DECEMBER 15, 2007


HPV vaccine campaign struggles

Low Ontario uptake rate "a huge
disappointment," says expert

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."

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.'"

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?

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.

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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