Reasons why mothers don't give daughters the HPV vaccine.

The latest medical studies explained.
Aug. 21 2008 5:01 PM

Cancer-Free Girls

Why don't moms give their daughters the HPV vaccine?

Gardasil. Click image to expand.
Gardasil vaccine

Question: One of the decisions confronting the parents of young teenage girls is whether to agree to give them the vaccine for human papillomavirus, which prevents cervical cancer. (One brand also prevents genital warts.) To me, the question is almost a no-brainer, because this is an extremely effective vaccine, and the first one specifically intended to prevent cancer. It's been on the market for more than two years now. Though the vaccine is expensive, many insurance plans and federal and state programs cover the cost. If my daughter were in the eligible age range, I'd be beating down her doctor's door to arrange for the series of shots. Yet only about one in five eligible girls has been immunized against this terrible disease. Why?

Rationales: Many reasons have been suggested. Some parents fear that giving a vaccine that makes sexual activity a bit less risky will increase the likelihood of teen sex. Others can't imagine their teen daughters in a sexual situation in which they'd need the vaccine's protection. Some could be put off by the potential pain of the shots or their children's fear of pain. And other parents are worried that the vaccine might be harmful.

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New study: Now a recent study points to additional factors. Mothers are more likely to vaccinate their daughters early, the authors found, if the mothers have a history of sexually transmitted disease and if they see themselves as closely monitoring their daughters' behavior. Mothers' expectations about whether their children will mind the shot also matters. And when mothers are worried about the safety of the vaccine, they're less likely to use it.

Safety: This is the factor I think plays the strongest role in discouraging HPV vaccine use. Recently, rumors and news reports have called into question the safety of the vaccine, leading the Centers for Disease Control to restudy the question. The CDC's recent report is quite reassuring. Of 16 million doses, there have been 21 reported deaths following the shots. I always like to remind people that just because one event follows another, it doesn't necessarily mean that they are related. So far, the CDC hasn't established a causal relationship between immunization and a death, though they are still looking. Additionally, Guillain-Barré syndrome, in which spinal-cord damage may follow HPV immunization (it follows the administration of other vaccines and can also occur spontaneously), has been reported 44 times after the HPV vaccine was given (with some of those reports not confirmed). The CDC is investigating here as well, but the number of cases is pretty much what might be expected in the general population, with or without the vaccine.

Age: At what age should girls receive the vaccine? Between 9 and 12. The immune response to the vaccine is exceptionally strong when administered to girls this young. Also, the vaccine is pretty much worthless if given after HPV exposure has already occurred, and few girls will have had a sexual exposure to HPV this early. Parents who choose to delay giving the vaccine because they don't think girls this young need it are entirely missing the point. It's precisely because their daughters are not yet sexually active, and also have such powerful immune responses, that this is the ideal age. If we had better data on long-term protection, and knew that the effects of the vaccine don't fade, we might give this vaccine to younger children, so as to shift our thinking about its link with early sexual activity. I don't have anything printable to say to parents prepared to risk their children's health in the hopes that they will be scared away from bad behavior or, if that doesn't work, punished for it.

Conclusion: So where do we stand? The vaccine seems quite safe and very effective—especially when compared with the risks of not immunizing. I wish it were a lot cheaper. I also wish it could be given to younger children and to both boys and girls (both would get some benefit, though girls more).

Sydney Spiesel is a pediatrician in Woodbridge, Conn., and clinical professor of pediatrics at Yale University's School of Medicine.

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