Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, February 12, 2007

A Gardasil Analogy: Killer Salmonella

Comments on my anti-Gardasil post have continued to trickle in. The general sense is that of disagreement with my position, and I must admit that my economic analysis was somewhat off-the-cuff. But I remain opposed to the vaccine on a pragmatic basis, which I hope to explain a little further here by way of an analogy:

Did you know that you can die from Salmonella? Really. Severe abdominal pain, nausea, vomiting and copious bloody stools can lead to dehydration and vascular collapse, which can be fatal!

Now what if I told you that for about $400 you could buy a special cutting board that could reduce (not eliminate) your chances of getting Salmonella? (And remember, you can DIE from Salmonella.) Wouldn't that be wonderful? [Note: the expensive cutting board piece is fictitious; everything else is real.]

Hopefully, you would say that's ridiculous. Salmonella can usually be avoided by commonsense precautions like avoiding the consumption of raw or undercooked eggs, poultry and shellfish. Even if you do contract Salmonella, it is eminently treatable with antibiotics and supportive measures to prevent dehydration. Although technically one can die from it, as a practical matter the only way to do so is if you don't get any medical care at all. Why spend such a ridiculous amount of money against a disease that isn't all that hard to avoid in the first place, and is essentially never fatal with relatively modest levels of medical care. And yet nothing I said above about Salmonella is wrong -- technically. The only difference is that it doesn't cause "cancer," which is a scary word.

That's my argument against HPV vaccination. I'm not disputing that HPV -- left untreated for many years (10-12) -- can cause cervical cancer. I'm not disputing that Gardasil can reduce (but not eliminate) the chances of contracting high risk strains of HPV. But early stage HPV disease is eminently treatable, and completely avoidable via abstinence (of which I am an advocate in principle, although not a "Just Say No" fanatic.) Finally, it is virtually impossible to die of cervical cancer unless you never see a doctor.

The vaccine costs $120 per dose, with a recommended 3-dose schedule. The jury is still out on booster doses at this time. That's a pretty hefty sum spent to reduce -- not prevent -- a disease that, with usual medical care, will never occur. Yes, it may cut down the number of abnormal paps, but it still seems to me to be too little benefit for too great a cost. The appeals made by advertising are to the emotions provoked by the word "cancer."

That said, in answer to the question about who should get it: anyone with enough money to spare, to whom "peace of mind" is worth it.

Don't even get me started on a certain Governor who signed an executive order -- never mind bothering with the legislature to, yanno, pass a law -- mandating this vaccine for all 11 and 12 year old girls in his state. However much Merck spent to buy him, you know they stand to make it back big time.


At Mon Feb 12, 05:29:00 PM, Blogger Zany Mom said...

Makes me glad my 12-yr-old girl doesn't go to school, esp. not in Texas.

We opted out of the chicken pox vaccine, too, though that's another issue altogether.

At Mon Feb 12, 06:18:00 PM, Anonymous Anonymous said...

Not only that, it's a "wimmin's cancer." Just like breast cancer! Just like ovarian cancer! Ooh, how special!

I'm sorry to be so sarcastic, but there are clearly special-status diseases in the cancer hierarchy, women's cancer being at the top of the heap. And it has a huge influence in how research dollars are spent and how products such as Gardasil are marketed.

Don't even get me started on those smarmy Gardasil television commercials and their appeal to the sistahood of everyone with a cervix. I don't appreciate the way they try to manipulate my emotions.

At Mon Feb 12, 06:31:00 PM, Blogger MedStudentGod (MSG) said...

I'm not sure I'm buying, Dino. I don't agree that it should be mandatory, but I think that a good discussion with patients before just "giving it" will enable more people to realize the risks and benefits.

As far as Anon's comment goes: I do agree with some of what was said. I have a hard time handling the "women's only disease" mantra that is soooo clear in those commercials. Men are also affected by this virus which can lead to anal cancers, condyloma, and other embarassing or disfiguiring diseases. Yet, only women are *allowed* to get the chance to be "Oneless"? Please. If for no other reason, I don't like "forcing" Gardasil for the discrimination it is.

At Mon Feb 12, 06:57:00 PM, Anonymous Anonymous said...

I believe the real cost analysis would be whether we could decreae the number/frequency of Paps/ Colpos, cryos, leeps, all that attention, At your cervix madam.
And I'm amazed they have't tried that as a maketing item, Hey, less Paps! Oh, but they have to keep the Ob/Gyn's on board. The Gyn group in my town does annual Paps on 70 yr old women who had hysterectomies 20+ years ago....

At Mon Feb 12, 07:21:00 PM, Anonymous Anonymous said...

Thank you bringing this up. I watch those ads and choke.

I once had dysplastic cells they told me came from HPV and multiple partners (not one or two), and they removed it by freezing part of the cervix. End of story.

But to sell this to our teens, especially anyone who doesn't need it, is real deception. It's a money maker for sure. When my teen went to her GP last month, he harped on her about getting it and told her that doctors are informed that they should push this vaccine.

And don't get me started on the whooping cough vaccine which didn't work for my kid. The local health department told me that it often doesn't "hold" and that whooping cough is with us and most people don't even know.

I lost my trust in all vaccines after that, although tetanus is still on my list of doables.

At Mon Feb 12, 07:30:00 PM, Blogger #1 Dinosaur said...

Anon: Pertussis vaccination is still important, even though it's only about 85% effective and even though the immunity wanes. The idea is to protect young infants, who are most at risk of dying from it.

Here are two fascinating discussions of pertussis from Flea and TundraPA.

At Mon Feb 12, 07:55:00 PM, Anonymous Anonymous said...

What was actually shown in the vaccine trials - if you read the package insert - was a decrease in the number of procedures for the treatment of dysplasia. This is IMHO a worthy goal in itself. LEEPs aren't any fun and, more to the point, are associated with an increased risk of PROM and preterm labor. A vaccine to avoid minor surgery just doesn't sound as important as a vaccine to avoid cervical cancer, so I can see why Merck marketed things the way they did. However, as an Ob/Gyn, I'm much more interested in avoiding the LEEPs and associated ob complications than avoiding the cervical cancers which I was going to prevent anyway, as you point out. Avoiding the LEEPs and cones - which it does measurably do - is a worthwhile goal. Selling the vaccine to women as The Way to avoid cervical cancer - as opposed to paps that they will continue to benefit from anyway - is more than a bit slimy. So I'm pro-vaccine, but anti-Merck advertising.
(Heck, colpos aren't any fun at all either - 15 minutes with a speculum getting biopsied? I'd take a vaccine or 3 to avoid that any day of the week, though the FDA probably wouldn't mandate it for that reason. However, I'm no longer, sigh, in the risk group. Ah, lost youth...)

At Mon Feb 12, 11:09:00 PM, Anonymous Anonymous said...

Oh my Goodness, you know I have to respond here, dont ya? But the truth is I am to tired tonight to do it justice and tomorrow I have a carnival to get ready.

Give me a couple days and I will be back.

To that first anon up there. I only read your first paragraph, and even though you are correct, in that HPV is a "Wimmem's" cancer,did you not know that it is transmitted by "Min"?..

At Mon Feb 12, 11:11:00 PM, Anonymous Anonymous said...

I'm pro vaccination. I had a girlfriend who had excellent medical care and whose CIN will probably never get a chance to progress to something more serious, but the amount that she had to worry about it, the cost of the high frequency of visits, and the discomfort of having the epithelium frozen and scrapped repeatedly seems a high enough cost to swallow the bitter pill of $120.

That said, if you're going to make it mandatory, I'd prefer to see the state buy the vaccine in bulk and then administer it to the girls at a bargained price.

At Tue Feb 13, 05:42:00 AM, Blogger Big Lebowski Store said...

Decreasing the number of LEEPs is a good thing. I'm concerned about two bad things: Fewer women seeking regular gyn care including Pap smear, and relatively more false-positive Pap smears.

Anybody worked these numbers? My sense is that there are at least two unintended consequences of this that will come back to bite us (at least three if we throw in the bit about sexual activity but never mind...)


At Tue Feb 13, 12:10:00 PM, Anonymous Anonymous said...

Isn't there the question of choice?

If the vaccine has its benefits and people choose to go with it, more power to them. For some of us and our girls who get regular GYN care and regular PAPs, I just don't see the benefit.

I was watching the Today Show and only caught the very end of it this morning.

My question is: WHY is this being pushed so hard? It's not like they're just offering it up. They're pushing it and that is always a signal to me.

No, I'm not a doc and I don't know what the docs know. I'm just a regular person who, like many women in this country, finds it suspicious that this is pushed so hard. (And a LOT of women think this.) Especially since there's no epidemic out there to point to.

And then there's that question of choice. It seems that some want to make this mandatory. That makes me just want to set my hair on fire.

At Tue Feb 13, 01:05:00 PM, Blogger Radioactive Tori said...

I'm not sure how I feel about this. I have a daughter who is 9, and part of me wants to be a "good mom" and get her vaccinated against this. The other part of me feels that she doesn't yet need it and since it is relatively new, maybe I don't want her to have it. It makes me sick that anyone is thinking of making it mandatory though, and the commercials make me wretch with their whole "tell someone" crap, so I still don't know what I will end up doing. Thanks for the great post. I appreciate learning about the options and consequences from someone who seems to know what they are talking about.

At Tue Feb 13, 01:57:00 PM, Blogger Radioactive Tori said...

I tried and tried, but I just can't let my spelling error go. I meant retch, not wretch. As soon as I hit "publish" it started bugging me that in my sleep deprived state, I typed the wrong one. I tried to just leave it alone, but just can't do it. Forgive me for the error in the first place, and also for being compulsive enough to need to come back and correct it.

At Tue Feb 13, 02:35:00 PM, Anonymous Anonymous said...

I think like every other vaccine, if enough get vaccinated, then (one day)we might get to herd immunity.

There is a stigma to cervival cancer that is not helping with this situation at all. Even in this comment section I see it referenced to.

The general public have this misconception that it is one type woman (multiple sex partners)is much more likely to get HPV ..Not true.

You do not have to sleep with 2,5, 100 or 1000 different men to become infected with HPV. All it takes is 1 man and you are at risk.

Like any other highly communicable disease, if enough people are immunized then the public in general benefits. Now Im all for free choice but when someone elses choices may effect my health or the health of my loved ones then I do think those folks really need to get informed.

Say someone's daughter was not vaccinated against HPV, and then her ex partner one day meets up with your daughter. Now because someone at some point didn't take precautions, your child pays the price for it, by acquiring the HPV virus from him? Is that fair to your child? Is it fair that now your child will have to go through painful biopsies and procedures that will absolutely be far more costly financially than the $360.00 if she had been immunized....Or, if this other woman had been immunized.

When Drs. say that women need multiple sex partners (As one of the posters above claims)to acquire HPV they are giving FALSE information.

Low risk is one thing and only one thing. Virgin + Virgin meet, fall in love, marry and NEVER in their life time have another partner, then they =low risk...No one else.

HPV and cervical cancer is kind of like a battle of the sexes. Men know they are carriers of it, but they don't worry about it, becuase it does not cause cancer in them. If the tide could turn and all these men who so gladly spread it around, got cancer of the penis, and the cure was to lose it or to atleast lose a portion of it, don't you think they would be advocating strongly for something to be given to them to stop the spread of this disease? In addition to gardasil for women and girls, men need to have a wake up call. Why aren't we giving them one?

Count me in as an advocate of Gardasil vaccines!

At Tue Feb 13, 03:27:00 PM, Anonymous Anonymous said...

If men are the carriers, why aren't they the ones who are being treated?

At Tue Feb 13, 04:30:00 PM, Anonymous Anonymous said...

Anon, I imagine the answer to that lays in the fact that even though they are absolutely the carriers, they don't suffer ill effects from it. It is dormant in them just waiting to be passed on to women. If they developed cancer from it, then it would be a whole different scenerio.

There would be a 50 million man march in Washington DC, demanding the Federal Govt. take steps to protect them and their anatomy. Its sad really, that the men of this society care so little about the implications of their actions on other people.

The numbers all indicate women are the ones that get ill from it, so we are the ones who get treatment. But it really isn't the best option in my opinion. There isn't even education for our boys in middle school about HPV and how it is transmitted? Why isn't there? Why should they be allowed to go through life being oblivious to it, while our little girls are being taught about HPV, cancer and death rates?

At Tue Feb 13, 08:20:00 PM, Anonymous Anonymous said...

This comment has been removed by a blog administrator.

At Tue Feb 13, 09:53:00 PM, Blogger Narya said...

Oh, please. how about some first-hand reporting here, from someone who's been dealing with HPV for 25 years.

I had my cervix frozen 25 years ago, and it helped at the time. I continue to get abnormal paps--more frequently, recently. I had a colposcopy last year, too, and I had one a few years ago. Okay, fine, that's a way to manage it (though I don't personally find a poke in the cervix with a sharp stick to be a pleasant experience, I'll do it every two years). I'm pretty good about getting regular health care.

However, I lost my health insurance, and the insurance I have now won't cover anything related to HPV because it's a pre-existing condition. I've had to wait an extra four months while I solved the insurance problem--I was supposed to go back for a return pap in November, but now it'll be March. I'll suck it up and pay for whatever the health insurance company won't cover, of course, AS LONG AS I CAN AFFORD TO DO SO, but what happens if/when the dysplasia becomes cancer? What happens if I can't afford to pay for the colposcopy a year or two from now? What happens if the health insurance won't pay for anything except one pap a year? I make about $30,000 a year (I used to make a lot more), and there's a limit to what I can afford.

So enough already; if I had a daughter, I'd get her vaccinated--no question about it.

At Wed Feb 14, 08:56:00 AM, Blogger MedStudentGod (MSG) said...


Men are only silent carriers causing disease on women? Please. Women can pass this along to men just as easily as men can to women. Both sexes suffer cancers (cervical, anal), and both suffer from debilitating effects. Men should not be summarily found guilty related to this issue. It is across the board - both men and women are culpable for the disease transmission.

Being a man I find it very concerning when something that clearly affects both men and women is targeted with such discrimination. There should be a million man march - to stop reverse sexism and racism.

I do think the vaccine should be given to those who want it, but there shouldn't be state mandated laws regarding its use.

At Thu Feb 15, 01:11:00 PM, Anonymous Anonymous said...

MSG, Well of course it is passed by both sexes (Men originally get it from a woman and then they spread it around) but men are absolutely a carrier, who suffer no disease process of HPV. You talk of men getting cancer from it? If so, where ? I have NEVER heard of one man getting cancer from HPV infection.

I would like to read the studies on that, if it is so, please direct us to the information.

At Thu Feb 15, 03:42:00 PM, Anonymous Anonymous said...

Sorry Dino for using this as a forum - I will make it brief.

In response to your comment Cathy, being a medical student and having a limited amount of time to fully research this (being the end of my Peds rotation and all) I will have to take some time before I get back on that information. The research is being done and more and more evidence is linking HPV to cancers of the anus and genitalia - it's just the incidence is less than cervical cancer.

So, please wait and I will have an answer eventually.

At Thu Feb 15, 03:43:00 PM, Anonymous Anonymous said...

The Facts About GARDASIL

1. GARDASIL is a vaccine for 4 strains of the human papillomavirus (HPV), two strains that are strongly associated (and probably cause) genital warts and two strains that are typically associated (and may cause) cervical cancer. About 90% of people with genital warts show exposure to one of the two HPV strains strongly suspected to cause genital warts. About 70% of women with cervical cancer show exposure to one of the other two HPV strains that the vaccine is designed to confer resistance to.

2. HPV is a sexually communicable (not an infectious) virus. When you consider all strains of HPV, over 70% of sexually active males and females have been exposed. A condom helps a lot (70% less likely to get it), but has not been shown to stop transmission in all cases (only one study of 82 college girls who self-reported about condom use has been done). For the vast majority of women, exposure to HPV strains (even the four "bad ones" protected for in GARDASIL) results in no known health complications of any kind.

3. Cervical cancer is not a deadly nor prevalent cancer in the US or any other first world nation. Cervical cancer rates have declined sharply over the last 30 years and are still declining. Cervical cancer accounts for less than 1% of of all female cancer cases and deaths in the US. Cervical cancer is typically very treatable and the prognosis for a healthy outcome is good. The typical exceptions to this case are old women, women who are already unhealthy and women who don't get pap smears until after the cancer has existed for many years.

4. Merck's clinical studies for GARDASIL were problematic in several ways. Only 20,541 women were used (half got the "placebo") and their health was followed up for only four years at maximum and typically 1-3 years only. More critically, only 1,121 of these subjects were less than 16. The younger subjects were only followed up for a maximum of 18 months. Furthermore, less than 10% of these subjects received true placebo injections. The others were given injections containing an aluminum salt adjuvant (vaccine enhancer) that is also a component of GARDASIL. This is scientifically preposterous, especially when you consider that similar alum adjuvants are suspected to be responsible for Gulf War disease and other possible vaccination related complications.

5. Both the "placebo" groups and the vaccination groups reported a myriad of short term and medium term health problems over the course of their evaluations. The majority of both groups reported minor health complications near the injection site or near the time of the injection. Among the vaccination group, reports of such complications were slightly higher. The small sample that was given a real placebo reported far fewer complications -- as in less than half. Furthermore, most if not all longer term complications were written off as not being potentially vaccine caused for all subjects.

6. Because the pool of test subjects was so small and the rates of cervical cancer are so low, NOT A SINGLE CONTROL SUBJECT ACTUALLY CONTRACTED CERVICAL CANCER IN ANY WAY, SHAPE OR FORM -- MUCH LESS DIED OF IT. Instead, this vaccine's supposed efficacy is based on the fact that the vaccinated group ended up with far fewer cases (5 vs. about 200) of genital warts and "precancerous lesions" (dysplasias) than the alum injected "control" subjects.

7. Because the tests included just four years of follow up at most, the long term effects and efficacy of this vaccine are completely unknown for anyone. All but the shortest term effects are completely unknown for little girls. Considering the tiny size of youngster study, the data about the shortest terms side effects for girls are also dubious.

8. GARDASIL is the most expensive vaccine ever marketed. It requires three vaccinations at $120 a pop for a total price tag of $360. It is expected to be Merck's biggest cash cow of this and the next decade.

These are simply the facts of the situation as presented by Merck and the FDA.

For a more complete discussion on GARDASIL with sources, click on my name.

At Thu Feb 15, 04:19:00 PM, Blogger Jo said...

MSG, Gardasil is being tested on males as we speak/type. It was promising enough in females, though, that Merck went ahead and rolled it out for chicks before they finished the studies on guys.

And Dino, I had both condyloma and cervical dysplasia many moons ago--about 20 years, now (eesh). The treatment cost well over two grand at the time. Add to that the cost of follow-up Pap tests (once every six months for years and years), and the fact that I *still* pay out of pocket for ThinPrep Paps...well.

Had there been a vaccine at the time that protected against the four most commmon strains of HPV, it would've protected me. And it would've saved me a whole lot of cash, as well as a whole lot of worry and paranoia.

I live in Texas. This is the first even marginally pro-women's-health thing Governor Goodhair's ever done. Shame it has to be tied to an eight-grand donation to his gazillion-dollar re-election campaign.

At Fri Feb 16, 04:54:00 PM, Blogger MedStudentGod (MSG) said...

Post is up.

At Tue Feb 27, 06:13:00 PM, Anonymous Anonymous said...

I have gotten the HPV vaccine, but unfortunately for me, it wasn't approved soon enough.

I waited until I was 20 years old and in love before I became sexually active, while most of you old geezers probably did it at 16 and didn't even know what AIDS or a condom was. I ALWAYS used protection, yet severaly months later I was diagnosed with HPV and cervical dysplasia. Yes, I suppose it's "easily treatable" but having liquid nitrogen blasted up your vagina is hardly a pleasant experience, so get real. It's so painful that many women pass out from the procedure. I almost threw up during it. They do not use any form of anesthesia during cryotherapy.

Perhaps you might convince your daughter to be abstinent till marriage, but that still won't make much of a difference. Her husband may have have picked it up in college and not known he had it. It can lie dormant for years.

Instead of assuming you know best, and assuming that your kid will be smart, why don't you do what you can to spare them any suffering. Soo many young people are getting this nowadays, nice guys and girls as well as the man-whores and sluts. That's reality!

At Tue Mar 20, 03:56:00 PM, Anonymous Anonymous said...

This comment has been removed by the author.

At Fri Jan 11, 12:08:00 AM, Anonymous Anonymous said...

I'm sorry. Who told you that HPV was treatable? Because it isn't.

That sort of kills your entire analogy... salmonella being curable, and HPV not.

And $400 - I'm sorry that's an obscene amount for you.

Most importantly - some insurance does cover 100% of the vaccine. It's just in the early stages, so your doctor's office must contact your insurance carrier.

At Tue Feb 26, 02:29:00 AM, Anonymous Anonymous said...

Listen here fossil, if it was left to you and your "abstinence" theory, there'd be no human race. I waited until I was 25 years old before I first dove into the realm of intimacy. I never caught HPV from any of the girls I had casual dealings with. It was the woman that I was with and faithful too for over three years. Apparently she had contracted it (unknowingly) from a previous encounter. It was picked up on a pap smear after we had been together for over a year and a half. Things didn't work out in the end and I'm single again... such is life, but at least I tried... and I didn't flip out on her when she was diagnosed... shit happens, nothing you can do about it... we used condoms and yet here I am with a Virus that medical science is baffled by... and of course (and rightly so) they want to vaccinate young women to prevent the spread, which is great, but they are doing nothing to prevent men from having it. Vaccination for women is supposed to reduce the cases of HPV, but if that's the case, then why the hell aren't people like you (within the medical community) working on a vaccination for men as well??? then perhaps the girl I spent those years with wouldn't have been infected in the first place. As far as I'm concerned (and I apologize to the real professionals out there beforehand) there are too many quacks out there practicing medicine with a say die attitude... No wonder we haven't cured cancer or aids or anything else for that matter... too many say die attitudes and bible thumpers with high and mighty morals saying that stem cell research and the like is bad.

Live in the now people

Concerned for the world.....

At Fri Mar 21, 12:31:00 AM, Anonymous Anonymous said...

radioactive girl - and everyone else questioning this vaccine...

There are 9 year old girls out there having sex right now; whether willingly or by force, sexual encounters happen. Aside from all of the other horrific consequences at that age, wouldn't it be worthwhile to avoid cervical cancer if you can??

All of you on here talking about how vaccines aren't worth the money - develop ceancer and then we'll sit down and talk. Until then, I cannot believe that you are making these choices for your daughters. Girls have sex - sorry to break it to you, but abstinence is not the route every person takes and with intercourse comes so many issues (emotional and physical) - if you can take precautions to be protected from one issue, isn't it worth it?

Oh, and the comment about the cost of the vaccine...spare me!! Many insurance carriers will cover the cost and if you lack insurance, the vaccine is a tiny drop in the bucket in comparison to cancer treatments.

If you want to light your hair on fire about it becoming mandatory, go ahead.

At Mon May 12, 09:15:00 PM, Anonymous Anonymous said...

oops. i left a comment on the first blog, and decided to comment again. i have had hpv and have had the leep procedures and multiple biopsies and would rather have a thousand more leeps than to get a vaccination that hasn't been proven to work and is still in the dark about long term side effects. have we become that dependent on big drug companies to keep us alive and safe??? true, children are having sex at younger ages, but the good old fashion sex talk and the friendly condom never hurt anyone. plus, a yearly pap, like the good dr says, prevents all of this, and you have to get it anyways!!! theres a girl in my class convinced everyone should get the gardasil vaccine, and is doing the treatment herself. what if in 10 yrs she finds out she can't have babies? what if her boyfriend gets the male vaccine and no longer produces sperm? i'm not saying it will haooen, but either do they. they make commercials with jingles that my 8 yr old daughter sings along to. its disgusting. i'm already baffled at the number of vaccines my children have to get already, can we lay off the drugs? merck continues to peddle their drugs with no consequences for the side effects people like you and i suffer from every day. ask the merck ceo if his daughter will be getting the vaccine.

At Tue May 13, 02:07:00 PM, Anonymous Anonymous said...

This comment has been removed by a blog administrator.

At Sun Jan 04, 07:00:00 PM, Anonymous Anonymous said...

I don't understand, if you have money and can afford the vaccine, then you can be protected, but if not oh well. I guess people need less poor people in the world. It's not as though we need health care ourselves. Even though we work just as hard but don't make as much money. It's all about the almighty dollar not health.


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