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HPV vaccine

 
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HPV vaccine
Vaccine description
Target disease human papillomavirus
Type Protein subunit
Identifiers
CAS number  ?
ATC code J07BM01 J07BM02
PubChem  ?
Therapeutic considerations
Pregnancy cat.

?
Legal status
Routes injection

Human papillomavirus (HPV) vaccine is a vaccine that prevents infection with certain species of human papillomavirus associated with the development of cervical cancer, genital warts,[1] and some less common cancers (e.g., anal,[2] vulvar,[3] vaginal,[3] penile[2]). Two HPV vaccines are currently on the market: Gardasil and Cervarix.[4] Both vaccines protect against two of the HPV types that can contribute to the development of cervical cancer, and some other genital cancers; Gardasil also protects against two of the HPV types that cause genital warts.[1]

Public health officials in Australia, Canada, Europe and United States recommend vaccination of young women against HPV to prevent cervical cancer and genital warts, and to reduce the number of painful and costly treatments for cervical dysplasia, which is caused by HPV.[5] Worldwide, HPV is the most common sexually transmitted infection in adults.[6] For example, more than 80% of American women will have contracted at least one strain of HPV by age fifty.[7][8][9][10][11]

Although most women infected with genital HPV will not have complications from the virus,[12] worldwide there are an estimated 470,000 new cases of cervical cancer that result in 233,000 deaths per year.[13] About eighty percent of deaths from cervical cancer occur in poor countries.[14] In the United States, most of the approximately 11,000 cervical cancers found annually[15] occur in women who have never had a Pap smear, or not had one in the previous five years.

Since the vaccine only covers some high-risk types of HPV, experts still recommend regular Pap smear screening even after vaccination.[16]

Gardasil has been shown to also be effective in males, though it has not yet been approved by the FDA to be marketed as such.[2]

Contents

Safety

Gardasil is a 3 dose (injection) vaccine. There have been 24 million doses distributed in the United States, and there have been 13,758 Vaccine Adverse Event Reporting System (VAERS) reports following the vaccination. Ninety-three percent were reports of events considered to be non-serious (e.g., fainting, pain and swelling at the injection site (arm), headache, nausea and fever), and 7% were considered to be serious (death, permanent disability, life-threatening illness and hospitalization). There is no proven causal link between the vaccine and serious adverse effects - all reports are related by time only. That is, they are only related because the effect happened some time after the vaccination.[17]

There have been 39 deaths among women who took the vaccine reported to the CDC. Six are currently under investigation, and seven are unconfirmed because of a lack of patient identification information. None of the other 26 confirmed deaths were linked to the vaccine. Guillain-Barré Syndrome (GBS), a rare disorder that causes muscle weakness, has been reported after vaccination with Gardasil. There is no evidence suggesting that Gardasil causes or raises the risk of GBS. Additionally, there have been rare reports of blood clots forming in the heart, lungs and legs. Most of those who suffered blood clots were already at risk from other factors, such as taking oral contraceptives.[17]

Based on all of the information they have today, CDC continues to recommend Gardasil vaccination for the prevention of 4 types of HPV.[17] Merck, the manufacturer of Gardasil, will continue to test women who have received the vaccine to determine the vaccine's efficacy over a lifetime.

Note: information is current as of May 1, 2009.

History

In work that was initiated in the mid 1980s, the vaccine was developed, in parallel, by researchers at Georgetown University Medical Center, the University of Rochester, the University of Queensland in Australia, and the U.S. National Cancer Institute.[18] In 2006, the U.S. Food and Drug Administration approved the first preventive HPV vaccine, marketed by Merck & Co. under the trade name Gardasil. According to a Merck press release,[19] in the second quarter 2007, it had been approved in 80 countries, many under fast-track or expedited review. Early in 2007, GlaxoSmithKline filed for approval in the United States for a similar preventive HPV vaccine, known as Cervarix. In June 2007 this vaccine was licenced in Australia, and it was approved in the European Union in September 2007.[20]

Therapeutic HPV vaccines

In addition to preventive vaccines, such as Gardasil and Cervarix, laboratory research and several human clinical trials are focused on the development of therapeutic HPV vaccines. In general these vaccines focus on the main HPV oncogenes, E6 and E7. Since expression of E6 and E7 is required for promoting the growth of cervical cancer cells (and cells within warts), it is hoped that immune responses against the two oncogenes might eradicate established tumors.[21]

Prevalence of genital HPV

United States

See also: HPV: Prevalence of Genital HPV

According to the Centers for Disease Control and Prevention, by the age of 50 more than 80% of American women will have contracted at least one strain of genital HPV.[22] Both men and women can be carriers of HPV.[23] HPV is the most common sexually transmitted infection in the US.[22] A large percentage of the American population is infected with genital HPV[24] because HPV is highly communicable. As a result, American public health experts recommend widespread HPV vaccination.[25]

Only a small percentage of women with HPV develop cervical cancer.[26] Each year, between 250,000 and 1 million American women are diagnosed with cervical dysplasia, which is caused by HPV and is a potential precursor to cervical cancer.[27] About 11,000 American women are diagnosed with cervical cancer every year, and about 3,700 die per year of the disease.[15] Most cancers occur in those who have not had Pap smears within the previous five years.

HPV-induced cancers

There are 19 "high-risk" HPV types that can lead to the development of cervical cancer or other genital/anal cancers; some forms of HPV, particularly type 16, have been found to be associated with a form of throat cancer.[28] Studies have found that human papillomavirus (HPV) infection is responsible for virtually all cases of cervical cancer.[26][29]

Condoms protect against HPV, but do not completely prevent transmission.[30][31][32] College freshmen women who used condoms consistently had a 37.8% per patient-year incidence of genital HPV, compared to an incidence of 89.3% among those who did not.[30][31][32]

No data is kept by the U.S. government on genital wart infection rates,[33] however it is estimated that 20 million people are presently infected with genital warts, and there are six million new cases of genital warts every year in the United States.[34]

Worldwide

Worldwide, cervical cancer is the fifth most deadly cancer in women.[35] There are an estimated 470,000 new cases of cervical cancer, and 233,000 deaths per year.[13]

Vaccination and public health

Gardasil is available poster for a university health clinic

According to the American National Cancer Institute, "Widespread vaccination has the potential to reduce cervical cancer deaths around the world by as much as two-thirds, if all women were to take the vaccine and if protection turns out to be long-term. In addition, the vaccines can reduce the need for medical care, biopsies, and invasive procedures associated with the follow-up from abnormal Pap tests, thus helping to reduce health care costs and anxieties related to abnormal Pap tests and follow-up procedures."[16]

Current preventive vaccines protect against the two HPV types (16 and 18) that cause about 70% of cervical cancers worldwide.[36] Because of the distribution of HPV types associated with cervical cancer, the vaccines are likely to be most effective in Asia, Europe, and North America.[36] Vaccines that protect against more of the types common in cancers would prevent more cancers, and be less subject to regional variation.[36]

Only 41% of women with cervical cancer in the developing world are able to access medical treatment for their illness.[37] Therefore, prevention of HPV by vaccination may be a more effective way of lowering the disease burden in developing countries than cervical screening.[citation needed] However, individuals in many resource-limited nations, Kenya for example, are unable to afford the vaccine.[38]

Vaccine target populations

Gardasil and Cervarix are preventative vaccines and do not have efficacy for treating active HPV infection. They are recommended for women who are 9 to 25 years old and have yet to contract HPV. However, since it is unlikely that a woman will have already contracted all four viruses, and because HPV is primarily sexually transmitted, the U.S. Centers for Disease Control and Prevention has recommended vaccination for women up to 26 years of age.

When Gardasil was first introduced, it was recommended as a prevention for cervical cancer for women that were 25 years old or younger. New evidence suggests that all Human Papillomavirus (HPV) vaccines are effective in preventing cervical cancer for women up to 45 years of age.[39]

In November 2007, Merck presented new data on Gardasil. In an investigational study, their HPV vaccine reduced incidence of HPV 6, 11, 16 and 18-related persistent infection and disease in women through age 45. The study evaluated women who had not contracted at least one of the HPV types targeted by the vaccine by the end of the three-dose vaccination series. Merck planned to submit this data before the end of 2007 to the U.S. Food and Drug Administration (FDA), and to seek an indication for Gardasil for women through age 45.[40]

Vaccination during pregnancy

In the Gardasil clinical trials, 1,115 pregnant women received the HPV vaccine. Overall, the proportions of pregnancies with an adverse outcome were comparable in subjects who received Gardasil and subjects who received placebo.[41] However, the clinical trials had a relatively small sample size. Currently the vaccine is not recommended for pregnant women.[1] The long-term effects of the vaccine on fertility are not known, but no effects are anticipated.

Vaccination of males

Gardasil can also be used in males to reduce their risk of genital warts and precancerous lesions caused by HPV.[2] The reduction in precancerous lesions is expected to reduce the rates of penile and anal cancers in men.[2] Since penile and anal cancers are much less common than cervical cancer, HPV vaccination of young men is likely to be much less cost-effective than for young women.[42] From a public health point of view, vaccinating men as well as women might be useful if it decreased the virus pool within the population. Gardasil is in particular demand among gay men, who are at significantly increased risk for genital warts, penile cancer, and anal cancer.[43]

As with females, the vaccine must be administered before infection with the HPV types covered by the vaccine occurs. Vaccination before adolescence makes it more likely that the recipient has not been exposed to HPV.

In the UK, HPV vaccines are licensed for boys aged 9–15.[44] Merck, the maker of Gardasil, is expected to ask the FDA for permission to market the vaccine in the United States for boys and men ages 9–26.[2] The vaccine is already available in the United States and can be used off label for the vaccination of males.[2]

Mechanism of action

The latest generation of preventive HPV vaccines is based on hollow virus-like particles (VLPs) assembled from recombinant HPV coat proteins. The vaccines target the two most common high-risk HPVs, types 16 and 18. Together, these two HPV types currently cause about 70 percent of all cervical cancer.[36] Gardasil also targets HPV types 6 and 11, which together currently cause about 90 percent of all cases of genital warts.[26]

Gardasil and Cervarix are designed to elicit virus-neutralizing antibody responses that prevent initial infection with the HPV types represented in the vaccine. The vaccines have been shown to offer 100 percent protection against the development of cervical pre-cancers and genital warts caused by the HPV types in the vaccine, with few or no side effects. The protective effects of the vaccine are expected to last a minimum of 4.5 years after the initial vaccination.[45]

While the study period was not long enough for cervical cancer to develop, the prevention of these cervical precancerous lesions (or dysplasias) is believed highly likely to result in the prevention of those cancers.[46]

Although a 2006 study suggests that the vaccines may offer limited protection against a few HPV types that are closely related to HPVs 16 and 18, there are other high-risk HPV types are not affected by the vaccines.[45] Ongoing research is focused on the development of HPV vaccines that will offer protection against a broader range of HPV types.[47] There is also substantial research interest in the development of therapeutic vaccines, which seek to elicit immune responses against established HPV infections and HPV-induced cancers.

Vaccine implementation

Main article: vaccination policy

In developed countries, the widespread use of cervical "Pap smear" screening programs has reduced the incidence of invasive cervical cancer by 50% or more. Current preventive vaccines reduce, but do not eliminate the chance of getting cervical cancer. Therefore, experts recommend that women combine the benefits of both programs by seeking regular Pap smear screening, even after vaccination.[48]

Australia

Commencing in 2007 The Australian federal government began funding a voluntary program to make the Gardasil vaccine available free of charge to women aged 12–26 for a period of two years, with an ongoing vaccination program for 12- and 13-year-olds as part of the pre-existing high school vaccination program.[49][50]

The Australian government and the PBS (Pharmaceutical Benefits Scheme) have approved the vaccine for use and in 2007 began a nationwide vaccination program free of charge to schoolgirls in years 7 to 12. These programs are run by local councils with funding and vaccine supplies from the government. The subsidization approval process, however, appears to have been heavily influenced by political interference from politicians of all political parties, and by the Prime Minister who publicly advised that it would be approved (before approval). In addition, women between 18 and 26 years of age at the time of the first dose may receive the vaccine for free upon request from their general practitioner. After June 2009, the program will be scaled down to 12- and 13-year-old girls only. Australia also approved Gardasil for boys 9–15 years old, but Australia is not providing government funding for vaccinating boys.[51][52]

Canada

Canada has approved use of Gardasil[53]. Initiating and funding free vaccination programs has been left to individual Province/Territory Governments. In the provinces of Ontario, Prince Edward Island, Newfoundland and Nova Scotia,[54] free vaccinations to protect women against HPV were slated to begin in September 2007 and will be offered to girls ages 11–14. Similar vaccination programs are being planned in British Columbia and Quebec.[55][56][57]

France

On July 17, 2007, France issued a directive[58] authorizing state-aided voluntary vaccination for girls aged 14–23 years who have not yet become sexually active, or have been sexually active for less than a year. The state refunds 65% of the cost, based on a program of 3 vaccinations at €135 (slightly less than $200) per shot, meaning that the patient covers €141.75 (slightly more than $200).

Germany and Italy

On March 26, 2007, early approval for Gardasil vaccinations was granted in both Germany and Italy.[59]

Greece

On February 12, 2007, Greece made HPV vaccination mandatory for girls entering gymnasion (7th grade). All vaccines including hepatitis B are mandatory and are supplied free to everyone in Greece, with parents being allowed to opt out of vaccinating their kids. Cervarix and Gardasil are supplied free to all girls and women between the ages of 12 and 26.[60][61]

Kenya

Both Cervarix and Gardasil are approved for use within Kenya by the Pharmacy and Poison's Board. However at a cost of 20,000 Kenyan shillings, which is more than the average annual income for a family, the director of health promotion in the Ministry of Health, Nicholas Muraguri, states that many Kenyans are unable to afford the vaccine.[38]

Romania

In Novermber 2008, Romanian authorities launched a campaign to vaccinate 110,000 girls aged 10 and 11. The Ministry of Health acquired 330,000 vaccine doses for $23 million euros. By an order of the Ministry, the girls' parents must approve or reject the vaccination in writing, and must "fully assume the consequences for their children" if they reject the vaccination.[62]

New Zealand

From September 2008, Gardasil will be available for New Zealand girls and young women born in 1990 and 1991 through primary care and from 2009, the HPV immunization program will be part of the regular immunization schedule for 12-year-old girls.[citation needed][63]

South Korea

On July 27, 2007, South Korean government approved Gardasil for use in girls and women aged 9 to 26 and boys aged 9 to 15.[64] Approval for use in boys was based on safety and immunogenicity but not efficacy.

Sweden

In Sweden, starting January 1, 2010, girls born in the year 1999 or later and in the ages 10 to 12 can receive a free HPV vaccine.[65]

United Kingdom

In the UK the vaccine is licensed for girls and boys aged 9 to 15 and for women aged 16 to 26.[44]

HPV vaccination will be introduced into the national immunisation programme in September 2008, for girls aged 12–13 across the UK. Then, starting in autumn 2009, a two-year catch up campaign will vaccinate all girls up to 18 years of age. This catch up campaign will offer to vaccinate:

  • girls aged between 16 and 18 from autumn 2009, and
  • girls aged between 15 and 17 from autumn 2010.

By the end of the catch up campaign, all girls under 18 will have been offered the HPV vaccine.

When the HPV vaccination programme begins in 2008, women over the age of 18 will not be vaccinated as it would not be cost effective in preventing cervical cancer. This is because as soon as a woman becomes sexually active, she is at risk of infection with the virus.

It will be many years before the vaccination programme has an effect upon cervical cancer incidence so women are advised to continue accepting their invitations for cervical screening.[66]

United States

As of late 2007, about one quarter of US females age 13–17 years had received at least one of the three HPV shots.[67]

Legislation

Opt-out policies

Almost all pieces of legislation currently pending in the states that would make the vaccine mandatory for school entrance have an "opt-out" policy.[68]

State-by-State
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Last update: This section needs to be updated as the NCSL Updated their website on November 4, 2008

Other states are also preparing bills to handle issuing the HPV Vaccine.[68]

State Proposal Status Opt Out Policy
Alaska Voluntary vaccination program Passed N/A
California Bill would have required girls entering the sixth grade to be vaccinated. Withdrawn for further consideration. Yes
Colorado Bill would require 12-year-old girls to be vaccinated to attend school. Pending Yes
Connecticut Bill would require girls receive a first dose of the vaccine before entering the sixth grade. Allows parents to opt their daughters out on medical or religious grounds. Pending Yes
District of Columbia Bill would require girls to be vaccinated before they turn 13 to attend school. Pending Yes
Florida Bill would have required 11- and 12-year-old girls to be vaccinated to attend school. Died in committee Yes
Georgia Bill would require girls entering the sixth grade to be vaccinated unless parents can't afford the vaccine or object to it on medical or religious grounds. Died in Committee Yes
Illinois Bill would require girls entering the sixth grade to be vaccinated. Pending Yes
Kansas Bill would require girls entering the sixth grade to be vaccinated. Allows parents to opt their daughters out on medical or religious grounds. Pending Yes
Kentucky Bill would require girls entering middle school to be vaccinated. Passed House, to Senate Yes
Maryland Bill would have required girls entering the sixth grade to be vaccinated. Withdrawn Yes
Massachusetts Bill would require girls entering the sixth grade to be vaccinated. Allows parents to opt their daughters out on religious grounds. Pending Yes
Michigan Bill would require girls entering the sixth grade to be vaccinated. Pending. Yes
Missouri Bill would require girls entering the sixth grade to be vaccinated. Allows parents to opt their daughters out on medical or religious grounds. Pending Yes
Minnesota Bill would require 12-year-old girls to be vaccinated to attend school. Pending Yes
Mississippi Bill would have required girls entering the sixth grade to be vaccinated. Died. Sponsor planning to re-introduce it with an opt-out clause. No
Nevada Bill would require health insurance companies to cover the cost of the vaccine Passed into law N/A
New Hampshire Voluntary program provides vaccine free of charge to girls between the ages of eleven and eighteen. Passed and presently in effect. Yes
New Jersey Bill would require girls in grades seven through 12 to be vaccinated. Allows parents to opt their daughters out on medical or religious grounds. Pending Yes
New Mexico Bill would require nine- to 14-year-old girls to be vaccinated to attend school. Passed legislature. Vetoed by governor. Yes
Ohio Bill would require girls entering the sixth grade to be vaccinated. Pending Yes
Oklahoma Bill would require girls entering the sixth grade to be vaccinated. Pending Yes
South Carolina Bill would require girls entering the seventh grade or 11 years of age to be vaccinated. Allows parents to opt their daughters out on medical or religious grounds. Pending Yes
Texas Governor issued executive order requiring that girls entering the sixth grade be vaccinated. Texas legislature overrode executive order and barred mandatory vaccination until at least 2011. Yes
Vermont Bill would require girls entering the sixth grade to be vaccinated. Allows parents to opt their daughters out on medical, moral or religious grounds. Pending Yes
Virginia Bill requires girls entering the sixth grade to be vaccinated. Passed the legislature. Goes into effect Oct. 1, 2008; to be implemented in fall of 2009. Yes
West Virginia Bill would require girls entering the sixth grade to be vaccinated. Allows parents to opt their daughters out on medical grounds. Died Yes

Source: National Conference of State Legislatures, state legislatures

Immigrants

All vaccines recommended by the U.S. government for its citizens are required for green card applicants. Therefore HPV vaccine is required for young women seeking to immigrate to the United States. This requirement has also stirred controversy because of the cost of the vaccine, and because all the other vaccines so required prevent diseases which are spread by respiratory route and considered highly contagious.[69]

Opposition in the United States

Main article: Vaccine controversy

Health insurance companies

There has been significant opposition from health insurance companies to covering the cost of the vaccine ($360).[70][71][72]

Religious right and conservative groups

Several conservative groups in the U.S. have publicly opposed the concept of making HPV vaccination mandatory for pre-adolescent girls, asserting that making the vaccine mandatory is a violation of parental rights. They also say that it will lead to early sexual activity, giving a sense of immunity to sexually transmitted disease. Both the Family Research Council and the group Focus on the Family support widespread (universal) availability of HPV vaccines but oppose mandatory HPV vaccinations for entry to public school.[73][74][75][76]

Many organizations disagree with the argument that the vaccine increases sexual activity among teens. Dr. Christine Peterson, director of the University of Virginia's Gynecology Clinic, said "The presence of seat belts in cars doesn't cause people to drive less safely. The presence of a vaccine in a person's body doesn't cause them to engage in risk-taking behavior they would not otherwise engage in." [77]

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  51. ^ Poljak, Vesna; Daley, Gemma (2006-11-29). "Australia to Subsidize Merck Cervical Cancer Vaccine (Update3)". Bloomberg. http://www.bloomberg.com/apps/news?pid=20601081&sid=adOT2d961UKo&refer=australia. Retrieved on 2007-01-26. 
  52. ^ The Department of Health and Ageing (2007-08-13). "The National HPV Vaccination Program - Frequently Asked Questions for Young Women". http://www.health.gov.au/internet/standby/publishing.nsf/Content/young-women-faq. Retrieved on 2007-09-28. 
  53. ^ Human Papillomavirus (HPV) Prevention and HPV Vaccine: Questions and Answers
  54. ^ HPV Immunization Launched
  55. ^ "McGuinty Government Launches Life-Saving HPV Immunization Program:". Premier of Ontario. 2007-08-02. http://www.premier.gov.on.ca/news/Product.asp?ProductID=1552&Lang=EN. Retrieved on 2007-12-02. 
  56. ^ "HPV Immunization Launched". Province of Nova Scotia. 2007-06-20. http://www.gov.ns.ca/news/details.asp?id=20070620002. Retrieved on 2007-12-02. 
  57. ^ "British Columbia To Launch Program To Provide HPV Vaccine to Sixth-Grade Girls Next Fall if Approved, Official Says". Kaiser Daily Women's Health Policy (Kaiser Family Foundation). 2007-08-09. http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=46766. Retrieved on 2007-12-02. 
  58. ^ "Gardasil authorised for subsidised vaccination". French govt news release (in French). 2007-12-31. http://www.service-public.fr/actualites/00589.html. Retrieved on 2007-12-31. 
  59. ^ Fagbire, OJ (2007-03-26). "Gardasil, Merck HPV Vaccine, Gets German And Italian Approval For Girls". Vaccine Rx. http://www.vaccinerx.com/news/cervical-cancer/gardasil-merck-hpv-vaccine-gets-german-and-italian-approval-for-girls-20070326-149-26.html. Retrieved on 2007-03-27. 
  60. ^ fskilkis.gr - Tο εμβόλιο κατά του καρκίνου τραχήλου της μήτρας και Cervarix vs Gardasil , Φαρμακευτικός Σύλλογος Κιλκίς (Pharmacy Association of Kilkis).
  61. ^ iatronet.gr - Υγεία / Γυναικολογία - Μαιευτική / Καρκίνος του τραχήλου της μήτρας / Ο εμβολιασμός κατά του HPV στην Ελλάδα
  62. ^ (Romanian) Claudia, Marcu (21 November, 2008) "100.000 de fetiţe, injectate cu un vaccin controversat" (100,000 girls injected with a controversial vaccine) Gândul
  63. ^ http://www.cervicalcancervaccine.govt.nz/questions_and_answers.php#info_girls
  64. ^ "가다실 제품 허가 공지". 2007-06-27. http://www.msd-korea.com/content/corporate/news/announcement/company22-gardasil.html. Retrieved on 2007-08-06. 
  65. ^ "Information om det allmänna barnvaccinationsprogrammet" (in Swedish). Smittskyddsinstitutet. http://www.smittskyddsinstitutet.se/hem/mest-efterfragat/allmanna-vaccinationsprogrammet/. Retrieved on 2009-05-06. "Den 1 januari 2010 införs vaccin mot Humant papillomvirus (HPV) i programmet för flickor, födda 1999 eller senare, som skydd mot livmoderhalscancer orsakad av HPV." 
  66. ^ "NHS Cervical Screening Program". http://www.cancerscreening.nhs.uk/cervical/index.html. Retrieved on 2008-06-26. 
  67. ^ "1 in 4 US teen girls got cervical cancer shot". http://www.washingtonpost.com/wp-dyn/content/article/2008/10/09/AR2008100901452.html?sub=new. Retrieved on 2008-10-12. 
  68. ^ a b HPV Vaccine
  69. ^ MIRIAM JORDAN. "Gardasil Requirement for Immigrants Stirs Backlash". The Wall Street Journal. http://online.wsj.com/article/SB122282354408892791.html?. Retrieved on 2009-01-15. 
  70. ^ HPV Vaccine - Why Your Doctor Doesn't Offer the HPV Vaccine - Gardasil
  71. ^ Public Health & Education Detroit News Examines Cost of HPV Vaccine Gardasil - Kaisernetwork.org
  72. ^ A question of protection
  73. ^ Sprigg, Peter (2006-07-15). "Pro-Family, Pro-Vaccine — But Keep It Voluntary". The Washington Post. http://www.washingtonpost.com/wp-dyn/content/article/2006/07/14/AR2006071401532.html. Retrieved on 2007-02-04. 
  74. ^ Coyne, Brendan (2005-11-02). "Cervical Cancer Vaccine Raises 'Promiscuity' Controversy". The New Standard. http://newstandardnews.net/content/index.cfm/items/2552. Retrieved on 2006-08-28. 
  75. ^ Family Research Council: Thursday, February 7, 2008 "IF07B01"
  76. ^ Focus on the Family Position Statement: Human Papillomavirus Vaccines
  77. ^ "Lifesaving Politics." Ms. Magazine. pp 12–13. Spring 2007.

External links

Information about the HPV and vaccination

Major media coverage

Organizations in favor of vaccination

Organizations opposed to vaccination

 The examples and perspective in this article may not represent a worldwide view of the subject. Please improve this article or discuss the issue on the talk page.
v • d • e
Papillomavirus - Human papillomavirus
Related
diseases
Vaccine
HPV vaccine (Gardasil, Cervarix)
Screening
Colposcopy
Biopsy histology
Treatment
History
v • d • e
Artificial induction of immunity / Immunization: Vaccines, Vaccination, and Inoculation (J07)
Development
Administration
Global: GAVI Alliance · Policy · Schedule · Vaccine injury
USA: ACIP · VAERS · VSD · Vaccine court
Vaccines
Bacterial
Viral
Protozoan
Other
Controversy
See also

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