Well, this is going to tick some people off

The new vaccine against the human papilloma virus is something I've discussed a time or ten here. Reaction to the vaccine by many religious groups has morphed with time, from outright resistance to a more common stance right now that they're accepting of the vaccine, but don't want it to be mandatory. Well...

Michigan legislation would require girls to get HPV vaccine

Michigan girls entering the sixth grade next year would have to be vaccinated against cervical cancer under legislation backed Tuesday by a bipartisan group of female lawmakers.

The legislation is the first of its kind in the United States, said Republican state Sen. Beverly Hammerstrom, lead sponsor.

A government advisory panel said that ideally, the vaccine should be given before girls become sexually active.

The American Cancer Society estimates that cervical cancer will be diagnosed in 9,700 women nationwide, and that 3,700 will die.

"We believe we can save the lives of these girls," Hammerstrom said.

Guess who doesn't like the idea, and why?

Some critics around the country have expressed concern that schools would make the vaccine a requirement for enrollment. They have argued that requiring the vaccine would infringe on parents' rights and send a message that underage sex is OK.

Of course, this is absurd. We vaccinate against influenza and diptheria, but we also teach our kids to wash their hands and not cough on each other. Being vaccinated doesn't make it safe or moral to engage in these behaviors; it's just a vaccine. What it *does* do is protect against a potentially deadly disease.

So, who's objecting?

"We don't feel using school attendance as a form of coercion to get parents to vaccinate their child is appropriate, simply because this disease is not transmitted through casual contact the way other diseases are that are subject to school mandates," said Peter Sprigg, vice president for policy at the Family Research Council in Washington, D.C.

For those unfamiliar with the Family Research Council ("defending faith, family, and freedom"), James Dobson was a founding member, and Gary Bauer is a former president. Their "about" page states:

The Family Research Council (FRC) champions marriage and family as the foundation of civilization, the seedbed of virtue, and the wellspring of society. FRC shapes public debate and formulates public policy that values human life and upholds the institutions of marriage and the family. Believing that God is the author of life, liberty, and the family, FRC promotes the Judeo-Christian worldview as the basis for a just, free, and stable society.

And of course, they have anti-homosexual and anti-abortion material on their site, including promotion of the debunked abortion-breast cancer "link". Yet despite the lip service paid to "sanctity of life," they're against mandatory vaccination with an injection that could quite possibly save a woman's life.

They're not gonna be happy about where this is heading, either:

The announcement of legislation in Michigan came the same day that Women in Government, a national group representing female lawmakers, recommended that all girls entering middle school be vaccinated against HPV.

"Every state needs to look at this," said Susan Crosby, president of the Washington-based nonprofit organization. "It's one of the first cancers we can look at truly eradicating."

3,700 deaths a year. 9,700 new cases. Most of which can be prevented with a simple jab. Plus, if these people feel it's so important to scare kids into staying absinent with talk of nasty diseases, there's still a plethora to choose from; they don't need HPV. Meanwhile, my hat's off to Michigan, and hopefully other states will follow suit.

[Edited to add, via U dream of Janie I found this post on the same topic, noting that "People are always pointing at scientists and screaming, "Why don't you find a cure for cancer?", and now that we have one, some people want to deny it to their daughters.]

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Just more proof that these crazy people don't actually care about life, just their twisted "family values". I guess the families who lose a mother or grandmother to HPV don't count. It's disgusting.

I'd like to point out that even if a young woman lived up to this religious ideal of virginity up until monogamous marriage, she could still contranct HPV and subsequently contract cancer through her partner's infidelity, her partner's previous experience, or rape. The Family Research Council's position is a "Blame the Victim" stance.

Don't even get me started on the double standard.

By somnilista, FCD (not verified) on 14 Sep 2006 #permalink

This is fabulous news. I hope other states follow Michigan's lead.

I can't even express my feelings against any one who would refuse this vaccine to young women. I'm flabbergasted.

I have to say I agree with them here. I do think that every girl* should get vaccinated against HPV, but I question legislating it and particularly linking it to school. The rational, it seems to me, for requiring vaccination for other diseases before entering school is that without vaccination, the classroom (where the students are required to be) can be a location where disease spreads. The same sort of situation does not exist with HPV, and I fail to see why the school should have (for lack of a better term) jurisdiction.

*I've got a tangential question. Is there a reason that vaccinating men isn't ever brought up? The effects of HPV on men are, of course, much less than the effects on some women. However, even if all men never experienced any symptoms, I would think that vaccinating the carriers would be wothwhile. I realize why the focus is on young girls, but is there a physical reason why men can't be vaccinated too? I wouldn't have thought so, but I'd like to know if I am wrong.

The same sort of situation does not exist with HPV, and I fail to see why the school should have (for lack of a better term) jurisdiction.

Well, I guess that depends on the school. Some schools (and their school-sponsored activities, and the social scene of people who meet and interact in school) *are* locations where HPV could spread. In fact, probably most schools, whether they want to admit it or not.

Pursuing herd immunity seems quite reasonable to me; I just wonder if they can't do better than requiring it for school attendance and instead require it for everyone (although coming up with the money to subsidize it for people who can't afford it might be an issue, but they're going to have that problem with public schools too). Private schools and home schooling are becoming more common and if they become reservoirs of HPV, little progress will be made.

I'm also curious about whether or not vaccinating men would prevent them from carrying and transmitting HPV. Gee, if only there were an epidemiologist around here somewhere... :)

Great post! Hopefully California will take up the cause soon.

Colst (poster above), what's your solution then? Vaccinations linked to school are the best way to ensure the job gets done. I disagree with the thinking that the classroom doesn't help spread the disease. Obviously kids aren't sleeping together in the classroom, but relationships that lead to the act are formed there.

James Dobson is a sad, pathetic shell of a man filled with an empty religion based on hatred and ignorance. But he always manages to crack me up. Those silly FRC guys.

J

By Make It So (not verified) on 14 Sep 2006 #permalink

*I've got a tangential question. Is there a reason that vaccinating men isn't ever brought up? The effects of HPV on men are, of course, much less than the effects on some women. However, even if all men never experienced any symptoms, I would think that vaccinating the carriers would be wothwhile. I realize why the focus is on young girls, but is there a physical reason why men can't be vaccinated too? I wouldn't have thought so, but I'd like to know if I am wrong.

No physical reason, but testing isn't complete yet in men yet (though it's ongoing and definitely an issue for the future). Remember that HPV also causes genital warts and penile cancer in men (rare, luckily), so a vaccine for them would also help to protect against those (although since this is a vaccine against limited serotypes, warts could still be an issue).

Here in the UK in the pre-MMR days, every girl was given a rubella (german measles) vaccine at 12 as rubella is potentially harmful to a foetus. Was this also the norm in the US? If so, surely the same logic applies as for the HPV vaccine?

"what's your solution then?"

I don't have one beyond the possibly inadequate route of publicizing and educating.

Vaccinating everyone would be a good thing. I'm somewhat suspicious, though, about whether the Michigan legislature has the authority to mandate it. I'm even more suspicious about them having the authority to link it to school attendance.

Good point, Tara. the risk of penile cancer should be at the forefront of this conversation. Threaten the pride and joy of these schmucks and and we will see this fly through congress.

'"what's your solution then?"

I don't have one'

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I tend to be on Colst's side in that we don't actually need a government solution to every problem.

Why should we have ANY mandatory vaccinations (or mandatory school attendance). There are people who think that they can teach their kids just fine, and that vaccines are the work of the devil. I'm totally okay with these people suffering whatever consequences come from thinking like a medieval peasant. From a humanitarian perspective, we're all better off if we expect more from people, not less.

Is there an objective, epedemiological reason to support a mandatory vaccination program?

The main reason to make it mandatory is so that it will be subsidised, so that even the poor can afford it. Schools are just a convinient place to make them mandatory.

The CDC website says it's been studied in girls ages 9-26 but they don't supply any references. I recently heard that the vaccine hasn't been tested in the targeted age group. I've done a PubMed search and can't find any studies on girls under 15. Can anyone point me to studies among 9-15 year olds? I'd like to correct the misinformation I'm hearing (if it is misnformation), but need to back it up with studies.

By eduranter (not verified) on 14 Sep 2006 #permalink

Are the schools also going to pay for it (3 shots @ $120 apiece) for those families without insurance and/or who can't afford it? Is it going to be available at clinics and for those on Medicaid? Unfair IMHO to require it unless/until its availability and affordability can be assured.

Oh, and those 9700 cancer cases and 3700 deaths projected for 2006? Virtually all in women who never got a pap for one reason or another (insurance; cultural taboos; immigrants) Regular paps, even just once every 5 years, will essentially prevent the development of invasive CA. Not at all easily "prevented with a single jab" (3 shot series; remember?)

More on this subject here.

By #1 Dinosaur (not verified) on 14 Sep 2006 #permalink

Is there an objective, epedemiological reason to support a mandatory vaccination program?

It's in the interest of the public health. Having improved health conditions in individuals benefits us all in many ways. It not only prevents the spread of these pathogens, but it also means less money needs to be spent on treatment, lost work days and productivity, and on and on--stuff the taxpayers end up footing the bill for.

Are the schools also going to pay for it (3 shots @ $120 apiece) for those families without insurance and/or who can't afford it? Is it going to be available at clinics and for those on Medicaid? Unfair IMHO to require it unless/until its availability and affordability can be assured.

They've already got a proposal for that in Michigan. From the article:

Hammerstrom said that most Michigan employers will cover the vaccine, and that uninsured girls could be covered through the federal government's Vaccines for Children program.

#1 Dinosaur,

Oh, and those 9700 cancer cases and 3700 deaths projected for 2006? Virtually all in women who never got a pap for one reason or another (insurance; cultural taboos; immigrants) Regular paps, even just once every 5 years, will essentially prevent the development of invasive CA. Not at all easily "prevented with a single jab" (3 shot series; remember?)

First, I said "simple," not "single." Second, yes, paps definitely help, but it's much easier (and more cost-effective, not to mention less of a hardship for the woman) to prevent the individual from getting HPV in the first place, rather than dealing with it once a pre-cancerous condition begins.

And eduranter, I also didn't see any studies in under-16 year olds. I'll try to find out more about that.

Also, do those 9700 cases include things like carcinoma in situ and severe cervical dysplasias -- things that aren't diagnosed as cervical cancer yet, but are the marks of it's developmental stages and can also be prevented by this vaccine? These health problems occur even in women with a history of regular pap smears and can have some serious consequences in future fertility since their treatment can cause cervical incompetence and problems with dilation in child birth. Even though it isn't as scary, since it doesn't involve the dreaded C-word, it's numerically an even greater public health issue.

I've got a tangential question. Is there a reason that vaccinating men isn't ever brought up?

No physical reason, but testing isn't complete yet in men yet

I think the price tag has something to do with it, too. Since this is the most expensive vaccine ever developed, it'll be hard to convince the public to pay for men to get it, what with penile cancer being so rare and warts being mostly a cosmetic issue. The vaccine would protect against anal cancer as well, but that's mostly in gay men and I don't see the right stepping up tp protect their health any time soon.

Here in the UK in the pre-MMR days, every girl was given a rubella (german measles) vaccine at 12 as rubella is potentially harmful to a foetus. Was this also the norm in the US? If so, surely the same logic applies as for the HPV vaccine?

In Alberta, where I'm from, they did that for a few years until they realized the boys were acting as a reservoir and infecting girls who didn't develop complete immunity. Depending on the efficacy of the vaccine and the infectivity of HPV, I could see vaccination of boys being implemented for the same reason it was with rubella.

There is no such thing as a "mandatory" vaccine. All you have to do is tell hte school that you have religious objections to vaccines and they wont make you get any of them.

So its really misleading to say that any vax is "mandatory" there are lots of loopholes to get around them.

I found this, which indicates that immunogenicity was studied in 9-17 and 18-26 year olds, but safety was studied only in the over 16 group. While I am all in favor of this vaccine, I am a little bothered about targeting 9-11 year olds if there truly is no data about safety in this age group.

By eduranter (not verified) on 14 Sep 2006 #permalink

Regular PAP smears can catch dysplasia early and treat it, but treatment is painful in ways you cannot imagine if you've never actually had your sensitive bits scraped at with an electrified wire loop. Also, despite the vaccine cost, I'm is still less expensive than the pre-LEEP biopsies (I had 3), the LEEP itself and the extra follow-up PAP exams. I promise you, it is also less emotionally wrenching than being told you have a pre-cancerous condition, that you may lose the ability to have children, that you may die.
The wackos would tell me I deserved it, I would tell them no one deserves it. I would tell them their daughters don't deserve it. I would tell them I developed CD after being married for under a year, I developed it because the man I loved is normal enough in this day and age to have had a previous sexual history. I would give anything to not live with the fear of recurrence every year, to have had the chance at the vaccine. The return to an annual 'normal' exam is never routine anymore, its a date with fear.

Here is certainly a crisis point for those who object to public-health measures related to sex. Their hypocrisy is really going to be highlighted if they insist on making a battle over this one.

"The main reason to make it mandatory is so that it will be subsidised"

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The presumption being that subsidies are a good thing... but if, like me, you don't support government subsidized health care, this is not persuasive. The real question is: if I am vaccinated against pathogen P, and you aren't, is there a reason for me to care enough to force you to get vaccinated?

Someone posed the question. Why make vaccines mandatory or compulsory? What ethical or epidemiological justification might there be? I'm surprised Tara hasn't already answered this. So I'll have a crack.

Herd Immunity. Herd immunity is where the proportion of people in a population that are immune to an infection is so high as to effectively protect the people who do not have immunity from being infected. The reason for this is that there are too few people around to carry and pass on the disease to the susceptible. The proportion required for this to operate depends on the population density, the infectivity of the pathogen, and the susceptibility of the un-immune to be unable to become immune to the pathogen (non-immunisation related immune protection). As I understand it the proportion for most the vaccinated diseases above which herd immunity operates is about 90% (Tara?).

In infectious diseases the benefits of herd immunity have some of the same characteristics what economists call a "public good". Street lighting, clean air, PBS etc etc are public goods that you cannot directly charge for because you cannot restrict access to them. To pay for these public goods generally requires taxation of some sort to be mandatorily be levied. This is because if you ask for people to pay for something- that they have free access to already that they cannot be restricted from enjoying - they tend not to paye.

This is called free-riding. Free-riding is enjoying a public good without paying/contributing for/to it. Anti or non-vaxxers are free riders who enjoy the benefits of publicly provided herd immunity without incurring the cost. The cost in this case is not just financial but aslo in the small risks of adverse events and also the hassle and irriation of having to go and get vaccinated.

See what happened after the MMR problem. The ratio of the protected to unprotected dropped too low to confer herd immunity and the infection rates markedly increased.

Granted, I haven't delved into all of the FRC stances on immunizations, but if they are consistent, then they should also be pitching a hissy fit over mandatory Hepatitis B vaccination. Hep B isn't spread by casual contact, but it is commonly spread sexually and by injectable drug use/needle sharing. And for goodness sake, we give the vaccine to babies! Oh horrors!

I'll always remember Dobson for his death row "exclusive" interview with Ted Bundy. Dobson's thesis was that pornography led Bundy to be a serial rapist/killer. Bundy, being the consummate sociopath, fed Dobson exactly what he wanted to hear.

By Dan Hocson (not verified) on 14 Sep 2006 #permalink

"Herd immunity is a big reason, but it's not the only one."

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Leaving aside all issues created by the existence of subsidized health care, does herd immunity benefit the immune herd members?

Assume that half the animals are immune (vaxers). Is there a personal health reason for them to be concerned about the immunity of the other half?

Sure; how about the fact that even all the vaxers won't be immune themselves, since no vaccine is 100% effective.

"Leaving aside all issues created by the existence of subsidized health care, does herd immunity benefit the immune herd members?"

Yes. Those folks unable to pay stand a greater risk of disease in the future. They'll still be unlikely to pay at that time as well. So, those of us who can pay end up subsidizing them later on by paying higher prices to compensate for the uniunsured. Unless of course you believe we should just let the uninsured go without medical care. Small investment now, much larger investment later (with far lower positive results rate). Pretty simple choice, really, outside of Ebenezer Scrooge's ideal world.

By Dale Austin (not verified) on 15 Sep 2006 #permalink

Hey, you wanna hear a joke?

Culture of Life

I didn't say it was a funny joke.

By somnilista, FCD (not verified) on 15 Sep 2006 #permalink

"So, those of us who can pay end up subsidizing them later on by paying higher prices to compensate for the uniunsured."

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You realize that you responded to a question that began "Leaving aside all issues created by the existence of subsidized health care" with an answer about subsidized health care, right?

I responded to the scrooge thing here.

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since no vaccine is 100% effective.

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point.

Not sure if they contain anything that the GARDASIL label doesn't, but the FDA analyses of the Merck data are on the FDA dockets website. There are also slides from the Vaccines and Related Biological Products Advisory Committee hearing, a transcript and the minutes.

By Richard Jefferys (not verified) on 15 Sep 2006 #permalink

There was an announcement in the UK that the Government is considering bringing in HPV vaccines for boys as well as girls. It makes sense, it wasn't until very recently that boys recieved a booster rubella jab. I was given a rubella jab at two (prior to the MMR days), but wasn't offered one at twelve.

By David Godfrey (not verified) on 16 Sep 2006 #permalink

Sure; how about the fact that even all the vaxers won't be immune themselves, since no vaccine is 100% effective.

Don't forget that having an unvaccinated population makes a large reservoir of infected individuals. Such a reservoir then makes it possible for a virus to grow, mutate and find other hosts [maybe vaccinated]. This provides a selective drive on the virus to adapt the structures the vaccine is effective towards and overcome the immunity of other potential hosts. So effectively, unvaccinated individuals are a means of producing more pathogens and allow them to play evolutionary war games (You can't evolve if you're unable to grow or replicate in any manner!).

This of course does depend on a lot of different factors however.

Thanks for the information and the arguments. I'm always hesitant to mandate something without a compelling interest to the general good, but the limittign of a mutation pool and protecting those who get vaccinated but don't become immune are fairly convinceing.

To Seth

I hope I understood your question. I'll have a go.

As Tara pointed out no vaccines are 100% effective (sorry about the herd immunity bad call. you did mention it. I didn't read carefully enough).

Back to Seth. Vaxers are prepared to pay the cost of being vaccinated (including any direct financial cost, inconvenience, discomfort, transportation, and possible acute or long term side-effects etc etc). But they have no guarantee that the vaccine will in fact make them immune for their entire lifetime. So it is in the best interests of the vaxxers to have enough people immune (which includes vaccination but may also include having had the disease already-like measles) so that herd immunity operates.

That way the cost that the vaxxers have paid to gain immunity (which they cannot be sure to have) is not in vain should their hoped for immunity not be there. This is done by massively reducing the possibility that the immunity will be tested.

"That way the cost that the vaxxers have paid to gain immunity (which they cannot be sure to have) is not in vain should their hoped for immunity not be there."

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The thing is, and as I mentioned on my blog, I'm not willing to use force to save myself money or guarantee an investment. I might be pursuaded to use force in order to save my life. I'm not sure that mandatory vaccination is a Good Thing... but I think that Joseph and Tara made good points about the biology and epedemiology of the situation, demonstrating clearly that there is a problem to be addressed.

Dan asked upthread whether FRC had a hissy fit about Hep B vaccine - I don't know FRC's position, but the Concerned Women of America had a fit about HBV vaccination. Same bullshit as with HPV - it'll promote promiscuity, blah, blah, blah. Never mind all the liver cancer the HBV vaccine will prevent.

FRC, CWA and their ilk all seem to equate infection with a virus to some kind of moral failing on the part of the victim. They consistently overlook the fact that you can do everything "right" and still get these viruses.

By Jen in Austin (not verified) on 18 Sep 2006 #permalink