Doctors are urging parents to vaccinate girls as young as nine against human papillomavirus, a sexually transmitted disease that can cause genital warts and cervical cancer.
But some parents aren't only weighing the decision of having their daughters vaccinated with the costly medication. For some, the choice is an ethical dilemma as well.
"I think the issue is: When is the best time -- the most effective time -- to give the vaccine and do you want to give your daughter that protection?" said Dr. Renee Jenkins of the American Academy of Pediatrics.
Three in four Canadians will have at least one HPV infection in their lifetime. HPV, the primary cause of cervical cancer, is also linked to vaginal, vulvar and anal cancers.
The best time to vaccinate for HPV, many experts say, is before girls are sexually active.
"Most women with HPV clear the infection on their own, but in some it causes cell changes that over time lead to cervical cancer," Dr. Dianne Miller, head of the Division of Gynecologic Oncology at the Vancouver Hospital and Health Sciences Centre said in a written statement. "In order to protect against this possibility, parents should be supported in their decision to immunize their daughters against HPV."
In recommendations released in late January, the National Advisory Committee on Immunization (NACI) said Canadian girls aged nine to 13 who have not yet become sexually active should be immunized with Gardasil, a vaccine that protects against four strains of HPV.
Gardasil, made by Merck and Co. and approved by Health Canada last July, protects against strains that are responsible for about 70 per cent of cervical cancer and 90 per cent of genital warts.
The committee said that females from 14 to 26 would also benefit from the vaccine even if they are sexually active, since it is unlikely that they will have been infected with all four HPV types in the vaccine.
"Because of NACI's position, vaccination against diseases caused by vaccine specific HPV types will now become the standard of care for cervical cancer prevention," said Dr. Joan Murphy, chair of the GOC Task Force on Cervical Cancer Prevention and Control.
"Cervical cancer and its precursors remain a significant health problem for Canadian women and we call upon the provincial governments to rapidly implement vaccination as a cancer prevention strategy against HPV types known to cause the majority of cervical cancers," she added.
Studies have shown that the vaccine, which is available in Canada, is 100 per cent effective at preventing disease from the HPV types that account for 70 per cent of all cervical cancers and 90 per cent of genital warts.
However, Gardasil is not recommended for girls under age nine, for males or for pregnant women.
U.S., Canadian differences
The Canadian committee's recommendations differ somewhat from those of its American counterpart.
The U.S. Advisory Committee on Immunization Practices issued guidelines in June suggesting that all 11- and 12-year-old females be routinely vaccinated against HPV, while girls as young as nine could get immunized at the discretion of their doctors.
In Texas, Gov. Rick Perry signed an order on Friday requiring that schoolgirls between the ages of 11 and 12 get vaccinated with Gardasil. The order will start in September 2008.
While Perry is a conservative Christian, he said the vaccine is no different that immunizing children against polio.
Some states have already implemented legislation requiring girls in the sixth grade to be vaccinated for HPV unless their parents opt out.
Until vaccination programs come into force, Canadians can obtain the vaccine through their physicians, but will have to pay for it themselves.
When Gardasil was approved last summer, a Merck Canada spokesman said the vaccine was expected to cost about $135 per dose, with three doses over six months needed to confer full immunity.
"We do a lot of things to protect our kids, educate our kids, feed our kids, and this is just one of those things we can do to protect them," said Dr. Robert Lotocki, a gynecologic oncologist at Cancer Care Manitoba.
But many parents say it's not the dollars that concern them, it's the discussion about sex.
"I don't see kids knowing that much about it in the first place, so you know, you're exposing them to something a little too early," one said.
Still others say the vaccination is about protection, and not about pride.
The question now is whether provinces and territories will take the next step and include HPV vaccination as part of their publicly funded immunization programs.
Historically, provinces and territories have often followed the national committee's guidelines on immunization.
"It is our hope that provincial health authorities will adopt a population-based vaccination strategy, combined with organized screening programs and a vaccine registry, which will have the greatest positive impact on cervical cancer prevention for all Canadian women," said Dr. Diane Provencher, chief of Gynecologic Oncology at Notre-Dame Hospital in Montreal and past President of GOC.
An expert working group, which includes members of NACI and the Canadian Immunization Committee, will be putting together recommendations on implementing HPV vaccination programs.
The group hopes to have its report ready by the end of this year.
Cervical cancer is the second most common cancer in Canadian women aged 20 to 44 after breast cancer.
An estimated 1,400 women are newly diagnosed with cervical cancer each year and more than 400 women die because of it.
With a report from CTV's Jill Macyshon
