Let Us Take Comfort in Gardasil, Moms.

"The days go slow, but the years pass by quickly."

How true this adage is now that my oldest is almost eleven. I remember year one. I left my life as a coastal city girl for the rural south.  I had a colicky baby, a weekend husband, and no friends nearby. Those days were achingly long. "Appreciate every minute," experienced mothers from our neighborhood would tell me. I'd smile. And quietly hate them.

But where did the years go? I have more wrinkles, more grays, more joint pain. And my littles aren't little anymore.  Neither are their friends. This summer was a prelude to middle school for a lot of kids we know.  We heard deepening voices and whispers of training bras at sleepovers; we breathed in the rank odor of BO mixed with deodorant at camps.  I had my first real talk about sex with my kids, one of many to be sure.

Moms clearly share anxiety over what the preteen/teen years hold for their children.  I mean, <blink>, how did we even get here?  A good friend of mine just reached out, her daughter a new 6th grader.  "Can you write a post about Gardasil?  It's the only vaccine I'm scared of and I know the pediatrician will want [her] to get it soon." Gardasil.  It's a vaccine that prevents a sexually transmitted disease. I know my friend is thinking, 'When did I join a world in which my baby needs protection from STDs?' because I'm thinking it, too.  But here we are, ladies. And there's no turning back.

So my thesis is this: let's embrace it. This time too is fleeting.  Before we know it we'll be releasing our flock, letting them fly without a watchful eye or safety net to catch them.  We must seize the opportunity, now, to educate our children about the intricacies of sex and to protect them as best we can. Gardasil is that protection - at least part of it. Here is the knowledge you need to take comfort in Gardasil.  Share it with your kids.  Vaccinate them.

The Vaccine

Gardasil was first approved for use in 2004 against the Human Papilloma Virus (HPV), the causative agent of nearly all cervical cancers in the U.S. as well as cancers of the vagina, vulva, anus, penis, and oropharynx (throat and tonsils). The initial vaccine targeted four HPV types (6, 11, 16, 18):  two "high risk" strains that cause anogenital cancers, including 70% of cervical cancers, and two non-oncogenic "low risk" strains that cause 90% of genital warts.  Gardasil was replaced by Gardasil 9 in 2014.  It's an improved form of the vaccine that protects against an additional five high risk strains (31, 33, 45, 52, and 58; hence the name Gardasil '9') also known to cause anogenital cancers including 20% of cervical cancers.  Therefore, Gardasil 9 offers protection from HPV that is responsible for over 90% of cervical cancers and 90% of genital warts. 

Gardasil 9 is the only HPV vaccine now distributed for use in the U.S. and it is up to 100% effective at preventing transmission of its nine target HPV strains. The vaccine is indicated for people (male and female) 9 to 45 years old, but it is only effective at preventing transmission of HPV strains that a person hasn't had previous exposure to (i.e. via sexual contact). Therefore, the CDC recommends Gardasil 9 be given to boys and girls ages 11 to 12 (who are presumed to not yet be sexually active) and those 13 to 26 who have not yet been vaccinated. Interestingly, the vaccine illicits a stronger immune response in children ages 9 to 15 compared to those older than 16 years of age.  As a result, 9 to 15 year olds require only 2-doses of the vaccine (given at 6 month intervals) while older children and adults require 3-doses to achieve equivalent protection.

The Virus

HPV is ubiquitous, meaning it's everywhere. I know; I cut my foot once on a plastic crate and grew an awful planters wart that I battled for years. Yes - HPV causes standard hand and foot warts too.  In fact, there are over 200 types of HPV known loitering on surfaces of every kind.  All strains infect a similar human cell, called epithelial cells, but different HPV types have unique epithelial targets: the skin of our hands and feet, the soft tissue of our mouth and respiratory tract, or the soft tissues of our anogenital areas.  Most HPV does not pose a major health risk - just perhaps some social awkwardness. However, forty types are transmitted sexually and thirteen of these cause cancer.

Many of us never know that we have been exposed to HPV though statistics show that over 80% of sexually active people (men and women) are infected with the virus at some point in their life. Our immune systems typically clear HPV infections within a two year period and many strains are asymptomatic. However, if a cancer-causing strain persists unnoticed in a person's tissue it can lead to abnormal "pre-cancerous" cell changes and eventually cancer. HPV unwittingly does this by inserting its genetic code into our cells' DNA and disrupting the structure and function of genes that otherwise maintain normal, healthy cells.

Cancer Statistics

In the U.S. twelve thousand women are diagnosed annually with cervical cancer caused by HPV and one third will die from the disease.  Worldwide the numbers are even more staggering: in 2018 an estimated 569,000 new cases and 311,000 deaths occurred from cervical cancer.  But cervical cancer is not the only cancer caused by HPV. According to registries maintained by the CDC and National Cancer Institute, thousands of American women suffer yearly from HPV-related anal, vulval, oral, and vaginal cancers and men from oral, anal, and penile cancers (see data below). 

Average number of HPV-related cancers, by site in the human body, for men and women in the U.S. annually. For more information, visit the CDC's website.

Take heart, though.  Gardasil 9 will change the trajectory of these cancer statistics.  We can change these statistics by vaccinating our children and reducing their risk of HPV-related cancers by up to 100%.  Let Gardasil 9 be a source of comfort for us.  Let it relieve anxiety.  Let it protect our kids.  

**TMI ALERT:  I'm about to get deeply personal.  I wish, in fact, that Gardasil 9 had been available when I was young. It would have saved me from the repercussions of an abnormal pap-smear.

I was in my late 20s: considerably mature, finishing graduate school, accustomed to long-term, committed relationships, and according to my university's student health office, positive for a high risk HPV strain.  My phone conversation with the nurse left me feeling nauseous.  How could this happen to me?  I was the girl studying STDs for my Ph.D., reporting on the statistics of chlamydia and ectopic pregnancies.  I was immune by way of the millions of responsible decisions I'd ever made.  I was in between boyfriends and, in fact...  incredibly naive.  The pill gave me a false sense of safety.  I lived in what I deemed a safe social bubble.  And my guy looked clean.  He was handsome, kind, well-known, and didn't seem the player type.  But none of that mattered or matters. Unprotected sex is unprotected sex.

Once you are diagnosed with an abnormal pap you experience a medical procedure that is as awkward to pronounce as it is to undergo: col-pos-co-py.  It's different than a colonoscopy (I get those routinely, too), though it's easy to confuse the consonants.  Colposcopy:  a medical procedure to examine an illuminated, magnified view of the cervix as well as the vagina and vulva.  It's performed with a scope and a scalpel as the goal is to remove pre-cancerous or cancerous lesions from your body.  My assigned doctor was a senile, white male with a Harvard sense of superiority who did little to put me at ease.  He walked into the exam room with a gaggle of young medical residents and projected my illuminated, magnified cervix onto a large screen for the world to see.  I lay in my paper robe with my legs splayed, feeling utterly humiliated, thinking... this is not me.

I will save my daughter from that wretched predicament - the feelings of regret, embarrassment, and the health concerns that followed.  I will give her the Gardasil 9 vaccine at age eleven. There is no reason not to.  

The vaccine is extremely safe and has few side effects.  Before licensure it was evaluated in 7 unique clinical trials that enrolled over 15,000 people (including young girls and boys) and the FDA continues to collect data through its Vaccine Adverse Event Reporting System (VAERS).  To date the most common side effects are injection-site pain, redness, swelling, and headache. Some people experience dizziness after vaccination so the FDA and CDC advise clinics to monitor patients for 15 minutes following injections.

The vaccine is also highly effective.  Not only does it provide up to 100% protection against its nine target strains but U.S. data shows population-level decreases in HPV infection, pre-cancer cases, and genital warts since Gardasil was first recommended in 2006. Australia serves as a valuable reference for us, too.  The Australian government mandated HPV vaccination for young children as of 2007 and they have since seen an 80% decline in HPV infections. Australia now has one of the lowest cervical cancer incidences and mortality rates in the world.  In fact, a recent study in the Lancet projects that by 2028 fewer than four in every 100,000 women in Australia could be diagnosed annually with cervical cancer — effectively eliminating the disease as a public health problem in their country.

The U.S. does not mandate Gardasil 9 as we do other vaccines, though perhaps we should. Currently its optional for parents to protect their children against HPV, which - amidst ill-founded vaccine concerns - contributes to the low HPV vaccination rate of U.S. teens (50% in 2018).  A close friend of mine, a nurse practitioner in family medicine, says that Gardasil 9 is by far the most controversial vaccine for parents, though there's no medical reason why it should be.  Gardasil 9 is safe, has minimal side effects, and significantly reduces a child's risk of cancers and genital warts in adulthood. Gardasil 9 shouldn't give parents anxiety, it should give them comfort.

Finally, moms: Giving your child the HPV vaccine will not promote sexual promiscuity.  Nor will talking openly about sex with your children.  In fact, the opposite is true.  Studies show that kids who grow up in families where sexuality is openly discussed are healthier, happier, and they postpone participation in a range of risky behaviors including sexual activity. Deborah Roffman, child advocate and professional leader in human sexuality education says, "Decades of research demonstrates that it’s open communication at home about sexual topics that is the most significant factor in keeping teens out of harm’s way. Regardless of the prevailing cultural or social milieu, parents can be the consistent voice that helps kids make wise decisions."

So moms, discuss sex with your children early and often.  Anatomy, reproduction, crushes.  Just start.  My first talk with my son happened casually while walking our dog and spontaneously veered toward female reproduction.  My daughter got to hear about fluid-born disease after kissing a boy this summer.  Each child is different, but they all need the same information and the comfort of knowing that sex is not taboo; that they can ask you questions and rely on you for support.  When it's appropriate, discuss with your kids the facts of sexually transmitted diseases including HPV and the consequences of unprotected sex. Discuss Gardasil 9.  Vaccinate with Gardasil 9.