Saturday, September 24, 2011

GOP Scrapes Bottom over the HPV Vaccine (by Skylanda)

Struggling to regain her position as heir-apparent to the dubious legacy of Tea Party darling Sarah Palin, Michelle Bachmann took the opportunity at the recent Republican debate to let the crazy out of the GOP closet on topic of Gardasil vaccine. Bachmann railed at Perry for making the vaccine mandatory for sixth grade girls in Texas; Perry waffled on the issue, guessing that maybe he should have taken it to the Texas legislature before issuing the rapidly-rescinded edict. Hilarity ensued.

There are many good reasons to make a vaccine mandatory. It pushes insurance to cover the drug, it normalizes the process of opting out rather than opting in (which drives higher acceptance rates among those who don’t really care one way or the other, but wouldn’t go out of their way to get the injection), it gives uptake rates a hard shove toward the threshold needed for herd immunity. There is only one bad reason to make a vaccine mandatory, and Rick Perry managed to nail it: because the manufacturers donated $5000 (oops, or was that $30,000?) to your campaign coffer.

Meanwhile, in the opposite corner, Bachmann went on record as stating that she opposes the vaccine in no small part because a woman came up to her after the debate and claimed that her child’s mental retardation was caused by the HPV vaccine. The most obvious guess on this gaff is that Bachmann was probably thinking of the MMR vaccine (also long exonerated as a causal factor in autism) when the letters “H-P-V” conveniently popped into her head, but no matter: this brings a new low to the quality of rhetoric in this country. The HPV vaccine is first given at age nine or later; it would be an extraordinary case if a nine year-old suddenly experienced new-onset mental retardation except by means such as surviving encephalitis. [I was able to pull up 203 adverse events for the HPV vaccines on the CDC's somewhat clunky Vaccine Adverse Events Reporting System (VAERS); this included a number of events like “broke out in a rash a month later” and the dryly amusing “adverse events: none.” Aside from these dubious contributions, I found two references to encephalitis – one of which was probably due to HIV and one of which may have been the real deal – and one reference to a severe central nervous system event that occurred several months after the vaccine was administered and could not be conclusively linked to the vaccine. I could find no references to mental retardation.] So unlikely is the veracity of Bachmann’s off-the-cuff claim that renowned bioethicist Arthur Caplan offered a rather substantial sum of cash to anyone who can produce the child (with medical records) that Bachmann was referring to with this statement. So far the cash has not been claimed.

Still, mental retardation is a difficult thing. So let’s examine the role of the HPV vaccine in mental retardation because – really – there actually is a connection. It goes like this.

Pre-term labor is the bane of obstetrics. There are many things that obstetrics has become quite good at, and many of those things border on heroic on any day of the week (if you’ve ever seen a baby with no measurable heartbeat on a monitor survive a crash c-section, you know this with a gut terror you’ll never forget). Many of these things are boring as heck but very quietly result in decreased morbidity or mortality for moms and babies that would have died in other eras; controlling diabetes in pregnancy is one of these areas.

Pre-term labor is not one of these areas. Despite decades of efforts to the contrary, obstetrics as a practice is piss-poor at predicting pre-term labor and – once it gets started – finding any way to stop the steam-roller progress of a baby coming into the world too soon, with lungs and eyes and a gut not ready for the outside world. Mortality in this group is high; so are complications like blindness, gastrointestinal disease, and cognitive impairment – that is, mental retardation.

There is one factor though that we know causes pre-term labor – a predictable risk, a known quantity in the preterm labor game: having your cervix frozen, cut, or cauterized because of HPV disease, also known as cervical dysplasia. The damage to the cervix from these procedures – which are done to stop the progress of high-grade lesions a couple steps short of actual cervical cancer – raises the risk of preterm birth and causes a somewhat undefined number of NICU visits in the US every year. In fact, this problem is a large part of why the latest revision to the Pap smear guidelines in the US dictate that no woman under 21 should even get Pap smears (except under special circumstances like known immuno-suppression): cervical cancer is vanishingly rare in this group – most women pick up one HPV strain or another in their teens (yup, guess what, sex happens), but young women clear even high-grade lesions extraordinarily well. The net impact of doing Pap smears in this group is the treatment of lesions that would have disappeared on their own, with the consequence of putting those women at life-long risk of preterm labor just as they are starting their reproductive years. Pap smears are best reserved for women in the age groups that do develop cancer: women in their 20s-60s, where the benefits of looking for abnormalities and treating precancerous lesions outweigh the risks of messing around with the cervix.

And that’s where the HPV vaccine comes in. Yes, Gardasil and its cousin Cervarix are “cancer vaccines,” but this a cancer we already know how to treat in its early stages. So this “cancer vaccine” prevents more than cancer – it prevents the sort of medical treatment for cervical dysplasia that can lead to very high morbidity in future pregnancies. In one of the stunning ironies of the great GOP race of 2011, mental retardation can actually be prevented with the HPV vaccines. (If you’re looking for other ironies in the vaccine debate, you’ll note that an autism-like cognitive disorder is one of the harms of congenital rubella that the MMR vaccine was designed to prevent. That’s always a fun one to bring up with the Jenny McCarthy-ite crowd.) Because a portion of pre-term babies die, there’s a certain pro-life tang in here too: remove all the sex-panic hypocrisy – as well as the known phenomenon of anti-abortion-ites caring about babies right up until the moment they are born – and what you have here is the world’s first pro-life vaccine.

But the best conclusion to this fiasco came from an unlikely source: Rush Limbaugh – not known for temporizing or thoughtful rhetoric – commented that it looked like Bachmann’s campaign might have finally “jumped the shark” with this debacle.

We can only hope.

Cross-posted from my recently re-located and re-launched blog, America, Love It or Heal It.