HPV vaccine | Imamother

amother

Phlox

Tue, Jun 22 2021, 11:42 am

A group of Orthodox Jewish healthcare providers have written in to Mishpacha Magazine following a recent Anti-Vaccine column featured in the magazine regarding the HPV vaccine.

The author claimed that:

1. Orthodox Jewish people aren’t at risk for the HPV virus
2. The vaccine isn’t safe
3. The virus can be prevented via less invasive methods
4. The vaccine doesn’t work.

Here are the Physicians and Nurses responses:

Dear Mishpacha Editor,

As pediatricians, we were deeply dismayed by the recent opinion piece by Yonoson Rosenblum, “A Shot In The Dark.” During the recent measles outbreak in New York, we learned that some of our frum communities had inadequate access to accurate information about vaccines. They were therefore more vulnerable to misconceptions and inaccuracies spread by both “anti-vaxxers” and other misinformed community members. We have been working hard since then to try to make reliable and accurate vaccine information available to our frum communities.

Unfortunately, Mr. Rosenblum’s piece contains significant fallacies and misrepresentations about the HPV vaccine. Contrary to Mr. Rosenblum’s assertions, the vaccine is no longer so new – it was approved initially in 2006, but clinical trials had started back in 1997. The HPV virus can cause cancer- 99% of cervical cancers are caused by it – but also genital warts (100%), backside cancer (90%), throat cancer (70%), and recurrent respiratory papillomatosis, which can occur in babies born to mothers with HPV. HPV may also be involved in other diseases, including nonsmokers’ lung cancer. The current HPV vaccine protects against 9 types of HPV, covering the ones which cause most of the cancers. HPV causes about 35,000 cancers per year in the US, and the HPV vaccine can prevent 90% of these cancers. HPV is a very common virus. There are about 79 million Americans who are currently infected with HPV, and every year, about 14 million more become infected with it. About 80% of s-xually active people have been exposed to HPV. HPV infections initially do not cause any symptoms, and although the body can sometimes clear it, if the infection persists, it can cause precancerous and then cancerous changes over a long period, sometimes more than 20 years.

Although “following a chaste and monogamous Torah life” can significantly decrease the chance of getting an HPV infection, significant risk remains. Unlike many other infections that we tend to associate with intimate contact, the HPV virus is too common not to pose an ongoing threat to us all. It is not just for “high risk” people. Furthermore, the frum community is not immune to behaviors and circumstances that put its members at risk of contracting HPV. While we all strive to follow Torah law and raise our children to do so as well, there are still community members who make mistakes. It would be tragic for them to suffer permanent harm from HPV infection, even if they are able to do teshuva and rejoin the fold. There are also ba’alai teshuva who become integral members of our communities. They, and their spouses, also deserve protection from the errors of their youth. Finally, no matter how vigilant we are in protecting our children, some of them do come into harm’s way. As physicians, we have both, rachman litzlan, treated frum children who were the victims of s-xual abuse or molestation. These children have so many injuries, both physical and spiritual, to heal from; HPV infection should not have to be one of them. The Torah tells us to follow a modest lifestyle (וְהַצְנֵעַ לֶכֶת, עִם-אֱלֹהֶיךָ), and we must all do our best to do so. However, the Torah also tells us to take all necessary precautions to keep ourselves safe (וְנִשְׁמַרְתֶּ֥ם מְאֹ֖ד לְנַפְשֹׁתֵיכֶ֑ם). Vaccines, including the HPV vaccine, are an important way for us to do so.

Pap screens (and the new HPV test) are certainly essential parts of preventive healthcare for every woman, but they are NOT an acceptable alternative to the vaccine. Pap smears allow early detection of HPV infection, but do nothing to prevent or treat it. Preventing infection by the virus is much better than detecting it! It is important to do everything we can to prevent HPV transmission, including following a Torah lifestyle and getting the HPV vaccine, as well as continue ongoing screening in order to initiate early treatment should an infection still occur. We need both – the vaccine and the testing.

The HPV vaccine is extremely safe, and much less invasive than the treatments for HPV-induced cancers, which can require surgeries, chemotherapy, and radiation. There is no actual evidence that the HPV vaccine increases cervical cancer‫ ‬(the one recent paper to even suggest this was retracted for inaccuracies and questionable practices in data collection and analysis, as discussed below), and there is plenty of evidence that the vaccine prevents precancerous changes to the cervical mucosa. There is also emerging evidence of actual cancer prevention‫ ‬(remember that it takes decades for some HPV cancers to develop, so several studies that began in the 1990s are now reaching publication).

There is no “preliminary evidence that HPV vaccines may lead to increased cervical cancer.” We believe that Mr. Rosenblum is referring to the now-retracted article in the Indian Journal of Medical Ethics from April 2018, written by a man who lied about his name, research affiliation, and data. It is truly a measure of the insidiousness and dangerousness of anti-vaccine propaganda that even Mr. Rosenblum and your prestigious magazine were fooled by this charlatan. There is, in fact, robust evidence that the HPV vaccine prevents precancers, and emerging evidence that it prevents cancers as well.

There is no reason to believe that the same vaccine that safely and effectively prevents HPV infection and precancerous lesions caused by HPV will not also prevent HPV-caused cancers. Evidence continues to mount with each year that passes since the vaccine was approved. A recent (2019) and very powerful meta-analysis by Drolet, et al., which looked at the data from 65 different studies, shows a very large drop in HPV-associated lesions, including more invasive precancerous ones in teens and young adults, after HPV vaccination.

So, based on abundant safety and efficacy data (which we will be happy to forward to you upon request), we strongly disagree with Mr. Rosenblum’s assertion that the HPV vaccine is not “remotely necessary” for frum individuals. If you don’t believe us, ask fellow Jew, Jason Mendelsohn, who was diagnosed with stage IV throat cancer caused by HPV, and now advocates as “Superman HPV.” You can’t ask Laura Brennan, also a passionate advocate for the HPV vaccine, because she died at age 25 of cervical cancer from HPV. Due to the stigma associated with HPV (which is made worse by editorials like Mr. Rosenblum’s), there may not be many frum people willing to come forward with their HPV related illnesses, but we should know that we are not immune to this very common virus. As frum Jews, we believe in getting the best health care as part of Hashem’s mandate to us to safeguard the bodies he created for us b’tzelem Elokhim. We also believe that we are all responsible for each other, as כל ישראל ערבים זה בזה. If even one person who reads Mr. Rosenblum’s piece and chooses not to get the HPV vaccine later develops a preventable HPV-associated cancer, Mr. Rosenblum and Mishpacha magazine will bear responsibility.

We plead with you to publish a correction or rebuttal to Mr. Rosenblum’s essay to correct the misconceptions it endorses and provide accurate information on this lifesaving vaccine for your readers.

Sincerely,

Alisa Minkin MD
Community Pediatrician
&
Maureen Nemetski MD, PhD, FAAP
Pediatric Emergency Medicine Physician

Co-chairs, Preventive Health Committee
Jewish Orthodox Women’s Medical Association
JOWMA_org
————————

Dear Editor

I am writing this letter in response to the piece written by Yonoson Rosenblum “A Shot in the Dark?” published in the Mishpacha magazine dated December 11, 2019. As an introduction, I am a gynecologic oncologist, which means that I am a gynecologist who has specialty training in treating womens’ cancer. I am also a mother of 4 girls, the oldest of which has received the HPV vaccine already, and the other three will IYH be vaccinated when they are the appropriate age.

I agree with Mr Rosenblum’s premise that forcing parents to provide their children with treatments that they deem unsafe may be unconstitutional, unless it is a time of crisis (such as the near epidemic proportions measles outbreak that occurred last year), but that is where my agreement with him ends. The presumption that Gardasil, the 9 valent HPV vaccine, is dangerous and unnecessary is unfortunately very inaccurate, and appears to be based on skewed information.

HPV is a double stranded circular DNA virus, and can incorporate its DNA into human cells. This integration of viral DNA into human cells may cause the cells to undergo malignant transformation (cancer). The virus has many different subtypes, and its presence is pretty much ubiquitous among human beings. Some strains of this virus can lead to deleterious effects, some of which are benign and unsightly (such as warts), and some may lead to precancerous changes that can eventually develop into cancer. HPV related cancers are cervical, vaginal, vulvar, penile, backside, and oropharyngeal. In order for cancer to develop, the HPV infection needs to be persistent and prolonged. Developing precancerous changes of the cervix (otherwise known as dysplasia) requires at least two years of persistent HPV infection, often longer. Progressing from pre cancer to cancer takes even longer (though not always) in the range of 10 years.

Historically, cervical cancer was one of the leading causes of cancer related deaths worldwide. In the United States, the advent of the pap smear in the 1940’s significantly impacted the rate of cervical cancer by detecting precancerous cells and treating them before they develop into cancer. A study published in 2012 revealed a 54% decrease rate of cervical cancer in the previous 35 years, largely due to pap smear screening. Currently, according to a national cancer database (SEER database) there are 13,170 projected diagnosis of cervical cancer in 2019. HPV, which is a known precursor to over 95% of cervical cancers, is a virus that is transmitted through skin contact, often intimate contact. Currently, approximately 80% of people in the United States who have been intimate will be infected with HPV at some point. Of these people, 7% will have persistent infection, and will go on to develop pre cancer cells, which may eventually develop into cancer.

The HPV vaccine was developed to decrease the incidence of HPV infections, thereby avoiding the precancer phase, and hopefully eliminating all HPV related cancer. Currently, it is the only vaccine that is available to eliminate cancer.

In the US, HPV vaccine Gardasil is recommended by multiple organizations, including the AAP (pediatrics), ACOG (gynecology), ACS (cancer), ACIP (vaccines), and CDC, amongst many others. Current schedule recommends vaccination starting ages 11 to 12 ( though may be given as young as 9, but not currently recommended starting age), up to the age of 26 (21 for men). Recently, approval for the vaccine has been extended to the age of 45 in some extenuating circumstances.

Has the vaccine been effective? It has. Australia, which was one of the first countries to embrace the vaccine, and mandated it as part of their national immunization, is currently on the verge of eliminating cervical cancer from their country. A large study published in the Lancet Public Health in 2018 analyzed rates of cervical precancer and cancer after approximately 9 million doses were administered. What they found was that approximately 77% of cancer related HPV subtypes were eliminated, with a 50% reduction in the incidence of high grade cervical abnormalities (precancerous conditions). In the US, there are approximately 30,000 HPV related cancers annually. A study from Alabama already demonstrated a significant drop in the rate of cervical cancer, as well as other HPV related cancers as well.

Is it safe? Yes! Combined studies of over 2.5 million doses revealed an extremely low incidence of adverse effects. A study published in the Journal of Pediatrics in 2016 looked at 838,991 doses of the 9 valent HPV vaccine, and demonstrated the safety of the vaccine, with an extremely low incidence of serious adverse effects.

Now that we have established that the vaccine is safe and effective, we need to establish whether or not the vaccine is applicable to us.

The author of the article contends that following a “chaste and monogamous Torah life” will protect against HPV and subsequently cervical cancer. The only thing that can truly protect someone is absolute abstinence, as was demonstrated in a large study analyzing the rates of cervical cancer in nuns in a monastery. As we know, a true Torah life does not condone, or even allow, a life abstinence. Once someone has been intimate, they are automatically at risk of acquiring the HPV vaccine. Well, one would say, how can a man and woman, who have been intimate only with each other their entire life, acquire the virus? The truth is, even in the most stringent, frum circles, monogamy is not a given. Chlamydia, another infection that is transmitted through intimate contact, has been used as a surrogate for detecting HPV infections rates, given that the presence of chlamydia is strongly associated with the presence of HPV infection. . A study in Israel looked at several hundred chareide women who were screened for chlamydia during their pregnancy – what they found was that 6% of chareidi women had active chlamydia infections, and 12.3% had evidence of prior infection. No promiscuity? A survey of teenagers in yeshivot in Israeli revealed that 6% of chareidi teenage girls, and 11% of boys admitted to engaging in a form of intimate activity. 11%- meaning ‪1/10‬ yeshiva boys have had some exposure. The frum society is unfortunately subject to the same human weaknesses as other societies. Are the rates lower? Probably. Are the rates negligible? Absolutely not. As a practicing gynecologic oncologist, treating cancer is what I do every single day. Unfortunately, I have seen a fair share of frum women with pre cancer of the cervix, vulvar precancerous, and vulvar cancer. And what about the good people who are strictly Halacha abiding and have never been promiscuous? Have good frum people never been remarried? What about our growing number of sincere, frum, baalei teshuva? And less likely, though a sad reality, victims of incest, molestation, and rape. Do they not deserve to be protected? How, as a parent, despite all of the chinuch, tefillos, and hopes, you be certain that your child will not be among those who are exposed to the virus???

The author claims that “There are far cheaper, less invasive, and safer ways to prevent cervical cancer than vaccination”. Unfortunately, this statement is inaccurate. It is true that pap smears have significantly decreased the rate of cervical cancer. Detection of precancerous cells is treating a disease that is already present. The vaccine prevents the disease from occurring in the first place. Pap smears are neither comfortable, nor inexpensive. Furthermore, once a pap smear detects abnormal cells, followup is needed in the office in the form of a very invasive exam called a colposcopy. This entails a microscopic inspection of the cervix, with subsequent biopsies. Some precancer biopsy results require more aggressive treatments, where a portion of the cervix is removed. This is often performed in the operating room. This involves blood work, anesthesia, post operative pain, and bleeding post operatively. These procedures carry with them a long term risk of infertility and early pregnancy loss, as well as a significant risk of recurrence. Does this sound less invasive than 2-3 shots given to a young adolescent?? And let us not forget the impact that all of this workup has on a woman’s mental well being. The anxiety before and after every exam. The issues with niddah related to the exams and biopsies. The effects on the woman and her marriage are manyfold.

The author of the article also states that there is a suggestion of increasing rates of cancer in patients who received the vaccine. This statement is based on false information. Below is a copy of the headline of the article that suggested a link between HPV vaccine and increased rate of cervical cancer:
RETRACTED: Increased incidence of cervical cancer in Sweden: Possible link with HPV vaccination.
Indian J Med Ethics. 2018 Jul-Sep;3(3):246. doi: 10.20529/IJME.2018.057. Epub 2018 ‪May 26‬
The article was retracted. The author falsified his name and workplace, and supposed data was never verified.

So where do we go from here? Every parent needs to make the decision they think is right for their children, and protect them. My oldest is already vaccinated, and my younger three will be vaccinated when they turn 11 or 12. We have a safe, preventative, intervention that has been proven to decrease rates of a very cumbersome disease in women in their reproductive years, and prevent cancer. I feel I would be failing my obligation as a parent and a doctor if I did not give my child every opportunity available to them to lead a healthy life.

Mira Hellman-Ostrov, MD, FACOG
Gynecologic Oncology

———————

To the editor,

I was extremely disappointed that you chose to publish Rabbi Yonoson Rosenblum’s article on government mandates and the HPV vaccine. I am a school nurse residing in Maryland, another very progressive state, where there has been no discussion regarding removing religious exemptions for vaccinations or mandating HPV vaccines. Perhaps part of the reason for this is that the Va’ad HaRabbanim of Baltimore has advised all of the mosdos in Baltimore to refuse religious exemptions for all vaccines required for entry to school, despite the fact that the state allows them. I do not feel qualified to comment here on the legalities and possible repercussions of mandates, and had that been the entire opinion piece I would not be writing this letter. Unfortunately, the article then goes on to make multiple false claims regarding the HPV vaccine, which I do feel compelled to refute.

With regards to the HPV vaccine, Rabbi Rosenblum states that he is convinced that not a single Orthodox parent would willingly vaccinate their children for HPV. Working in a frum boys’ school with over a thousand students, I can say with certainty that this is patently false. Many, if not most, parents trust their child’s pediatrician to provide evidence based preventative care to their children, which includes vaccination against flu and HPV. In fact, a very large proportion of the student body sees frum healthcare providers who are part of the community themselves. These providers have their patient’s best interest in mind and recommend the HPV vaccine because they have examined the research and know that it is safe and effective, not because they are influenced by pharmaceutical company advertising and lobbying.

There is a tremendous amount of research demonstrating the safety and efficacy of the HPV vaccine. A Cochrane review of 26 studies found that the HPV vaccine was very effective at preventing the development of abnormal cervical cells which are precancerous. Precancerous cells take many years to develop into cervical cancer, therefore data on the full positive effect of the HPV vaccine on cancer is just starting to become available. Inexplicably, Rabbi Rosenblum instead claims that the HPV vaccine may lead to an increase in cervical cancer without stating a source for this claim. The HPV vaccine has also consistently been shown to be safe in both pre-licensure and post-licensure studies (for some high quality studies, see papers by Gee, 2011; Yih, 2016; Siegrist et al., 2007; Arana et al., 2018).

While I certainly agree with the author that the rates of cervical cancer among women in developing countries are higher, that does not mean that it is not prevalent here. According to the American Cancer Association, in 2018 alone there were about 13,250 new diagnoses of invasive cervical cancer in the US. But cervical cancer is only one type of cancer caused by HPV; about 44,000 HPV associated cancers are diagnosed each year with 19,000 of them occurring in men (CDC). Unlike a routine pap smear that can detect precancerous cells, other HPV associated cancers, such as oropharyngeal cancers, are not routinely screened for. My husband is a radiation oncology resident and he routinely treats patients who are suffering greatly from such cancers.

While I also agree that ideally following a Torah lifestyle provides protection against HPV, not everything is in our control. Ten years ago, as a young kallah engaged to a serious yeshiva bachur, I questioned the need for the HPV vaccine when my doctor recommended it. My doctor sensitively explained that life doesn’t always work out the way we expect, and that infidelity or remarriage after death or divorce can put me at risk later in life. I got the vaccine.

A study in the American Journal of Psychiatry found that 26% of married Orthodox Jewish women reported a history of s-xual abuse, with 16% of the abuses occurring before the age of 13. Rates were higher in the ultra-orthodox as opposed to the modern-orthodox. Another study from 2018, found that across the Jewish religious spectrum, the rates of childhood s-xual abuse were statistically equivalent to the national rates, and higher than national rates in those who are formerly Orthodox but no longer identify as such. There are no statistics for the percentage of teenagers and young adults in the community who engage in relationships before marriage nor are there statistics on marital infidelity. While I do believe these numbers may be significantly lower than the general population, they are not nonexistent.
Regardless of one’s political views, opining on a medical topic without having the appropriate background is irresponsible and shallow. I hope that Mishpacha will, at the very least, provide an alternate viewpoint from a qualified medical provider on the evidence that supports the vaccine, and a disclaimer on the importance of discussing these issues with one’s health care provider.

Sincerely,
Adena Friedman Cohen, RN BSN

—————————

Dear Editor,

As you know, I have been battling vaccine misinformation in the frum community, which has been propagated and shared deliberately by frum anti-vaccine activists. This widespread propaganda effort culminated in the largest measles outbreak in recent decades and brought chillul hashem upon all of us. We had twenty frum children in the ICU, and thousands of cases of the measles in New York, which causes long-term immune consequences.

Along with a passionate and dedicated team of frum doctors, nurses, and community members, we have been explaining the science of vaccines and how they prevent infectious disease and keep children and adults safe to parents in the communities, and providing tips on parent communication to providers in the tri-state area. And yes, as frum doctors who know that HPV can be prevalent even in a community with careful parameters around monogamy, we discuss and encourage HPV vaccination all the time!

I am distraught that one of the premier frum magazines, which we would think takes care to provide careful, well-researched information, has become yet another misinformed publication.

Mr. Rosenblum’s article, which argues against mandatory HPV vaccines, uses false, retracted, and non-evidence based theories to substantiate his personal opinion on whether the HPV vaccine works, whether it is safe, and whether it should be mandated. While the question of whether vaccines should be mandated induces many different fierce opinions, these opinions need to be based on accurate information, and this is what I wish to point out here.

Over the last decade and even more so in the last few months, studies continue to show that the HPV vaccine continuously prevents cervical pre-cancers, lowers HPV rates, and saves men and women from preventable cancers. Mr. Rosenblum failed to include this in his highly biased and inaccurate opinion piece. He also falsely claimed that there are “other” ways to prevent cervical cancer, which is untrue. Pap smears do not prevent cancer, they’re simply an early screening tool. Furthermore, in the event that a woman has an abnormal smear, she would need biopsies and even more frequent Pap smears, increasing the likelihood of complications from repeated invasive exams. The HPV vaccine would reduce the likelihood of all of this.

Mr. Rosenblum explains that he gets his flu shot and that therefore that he shouldn’t be accused of being “anti-vaccine.” However, his choice to use false information without consulting medical professionals who deal with HPV all the time, or who know the science behind this vaccine, says otherwise.

I, and many other knowledgeable and frum healthcare providers, would be glad to see his piece either corrected, or retracted.

I await a response from you.

Blima Marcus, DNP RN ANP-BC OCN
Medical Oncology

———————

Dear Editor,

In response to the outlook article titled “A Shot in the Dark?” I would like to inform the author that I am an ultra-Orthodox Jewish parent who willingly consented to the HPV vaccination of my children. I am also a Nurse Practitioner and women’s health provider. I encourage my younger patients to get their Gardasil vaccines because it is the first vaccine to protect women and men from cancer. Gardasil targets a number of high risk HPV strains that are known to cause cervical cancer as well as other genital, head and neck cancers.

Although HPV is not contracted via exposure to airborne droplets or through ‘casual contact,’ I strongly disagree with the premise stated that “there are far cheaper, less invasive, and safer ways to prevent cervical cancer than vaccination.” The first way was cited was living a “chaste and monogamous Torah life.” While this might keep cervical dysplasia and cancer rates lower in our community, the vaccine is not only targeting the “average Torah-observant patient” among us. What about struggling teens and young adults at risk, victims of molestation, people in second marriages, and those marrying partners with a past non-Orthodox life? How can any parent be sure of their child’s future? I would recommend speaking with representatives of some of our incredible organizations like Amudim, Relief, and Madraigos to get a true representation of whether our population is well protected.

As for the second recommendation – “going for regular exams and undergoing the appropriate screening tests,” I am a strong proponent of this along with HPV vaccination. Unfortunately, I can attest to the fact that many women and men are much better caretakers of their children’s healthcare than they are of their own and are lax with preventative care visits. Where I work, one reliable way to get our patients to come in for annual exams is to make an office visit a requirement for contraception refills. Additionally, unlike vaccines, Pap smears are not preventative; they are screening examinations to determine whether cervical changes have already occurred. As for vaccines being invasive, I would venture to say that most women would find vaccines much less invasive than pelvic exams.

I would also like to stress that the HPV vaccine has been extremely effective at reducing the spread of HPV-related cervical changes as well as cervical cancer. The evidence has not shown patients experiencing long-term adverse effects. When cervical changes are found on Pap smear results, patients may require follow-up cervical biopsies which can be painful and cause cervical scarring. This can have a detrimental effect on a woman’s fertility. These same women, as well as those not recommended for colposcopy and biopsy, will need more frequent Pap smears until their screens come back normal. I imagine that most women would prefer to have Paps according to the recommended schedule of every 3 years until age 29 and every 5 years (or 3-5) from age 30-65.

Finally, I wonder if the misuse of religious exemptions is what led to the passing of the law in NY. Most mainstream rabbanim have strongly advocated for vaccination, and we have historical mandates to follow the majority of medical opinions as well as the majority of halachic opinion. This concept should extend to vaccination and therefore there is little room for religious exemption.

Sincerely,
Esther Lebovic DNP, FNP-BC, CSC

———

To the editor,

I read this article with a mixture of sadness, frustration, and deep fear for our community. I am used to reading anti-scientific and illogical diatribes in publications of less repute, but to see the venerated Mishpacha name associated with such a piece is heartbreaking for me.

I believe there are multiple flaws in the legal logic used by the author in describing the case law surrounding religious liberty. That said, I would never attempt to argue legal precedent with anyone. I am not a lawyer. I have precisely zero formal legal training. What I do have is extensive medical and research training, including a doctoral degree focused on clinical research. I wish that others would have the respect for medical research and practice that I have for arguing about American law.

Let’s be really blunt. Frum people die from the cancers caused by HPV. Not just theoretically or potentially, but actually. They get the exact same HPV-related cancers that all other people do, and their bodies wither and fail in precisely the same horrendous ways. Many will argue “I have never met a frum person who told me they had HPV or one of the cancers that it causes.” Is that a surprise? Would you imagine that a person who did would post about it on the shul bulletin board? Of course not.

Every frum parent insists to me that their child would never, ever, in a million years do any of the things that could lead to getting HPV. I feel the same way about my own children! None the less, my children will be getting the Gardacil vaccine as soon as they are old enough.

The Gardasil vaccine is both highly effective and very safe. It has been rigorously tested and passed with flying colors. As with all vaccines, anti-vax advocates have invented plenty of imagined dangers they associate with Gardasil, and some of these are repeated in the article. Instead of debunking them point by point, I would encourage anyone interested to read the fantastic research published in The Lancet (Drolet et al., 2019), and Cochrane Database of Systematic Reviews (Arbyn, Xu, Simoens, & Martin-Hirsch, 2018). Long story short, Gardasil is excellent at saving lives, and carries close to zero risk. Nothing in the world is truly zero risk, but it is accurate to say about all vaccines, including this one, that the most dangerous part of getting them is the drive to the office and the drive home.

Pap smears, while vitally important, are absolutely not sufficient protection against these cancers. Also, I would encourage the author to inquire of his wife or mother whether she agrees that Pap smears are “less invasive” than a vaccine.

I would be overjoyed to see a retraction of this article, but at the very least I would hope to see a piece published that explains all the things I mentioned above. I would happily participate in writing such as piece, and I have many colleagues who would join me. If even one parent reads Mr. Rosenblum’s article and, based on its inaccuracies, chooses to refuse this vaccine, he and the magazine will have participated in risking that child’s life. I do not mean to be harsh or hyperbolic. That is the simple reality.

Sincerely and respectfully,
Ephraim Sherman, DNP, AGPCNP-BC

—————

Dear Editors,

As an infectious diseases physician, I feel compelled to respond to the recent article by Yonoson Rosenblum, “A Shot in the Dark,” in which the author expressed concerns about current bills in the New York legislature that would mandate vaccination against Human Papilloma Virus (HPV).
First, I must say that I appreciate the author’s concerns over state interventions that threaten the rights of families and the collective integrity of our religious communities. The past decade has witnessed several intersections between New York Haredi communities and city and state health departments within the terrain of infectious diseases. Health departments have vigorously responded to recent outbreaks within New York Haredi communities, including mumps, herpes simplex virus in infants following circumcision and measles. These encounters have involved increased state regulatory acts over individual, community and religious practices and collective movement in the name of protecting public health. These acts, in addition to New York State hypervigilance in monitoring educational content in yeshivas, create a tension and a sense that Orthodox communities are under siege.
I believe, however, that the proposed mandate for HPV vaccination is a public health measure and not a religious issue particular to the Orthodox community. Like mandated child car seats and house lead inspections, it is simply about the safety of our children in a world that we cannot predict. It is an opportunity to keep our children free and pure from a common virus that can cause cervical, oral, vaginal, penile and backside cancers later in life, as well as warts. With certainty, we can state that the HPV vaccine prevents HPV-cancer-causing infections and precancers. With certainty, we can state that with over 12 years of monitoring and research, and over 120 million doses of the vaccine distributed, data continue to show that the vaccine is safe. HPV vaccine does not cause HPV and it does not cause cervical cancer. It is made from a natural protein separated from the virus itself that leads our own bodies to develop neutralizing antibodies that prevent HPV infection when exposed. Contrary to Mr. Rosenblum, I can see no downside.
Mr. Rosenblum asserts that the state legislature is acting in place of the parents in providing informed consent for the child, and that this could be dangerous because the state “does not have detailed knowledge of the child’s medical history that might bear on possible risks for the vaccine, so informed consent is impossible.” True, the state does not have this knowledge. But the child’s doctor does. If a medical exemption is indicated, then this exemption should be granted.
Rather than wait until “after-the-fact” of HPV exposure and rely on cancer screening, and rather than undergo the significant morbidity of procedures to treat pre-cancerous lesions, we are much better off preventing the infection that leads to these lesions in the first place. We cannot miss this opportunity to take advantage of a vaccine that does what no other vaccine has done before: prevent cancer. Talk to your family doctor or child’s pediatrician about this vaccine.

Ellie Carmody, MD, MPH
Department of Medicine, Division of Infectious Diseases and Immunology
New York University School of Medicine