Renewed Debate over the HPV vaccine

MS. DIANE REHM

10:06:54
Thanks for joining us. I'm Diane Rehm. The vaccination that adolescents, mostly girls, get to protect against the sexually transmitted HPV virus is, again, in the news. In a Republican debate earlier this week, Congresswoman Michele Bachmann alleged the vaccine could have very dangerous side effects. She faulted Gov. Rick Perry for once pushing that all sixth grade girls be vaccinated.

MS. DIANE REHM

10:07:33
Joining me to talk about HPV and the latest debate over the vaccine, Dr. Roberta DeBiasi of the Children's National Medical Center, Peter Sprigg of the Family Research Council, Liz Szabo -- she's a reporter at USA Today -- Dr. Renata Sanders of the Johns Hopkins Children's Medical Center. Throughout the hour, I look forward to hearing from you. Join us on 800-433-8850. Send us your email to drshow@wamu.org.

MS. DIANE REHM

10:08:21
Feel free to join us on Facebook or Twitter. Welcome to all of you. Liz Szabo, if I could start with you. Explain just how the HPV vaccine came up in that Republican debate.

MS. LIZ SZABO

10:08:38
Sure. Well, before Rick Perry entered the national spotlight for the race for the presidency, he was really well-known for his stance on the HPV vaccine. He had actually put forward an executive order in Texas to try to make the vaccine mandatory for school entry. The state legislature opposed that, and he didn't fight them on it. So the measure actually never went through.

MS. LIZ SZABO

10:09:03
But he was well-known for taking a stance on trying to get all girls to get vaccinated against HPV.

REHM

10:09:10
So it was more regarding his approach than just about anything else?

SZABO

10:09:18
Right. There's been a debate about how best to handle school mandates. Really, the traditional way is for the state legislatures to debate the issue. I've heard people say that school vaccine mandates are one of the great examples of American democracy because they're debated in bicameral legislatures in 50 states, and the state legislatures make the decision.

SZABO

10:09:42
So far, there are only -- only two jurisdictions have actually voted to require them, the state of Virginia and the District of Columbia, and both have opt-out provisions.

REHM

10:09:52
So when Gov. Perry signed the order then, there was an uproar, and then it went back to the state legislature, which voted it down.

SZABO

10:10:06
That's right.

REHM

10:10:06
And he did not veto that, right?

SZABO

10:10:10
That's right. He didn't pursue it any further. And Merck, which makes the Gardasil vaccine, actually stopped its efforts to try to get the vaccine required because the company says it seemed distracting.

REHM

10:10:24
Liz Szabo, she's a reporter for USA Today. Turning to you, Dr. DeBiasi, I gather there are two different kinds of vaccines, is that right, for the HPV virus?

DR. ROBERTA DEBIASI

10:10:40
That's correct. So there are two licensed vaccines. The Gardasil contains four strains of human papillomavirus, two of which are associated with genital warts and two of which are associated with cervical cancers. The second vaccine, the Cervarix, contains two of the HPV viruses and only the two that are associated with cervical cancers.

REHM

10:11:06
So is one regarded as better than the other?

DEBIASI

10:11:13
Both vaccines had excellent efficacy and safety data for prevention of cervical cancers. And, obviously, since the Cervarix doesn't contain the strains against genital warts, it would not have efficacy for that particular indication.

REHM

10:11:30
So here in the District, since you are at the Children's National Medical Center, the vaccine is imperative?

DEBIASI

10:11:43
Yes.

REHM

10:11:44
For girls at what age?

DEBIASI

10:11:46
The recommendation from the CDC Advisory Committee on Immunization Practices is that girls between the ages of 11 and 12 be vaccinated, but anyone up to the age of 26 may receive the vaccine.

REHM

10:12:00
Can they opt out?

DEBIASI

10:12:01
Yes.

REHM

10:12:03
In any state that -- or District of Columbia, they can opt out if their parents want them to opt out. Is that correct?

DEBIASI

10:12:11
Yes. And, again, to reiterate what Liz said, only two states, or districts, so Virginia and District of Columbia are the only two that have this mandatory, although about 20 states initiated legislature to potentially make this mandatory. But it eventually went through on the two.

REHM

10:12:31
I see. Dr. Roberta DeBiasi is at the Children's National Medical Center here in Washington, D.C. And turning to you, Dr. Renata Sanders, what are the CDC recommendations about this?

DR. RENATA SANDERS

10:12:51
Well, the American Academy of Pediatrics, the Centers for Disease Control and Prevention and the American Family Physicians recommend that women 11 and 12 receive their first dose of the HPV vaccine. That's because that's the time before many young women have been exposed to the HPV infection and also when it's thought to have the best immune response.

REHM

10:13:19
And, as I understand it, there's a series of three injections.

SANDERS

10:13:26
Yes, that's correct. So there's a three-shot series that's recommended to be administered over six months.

REHM

10:13:33
Have we seen any ill effects of the vaccine?

SANDERS

10:13:40
There are adverse events reported to the Vaccine Adverse Event Reporting System. And the common side effects include nausea or feeling sick to your stomach, dizzy or light-headedness, pain or tenderness or bruising at the site. Those are the most common side effects. There have been some other serious adverse events that have been reported.

REHM

10:14:09
Such as?

SANDERS

10:14:10
Such as Guillian-Barre syndrome, but that was found not to be in excess of what's considered in the normal population. And all the other adverse -- serious adverse events were not found to be associated with the vaccine.

REHM

10:14:31
Congresswoman Bachmann said that she had just talked with a mother whose child became autistic after her injection with the HPV vaccine. Are there other reports to that effect?

SANDERS

10:14:52
So, looking at the data that's collected by the Vaccine Adverse Event Reporting System, there are no other cases where mental retardation, autism have been associated with HPV. In fact, the American Academy of Pediatrics came out with a statement discussing how HPV vaccine -- the HPV vaccine has not been associated with mental retardation.

REHM

10:15:20
Dr. Renata Sanders, she's at the Johns Hopkins Children's Medical Center. And to you, Peter Sprigg, what were your thoughts when you heard Congresswoman Bachmann's comments?

MR. PETER SPRIGG

10:15:38
Well, I agreed with Congresswoman Bachmann's criticism of the action that Gov. Perry took back in 2007. And we at Family Research Council were quite critical of Gov. Perry's executive order at the time, not just because he failed to involve the legislature, but also because he -- we oppose the mandate idea at all.

MR. PETER SPRIGG

10:16:02
And we believe that if there is a public effort to encourage vaccination that it should be done on an opt-in basis rather than an opt-out basis. We felt that, in this case, an opt-out situation still is somewhat coercive and, therefore, violates parental rights. So I'm glad that Gov. Perry has now admitted that he made a mistake in how he handled the situation back in 2007. I'm not aware of any data like that that Rep. Bachmann reported.

MR. PETER SPRIGG

10:16:41
I mean, I have no reason to doubt her anecdote about the woman coming up to her after the debate and saying that. However, we always have to remember -- and I'm sure the medical people here would agree and would understand better than I -- that simply because you have event A followed by event B does not mean that event A was the cause of event B.

MR. PETER SPRIGG

10:17:03
And with these adverse event reports, even when there are adverse events reported, that's not necessarily proof that the vaccine was the cause of that adverse event. So that's just something that people need to bear in mind when you listen to reports like that.

REHM

10:17:22
But is the Family Research Council on record as being for or against a mandate for HPV vaccine?

SPRIGG

10:17:36
Well, we supported the approval of the vaccine for use, but we oppose any sort of mandate, state mandate that it be given as a condition for school attendance. The reason is because HPV is not a disease that is transmitted through casual contact. It's not like measles or mumps or other childhood diseases, where merely being in the classroom with someone who is infected puts you at risk.

REHM

10:18:06
It is transmitted by sexual contact.

SPRIGG

10:18:07
It's sexually transmitted, exactly. And so, therefore, it's also preventable through behavioral change or behavioral self-control. And so that puts it in a different category from other diseases where we think a vaccine mandate may be justified.

REHM

10:18:24
Peter Sprigg, he is senior fellow for policy studies at the Family Research Council. We'll take a short break here. I see many of you are on the phone. We'll have your emails, your Twitters, your Facebook postings after we come back.

REHM

10:20:03
Welcome back. We're talking about the HPV vaccine that -- an issue that was raised at the Tea Party debate the other night among the Republican candidates for nominee to the presidency. And we have four people here in the studio. Liz Szabo, she's a reporter for USA Today. Dr. Renata Sanders is at the Johns Hopkins Children's Medical Center. Dr. Roberta DeBiasi is at the Children's National Medical Center here in Washington, D.C.

REHM

10:20:51
Peter Sprigg is at the Family Research Council. And I look forward to hearing your questions and comments. I'm quite interested in the woman that Michele Bachmann mentioned during the debate and then the next day on the "Today" program. Has anyone been able to find out who that woman was and how her child was afflicted? Liz Szabo.

SZABO

10:21:31
No. To my knowledge, this woman has not come forward. Maybe somewhat amusingly, a couple of professors have actually offered a sort of reward if anyone can produce medical records showing that a child was injured by the HPV shot in a way that caused mental retardation. So, no, I don't think this woman has stepped forward.

SZABO

10:21:59
According to the American Academy of Pediatrics, there's just no scientific validity to the claim that the HPV shot would cause mental retardation.

REHM

10:22:12
Now, here's an email from Tracy, who says, "My name is Tracy Wolfe (sp?). My daughter Alexis was seriously injured by Gardasil. She now has brain damage and an uncontrollable seizure disorder. This vaccine needs to be taken off the market. The girls and boys who've been injured need help." So, Dr. DeBiasi, have you seen any other emails, messages, phone calls that reflect the same kind of problem?

DEBIASI

10:22:58
Yeah, and I think this is the important part here, is to move away from anecdotal reports. Let's just look at the bigger body of data for safety of the vaccine, and then we can come back to the anecdotal reports. So the initial licensing of the vaccine involved four very large phase two and phase three, meaning thousands -- 30,000 people, women and, in another study, boys. And that was for efficacy, but also looked at very closely for safety.

DEBIASI

10:23:29
And in those initial studies -- so large numbers of people -- there were, essentially, no significant severe side effects. There were -- all the adverse events were primarily redness at the site of the vaccine, some low-grade fevers, pain. So that was why it was felt to be safe 'cause it had been studied in a large population and large -- there had not been concerns for safety.

DEBIASI

10:23:52
In addition to that, in the six years since it's been in use, there have now been 35 million doses given, and the VAERS...

REHM

10:24:00
Thirty-five million. Okay.

DEBIASI

10:24:02
Thirty-five million doses. And that data is looked at very carefully, as well in what's called post-licensing monitoring for safety. And the VAER system, the Vaccine Adverse Event Reporting System that Renata mentioned, is a system by which any report, anything that happens to someone who's received a vaccine, can be reported. So the effect of reporting does not, in any way, imply cause, and I'll give you an example of that.

DEBIASI

10:24:30
For instance, if a child was vaccinated and died, then that would be looked into. And, for instance, some of the deaths that were reported following Gardasil, the child actually died in a motor vehicle accident.

REHM

10:24:44
Oh.

DEBIASI

10:24:44
Or, for instance, if you compare that to people in the pre-licensing study for placebo studies, there was no increase in the number of these effects between the people that received placebo or who received the vaccine. So it's difficult when someone comes with a single anecdote, and, of course, that catches our attention. But when we look at the broad data, there's no evidence at all that there is any serious significant effects due to the vaccine in this population.

REHM

10:25:14
Now, we should mention here that boys are now being given the vaccine as well. Peter Sprigg, as I understand what you're saying, you have less objection to the vaccine itself than you do to the mandate.

SPRIGG

10:25:36
That's exactly right. We have no objection to the vaccine being made available. Cervical cancer caused by HPV is a very serious problem, and this does have the potential to save the lives of many American women.

SPRIGG

10:25:50
And so we welcome that. At the same time, of course, we emphasize that the most effective prevention of sexually transmitted diseases is for people to practice abstinence from sexual activity outside of a mutually monogamous relationship with an uninfected partner -- generally, abstinence until marriage.

SPRIGG

10:26:12
So we don't want anything to take away from that message, but, at the same time, we realize not everybody is going to practice that. And this preventive medicine is a positive thing.

REHM

10:26:25
Help me to understand. Does the vaccine not only prevent, but also treat the virus? Dr. Sanders.

SANDERS

10:26:35
No. So the vaccine only prevents HPV infection, new HPV infection. It does not treat already established HPV infection.

REHM

10:26:46
What does HPV infection look like?

SANDERS

10:26:51
Well, it's interesting that he just talked about the requirement of people being in a monogamous relationship to protect against HPV infection. Unfortunately, many people do not know that they have HPV. In fact, many people do not have any signs or symptoms of HPV infection. That's for a number of reasons. One, about 90 percent of HPV infections clear with the human immune response naturally in two years.

SANDERS

10:27:27
But there are, actually, a number of cases that go on to result in genital warts and recurrent respiratory papillomatosis, and also -- and cancer, such as cervical cancer, cancer of the vulva, vagina, anal area, and then also of the oropharynx.

REHM

10:27:48
Are there any other means or any other ways that an individual can acquire genital warts?

SANDERS

10:28:01
So genital warts or any HPV infection can be acquired through genital-to-genital contact, usually vaginal or anal sex, but it can also be acquired through skin-to-skin contact, so rubbing against two individuals. It can also be acquired through oral sex, for example, as some of the ways that individuals can actually get the HPV infection.

REHM

10:28:29
Tell me this. Suppose an individual with the HPV virus goes into a public swimming pool. Is there any indication that the virus can be transmitted in that way, Dr. DeBiasi?

DEBIASI

10:28:51
No. I think it's also important -- because we haven't touched on it -- to just talk about how common not only the infection is -- and maybe we could expand on that. So if you take all sexually active individuals, 50 percent have HPV infection. So we're talking about a very common...

REHM

10:29:06
Fifty percent?

DEBIASI

10:29:07
Yeah, we call it the common cold of sexually transmitted diseases, so -- but as Renata said, it's usually asymptomatic and doesn't lead to any -- you know, other than potentially cosmetic warts. The vast majority of people will clear the virus, and that's why it's so much -- it's around so much. On the other hand, 10,000 cases a year in the U.S. occur for cervical cancer.

DEBIASI

10:29:30
And the only link for cervical cancer is HPV. So this is a clear cause association with cervical cancer.

REHM

10:29:40
Peter.

SPRIGG

10:29:41
One medical point I'm not sure we've mentioned yet is the fact that the vaccine that's on the market targets only certain strains of HPV, the ones that are responsible for most cases of cervical cancer. But these strains are responsible for, I believe, about 70 percent of the cervical cancers. So even a woman who has received the HPV vaccine is still at risk from the other strains, still has to receive Pap smears and so forth.

SPRIGG

10:30:09
And, again, this is another reason why abstinence is an important and, in a sense, superior method of prevention.

REHM

10:30:21
Dr. Sanders.

SANDERS

10:30:22
I think when we counsel youth and parents, when they present in routine care and they have questions about HPV and prevention of HPV, we talk about the importance of getting the vaccine because it protects -- the HPV or the Gardasil vaccine protects against -- as he mentioned, it protects against 75 percent of all cervical cancers, but 90 percent of all genital warts.

SANDERS

10:30:47
It also has advantage of protecting against 50 percent of vulva cancers and 70 percent of vaginal cancers. You mentioned earlier that it's being recommended and used in boys ages 9 to 26. In young men, it also protects against 90 percent of genital warts. So it has many advantages.

REHM

10:31:08
Interesting.

SANDERS

10:31:09
So we start by recommending the vaccine. We also do encourage condom use if individuals do decide to choose to have sexual activity.

REHM

10:31:18
Here's an email. This one's sort of something we haven't talked about. A young man, Rick, says, "HPV also causes tongue-based cancer in men. I had it last year," says Rick. "Chemo and radiation killed it, but it wasn't pleasant. Since I had it, I've heard many other men who've had it. It's quite an epidemic. Thus the vaccine could also be advisable for pre-sexual boys." Have you heard of this happening, Dr. Sanders?

SANDERS

10:32:04
Yes. So he is exactly right that HPV has been found to cause some common oral cancers in the oropharynx, which is at the base of the tongue and includes the uvula or the tonsil area and the throat. So it can have multiple benefits for people.

REHM

10:32:25
How much does the vaccine cost, Liz?

SZABO

10:32:30
My understanding is it's about $600 for a three-dose series or so -- lower than that.

DEBIASI

10:32:35
It's a little low. It's about $140 per dose, so it ends up being around $400.

SZABO

10:32:39
Oh, okay. I'm sorry.

REHM

10:32:40
What about people who can't afford it who want it for their children? What happens there?

DEBIASI

10:32:47
It's actually covered by the Vaccines for Children. So if they can't afford it, it is covered.

REHM

10:32:53
So you're telling people whose parents are listening that if they want coverage for their children and cannot afford those high-cost doses, what should they do if -- Peter Sprigg, I do acknowledge that your solution is non-sexual behavior early on. But if they want it for their children, what should they do?

DEBIASI

10:33:23
Yeah, so if you have insurance, many insurance providers cover it.

REHM

10:33:28
Right. If you don't?

SANDERS

10:33:30
If you don't have insurance, the Vaccines for Children Act will cover it, so it's a covered vaccine for people who don't have insurance.

REHM

10:33:36
So if you go to your doctor...

SANDERS

10:33:38
Yes.

REHM

10:33:38
And your doctor will not charge you.

SANDERS

10:33:42
Correct.

REHM

10:33:43
You're listening to "The Diane Rehm Show." We have lots of callers waiting. Let's open the phones, 800-433-8850. To Dexter, Mich. Good morning, Laurie. (sp?) You're on the air.

LAURIE

10:34:02
Good morning, Diane. Thank you for taking my call.

REHM

10:34:04
Certainly.

LAURIE

10:34:05
I also wanted to follow up with the emailer. We did have my son vaccinated with Gardasil three years ago, prior to it being approved by the FDA for boys, because there was head and neck cancer in his father's family. My husband passed away last year after a three-year battle with head and neck cancer. And there are many, many, many stories of young men. My husband was otherwise very healthy.

LAURIE

10:34:36
Both of my children, son and daughter, have been vaccinated with no side effects. And I do want that to get out there that this is another reason to follow up with this vaccine.

REHM

10:34:49
Gosh, Laurie, I'm so sorry about your husband. To what extent is there this connection between the vaccine and head and neck cancer?

DEBIASI

10:35:01
It really depends on the type of head and neck cancer. So, as Renata was taking about, there are specific cancers in those regions, but I don't know the data for the percentage. For instance, for cervical cancer, it's 100 percent link between virus being present and the cancer. I don't know what the number is for these particular oropharyngeal cancers.

REHM

10:35:21
All right. Thanks for calling, Laurie, and sharing that story. To Deborah in Austin, Texas. Good morning. You're on the air.

DEBORAH

10:35:31
Good morning. I'm calling, in part, because I think it's interesting this debate has come up again, largely, in a political context because of Gov. Perry. And I'm actually a parent who would have been affected by his executive order. My daughter was 12 at the time that he attempted to put it in place. And I have three children, all of whom I have had vaccinated on schedule for every childhood disease.

DEBORAH

10:35:56
And I requested an exemption from the state for this one, not because I don't intend to vaccinate my daughter at some point but because I had had a conversation with her pediatrician about this vaccine because she was premenstrual at that time and because we didn't know what impact it might have on her ultimate development and fertility. Before she goes to college, she will have all three doses of the vaccine.

DEBORAH

10:36:22
But, for me, rather than mandating it for children at such a young age, I believe there should be options for parents and that it should be one of those things like mammograms, that if you can't afford, it should be covered, and that insurance should be required to pay for, that it shouldn't be optional if a family chooses it.

REHM

10:36:41
Dr. Sanders.

SANDERS

10:36:43
To my knowledge, there has been no evidence that the Gardasil vaccine impacts fertility, so we routinely recommend it in adolescents. Eleven to 12 is in the early ages of adolescence. There have been studies that have looked at barriers to HPV vaccine and found that parents' perception of the vaccine is an important barrier, but also physician endorsement or lack of physician endorsement may be an important barrier.

SANDERS

10:37:14
Additionally, what we find is that adolescents often will come in on their own seeking the vaccine when they get older.

REHM

10:37:26
Dr. Renata Sanders, she's at the Johns Hopkins Children's Medical Center. We'll take a short break here and be right back.

REHM

10:40:03
And we're back. Talking about the HPV virus, the HPV vaccine and exactly who is getting the vaccine, whether it should be mandated or an opt-in program, as you, Peter Sprigg, had commented. Tell me about your program to advise young people to refrain from sexual behavior.

SPRIGG

10:40:39
Well, there's no question that abstinence from sexual behavior is the only 100 percent effective means of preventing not only sexually transmitted diseases but unwanted pregnancy and as well as a range of negative psychological health effects that result from early sexual conduct. So we have been very supportive of abstinence education programs in the schools and including federal funding for abstinence education.

SPRIGG

10:41:07
President Obama has removed any funding for abstinence education in his budgets. There is currently a bill to try to restore some abstinence funding. And evidence has shown that well-structured abstinence education programs can be effective. Obviously, nothing is going to be 100 percent effective in changing the behavior or controlling the behavior of young people, but they can be effective.

REHM

10:41:40
Dr. DeBiasi, tell me why the age of 11 was chosen as the age to begin inoculating.

DEBIASI

10:41:50
And I -- this is a very important point and I, 100 percent, agree that abstinence is the only way to prevent these diseases. But we have to also look at the actual data to know the baseline from which we're working against. So at -- there have been two large surveys done, five years apart, 2002 and 2007, looking at sexual activity in adolescents.

DEBIASI

10:42:09
And it -- unfortunately, 24 percent of children by the age of -- age 15 are sexually active, 40 percent by age 16 and 70 percent by age 18. And even more frighteningly, if you take those children that are sexually active -- these are seniors in high school -- 20 percent of them have had more than four partners. So this is a frightening number of children that are sexually active.

DEBIASI

10:42:35
So when you're trying to decide when to use a vaccine that is most effective, if you've had no sexual exposure, it makes sense that we need to go under age 15. And the number 11 was chosen because if we go less than 13, we're down to 4 percent of children.

REHM

10:42:51
Dr. Sanders.

SANDERS

10:42:52
I guess -- thank you for bringing that up. I think that you're talking about the youth risk behavior surveillance system, which is a survey that is collected in high school students from across the country. So the data is from students reporting on their own sexual behavior, so this is not anecdotal evidence. It's data.

SANDERS

10:43:12
And, I think, I would just only add one thing that, as far as abstinence-only education to prevent sexual transmission of sexually transmitted infections, there's good evidence that, although abstinence can be effective in certain settings, abstinence in a comprehensive sexual education approach is more effective than abstinence-only education. So using only abstinence is not as effective as abstinence with a comprehensive sexual education curriculum.

REHM

10:43:49
All right. To -- here is a caller in Cincinnati, Ohio. Good morning, Kimberly.

KIMBERLY

10:43:59
Good morning. If I can just say, I find it extremely disappointing that, once again, we have a female politician who is sacrificing women's health for a -- what is going to be a extremely small political gain. And I find it extremely disappointing because it's not just about teenagers having sex. This goes through your entire life as -- in your entire adult sexual history.

KIMBERLY

10:44:24
And whether you're married later on and the spouse will cheat on you, you can get this disease. And even if you're a responsible woman that goes to the doctor annually for her Pap smear, if you get that, then you get dysplasia. There's -- you can treat it, but you get what's called a LEEP procedure, which can remove some of the cells on your cervix and can cause incompetent cervix.

KIMBERLY

10:44:47
So it really increases your risk for miscarriage later on and a lot of bed rest. And it's just very sad. And, also, is this -- again, all on women's shoulders, who -- as far as I know, boys don't really -- and men don't have a system in place where they go and get treated or screened for this virus. And so it's up to girls to follow and have a comprehensive system for staying healthy.

DEBIASI

10:45:22
Thank you for that point. I think this is also a very important point. One thing I wanted to say was, what our -- you know, people may not have an idea of what our coverage rates are right now with this vaccine. So in the very latest data that came out, about 50 percent of girls and women in the target group have received at least one vaccine.

DEBIASI

10:45:41
So this is below what we want, which is -- if we achieve 70 percent, we can reduce the cervical cancer by about two-thirds when we look at modeling. Now, if we look at people that have gotten all three, the required three-dose regimen, it's smaller. It's about a third now. So -- but each year that this has been looked at, there has been increase in the uptake.

DEBIASI

10:46:01
So I don't think the message should be no one's getting the vaccine, and we're all afraid of it. Clearly, a large percentage of the population has gotten the message. And, I think, it's just important to look at the post-marketing surveillance data, both efficacy and safety, and it's very, very good.

REHM

10:46:17
Here's an email from Anne in College Park, Md., "I'm a sexually active female in my late 20s. Should I get the HPV vaccine? If so, why are all the discussions focusing only on 12-year-old girls?" Dr. Sanders.

SANDERS

10:46:39
That's a great question. The Centers for Disease Control and Prevention recommends catch-up immunization or vaccination against the HPV infection in 13- to 26-year-olds. So, right now, it's FDA-approved up to 26-year-old. I'm not sure the age of the email person. But, depending on their age, they may actually be eligible for the vaccine within that age category.

SANDERS

10:47:08
However, there are studies looking at whether or not it can be used in even older woman because there's a big need for evidence to show whether or not it's as effective in the older population as it is in the younger population.

REHM

10:47:22
What about the use of condoms? Does that, in any way, prevent the transmission, Liz Szabo?

SZABO

10:47:31
What I've been told by experts at the American Cancer Society is that condoms do reduce transmission, but not completely eliminate it. I'm not the doctor here, but...

REHM

10:47:42
Dr. Sanders.

SANDERS

10:47:43
Yeah, so condoms are effective, but they only cover but so much. So because HPV infection can be transmitted through genital-genital contact and skin-to-skin contact, it's not going to cover all the parts that are necessary. And when we talk to teens about using condoms, we talk to -- and young women and young adult men, we talk about using -- and young men, we talk about using condoms from start to finish.

SANDERS

10:48:12
So sometimes people forget that they really need to put a condom on from the beginning all the way through to the end of sexual activity. But condoms are not 100 percent effective in reducing or preventing HPV infection.

REHM

10:48:28
All right. To New Mexico, Cloudcroft. Good morning, Susan.

SUSAN

10:48:34
Good morning, Diane. What a treat to hear your voice.

REHM

10:48:36
Well, glad to have you on.

SUSAN

10:48:39
Thank you very much. I have -- you all have nibbled around the edges of this issue, but I'd like to see if you would take a bite out of the middle, please. Historically, in our country, sexual behavior has been the responsibility of women for their prevention of pregnancy and addressing the transmission of sexually transmitted infections.

SUSAN

10:49:00
And I would like to know if there is a cultural bias at work that is causing the national conversation to center only on girls. Since the inoculation is appropriate for boys also...

REHM

10:49:14
Indeed.

SUSAN

10:49:14
...what is causing both the mandates in the states as well as the national conversation to focus only on women?

REHM

10:49:23
Dr. DeBiasi.

DEBIASI

10:49:25
This is an excellent question as well. First of all, it is safe, and it is -- the wording is boys may be vaccinated. It's not mandated. The primary reason that is, is based on cost analysis of efficacy of prevention of cervical cancer. So if we actually achieved 70 percent vaccination rate in girls, additional vaccination of boys would not -- when you look at the costs would not be a cost-effective measure.

DEBIASI

10:49:54
However, if you look on it on an individual basis for your son, it is highly effective in preventing genital warts in that individual. But genital warts are not associated with cervical cancer. It would be highly protective for that boy who then has future sexual partners in -- to prevent infection of his future sexual partners. But if we look at it on a large public health scale, it's not as cost-effective.

REHM

10:50:16
Hmm, interesting. Thanks for your call, Susan. And to Simsbury, Conn. Good morning, Lester. You're on the air.

LESTER

10:50:28
Hi. I'm a pediatrician in Connecticut, and I was totally...

REHM

10:50:32
Lester, I'm sorry. I can just barely hear you. Can you speak up, please?

LESTER

10:50:42
Can you hear me now?

REHM

10:50:43
Yes. Thank you.

LESTER

10:50:44
Okay. I'm sorry. I was hands-free. I'm a pediatrician in Connecticut, and I was totally outraged and aghast when I heard Rep. Bachmann's statement on "The Today Show." But the point I'd like to make is that the credibility of this statement is completely undermined by the use of the term mental retardation. Mental retardation is a developmental disability, and it's not something that appears at the age of 11 or 12 after some event or cause.

REHM

10:51:19
Go ahead, Peter.

SPRIGG

10:51:20
Yeah, I just -- I mean, I'm just speculating here, but that was my reaction as well when I heard of this incident. And I almost wondered if the woman who approached Rep. Bachmann was confusing this with a different vaccine. And just in a little research I was doing, for example, the hepatitis B vaccine is sometimes referred to as HBV vaccine, as opposed to HPV. And that's one that's given in infancy, I believe.

SPRIGG

10:51:50
And so I wondered if perhaps this woman's child had actually received the HBV vaccine rather than the HPV. That's just sheer speculation on my part.

REHM

10:52:00
Liz.

SZABO

10:52:02
Yeah, that's a good point. I wanted to address the pediatrician who talked about the outrage. What really interested me about this story is the backdrop of overall suspicion of vaccines, which pediatricians are extremely worried about.

SZABO

10:52:15
And the sense I got from the American Academy of Pediatrics is that they're worried that Bachmann's comment will not only undermine faith in the HPV shot but in other vaccines because there has been a movement of more and more skepticism about vaccines that has been blamed for resurgence in communicable diseases, like the current measles outbreak.

REHM

10:52:38
Liz Szabo, she is a reporter for USA Today. And you're listening to "The Diane Rehm Show." Lester, thanks for your call. Let's go now to Tampa, Fla. Good morning, Bill. Thanks for joining us.

BILL

10:52:54
Good morning, Diane. I just wanted to call in and -- of course, you casually addressed the males, but I'm a cancer survivor of 11 years. I had a head and neck cancer squamous cell. They didn't know what caused it. I did not have any of the typical risk factors, and now they believe it was HPV. And at the time I went through treatments back in '99, 2000. I now have no salivary glands. I've had, you know, the chemo, radiation and surgery.

BILL

10:53:29
I have muscle issues with my neck, all sorts of things. And my only point is that maybe, you know, when kids are teenagers and they act and do what teenagers do, I just really don't think abstinence is an answer. I was fairly young when I got mine.

BILL

10:53:46
And now I got to go through the rest of my life with all these issues because I got the cancer instead of possibly getting a vaccine, to where doing what teenagers will do, you know, may have prevented it.

REHM

10:53:59
Bill, I'm so sorry for your illness. I hope the treatment has taken care of it. And, finally, to Williamsburg, Va. Good morning, Amy.

AMY

10:54:15
Good morning. I just wanted to comment that this issue reaches so far beyond the health of our own children. It's a cultural issue, and we have to take responsibility and teach our children to take responsibility for contagious disease. I have a 14-year-old son, and I have had him vaccinated because he will have partners in the future, whether it's now or in college or later. And it's his responsibility to take care of his partners.

AMY

10:54:44
This disease is something that is spread through sexual contact and can't -- you can't assume that just protecting the girls is going to take care of the matter. We have to get in as far as we can and stop it at all levels.

REHM

10:55:02
Dr. Sanders.

SANDERS

10:55:04
I appreciate that call. That was excellent. I think that what this parent brings up is that sexuality and sexual development is a normal part of adolescent development. It's something that everyone goes through. And we hope that people are normal or healthy adolescents and then can transition into being healthy adults. And in order to do that, you have to go through important stages of adolescent development, and sexuality is part of that.

SANDERS

10:55:34
And so -- and understanding one's sexuality is also a part of that, and that's why teens -- we have to prepare teens. Give them good information about how to prevent contacting diseases -- contracting disease and how to prevent illnesses that may occur and affect them when they're in their adulthood.

REHM

10:55:54
Peter Sprigg, I'm going to give you the last word.

SPRIGG

10:55:58
Well, I did want to mention that some parents, parents who feel confident that their children are going to abstain from sexual activity as young people may choose not to give this vaccine. And then at age 18, the individual may be able to choose themselves whether they want that.

SPRIGG

10:56:16
On the other hand, we have not recommended that anybody refrain from giving the vaccine because it is true that even a person who practices abstinence could potentially become infected either through sexual assault or through marriage to a previously infected partner or to an infected partner. So we feel that parents need to look at this issue and make the decision themselves.

SPRIGG

10:56:39
And we want the government to respect their right to do so. But, you know, we -- people need to take all of those considerations into account.

REHM

10:56:51
I said I'd give you the last word. But, Dr. DeBiasi, what do you think about that mandate? Very quickly.

DEBIASI

10:57:00
I think mandate should be considered in the context of personal and state-level decisions. And I think there should always be an opt-out.

REHM

10:57:10
Dr. Roberta DeBiasi, Peter Sprigg, Liz Szabo and Dr. Renata Sanders, thank you all so much.

SPRIGG

10:57:20
Thank you.

DEBIASI

10:57:21
Thank you.

REHM

10:57:21
Thanks for listening. I'm Diane Rehm.
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