Wednesday 12 October 2016

HPV collateral damage

Last week in September was multi-post week on blood, Rhesus, anti-D and hepatitis C I - II - III - IV. This week we're onto another controversial health intervention. Human Papilloma Virus HPV, anti-HPV and cancer. I - II.
The analysis so far of the profit and loss of HPV immunisation has not yet taken account of the collateral damage. The girls who have experienced adverse effects shortly after getting their HPV shots. I've deleted the shortly because the time-line for association can be months down the line.The news last week was about the uptake of the [free] vaccine falling from 87% in 2013 to 70% last year. This is probably on foot of media coverage of the adverse effects giving parents the same wobblies as we experienced about MMR in 1976. Some of the parents of these affected girls have gotten together to raise awareness, compare notes and get redress for the tragedy that has devastated their homes and families. Their organisation has got itself a shocking name "Reactions and Effects of Gardasil Resulting in Extreme Trauma" REGRET and a website.  Like your approach to literature from National Immunisation Office and Merck, you need to put on your skeptical hat when assessing the information put out by REGRET. William Campbell claims that they are wilfully misreading the evidence to agree with their own certainty.

We've had a case of willful mis-reading of the evidence aka cooking the lab-books over vaccination before. In 1998, Dr Andrew Wakefield published a report on an association between MMR vaccination and autism which was widely, even jubilantly, reported by the common press.  It was subsequently found that Wakefield had faked / massaged /sexed-up his data to push the association into statistical significance. The paper was subsequently retracted. That retraction wasn't news and so only appeared, if at all, on page 5 in small print. The hullabaloo seeded Joe Public's mind with the idea and the anti-vax movement really started to rock-and-roll. That could be bad from two angles:

  • reducing the number of measles-vaccinated children will increase the susceptible herd, and a measles outbreak becomes more likely to propagate. Measles is no fun even if you don't end up blind, convulsed or dead.  Dau.I contracted mumps [after vaccination] when she attended a middle class Summer School in DCU where a large enough proportion of the teens had not been vaccinated.
  • by fingering the wrong culprit we go off the boil in trying to find the true cause of the epidemic in autism . . . first off, of course, we have to establish whether there is, or has been, such an epidemic rather than it's just that doctors are now recognising, diagnosing and reporting more cases.

The Gardasil information page put out by the FDA after consultation with the CDC lists all the adverse events that have come to them through  Vaccine Adverse Event Reporting System VAERS. It reads like the time-worn advice never to browse a medical encyclopedia: "local injection site reactions, syncope, dizziness, and nausea, headaches, hypersensitivity reactions, such as rashes, hives, itching, anaphylaxis, Guillain-Barré syndrome (GBS), transverse myelitis, motor neuron disease, venous thromboembolic events (VTEs), pancreatitis, autoimmune disorders, pregnancy, and death". Surely the outcome 'pregnancy' after a course of injections is based on confusion about what got poked into where? The position of Dr Corcoran and the HSE is that we have not seen a spike in incidence for any of these events. If there is something generally wrong with Gardasil or Cervarix, and 30,000 young girls get exposed to it every year for several years, you'd have to see the effects. But neither in USA, with 100x the population, nor in Ireland have we seen more moodiness, lethargy, painful wrists, rashes or whatever you're having yourself  in the teenage girl cohort.

The thing is that puberty is a time of change. The hormonal tsunami, the spots, the tuftiness down there; exposure to a larger and more diverse / diseasy population in secondary school; the difficulties of creating a separate identity from your parents; the expense of adopting an identical identity to your peer group. Just look at the hormone aspect: estrogen does a lot more than make breasts develop [in Alan Turing for example]. We only have a few hormones and a few hormone receptors [part of the 100,000 strong complement of proteins we make on a daily basis] and an immensely complex [100 trillion cells!] organism, so all the actors have many parts to play. Why just last night I read in IFLS a piece associating The Pill [=hormones] with Depression [or at least anti-depressants]. And, if the epidemiology of osteoporosis tells us anything, then estrogen has something to do with maintaining bone-density. Not everyone is able to regulate the flood of new hormones equally well and the difference can manifest in peculiar ways. There is likely a genetic component, so if your older sister gets horrendous period pains, you may have to brace yourself for similar. There are 10,000 Irish cases of chronic fatigue syndrome, for example, but it's no more common now than it was before-Gardasil; except in the sense that the population is larger because the economy is picking up and a) the diaspora are drifting home b) couples are trying for a family.

It seems like REGRET have mustered about 400 families with teenage girls who a) had the Gardasil b) had various crappy outcomes. It is not beyond the bounds of possibility that some of these girls have a peculiar / particular genetic make-up for which HPV acts as a trigger. Like a taste of Campylobacter jejuni, from a dodgy chicken nugget, develops, in a tiny fraction of cases, into Guillain-Barré syndrome. You should re-read that piece because it reviews the association between the Pandemrix 'flu-jab and nacrolepsy. The data there look pretty convincing that you're about 15x more likely to experience narcolepsy if you have the jab than if you don't BUT in neither case is that condition at all common. Some of the REGRET cases would have happened anyway but it is also unlikely that none of them are due to being insulted with proteins derived from HPV. You the parent have got to assess the balance between these two extremes. That will be difficult if you think, along with most people as the Minister of Finance announces the 2017 Budget, that a billion is about twice as big as a million.

If we had achieved the socialist paradise proclaimed by St Padraig of Pearse in 1916 then we would be "cherishing all the children of the nation equally". But that fine aspiration never made it into the Constitution. We have become instead a nation ruled by the adversarial system of the courts. IF you want help with raising children who are too much for any family to cope with; or you want a level playing field to minimise the difficulties which your child experiences THEN you have to prove culpable negligence on somebody's part. Look at the anti-D cohort of women, they had to fight their elected representative and the apparatus of the state to get the acknowledgment and support they deserved.

Is it worth investing a couple of million €€€s in a retrospective study of the genetic make up of the REGRET 400?  Probably not, because the sample [each a tragedy is acknowledged] is too small to achieve an unequivocal result. Too small? = too noisy: the some vs none argument two paras above suggests that many of the girls will have a different cause for their troubles and of those which are genuinely HPV-sensitive, each could be due to a raddle of different genetic / biochemical causes. The only useful outcome would be pharmacogenetic. That's the idea of tailored medicine: drugs only given to those who will respond.  It's unlikely that there will ever be a black&white pre-HPV-jab test that will say: you really shouldn't have this treatment; it will be less risky for you to dice with cervical cancer later.

If you have a teenage daughter [or son, they help spread HPV16 because it takes two to tango], you should put aside the suspicion that Big Pharma is driven by profit; that government cares less about the welfare and future of citizens than getting elected next time round; that your kidder will be among the 98% won't get cervical cancer and you'll be dead before she does . . . and sign the consent form.

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