HPV vaccine: An (unpublished) letter to the editor

A quiet six-month-long campaign by two Toronto physicians, Rob Wagman and Raymond Tellier, to have the university distribute on its student listserv a simple message about the human papillomavirus (HPV), ended in failure earlier this month when the school’s governing council declined to reconsider a decision made by U of T president David Naylor and provost Vivek Goel.

Both Dr. Wagman and Dr. Tellier say they are bewildered by the decision, particularly as it was made by the university’s top two officials, both of whom are physicians.

Mr. Naylor is the university’s former dean of medicine and Mr. Goel a former chair in the faculty of medicine.

Ironically, Mr. Goel’s online biography notes that “his primary research interests include health care evaluation with a focus on medical screening intervention, especially cancer screening…”

As Dr. Tellier, a microbiologist at the Hospital for Sick Children, told The Globe and Mail yesterday, “A vaccine against cancer: How cool is that?”

HPV is the name for a group of more than 100 viruses, more than 30 of which are sexually transmitted and a handful of which lead to cervical cancer - the second most common cancer in Canadian women under the age of 44 - and genital warts, and are also linked to vaginal, vulvar and anal cancers.

In June, 2006, when the U.S. Food and Drug Administration formally approved the HPV vaccine Gardasil as safe and effective - a decision followed less than a month later by Health Canada - it was hailed as a breakthrough day for women’s health against the most common sexually transmitted infection in both countries.

In Canada every year, about 1,400 women are diagnosed with cervical cancer, and 400 die of it.

In clinical trials in young women aged nine to 26, the vaccine was found to prevent 70 per cent of cervical cancers and 90 per cent of genital warts and was nearly 100 per cent effective in preventing precancerous lesions.

Because Gardasil doesn’t prevent all cervical cancers, women are strongly urged to continue getting regular Pap smears and to use condoms.

The manufacturer, Merck Frosst Canada Ltd., is studying the effectiveness of the vaccine in men, but with 75 per cent of sexually active Canadians estimated to get at least one HPV infection during their lifetimes, some doctors already recommend the use of the vaccine for men.

The effort to get the country’s largest university - the U of T has about 70,000 students at three campuses - to push the vaccine began with Dr. Wagman, who is an ophthalmologist with a large pediatric practice.

In an interview at his office yesterday, he gestured to the usual chair and eye doctor’s equipment, grinned and said, “As you can see, I’m a gynecologist and obstetrician.”

Now 53, Dr. Wagman’s young patients have grown up with him, and he sees himself as their advocate.

So, when the HPV vaccine became available about 18 months ago, he began asking his teenage female patients, “Got your HPV vaccine yet?” Inevitably, he said, they answered, “What’s an HPV?”

When one patient in her 20s replied, “Unfortunately, I’ve had cervical cancer,” Dr. Wagman decided, “Screw this.”

Last summer, he approached the health service at U of T, where he is on the faculty of the medical school, and suggested it send out a simple statement to female students: “Cervical cancer is the second-most common cancer in women under age 50 today. HPV is the most common sexually transmitted infection at the U of T today. HPV can cause cervical cancer. Talk to your doctor about the new HPV vaccine.”

By September, Dr. Wagman learned the health service “was being blocked” from sending out the information, and enlisted the help of his patient and friend, Dr. Tellier, and together, they wrote Mr. Goel and then Mr. Naylor.

On Nov. 30, Dr. Tellier sent a letter of his own, citing the clinical studies and pointing out that the National Advisory Committee on Immunization recommended vaccination not just for the younger age group covered by three provinces (Ontario, Nova Scotia and Prince Edward Island) but also for women aged 14 to 26.

“We are not asking that the university of Toronto recommends the vaccine, but merely that it provides by e-mail to its student listserv, or points to the relevant information,” Dr. Tellier wrote. The two doctors then appealed to the university’s governing council, and on Jan. 18, received a letter from chair Jack Petch, telling them Mr. Naylor and Mr. Goel had “made a decision appropriately” and that the council “has no reason to reconsider.”

In fact, as U of T spokesperson Ruta Pocius confirmed yesterday, the matter never even went before the council.

On Jan. 21, Dr. Wagman made one last pitch, and sent Mr. Naylor a final e-mail.

This time, he included a notice that was sent to male and female students at the University of Ottawa by its health services director, Don Kirby, that explained in clear language the virus and the vaccine and recommended it for both women and men, noting that the latter “are also carriers and equally responsible for the prevention of HPV infection.”

The notice also pointed out that the three-dose vaccine - each dose costs about $135 - is partly subsidized for those covered by the Univesity of Ottawa’s student health plan.

Only yesterday did Dr. Wagman receive a reply from Mr. Naylor.

This terse letter was provided to The Globe by Ms. Pocius shortly after Dr. Wagman was sent his copy.

In the letter, Mr. Naylor sniped that the Ottawa university had issued a clarification about the recommendation for men, although, in fact, the “clarification” strongly reiterated Dr. Kirby’s original recommendation, but acknowledged that Health Canada was not suggesting it for males at this time.

“I respect your commitment as manifested by multiple e-mails,” Mr. Naylor wrote, “but I have ongoing doubts that the appropriate communication and vaccination strategy is as straightforward as you have argued.”

He noted that the university has “the vaccine available,” will offer it “where it is clinically indicated” and has promoted the vaccine on the student health website.

“We have not issued a mass direct mailing ... as there is no public health recommendation for mass immunization in our target age group.”

But Mr. Naylor is plainly wrong.

In August of last year, the Society of Obstetricians and Gynaecologists of Canada strongly recommended that all Canadian girls and women aged nine to 26 be vaccinated, the recommendation endorsed by no fewer than six other Canadian health groups, including the Canadian Pediatric and Adolescent Gynaecology and Obstetrics Committee, the Quebec Association of Pediatricians, and the Federation of Medical Women of Canada.

But while the quality and availability of HPV information varies from campus to campus across the country, a spokesperson for Merck Frosst says the U of T’s approach is sadly typical - the matter is left to university health clinics, whose staff do one-on-one outreach.