I am writing this letter in response to the piece written by Yonoson Rosenblum, “A Shot in the Dark?” published in the Mishpacha magazine dated December 11, 2019. As an introduction, I am a gynecologic oncologist, which means that I am a gynecologist who has specialty training in treating women's cancers. I am also a mother of 4 girls, the oldest of whom has received the HPV vaccine already, and the other three whom will IYH be vaccinated when they are the appropriate age.
I agree with Rabbi Rosenblum’s premise that forcing parents to provide their children with treatments they deem unsafe may be unconstitutional unless it is a time of crisis (such as the near epidemic proportions measles outbreak that occurred last year), but that is where my agreement with him ends. Unfortunately, the presumption that Gardasil, the 9-valent HPV vaccine, is dangerous and unnecessary very inaccurate, and appears to be based on skewed information.
HPV is a double stranded circular DNA virus, and can incorporate its DNA into human cells. This integration of viral DNA into human cells may cause the cells to undergo malignant transformation (cancer). The virus has many different sub-types, and its presence is pretty much ubiquitous among human beings. Some strains of this virus can lead to deleterious effects, some of which are benign and unsightly, such as warts, and some may lead to precancerous changes that can eventually develop into cancer. HPV related cancers include cervical, vaginal, vulvar, penile, anal, and oropharyngeal cancers. In order for cancer to develop, the HPV infection needs to be persistent and prolonged. Developing precancerous changes of the cervix (otherwise known as dysplasia) requires at least two years of persistent HPV infection, often longer. Progressing from pre-cancer to cancer takes even longer (though not always), in the range of 10 years.
Historically, cervical cancer is one of the leading causes of cancer related deaths worldwide. In the United States, the advent of the pap smear in the 1940’s significantly impacted the rate of cervical cancer by detecting precancerous cells and treating them before they developed into cancer. A study published in 2012 revealed a 54% decrease rate of cervical cancer in the previous 35 years, largely due to pap smear screening. Currently, according to a national cancer database (SEER database), there are 13,170 projected diagnosis of cervical cancer in 2019. HPV, which is a known precursor to over 95% of cervical cancers, is a virus that is transmitted through skin contact, often intimate contact. Currently, approximately 80% of people in the United States who have been intimately active will be infected with HPV at some point. Of these people, 7% will have persistent infection, and will go on to develop pre-cancer cells, which may eventually develop into cancer.
The HPV vaccine was developed to decrease the incidence of HPV infections, thereby avoiding the pre-cancer phase, and hopefully eliminating all HPV related cancer. Currently, it is the only vaccine that is available to eliminate cancer.
In the US, HPV vaccine Gardasil is recommended by multiple organizations, including the AAP (pediatrics), ACOG (gynecology), ACS (cancer), ACIP (vaccines), and CDC, among many others. The current vaccine schedule recommends beginning vaccination starting ages 11 to 12 ( though it may be given as young as 9, but it is not currently the recommended starting age), up to the age of 26 (21 for men). Recently, approval for the vaccine has been extended to the age of 45, in some extenuating circumstances.
Has the vaccine been effective? It has. Australia, which was one of the first countries to embrace the vaccine and mandated it as part of their national immunization, is currently on the verge of eliminating cervical cancer from their country. A large study published in the Lancet Public Health in 2018 analyzed rates of cervical pre-cancer and cancer after approximately 9 million doses were administered. What they found was that approximately 77% of cancer related HPV sub-types were eliminated, with a 50% reduction in the incidence of high grade cervical abnormalities (precancerous conditions). In the US, there are approximately 30,000 HPV related cancers annually. A study from Alabama already demonstrated a significant drop in the rate of cervical cancer, as well as other HPV related cancers as well.
Is it safe? Yes! Combined studies of over 2.5 million doses revealed an extremely low incidence of adverse effects. A study published in the Journal of Pediatrics in 2016 looked at 838,991 doses of the 9 valent HPV vaccine, and demonstrated the safety of the vaccine, with an extremely low incidence of serious adverse effects.
Now that we have established that the vaccine is safe and effective, we need to establish whether or not the vaccine is applicable to us.
The author of the article contends that following a “chaste and monogamous Torah life” will protect against HPV and subsequently cervical cancer. The only thing that can truly protect someone is absolute abstinence, as was demonstrated in a large study analyzing the rates of cervical cancer in nuns in a monastery. As we know, a true Torah life does not condone, or even allow, a life of abstinence. Once someone has been intimate, they are automatically at risk of acquiring the HPV vaccine. Well, one would say, how can a man and woman, who have been intimate only with each other their entire life, acquire the virus? The truth is, even in the most stringent, frum circles, monogamy is not a given. Chlamydia, another infection that is transmitted through intimate contact, has been used as a surrogate for detecting HPV infections rates, given that the presence of chlamydia is strongly associated with the presence of HPV infection. . A study in Israel looked at several hundred chareidi women who were screened for chlamydia during their pregnancy - what they found was that 6% of chareidi women had active chlamydia infections, and 12.3% had evidence of prior infection. No promiscuity? A survey of teenagers in yeshivot in Israeli revealed that 6% of chareidi teenage girls, and 11% of boys admitted to engaging in a form of intimate activity. 11%- meaning 1/10 yeshiva boys have had some exposure. The frum society is unfortunately subject to the same human weaknesses as other societies. Are the rates lower? Probably. Are the rates negligible? Absolutely not. As a practicing gynecologic oncologist, treating cancer is what I do every single day. Unfortunately, I have seen a fair share of frum women with pre-cancer of the cervix, vulvar pre-cancer, and vulvar cancer. And what about the good people who are strictly Halacha abiding and have never been promiscuous? Have good frum people never been remarried? What about our growing number of sincere, frum, baalei teshuva? And less likely, though a sad reality, victims of incest, molestation, and rape? Do they not deserve to be protected? How, as a parent, despite all of the chinuch, tefillos, and hopes, can you be certain that your child will not be among those who are exposed to the virus?
The author claims that “There are far cheaper, less invasive, and safer ways to prevent cervical cancer than vaccination”. Unfortunately, this statement is inaccurate. It is true that pap smears have significantly decreased the rate of cervical cancer. Detection of precancerous cells is treating a disease that is already present. The vaccine prevents the disease from occurring in the first place. Pap smears are neither comfortable, nor inexpensive. Furthermore, once a pap smear detects abnormal cells, followup is needed in the office in the form of a very invasive exam called a colposcopy. This entails a microscopic inspection of the cervix, with subsequent biopsies. Some pre-cancer biopsy results require more aggressive treatments, where a portion of the cervix is removed. This is often performed in the operating room. This involves blood work, anesthesia, post operative pain, and bleeding post-operatively. These procedures carry with them a long term risk of infertility and early pregnancy loss, as well as a significant risk of recurrence. Does this sound less invasive than 2-3 shots given to a young adolescent? And let us not forget the impact that all of this workup has on a woman’s mental well-being. The anxiety before and after every exam. The issues with niddah related to the exams and biopsies. The effects on the woman and her marriage are many-fold.
The author of the article also states that there is a suggestion of increasing rates of cancer in patients who received the vaccine. This statement is based on false information. Below is a copy of the headline of the article that suggested a link between HPV vaccine and increased rate of cervical cancer:
RETRACTED: Increased incidence of cervical cancer in Sweden: Possible link with HPV vaccination.
Indian J Med Ethics. 2018 Jul-Sep;3(3):246. doi: 10.20529/IJME.2018.057. Epub 2018 May 26
The article was retracted. The author falsified his name and workplace, and supposed data was never verified.
So where do we go from here? Every parent needs to make the decision they think is right for their children, and protect them. My oldest is already vaccinated, and my younger three will be vaccinated when they turn 11 or 12. We have a safe and effective intervention that has been proven to decrease rates of a very cumbersome disease in women in their reproductive years, and prevent cancer. I feel I would be failing my obligation as a parent and a doctor if I did not give my child every opportunity available to them to lead a healthy life.
Mira Hellmann-Ostrov MD, FACOG, Fellow Society of Gynecologic Oncology
This letter was written with the support of JOWMA, and reflects the organization’s views.
Eliana Fine, MD candidate 2022, Founder
Mimi Knoll MD, DABR, President
Sherrie Neustein Orzel, MD ,Vice President
Bat Sheva Maslow, MD FACOG, MSCTR, Chief Marketing Officer
Mira Hellmann-Ostrov MD FACOG, Secretary
Ilana Marguilies MD candidate 2020, Treasurer