HPV-related book reviews

"HPV Vaccine On Trial"

The book "HPV Vaccine On Trial", written by three longtime anti-vaccine activists, is a troubling and tedious rehash of current antivaccine talking points.

I and two other science communicators are reviewing it as a team:

Dorit Reiss, a professor of law who specializes in vaccine-related issues, contributed a review entitled "HPV vaccine fear mongering in an anti-vax book".
John Kelly, a career biochemist, and molecular biologist and a survivor of HPV+ cancer, is also writing a review, and I'll link to it here anon.
Me, Dan Kegel (here's my bio); my review follows below.

Adding balance to a lopsided 'trial'

Vaccine opponents often advise parents to "Read the insert!" Let's do that with the book. It begins with the following disclaimer:

"This book contains the opinions and ideas of its authors. It is a source of information only and does not constitute medical, legal, or other advice to the individual reader. Neither the authors nor the publisher are liable or responsible for any injury, loss, or damage allegedly arising from this book."

In other words, following the advice in the book can be fatal. Caveat lector, indeed!

The authors purport to put the vaccine on trial for the charges of being unsafe, ineffective, and unnecessary. Yet, unlike in a real trial, they never give the defendant -- in this case, the vaccine -- a chance to tell its side of the story. Predictably, the authors conclude that the defendant is guilty of all charges. What other verdict could such a one-sided trial reach?

Someone needs to speak for the defendant, so let's provide the book's missing chapter. I happily grant permission to the authors to include it verbatim in future editions of the book.

Part V: The Defence Speaks

The prosecution freely admits that they have no scientific expertise. Indeed, from a scientific point of view, nearly every page of their work rings false; their case seems to avoid presenting actual physical evidence, and appears to consist entirely of hearsay and circumstantial evidence, with a good helping of suspicion, fear, and distrust. So let's review the physical evidence here. We will show that the vaccine is a better solution to a serious health problem than was previously available, and that the observed health benefits so far already outweigh the observed risks.

Chapter 30: The health problem to be solved

The book's Chapter 4, billed as 'a primer on cervical cancer', neglects to mention a significant fact: cervical cancer makes up less than half of the cancer cases caused by HPV in North America [ https://www.ncbi.nlm.nih.gov/pubmed/28369882 ]. What a magnificent and efficient technique to minimize a problem - simply ignore most of it!

HPV causes a variety of cancers, and the book focuses on cervical cancer. Cervical cancer screening programs have been somewhat effective at preventing cervical cancer, though the book overstates that effectiveness. About three quarters of all women are up to date on screening, yet these women account for just under half of all cervical cancer cases [ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5840841, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3457878/ ]). Just as important, though, no general screening is currently effective or recommended to prevent other HPV-caused cancers (anal, head and neck, penile, and vulvar) [ https://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations ].

Even including the effect of screening, the lifetime risk of an HPV-caused cancer in the US is about 1 in 71 for women, and 1 in 110 for men [ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4911256/ ].

And that's a problem. If schoolteachers can remember the names of 71 girls, it's hard to say that HPV-caused cancer is rare, even with available screening. Indeed, if there's a better way to prevent it, it's our moral obligation to pursue it.

Chapter 31: The vaccine's measured effectiveness

The very first thing the vaccine should prevent is, of course, HPV infections. It does this very well indeed; for instance, in Australia, Norway, and England, vaccine-type HPV has fallen by about 80% among young women ( http://www.ncbi.nlm.nih.gov/pubmed/29425358 http://www.ncbi.nlm.nih.gov/pubmed/29917082 http://www.ncbi.nlm.nih.gov/pubmed/30010913 ).

The next thing the vaccine should prevent is precancerous lesions. Multiple studies show it does this well, too; in Connecticut, Northern California, and Australia, serious precancerous lesions have fallen by 75% in women under 20, by about half in women 20-25, with an upwards trend ( http://www.ncbi.nlm.nih.gov/pubmed/28520854, http://www.ncbi.nlm.nih.gov/pubmed/30236379, http://www.vccr.org/site/VCCR/filesystem/documents/dataandresearch/StatisticalReports/17030_VCS_StatsReport15_ART.3.pdf ).

Finally, the vaccine should effectively reduce cases of cervical cancer. Because the disease usually takes many years to develop, clinical trials measuring this in young women weren't expected to reach statistical significance until 2022. Happily, though, early results indicate this is happening as expected; a Finnish study found zero cases of cervical cancer in 9,529 vaccinated women vs. ten cases in 17,838 unvaccinated women ( https://www.ncbi.nlm.nih.gov/pubmed/29280138 ). Also, a study of cervical cancer in US women to age 24 found rates in 2011-2014 were 29% lower than in 2003-2006 ( https://www.ncbi.nlm.nih.gov/pubmed/29859731 ).

A long-term followup study found that protection lasts at least ten years ( https://www.ncbi.nlm.nih.gov/pubmed/29029053 ), despite a waning of detectable antibodies to HPV18.

Modeling indicates most HPV infections that lead to cervical cancer probably occur before age 22, which means vaccinating at age 12 reduces lifetime risk of HPV-caused cancer by over half even if the vaccine only protects for 20 years. [ https://www.ncbi.nlm.nih.gov/pubmed/28531261 ].

Whew! That's a mouthful - it took 200 whole words to describe the vaccine's effectiveness.

So, how well did the book do at presenting this evidence? Although it promised "a clear and concise description of the effectiveness of the HPV vaccine", mostly, it avoids the topic. Chapter 4 devotes just a few lines to this, and fails to give any data from the above studies, hiding the only discussion of them away in a footnote... and concludes by misleadingly saying the long-term effectiveness is unknown.

Chapter 32: The vaccine's measured risks

[ to be continued ]