On Mandating Immunity

February 9, 2007 at 11:40 am (AE Beacon's Posts)

The HPV vaccine. To me this ranks along with recent developments in stem cell technology as one of the most significant medical breakthroughs of our generation. A vaccine that prevents the second leading cause of cancer in women, unbelievable. However, despite the proven life saving ability of this vaccine, I’ve still encountered quite a few people who are ambivalent about its use.

One of the chief arguments against the HPV vaccine is that it will encourage premarital or unprotected sex. First, 90% of people in the
United States engage in premarital sex, 90%. I sincerely doubt that a vaccine could in any way increase that number. Second, quite frankly I doubt that most people think about their risk of getting HPV first or even tenth when they decide to have unprotected sex (or following the decision). From AIDS to unwanted pregnancy to herpes and gonorrhea, there are a plethora of other things that come more immediately to mind (in my male biased opinion). Obviously this is unfortunate since HPV, aside from the strains that do have acute symptoms like genital warts, is one of the STIs that can kill you. Additionally, given HPV’s prevalence at upwards of 70%, it’s pretty likely that your partner will have one of the 100 strains (hopefully an innocuous version). Either way, the risks of HPV are so under appreciated that I sincerely doubt people will change their behaviors even if there’s a vaccine.

Moving on to implementation. HPV is a clear chance to save lives and save our public health infrastructure money. HPV is the cause of most cervical cancer and, through available vaccines we can prevent most types of HPV. This will definitely save lives now and in the future. Cervical cancer costs tens of thousands of dollars per person to treat whereas the HPV vaccine costs only a few hundred dollars per dose.  It is in the interest of insurers, hospitals, doctors and consumers to take advantage of the HPV vaccine.

The key words for implementation are young, national and mandatory. The vaccine is recommended for women ages 9-25 (or 26) who have not yet contracted any form of HPV. Given the prevalence of HPV, it is therefore likely that a younger age will need to be treated. Vaccinating at the younger threshold, say 9-11, not only decreases the likelihood of previous exposure but also reduces the slim chance of changing sexual behaviors since most young women aren’t sexually active yet. Second, the vaccination must occur nationally and eventually
internationally. Domestically there are about two million female nine year olds who will need to be vaccinated. Those that aren’t covered by private insurers should be covered by Medicaid. Finally, the vaccine should be mandatory. While perhaps consumers are ambivalent about whether their child should get vaccinated, savings from the eventual reductions in cervical cancer treatment costs will be passed down to them (hopefully) as costs to insurers are reduced. Oh right, and there will be vast reductions in the number of people who get cervical cancer.

A closing note on gender equity and the HPV vaccine. I’ve heard quite a few complaints, that there isn’t a vaccine for men. Right off that bat I will admit men are equally as responsible for the spread of HPV as women and ostensibly should share the responsibility of eradicating the virus. However, women bear the brunt of the disease and the strong majority of the costs. Men can get genital warts and this alone is a good reason to develop a vaccine for men but for now it only makes sense to focus our resources on getting the vaccine into the hands of women. Additionally, given the huge costs associated with developing a drug, often estimated at around $100 million, making the existing treatment cheaper seems a better investment than creating a new vaccine.  

Æ Beacon

Advertisements

6 Comments

  1. Alexandra Coria said,

    I agree with everything you say, but I want to take your comments on accessibility a step further. While, yes, I agree that all women should be vaccinated against this virus that causes so much harm and also so much expense, I don’t want to rule out the development of a vaccine for men. This for the simple reason that vaccinating a woman’s partner is the same thing as vaccinating her. So, for women who have no choice in the matter because their families are not supportive of vaccination for HPV (or in general), even if they reach 25 without having been vaccinated, their partners still might have been. Quite simply, if fewer people have a disease, fewer people catch it. Male vaccination is a means to circumvent the naysayers to the maximum extent possible, and I think it is an important goal for the reproductive health community.

  2. misarita said,

    I want to throw something out there that may be implicit in what you’re saying. I agree with you about the vast implications of having an HPV vaccine, especially (as Alex mentioned) if we can find a way to include men in the community of people with herd immunity. But, I wanted to put out a thought about making the vaccine mandatory.
    From an NPR article on the issue:
    “Catania insists that the legislation [to make HPV vaccination mandatory in Washington DC] doesn’t target any particular group and the vaccination wouldn’t exactly be mandatory. “What we are doing is we’re forcing the conversation. Either you are going to have your child vaccinated, or you will make an informed decision to opt out,” Catania says.”
    http://www.npr.org/templates/story/story.php?storyId=7190905

    The biomedical ethics field has pretty much decided that it isn’t ethical to force someone to take a medical treatment. People have a right to autonomy over their own bodies and that of their children, even when we as medical/public health people find that fact frustrating. We certainly can give some very strong enticements to get children vaccinated (like mandating that all children in public schools get it, or something else that involves receiving a public good in exchange). What these challenges say to me is that we need to open the dialogue about the vaccine and, more broadly, about sexuality. If this is an issue in the US, I can guarantee that the conversations about a vaccine that prevents sexually transmitted infections will be much more difficult and fraught with miscommunications elsewhere in the world.

    Aside from the ethical aspect, I don’t think that a gov’t or insurer or private doctor is willing to take on the risk of repercussions if someone who they ‘forced’ to get vaccinated has a side effect. All vaccines have potential side effects. We don’t know enough about immunology to prevent/detect all these possible outcomes. But, I’m very excited about this vaccine (only partially because immunology gets me excited anyways). I think it is a great step towards allowing women to be protected against a pretty lethal virus and will force us to open up a sticky area of debate and give it some air.

  3. msoule said,

    Sarah, my question is whether it’s necessary to advertise the HPV vaccine as one that prevents STIs or whether it’s necessary to bill it as one that can prevent cancer. While the transmission of the virus is through sexual contact (are there other ways? I’m really not familiar with it), it is also a huge killer through cancer (which is not really a socially sensitive topic). I realize that people will want to know if there’s any other way to prevent the illness and the answer lies in safer sex practices.

    The trouble, however, with “opening the dialogue” about the vaccine is that most people don’t have the vocabulary to discuss it aside from “Is it dangerous?” and “How will it help me?” I realize this might sound more than a bit arrogant, but I also am aware that framing a discussion of the costs and benefits of a medical treatment in an accessible way is a challenge that is faced by all health professionals. This debate would easily get bogged down in the debate around promiscuity and sexual practices. It could also, in the way that that discussion sometimes goes, turn to blaming the woman for getting infected. I know that this is one of the ways that the discussion around AIDS goes in many parts of the world. Really what we’re trying to focus on is the vaccine’s effectiveness against cervical cancer, right? Is it possible to just talk about that?

    Also, I think that this will be a hard sell for men. They’re not directly affected and things that don’t directly affect people aren’t usually things that those people jump at the chance to do something about. However, if it’s possible to get them young, they won’t really know that it doesn’t affect them. It’ll just be another shot on the growing list of shots.

  4. aebeacon said,

    A few rebuttal comments.

    I am not ruling off the development of a vaccine for men. I’m fine with developing a vaccine for men just so long as availability for women is in no way diminished. In reality there is a limited pool of money for research and distribution. Any funds devoted to vaccine development for men will cut the money that should be used to streamline the vaccine production and dispersal. Therein, I just don’t think a vaccine for men makes sense at this point.

    The presumption that vaccinating a female’s partner will ensure her own safety is false. While male promiscuity has certainly played a central role in the spread of infectious diseases like HIV/AIDS it is incorrect to assume that women don’t have relations outside of their partner. Further, I find it highly unlikely that on average there are going to be more families who would vaccinate a son over a daughter. Given the risks, parents are far more likely to vaccinate against the higher potential for disease.

    I used the word mandatory within the framework of vaccine distribution. The TB, rubella and mumps vaccines are all compulsory however, there is an implied opt-out process. Mandatory vaccination should only be used during a catastrophic event where unvaccinated individuals place a significant threat on the lives of other citizens. With that said, the HPV vaccine should otherwise be given automatically along with the typical battery of shots.

    Finally, HPV cannot necessarily be prevented by safer sex practices. Condoms protect primarily against the areas directly contacted by sexual fluids. However, there are a wide variety of other genital areas which may come in contact during sex. Like herpes, any openings in the skin could then spread the virus independent of whether it is prevented from being transferred by sperm or vaginal fluid.

    A final word on opening the dialogue. Honestly, I don’t think that this vaccine is going to make much of a difference in “opening the dialogue”. Policymakers and the American public have been accosted for decades over the foolishness of abstinence heavy sex education. A strong body of scientific literature linked with the practical experience of field workers and educators have been doing their best for years to expound the inadequacy of such policies and yet have made little progress. In this case I would prefer that the HPV vaccine was quietly made mandatory and that the subsequent discussions were had in the privacy of the doctor’s offices away from the absolutist and unrealistic rhetoric that already dominates sexual health policy.

    Æ Beacon

  5. misarita said,

    In a fit of frustration, one of my professors told me once that abstinence has been preached for 2007 years now and it hasn’t worked yet, so why would be think that it would start now. It certainly has been a long term heavily weighted debate on promoting abstinence over other forms of protection. I would love it if, as you both mentioned, we could quietly ignore the fact that HPV is a highly contagious STD and simply focus on cancer prevention. But, even now, the media has latched onto this as a sexual issue. I don’t think that there is any way to make it quiet now, or to make that fact disappear. So, the question remains of how to make this vaccine available and acceptable to people who don’t want to ever think that their children would have sex outside of a monogamous partnership. It may be unrealistic and absolutist, but it is how people are already addressing this vaccine. I’m afraid that mandating it, at this point, would be rejected by a very large community of people.

    So, I’m not sure of the best way to move forward with this, outside of trying desperately to make it a more open discussion on how parents can protect their children. The word is out now and I don’t think that we can move backwards.

  6. misarita said,

    http://news.bbc.co.uk/2/hi/health/6342105.stm

    I just caught this BBC article about how much demand there is for the HPC vaccine among homosexual communities, who are at a higher risk of contracting diseases from HPV. Just to add another dimension to the complexity:

    Dr Szarewski agreed, saying: “It is bad enough suggesting to people that their 12-year-old daughter might need a vaccine against a sexually transmitted infection. I would be interested to see the response of suggesting to parents that they should vaccinate their boys at 12 in case they become gay.”

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: