Tuesday, January 16, 2007

More vaccine talk

I'm back from traveling again. I didn't have reliable Internet access, but I do have some blog posts I'll put up soon. There is one the recent discussion over at It's Matt's World on the HPV vaccine, but Fig wrote this and asked me to post it here. As it's in better shape than what I've got, I'm putting this up forthwith. (The last time she asked me to post something here, it wound up getting published in a newspaper. Sure, the local community college newspaper, but at least someone is paying attention.)

I realize that I'm chiming in several days too late, I felt that as an MD with an MPH [Master of Public Health -N] who has been a sex educator I should clarify a couple of things and chip in my $0.02.

First let me say Mr Bambenek is correct. It is an HPV vaccine, not a cervical cancer vaccine. Merck markets the drug as "against cervical cancer" because of smart marketing strategy. They could market it "against genital warts" or "against penile cancer" (nearly 100% of penile cancer is caused by HPV). For a variety of reasons, including the fact that most people haven't heard of HPV, women die of cervical cancer, warts are yucky, and most men don't want to think about the fact that the treatment of choice of penile cancer is surgical removal, Merck made the decision to push the drug as "against cervical cancer." I would take strong objection, however, to his statement that "the medical community refuses to describe this vaccine by what it actually does." The medical community calls it the HPV vaccine and we discuss it with our patients as "a vaccine that offers protection from certain strains of the virus responsible for cervical cancer." We don't call it a cervical cancer vaccine. We also don't usually discuss "the stomach flu," "spinal meningitis," or "head colds" or any of the other odd names the lay press uses. Please do not assume that the medical community uses the same terminology as you see in the newspaper or in drug ads or that the medical community goes hand in hand with drug companies.

Cervical cancer is not to be taken lightly. In 2007 it will cause nearly 10,000 cases of cancer and more than 3,500 deaths. This comes at a considerable cost to the economy. There are approximately 3.5 million abnormal Pap results experienced by American women each year, most of which are caused by HPV infections. These abnormal Pap results require women to seek follow-up care which ranges from additional Pap tests (moving from once every 3 years to once every 3 months) to more invasive procedures such as colposcopies and biopsies. This additional care costs an estimated $6 billion in annual health care expenditures. We pay for that. We pay for it through higher insurance costs, higher hospital charges and higher taxes to pay for those without insurance, and loss of productive time at work for these women. One of the compelling reasons to consider getting this vaccine, based on cost effectiveness analyses covered in public health journals in the last year, is that even at $360 per person for a full course and even though it only is against four strains of HPV (two of which cause 70% of all cancers, two of which cause 90% of all warts) so it offers protection -not immunity- from cervical cancer, a significant decrease of the disease burden in the community would be cost saving within the foreseeable future.

While I understand Mr. Bambenek's point that abstinence would be effective in preventing HPV, so far abstinence programs have not be shown to be effective. If he has a great idea of a cost effective way to ensure that all children that are covered by the Unit 4 school board were not going to have sex at all I and all other public health professionals would be interested in hearing it. However, even if tomorrow we could enact a program that would ensure that all people were abstinent until marriage (leaving aside the issue of whether this is a good thing), there would still be an infectious pool of HPV. With the large reservoir of HPV in the population, even if a young woman was abstinent until marriage she still could contact HPV from her partner.

I met my close friend L in medical school. L strongly believes that there should be no sex before marriage. She abstained. She married a very religious man who had gone through a "troubled time" in his adolescence and then, as he described it, had "seen the light and been saved." At her next routine pap, L found that she had cervical dysplasia. 2 years later, at the age of 26, she had a hysterectomy to stop the spread of her invasive cancer. Here is a woman who did everything "right" by Mr. Bambenek's standards and she still suffered the results of HPV infection. L now has an adopted son and daughter - she is raising them with the belief that one should be abstinent until marriage...and getting them both vaccinated against HPV as soon as they are age eligible. Given her experience, she feels that the vaccine should be mandatory to save other people from what happened to her. I realize that anecdote is not data, but I find that to be a compelling story. Further more, as I'm sure Mr. Bambenek is aware, not all sex is consensual sex. A girl could be as pure as driven snow, but if she is raped she can contact a sexually transmitted disease. Some of these diseases can be treated with antibiotics, some of these diseases are fatal. Wouldn't it be nice to be able to assure the woman who was raped that, due to her immunized status, she has a far lower risk of contacting one of those diseases?

Obviously requiring HPV vaccinations in public schools raises questions about the scope of parental autonomy and the role of political advocacy in determining how preventive health measures are implemented. All 50 states allow parents to opt out of vaccinating their children for medical reasons, 48 states allow opting out for religious reasons, 20 states (including Michigan, where I currently live, but not Illinois) allow opt out for philosophical reasons. Unlike what Mr. Bambenek states in his article, however, mandatory vaccines are to prevent easily communicable diseases or even to protect against the disease itself. Mandatory school vaccines further society's interest in ensuring that people are protected from disease throughout their lives; they are a highly efficient means of eradicating disease in the larger community. Tetanus has been mentioned several times earlier in these comments and is an excellent point. It is non communicable, we require the vaccine. Why? Because it is cheaper to vaccinate everyone than to pay for the health care costs associated with tetanus infection. Why do we mandate it (and have the state pick up the cost for those who can't pay) as opposed to just encouraging people to get it? Mandatory vaccination address the issue of income disparities - the people who are least likely to get the vaccine are also the people who are least likely to be able to afford to pay for their intensive medical care. Nobody objects to the MMR vaccine. What's it for? Measles. That makes sense, they can cause a horrible encephalitis and kill you. Mumps. Also makes sense - mumps can leave men sterile. Rubella. Also known as 3 day measles - a time limited mild viral infection that gives you a rash, conjunctivitis, swollen glands, and a low grade fever. Not fatal, not even particularly debilitating. So why do we immunize against rubella? Because if a pregnant woman becomes infected the fetus is at huge risk for growth retardation; mental retardation; malformations of the heart and eyes; deafness; and liver, spleen, and bone marrow problems. Again, it's a cost effectiveness issue. Much cheaper to jab all kids with an immunization than to have society providing life long care for terribly damaged individuals. Chicken pox is vaccinated against for similar reasons. 47 states, including Illinois, require Hepatitis B vaccination. Hep B isn't spread by casual contact, only sexually and by injectable drug use/needle sharing. But there is no cure and a new liver is an expensive and rare commodity. So, again, it's cheaper to immunize everyone to prevent the spread of the disease and for cost saving in the future.

I'm a little unclear as to why Mr. Bambenek feels that the HPV vaccine requirement is a more burdensome invasion of privacy than any other vaccine or, for that matter, required school sports physicals. More lives are at stake here *each year* than all the lives lost on 9/11. We have suffered ridiculous and far reaching invasions of privacy due to that. Why is asking parents to be aware that a vaccine exists so onerous? I could be wrong but I doubt that anyone other than the school nurse knows who has been vaccinated and who has not. In Ann Arbor there are many parents who choose not to immunize their children. Their children are not ostracized, the teachers and other parents have no idea which children are vaccinated and which aren't, there is no secret registry of un-immunized children As I understand it, Jakobsson's bill would require the parents of girls entering 6th grade to present an immunization form or a form that stated had been informed about the connection between HPV and cervical cancer and still declined to have their child vaccinated. You don't have to get your kid immunized, you just need to prove that you are aware that the vaccine exists and you don't want it. From reading the language of the bill, it doesn't change your medical decision making capacity, it just forces parents to be aware. There is a case to be made that asking to know if a child has been immunized at all to anything is an untenable breach of medical privacy but I'm not sure why someone would care. If your daughter is immunized it doesn't mean she's sexually active and it doesn't mean she's *not* carrying the virus; if she isn't immunized it doesn't mean she is either a horrible pit of disease or abstinent. It means that she received the vaccine or not. Why is this inappropriate for schools to know? Why do parents care if schools know it?

There is the argument that if girls receive the HPV vaccine they will promptly feel that they are free to have sex with anyone, anytime, anywhere. This seems specious. I think - prior to the advertising blitz by Merck - awareness of HPV was so low that fear of contracting HPV did not stop anyone from engaging in sexual activity. Most children have no idea what they are immunized against. Most girls/women are far more worried about contacting HIV or getting pregnant than anything else. And if finding out that they are somewhat protected against a virus that may or may not cause them cancer many years down the road undoes all their teaching that they should only have sex with the person they are married to/someone they love/someone who can prove they are disease free (or whatever else they have been taught at home, at school, or at their religious institution) it seems that the teaching wasn't very effective in the first place.

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