The campaign to inoculate Canadian
schoolgirls against human papilloma virus (HPV) has
been struck by a wave of adverse reactions. But it's
not fever or fainting that's perplexing public health
officials in Ontario - the vaccine Gardasil seems to
be admirably safe - rather it's a rash of parental refusals
that is leaving many districts trailing far behind their
targets.
Less than 50% of Ontario parents
have agreed to let their daughters get the vaccination,
which is covered by the province's public insurance
for Grade 8 girls. And "uptake intent" among British
Columbia and Yukon parents was estimated at just 63%
in a new survey published December 4 in CMAJ.
At a conference in Montreal last
month, Dr Ian Gemmill, the medical officer for Kingston,
Frontenac and Lennox & Addington Public Health,
in Ontario, said the refusal rate — a paltry 28%
in one district — was unprecedented in the province.
"This is a huge disappointment," he later told CanWest
News. "There are lessons to be learned from the Ontario
experience. You don't want to undermine the program
before you start."
'IRRESPONSIBLE'
CRITICS
Ontario's HPV vaccination program, announced in August
and funded by a portion of the $300 million in the 2007
federal budget for such efforts, was injured before
it even started by sensationalist media reporting and
irresponsible articles in scientific journals, alleged
Dr Gemmill.
He was referring to an article
that appeared in CMAJ the day before Ontario
officially kicked off its program. The article questioned
the haste with which Gardasil was being introduced,
the wisdom of diverting so much healthcare money to
a disease which kills 400 Canadians a year, and the
quality of the research, which is decidedly thin for
the age group now being immunized.
The lead author of that article,
Dr Abby Lippman, an epidemiologist at McGill, told NRM
she was pleased to hear about the low rate of uptake
in Ontario. "I was actually in the next room when he
made those comments," she says. "I wish I'd been there."
Does she agree with Dr Gemmill
that her article drove Ontario parents away from the
Gardasil program? "I don't know if I deserve much of
the credit or blame for that," she says. "But if it
did play a role, if patients really are doing things
based on CMAJ articles, I would say 'good, at
last people are starting to make informed health decisions
for themselves.'"
THE
MACLEAN'S EFFECT
In reality, the hostility to Gardasil in Ontario probably
has far more to do with a controversial article that
appeared in Maclean's magazine in late August.
The article focused extensively on perceived concerns
about short-term adverse reactions to the vaccine -
an issue that Lippman and colleagues never pressed.
"I'm not arguing that Gardasil has been shown to be
dangerous in a fourth-grade population," says Dr Lippman.
"My whole point is that we have insufficient data to
know what the effects are in this age group."
Gardasil's more serious critics
regard the Maclean's intervention as unhelpful;
there's no evidence to suggest that Gardasil is an unsafe
shot. There have only been three really serious post-injection
complications, and all were thoroughly investigated
and traced to other causes. A recent case in Australia
where a whole class of schoolgirls complained of faintness
after their shot was an obvious case of mass hysteria.
But the critics of Canada's Gardasil
campaign aren't really criticizing the vaccine. They're
criticizing the campaign. They ask: why now, why the
urgency, and how do we know this is the best way to
spend these vast sums of money?
SUSPECT
MARKETING
The proponents of Gardasil, especially the vaccine's
manufacturer Merck, have only themselves to blame if
there is suspicion, argues Dr Lippman. Merck's marketing
campaign and the government's publicity campaign for
immunization ran together in a seamless continuum that
suggested an unhealthy degree of coordination.
Aides to both Stephen Harper and
Ontario Health Minister George Smitherman quit their
jobs just weeks before the Gardasil funding was announced,
to register as lobbyists for Merck. In Texas, Merck
made a campaign contribution to the governor on the
day he met to deliberate on a Gardasil program; it was
approved, only to be vetoed by the legislature later.
Even the American Academy of Pediatrics - a major advocate
for HPV immunization - formally asked Merck to quit
lobbying as it was doing more harm than good.
FUTURE
PROSPECTS
Despite Ontario's low numbers and the so-so projections
of uptake intent, early reports suggest that uptake
in the Atlantic provinces has been high.
But in Quebec a coalition of women's
groups last week sent a letter to health minister Philippe
Couillard to ask the provincial government to cancel
next year's planned program.
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