MS. SUSAN PAGEThanks for joining us. I'm Susan Page of USA TODAY sitting in for Diane Rehm. She's on vacation. An estimated 99,000 future cancer cases would be prevented in the United States if HPV vaccination rates were as high as other vaccine rates. With me in the studio to talk about why HPV vaccination rates are so low, Barbara Rimer, chair of the president's cancer panel, Yolanda Lewis-Ragland at Children's National Medical Center and Sherrie Wallington with the Lombardi Comprehensive Center at Georgetown University.

MS. SUSAN PAGEAnd joining us by phone from Atlanta, Melinda Wharton of the Centers for Disease Control and Prevention. Welcome to you all for being with us on "The Diane Rehm Show."

MS. BARBARA RIMERThank you.

MS. YOLANDA LEWIS-RAGLANDThank you.

MS. SHERRIE WALLINGTONThank you.

PAGEWe're going to invite our listeners also to join our conversation. We've already seen a lot of interest on Facebook and Twitter for this hour. You can call our toll free number, 1-800-433-8850 or send us an email at drshow@wamu.org or find us on Facebook or Twitter. Well, Barbara, let's start with you. This report came out from the president's cancer panel. What did you find when you looked at HPV vaccination rates.

RIMERWe found an incredible opportunity to prevent cancer and a lack of realization of the potential to do this. So about one-third of girls in this country are getting all three doses of this vaccine. It requires three doses. And only about 7 percent of boys. And that is in contrast to the incredible opportunity that we have to prevent cancers.

RIMERAnd this is a virus. There are about 100 different HPV viruses. About four of them account for most cases of cancer in genital warts. So we could prevent cancers. We could prevent maybe about 53,000 cancers in children today who, as they age, but we're not doing that.

PAGEAnd you said a third of girls, just 7 percent of boys. How does that compare with other kinds of vaccination that kid's get?

RIMERIt's very different. What we've seen with other adolescent vaccines and childhood vaccines is a rise to about 80 percent of kids getting them within a fairly short period of time. And CDC tracks these data and Melinda may want to comment more. But it is in contrast to those.

PAGEMelinda, tell us about the contrast between the HPV vaccine and other kinds of vaccine that kids are encouraged to get.

MS. MELINDA WHARTONYes. There were several vaccines that were added to our recommended immunization schedule to be given routinely at 11 to 12 years of age, beginning in 2005, 2006. And for two of those vaccines, we've had steady increases every year and we're actually above 80 percent for one of them, the tetanus, diphtheria and Acellular pertussis vaccine, are most recent data showed that we were at almost 85 percent coverage among 13 to 17-year-old kids in the U.S.

MS. MELINDA WHARTONWith the meningococcal vaccine, it's a little bit lower, but it's still 74 percent and as Dr. Rimer said, we are doing so much worse with HPV vaccine, with only about a third of girls and only about 7 percent of boys completing the three-dose series.

PAGEWe want to talk about...

WHARTONSo it really is different.

PAGEWe want to talk about why it's different, but first, let's just take a step back and talk about what is the HPV vaccine. What is it and what does it do? Sherrie, could you explain that for us?

WALLINGTONOh, absolutely. The HPV vaccine, there are two licensed, approved vaccines in the U.S. That's Gardasil and Cerverex. And the vaccine prevents 99 percent about all cervical cancers and then other HPV associated cancers related to the human papilloma virus.

PAGEAnd so when you -- Yolanda, you're a pediatrician. You deal with a lot of parents with kids who are in this age group. Are parents resistant? Is that one reason why we're seeing these low rates of vaccination?

LEWIS-RAGLANDSo, yes, oftentimes you have some resistance of parents and a lot of it is just because of some of the controversial information, I think, that they're getting in terms of media, in terms of sort of the understanding that they have the option to refuse the vaccine. You know, there is this opt-out, you know, form that you have that comes with this vaccine that doesn't come with other vaccines.

PAGEThat's here in the District of Columbia.

LEWIS-RAGLANDThat's here in the District and so I don't know about other, you know, and there is -- in other areas, because it isn't as, you know, because it is a new vaccine and it isn't as -- it seems to be as important so, you know, it depends on how your pediatrician, I think, is educated and how they're informing, I believe, their patients that really determine how much the parent understands the importance of the vaccine.

PAGESo when you're offering this vaccine to a parent saying, I recommend that your child get this vaccine, what do they say to you? What kind of concerns do they have?

LEWIS-RAGLANDSo oftentimes, the questions, you know, come about, you know, what are the adverse effects. You go into those, very small numbers. They want to -- they often will link them with adverse effects that they've heard about with something, you know, that's not related to the vaccine. So maybe that -- what they may have seen with the swine flu vaccine or something they've seen with some -- and so there is this sort of skepticism about sort of what would happen to my child, you know.

LEWIS-RAGLANDDidn't this happen over here in Colorado? Didn't this happen over here? And oftentimes they are really unrelated topics and so you have to sort of get them back on track and really talk about what we're trying to prevent and this has, you know, that those two vaccines are very different.

PAGEAnd Melinda, this is some resistance from parents. How about resistance from doctors? 'Cause doctors are really the front line in informing parents about whether a vaccine is right for their child.

WHARTONProvider recommendation is really important. And when we ask parents who didn't vaccinate their child why they didn't, they frequently respond that it wasn't recommended by their doctor or their child doesn't need it. And both of those translate into, I think, that the family didn't perceive that they were given a strong recommendation for the vaccine.

PAGEAnd Barbara, what did you conclude in your report about -- to explain this disparity in vaccination rates?

RIMERWell, we, first of all, concluded that this is an incredible missed opportunity. So about 80 percent of adolescent girls, and there are more data now on girls, are seeing their physicians, but only a small proportion of them are coming out with having had the HPV vaccine. About two-thirds of them are getting other vaccines. And what we concluded is that physicians aren't giving the recommendation or aren't giving it in a strong enough way.

RIMERAnd some of that is because this is still a relatively new vaccines. Physicians don't necessarily understand its cancer prevention value and some of them don’t want to talk about something that is a sexually transmitted disease with their patients.

PAGEWell, talk about that, Sherrie, if you would. I mean, it does seem as though sexual activity is part of life. You're talking to teenagers, you're gonna pretend that sexual activity isn't part of the health discussion?

WALLINGTONYes. You know, at Georgetown, we had, across the District, we've had many opportunities to talk to parents and also a lot of my researchers focus on adolescence. And what we're hearing from parents is that, you know, having that conversation sometimes is very difficult and sometimes a lot of parents aren't sure how to have that conversation. Not just about HPV, but also about sexual activity and then when you talk to adolescents directly, you know, many of them feel that they're not able to talk to their parents about these types of subjects.

WALLINGTONAnd so one of the worst things is they talk among themselves or, as Dr. Ragland has indicated, some adolescents go to the internet and they're not getting accurate information. So one of the things that we're doing at Georgetown, we encourage parents to have that conversation not just about HPV, but just about sexual activity.

WALLINGTONBut the reality is many adolescents say, you know, when that time comes it's not exactly like we're going to say, mom or dad, you know, I'm ready to have sex. And so one of the things, I think, parents can continue to do and that's to do the best job they can as parents and equip their children with accurate information so that they can make good choices.

WALLINGTONAnd as far as the HPV, we need to equip parents with good, accurate information so they can make an informed decision about vaccination.

PAGENow, during the 2012 presidential campaign, there was a debate that involved Texas Gov. Rick Perry who made it mandatory for school-aged girls in Texas to get this vaccine. Congresswoman Michele Bachmann said it was unsafe, said it promoted promiscuity. Is there evidence on whether it is linked with higher rates of promiscuity?

LEWIS-RAGLANDAnd so absolutely not. You know, one of the things we really don't discuss is that, you know, hepatitis B is a sexually transmitted disease. We give hepatitis B vaccinations to infants. We've had it long enough now that it's safe and we know that we can start vaccinating these children at birth so it has nothing to do with their sexual activity.

LEWIS-RAGLANDWe don't talk about it then so why do we talk about it, you know, why do we talk about it just because it's a new vaccine and this is the age that we've decided to give it and we're capturing, you know, with other vaccines at this 11 to 13-year-old age. It just happens to be a convenient age because it's newly introduced. I really believe that if, at some point, we get to the area where we know this is very safe, we can use this, and we can go younger and younger, I think it really would diffuse and really kind of get that whole topic off the table.

LEWIS-RAGLANDBecause most of the girls that -- as a pediatrician that -- and families that come in, these are responsible families, responsible girls and boys -- let's stop talking about, you know, just the girls that are getting these because, you know, as a parent, I've vaccinated both my daughter and my son and so this is not just about girls. So these are responsible adolescents. And really we should be talking about responsible parents getting their children vaccinated against something that could be harmful for them later in life and that we can actually stop the spread of.

PAGEYolanda Lewis-Ragland, she's a pediatrician with the mobile health program at Children's National Medical Center in Washington D.C. I'm also joined in the studio by Sherrie Wallington, an assistant professor and program director of the Health Disparities Initiative at the Lombardi Comprehensive Cancer at Georgetown University Medical Center.

PAGEAnd by Barbara Rimer, chair of the president's cancer panel and dean of the Gilling School of Global Public Health at University of North Carolina. Joining us by phone from Atlanta, Melinda Wharton, director of the Immunization Services Division at the Centers for Disease Control and Prevention. We're going to take a short break.

PAGEWhen we come back, we're gonna go to the phones. Our phone lines are busy. We're gonna read some of your emails. Stay with us.

PAGEWelcome back. I'm Susan Page of USA Today sitting in for Diane Rehm. We're talking about the HPV vaccine and why rates of vaccination have been so low in the United States. Let's go to the phones and take some of our callers. We'll go first to Belvidere, IL and talk to Mandy. Mandy, hi, you're on the air.

MANDYHello. Thank you for taking my call. I'm a gynecologist and I deal with kind HPV education in my practice because I treat patients with abnormal Pap smears. So I see them, you know, years down the line when they would have had an HPV vaccine. I see teenagers and I -- in general, I'm in favor of the HPV vaccine. But I wanted to press your panel just a little bit on this idea that the HPV vaccine would prevent 99 percent of cervix cancers.

MANDYAnd I'd like to know where the numbers are coming from on just the number of cases of cancer that might be prevented in the U.S. because my understanding is that cervix cancer, in general, is still -- is fairly unusual cancer because of our Pap screening programs. And that, really, the greater benefit for HPV vaccination might be outside the U.S.

PAGEAnd, Mandy, before we let you go. When you talk to your patients, maybe to the parents of younger patients, what's their attitude toward the HPV vaccine?

MANDYMy attitude is positive in general. You know, I tell them that it can help prevent not only cervix cancer but dysplasia, which is a precancerous condition of the cervix. And, you know, I tell them that it covers four vaccines -- I mean, four types of HPV, two that cause cancer -- and this is Gardasil in particular -- and two that cause genital warts. But genital warts don't cause cancer.

MANDYAnd those are separate from the cancer-causing benefits -- or cancer-causing issues with HPV. So...

PAGERight, you're positive about it but I wonder if your patients and the parents of your patients, do they -- are they more suspicious of it than they are other -- maybe other kinds of medical treatment that might be recommended for them?

MANDYThey are. And a lot of them do say that their pediatrician wouldn't give it to their child. And so, they bring their kid to me to get the vaccine because the pediatrician was very disparaging even sometimes.

PAGEIsn't that interesting. Barbara, let me give you a chance to respond to Mandy's comment about the number of cancers that might be prevented if we could get higher vaccination rates.

RIMERSo, actually the rates of cervical cancer have not gone down very much in this country at all. They've stayed about 12,000, 12,500 cases, about 4,500 deaths a year. And your caller is right that the majority of cervical cancers are global, about 530,000 cases around the world. We've said in our report, and the estimate is at about 75 percent are related to the HPV virus and those are, in general, cases that could be addressed by the vaccine. So we -- it is 99 percent, but it is very high.

PAGEWe said in the introduction that 99,000 cancer incidents might be prevented...

RIMERRight.

PAGE...with higher rates of vaccination. So perhaps that's the number that Mandy heard.

RIMERYeah.

PAGELet's go to New York City and talk to Nikki. Nikki, hi, you're on the air.

NIKKIHi, everybody. How you doing? I am calling because I am a parent of a teenage daughter. And I opted not to get her the vaccine. The pediatrician didn't mind at all. And it was after I read a report that was released October 2013 by Duke University School of Medicine by Catherine Hoyo. And it found that the HPV vaccines may be less effective for black women. Not ineffective, but definitely less significant by a fairly significant number.

NIKKIIn particular, they talked about the strain targeted by Gardasil in the cervix, which is the two types that pediatricians tend to promote. And I don't buy the argument that it's going to make the girls sexually promiscuous. That's what -- that's just total nonsense. But I do think that it is something that is in the back of my mind as a woman of color.

NIKKIAnd also, I think we need to discuss it in the context that, generally, when it comes to a lot of disease, the history of testing of medicines regarding uterus, the women's vaginal health, et cetera, disproportionately women of color, our bodies have been used for experimentation, whether it's for the pill in Puerto Rico and other places. So all that is operating in my mind as I'm looking at the study and is being promoted as something we should have everyone do.

NIKKIBut they're not talking about some of the effectiveness, the different effectiveness rates among different ethnic groups. I'll my answer off the air.

PAGENikki, before you go, though, when you said to your pediatrician you were suspicious of this, you had concerns about it, what did your pediatrician say back? Did they encourage you to do so?

NIKKIShe still encouraged for me to take it, but she couldn't answer the concerns that I have. I talked to other pediatricians and they themselves acknowledged that this is not -- this panacea that everyone's talking about. But they still, nevertheless, said, look, it's better to do it. Just almost like better be safe than sorry. But they couldn't really say more than that. And they themselves were grappling with the fact that it wasn't as effective according to the study.

NIKKIIt's not as effective among black women as it is in other women. And they couldn't understand why that's not being studied. And I've also experiment -- experienced this in the area of mammography. You know, I have dense breast tissues and I don't talk to the doctors about that all the time. And they don't -- they just keep saying, get your mammograms every year. They don't want to sit there and look at the different effectiveness rates and addressing that. And it drives me crazy.

PAGENikki, thanks much for your call. Such an interesting point. Let me ask the panel if anyone can address this issue of different rates of effectiveness by race.

LEWIS-RAGLANDWell, I'm not sure exactly about the different rates of effectiveness by race. But I will say is this -- and I am a pediatrician, I am a woman of color and I do read these reports that refer to a lot of the sort of differences between races. And a lot of times one of the biggest issues, and there is that, the historical sort of skepticism based on, you know, the Tuskegee experiment, you know.

LEWIS-RAGLANDAnd as she said with the pill in Puerto Rico, African Americans have been exploited and definitely have a real founded fear of not getting the truth about what the information is. And so, really needing people to sort of sit down and say, okay, this is exactly what's going on. And so what I have found and what studies show is that because of this fear, we really don't tend to participate in a lot of clinical trials.

LEWIS-RAGLANDAnd because we don't participate in a lot of clinical trials, there's not a lot of information about our -- about the effect on us. So here we are -- now we're at this crossroads. We need more information about how it affects us as African Americans, but we won't participate in the trials because of our historical fear of what has happened in the exploitation of us. And so, you know, at some point, we have to get to an area where we have, you know, gotten us to, you know, comfortable and confident and really sort of protected and informed.

LEWIS-RAGLANDSo that we are willing to participate in trials, so that we can get these numbers and get this information, so it will be helpful for us in the end. But as long as we sort of stay away from the clinical trials, we will always be left out in terms of the numbers and what it looks like and how it's going to affect us. And then we won't have the true, you know, picture of -- and that's not just for us as African Americans.

LEWIS-RAGLANDThat's going to be what really to show America. This is the picture of what America looks like. So if we continue to keep ourselves out of the trials, then it won't be a true picture of what, you know, how it affects Americans.

PAGESherrie?

WALLINGTONOh, thank you. I agree with Dr. Ragland. And one of the big issues that we see is a lot mistrust. And a lot of that mistrust definitely does link back to, you know, studies like Tuskegee. But also more recently when you look at top two more younger parents, a lot of that mistrust stems from how they themselves have been treated, you know, in the medical system. So there's still a lot of work that we need to do as far as that.

WALLINGTONBut the specific study that Nikki talked about, the researches I think did conclude that they did need to do more research looking at the effectiveness of the vaccine. And probably it has to do with the fact that there is -- they saw that a lot of black and Hispanic women may not have necessarily been exposed to the HPV types as Dr. Rimer said in her introduction when we came on air.

WALLINGTONThere are over 100 different types. And it could be that the types that the vaccine covers, that these particular women -- they found that these women were not necessarily exposed to those types. But it's still -- the CDC recommend that they still get vaccinated.

PAGEAnd so this panel, this expert panel, would you urge Nikki to reconsider her decision not to vaccinate her kids?

LEWIS-RAGLANDI would highly recommend it, and not just her pediatrician. And I wish, you know, again, I'm hearing doctor didn't recommend it and the doctor didn't know. I wish they would come down to Children's National Medical Center. We are well-informed and we have this conversations with our patients. And our patients know. And we have a pretty high rate of vaccination, I would say, at least in our clinic, in our area because we do have that conversation.

LEWIS-RAGLANDAnd they know us well enough to ask, you know, what is your opinion and what have you done and why. And so we have those conversations.

WALLINGTONAnd I found, too, in the work that I've done with parents and adolescents and also partnering with the D.C. Department of Health, a lot of parents, once they get accurate and balanced information, they make the decision. They'll say, maybe not now. But now that I have this information and I learned how to seek out accurate and balanced information not just from my pediatrician but also from organizations like Departments of Health and the CDC, more people are now -- they're moving toward considering vaccination. Whereas before they were not.

PAGEBarbara?

RIMERYeah. And I think the important message is how significant a physician's recommendation is.

WALLINGTONYes.

RIMERSo when that recommendation is strong, adolescents are four to five more times likely to have had the HPV vaccine.

PAGEAnd yet, Melinda, I was shocked by our first caller, Mandy, who's a gynecologist saying she is treating -- giving the shot to kids who come to her because their pediatrician is dismissing or refusing to give it. And I don't understand that. Why would that be?

WHARTONIt -- I'm not sure. I think that there are pediatricians who, for whatever reason, are not making the strong recommendation and are not strongly promoting the vaccine in their practice. Whether -- to what degree this reflects not being comfortable with the vaccine or fiscal reimbursement issues, I think it's hard to know. But I've heard the same kind of accounts, and I think this is part of the reason why having conversations like this are so important.

WHARTONBecause pediatricians have a chance when that child is in their office to give them a vaccine that will prevent that young person from potentially having cancer in the future. And that's just too good of an opportunity to lose.

PAGEI'm Susan Page. And you're listening to "The Diane Rehm Show." We're taking your calls, 1-800-433-8850. Let's go to the phones and talk to Jean calling us from Oklahoma City, OK. Jean, you're on the air.

JEANHi. I work in a health care setting. So when this came out, I immediately asked my GYN, should I get this for my daughter. And she told me -- she said, well, I'm on the fence, I'll let you know. A year later, I went back and one of the first things she said was, have you gotten your daughter vaccinated? And I said, well, I'm waiting for you. She said, yes, I'm for it. So immediately I got her vaccinated.

JEANAnd I kept asking -- with the GYN and the pediatric office why not the boys? They're half of this equation. And they kept saying, no, no, no. Now, they want the boys done and my son's too old. He's out of the window. And it seems to me that it's a missed opportunity for a bunch of boys that are my son's age.

PAGEAnd how old is your son now?

JEANHe is 24.

PAGEAnd so, let me ask Barbara. Has he aged out? Is it not appropriate now for him to get this vaccine?

RIMERThe -- I think most physicians would say he should still get it.

WALLINGTONActually, so that the age for boys -- I mean, so they're -- yeah, for boys, the age range is actually nine to 21. That's the recommendation. I would venture to say, however, if you, you know, not sexually active or whatever, you could still get the vaccine if someone's going to give it to you. So I don't necessarily know that you -- because if you haven't been exposed, then, you know, getting the vaccine is still going to be beneficial. But the recommended age is nine to 21, for women up to 26.

PAGESherrie?

WALLINGTONThat's correct. The recommendations for girls is nine to 26 and for boys it's nine to 21. But it's important to remember, only the Gardasil vaccine is only approved for boys.

PAGEAnd why was there a focus, initially at least, on girls, a recommendation for girls and not a recommendation for boys? Melinda, maybe you could address that.

WHARTONYeah. The vaccine was initially -- both vaccines were studied first in young women and girls and then one of the two vaccines was studied in young men and voice. But the initial licensures were just in girls. And so the initial recommendations for vaccine used were focused on girls and young women.

PAGEAll right. Let's go back to the phones. Let's talk to Diana calling us from West Olive, MI. Diana, thank you for holding on.

DIANAHi, Susan. I'm happy to talk to you and your expert panel. And I am a believer in vaccines and would have all of my six grandchildren vaccinated. But I do think that your panel had tended to gloss over the very few possible and very adverse reactions that can occur on rare occasions. And I don't think it's right to present it as a panacea, as was mentioned by an earlier caller, because sometimes there can be these adverse reactions.

DIANAMy friend's granddaughter, Krista, had the vaccine, had a reaction right in the doctor's office and has since lost many, many days of school because of neurological problems. And the pediatrician has just, you know, passed her on to experts. So I do think that people need to know, maybe it's one in a million. But it's wrong to just gloss over the fact that these reactions can possibly occur.

PAGEWell, Diana, that's a good point. I wonder if our panel could address adverse reactions and specifically if there's any kind of finding of neurological problems in response to the vaccine by anyone.

WALLINGTONI just want to say, you know, I don't think that we certainly have glossed over. And I think that we don't say it's a panacea. You know, one of the things I think is important is to talk with parent and adolescents about prevention. We also talk about abstinence. For a lot of young people, that's still a viable option. But for those parents of young people who are in for one, have gotten good information, they feel vaccination is right for you.

WALLINGTONPart of that is, as you say, Diana, is to inform them of the side effects. And the CDC, they track these side effects. They're a good resource for monitoring those side effects as well.

PAGEWe're going to take a short break. We'll be back with more of your calls and questions. Stay with us.

PAGEWelcome back. I'm Susan Page of USA Today, sitting in for Diane Rehm. We're joined this hour by Barbara Rimer, chair of the president's Cancer Panel. And Yolanda Lewis-Ragland, a pediatrician with Children's National Medical Center here in Washington, D.C., and Sherrie Wallington. She's with the Lombardi Comprehensive Cancer Center at Georgetown University Medical Center.

PAGEAnd joining us by phone from Atlanta, Melinda Wharton, director of Immunization Services Division at the Centers for Disease Control and Prevention. Now here's a tweet that we've gotten from Jennifer. She writes, "My concern is that this is a new vaccine, that's the HPV vaccine. I'm a mom of three boys. I trust drugs/vaccines that have been around for a long time with a good track record."

PAGE"So often we hear that new medications are being pulled. How do these vaccines compare to drugs in regards to research and testing?" And, Melinda, this goes to our previous caller who expressed concerns about adverse reactions and said that she knew someone whose granddaughter had had a neurological reaction that's been problematic since she received the HPV vaccine. What would you say to these two listeners?

WHARTONWell, thanks for the question. You know, one of the things that's important to know about vaccines is there's a very high bar for them to be licensed by the Food and Drug Administration. Because they're given routinely to healthy people, there really is a requirement that there be a lot of information on safety as well as efficacy so that those decisions about risks and benefits can be made.

WHARTONSo there were studies done prior to licensure with both vaccines involving thousands of people that since the vaccines have been licensed, there's been more than 60 million doses of Gardasil, which is the vaccine that's most commonly used in the United States, distributed here, and many more millions of doses globally. And there are systems in place that systematically look for patterns and adverse events that may help us identify a problem.

WHARTONAnd soon after we began using HPV vaccine routinely in adolescents, we actually saw a big increase in reports of syncope or fainting post-vaccination. And this wasn't just seen with HPV vaccine. As I mentioned earlier, we also had a couple of other vaccines we were routinely recommending at the same age. And as we began to administer more vaccines to preteens and adolescents, we simply began to get reports of fainting after vaccination.

WHARTONAnd, of course, kids faint. They faint more than younger children do and perhaps more than adults do. And as we began using, giving more immunizations to this age group, more of these episodes were seen. And so we actually really emphasize the importance of giving the vaccine in a way that the young person doesn't get up and stand up immediately after immunization, which would reduce the risk of fainting.

WHARTONAnd, you know, this is a nontrivial matter. People can fall. They can have serious injuries. And there's even occasionally a death due to post-immunization syncope. And, you know, this really isn't vaccine-related, it's about having a medical procedure. And so it can be seen with any procedure given to that age group, we were seeing it post-vaccination. As far as the kind of adverse events people usually are thinking about, there have been a number we looked at and studies done.

WHARTONAnd, unfortunately, we really have not seen any significant adverse events other than the syncope and perhaps anaphylaxis.

PAGEAnd this continuing neurological problem that one of our callers has seen in the granddaughter of a friend, have you seen that in any cases?

WHARTONYou know, there's been more than 60 million doses administered in the United States. So there are things that happened post-vaccination that are seen in people who were recently vaccinated but it doesn't mean they were caused by vaccination. And to demonstrate it was caused, it really needs to be specifically studied. And a number of these outcomes have been studied and we have not found a link to vaccination.

WHARTONBut, of course, it's important that they be reported and be evaluated. And it's very important that people who experience these kinds of symptoms get a good specialist evaluation so that the medical condition is understood as well as possible.

PAGEBarbara?

RIMERYeah. And for this caller and the previous caller, I think we're saying that there should be informed discussions between parents and adolescents and physicians. That parents and adolescents should make informed decisions, but that we need to look at the cost-benefit also. We're talking about preventing future cancers and not just in girls but in boys too. We haven't talked about cancers that affect men and women like anal cancers or cancers of the back of the mouth, oropharyngeal cancers.

PAGEWell, in fact, we have an emailer who's asking about that. He writes -- Robert in New Hampshire writes, "I heard mention of vaccine for boys as well as girls and mention of other cancers. What are we talking about? What cancers does this vaccine prevent?

WALLINGTONIn boys or men, it's related to, as Dr. Rimer just mentioned, penile cancer, also anal cancer, and then also of course head and neck cancers, cancers in the mouth and the upper neck area.

PAGELet's go back to the phones. We'll talk to Pete. He's calling from Wichita, KS. Hi, Pete.

PETEYes.

PAGEPete, do you have a question or a comment?

PETEYes. I was curious what the panel's insights could be on addressing the sector of our society that looks at this as a religious or social issue and that they don't want their children getting vaccinated because it's associated with sexual activities and they don't want to address that.

PAGEAll right, Pete, thanks so much for your call. Who on the panel would like to address that issue? Yolanda?

LEWIS-RAGLANDSo the question is why these callers themselves or why there are some Americans who don't want to get it because it's associated with...

PAGEAnd maybe for religious reasons feel that -- for social or religious reasons feel like it's not a good vaccine to get for their kids.

LEWIS-RAGLANDAgain, so, you know, I make the comment as I made earlier that we do give vaccinations that are associated with sexually transmitted diseases for small babies that I don't know, you know, I believe that we informed them and I'm hoping that this isn't the first time people are hearing that hepatitis B is a sexually transmitted disease, but it is. And we give that vaccine and it's a safe vaccine.

LEWIS-RAGLANDAnd we've given it for years, and there has been, you know, no adverse effects or very minimal adverse effects. And so, this has nothing to do with the license to have sex. This is not about telling children, okay, now that you're vaccinated, go have, you know, go for it. It is, we are protecting you just like we're protecting you against measles, mumps and rubella. We're protecting you against, you know, polio.

LEWIS-RAGLANDYou know, we've practically wiped out, you know, we don't see things like small pox anymore. We don't see things -- there are so many things that we've actually, you know, eliminated because of our vaccination process. And we're the best in the world at doing this. And so, we're in the forefront. And this is why it's here. This isn't about, you know, the activity of the children, this is about protection of the children.

LEWIS-RAGLANDAnd if the pediatricians and the parents can understand that we're really here advocating for your children and your children's health and not really concern about what your children do, you know, behind closed doors, this is not that topic at all.

PAGEBarbara?

RIMERWe also really need to get over the way we, as a society, are stigmatizing sexually transmitted diseases. I mean, 80 million people in this country have HPV infections. That's one in four people. Fourteen million people are infected every year. This is -- it has been called the common cold of sexually transmitted diseases. It's common.

PAGEHere's an emailer Tom who asks, "Shouldn't this vaccine be required for all children entering middle school? And I wonder, I mean, we require some vaccinations for children to go to school. Why is that not commonly required for this one?"

WALLINGTONIn the United States, there have been 41 states that have looked at passing HPV legislation. So we saw Texas have passed legislation, and then also the District of Columbia passed legislation in 2009 that requires girls going into the sixth grade to be vaccinated or opt out. And also, the state of Virginia has passed legislation. But every state is different. And one of the main reasons they pass this legislation in the District of Columbia was because of the high incidents of cervical cancer rates.

WALLINGTONAnd they wanted to make sure that all girls, regardless of their parents' ability to pay would have access to this cancer prevention vaccine. And I want to just get back to the other caller who talked about parents not wanting to vaccinate because of religious or cultural reasons. And I've spoken to many parents in the District of Columbia. And even though they have a strong opposition not just to HPV vaccine but all vaccines, one of the things they really appreciated was the fact they were able to learn more about the HPV virus in general.

WALLINGTONAnd even though they're still not sure vaccination is for them, they really welcomed the opportunity to learn more about what HPV was and the cancers linked to it. So I think that still that type of education is very important.

PAGELet's go to Dave calling us from Indianapolis. Hi, Dave. Welcome to "The Diane Rehm Show."

DAVEHi. Thanks. The question for all of us graying baby boomers, for adults who have been monogamous for decades or even life and have even been tested and know they're HPV negative. If these folks suddenly find themselves single, you know, widowed or divorced or whatever, should they be vaccinated? I'll take my answer off the air.

PAGEDave, thanks very much for your call. So there are age parameters for recommendations. Melinda, tell us what are the appropriate ages to get the HPV vaccine.

WHARTONWell, the vaccine -- both vaccines are licensed for use in older children and up through young adults. But that's based on the age groups that were studied and the age group for which the vaccine is licensed. And individual physician can use a vaccine off label. And if they believe that the risk and benefits are favorable, can certainly use a vaccine off label for an individual patient.

PAGEIf someone is older and gets the vaccine, are there -- I mean, problems with getting it or does it just not work as well?

WHARTONWell, the issue with the vaccine is it only protects you from HPV types that you have not previously been exposed to. And as people get older and just accumulate more exposure, at a population level, the odds are that people have been exposed to more types. But that doesn't mean that an individual necessarily has and even people who have been exposed to one or two types are unlikely to have been exposed to, for example, all four types in quadrivalent vaccine.

WHARTONSo for most people, there would be a benefit. And if they were interested in getting the vaccine, I would encourage them to talk to their doctor.

PAGESo Dave should go talk to his doctor if that's of interest to him you would think?

LEWIS-RAGLANDAbsolutely, absolutely.

WHARTONYes, yes.

PAGEI'm Susan Page. And you're listening to "The Diane Rehm Show." Let's go back, pick up another caller. Sarah is calling us from here in Washington, D.C. Sarah, hi.

SARAHHi. Well, actually it's more a comment. I'm really surprised by how many parents aren't interested in getting their kids vaccinated even if they have doubts about it being 100 percent effective. There don't seem to have any extremely poor reactions to it or really any vaccine in the last, I'm not really sure. I'm sure one of the doctors can tell more than that. When I was on hold, I actually had a phone call from my gynecologist office that I have reschedule a Pap smear because I have to go every three months.

SARAHAnd that's because I have HPV and I did have abnormal Pap smear. And as a result, I have to go every three months for one and also have a colposcopy and all kinds of uncomfortable, painful tests. I would have loved to have gotten the shot when I was younger.

PAGESarah, thank you so much for your call.

WALLINGTONThank you so much, Sarah. And that's an important message that is important that we leave this discussion knowing that the HPV vaccines are a cancer prevention vaccine, an important tool for powerful prevention.

PAGENow here's a reason some people may not get the HPV vaccine. Here's an email from Bob in San Antonio. He writes: "Our general practitioner charges $300 per shot, three shots required, it's not covered by our insurance. This seems really expensive." Barbara, is this be a factor?

RIMERIt should not be $300 per shot. It should be $300 for the three dose series. And I would be very surprised if somebody is charging that amount of money. I'm not doubting the caller, but that's not the cost of the vaccine, right?

PAGEEven $300 for the series is a lot for some families.

RIMERIt is more than other vaccines. But we have really good coverage for kids in this country. So about 40 percent of kids under -- are covered under the Vaccines for Children Program. It's covered under most conditions of the Affordable Care Act. There are some people that fall through the cracks, but we're doing a pretty good job.

PAGEHere's a question that Jonathan sends us by email. "What are HPV vaccination rates outside of the United States?" Melinda, I wonder, is this a problem in other places? Or is this a distinctly American problem?

WHARTONWell, there's a lot of variability in different countries. Two countries that have done much better than we have in achieving high HPV coverage are Australia and the United Kingdom. And in both of them, there's a national program with a single payer and it's been acceptable school based immunization there. So they've actually been able to achieve high coverage among girls in both of those countries.

WHARTONThere's also some developing countries that have achieved high coverage. And, again, it's been primarily based on public sector or school based programs.

PAGEYes, Sherrie.

WALLINGTONAnd, well, Melinda just mentioned about Australia and U.K. and I've looked at some of the research. And one of common themes that you see in these countries is that they have a very well-structured infrastructure for vaccination delivery, school based. And that's something here in the United States, it varies according to states whether or not a very good school based infrastructure. And that's been a big key in vaccination uptake and delivery.

PAGEBarbara?

RIMERAustralia is particularly notable because of the way they've approached it on a central level. So they've had a major campaign with very good kinds of messages that have been broadcast to the entire country. And that was one of the recommendations that we had from the President's Cancer Panel that there should be an integrated national campaign directed at both physicians and at the general public and parents and adolescents.

PAGEBecause it's been a surprise, I suspect, to medical experts like yourself that this has become such a difficult thing in the United States.

RIMERIt's very unfortunate because we're taking our eye off, really, what all the panel has upset which is the potential benefit of preventing cancers.

PAGEI want to close with an email we've gotten from Diane. She writes, "I'm an anal cancer survivor, which is due to HPV. The vaccine would have protected me from this. However, it wasn't available to me since I'm over 26. I had to go through six weeks of radiation and chemo. The treatment is awful and has left life-long effects. Every girl and boy should get this vaccine." Diane, I want to thank you very much for your email.

PAGEAnd I want to thank our panel for this interesting discussion this hour. Barbara Rimer, Yolanda Lewis-Ragland, Sherrie Wallington, and from Atlanta, Melinda Wharton, thank you all for being with us.

RIMERThank you.

WALLINGTONThank you for having us.

LEWIS-RAGLANDThank you so much.

PAGEI'm Susan Page of USA Today, sitting in for Diane Rehm. Thanks for listening.