Circumcision and Vaccines: Twins Separated at Birth?

December 18, 2014

If we had a vaccine that was as effective at reducing HIV infection as circumcision, it would be a recommended vaccine here in the US, argues this pediatrician.

More similarities exist between circumcision and vaccines than you might think. Just as vocal anti-vaccine groups exist, so do anti-circumcision groups. Both factions tend to be extremely passionate about their beliefs. The CDC has stirred up the anti-circumcision groups with its recent draft recommendations, which suggest that health care providers counsel parents and uncircumcised older males on the health benefits of the procedure. The CDC did, however, stop short of saying all babies should routinely be circumcised Some arguments against routine vaccinations and circumcision overlap: “forcing something on an infant who can't decide for himself,”. . .  “it's only being done so doctors/vaccine companies can make money,” and  . . . “it's not natural” are comments of both the “Anti” camps.

Let’s now look at another similarity between circumcision and vaccines that actually led the CDC to its draft proposal: both reduce the risk of infectious disease. A meta-analysis of multiple studies done in Africa in heterosexual males in high prevalence areas for AIDS showed a significant reduction in risk for contracting HIV (44%) among circumcised males as compared to uncircumcised males.1 The risk reduction was highest (77%) in men at high risk-such as patients from STD clinics.

Critics of the CDC's tentative recommendation argue that studies done in Africa on HIV transmission don't apply to the US where transmission patterns are different. Nevertheless, heterosexual transmission does occur in the US.

If we had a vaccine that worked this well against HIV infection, I have no doubt it would be a recommended vaccine here in the US. About 10% of the roughly 50,000 new HIV infections in the US each year occur in the heterosexual population, but circumcision seems only to be helpful for the circumcised male heterosexual. The CDC fact sheet points out that studies do not consistently show any benefit of male circumcision in the male-to-female or male-to-male transmission of HIV.

In addition to reducing the risk of HPV disease, circumcision has been shown to significantly reduce the incidence of genital HSV type 2 as well.2-5 Studies are mixed about whether the risk of acquiring syphilis is reduced in circumcised males.

We have 2 vaccines that reduce the risk of cancer (HPV and Hep B). Circumcision also reduces the risk of cancer. Over 60% of American men are currently circumcised, but 98% of invasive penile cancers and 84% of in situ penile cancers occur in uncircumcised males. Prevalence studies show circumcision appears to lower the risk of harboring carcinogenic subtypes of HPV. It is not clear whether this is because of lower acquisition rates or reductions in persistent infection-or both. HPV causes 100% of cervical cancers (still about 3,500 deaths a year in the US), 90% of anal cancers (the cause of Farrah Fawcett’s death), 60% of oropharyngeal cancers (Michael Douglas's type of cancer), and 40% of penile, vaginal, and vulvar cancers. Reducing the spread of oncogenic HPV types should reduce the prevalence of these cancers. 

Another small benefit of being circumcised as a neonate is the reduction in risk of UTIs in early life.

Do all these benefits add up enough so that health care providers should urge this procedure like we do for vaccines?

Each provider needs to look at the data and decide for him/herself. In any event the data should be presented to the parents who will ultimately be responsible for making the decision. As with vaccines, if a parent doesn't want it, the child doesn't get it in spite of what we recommend. 

The American Academy of Pediatrics actually looked at the data and came to the same conclusion in 2012 when its guideline on circumcision was released.

Health benefits from circumcision outweigh the small risks from the procedure. Circumcision costs should be covered by insurance plans. Parents make the decision.

The CDC tentative guidelines encourage a discussion between the un-circumcised adolescent and his health care provider about the benefits and risks of circumcision. The risks and expense of circumcision are certainly higher at this age. However, including the person to be circumcised in the discussion obviates one of the primary objections of the anti-circumcision groups: that the procedure is being done to someone who cannot provide consent.

Circumcision and vaccines are obviously not identical twins separated at birth . . . more likely they are fraternal. Deciding whether to circumcise your boy tends to include a lot of considerations beyond health benefits. Religious, cultural, familial (“I want him to look like his dad!”), and even geographic factors (reduced rates in western US versus east coast). Pediatricians spend a lot of time talking about vaccines. Given the publicity generated by the CDC release, I suspect we're going to be spending a little more time talking about circumcisions now.

When I talk with a prenatal couple, I’m always glad when I hear a baby girl is inside mom. Inside me is a little voice shouting , “Hooray, no circumcision discussion!”

 

      

 

 

References:

1. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS. 2000;14: 2361-270.

2. Sobngwi-Tambekou J, Taljaard D, Lissouba P, et al. Effect of HSV-2 serostatus on acquisition of HIV by young men: results of a longitudinal study in Orange Farm, South Africa. J Infect Dis. 2009;199:958-964.

3. Tobian AA, Serwadda D, Quinn TC, et al. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med. 2009; 360:1298-1309.

4. Sobngwi-Tambekou J, Taljaard D, Nieuwoudt M, et al. Male circumcision and Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis: observations after a randomised controlled trial for HIV prevention. Sexually Transmitted Infections. 2009;85:116-120.

5. Background, Methods, and Synthesis of Scientific Information Used to Inform the “Recommendations for Providers Counseling Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV infection, STIs, and other Health Outcomes."