PoPulationand Public HealtH etHics

policy
Case
Following the pharmaceutical company’s lead, 4 the Ontario program frames
the product as a cervical cancer vaccine, not an stI vaccine. As a risk-communications
strategy, the program deliberately conflates HPV infection with
cervical cancer to create the perception of a public health crisis. 5–8 The framing
of the product as a “cancer vaccine” also makes vaccination more palatable to
parents who may be uncomfortable with vaccinating their children against
stIs. The vaccine is not aimed at eradicating the virus, as is typical in most
population-based vaccination programs; if it were, males would need to be
included to achieve herd immunity.
The National Advisory Committee on Immunization recommends a policy
of mass vaccination for all girls aged 9 to 13, yet young girls aged 9 to 15 represented
only a small proportion of those enrolled in the clinical trials of the
vaccine, and the youngest of these girls were followed for only 18 months. 9
We know that the vaccine is effective in providing immunologic protection
for up to five years. 10 The true length of protection it provides is unknown,
however, as is whether boosters will be needed and, if so, how many. Also
unknown is whether the immunity conferred through mass vaccination will
allow other carcinogenic strains of HPV to become dominant. 7
As is the case for most risks for chronic disease, risks for cervical cancer in
Canada are not distributed evenly across the population. The introduction of
universal Pap screening in Canada resulted in declines in cervical cancer incidence
and mortality among all income groups, with the biggest reductions seen
in low-income women. 11 Despite this, a socioeconomic gradient in cervical cancer
persists 11–12 and the prevalence of cervical cancer among marginalized groups,
such as Aboriginal women, is higher than in the general population. 6 This has
been attributed to poor reproductive and primary health care, low socioeconomic
status and poor nutrition. If universally accepted, increasing access to HPV vaccination
in schools may have a levelling impact and decrease differentials in
risk for cervical cancer from HPV strains 16 and 18. However, most girls who
receive the HPV vaccine are already at a low lifetime risk for cervical cancer. 6
Questions about the cost-effectiveness of this vaccine have been raised, due
to both its high cost and the fact that it will not lessen the need for Pap testing,
other screening and other reproductive health care programs. It has been
suggested that, to be cost effective, screening programs for cervical cancer
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