. At the same time if we eliminate the advertisements, we can save billions of dollars.

  162. Randy

    @Todd

    If I can’t trust the Harvard Med School and quality commentators here, who can I trust? I’m not intelligent enough to figure it out myself.

  163. @Jefferson

    I guess the overall tone of the article, the way they worded things, made it seem slanted a bit more toward avoiding the vaccine.

    @Randy

    If your insurance company covers some of those woo treatments, you could start by writing to them. See if there are other companies that do not cover those things and let your company know that you’re going to switch, and why. You could also write to your senators and representatives.

    As to HMS, I’m just saying, don’t trust them simply because of who they are. Read the study yourself. Do a little research to see if anyone else has done similar research and what conclusions they reached. Science-Based Medicine has a nice series of posts about how to evaluate a source of info. (Search for Science-Based Medicine 101)

  164. Randy

    Thank you for all the information. This was my fist time commenting on any blog and I have learned a lot.

  165. @Randy

    Stick around. You’ll learn lots more! Also take a look at Science-Based Medicine blog if you’re interested in that subject. And Orac at Respectful Insolence has dealt a lot with the vaccine issue.

    I’m actually surprised we didn’t have a major anti-vaxer hijacking of this thread.

  166. Mark Hansen

    @Todd W.
    …If your insurance company covers some of those woo treatments, you could start by writing to them. See if there are other companies that do not cover those things and let your company know that you’re going to switch, and why…

    Unfortunately here in Aust. it seems that all the health insurers cover woo CAM. Probably the way they look at it is “If rival company X covers it and we don’t, people will go there.

  167. 165. Randy Says: I’m not intelligent enough to figure it out myself.

    [Hope this will just be a short rant, if not, sorry]

    No, actually you are ‘ignorant’, not ‘stupid’ (with stupid~not intelligent).
    That, of course, is not an attack, since I am ‘ignorant’ about Calculus, how to fix a (modern computer controlled) auto engine, how to design a plane’s wing, and a whole bunch of other stuff, and others are ignorant about many other things.
    However, we have to ‘define the terms’. Ignorance is a lack of knowledge about one or more subjects, but ‘stupidity’ is a deliberate action to not know about something and refusal to accept more data and mental techniques to remove ignorance (“ignorance is curable, stupidity is terminal”)
    Intelligence is usually considered to be ‘the ability to learn and understand’.. for instance, I once derived the equation (incorrectly, BTW) for the Doppler Effect. Being willing to try and do such a thing on my own would be classed as ‘intelligent’ (IMHO). But my not comprehending Calculus does not mean I am also ‘stupid’… some people just don’t have a mind that works in particular ways.
    Also, not having the ‘training’ to understand something does not mean someone is not intelligent, that moves back to ‘ignorance’. I have always considered Curiosity to be a defining factor in intelligence, if someone wants to know more they are more likely to be able to comprehend things that the less curious, if they are presented with facts and logical techniques of investigation (the scientific technique, e.g.), will not retain nor use.

    J/P=?

  168. Dawn

    @Todd W (re comment #155)…I’m a little confused. If the Gardisil vaccine was only approved 1 year ago, how did my daughters get it 2+ years ago? It was out of clinical trials then, as my insurance covered it (and they don’t cover clinical trials). Or were you referencing an article from a while ago, when it had only been approved for 1 year? (BTW…I really like your vaccines work; please keep it up).

    Also, people and Dr Harper (who is named in the linked article # 145 as working on the Level II and III clinical trials), seem to be ignoring the history of the vaccine. If I recall correctly (and it’s been a while since I read the medical articles), Gardisil was used in Europe and Africa several years prior to USA FDA approval. So, while there may not be studies in the US that is is effective for more than 5 years, how about the other countries where it has been in use longer?

    Pap smears look for abnormal cells in the cervix. However, if the cells picked up by the brush are normal, cervical cancer can easily be missed. And, with the current recommendation of 3 years between pap smears if a woman has had 3 normal paps, it is possible a fast growing cancer can occur between paps. A pap can be uncomfortable for a woman, depending on many factors.

    WARNING: YOU MAY NOT WANT TO CONTINUE READING IF YOU DON’T HAVE A STRONG STOMACH!

    Last comment: as a midwife, I saw many young girls with HPV. If the vaccine can prevent the growth of the cancerous HPV, then I wouldn’t have had to tell the 16 year old that she had cancer and needed a hysterectomy. Maybe I wouldn’t have seen the 15 year old who had such an overgrowth of HPV that her entire perineal area looked like a cauliflower. She couldn’t wipe herself after urinating without causing tons of bleeding (HPV infected tissue tends to be very fragile and bleeds easily). She and her boyfriend underwent treatment for the warts…what teen age boy or girl wants caustic liquid applied to the perineal/penile area for weeks? Too many sad stories. How about the woman, monogamous for 25 years, who had HPV appear on a pap smear? She nearly divorced her husband, certain that he was cheating on her. We finally convinced her through genotyping and testing her husband, that she had simply been exposed many years previously and had never had an infection.

  169. @Dawn

    I may very likely be mistaken. I was trying to find the original approval date for the vaccine and probably looked at the wrong piece of info. As to trials outside the U.S., I’d have to do a bit more digging around.

  170. DanVeteran
  171. Nigel Depledge

    Randy (148) said:

    I agree with sisu.

    The cheaper flu vaccines can possibly save 60,000 lives per year where as the HPV vaccine possibly only saves 4,000. By cheaper, I mean the per dose is cheaper. I do not know if the total cost would be cheaper, but I would imagine so.

    On the other hand, if the HPV vaccine is paid out of pocket, then there’s no issue with me to get both.

    But this is not a valid comparison.

    Flu vaccines may be cheap, but they rapidly cease to be effective, because flu evolves very very quickly. A new vaccine must be prepared every year. So, having had a flu shot (or a course of flu shots), you are immune only to that season’s prevalent flu strain.

    IIUC, HPV evolves relatively slowly, so a short course of injections (such as Gardasil) can confer long-term protection (at least 4 years, if I have understood the info in other comments corectly).

  172. Nigel Depledge

    Randy (164) said:

    What bothers me most are the advertisements and television commercials on tv. I believe doctors are better suited to recommend treatment. At the same time if we eliminate the advertisements, we can save billions of dollars.

    Here in the UK, pharmaceuticals companies are not permitted to advertise prescription-only medicines to patients. So the only ways for the pharmaceuticals companies to get a larger market share are (1) to advertise to the physicians, and (2) to produce more effective treatments.

    Furthermore, because we have a national health service (the NHS), this reviews new treatments and either recommends them or not. Obviously, efficacy and cost-effectiveness are key factors in this assessment. But sometimes other factors creep in, too. Apparently, the NHS funds some CAM “remedies” that have very little basis in evidence.

  173. The arguments on this thread are interesting on both sides. Here’s my issue with Gardasil. It’s expensive. It’s about 90% effective (which is excellent) for about 70% of the viruses out there which cause cancer, and even less of those which cause condylomata.

    Which is a start. However, the people who need it most are the poor (who can afford it less than regular pap testing) because their access to regular pap testing may be less than ideal; the irresponsible (who are unlikely to show up to get it) because they are unlikely to show up for their regular pap testing; and the underinformed (who might not be allowed to get it due to political and religious prejudices keeping them underinformed) who don’t have access to sex ed and understand about HPV.

    Your average promiscuous teenager who worries about STIs and shows up at the doctor’s office worried about gonorrhea whenever she gets any discharge at all, she’ll get her paps and (though there are unfortunate exceptions as someone mentioned above- medicine still is not perfect) detect and treat early and ta-dah! All will be well. But she’s most likely to get gardasil, which is probably a waste of $400.

    Worse again, there is the group that gets gardasil and thinks they are protected. I see this in the above thread over and over. This vaccine is against the two viruses which cause 70% of the cancers, which are already rare. There are still another 30% out there. Paps are still important. Cervical cancer is not eradicated.

    As the vaccine becomes more and more common, the less common variants of the virus will become more and more important as cause of disease, and will likely increase in frequency. We have already seen this with Pneumococcus. I’m not against gardasil, but I am against a false sense of security.

  174. Randy

    What does CAM stand for?

  175. @Randy

    Complementary and Alternative Medicine. It includes things like acupuncture, reiki, magnets, herbal supplements. Basically, anything that has not actually undergone proper safety and efficacy testing to become real medicine.

  176. Randy

    @John Paradox

    Thanks. I think it’s a compliment, though I’m not exactly sure.

    I struggle with many issues in life, balancing between my beliefs, and what I understand as what the majority thinks.

    What gives me comfort is that most people, I believe, trys to do what they believe is right. I believe people learn to do good and are good instead of evil.

    So the issue seems to be the lack of easily accessible information on topics such as these. As we proved, perhaps there are one or two that wrote the truth, but in general, we are ignorant. I actually prefer the word “uninformed.”

    Blogs are good for people like me, but in general, difficult to read and follow. Many factual sites are one sided and does not address the human condition as many did here.

    I have good ideas for a wiki based website that will balance many of the issues and hopefully present it fairly and accurately in one summary view, but I neither have the time nor the skill to create it.

    Maybe there is one already out there?

  177. Na

    I watched a similar story being told on the Australian TV channel SBS and was appalled. You could hardly call the channel commercial and they’re generally less ‘magazine’ news than other channels, but for the first time I wondered what kind of journalism they were doing over there. They didn’t even counter half the claims about Gardasil, or report correctly that there have been no deaths linked to the vaccine, despite the claims being made about its affectiveness. Pathetic.

    My mum was watching too, and mentioned that after having seen the news item, she’d be scared off from the vaccine: despite the fact that I explained that the claims were false.

    The saddest thing is that this is an Australian scientific breakthrough, and now the scientists are having to defend themselves from the media on something they’ve worked so hard to achieve; and I think it’s probably only an issue because American anti-vaxxers are making noise about it and it’s loud enough to hear over here.

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