THE IMPORTANCE OF REGULAR GYNECOLOGICAL VISITS vs. HPV VACCINATION 

Publicado por DigitalConnection no dia 2.01.2020

Ivone Mirpuri – 12/2019

INTRODUCTION

Over 10 years ago I wrote a bibliographical review in regard to vaccination against HPV. At that time, I decided not to vaccinate my children. All these years later, and because I continually see my patients being advised to get the vaccine, even after age 50, which really baffles me, I have decided to do a second bibliographical review. My opinion holds, but now even more consistently.

In this brief article I will explain why.

When doing research, we should not only look for the strong points. We should also look for the weak points that defend or refute our position because in truth, the weight that these two points carry should be analyzed in order for us to reach a decision.

My research would be endless, if I were to actually treat these women but my role is simply to guide them to seek a gynecology consult regarding this issue. Therefore, this is only my informed opinion, after extensive study on the topic, in order to enable me to correctly clarify women who seek out my services, and whom I treat in my area of specialization: hormonal modulation and healthy aging.

On the other hand, HPV has been documented to be the second most deadly neoplasia after breast cancer in young women. This is a fact when we analyze this data statistically on a global level. Taking into account the countries where the prevalence is greatest, and given what little primary and secondary prevention is available, there, the vaccine would in fact be justified. Poor and underdeveloped countries. Amongst the new cases, 84% can be found in these countries. (WHO website). Over 85% of deaths related to cervical cancer also originate there. (WHO website).

These are the women who should be vaccinated and are not. Furthermore, they should because they have no other form of prevention – primary or secondary.

In Portugal, the number of cervical cancer related deaths per year, before the vaccine was included in the National Vaccination Program (NVP) in 2008, was 200. (12) In 2018, 10 years after the HPV vaccine’s introduction into the NVP, the number of cervical cancer related deaths was close to 340 (9), a 75% increase. There is therefore a substantial increase amongst a population who inoculated close to 85% of the target population during the first 10 years of the vaccine’s introduction. (11)

Why did this happen if the vaccine is effective in protecting patients from the strains it contains and the program was a success after reaching its vaccination objective? I believe the most logical explanation is the lack of vigilance associated to the false protection that the vaccine offered.

The majority of women who have cervical cancer are not monitored. Many go as long as more than five years without being observed by a physician. Hence, the importance of regular gynecological checkups. Getting the vaccine is a “green light” to let up on regular visits to the gynecologist because patients believe they are protected against the “the greatest cause of cervical cancer , which kills so many it is the second cause of death across the globe after breast cancer”. I have already explained that this much disclosed piece of news by the media, leads many to interpret it incorrectly.

Globally, 70% of cervical cancer cases result from the persistent infection of HPV strains 16 (20%) and 18 (50%), which are protected from the vaccines currently used. (1) This is true but only if the patient was vaccinated before any contact. (1) The vaccine is preventive but it does not treat the disease. Hence, why we advise women between the ages of 9 and 26 to get the vaccine. After initiating sexual intercourse, over 80% of the population is estimated to have had contact with the HPV virus. If people are regularly monitored they will be treated and the body will resolve over 90% of cases on its own in only two years.

The vaccine is recommended between the ages of 9 and 10. Close to 7.5% of children initiate sexual intercourse before the age of 12 (! World Statistics once more. Is this the solution as opposed to sexual education? Is this the solution for a future happy emotional life? Some studies indicate lower birth rates in women who have been vaccinated. I doubt the reason is infertility. I am more inclined to think that the lives they have led did not encourage them to become mothers. I am not saying that the vaccine is a passport to promiscuity but the false freedom the vaccine confers has grave consequences in a young woman’s physical and emotional development.

In Portugal, 49.3% of adolescents between the ages of 15 and 19 had already had sexual intercourse (2005 data). (11)

There are however other high-risk genotypes such as 35, 39, 51, 56, 59, 68, 73 and 82. (Skeate et al, 2016) which are not included in any vaccine. (2) The vaccine offers no protection against these, nor does it grant cross-reactivity, therefore populations with a greater frequency of these serotypes are not protected by the vaccine. (2)

This happens for example in Latin America.

In Portugal the most common strains are in fact 16 and 18, which are those responsible for the great majority of cervical cancer tumors. (9)

The HPV Information Centre published a World report on Europe and Portugal, which has been available online since June 2019 and can be accessed and consulted. (6), (7) and (8).

HPV

HPV, constitutes a group of DNA viruses with close to 200 genotypes as we have already seen. These viruses infect mucous epithelial membranes and skin. Close to 40 of them have the capacity to infect the genital tract and there are close to 15 HPV serotypes (species) capable of infecting the genital tract, as well as triggering malignant tumors, especially in the cervix. These are known as the high risk viruses.

HPVs capable of developing tumors are known as high-risk (oncogenic); the other, low-risk ones are called non-oncogenic. Two of the low-risk ones, serotype 6 and 11, are the one responsible for the appearance of common warts (condiloma acuminatum) but other low-risk one may not provoke a visible legion.

HPV is also responsible for other diseases such as recurring juvenile Laryngeal papillomatosis. (9)

VACCINES

The vaccine is made up of a non-infectious component present in the virus particle L1, which is a major structural particle of the viral structure. L1 triggers the formation of neutralizing anti-bodies when connected to particles similar to the virus (VLPs – Virus Like Particles) from various serotypes, according to the vaccines, which inhibit the development of the. pathogenic agent when in contact as they are able to recognize the virus through this tiny particle. (3)

We must keep in mind that the vaccine is preventive and not therapeutic. The tumoral cells do not manifest the L1 protein in significant quantities that would warrant a response to the vaccine that uses the protein responsive to the tumor.

The two best known vaccines against HPV are Gardasil (Merck), approved in the European Union and in the USA in 2006, and a Cervarix (GSK), approved in the European Union in 2007. (3) We have had very little time to evaluate its efficacy in the long term. (2)

As a Clinical Pathologist, one of my main concerns is chemical reactions. I have not found any studies on a micro-molecular level to explain what the vaccine triggers in the human body in regard to auto-immune stimulus, the release of inflammatory cytokines, and other chemical processes that may develop when we inoculate our organism with strange particles. I have not detected anything in regard to the passing of the brain-blood barrier, or any action on the cells of the nervous system, activation paths and chemical inhibitions.

All vaccines contain an adjuvant to aid in the immune response. Gardasil 4 contains 225 ug of aluminum hydroxide. Gardasil 9 contains double, 500 ug. (Gee et al, 2016).

Cervarix contains its “own” adjuvant, ASO4, which in addition to aluminum salt also contains 3-O-Desacyl monophosphoryl lipid A (MPL), which is even more powerful. Since AS04 is an originate component we are still unaware of the reactions it may trigger in the long term.

Cervarix is a bivalent vaccine produced in the cells of insects, composed of L1 VLP of HPV 16 and HPV 18. These two types are responsible for close to 70% of cervical cancers.

Gardasil 4 is a quadrivalent vaccine that is produced in yeast, containing HPV 16, HPV 18, HPV 6 and HPV11 VLPs. The latter two are responsible for over 90% of genital warts.

Gardasil 9 is a nonvalent vaccine, which contains over five frequent high-risk serotypes more than Gardasil 4. (It contains HPV 6, 11, 16, 18, 31, 33, 45, 52 and 58 VLPs).

Both were administered in three doses during a six month period. Starting in 2018, they started administering only two doses in populations ages 9 to 14, and in three doses in populations over age 15.

Both confer seroconversion in over 99,5% of those vaccinated, as long as there has been no previous contact with the viral strand. (3)

The vaccine’s prophylactic protection appears to be long-lasting, although it has only been used clinically for 11 years.

Despite its efficacy in disease prevention and future infection, the vaccine does not cause the already established lesions to regress. (3)

Cross-protective immunity occurs only between serotypes 16 and 18, which are the most similar, (3) contrary to what many believe.

ADVERSE REACTIONS

There is no general consensus regarding vaccination amongst all countries; in Canada, Brazil, Mexico and Argentina the stipulated number of vaccinations is much lower than desired.   

This because many negative adverse effects have been associated with vaccination.

In Colombia moreover, suicides were registered after vaccination (Tabackman 2017).

After its introduction, Japan suspended the recommended immunization against HPV in 2014 (Larson et al, 2014). This decision was reached due to cases of chronic pain and other symptoms. (2)

I believe they have not yet reintroduced it.

The most frequently reported after-effects from Gardasil are: pain, swelling, bleeding, inflammation of the injected area, headaches, fever, nausea, diarrhea, abdominal pain and syncope.

Reactions related to Cervarix are in over 20% of cases local, as with Gardasil where over 20% of the general complaints are related to tiredness, myalgias, gastro-intestinal symptoms and arthralgias.

The most frequent symptoms in one or the other vaccine include chronic pain such as paresthesia, headaches, fatigue and orthostatic intolerance (Martines-Lavin 2015).

Up till now all is well because these reactions are common in other types of vaccines, and would not be serious if they were not more persistent.

But in fact, over 93% of those affected by these symptoms continue to be so for over four years resulting in the incapacity to return to school or work. (Tomljenovic et al, 2014, Martinez-Lanvin et al, 2015) (2)

Chronic arthropathy has already been associated to other vaccines such as Rubella and Hepatitis B.

In the meantime, the WHO considers the vaccine to be “safe”, as it was not proven that it caused the symptoms referred to above, and which led Japan to abolish the vaccine from its vaccination program.

Despite the vaccine being deemed safe, Colombia reported a disproportionate number of cases of neuropathic pain far superior to that reported by the company that produces Gardasil. (Sanchez, Gomes and Hernadez-Florez 2014) (2)

We should also take into account that the number of demyelinating disease reported after vaccination is not insignificant. It has also been reported with other vaccines.

The term ASIA (Autoimmune/Inflammatory Syndrome Induced by Adjuvants) encompasses symptoms associated to the adjuvant used and includes symptoms such as fever, myalgia, arthralgia and arthritis. With the HPV vaccine we observed 3,6 cases for every 100.000 doses of HPV. Since the dose for Gardasil is more powerful, the expected number is higher, and if there is a pre-disposition for an auto-immune disease in an individual, the more powerful dose should be taken into account given the potential risk. (2)

Colombia does not vaccinate women with this predisposition. (2)

Cases of Auto-immune Thrombocytopenia with antiphospholipid antibody syndrome after being vaccinated for HPV have also been documented. (Bizjak et al, 2016)

Other reported reactions included Retinopathy (Ogino et al, 2014) (2), which is thought to originate from autoimmune phenomenon.

Side effects should however by closely observed and accurately reported in order to guarantee that the vaccine’s benefits outweigh the dangers. (2)

But we doctors are not accustomed to reporting these adverse effects.

Deafness after taking Gardasil is frequent yet it is not reported as an after effect.

Neurological signs, which make up about 50% of the signs that persist, are reported and we all know of these cases.

Parents, due to lack of information, in most cases “do not associate”, or if they “do associate” do not have a voice, and often doctors will not admit to it because they most likely recommended vaccination. Furthermore, doctors will continue to recommend it or else they risk being “segregated” by other doctors.

I believe that only if the parents of children who have been affected speak up, will there be change.

It does not make sense to vaccinate children against diseases that are not common to children. Especially when their immune systems are more fragile and immature. Adverse reactions are in fact more common in children than in adults.

A COMBINATION OF FACTS

Risk factors for infections from HPV include a genetic predisposition, immune status, co-infections along with other sexually transmitted diseases and smoking. (2)

Also multiple births, precocious sexual activity, multiple sexual partners, the long-term use of ACO, HIV infections or other causes of immunosuppression are also risk factors. (3)

Persistent infections from this virus are not only associated to cervical carcinoma (frequently serotypes 16 and 18) but also to the oropharynx, anus, vulva, vagina and penis, and in the case of serotype 16, the head and neck. (2) and (9)

These tumors are also increasingly frequent in our country and yet Portugal prides itself on an efficient and comprehensive National Vaccination Plan. The vaccine was introduced 11 years ago. 

We also know that 90% of these lesions auto-correct themselves, in other words our body sorts them out.

Alterations of a lesser degree that are cytologically observed, in most cases, develop rapidly after infectious contact. These lesions of a lesser degree are detected through a routine cytology (ASC-US, LSIL or CIN1). In most cases, these small alterations regress.

5 to 15 years later, depending on the sensibility and intensity of the screening method used, a lesion of a higher degree, called CIN3, may then develop.

Progressing from a CIN3 to a more invasive tumor make take many years or even decades. (3)

The interval between initial contact to higher degree is usually lower that the interval between higher degree and tumor.

If during the decades it takes for the tumor’s potential development during which the woman should have been monitored (actually since she initiated her sexual activity) these alterations have not been detected, then determined virus particles will incorporate into the epithelial cell’s own genetic material and lead to the development of a tumor.

In truth, a “virus” has never been observed in lesions, only parts of the virus, fragments E6 and E7. There are even those who call into question the etiology of the tumor by HPV. The truth is that protection is conferred by neutralizing antibodies against another protein, fragment L1, associated to the VLPs we have already discussed. These are specific to each serotype and the vaccine offers protection from the development and progression of the disease, in case contact comes after vaccination. 

Therefore if we are regularly monitored by a doctor, early detection, adequate treatment and most probably a cure will be the outcome, instead of running the adverse risks associated to the vaccine or long-term effects not yet known to us.

Some will say that it is not pleasant to have condylomas. I would agree. But only one of the vaccines protects us from serotype 6 and 11, which are associated to condylomas, and most infections are not of this serotype. Considering the risks of vaccination, and the probability of prevention, I do not even consider vaccination valid for these cases. In addition, close to 10% of genital warts are not protected by vaccination. (3)

We are injecting a risky product to eventually protect us from a situation we can avoid in another way.

The interval for lesions to develop is between 5 and 20 years but as we have previously seen, and to reiterate, it also depends on associated risks such as decreased immunity, smoking, medication, stress, acute or chronic physical or mental illness and multiple sexual partners. In these cases, patients must be more closely monitored, and we recommend a visit to the gynecologist every six months.

The term for evaluating a vaccine’s efficacy is 15 years. And what is written everywhere, if we look, is the exponential burden of the HPV infection, post vaccination. (9)

If time cures most lesions, women are monitored by their physicians and treatment started early, be it with Coriolus Versicolor (which is apparently unknown to many people, even doctors, given the ridiculous comments I have heard) even though many gynecologists already use it with it with cryotherapy, which of course depends on the degree of the lesion, then why do we need to administer a risky vaccine to these women?

If we were in a third-world country, with no access to good or bad information and with no primary or secondary prevention, my opinion would obviously differ.

Because 7.5% of girls initiate their sexual activity before the age of 12, we recommend the vaccine between the ages of 9 and 10.

Data from 2005 in Portugal reveals that close to 50% (49,3%) of youths between the ages of 15 and 19 have already initiated their sexual activity. (9)

I absolutely disagree with this measure. At this rate, one day soon we will be vaccinating our girls at birth instead of giving them consistent sexual education from an early age. It has always been my philosophy to prevent, not remedy. And the earlier we vaccinate our children, the greater the risks, given the fragility of their immune systems.

The risks associated with vaccination may be mild as we have seen (inflammation of the injection site, tiredness and lypothymia) but they can also range to severe neurological signs and exponentially death. Even a simple mosquito bite can have similar consequences. True.

But as we have already seen, if the nervous system is affected, the neurological signs persist, incapacitating the patient who is often quite young.

How often do we report adverse reactions we have had to medication to Infarmed (the Portuguese Authority for Medicine and Health Products)? These adverse effects are the third leading cause of death in the United States after cardiovascular disease and cancer. (British Medical Journal, 2016)

I believe very few have actually reported reactions unless the adverse effect was extremely serious. The Infarmed website warns us to report only grave side effects, and by grave they mean death. If this has already happened in Portugal, it was not related to the vaccine.

During the study that tested the efficacy of Gardasil 9, seven deaths were reported. “None was related to the administration of the vaccine.” (15,776 people vaccinated ages 9 to 26). (14)

Doctors often do not admit that the adverse effects are related to the vaccine.

This vaccine’s grave adverse effects are, in over half the cases, neurological, incapacitating and limitative.

The truth is that in countries that massively vaccinated their youth population when the vaccines were first introduced experienced an increase in risk in the following decade as opposed to those who opted not to get the vaccine. These can now function as the control group, as France has. (5)

PRIMARY AND SECONDARY PREVENTION FOR INFECTION THROUGH HPV AND CERVICAL CANCER

Secondary prevention means monitoring these women regularly with the aim of detecting and treating early any observed lesions before they progress into a tumoral state.

Consequently, the cytological (Papanicolaou) exam in industrialized countries has greatly reduced this tumor’s incidence. An annual cytology exam, as well as a gynecological medical is also essential. It is never enough to emphasize the importance of regular gynecological exams once sexual activity has started.

If tumoral lesions continue to increase then the method is failing. This is not what should be happening in developing countries.

A Cytology exam is a simple and economic method.

But vaccinated children who have initiated their sexual activity (yes, we vaccinate children, and as we have seen they start having sex at an increasingly early age) believe they are protected, and therefore, do not go to a gynecologist. They do not even know that they should go nor do they ask their parents to take them. If there were good communication between parents and children maybe this, and initiating their sexual activity so prematurely would not happen.

All the works I consulted regarding a cost-benefit analysis indicated that the vaccine is cost-effective. However, they do not take into consideration the vaccinated population’s neglect for secondary prevention. Thereby, long-term projections are not verifiable. The truth is we are finding an increase in the infected population after the introduction of the HPV vaccine in the National Vaccination Plan (NVP). (9)

If periodic monitoring is failing, the solution is to put into play a more effective primary prevention, educate the population, instead of searching for solutions to problems that will never be solved but will  lead to a sick and unproductive society.

Given the belief that all HPV infections are responsible for most cases of cervical cancer, it is urgent to implement primary prevention to reduce this one, as well as all the other types of cancer attributed to HPV.

The objective of primary prevention is to avoid or remove casual or risk factors before they can develop into the pathological mechanism that leads to disease.

Primary prevention should be given to children, adolescents, young adults and even their parents. Basically the entire population should receive this care with the aim of diminishing the disease by teaching them associated risk factors, the importance of secondary prevention stressing its huge importance. Above all, regular visits to a gynecologist must be stressed.

The vaccine is primary prevention but it has, as we have seen, associated risks, and is expensive. Gardasil, which protects against nine serotypes, costs close to 140 Euros and Cervarix, which protects against the two most frequent serotypes, 16 and 18, costs 72 Euros.

The vaccine does not protect against all serotypes. Secondary prevention is also needed; especially since in the immature minds of our youth, the vaccine appears to offer a false sense of security leading them to think that being monitored by a gynecologist and having a cytological exam are unnecessary. The vaccine must always be complimented by regular cytology exams! What do we gain when the risk of changing our lives negatively forever is so great? With good primary and secondary prevention, we can avoid the unfortunate after effects of spending millions, not to mention the elevated moral cost involved.

Primary prevention, aside from vaccination, is hard to implement because it would entail giving children a more solid structural/emotional sexual education with the aim of reducing the number of sexual partners they have, and increasing the age they initiate their sexual activity. Furthermore, many parents and teachers neglect their roles as educators.

Campaigns for raising awareness geared at the population, especially girls who are about to initiate their sexual activity, are fundamental. This should be happening between parents and children, at school and in the media.

Using a condom does not offer adequate protection. Circumcision amongst boys appears to confer a certain degree of protection but it does not significantly decrease the incidence. Reducing the number of sexual partners people have would obviously be an excellent form of eventually reducing the incidence of infection.

Vaccination is also an integral part of primary prevention and will play a very important role in developing countries where primary prevention and even cytological screening fail.

But in Portugal I believe we could further reinforce primary prevention without vaccinating children this young and investing more in screening awareness.

Vaccination would be more adequate for older adolescents or young adults who have more mature immune systems, and should be given before initiating sexual activity after weighing some factors and explaining the need for continued screening. Just because children are having sex at a younger age, this is no reason to vaccinate them so young. At this rate we will be vaccinating them at birth, as we did for hepatitis B, which made no sense whatsoever for this age group especially since the disease is not at all prevalent during childhood. The detriment is that the younger the child, the greater the accumulation of aluminum adjuvant, in addition to the amount already present resulting from the needed vaccines for the childhood diseases and an immature immune system.

Vaccination is also an integral part of primary prevention and will play a very important role in developing countries where primary prevention and even cytological screening fail.

But in Portugal I believe we could further reinforce primary prevention with vaccinating children this young and investing more in screening awareness.

Perhaps vaccination is fundamental when we are dealing with a family where we know that the lack of dialogue between parents and children will place them at risk. In Portugal, there is a structured National Healthcare System.  It is true that we are lacking in family doctors in many regions but vaccination will not decrease the incidence of cervical cancer and the mortality associated to it. A lack of periodic monitoring will because the number of deaths resulting from cervical cancer has almost doubled in the 10 years following vaccination.

I would like to stress the importance of testing to detect HPV, forcing in this way women to be regularly monitored, and if needed seek early treatment thereby preventing the development of cervical cancer.

Searching for HPV-DNA using PCR is a very sensitive test if positive for up to two years with a high CIN degree elevated diagnostic predictive value in the following five to 10 years.

CONCUSION

Doctors should be motivated by their patient’s well-being. Awareness of an effective plan for combating cervical cancer in Portugal is the objective for all of us.

I do not support any “anti-vaccination movements”; I advocate for mandatory vaccination in childhood. There is the danger of adjuvants but these diseases are common in this age group. We therefore have to believe that they are important.

Today, we relate autism with the exaggerated quantity of aluminum that we give children through vaccination. Then let’s only vaccinate children against the infections that are frequent in children. I think we need not administer others.

I am opposed to some such as HPV, and Hepatitis B at birth an absurdity since the immune system is not sufficiently developed to offer up a response. Actually, the greater problem is exactly this. The earlier we administer these vaccines, the worse it is as I’ve previously referred. Someday soon we will be doing with the HPV vaccine what we did with Hepatitis B.

I have direct contact with a young girl who developed chronic juvenile arthritis four weeks after being vaccinated for hepatitis B before the age of one. She has been on immunosuppressant medication since then. The doctor who oversees her care never associated the two but to me it is obvious that her disease was an immunological reaction to the vaccine.

This same girl grew up and was advised to get the HPV vaccine as well. She already had a history of uncommon immunological reaction that was not valued. Shortly after she became deaf, uses a hearing aid at the age of 26 and has some mechanical limitations. Not so much, thanks to God.

The girl has learned to live with her handicaps. But the stress her parents and the entire family faces is not lightened upon seeing the child’s limitations. And this is a mild case; we can find numerous grave cases on the Internet, videos on YouTube made public by those who have no other voice. And we cannot dismiss them simply because they are not on PUBMED.

I would like to make it clear that what I strongly disagree with is giving a vaccine to eradicate a virus with grave risks and adverse reactions that is linked to sexual contact (It does not eradicate the virus. There are 35 high-risk serotypes yet no vaccine for all 35 serotypes). People need to realize that what needs to be done is educational primary and secondary prevention paired with regular gynecological monitoring, as well as teaching youngsters about STD prevention, which the vaccine alone does not.

I also advise you to read more about Coriolus Versicolor, which has been used for years by Chinese Medicine and appears to be highly effective in lesser, lower degree HPV infections.

According to Dr. Silva Couto from Coimbra’s Portuguese Oncology Institute, who conducted a study in 2008 in 40 patients with low-grade lesions, who followed a treatment protocol comprised of six pills per day during one year and regular exams every three months. “At the end of the trial, 72,5% of patients no longer presented any lesions and in 90% of cases the virus had disappeared” (sic). “This mushroom’s great advantage is in possessing a non-specific action”, says Dr. Silva Couto. “It does not target only one virus strain but it is effective in creating immunity against all virus types.”

Today many doctors are using it.

After all I have read and studied, I have reached the conclusion that it is much more productive and effective to have cytological exams and regular gynecological visits than spending money on a vaccine that presents consequential risks.

Returning to the beginning, I started to write and study about this topic because I systematically see women in menopause who are advised to get this vaccination. In my informed  opinion, it continues to make no sense because of what I have discussed above.

“The only thing necessary for the triumph of evil is for good men to do nothing.” Martin Luther King

  1. Prophylaxis of Cervical Cancer and Related Cervical Disease: A Review of the Cost-Effectiveness of Vaccination Against Oncogenic HPV Types
  2. Discrepancies in the evaluation of the safety of the human papillomavirus vaccine Jorge L Cervantes + and Amy Hoanganh DoanHuman Papillomavirus and Related Diseases Report PORTUGAL Version posted at www.hpvcentre.net on 17 June 2019
  3. HPV infection and the primary and secondary prevention of cervical cancer Douglas R. Lowy,1,* Diane Solomon,2 Allan Hildesheim,3 John T. Schiller,1 and Mark Schiffman3
  4. HPV vaccination and risk of chronic fatigue syndrome/myalgicencephalomyelitis: A nationwide register-based study from NorwayBerit Feiringa,, Ida Laakea, Inger Johanne Bakkenb, Margrethe Greve-Isdahlc, Vegard Bruun Wyllerd,Siri E. Håberge, Per Magnusf, Lill Trogstad
  5. Paradoxical effect of anti-HPV vaccine Gardasil on cervical cancer rate, January 2019, Dr G Delépine, oncologist, surgeon
  6. Human Papilloma Virus and related diseases report, HPV Information Centre, World report, Junho 2019
  7. Human Papilloma Virus and related diseases report, HPV Information Centre, Europe report, Junho 2019
  8. Human Papilloma Virus and related diseases report, HPV Information Centre, Portugal report, Junho 2019
  9. Safety of quadrivalent human papillomavirus vaccine administered routinely to females, Klein NP, et al, 2012
  10. WHO- site
  11. A 10-year history of the HPV vaccine in Portugal in the NVP. HPV Vaccination in Portugal, Technical Vaccination Commission, 2018. (A história dos 10 anos da vacina HPV no PNV A vacinação HPV em Portugal, Comissão Técnica de Vacinação, 2018)
  12. First study conducted in Portugal on indentifying the genotypes of the Human Papiloma Virus (HPV) amongst a sexually active vaccinated female population (Primeiro estudo em Portugal sobre a identificação dos genótipos do vírus do papiloma humano (HPV) numa população feminina vacinada com atividade sexual), Raquel Rocha, HPV Vaccine Study Group (Grupo de Estudo da Vacina do HPV), Nuno Verdasca, 2017
  13. High-Risk human papillomavirus genotype distribution in the Northern region of Portugal: Data from regional cervical cancer screening program, Hugo Sousa et al
  14. Safety Profile of the 9- Valent HPV Vaccine: A combined Analysis of 7 Phase III Clinical Trials Edson D Moreira et al, 2015