Vaccination has greatly diminished death, illness and suffering in the world. But no other medical technology has been so dogged with controversy. The book chronicles the development of the key lifesaving vaccines since the 18th century. It tells the stories of great scientists and their discoveries, of the protests and pain along the stumbling path of progress. This is the first book to tell the whole story of vaccination for a general audience. In light of controversies about flu vaccine and autism, it will be of particular interest to parents, pediatricians, public health workers and anyone fascinated by medical history. Read More>>

Also Available: Table of Contents and Index

Arthur Allen is a Washington DC-based journalist who has written on vaccine issues in The New York Times Magazine, the Washington Post Magazine, The New Republic, Atlantic Monthly, Salon and Slate.

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HPV? Yes, But Don’t Rush Me

Sometimes, good policy is a question of good timing. The HPV vaccine, which Texas mandated for its 6th grade girls last week, is a good example. I've written and spoken in favor of mandating this vaccine, but consistency, as they say, is the hobgoblin of small minds. And I've recently learned from some public health contacts that the push to mandate HPV vaccine may be misguided. Hence the following, a version of which appeared in today's Dallas Morning News:

By all accounts, the cervical cancer vaccine can provide an important advance in health. In scientific trials of the vaccine, it proved 100 percent effective in preventing infections with the two types of human papilloma virus that cause 70 percent of the 3500 deaths by cervical cancer that occur in this country every year. The vaccine also seemed safe to the 20,000 girls and women who got it during the trial.

Because it seems to be a good vaccine, HPV, as it’s known, also looks like a good candidate for mandatory administration to 6th grade girls. After all, the fact that HPV is sexually transmitted really should have no bearing on whether we take a step to protect our girls and women from a deadly infectious disease. In the past, we have required school-age vaccination against diseases like measles, polio, tetanus and whooping cough.

Seat belts don’t cause car crashes, and vaccines against viruses spread by sex don’t cause sex any more than vaccines against respiratory viruses cause breathing. HPV is a very common virus that most women will be exposed to at some point in life. And years of experience with vaccination campaigns have shown that they only reach those who need them when parents get a tap on the shoulder, requiring them to vaccinate their kids or keep them out of school. In the case of HPV, the women who get cervical cancer are often from the same socioeconomic groups that don’t get regular medical care.

Use of such forms of coercion is not uncommon in public health--think of laws prohibiting smoking in bars, and requiring seat belt use in cars.

For all these reasons, the Texas government’s decision to impose the HPV vaccine on Texas parents sounded, on its face, like good public policy. And it would be, perhaps, if the government had waited for a year or two – and if the legislature had made the decision.

But public health’s coercive function is a delicate instrument, and one that needs to be wielded carefully. By ordering mandatory HPV vaccination last Friday without getting the legislature’s support, Gov. Rick Perry may have blundered in a way that could end up hurting the success of the fight against HPV–and other infectious diseases.

In the past, public health authorities usually waited anywhere from a few to several years before requiring children to get a new vaccine. For example, Merck’s chickenpox vaccine, licensed in 1995, did not become mandatory in many states until 1999. The time between licensing and requirement allowed vaccine authorities time to view the safety and effectiveness record of the new vaccine before they ordered children to receive it. Even Jonas Salk’s celebrated polio vaccine, licensed in 1955, was not immediately required by any state–though almost the entire country viewed polio as a menace to be battled together.

But when Merck’s HPV vaccine was licensed in June, the company quickly began a direct-to-public marketing campaign designed to introduce the vaccine to the public. In the past several months the company has been actively lobbying state governments and legislatures to make the vaccine mandatory.

State public health officials, who usually take the lead in such campaigns, were taken by surprise. One public health commissioner I know told me that several legislators in his state had introduced mandatory HPV vaccination bills before he was even consulted about it.

Since Merck’s competitor, GlaxoSmithKline, is coming out with a very similar vaccine in about six months, it raises the presumption that Merck is cramming its vaccine down our throats (or rather, into our arms) in order to grab market share before the competition gets out of the blocks.

Such a strategy is dangerous for a couple of reasons. First, public health deparments around the U.S. do not have the cash to pay for this vaccine, which they will be obliged to do when it becomes obligatory (you can’t mandate a vaccine and then expect poor people to buy it). Since most of these departments can barely afford their current vaccine obligations, they aren’t too happy about Merck’s push. Second, and perhaps most importantly, people don’t like to be told what to do by the government. That’s never been more true than today. And when they’re being told what to do under conditions like those I’ve described, it brings out other kinds of skepticism. Questions along the lines of, "Why is the government is such a big hurry to vaccinate my 11 year old against a sexually transmitted disease?" and "Why do I have to hurry up and pay $360 to Merck?" In Texas, and in many other states, people can opt out of vaccination if they object for "philosophical" reasons. By imposing the HPV vaccine in such a rushed, questionable way, Gov. Perry’s action threatens to mobilize people who, under normal circumstances, would simply do what they were told, assuming it was best for them. This is not the best way to gain trust in an important public health measure.

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Comments

anonimouse

I do believe that once a track record of population-level safety has been established through Phase IV (post-licensure) surveillance, then adding the vaccine to the CDC's "recommended" list and mandating it for pre-teen females would be appropriate. If nothing else, then you have a base of clinical data - beyond the subjects in a Phase III trial - to illustrate its relative effectiveness and safety.

The shame of it all is that the HPV vaccine is a very good idea that will save lives and spare many women the tragedy of getting cancer. All this horrid public misstep does is give ammunition to the anti-vaxers and religious conservatives who object to the vaccine for reasons that have nothing to do with its effectiveness or safety.

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