Clutching Our Crystals: Myths, Fears, Immunization, and HPV
Michael B. Grosso, MD
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
Grosso MB. Clutching our crystals: myths, fears, immunization, and HPV [published online February 24, 2020]. Infectious Diseases Consultant.
Over the past 20 years, vaccine-preventable outbreaks of infectious diseases—including pertussis and measles—have occurred repeatedly in underimmunized communities. Case clusters of measles in 2019 were of particular concern and nearly led the World Health Organization to reclassify the United States as a measles-endemic country. Rather than an issue of access, this has been a crisis of confidence fueled by antivaccine messaging that contradicts the extensive data on vaccine safety. Activists cite debunked theories about immunization and developmental disability, and a whole subculture of anti-immunization, whose membership includes mostly affluent, well-educated families, has emerged. It seems that at least 3 factors contribute to antivaccination sentiment.
Libertarianism. The notion that routine, let alone mandatory, immunization impinges on parents’ right to make health care decisions for their child has wide currency. US Senator Rand Paul (R, Kentucky), an ophthalmologist, commented last year during Senate hearings on the immunization problem: “Even the government admits that children are sometimes injured by vaccines … I still don’t favor giving up on liberty for a false sense of security.”1
Antiscientific societal bias. Perhaps this is part of societal skepticism about academic authority in general. Whatever its basis, pseudoscience is in the ascendancy. Observing cultural trends from creationism to alien abduction and many forms of alternative medicine, the late science writer and astrophysicist Carl Sagan dramatically noted, “I have a foreboding of an America in my children’s or grandchildren’s time … when the people have lost the ability to set their own agendas or knowledgeably question those in authority; when, clutching our crystals and nervously consulting our horoscopes, our critical faculties in decline, unable to distinguish between what feels good and what’s true, we slide, almost without noticing, back into superstition and darkness.”2
Unfamiliarity with vaccine-preventable conditions. Our international program of childhood immunization has, in the 21st century, become the victim of its own dramatic success. Most young parents are unaware of what diphtheria, pertussis, measles, or mumps look like, let alone their consequences. This lack of awareness means that any risk, real or otherwise, easily outweighs the perceived benefit of immunization.
Antecedents of Vaccine Hesitancy
Although fears about vaccine safety date from the days of Edward Jenner and smallpox, the contemporary era of vaccine reluctance arguably traces to 1998 with the publication of Andrew J. Wakefield’s Lancet paper,3 which suggested a link between the measles, mumps, and rubella vaccine and autism. This report, as we know, was later found to be not only flawed scientifically, but also fraudulent.4 Nonetheless, it set off a decade-long public health scare about the safety of that vaccine before it was disclosed that the data for his case series were fabricated to support a lawsuit against the vaccine manufacturer. Wakefield’s medical license was later revoked in a highly publicized action.
In 1999, concerns about thimerosal, a mercury-based preservative, led federal agencies to call for the removal of this compound from most vaccines as a precautionary measure, despite an absence of evidence that this compound was associated with any form of injury. Rather than quell public concerns, the mercury issue appeared to increase public skepticism. Meanwhile, the underlying hypothesis that thimerosal accounted for a rising incidence of autistic spectrum disorder (ASD), was contradicted by a natural experiment, as exposure decreased dramatically while the prevalence of ASD continued to rise in the ensuing years. Systematic literature reviews have also refuted both biological plausibility and epidemiological association between the preservative and ASD.5
Preventing HPV-Related Cancers in an Era of Vaccine Hesitancy
Imagine that a newly discovered virus was reported to cause 14 million new infections and 33,000 cancers every year. This year, next year, and every year thereafter. The public outcry would be deafening. There would be calls for research and some way to stop the scourge. A vaccine perhaps.
Needless to say, this is a description of the human papillomavirus (HPV), which was first identified in 1956 and almost 30 years later was found to be the main cause of cervical cancer and several other malignancies, including head and neck cancers, anorectal lesions, and penile cancer.
A safe and effective vaccine, HPV4, was introduced in 2006 and added a year later to the list of routinely recommended immunizations by the Advisory Committee on Immunization Practices. In 2014, this product was improved with the release of HPV9, now covering almost all of the oncogenic serotypes. What was the result? According to 2018 data from the Centers for Disease Control and Prevention, only about 51.1% of eligible adolescents aged 13 to 17 years are immunized against HPV—a far poorer rate of coverage than for other routinely recommended childhood vaccines.6 The underlying causes of this public health failure surely include all of the contributors to vaccine hesitancy discussed above.
Gardasil: A Special Case
However, the HPV vaccine has faced additional, unique barriers. Antivaccine advocacy groups have circulated 2 myths in particular: that there have been “deaths from Gardasil,” and that the vaccine causes infertility in girls. Neither has a basis in fact. A 2019 study analyzing VAERS (the Vaccine Adverse Event Reporting System, a passive data repository) data found no evidence of mortality attributable to HPV immunization.7 The fertility issue has been analyzed with similarly reassuring results.8
Additionally, there is a pervasive concern about immunizing 11- and 12-year-olds against a sexually transmitted infection. Whether parents are reacting viscerally to this reminder of teenage sexuality or specifically believe that immunization will encourage promiscuity (another myth), the timing of HPV9 in the vaccine schedule has been problematic.
What You Can Do: An Evidence-Based Approach
Several studies shed light on effective messaging in the office. For example, Nyhan and colleagues9 found that dramatic stories of vaccine-preventable outcomes delivered to vaccine-hesitant parents may decrease, rather than improve, the likelihood of consent. This curious result reaffirms an important feature of evidence-based practice generally, which is that the data sometimes contradict “common sense” assumptions. On the other hand, Opel and colleagues10 found that a “presumptive” (as opposed to a “participatory” approach) had a positive effect on immunization rates for both vaccine-hesitant (83% vs 26%) and nonhesitant (89% vs 30%) families. Finally, a body of work on medical communication indicates that strong, trust-based physician-patient relationships favorably impact adherence to medical advice.11-13 With these results in mind, here are 5 actions we can take with our patients:
- Incorporate the presumptive approach. Treat HPV9 like every other vaccine. Do not say, “What do you think about the HPV vaccine?” but rather, “Johnny is due for 3 vaccines today: Tdap, Gardasil, and Menactra.”
- Be a respectful listener. Trying as it may be to be challenged so often, our better angels remind us to be compassionate toward the many parents who struggle with these decisions, especially when so much confusing information circulates in the marketplace of ideas.
- Titrate the message. This can be very difficult, but just as a laissez-faire approach conduces to immunization delays, so does coercive pressure. Remember the first rule of conflict management: Use “I” language. “You need to do this for your daughter” is hostile and off-putting. “I am concerned that Erin is overdue for this vaccine,” expresses our interest in doing what is best.
- Refocus the message. Encouraging immunization prior to sexual debut is good epidemiology but very bad psychology. Fortunately, another argument is at hand. Immune response to HPV9 is so much more robust in earlier life that only 2 doses are needed if immunization starts before age 15 years; after that, a third dose is required. My personal preference would be to offer the vaccine at the earliest age at which it is approved by the US Food and Drug Administration, currently at age 9 years. This creates a more comfortable distance between the recommendation to immunize and the issue of sexual debut.
- Influence the public conversation. I have been honored to lead an HPV task force in our hospital for the last year. Our message goes out in articles and editorials to every local paper, to schools, and to libraries. We do radio shows and podcasts. We have delivered testimony to our county legislature and have more activities planned for 2020. Remember the 3 rules of marketing: First, the more one repeats a message, the more people believe it. Second, the more one repeats a message, the more people believe it. Third, the more one repeats a message, the more people believe it.
Michael B Grosso, MD, FAAP, is the medical director at Huntington Hospital and an assistant professor of pediatrics at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in New York.
- Sonmez F. Sen. Rand Paul says government should not force people to receive vaccinations [published online March 5, 2019]. Washington Post. https://www.washingtonpost.com/politics/sen-rand-paul-says-government-should-not-force-people-to-receive-vaccinations/2019/03/05/bfae6534-3f6e-11e9-9361-301ffb5bd5e6_story.html.
- Sagan C. The Demon-Haunted World: Science as a Candle in the Dark. Ballantine Books; 1997.
- Wakefield AJ, Murch SH, Anthony A, et al. Ileal lymphoid nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children [retracted]. Lancet. 1998;351(9103):637-641. https://doi.org/10.1016/S0140-6736(97)11096-0.
- Dyer C. Lancet retracts Wakefield’s MMR paper. BMJ;2010;340:c696. https://doi.org/10.1136/bmj.c696.
- Parker SK, Schwartz B, Todd J, Pickering LK. Thimerosal-containing vaccines and autistic spectrum disorder: a critical review of published original data. Pediatrics. 2004;114(3)793-804. https://doi.org/10.1542/peds.2004-0434.
- Jenco M. CDC: Teens’ HVP vaccination rates improve slightly [published online August 22, 2019]. AAP News. https://www.aappublications.org/news/2019/08/22/teenvaccination082219.
- Shimabukuro TT, Su JR, Marquez PL, Mba-Jonas A, Arana JE, Cano MV. Safety profile of the 9-valent human papillomavirus vaccine. Pediatrics. 2019;144(6):e20191791. https://doi.org/10.1542/peds.2019-1791.
- Naleway AL, Mittendorf KF, Irving SA, et al. Primary ovarian insufficiency and adolescent vaccination. Pediatrics. 2018;142(3):e20180943. https://doi.org/10.1542/peds.2018-0943.
- Nyhan B, Reifler J, Richey S, Freed GL. Effective messages in vaccine promotion: a randomized trial. Pediatrics. 2014;133(4):e835-e842. https://doi.org/10.1542/peds.2013-2365.
- Opel DJ, Heritage J, Taylor JA, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics. 2013;132(6):1037-1046. https://doi.org/10.1542/peds.2013-2037.
- Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152(9):1423-1433. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1337906/.
- Street Jr RL, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient Educ Couns. 2009;74(3):295-301. https://doi.org/10.1016/j.pec.2008.11.015.
- Zolnierek KB, DiMatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47(8):826-834. https://dx.doi.org/10.1097%2FMLR.0b013e31819a5acc.