February 5, 2007
From the desk of Jane Galt:'Splain me, please
I'm not sure I understand the objections to mandatory vaccination for HPV.
Vaccination does its best work through herd immunity--which is to say, denying the virus a sufficient number of people to make a disease reservoir. That's why socially irresponsible dimwits in America can now excercise their beautiful freedom of choice not to vaccinate their children . . . because they're free riding on everyone else's willingness to bear the very rare side effects. I promise you that if it weren't for herd immunity, those parents would be a hell of a lot more worried about actual polio than the vaccination for it. Call me a bad libertarian, but public health campaigns like these seem to me to be one of the few cases where government coercion is a slam dunk--much better than, say, income taxes or speed limits.
HPV is a nasty virus that is imperfectly blocked by condoms, incurable, and causes an appalling cancer that kills many women and renders others infertile. The vaccine is, to be sure, expensive. But as public spending goes, the possibility of eliminating an awful disease seems a pretty good use of $140.
As for why do it in school--what better time? We're already sticking the little darlings for everything from measles to chicken pox; they'll hardly notice one more needle. Plus if we wait until the virus is a bigger threat, we'll miss kids who become sexually active early--and are probably at greater risk than the general population--and also get tangled in the understandably mixed emotions parents tend to have when their sons and daughters start developing sexually. As a public policy measure, I should say it was far better to do it when those sorts of questions are entirely academic.
So why should I be against this?
Posted by Jane Galt at February 5, 2007 10:59 AM | TrackBack | Technorati inbound links"); ?>$291 million per year.
Quite possibly some of the most effective money the government could spend.
Posted by: TW Andrews on February 5, 2007 11:28 AMWhether mandatory vaccination is warranted would seem to depend on how much more effective, in this particular case, is the vaccine with 'herd immunity' than without it?
It also strikes me that this is an odd sort of case, since HPV also infects males (though it rarely causes health problems), males are the ones infecting females, and yet the virus is not approved for males, so they obviously cannot be part of the 'herd immunity'.
Posted by: Slocum on February 5, 2007 11:36 AMThe list price is actually $360. I don't know where Jane got $140. That means $747 million per year, or $1.49 billion if boys get it too.
That's the up-front monetary cost. What are the side effects? What are the long-term risks? Does anyone even know?
Now, the benefits. There are 11,150 cases of invasive cervical cancer diagnosed per year. Diagnoses have been on a downward trend, and the median is probably in the late 40s or later, meaning the results of any large-scale vaccination program won't be known for decades and may not even be distinguishable from the general trend.
How effective is the vaccine? How many cases per year are attributable to HPV strains that the vaccine would have prevented? Is the cost of treating HPV more or less than $67,000/$134,000?
Anyone know?
Posted by: AT on February 5, 2007 11:42 AM@ 5K cervical cancer deaths/year, and 70% coverage by the vaccine, that's just a hair under $100,000 to prevent 1 death.
You can add to the benefits the decreased costs of excisions of the high grade cervical dysplasias and the medical side effects of the procedures.
Posted by: Trent McBride on February 5, 2007 11:45 AMI completely understand the other side of this argument, I just don't agree with it.
$291 Million Dollars per year? How much would you pay for a cure for cancer. Okay, only one kind and it only reduces your chances by 70% but still, according to the CDC, 12,000 women we diagnosed with Cervical Cancer in 2002 and nearly 4,000 died from it that same year. It was estimated that mroe than $2 billion per year is spent on treatment for Cervical Cancer. 70% fewer would be 3,600 cases of cervical cancer, 1,200 deaths and only 600 Million in funding. That means we save 1.4 Billon gross or, taking into account for the cost of the vaccine,a 1.1 Billion net. Pretty compelling financially.
http://www.cdc.gov/cancer/cervical/statistics/
Also according to the CDC the side effects are negligable:
http://www.cdc.gov/std/hpv/STDFact-HPV-vaccine.htm
And, hey, something I didn't know before writing in this comments section just now, it also prevents 90% of all genital warts.
So, the only other objects I can find are:
1) I shouldn't be forced to do anything, and
2) It encourages sexual activity.
And my understanding is:
1) There are opt-out provisions if you really want to opt-out, and
2) Puberty encourages sexual activity. Just because you raised your kid right and she doesn't have sex before she was married, doesn't mean her partner will have been raised as well. wouldn't you rather be safe than sorry?
So is this the most effective use of $1 billion/year in public health spending? That's real money to some people.
Posted by: AT on February 5, 2007 12:03 PMThe stats on cervical cancer are available. Per the CDC in 2002 (last avail data http://www.cdc.gov/cancer/cervical/statistics/ ) the number of new cases was 12,085, deaths 3,952 though you have to remember that most of the people who died in 2002 were diagnosed earlier (side note, cervical cancer tends to be a slow killer and often horribly painful). Although the costs are really vague estimates, the WAG stated by the cdc is 2 billion dollars/year (year 2000 dollars). So by pure cost benefit the vaccine will probably be effective although it'll take years (HPV--> Cervical Cancer transition takes a long time, that's why Pap smears can detect dysplasia b/f there's invasive CA).
That being said -- two points come to mind with mandatory HPV vaccination. 1) HPV, like HIV and unlike Polio, Tetanus, Pertussis, etc is 100% preventable by behavioral change. Should this matter? Debatable, but it is clearly a factor in the decision making. From a liberalterian standpoint is it a "neighborhood effect" if a negative effect is easily avoidable? 2) It's not the government spending this money. When they make vaccination mandatory it is an UNFUNDED mandate. They only cover those people on medicare/caid/government workers. For everyone else it's out of pocket or out of insurance.
Posted by: BladeDoc on February 5, 2007 12:10 PM1) HPV, like HIV and unlike Polio, Tetanus, Pertussis, etc is 100% preventable by behavioral change. Should this matter?
Since children cannot legally consent to sex you cannot have it both ways. If they are too young for the consequences of sex then you cannot really use this as an argument. It's a bit like smoking. Making smoking illegal for teens is not like making it illegal for adults. Teens do not have the ability to make an 'informed consent' to the risks of addiction and cancer the way adults do.
It's not the government spending this money. When they make vaccination mandatory it is an UNFUNDED mandate.
How horrible. You mean you can actually be *required* to spend money on certain things if you have kids? True the price is high for this vaccine but that is primarily because it is the first on the market and it enjoys patent protection. Both of those will pass in the long run so the price will come down. In the meantime taxpayer money and selective price breaks by the manufacturer can be used for those who truely lack the means to afford the vaccine for their children.
Posted by: Boonton on February 5, 2007 12:19 PMhttp://www.chron.com/disp/story.mpl/ap/health/4523542.html
They just made the vaccine required in Texas.
Posted by: bristlecone on February 5, 2007 12:27 PMAlso pertinent: Jane quotes the price at $140. That is per shot; but it is a series of three - thus, my original figure of $100,000 per death prevented should be $300,000. Moreover, the long term efficacy has yet to be tested - they were followed for just a few years, and the long-term info will not be known for years.
Posted by: Trent McBride on February 5, 2007 12:47 PMImagine that 20 years from now it becomes apparent that the immunizations are positively correlated to an astounding rise in birth defects. Oops!
Or, the slippery slope argument. Maybe this one is just fine, but then the government decides to definine a list of mandatory injections. Or decides to modify the water or atmosphere...
"It was the PAX... G-23 Paxilon Hydrochlorate..."
Posted by: Randy on February 5, 2007 12:51 PM
P.S. For those who don't recognize the quote;
http://en.wikipedia.org/wiki/Reaver_(Firefly)
Posted by: Randy on February 5, 2007 12:55 PMYou mean like how some are now saying that polio vaccines cause autism or other problems? If your position is that the vaccine is unsafe then you should be campaigning for FDA approval. It is, after all, being used on children not volunteers or adults whether or not it is made mandatory.
Posted by: Boonton on February 5, 2007 1:11 PMI know, it seems pretty far fetched to think that our trusted medical and scientific communities, with the aid of government oversite, could actually create a negative outcome. But then again, the medical and agricultural advances of the last century have enabled a human population explosion... and now the planet is getting warmer...
Posted by: Randy on February 5, 2007 1:20 PMRandy, is there anything to your argument that would not apply to the polio vaccine or any of the other numerous vaccines that are now routinely used and mandated in many areas? Would we have been better off if the polio vaccine was held up for 30 years or so to see if it caused an increase in birth defects?
Posted by: Boonton on February 5, 2007 1:31 PMYes, why not have the government mandate Hepatitis B and TB vaccines, and a regular exercise regimen and a balanced diet. We don't need cost/benefit analyses if it's for the children.
And as much as one side may be against it because it supposedly promotes teenage sex, I wonder if the other side isn't all for government mandates for the same reason.
Posted by: AT on February 5, 2007 1:31 PMI have no doubt in my mind that getting that vaccine affects you in some way. I can not understand how people can think otherwise. Hopefully our bodies adjust and move on. But I would not get any vaccine I did not consider to be necessary. I have never known anyone in my family that got HPV. And if they did I'd feel sorry for them and wish they weren't behaving in a manor that would put them at risk for getting it.
If you feel like you're at risk to get it or your kids will be then give it to them. Herd immunity does not apply here. It's not like because your kid is sitting next to someone in school and got sneezed on they are gonna get this.
And if it ever does come to the point where stds can be transmitted through even non-sexual casual contact, I would HOPE that society would be wise enough to determine that perhaps our behavior which encourages stds needs to be changed, not coming up with a better solution on how to fight and prevent the last war.
Posted by: doubt on February 5, 2007 1:32 PMI think the biggest problems with mandatory are:
= this vaccine is NOT going to accomplish herd immunity (no men, no women above an age who may have already been exposed to hpv)
= it's a relatively new vaccine with unknown possible side effects. Obviously there is a difference between "hey, looks like it's ok and safe for your child" and "You *must* have your child vaccinated". I expect a lot higher standard when the government tells me i have to do something, and i'm not able to choose the level of risk i wish to take.
= it's expensive. i have a problem with telling a struggling family that they have to spend that kind of money. it should be their decision, not mine.
If you feel like you're at risk to get it or your kids will be then give it to them. Herd immunity does not apply here. It's not like because your kid is sitting next to someone in school and got sneezed on they are gonna get this.
Actually it is more like that than you think. Unlike HIV, for most people HPV infection does nothing. You have no symptoms and will never become ill but you can spread it to others. It is therefore quite easy to get even if you have a 'normal' sex life that's restricted to a few partners or even a monogamous marriage-only sex life (which is a very small minority of people even if you do want to hold that up as ideal). In other words even if you keep to yourself it is very easy to pick up from a partner and since lifetime chasity is NOT a normal behavior for all but a small few percentage of people it is something that's an issue. Because the virus by itself is not anywhere as risky as HIv it really isn't worth it to test and choose partners for it.
I would agree there should be room for those who want to 'opt out' of mandated vaccines in some circumstances but Jane is right, their 'opt out' should be properly seen as something the rest of society is tolerating as a free rider. Should the risk of opting out become serious society has every right and duty to say enough. Here is where you may find some differences with the polio vaccine.
Posted by: Boonton on February 5, 2007 1:44 PMThe ley point is the interaction between the (unknown) risks, and the controllable exposure.
A mandatory vaccine makes sense for casually contagious diseases. It doesn't, to me, make sense for diseases where you can control your exposure.
Posted by: SamChevre on February 5, 2007 1:47 PMBoonton, understand that I am not opposed to the vaccine, just the mandate. Yes, I think that those who would rather risk getting polio than get the vaccine should be allowed to do so. There is no shortage of people in the world.
Posted by: Randy on February 5, 2007 1:49 PMdot,
Over time the virus would establish herd immunity as the entire sexually active population becomes filled with those who were vacinnated as youths. The vaccine appears to work on men as well (it just needs to go through the FDA process for approval) and it does work for adult women. It isn't being marketed to them as much because the vaccine is useless against those already infected and a huge portion of sexually active people carry the virus.
Safety is a catch-22. There's no way to really know if it is safe unless a lot of people use it and use it for a very long time. Clinical studies can only take you so far here and as I asked should we have delayed mandating the polio vaccine for 30 years (and if we did how could we study long term side effects on sample sizes in the millions if millions didn't use it!).
Perhaps a better policy would be to delay mandating it for a few years. That would allow the accumulation of more data as well as let the price fall a bit.
Posted by: Boonton on February 5, 2007 1:49 PMBoonton, it seems to me that you've just made a strong case for mandatory inoculation of boys as well as girls. Isn't a male carrier in exactly the same position as an asymptomatic female carrier? If so, doesn't it seem daft not to vaccinate half the potential carriers?
Posted by: Michelle Dulak Thomson on February 5, 2007 1:51 PMdot - the lack of herd immunity assumes that adult women (and men) won't *choose* to get the vaccine. I suspect quite a lot will do so.
Posted by: Anthony on February 5, 2007 2:05 PMThis is just another step in government, not medicine. If it were medicine then government would observe but not mandate.
The majority now thinks government must protect us from almost everything. And no one knows how this can be done unless government has control of everything. And that everything includes us.
The conclusive argument is that everything is connected. Thus secondhand smoke justifies banning smoking. Public health justifies forced medicine. Transfats and dodgeball today, mandated gene therapy tomorrow.
The day is not far away when children will take blood tests at school. The state will then diagnose and order treatment. For their own good of course.
For most of us the boundaries are gradually accepted because good things often result. For those whose nature is different the state has better corrective ideas every year.
Posted by: K on February 5, 2007 2:07 PM
I'm not sure I understand the objections to mandatory vaccination for HPV.
I'm cynical. Would there bu such an outcry if a Clinton White House has proposed this?
Posted by: Brian on February 5, 2007 2:12 PMMany parents aren't making a choice between vaccinating their daughters or letting them be unprotected. Instead, they're choosing between vaccinating at 11 and vaccinating at 15. The likelihood a girl catchs HPV before 15 is pretty low, especially among upper class whites - so the gain from vaccinating at 11 is minimal. In contrast, the cost is not. The time value of $360 for four years is about $140 - a non-trivial cost (using about 10% discount rate). In addition, the vaccine may require booster shots, so it would be more effective if given later in life. There is also the additional possiblity prices will fall over time, so that parents can save even more by waint a bit.
Posted by: Rachel on February 5, 2007 2:20 PMI support this vaccine and flatly reject the current drive to mandate it.
It looks to me like merck is short circuiting the normal vaccine peer review and vaccination recomendation process. It is using raw political power and lobbying to pass laws or get executive orders to mandate the use of the vaccine and make itself a market.
The fact that this is a political action by a manufacturer not a scientific / medical action with good scientific oversight and review is disturbing. This is very dangerous precedent and threatens to replace good science in medical decision making with the use of lobbyists and raw political power.
The process is the problem not the result.
Posted by: TJIT on February 5, 2007 2:41 PMJane,
I'm with you on this one. Vaccines are in general the most cost-effective expenditures.
About the comment from doubt-
-I have never known anyone in my family that got HPV. And if they did I'd feel sorry for them and wish they weren't behaving in a manor that would put them at risk for getting it.-
-there is no way to know you have HPV unless you are tested since it doesnt cause any symptoms until cancer many years later. If you have had sex-you are likely to have been infected with HPV.
Posted by: GS on February 5, 2007 2:41 PMBoonton, it seems to me that you've just made a strong case for mandatory inoculation of boys as well as girls. Isn't a male carrier in exactly the same position as an asymptomatic female carrier? If so, doesn't it seem daft not to vaccinate half the potential carriers?
That would be an interesting question. The benefit seems to accrue mostly to girls so let's make it simple and assume 100% of the benefit falls on girls (reduced cervical cancer) and 0% of the benefit falls on boys (in reality there's some benefit in reducing the risk of anal cancer and other problems).
If 100% of girls were vacinnated you'd have a 70% reduction in cervical cancer and eventually achieve something like herd immunity in both boys and girls because where will the boys get it if all the girls are clean? Vaccinating boys will have some added benefit because there will always be some girls who miss the vaccine and the virus may continue to pass itself down among men who engage in gay sex.
But the economics seem to rule against mandating it for boys. You get almost perfect coverage for half the cost by just mandating it for girls and leaving it as an encouraged option for boys and adults. Going the extra step and mandating it for boys doubles the cost but it doesn't double the benefit. Wouldn't a marginal analysis show it would be better to spend those resources on, say, fighting the remaining 30% of cervical cancers or other public health issues.
Many parents aren't making a choice between vaccinating their daughters or letting them be unprotected. Instead, they're choosing between vaccinating at 11 and vaccinating at 15. The likelihood a girl catchs HPV before 15 is pretty low, especially among upper class whites - so the gain from vaccinating at 11 is minimal. In contrast, the cost is not. The time value of $360 for four years is about $140 - a non-trivial cost (using about 10% discount rate).
Unfortunately the vaccine is useless if HPV is already present so waiting those few extra years will mean many preventable cases of HPV. Also people tend to follow a pattern of engaging in more dangerous sexual activity while young before 'settling down' to stable partners either in marriage or at least in long term relationships. Even if the vaccine needs to be renewed 10 or 15 years after it is initially given just getting people into their low to mid-20's clear would probably be a big benefit.
Posted by: Boonton on February 5, 2007 2:48 PMGood article on this topic from an ER physicians blog.
Interesting Article on Cervical Cancer Vaccine Economics
Posted by: TJIT on February 5, 2007 3:02 PMHPV is present in nearly 100% of cervical cancers, but HPV is also divided into a number of sub-types. Two of those sub-types are implicated in 70% of the cancers and the vaccine that is now in use also prevents genital warts at about the same rate as it works against two of the most common sub-types of HPV that cause the warts. Trials with men are occuring right now.
By the age of forty, 80% of women test positive for at least one form of HPV. If you have one form of the virus and get the vaccine, you are protected from all the others and the chances of having abnormal Pap smears is lowered by a significant amount. Aprox 10,000 woman per year have what amounts to cervical cancer each year but millions are exposed to the virus for the first time in that same period.
If you have all four of the virus sub-types your chances of cervical cancer are greatly enhanced. The vaccine offers 100% immunity. Men and women should be getting the vaccine.
Cervical cancer is the only viral illness treated with surgery and in the case of the cancer radical surgery. It can be prevented with a vaccine. While the majority of cases are benign, the same could be said of polio and mumps (that only a certain few have the total environmental and genetic package that manifests itself as the disease) but we don't hestitate to treat that with vaccine.
Posted by: Mikeyes on February 5, 2007 3:48 PMWhy is it a waste? I was _totally_ for this thing (I have 2 young daughters and another on the way) until I _just_ read in Child Magazine (at the OB's office) that it is expected to prevent 10,000 cases of cancer _over 25 years_!!!
How many people is that over 25 years? 150 million? And it saves only 10,000 people?
Sounds like a masterstroke of the Merck marketing department, but like a boondoggle for the girls who could benefit from a better use of that money.
Am I missing something? Are Child Magazine's figures totally off? I want this to be a chance to save lots of women from cervical cancer, but because this vaccine only protects against a few varieties of HPV which is only one cause of cancer, it seems like less of a breakthrough.
Please, tell me Child Mag got it wrong. If not, isn't this hard to support?
Posted by: Colin Fraizer on February 5, 2007 4:11 PMRecent research also suggests that circumcision reduces HIV transmission by about 50%. Anyone for mandatory circumcision? No long term drug risk. Very low surgical risk. A real win/win.
Posted by: Ed Reid on February 5, 2007 4:30 PMWhy doesn't everybody who wants others to take this vaccine chip in to a fund and pay for it? They can also chip in more for incentives to people who would rather not take it; even for free.
If those who favor universal innoculations aren't willing to do this, it seems to me that they don't think it's worth their own money for this to happen: just other people's money. And, they want to forcefully override other people's considered judgement about the issue.
Every bad idea has this kind of support.
Posted by: Gil on February 5, 2007 4:49 PMRecent research also suggests that circumcision reduces HIV transmission by about 50%. Anyone for mandatory circumcision? No long term drug risk. Very low surgical risk. A real win/win.
If 80% of people were HIV positive by 40 years old sure I would.
Why doesn't everybody who wants others to take this vaccine chip in to a fund and pay for it? They can also chip in more for incentives to people who would rather not take it; even for free.
If those who favor universal innoculations aren't willing to do this, it seems to me that they don't think it's worth their own money for this to happen: just other people's money. And, they want to forcefully override other people's considered judgement about the issue.
The answer is that it is your classic free rider problem. I'm also wondering why I should have to pay for you to vaccinate YOUR children. I don't mind being required to help those in financial distress but don't you think that having children obigates you to certain necessary expenses? Let's imagine Gil saying this about...ooo..food...
"Why doesn't everyone who thinks my kids should eat chip in money to pay for their food! Who do they think they are ordering other people's money around!"
Posted by: Boonton on February 5, 2007 5:20 PMBoonton,
Wouldn't a marginal analysis show it would be better to spend those resources on, say, fighting the remaining 30% of cervical cancers or other public health issues[?]
Well, sure, except that in the absence of mandatory vaccination of boys, the money wouldn't be going towards any sort of research; it'd just stay in the parents' pockets, yes?
It seems to me that if the goal is to wipe out HPV altogether, inoculating boys makes sense even if, as you point out, twice the vaccinations doesn't equal twice the benefit. If you can really get eliminate the virus essentially completely in the younger generation, a decade or so on you could probably get by with not making vaccination mandatory for anyone a decade or so further on. Very few kids are having sex with people a decade or more older than themselves, and as most of them are probably making a living through prostitution, I imagine HPV is the least of their worries. Wipe out the virus in about ten years' worth of teens, therefore, and for practical purposes a vanishingly small number of the next batch of teens will contract it, vaccinated or not.
Posted by: Michelle Dulak Thomson on February 5, 2007 5:29 PMGil - Why doesn't everybody who wants others to take this vaccine chip in to a fund and pay for it?
They can also chip in more for incentives to people who would rather not take it; even for free.
Why doesn't the government pay for my gas if they want me to drive below the speed limit?
While I question this being mandatory since I think people have a right to control their own bodies, I think it makes a lot of sense.
Here's an idea; Anyone who refuses to get their kid vaccinated should be held criminally and civilly liable if their kid has sex with someone else before the age of consent.
Posted by: Ryan on February 5, 2007 5:33 PMCan you have a "classic free rider problem" with a non-public good? I mean, the people who get the vaccine get the benefits, and the people who don't, don't.
Posted by: AT on February 5, 2007 5:35 PMYou know, it occurs to me that the stronger public-health argument is actually for making the vaccine mandatory for boys, optional for girls. So far as transmission goes, no girls will be infected if either all the girls or all the boys are inoculated, yes? But the purpose of inoculating a girl is to prevent her being infected, whereas the purpose of inoculating a boy would be to prevent his infecting others. The latter seems the more obvious public-health concern to me.
Posted by: Michelle Dulak Thomson on February 5, 2007 5:40 PMThis debate is so ridiculous. I had my cousin who just got a nursing degree tell me that her professor said in class:
Bush didn't want people to have sex so he was preventing the hpv vaccine from being approved.
My cousin, from MA flat out believe this. Poor girl.
I don't care if 80% of the people by the time they are 40 get it. If they got it through personal choice and not through just normal contact why are we dicussing mandatory requirements?
80% of the people by the time they are 40 probably have partially clogged arteries, many of which will ultimately lead to death and health problems. Do we require mandatory injections into our kids because we're a bunch of pigs and can't stopping downing burgers and tacos?
Posted by: polar on February 5, 2007 5:52 PM"Would we have been better off if the polio vaccine was held up for 30 years or so to see if it caused an increase in birth defects?" No, but polio was killing and crippling a lot of people. Polio vaccine would have still been overwhelmingly beneficial even if one thousand kids had dropped dead right after receiving it. I think HPV is at least an order of magnitude less dangerous, and so a low order of risk may still be appreciable compared to the benefit expected from the vaccine.
I've been thinking a lot about HPV and cervical cancer. markm's comments made me wonder: where does it rank in terms of most cases?
A beginning to an answer is below:
http://www.cancer.gov/cancertopics/commoncancers
If they got it through personal choice and not through just normal contact why are we dicussing mandatory requirements
It's not nessicarily personal choice. The people involved didn't know they were getting it. Their partners may not know that they had it. Also, if a person is not legally able to consent to sex when they get a disease, why should we say that they got the disease 'through personal choice?'
I think what you mean is "if they got it through what many people believe is immoral activity." If you got a disease by hiking in the woods, I'm not sure people would be so quick to say that this was a matter of "personal choice." Hiking in the woods is not disapproved of.
I mean, the people who get the vaccine get the benefits, and the people who don't, don't.
The people who don't get a vaccine are still less likely to get infected if the rest of the population is vaccinated. If 90% of a population is vaccinated, the other 10% can safely go without the harms of the vaccine and still get nearly all the benefits of avoiding the disease, because the disease is far less common.
Posted by: Ryan on February 5, 2007 6:37 PM
The people who don't get a vaccine are still less likely to get infected if the rest of the population is vaccinated. If 90% of a population is vaccinated, the other 10% can safely go without the harms of the vaccine and still get nearly all the benefits of avoiding the disease, because the disease is far less common.
Which brings us back to the cost issue: how many people are going to get vaccinated on their own at $360 each? If it were cheap, the government wouldn't have to force people to take it. 90/10 and you may have a free-rider argument. Where does that end? 50/50? 10/90?
Posted by: AT on February 5, 2007 6:54 PM"So why should I be against this?"
For the same reasons you would be against any agency in society other than the state using coercion to get people to pay for things that they claim not to want.
Posted by: James on February 5, 2007 7:01 PMIt seems to me that if the goal is to wipe out HPV altogether, inoculating boys makes sense even if, as you point out, twice the vaccinations doesn't equal twice the benefit.
That would be a goal in a world of infinite resources but in a world of finite resources marginal analysis is more useful and marginal analysis asks what is the benefit of doing a little bit more versus the cost of doing a little bit more. There's a huge drop in added benefit when you go from univeral vaccination of girls to boys and I suspect there is where the costs will exceed the benefits.
Well, sure, except that in the absence of mandatory vaccination of boys, the money wouldn't be going towards any sort of research; it'd just stay in the parents' pockets, yes?
Perhaps which is not in itself a bad thing. Why should we make parents spend $600 when for $300 they can get 98% of the same benefit? On the other hand whose to say that there won't be vaccines developed that would be more sensible to give to only boys?
If you can really get eliminate the virus essentially completely in the younger generation, a decade or so on you could probably get by with not making vaccination mandatory for anyone a decade or so further on.
I think you have a point here. That is a bit of what happened with smallpox. Once it was eliminated there was no longer any need for vaccinations at all. That doesn't necessarily require universal vaccination. I believe smallpox was wiped out with a mix of some mandatory vaccinations and other targetted vacinnations.
Can you have a "classic free rider problem" with a non-public good? I mean, the people who get the vaccine get the benefits, and the people who don't, don't.
If everyone around you was vaccinated you can get away with skipping it because whose going to give you the HPV? Herd immunity here is the public good.
But the purpose of inoculating a girl is to prevent her being infected, whereas the purpose of inoculating a boy would be to prevent his infecting others. The latter seems the more obvious public-health concern to me.
Except the problem is infection in a girl carries the risk of an avoidable cancer death. If, say, 100 people are going to get infected despite the vaccination programs it would be better that they be boys than girls.
I don't care if 80% of the people by the time they are 40 get it. If they got it through personal choice and not through just normal contact why are we dicussing mandatory requirements?
How about e coli? If you cook food properly you will kill it so why care when people get sick after eating burgers at the local place...it was their choice right?
Posted by: Boonton on February 5, 2007 7:50 PMHere is why I am against mandatory vaccinations against HPV (and hepatitis B and HIV, if we ever get an effective vaccine).
All vaccines have economic costs and medical risks. Forcing parents to bear the costs and children to bear the risks can be justified only with highly communicable (airborne spread) diseases with serious consequences (such as measles, mumps, rubella, Hemophilus, etc.). In those diseases unvaccinated persons can spread disease to others (even vaccinated persons) without direct or intimate contact.
Vaccination against diseases that are spread via blood or sexual contact should be voluntary, because the general public is not at risk from unvaccinated persons.
The arguments in favor of mandatory HPV vaccination are seriously flawed.
1. Not all cervical cancers are caused by HPV.
2. The vaccine is only partly effective against HPV.
3. Cervical cancer is highly preventable already by eliminating dysplastic lesions found via Pap smears.
4. Most of the women who die of cervical cancer could have avoided death by seeking minimal gynecologic care. (Spare me the arguments about poor persons lacking access. Getting to a free gynecology clinic once every two years is not a great burden.)
Can you have a "classic free rider problem" with a non-public good? I mean, the people who get the vaccine get the benefits, and the people who don't, don't.
If everyone around you was vaccinated you can get away with skipping it because whose going to give you the HPV? Herd immunity here is the public good.
Ahem:
Which brings us back to the cost issue: how many people are going to get vaccinated on their own at $360 each? If it were cheap, the government wouldn't have to force people to take it. 90/10 and you may have a free-rider argument. Where does that end? 50/50? 10/90?
Posted by: AT on February 5, 2007 7:57 PMMaybe this one is just fine, but then the government decides to definine a list of mandatory injections. Or decides to modify the water
You mean by like adding fluoride to it?
Posted by: TW Andrews on February 5, 2007 9:09 PMA 70% prevention rate isn't very good statistically. I wonder if it would be enough to engender a certain degree of "invulnerability thinking", however?
Ever since the link between some variants of HPV and some forms of cancer of the uterus were discovered, I've been wondering if the same virus could be associated with reproductive tumors in men. Perhaps if cancers that kill men were taken as seriously as those that kill women, we might know...
Posted by: ellipsis on February 5, 2007 9:36 PMYou should be against it because it has an appalling cost-benefit structure. More than half of cervical cancers are diagnosed in women 35 to 55, and almost all the rest later than that. If Colorado starts vaccinating 11-year-olds now, the cost might be $300 million before the first life-saving benefit appears in the form of a cancer that didn't happen 25 years from now.
And if diagnosis and treatment improve in the next quarter-century -- could happen, don't you think? -- the number of deaths from cervical cancer fell by nearly three-fourths from 1955 to 1992 and continues to decline, according to the American Cancer Society. If the number of deaths falls, the cost of each one prevented (I figured about $300K each, too) shoots up.
Two problems; you have to do a huge number of vaccinations to prevent one cervical cancer, because it is such a rare consequence of an HPV infection;
and you have to pay the cost upfront, in dollars today, while the benefit is decades away, so it should be deeply discounted (and may, by then, not even exist).
How do you evaluate other costs? For instance;
Human papillomavirus-positive women had a decreased pregnancy rate 23.5% as compared with HPV-negative women 57.0%; P http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16782096&query_hl=1&itool=pubmed_docsum
So far, calculations have only taken into account direct effects (women who don't get a disease because they're vaccinated) and has ignored the costs saved from reducing the spread of a disease (or effectively reducing its virulence by combatting a negative strain.)
These vaccines might have unpredicted side effects. So might HPV. Many viruses, such as CMV, thought to be latent and harmless, have been associated with significant cognitive decline when high viral titers are present in the body. I don't know if HPV is systematic that way, offhand, but it does raise the issue.
Posted by: Ryan on February 5, 2007 10:08 PMThe arguments in favor of mandatory HPV vaccination are seriously flawed.
1. Not all cervical cancers are caused by HPV.
True but so what? Many are and this will prevent many of them and presumably future vaccines will be even more effective.
2. The vaccine is only partly effective against HPV.
True except instead of partly a more accurate word seems to be mostly.
3. Cervical cancer is highly preventable already by eliminating dysplastic lesions found via Pap smears.
4. Most of the women who die of cervical cancer could have avoided death by seeking minimal gynecologic care. (Spare me the arguments about poor persons lacking access. Getting to a free gynecology clinic once every two years is not a great burden.)
Perhaps but many women will not get 'minimal gynecologic care' either because of cost or because they don't believe they need it or they simply don't get around to it. Wouldn't it be better to avoid such lesions in the first place through a simple vaccine?
Posted by: Boonton on February 5, 2007 10:10 PMTo Ryan who thinks there is opposition solely because I disagree with premarital sex. I would agree with you that people who go hiking in the woods are at risk of getting bit by snakes. I dont think we should require the entire population to take some kind of anti snake venom vaccine. In fact, I'd suggest that if you go hiking in the woods, you take the necessary precautions and if you feel like the risk is not worth it perhaps you don't go hiking in the woods.
It has nothing to do with immoral activity and EVERYTHING to do with you feeling like you can tell me I have to take something so you can continuing doing what you would like to do, whether it is immoral or not. If you want to do it, take the vaccine.
Posted by: s on February 5, 2007 10:11 PMThere is a legit concern about people feeling 'invulnerable'...this is called 'moral hazzard'. It's not about morality but about incentives. Insurance companies deal with it all the time. If people know they are covered they may drive more dangerously.
Here's the thing, though, if 80% of women will aquire HPV in their lives then how much *MORE* risky behavior could the vaccine motivate? It's clear HPV is something most people don't bother to think much about, to test partners for or to take precautions against. As Jane pointed out there's little you can really do about it anyway since just about everyone has it and condoms only offer limited protection. Whose going to engage in risky behavior from this vaccine? The 3% of people who have decided to be lifelong virgins?
I would worry about moral hazzard more with something like an HIV vaccine that was 30% effective. Normally cutting transmission rates by 30% would be great but if people doubled or trippled their bed hopping thinking that AIDS was finally gone the benefit would be outweighed.
Ironically moral hazzard isn't a problem here because no one is holding back because of HPV.
Posted by: Boonton on February 5, 2007 10:42 PMIf you are worried about free-riding why not tax those who don't get the vaccination or subsidize those who do. It is almost always more efficient for the government to handle externalities through taxation and subsidies than through dictating conduct.
Posted by: James D. Miller on February 5, 2007 10:43 PMI'll be damned if you'll charge me a fine because I refused to get vaccinate so you can run around and hump everything like a rabbit. You want to live that way fine.
But don't charge me a penalty because I refuse to dance to the same tune you do and don't need to get vaccinated.
Here's where I think people are muddying the waters big time:
Which HPV are we talking about that 80% of women get? There are over 100 different kinds. A dozen of them (according to Wikipedia) are the cervical cancer kind. Those cause 70% of the cancers. Gardasil is 100% effective against those.
There's a missing link there = what percentage of the people who have HPV have the cancer-causing kind?
I would really like to see some numbers. What I'd really like to see are Venn diagrams.
Posted by: Klug on February 5, 2007 11:19 PMHmmm. According to the pregnancy rates quoted above, we save billions of dollars in health care and education expenses by *not* giving the vaccines. Pick your public benefit.
Oh, and by the way, Republicans in Texas are furious at the governor for mandating this.
Posted by: Twill00 on February 5, 2007 11:46 PMThe Facts About GARDASIL
1. GARDASIL is a vaccine for 4 strains of the human papillomavirus (HPV), two strains that are strongly associated (and probably cause) genital warts and two strains that are typically associated (and may cause) cervical cancer. About 90% of people with genital warts show exposure to one of the two HPV strains strongly suspected to cause genital warts. About 70% of women with cervical cancer show exposure to one of the other two HPV strains that the vaccine is designed to confer resistance to.
2. HPV is a sexually communicable (not an infectious) virus. When you consider all strains of HPV, over 70% of sexually active males and females have been exposed. A condom helps a lot (70% less likely to get it), but has not been shown to stop transmission in all cases (only one study of 82 college girls who self-reported about condom use has been done). For the vast majority of women, exposure to HPV strains (even the four "bad ones" protected for in GARDASIL) results in no known health complications of any kind.
3. Cervical cancer is not a deadly nor prevalent cancer in the US or any other first world nation. Cervical cancer rates have declined sharply over the last 30 years and are still declining. Cervical cancer accounts for less than 1% of of all female cancer cases and deaths in the US. Cervical cancer is typically very treatable and the prognosis for a healthy outcome is good. The typical exceptions to this case are old women, women who are already unhealthy and women who don't get pap smears until after the cancer has existed for many years.
4. Merck's clinical studies for GARDASIL were problematic in several ways. Only 20,541 women were used (half got the "placebo") and their health was followed up for only four years at maximum and typically 1-3 years only. More critically, only 1,121 of these subjects were less than 16. The younger subjects were only followed up for a maximum of 18 months. Furthermore, less than 10% of these subjects received true placebo injections. The others were given injections containing an aluminum salt adjuvant (vaccine enhancer) that is also a component of GARDASIL. This is scientifically preposterous, especially when you consider that similar alum adjuvants are suspected to be responsible for Gulf War disease and other possible vaccination related complications.
5. Both the "placebo" groups and the vaccination groups reported a myriad of short term and medium term health problems over the course of their evaluations. The majority of both groups reported minor health complications near the injection site or near the time of the injection. Among the vaccination group, reports of such complications were slightly higher. The small sample that was given a real placebo reported far fewer complications -- as in less than half. Furthermore, most if not all longer term complications were written off as not being potentially vaccine caused for all subjects.
6. Because the pool of test subjects was so small and the rates of cervical cancer are so low, NOT A SINGLE CONTROL SUBJECT ACTUALLY CONTRACTED CERVICAL CANCER IN ANY WAY, SHAPE OR FORM -- MUCH LESS DIED OF IT. Instead, this vaccine's supposed efficacy is based on the fact that the vaccinated group ended up with far fewer cases (5 vs. about 200) of genital warts and "precancerous lesions" (dysplasias) than the alum injected "control" subjects.
7. Because the tests included just four years of follow up at most, the long term effects and efficacy of this vaccine are completely unknown for anyone. All but the shortest term effects are completely unknown for little girls. Considering the tiny size of youngster study, the data about the shortest terms side effects for girls are also dubious.
8. GARDASIL is the most expensive vaccine ever marketed. It requires three vaccinations at $120 a pop for a total price tag of $360. It is expected to be Merck's biggest cash cow of this and the next decade.
These are simply the facts of the situation as presented by Merck and the FDA.
For a more complete discussion on GARDASIL with sources, click on my name.
Posted by: stickdog on February 6, 2007 3:09 AMWhile I have no problem recieving any vaccinations for things I am likely to get, I don't quite see the free-rider problem.
People can choose to get a vaccine for a disease, with the benifit that they won't get it and the potential cost of some side effects. But free-riders don't really cost us anything in this system, since people who vaccinate are immune to the diseases that the free-riders might get. While they might benifit from enough of us getting vaccinated against disease X, I wouldn't count that as a cost.
Posted by: Aaron on February 6, 2007 4:46 AMAnother way of looking at it is this:
You can campaign to eradicate a disease through vaccination, but it is time consuming, expensive, and needs to be 100% to work. (It seems polio, and other ancient diseases are coming back because people in the 3rd world rejected our vaccination aid out of suspicion that we were putting something over on them. So the campaign of eradication didn't work because of just slight non-participation at the margins.)
It seems that it's a more robust defense just to vaccinate yourself against diseases all the time, rather than wage an eradication campaign one generation, and not vaccinate, counting on the diseases nonexistence the next.
Posted by: Aaron on February 6, 2007 6:40 AMWow...apparently a lot of people have no problem forcing parents to have medicine injected into their children whether they want to or not.
What the hell has this country come to?
Posted by: Jay on February 6, 2007 10:40 AMSo far as transmission goes, no girls will be infected if either all the girls or all the boys are inoculated, yes?
Only if none of those girls ever has sex with any person, male or female, who is alive in America today and has been sexually active in the past. Remember, this vaccination doesn't simultaneously exterminate current carriers.
Posted by: Brittain33 on February 6, 2007 11:07 AMTo Ryan who thinks there is opposition solely because I disagree with premarital sex. I would agree with you that people who go hiking in the woods are at risk of getting bit by snakes. I dont think we should require the entire population to take some kind of anti snake venom vaccine. In fact, I'd suggest that if you go hiking in the woods, you take the necessary precautions and if you feel like the risk is not worth it perhaps you don't go hiking in the woods.
It almost seems as if you’re suggesting that the “slam dunk” rational for government coercion becomes less of a “slam dunk” when people have the ability to avoid the risk by altering their behavior.
Seriously if we were talking about an airborne illness or one spread by casual contact, I could see contemplating mandatory vaccinations. Although I’d still question whether the governor can simply order it as well as wanting some answers about the efficacy of the clinical studies.
But for a disease that requires some sort of sexual contact to be transmitted (including manual or oral) but that people cannot get simply by breathing or other casual contact, this doesn’t even come close.
Why are tetanous immunizations mandatory for school in most states? There's no externality to a person not being immunized.
[Tetanous is contracted from puncture wounds where the penetrating objects are contaminated by a perticular bacterial spore which is ubiquetous outdoors]
-dk
Thorley, do people seriously consider lifetime abstinence to be a viable choice for most people? (Straight people, of course; I know that many straight people think this is perfectly reasonable to recommend to gays, including those who run abstinence education programs.)
Women can get HPV from a monogamous marriage if they marry someone who has been exposed to the virus. Presumably most of those young girls are expected to get married and have children in the future. Isn't it too much to expect that they should only marry a fellow virgin, otherwise, they should expect the consequences? At what point does the expectation of behavior avoidance become too baroque for reality?
Brittain,
I don't think anyone is arguing that you should not get this if you feel like you need to. I think people are arguing against you (perhaps) and others who suggest it be a requirement for everyone, simply because you have a certain type of lifestyle.
Why, that would be akin to be claiming that we should not even administer this vaccine AT ALL simple because my lifestyle does not require it. I'm not doing that. But some people basically are.
It's kind of funny that some people have suddenly awoken to the fact that - gasp - there are consequences to our actions and that - gasp - maybe there is indeed some divine providence in the morality mandates that many people try to adhere to.
If you want to attempt to circumvent those consequences through science, go right ahead, but I'd hope you remember that there is no free lunch...
Posted by: no on February 6, 2007 1:16 PMThe scary thing about this is that it's all a result of Merck lobbying state legislatures to require all children to receive their medicine. The fact that they succceeded is scary as hell. Do we know what else they are lobbying to put into the entire population?
Posted by: Wolf Samuelsson on February 6, 2007 1:18 PMThe scary thing about this is that it's all a result of Merck lobbying state legislatures to require all children to receive their medicine. The fact that they succceeded is scary as hell. Do we know what else they are lobbying to put into the entire population?
I thought that this was being done by executive order of the governor rather than by a new law passed by the legislature of Texas (which surprises me since I was under the impression that Texas had a “weak governor”).
Regardless though, I don’t think it’s fair to attribute this all to Merck. There is a very real concern about HPV and the drug appears to be effective in dealing with the virus that is thought to be the cause of 70% of the cases of cervical cancer.
I’m not familiar enough with the specifics of how the clinical studies were conducted to comment intelligently on whether they were proper but my libertarian tendencies aside, I tend to be a strong proponent of informed consent and making sure that we have safe drugs and devices on the market. If there were indeed shortcuts made, I think it’s a real concern particularly if someone is proposing to make this a mandatory vaccination.
That being said, even if the drug were proven safe, my real concern is that I believe there should be a pretty high bar for the government to justify mandatory vaccination of citizens (particularly children in the custody of their parents or guardians). If this disease were airborne or transmitted through casual contact, it would be a matter of weighing the costs and benefits and what ways if any people would be able to opt out. But since the disease appears to only be transmittable through sexual contact which people can easily protect themselves against, I don’t think we are anywhere near the point where I could in good conscience support allowing the State to exercise this power.
Dick King asked:
Why are tetanous immunizations mandatory for school in most states? There's no externality to a person not being immunized.
[Tetanous is contracted from puncture wounds where the penetrating objects are contaminated by a perticular bacterial spore which is ubiquetous outdoors]
I'm not aware of any such requirement. To the best of my knowledge, all children who wish to attend a public school must have received the DPT vaccine, which is intended to protect against diptheria, pertussis and tetanus.
Non-clickable link:
http://en.wikipedia.org/wiki/DPT_vaccine
Diptheria is highly contagious, any skin contact or breathing the aerosol coughed out by a sick person will suffice.
http://en.wikipedia.org/wiki/Diphtheria
Pertussis and tetanus can be life-threatening diseases even with treatment, hence the inclusion in DPT. The vaccines for tetanus, pertussis and diptheria are rather well understood by now.
I don't see the analogy between DPT and Gardisol.
Posted by: ellipsis on February 6, 2007 1:37 PMOoh! Oooh! Thorley Winston has indirectly brought up a big philosophical issue:
Doesn't mandating this vaccine for all girls take away choice?
Posted by: ellipsis on February 6, 2007 2:05 PMTo add in to ellipsis's comment about tetanus, it's pretty common for a kid to get cuts and scratches at school. It's not like a kid ever fell off the slide and got an std.
Posted by: also on February 6, 2007 2:05 PMOoh! Oooh! Thorley Winston has indirectly brought up a big philosophical issue:
Doesn't mandating this vaccine for all girls take away choice?
Discuss....
Posted by: ellipsis on February 6, 2007 2:05 PMAnd now, to add fuel to the fire, let us all travel back to the year 1955, and watch someone say:
"I don't see any reason why pregnant women shouldn't take thalidomide for morning sickness. After all, the government says it is safe!".
Posted by: ellipsis on February 6, 2007 2:18 PMI think people are arguing against you (perhaps) and others who suggest it be a requirement for everyone, simply because you have a certain type of lifestyle.
Right. Their argument is based on a misunderstanding of what type of lifestyle puts women at risk for HPV and cervical cancer. The lifestyle which does so is one that parents of nearly all children envision for their children: one in which they have sex at least once.
Most people don't want their children to have sex, but that doesn't apply when their children are, say, 35 and it's far too late for this vaccine to be effective.
People are in denial about the epidemiology of HPV if they think that being good is protection against it. That was my point aboce.
Posted by: Brittain33 on February 6, 2007 2:21 PMEllipsis, I find the other conclusion more troublesome: doesn't your argument say that women who only have sex within a monogamous marriage can still be culpable for their own cancer, because they behavior causes it?
Posted by: Brittain33 on February 6, 2007 2:23 PMEllipsis, I find the other conclusion more troublesome: doesn't your argument say that women who only have sex within a monogamous marriage can still be culpable for their own cancer, because they behavior causes it?
What argument of mine are you referring to? Please be specific.
Posted by: ellipsis on February 6, 2007 2:29 PMRandy and AT -
"Yes, I think that those who would rather risk getting polio than get the vaccine should be allowed to do so. "
"Can you have a "classic free rider problem" with a non-public good? I mean, the people who get the vaccine get the benefits, and the people who don't, don't."
I'm not sure if this applies to the specifics of this particular vaccine, but in general there may be people who shouldn't receive a vaccine and will be at risk if others opt out in order to free-ride. My son's doctor at first (years ago, before DTaP) recommended that my son not get the pertussis vaccination (for whooping cough; the P in DTP), because he had a previous traumatic brain injury. There are periodic outbreaks of whooping cough in the US, largely due to those that choose not to be vaccinated, and my son was at risk because of those people.
My point is simply that there may be externalities - those that are medically vulnerable and should not get a vaccination are affected by the choices of others.
Another possible consideration - as I understand it, a certain proportion of vaccinations don't "take". If everyone gets vaccinated, then the proportion that doesn't work may be low enough that most people are protected anyway, because of the "herd immunity" - they're unlikely to be exposed. But if many opt out, then even those that are vaccinated are at greater risk.
You can debate the likelihoods, but I don't think it's accurate to assume zero externalities.
Posted by: Ann on February 6, 2007 2:48 PM"You can debate the likelihoods, but I don't think it's accurate to assume zero externalities."
True. Positive or negative externalities. Assuming the negative side of things I'd prefer to keep the needles away from my daughter in this case.
Posted by: a on February 6, 2007 3:26 PMI see no problem with being forced to vaccinate as long as I get monetary compensation on par with being in a clinical study, since I'm not irresponsible enough to need it. (Well, if I were female.)
Posted by: Person on February 6, 2007 3:28 PMI see the 70% of cancer cases caused by HPV a lot. How many people who contract HPV eventually develop cancer? If I am reading correctly, it isn't that 70% of people with HPV end up with cervical cancer but that 70% of cervical cancer is cause by HPV. Exactly how much protection is being provided here?
Posted by: cyall on February 6, 2007 3:50 PMand as I asked should we have delayed mandating the polio vaccine for 30 years
As markm noted, the consequences of not dealing with polio were much higher and consideraly more immediate than any risks the vaccine might pose 30 years down the road. Also, polio is transmitted via the fecal-oral route. If you must reach for an anlogy, try hepatitis -- it works a lot better than polio (which doesn't really serve any useful analogous purpose here).
Posted by: anony-mouse on February 6, 2007 4:01 PMAlso, if a person is not legally able to consent to sex when they get a disease, why should we say that they got the disease 'through personal choice?'
You could make a fair argument for mandatory underage abortion with logic like this. It would be a rather foolish argument, though.
Posted by: anony-mouse on February 6, 2007 4:03 PMI looked up a review of HPV epidemiology (Baseman and Koutsky, 2005, J. Clin. Viro) and one of the associated papers. IANAE; but it certainly was an eye-opener. It was published in 2005, so likely there is better data out there. I cherry-picked what I thought was the most relevant stats.
As far of rates of high-risk HPV, it's pretty high among the populations surveyed. In a Planned Parenthood population in the US with a mean age of 25 years, it was 27.4%. In a study in Scotland with a mean age of 37, it was 15.7% and 20.5% for all HPVs.
As for rates of all HPVs, it is still pretty common. According to this, it's not nearly as high as some of the numbers I've seen in the blogosphere. The 3-years cumulative incidence of HPV infection was 43% in one study and 42.8% in another (both in the US). The high was 44% over 3 years and 60% at 5 years in one English study of 15-19 yo women. The low was a Brazilian study over 18 months; the infection rate was 23.6%.
Interestingly (but perhaps obviously), the infection rate correlated most strongly to number of sex partners. In one study of teen girls (11-19) in Atlanta, the rates of girls who had 1 sex partner for any HPV was 34%. For girls with more than eight (!), it was 84%.
Let me lay my cards out on the table one more time: I'm not anti-vaccine (in terms of the side effects, autism, etc.) I am a social conservative, but I lean libertarian in terms of actual governance. I find certain vaccine requirements odd, even odious. (HepB?) Again, I cherry-picked. Others are welcome to post better stats.
I do think the waters are being muddied big time, partially as a means of convincing the public and in part as a means of hitting social cons over the head with something. (Sometimes, we deserve it.)
Here's the thing: look at that Atlanta number for girls with one sex partner. It's 34%. That is very, very high. It is the actual rate? Dunno -- they don't talk about frequency of intercourse. It's high enough to get this potential parent to think about getting his daughter anti-HPV.
Moreover, doesn't this whole thing argue for a change in strategy to asking boys (all kids, but boys especially) to keep their f'ing zippers closed? It's not that hard; I managed to do it, more or less.
Posted by: Klug on February 6, 2007 4:08 PMCyall:
I could be ENTIRELY wrong here, but this is my reading of this review and everything I can find on wikipedia. Again, I am SO not an epidemiologist.
Out of 100 women that get the strains of HPV that cause cancer in the 20s, eight will get cervical cancer by their 40s or 50s. Of those, three or four will die. Presumably, those four or five that do not die will be very negatively affected.
Of the nearly 100 strains of HPV, 2 strains (HPVs 16 and 18) cause 70% of invasive cervical cancer. It is my understanding that Gardasil is 100% effective.
Posted by: Klug on February 6, 2007 4:21 PMIn one study of teen girls (11-19) in Atlanta, the rates of girls who had 1 sex partner for any HPV was 34%.
That's 34% at 19 for girls with 1 partner. Naturally it goes up after that since once infected it is with you for life and the population will not become 100% chaste upon hitting 19.
Moreover, doesn't this whole thing argue for a change in strategy to asking boys (all kids, but boys especially) to keep their f'ing zippers closed? It's not that hard; I managed to do it, more or less.
This is a good strategy overall since it would cut down on lots of STD transmissions...however the fact is the majority of people are going to engage in intercourse at some point in their lives. So yes it isn't like you can catch this from someone sneezing next to you but at the same time you don't have to go to extraordinary lengths to catch it...simply having an average sex life will is more than sufficient.
Using the above numbers, if you're a 'good girl' who remains a virgin and marries a boy who only had 1 sexual partner before you already have a 1/3rd chance of catching HPV (since 34% of 1 partner girls has it I'm figuring 1/3 of 1 partner boys has it too). Now if you not such a good girl and had a single partner you're already starting with a 34% chance of having it, hooking up with a 1 partner boy adds to it... What I'm getting at here is that it doesn't take extraordinary amount of sexual irresponsibility to get this. A sex life that is probably rather mild compared to yours is sufficient.
There's nothing wrong with advocating responsibility and moderation but it has to be done in the context of realism. If your policy begins with the premise "why just establish virginity as the norm until age 27" you might as well just quite now.
Posted by: Boonton on February 6, 2007 4:43 PMIt is my understanding that Gardasil is 100% effective.
For how long, I wonder? A better constructed set of studies might tell us this and a few other important things. Too bad there don't seem to be any...
Posted by: ellipsis on February 6, 2007 4:53 PM
I just read that if Merck can get Gardasil on the list of "mandatory for school" vaccines, the Federal government then takes over liability. That's mighty convenient, since the technique used (recombinant VLPs assembled from the L1 proteins of HPVs 6, 11, 16 and 18) appears to be used for the first time in Gardasil, and the long-term effects are totally unknown...including whether Gardasil itself is or is not a carcinogen.
This gets curiouser and curiouser, as Alice said...
Posted by: ellipsis on February 6, 2007 6:13 PMBoonton:
I don't want to be coy, but I have to think about this more. As I said, I only read one review and one study connected with that review. In that study (the one with the 34% number), the authors refer to the population as "high risk." You are right, though -- having 2 or 3 partners raised their chances of HPV to 59%.
[Part of this that I don't understand what constitutes sexual promiscuity amongst young adults. Apart from that awful Frontline documentary, that is.]
The feeling that I get from all of this is that the proverbial horse is out of the barn and the various stakeholders (public health, media, etc.) are firmly behind it. That being said, I think that 1) it is probably better to be offered than required, 2) this will increase resentment against vaccines amongst the general populace (even though it may be good for everyone) and 3) sexual precocity is best avoided and creates far more broken people than great lovers. (But 3 is just me being a socon. ;-)
Posted by: Klug on February 6, 2007 6:48 PMIf you don't want to risk the disease, why not pay for your own vaccination? Why should we pay for it? How do you expect to avoid both the disease and the vaccination by making vaccination a mandatory government program?
Posted by: Aaron on February 6, 2007 7:03 PMPS. It's wonderful that they developed a vaccine for this, but mandates are the wrong way to go about healthcare.
As markm noted, the consequences of not dealing with polio were much higher and consideraly more immediate than any risks the vaccine might pose 30 years down the road. Also, polio is transmitted via the fecal-oral route. If you must reach for an anlogy, try hepatitis -- it works a lot better than polio (which doesn't really serve any useful analogous purpose here).
Hmm...yeah, that reads funny. Polio and Hepatitis vaccinations are potentially analogous because they are spread similarly and have a similar scope of negative effects (well, polio perhaps more so in adults, and less so in young children).
A better comparison for HPV would be Herpes -- multiple strains, relatively widespread infection in the adult population, but typically only the HSV-2 variant (which functions primarily as an STD) leads to more serious disease once it has been contracted.
Posted by: anony-mouse on February 6, 2007 8:00 PMAnother question comes to mind; is there any long-term effects on fertility? DES was used for over 30 years before its effects upon the offspring was finally noted, and "DES daughters" are still with us today. The only documentation I can find on Gardasil refers to animal tests, which simply isn't good enough for a new vaccine using a new technique, IMO. The proponents of mandatory vaccination seem to be engaging less in "reality based" thinking, and more in "faith based" emoting...
Maybe if Jane studied libertarianism, she'd be able to 'splain to herself why mandatory injection of chemicals with unknown long term effects into children could be a poor idea...
Jane makes a great point, and overall, demonstrates strong credibility with her reasonable libertarianism.
If only other libertarians were half as reasonable, libertarianism might actually have a chance as a political philosophy.
Posted by: Viscus on February 6, 2007 9:28 PMPeople have brought up thalidomide and DES. However, I'm not sure if those are really relevant to this considering that the girls involved are being vaccinated before +99% of them are likely to be pregnant.
Both of the mentioned cases involve effects from drug treatment during pregnancy.
Aaron - did you read the thread? Everyone who gets this pays for their own vaccination. And theoretically, they can opt out. I wonder how much red tape there is for that...
Posted by: Ryan on February 6, 2007 10:38 PMRyan wrote:
People have brought up thalidomide and DES. However, I'm not sure if those are really relevant to this considering that the girls involved are being vaccinated before +99% of them are likely to be pregnant.
Both of the mentioned cases involve effects from drug treatment during pregnancy.
Both drugs were certified by government to be safe in their intended use, and turned out not to be, because the testing regime was insufficient. Gardasil has been tested for a rather short time on a fairly small, in epidemiological terms, group of women. The long term effects, specifically on fertility, are unknown at this time.
It hasn't been tested on 9 year olds at all. So anyone who has their daughter vaccinated with this compound is participating, knowingly or not, in an extension of the Phase III testing.
Mandatory "beta testing" of drugs on children seems questionable to me.
Posted by: ellipsis on February 6, 2007 11:17 PMBefore I wrote this comment there were nearly 20 occurences of the word "effective" in these posts. I'll at least echo the sentiment. What is the point in a vaccine that is 60 or 70% effective? It would seem doing nothing would be nearly as good. Assuming of course a 50/50 proposition.
It is also interesting so many hail the new remedy when so many in the past have tried to crucify those responsible for remedies that have caused unexpected results years later.
Seems that often are problem solving reflects are subjective rather than objective analysis.
Both drugs were certified by government to be safe in their intended use
But not the US government. Thalidomide is still used to good effect. Just not by women who might be pregnant at the time it is used. Likewise, this vaccine is unlikely to be used by women who are pregnant while receiving it.
The long term effects, specifically on fertility, are unknown at this time. The long term effects of HPV on fertility are harmful. There are some suggestions that gardasil might spur cross-immunity to other HPV types (even though it's just approved for four.) Is there any possible mechansim by which this vaccine might harm fetuses years after a person has taken the vaccine, and also be more harmful than exposure to actual HPV viral particles (carcinogenic or not) would be?
Granted, the fact that the gov't is now liable is a bit frightening. But I want to make sure that the costs of inaction, as well as action, are weighed.
Posted by: Ryan on February 7, 2007 1:19 AMThe lobbyist for the company that makes the vaccine, Merck, was Rick Perry's Chief of Staff. How cozy. So like everything else in politics.
The vaccine's short term and long term risks are unknown.
I thought (cough)libertarians(cough) were big on individual rights and freedoms. How does forcing your certainty down my unconvinced throat equate to freedom?
Posted by: genevieve on February 7, 2007 3:26 AMWell, the risks of the vaccination vs the risks of the disease is just one part of this debate.
The other is whether you'll let each individual decide which set of risks to assume, or if you'll remove that decision by making vaccination mandatory.
"Aaron - did you read the thread? Everyone who gets this pays for their own vaccination. And theoretically, they can opt out. I wonder how much red tape there is for that..."
Oh. Nevermind then. I thought we were talking about maintaining herd immunity or something through a mandatory vaccination. Just giving my answers explaining my objections.
Posted by: Aaron on February 7, 2007 4:53 AMBefore I wrote this comment there were nearly 20 occurences of the word "effective" in these posts. I'll at least echo the sentiment. What is the point in a vaccine that is 60 or 70% effective? It would seem doing nothing would be nearly as good.
I think you might be confusing what the 70% figure refers to. The article Jane linked to said that 70% of the 3700 women in the United States who develop cervical cancer annually have HPV. That doesn’t mean that Gardasil (which prevents HPV infections) is only 70% effective (which would suggest that it would fail to prevent 30% of the women who were treated with it from developing HPV infections) but rather than it can potentially prevent the 70% of cases of cervical cancer believed to be caused by HPV.
That doesn’t mean that there aren’t legitimate questions about its long-term effectiveness and potential side-effects (as well as effectiveness in treating girls younger than the testing groups). Nor does it IMO justify mandatory vaccinations for a disease which AFAWK isn’t transmitted through casual contact.
Posted by: Thorley Winston on February 7, 2007 10:35 AMI wrote:
Both drugs were certified by government to be safe in their intended use
Ryan replied:
But not the US government.
So? Are you asserting that the US government is infallible?
Thalidomide is still used to good effect. Just not by women who might be pregnant at the time it is used.
True, but irrelevent to my point, which you seem determined to ignore. I'll spell it out: we have at least two examples of compounds that were used to bad effect in the past, that received minimal testing prior to use. Gardasil has been shown to be effective and to have no serious side effects in a small Phase I and a larger Phase III test on women in their 20's and a relatively small cohort of teenagers 16 and above. You cannot extrapolate from those tests in any scientific way to state that it absolutely is therefore safe for use in pre-pubescent girls, nor can you assert how long the immunity lasts, nor can you assert it has no effects upon fertility.
Therefore, mandating its use is not scientifically supportable. Do you understand this?
Likewise, this vaccine is unlikely to be used by women who are pregnant while receiving it.
How do you know that to be true?
The long term effects, specifically on fertility, are unknown at this time. The long term effects of HPV on fertility are harmful.
What is the mechanism that leads some (many? all? I don't know) strains of HPV to reduce fertility, I wonder? Recall that Gardasil is created from HPV via a new modification technique; is it possible for Gardasil to affect fertility, or not? I don't know the answer, do you?
There are some suggestions that gardasil might spur cross-immunity to other HPV types (even though it's just approved for four.)
Really? I have not run across that suggestion so far, not in any document from Merck or from Medline. Please provide a pointer to this suggestion.
Is there any possible mechansim by which this vaccine might harm fetuses years after a person has taken the vaccine, and also be more harmful than exposure to actual HPV viral particles (carcinogenic or not) would be?
I do not know. Do you? Can you state with 99% certainty that Gardasil has no, none, not any short term OR long term side effects when administered to pre-pubescent girls? No, you can not, nor can anyone else. Yet you seem to think it a good idea for every pre-pubescent girl on the planet to become a lab-test rat for Merck. Why is that?
Granted, the fact that the gov't is now liable is a bit frightening.
I do not know this to be true, it seems that it could be true in the future. However, I must wonder why Merck is pushing so hard to get Gardasil put into the category of a mandatory vaccine. Is it just the "cash cow" aspect? Or is there some other reason? This haste to mandate a barely-tested vaccine for use on people that it was never tested on is simply unscientific.
But I want to make sure that the costs of inaction, as well as action, are weighed.
Please be so kind as to read back up the thread, where the costs of inaction were described. This isn't like the smallpox vaccine, or polio, or a vaccine against the 1918 "Spanish" flu. This is a vaccine that is purported to be 100% effective against virii that cause 70% of one particular cancer that only a minority of women exposed to the virii in question ever get.
I am not opposed to vaccines. I am not opposed to this vaccine. I am opposed to mandating the use of this vaccine in general, and very much opposed to mandating the use of this vaccine on a population that it has never been tested on. Frankly, I am bothered by the unseemly haste involved as well. It gives the impression that there is something questionable going on.
Posted by: ellipsis on February 7, 2007 10:39 AM"Frankly, I am bothered by the unseemly haste involved as well. It gives the impression that there is something questionable going on."
I agree, ellipsis. Even though the odds are that it's an okay vaccine w/o any really detrimental side effects, it seems that Merck has, for whatever reason, decided that this is the right marketing strategy. That we're having this debate is evidence that it has failed.
Posted by: Klug on February 7, 2007 11:22 AMThe feeling that I get from all of this is that the proverbial horse is out of the barn and the various stakeholders (public health, media, etc.) are firmly behind it. That being said, I think that 1) it is probably better to be offered than required, 2) this will increase resentment against vaccines amongst the general populace (even though it may be good for everyone) and 3) sexual precocity is best avoided and creates far more broken people than great lovers. (But 3 is just me being a socon. ;-)
I suspect that there will be a bit of uproar (mostly manufactured) about mandating the vaccine but it would quickly die out. From a sexual morality standpoint I think there's a lot less here than meets the eye of those seeking a sensational story.
The thing is no one seems to care much about getting HPV. Therefore it isn't having a big impact on sexual behavior. In other words, if you pluck a virgin out of the population whatever reason that person happens to be a virgin almost certainly has nothing to do with HPV. I think it would be different if we were talking about an effecitive AIDS. If someone introduced a good AIDS vaccine tomorrow there would be people who would go out and start having more risky sex. Of course such a vaccine would still be wroth it.
No one is going to run out and be a slut because of this vaccine and because it is recommended at such a young age the odds are going to be even less likely. At 11 or 12 I can see a child thinking of this as yet another shot they must take. At 16 or 17 I can see it being jokingly referred to as the 'ok to have sex' shot.
Likewise most normal parents, even very conservative religious ones, want their daughters to eventually marry and have families. HPV is no friend to that since even a very modest sex life exposes one to a high risk of aquiring HPV either directly or through one's partner.
I understand about safety concerns but here again we have to turn towards the fact that we will always have imperfect knowledge BUT we do know that HPV is not a good thing. True most people who are infected will never have any problem or only have a minor one if they do. We do run the risks of uncertainity by mandating use of the vaccine but we do have to take these risks with a grain of salt. Yes I cannot prove that the vaccine will not cause us to all become zombies in 20 years but I think the chances that we have missed such a thing are slim.
Posted by: Boonton on February 7, 2007 2:53 PMIf they got it through personal choice and not through just normal contact why are we dicussing mandatory requirements
Let's just say it: having sex is normal. Sexual contact is normal. Having sex during your lifetime is as normal as getting sneezed on during your lifetime.
I'm not offering any kind of opinion on mandatory-ness here. But insisting that HPV is different because you can "choose" not to risk exposure is as unrealistic as insisting that the flu is different because you can "choose" to live in a plastic bubble and breathe filtered air. This argument is just a trojan horse for the idea that sex is exceptional, unusual or immoral, and that you deserve what you get if you make the extraordinary and obviously-questionable decision to engage in it.
Posted by: Mark on February 7, 2007 3:10 PMMark:
I'm sorry, we disagree. I believe that you're trying to muddy the waters here. I don't really want to get into the sexual morality stuff, especially because it doesn't get into the public health part. But I can't let your statement go without comment.
Sex outside of marriage or otherwise long-term monogamous relationships may not be exceptional or immoral, but it certainly can be unwise and likely costs more than you gain. To deny these negative aspects is not a good idea, as personal morality or as public policy.
Posted by: Klug on February 7, 2007 3:53 PMHere's a though. My understanding is that we've made it illegal for:
cars to produce certain levels of emissions
foods to contain certain types of fats
And I'm sure a few other things...all in the name of choice. Why not make it illegel for:
People to have sex outside of marriage
Obviously that's a bit of a ploy, but if we're so comfortable legistlating other things which can end up being "bad" for us. Why not the sex part. Clearly more people suffer from STDs than from excess transfats in their cheetos or C02 in their tailpipes.
Posted by: thought on February 7, 2007 4:25 PMMark,
You make a good point. It isn't a very good argument to say I don't want the shot because I can choose to be careful. A better argument is more along the lines of I can choose not to have the shot because, well... just because. My reason doesn't have to be good because it still trumps your right to force me. My reason is mine and you have no right to take it away from me. Also, though a bit extreme perhaps, I think there is reason to believe that those who make incorrect choices should be wiped out.
We have no organ at all for knowledge, for “truth”: we “know” (or believe or imagine) precisely as much as may be useful in the interest of the human herd, the species: and even what is here called “usefulness” is in the end only a belief, something imagined and perhaps precisely that most fatal piece of stupidity by which we shall one day perish. Friedrich Nietzsche
Klug, I don't understand how your comment constitutes a disagreement with the idea that sexual contact is "normal", which was my point.
I did notice, though, that for someone who doesn't want to "get into the sexual morality stuff", you were the first to mention marriage and monogamy.
Posted by: Mark on February 7, 2007 5:21 PMJust a thought, but how is the "free rider problem" ever, by itself, a sufficient justification for eliminating freedom? Public health - maybe. Free riders - never.
Posted by: Randy on February 7, 2007 5:22 PMNor does it IMO justify mandatory vaccinations for a disease which AFAWK isn’t transmitted through casual contact
Your presumption, that somehow being able to make a choice and not get the disease, is flawed. You can't choose to not get the flu because you can't reasonably tell when you're at risk.
The same thing applies to HPV. While many people may be able to make a choice to be monogamous, they marry people who aren't all the time. What with divorce rates, they then marry other partners. In fact, single-partner people are the exception, they certainly aren't common. The rate of HPV transmission is very high, partly because you usually can't tell if your partner has it or not.
Not only can you NOT make that choice because your partner makes it for you, sexual partners are one of the biggest things people lie about.
In fact, you are trying to posit that acting abnormal is somehow a reasonable choice to avoid a disease that we can try and get rid of, or at least drastically reduce the presence of. A disease that affects people who are NOT able to choose not to get it, all the time.
Posted by: Jeffrey Boser on February 7, 2007 5:35 PMJeffrey,
Can not the same argument be said for Herpes, Gonorhea, HIV and just about everything else out there? Do we require mandatory vaccination to protect against all of these because it's just too old fashioned, irresponsible, religious, etc. etc. to expect otherwise?
Posted by: j on February 7, 2007 5:50 PMYou know, a lot of this is devolving into the "AIDS is a disease" debate of the early '90s. Needless to say, no thanks, I've been there before.
Mark: As to the mentioning of marriage and monogamy, guilty as charged. I'm gonna guess that what exactly is "normal" is where we're gonna disagree.
Posted by: Klug on February 7, 2007 6:52 PMsddqdgqwejhdh
NASA Astronaut Lisa Nowak Charged With Attempted Murder in Bizarre Love Triangle
ffff
Posted by: dqd on February 7, 2007 7:19 PMCan not the same argument be said for Herpes, Gonorhea, HIV and just about everything else out there? Do we require mandatory vaccination to protect against all of these because it's just too old fashioned, irresponsible, religious, etc. etc. to expect otherwise?
I think if they came up with a safe and effective AIDS vaccine it probably would be made mandatory and probably should be. While we are at it I don't think we are really talking about mandatory vaccination. Parents can opt their kids out of inoculations by filing an affidavit voicing their objection. The policy really if you don't want the vaccine you have to do a bit of work rather than the default of you have to work to get the vaccine.
Boonton,
The policy [being] really if you don't want the vaccine you have to do a bit of work rather than the default of you have to work to get the vaccine.
Except that you "have to do a bit of work" to get the vaccine anyway, unless you have a tree out back that grows $20 bills instead of leaves. We're talking, what, a week and a half's full-time wages at minimum wage, yes? Making the vaccination mandatory doesn't make it easier or cheaper for those who would've gotten it anyway; you presumably still have to (1) schedule an appointment with your pediatrician, and (2) pay for it. It's not a bit easier to get the vaccination than it was; it's just a lot harder not to.
Posted by: Michelle Dulak Thomson on February 7, 2007 8:23 PMI read another review of the literature (Trottier and Franco, Vaccine. 2006, 24S1, S1/4) of HPV infection. It’s pretty interesting stuff, if amateur epidemiology is your thing. IANAE, so take this with a grain of salt.
Things I have learned so far:
HPV infection is pretty high, but no one knows what the real number is. Both of these reviews I’ve read cite many small papers that study relatively small populations. The numbers range from 2% to 44% in these studies. The Baseman review assumes that “most (>50%) sexually active women have been infected by one or more genital HPV types at some point in time.” It’s relatively high among men too, with numbers like 17% (Finnish conscript study) or 33% (US college students.) As I’ve said before, some of the numbers I’ve seen in the blogosphere (>70%) are overblown.
HPV infection (as far as I can tell) happens when you’re young. The younger you are, the more likely you are to get it. (Some of the prevalence/age graphs are U or J-shaped over 30 years starting in your 20s, though.) HPV infection is negatively correlated with age of first intercourse, but positively correlated with number of lifetime partners or recent partners. In fact, the most consistent risk factor is number of lifetime partners, according to Baseman.
As Jane says, HPV infection is not entirely prevented by condom use. Matter of fact, condom use appears to increase risk, but that’s likely the effect of people who are at high risk using condoms. The “everything-but” folks are in for it, as HPV transmission doesn’t even require penetration. Low-risk (non-cancerous) HPV has been detected on the fingers of people with genital warts (wash those hands!) According to Trottier, “among virgin college students, any type of non-penentrative sexual contact was associated with a 2.4% 24-month cumulative incidence of infection.”
What does this all mean? I’ll take away a few things: 1) assuming a safe, effective and comprehensive vaccine (i.e. better than what we got right this minute), it will be darn near mandatory, 2) if you plan on having what people consider a normal "fun" sex life, it’s probably a good idea to get the vaccine on your own (especially if your’re a woman) 3) my personal guess is that high-risk HPV is localized in a few communities or behaviors and we’re all being ‘punished’ and 4) best to keep your pants zipped and your hands to yourself. Oh, and 5) there needs to be better research into modes of transmission and associated risk (boy to girl, girl to boy, hand to mouth, you get the idea.)
I may be showing ignorance, but won't the cost go up when the government mandates it.
Posted by: mike on February 7, 2007 8:42 PMThe fact that you need close contact to transmit HPV makes it more of a choice and less of a free rider problem in my opinion because 1) the person choosing whether or not to be vaccinated (or their parents) can evaluate risk/benefit and 2) the future partners of the person in question can also use the persons HPV/vaccination status as part of a risk/benefit decision (i.e. "Did you get the vaccine? If not, let's get tested."). Maybe it's not realistic, but it should be and people should be expected to take that level of responsibility for themselves as they are expected to do with HIV. I would argue that if a vaccine for HIV were developed we would not have to make it mandatory to get people to take it because the risk/benefits are clear. If you have to force people to do something maybe it's because they have a different cost/benefit analysis. Maybe they're right, doesn't matter, it's their life.
Posted by: BladeDoc on February 7, 2007 8:46 PMWhy the opposition?
This is actually the first time I've seen a rational discussion of the costs vs. benefits.
All the other discussion I've heard on the subject came from the same sorts of people who don't want condoms available to minors (or in some cases, to anyone) They could care less about the costs, effectiveness, or side effects.
Just wait until they come up with a workable AIDS vaccine, then it'll really get crazy.
Posted by: Tim in PA on February 7, 2007 8:47 PMI'm not so sure. Merck would have a larger number of customers over which they could recover their R&D costs and profit...in other words if they want to make $1B the price per person is less if there's 75 million patients rather than 7 million.
Since patent protected drugs are a monopoly their pricing is rather delicate politically. There's no real market to send price signals so Merck would have to price the judge so as not to seem to be taking too much advantage of the mandate...otherwise people will revolt against the mandate and Merck loses a guaranteed market. The optimal strategy might just be to cut the price as more and more people have to buy the vaccine.
Of course while this vaccine is protected by patent there's nothing from stopping other companies from producing a different vaccine that does the same thing (probably improved ones that cover more strands of HPV). So we have an incentive to competition in place as well.
Posted by: Boonton on February 7, 2007 8:51 PMMerck's got a billion bucks to bring in, and they'll force laws everywhere so they can get access to vaccinate your daughters against something they should be taught to never get in the first place. And they'll pay off every lefty woman in legislatures nationwide in order to get it done.
Posted by: State 29 on February 7, 2007 9:21 PM"So why should I be against this?"
I don't care whether or not you are against it, and you ought not to care if I am. Get it, don't get it, I don't care. That you and the government would fail to offer me the same respect to decide for myself or my children is the height of paternalistic liberalism.
That you would call me a "dimwit" without knowing me or considering my analysis of the costs, benefits, and risks of vaccines as they relate to my children suggests more about your mental state than it does mine.
Actually, looking at the American Cancer Society statistics for 2006 they estimate 9710 cases of cancer for 2006 (there were 14,500 cases in 1997, 13,700 in 1998, 12,800 in 1999, 12,800 in 2000, 12,900 in 2001, 13,000 in 2002, 12,200 in 2003, 10,520 in 2004; does that seem like a trend to any of you?) and 3700 deaths. Using the 70% number above gives us 6797 cases and roughly 2500 deaths per year that this medicine may help; for this they want to forcibly innoculate 150 million people at a cost of, well, a lot, with what seems to be a relatively untested medicine?
If you think this is a great idea then how can you possibly be against the government regulating exactly what we are allowed to eat and forcing us to exercise, since various heart diseases kill some 700,000 people per year?
Where do I buy some Merck stock?
Posted by: Mr. Bingley on February 7, 2007 9:33 PMTim PA,
You said
Why the opposition?One of the big reasons is this from the Houston Chronicle.
AUSTIN — Merck & Co. is helping bankroll efforts to pass state laws requiring girls as young as 11 or 12 to receive the drugmaker's new vaccine against the sexually transmitted cervical-cancer virus.This is a perfect example of rent seeking and it is a bad precedent. It replaces medical review and risk benefit analysis with brute political force.
Posted by: TJIT on February 7, 2007 9:38 PM
Has anybody even though of taking into account the cost of side effects? How many children have received brain damage or worse from faulty vaccinations? Even if you look at the value for those affected beneficially, what about the ruined lives of those who had adverse reactions? If even one such life can be saved...
Posted by: Bob N on February 7, 2007 9:43 PMWe just did this, or to be more precise, our 15 year old daughter just had the vaccination. We paid for it as a part of our (her) annual check-up. Big deal - a new vaccination, for a known problem, more or less no side effects, probable future problems headed off - what's the issue? We got the polio, the mumps, the chicken pox vacciantions - why not this one?
OK, we did have to have a discussion about STDs and, no this is not permission to have sex.
Then, we found out thast insurance covered the shot. Yeah!
Mountains, Mole hills.
Posted by: John Lynch on February 7, 2007 9:46 PMHere is a link to another article from the Houston Chronicle.
From, among others, the Texas Medical Association and the American Academy of Pediatrics, many doctors are saying it's too early to mandate the vaccine
Another quote from the article
Opposition from doctors was less expected. Virtually all hail the vaccine as a great breakthrough and call for the highest possible proportion of girls and women — and boys and men, eventually — to get immunized in hope of one day eliminating the virus.
"But education needs to come first," said Dr. Joseph Bocchini, chairman of the AAP's committee on infectious disease. "Much of the public doesn't know about HPV and its link to cervical cancer and other diseases. You can't put a mandate ahead of that."and another
Dr. Patricia Sulak, a professor of obstetrics-gynecology at the Texas A&M Health Science Center College of Medicine, said health-care providers she knows were shocked by the order. "It's such a new vaccine — they haven't had time to explain it to patients," said Sulak.and another
Hinchey and others emphasized that although the vaccine is considered safe, there are questions of whether there is enough experience with it to warrant a mandate. They say that some girls eventually may experience rare adverse effects not yet identified.And here is the best one of the article
Hinchey said that TMA leadership expressed their concerns to Perry on Tuesday. He said the TMA arrived at its position after debating the issue in committees in recent days.
A spokeswoman for Perry reiterated Tuesday that the governor stands by the order. She said he is listening to the discussion but thinks the vaccine is safe and effective.Got that Perry, with his years of medical practice and expertise in immunology is telling the physicians group to go pack sand.
I suspect if this did not involve an STD people of all political stripes would be opposing the mandate.
Libertarians would see rent seeking, liberals would see abuse of corporate power, and conservatives would see parents rights.
HPV is providing an interesting test case. They are currently doing clinical trials on an anti herpes vaccine. HerpeVac Trial for Women. I hope the herpes vaccine maked it to market. I will be glad it is available just as I'm glad the HPV vaccine is available.
I just hope the physicians handle the introduction of the herpes vaccine, not the lobbyists and politicians
Posted by: TJIT on February 7, 2007 10:07 PMThat being said -- two points come to mind with mandatory HPV vaccination. 1) HPV, like HIV and unlike Polio, Tetanus, Pertussis, etc is 100% preventable by behavioral change.
Only if the "behavioral change" you're talking about is lifelong celibacy. That's fine for some people, but it isn't really a good option for the country or the species as a whole.
What people who assume "saving yourself for marriage" prevents disease forget is that people can only control who *they* sleep with. They can't stop their partner from cheating on them with an infected person. Even among ostensibly devout Christians, infidelity is extraordinarily common. A woman can thump the Bible all she wants, but if her husband's diddling the local cocktail waitress she might still wind up with cervical cancer.
Posted by: Dan on February 7, 2007 10:13 PMI am automatically against any proposition that starts with "The government should mandate that private individuals absorb this cost/risk because," and will change my mind only with significant evidence. The road to hell, and all that, is a part of it. More of a part of it is that I am sick and tired of having my freedom to live life as I choose eroded year by year. Already, my life is less free than it was when I was a child, and significantly less free than my parents' lives.
While there appears to be a benefit here, the benefit is in the far future and is highly arguable as to its size and relative utility. (For example, it is possible that the vaccine prevents no cases of cancer, because the study wasn't long enough to determine that. It couldn't be, and still maintain the patent in any meaningful way.) On the other hand, there are definite costs and risks, and part of the risk is that there may be additional unknown costs and risks.
It is therefore unclear to me whether I would vaccinate daughters, had I any, but is entirely clear to me that mandatory vaccination is wrong. The government should not be permitted to impose costs and risks on people except in very, very limited cases. This is not such a case.
this vaccine is NOT going to accomplish herd immunity (no men, no women above an age who may have already been exposed to hpv)
You're right that we won't have herd immunity until the women you mention above are dead. But the virus spreads from man to woman to man to woman. Take the women out of the equation and the virus can't spread anymore, and will die off with its current male carriers. That's herd immunity at work.
Posted by: Dan on February 7, 2007 10:17 PMQuestion: Just because the vaccine prevents the cancers that are caused by the virus, does the vaccine also go so far as to eliminate the presence of the virus and thereby prevent the spread of the virus?
Posted by: edhesq on February 7, 2007 10:22 PMMaking this PC-correct wrappings and trappings cocktail mandatory with such scant testing, to eradicate what, by the numbers given, is an apparently correlated outcome affecting a rather small number of people - what a horrifically stupid idea.
True, the numbers of people affected is totally irrelevant to either the sufferer of cervical cancer or their loved ones - and a cure for their pain is probably foremost in their thoughts, and in the hopes of anyone even slightly empathetic to their plight.
However, the numbers put forth in absolutely no way indicate nor in any way guarantee that sort of outcome. How can they, with such a small testing group, such a limited time span of observation, using half-assed methodologies and controls?
Mandating the introduction of, basically, an as good as untested substance into children because it may show a long term benefit in 25 years or so?
If people were dropping like flies and this appeared to stop that, well, offer it, but I still say give people the choice of dropping like flies if they feel so inclined.
But if we're talking such long term effect (put aside the 'sooner we get started, the sooner we get results, hurry, hurry, hurry' hysteria) then what's the problem with telling Merck - "hey, looks promising. Do a decent study, with about at least a five year, or better 10 year follow-up to see if there's any nasty 'uh-oh, we didn't think THAT would happen' pops up...
...and THEN let people make an INFORMED decision about wether or not they, or their children, should participate in the benefits of your no doubt wondrous, life saving discovery.
So, in answer to Jane's original question - oh yeah, I can see why LOTS of folks should have LOTS of problems with this drug, with this methodology, and with this whole half baked idea.
And you'll notice, no cost numbers involved here - the cost of saving a life or easing suffering? Incalculable. IF it proves effective, I've got no problems with Merck charging $500 or $1000 or more a pop to recoup the research, development and fielding costs to PROVE this is safe and effective.
By the same token, I don't think they should be allowed to GIVE this stuff away if all they've got to show for it's safety and effectiveness is the sham of a trial mentioned above.
the biggest problem is how this has been allowed to be framed... This is a vaccination for the virus responsible for most cervical cancer. End of story. How you get the virus is NOT material. That is where the preventable by abstention argument is a bit red herring... because you have to retroactively have had the shot to have the protection, so the only other way to prevent is to have tests done for you and any partner to see if you have it...
and then what? If you find that a partner has it due to the test, then what do you do? Break up with them? My understanding is that the vaccine is far less effective [if at all] on an established case, but I could be wrong. And THAT presumes that everyone is willing to put off 'hooking up' till they go out and get STD tests... and then unless you are already a committed couple and get the test results together, it's pretty easy to lie. Especially if you know that having HPV might mean your partner heads for the door. There are a lot of scenerios there...
Ultimately it comes down to paying for a youthful indescretion by dying of cancer later for a certain amount of people. Meanwhile that person has passed the virus on to all her partners, and their partners and so on.
It doesn't matter if Merck makes some cash form this, they are the ones putting up the billion to get the thing approved, all the R&D and testing. Their corner of the market will decrease quickly...
Two things bother me though...
Thing 1] so why arent boys mandated for this? It takes two to tango... how fast would you reduce the spread if you did both parties. {maybe there's a sensible explanation... dunno]
Thing 2] refers to the question of vaccinations and opting out. The problem really is simple. There is NO TEST to see if a child will have a side effect from a vaccination. The vaccination IS the test. In the very small percentage that fail? The kid can die, have brain damage etc. The liturature is extremely hard to tease out on this, but by all I can figure from the CDC... it's 1 in a million chance per vaccination... which seems low. Unless it's your kid. Then it's 1:1. And yet in all these years 50+ have they ever come up with a test? Obviously the odds just seem good enough to not wory about it. and for that reason they have set up National Vaccine Injury Compensation Program (VICP) For those 100 or 200 or more people who have died or had pernmanant brain damage. Given the hyper allergies in my family, neither of my children are immunized. A child isn't really able to be allergy tested in a meaningful way untill they are 5 or so, and what do you know? My son is so allergic to the egg carriers the immunizations are in, he would have gone into anaphalaxis, and probably died at his first immunization. Yet it would not have been the immunization itself that would be to blame, but what it is grown in.
So am I careful? Most parents have a good reason to keep their kids from immunization, when they do. The good reason is that NO-ONE looks out for THEIR children. Governments look out for populations, not individuals.
The bottom line is that immunizations should be mandetory UNLESS there is a reason for them not to be. In the case of the HPV parents can opt out for religious reasons anyway, so I don't see where the promiscuity card comes into play, EVEN IF you look at it from that direction first...
Posted by: D on February 7, 2007 10:39 PMPersonally, I think further study is needed before mandating this.
However, on the question of vaccinating boys vs girls: just guessing, but doesn't it seem likely that there would be less potential for long-term side effects (specifically birth defects) on the males? And if so, wouldn't it make more sense to vaccinate the males, and not the females? It would have the same long-term results. (Younger women having sex with older, unvaccinated men would be an obvious problem with this theory.)
Posted by: exhelodrvr on February 7, 2007 11:02 PMRent seeking by Merck? Has that occurred to anybody, including Jane?
I'm as big a boastful lower case l libertarian as they come, but even I can smell a rat here.
The assumption that Jane and the rest of the pro mandatory vaccination folks are making is that this is Salk/Sabin saving the kids from polio all over again. History Channel documentaries, early 30s soviet style.
Except it really really doesn't look like that once you start to get past the TV ads.
I have no problem telling my daughter to get it. I even have no problem providing it for free through my tax dollars to those who can't pay and who do want it. But the "kill the reservoir" argument doesn't work in this case. And passing a *law* to add two cents eps to Merck's bottom line? Based on a flimsy, to say the least, cost benefit analysis? And pretend not to notice what's going on here? If I work for Merck, or own stock, cool, but if not, maybe not so much.
And I'm a big fan of having my stock portfolio go through the roof, but I'm not a fool as to why it might.
Anyone? Or is it just pixie faieries whispering into the ears of the Texas legislature?
Posted by: DoctorOfLove on February 7, 2007 11:03 PMJust curious, are there any other "safe"/effective vaccines available now that are not mandated?
Posted by: exhelodrvr on February 7, 2007 11:10 PMOne word- thalidomide.
So, don't tell me the government is only here to help. Nothing like this should ever be mandated. EVER! Make all the arguments you like.
Just curious, are there any other "safe"/effective vaccines available now that are not mandated?
Chicken Pox Vaccine.
That was an overstatement. It's not 100% preventable by behavioral change in the case of one individual.
But we *can* beat it as a society if we turn around morals in this country. Like AIDS, there's no reason it need be a threat to our children or, at worse, our children's children. But we can't do that if send the (erroneous) signal that loose sexual morals come at zero risk, which is an idea this vaccine is promoting.
Not for *my* daughter.
Posted by: flipjack on February 8, 2007 12:24 AMDid you get the vaccine? If not, let's get tested.
A few people have made statements that seem to assume that there's a test for HPV. The tests used typically detect abnormal pap smears, not the virus itself. So you cannot 'test clean' for HPV. And if you're a man, I'm not aware of any routinely used test for HPV.
Posted by: Ryan on February 8, 2007 12:45 AMRyan:
I don't believe that's entirely true. It appears that public health types use molecular biology techniques (PCR, mostly) to assess negative results. I'm guessing that if PCR does not detect HPV over time (I emphasize over time) that it's considered a negative result.
I do not know if that test is readily available to all physicians, labs, etc., but it does appear to be routine for the papers I was reading. Men can be tested by genital swabs. Presumably, the same PCR techniques can be use to accurately assess HPV status. Again, I don't know about ready availability.
Posted by: Klug on February 8, 2007 1:11 AMMy bad Klug. Thanks for the catch. It seems they recently (~2003) started using PCR for to test for the actual virus.
Posted by: Ryan on February 8, 2007 1:44 AMDan: Take the women out of the equation and the virus can't spread anymore, and will die off with its current male carriers.
Unless, of course, someone invents homosexuality.
Given the number of sexual contacts is so much higher in some parts of the gay male community, I don't think that population should be ignored.
Posted by: Ryan on February 8, 2007 1:53 AMA woman can thump the Bible all she wants, but if her husband's diddling the local cocktail waitress she might still wind up with cervical cancer.
She'll likely end up with herpes or syphillis a long time before she ends up with cervical cancer. If a woman has an unfaithful husband, far worse problems are in the making than a (small) chance of getting one of the few HPV strains associated with cervical cancer, and then actually developing cervical cancer.
You're also going to find a VERY hard sell in convincing someone to become vaccinated "just in case your worst marital nightmare comes true."
Posted by: anony-mouse on February 8, 2007 2:06 AMBoy, am I late to this party.
To answer Jane's original question: It may be a public good to have widespread vaccination for this particular virus, but this way of going about it smells like rent seeking.
Posted by: Steven Den Beste on February 8, 2007 2:49 AMHere's a though. My understanding is that we've made it illegal for:
cars to produce certain levels of emissions
foods to contain certain types of fats
And I'm sure a few other things...all in the name of choice. Why not make it illegel for:
People to have sex outside of marriage
Obviously that's a bit of a ploy, but if we're so comfortable legistlating other things which can end up being "bad" for us. Why not the sex part. Clearly more people suffer from STDs than from excess transfats in their cheetos or C02 in their tailpipes.
You're assuming that just because something is mandated that EVERYONE is okay with it. Personally, I'm NOT okay with quite a few of the things our government has mandated over the years. The fact that they got away with it prior to now is no excuse not to fight this.
(Disclaimer: As others have stated, I'm not against the vaccine. I'm against the mandate.)
Posted by: Trelaina on February 8, 2007 5:52 AM"So why should I be against this?"
Because HPV is not casually communicable among prepubescent schoolchildren the way that polio, measles or mumps are. How is this a difficult concept for you?
It's also interesting that you are completely ignoring the rent-senking by Merck via Rick Perry's former chief of staff. You do claim to be an economist, right? Yet rent-seeking behavior doesn't enter into your analysis? Go figure.
Posted by: KipEsquire on February 8, 2007 7:23 AMHow about forced sterilization of anyone who's ever had more than one abortion?
Let's save the state some money and protect people who obviously can't manage contraception from unnecessary surgery. Why stop at HPV? There's a massive link between unnecessary use of abortion -> unwise family planning -> and the poverty trap.
Reason the civil rights movement won't touch this issue is because they think its a right-wing issue - which is why this might go through. When does everyone learn that the path to
dictatorship is always on the left - because the
left don't question their own.
There is NO TEST to see if a child will have a side effect from a vaccination. The vaccination IS the test. In the very small percentage that fail? The kid can die, have brain damage etc. The liturature is extremely hard to tease out on this, but by all I can figure from the CDC... it's 1 in a million chance per vaccination... which seems low. Unless it's your kid. Then it's 1:1. And yet in all these years 50+ have they ever come up with a test?
If it's a million to one possibility, the only way to test for it is to try it several million times. Test-tube investigations don't allow for all the complexity that exists in a living person. Animals don't react the same. People who've been vaccinated once before don't react the same. Adults may react differently than children. Problems can take decades to develop from the original cause. They can and do do all the screening possible for such risks, but you cannot be sure until you give it to millions of kids and wait a few decades.
That said, if I had a 14 year old daughter, I'd get her vaccinated now - as far as I can tell, the vaccination risks are lower than the alternative. If I had an 11 year old daughter, I'd prefer to wait three years and see if anything new was discovered about this. (My daughter is thirty-something now, and when she was 15 you'd have had to be a blind fool to think she was going to stay a virgin until adulthood, but before 14? No way. I have heard of grammar schools that had to establish day care centers for their student's children, but I've always done whatever it took to keep my family out of such areas.)
Finally, if studies really have shown that 11 is the optimum age, then they're studying neigborhoods where no one is going to have $360 for shots. So, is welfare going to pick up the tab, or are they just going to vaccinate those that need it least?
Posted by: markm on February 8, 2007 10:25 AMIf it's such a good thing, then why do not mandate that everyone, adults and children, receive the vaccine? If we are looking to wipe out cervical cancer, that would certainly be the best option.
As for why do it in school--what better time? We're already sticking the little darlings for everything from measles to chicken pox
Because, unlike measles and chicken pox, which are communicable in a school setting, the HPV strains that cause cervical cancer aren't. That is children should not be getting those HPV strains at school unless they now teaching "Group Sex 101" in 6th grade.
Posted by: kbiel on February 8, 2007 10:52 AMWhat is the chance of actually developing cancer if you have HPV?
And when will it happen in your life?
So we pay a couple billion up front, risk health issues, take away personal freedoms, and we save upwards of it looks like 7-10,000 people a year? Am I missing something?
There are far worse things out there. It really disturbs me the level of forced support this is getting...I can't imagine what will happen when someone invents a vaccine that keeps your heart from clogging, or prevents aids or herpes.
But we *can* beat it as a society if we turn around morals in this country. Like AIDS, there's no reason it need be a threat to our children or, at worse, our children's children. But we can't do that if send the (erroneous) signal that loose sexual morals come at zero risk, which is an idea this vaccine is promoting.
1. No one is restraining their sexual behavior because of HPV. Maybe they do because of AIDS, maybe other STDS but not HPV.
2. It really doesn't make sense to alter your individual behavior just because of HPV. For example, suppose you test clean but your potential husband doesn't.* There's no point in altering your plans because of that because HPV by itself carries very little risk to the individual. This is why such huge percentages of the adult population have it.
Like I said, if someone's a virgin it has nothing to do with HPV. There are no wannabe sluts out there who are just waiting to hear we got HPV licked.
3. What 'herd immunity' will accomplish is a massive decrease in a nasty form of cancer that does kill thousands per year and no doubt causes other problems less severe than death.
4. The 'zero risk lose sex' is NOT what this vaccine is promoting. You recall the stats cited here showed that 1/3 of teen girls who had only one sexual partner in their life were already infected with HPV. Assuming a girl has a single partner and then settles down with a husband who only had one partner himself that alone would probably drive the odds of infection close to 50%. Even a girl who remains a virgin and marries a husband who had one partner (assuming boys with 1 partner also have a 1/3rd infection rate) is stuck with a 1/3 risk of infection.
What #4 demonstrates is that from a risk management point of view you might as well be as loose as you want as far as HPV is concerned. Even if you happen to fall a little bit short of 'perfect sexual morality' the odds you will become infected are very, very high.
Using HPV to advocate sexual restraint is actually counter productive. It's like a diet where you can't eat any fat or sweets and if you slip up even once the whole thing will fail. Most people would rationally choose not to even bother trying such an impossible diet. What's the point of trying so hard only to cut your risk from 50% to 30%?
Other STDs are better for marketing sexual morality if you must. For example, even cutting back a bit on loose sex and adding a few precautions to your sex life can dramatically reduce your chance of getting HIV. There's a real payoff to making a bit of an effort to change your behavior. With HPV there's next to no payoff.
Ryan
Given the number of sexual contacts is so much higher in some parts of the gay male community, I don't think that population should be ignored.
True but here a targetted vaccination program would probably be more economical IMO.
If women are already vaccinated the 'payoff' is a lot smaller since the few HPV gay males who also have sex with women will not be passing HPV to them. Also by mandating the vaccine for women but not men you cut the cost in half. With that savings you could probably knock out the virus in the relatively small population of gay men with a targetted campaign. Smallpox, for example, was exterminated from the human species with targetted vaccination rather than a universal one.
Steven
To answer Jane's original question: It may be a public good to have widespread vaccination for this particular virus, but this way of going about it smells like rent seeking.
Well by definition Merk has achieved 'rent' since it has a patent on this vaccine granting it a monopoly. Yes it also supports people using the vaccine. So what? If the state mandates that all cars must have auto insurance that's pretty good for auto insurance companies right? Profit is part of the game and that's not a bad thing.
Trelaina
And I'm sure a few other things...all in the name of choice. Why not make it illegel for:
People to have sex outside of marriage
Hmmmm, let's take it as an economic argument. The 'cost' of prohibiting certain types of polluting cars or foods with certain types of fats can be calculated and while it's probably an impressive number when divided among all the people in the economy it is probably rather small.
The cost of having people ceed their sex lives to total government regulation is probably a lot higher. Let's imagine government offered people an out. In exchange for purchasing a special license, they could be exempt from such regulation and do as they please. People would probably pay thousands, tens of thousands for such licences. Multiply this by the economy and you can make an estimate of the cost of such regulation to be in the range of hundreds of billions of dollars.
Now compare the benefit of reducing STD's and you'll probably find the cost-benefit analysis fails to justify such a policy.
kbiel
If it's such a good thing, then why do not mandate that everyone, adults and children, receive the vaccine? If we are looking to wipe out cervical cancer, that would certainly be the best option.
That's the best option if money grew on trees. Since it doesn't a more limited mandate could accomplish the same thing for a fraction of the cost.
D
Thing 2] refers to the question of vaccinations and opting out. The problem really is simple. There is NO TEST to see if a child will have a side effect from a vaccination. The vaccination IS the test. In the very small percentage that fail? The kid can die, have brain damage etc. The liturature is extremely hard to tease out on this, but by all I can figure from the CDC... it's 1 in a million chance per vaccination... which seems low. Unless it's your kid. Then it's 1:1.
So there's about 300M people in the US. If we had 100% of females vaccinated and the population remained stable that would be 150M people vaccinated. If there was a 1 in a million problem you would have 150 'vaccination victims' per year. Yet you would also have, what, 7,000 or so fewer victims of cervical cancer per year? If you managed to make the HPV virus globally extinct you could even stop using the vaccine and then save those 150 people per year.
By opposing the vaccination you are protecting your daughter from a 1 in a million risk (maybe) but choosing to expose her to a risk of getting HPV that is probably at least 33% or greater. True her risk of getting cervical cancer won't be that high but it would certainly be much, much higher than 1 in a million.
The only answer to this seems to be along the lines of "If I raise my daughter to be a nun I can spare her both the risk of HPV and the vaccine". OK, what is the track record of parents getting their kids to turn out exactly the way they want them to?
For those carping "what about the boys". Well in the above example if you vaccinated everyone you'd have 300 vaccine victims per year but just about the same number of lives saved. So this is example of marginal analysis. Doubling your effort has a very low payoff so it makes sense to get the most bang for your buck.
* As Ryan pointed out there is no real 'test for HPV' that a person can just go into a doctors office and take, unless they are participating in a clinical study of it.
maid
So we pay a couple billion up front, risk health issues, take away personal freedoms, and we save upwards of it looks like 7-10,000 people a year? Am I missing something?
What personal freedoms are we taking away? Are children the personal property of their parents or do they have a legal obligation to provide for reasonable care to enable those children to make the most of their adult lives? How would you feel about an adult who said he didn't want his kids to be taught how to read and that this was part of his 'personal freedom'?
For the record, what Texas is doing is simply saying you have to vaccinate UNLESS you get off your ass and fill out a paper saying you object to vaccinating. So you still have your 'personal freedom' only you have to do a little bit of work.
There are far worse things out there. It really disturbs me the level of forced support this is getting...I can't imagine what will happen when someone invents a vaccine that keeps your heart from clogging, or prevents aids or herpes.
Do you really live in fear that they will find a vaccine to prevent such things? If so then that's a lot more disturbing IMO.
Posted by: Boonton on February 8, 2007 11:26 AMBoonton:
I re-emphasize, the 34% number is from a study of 312 teen girls in Atlanta. 95% of them were African-American. At the risk of being un-PC, I don't think that you can extrapolate from this one study; the authors refer to this population as high risk.
Posted by: Klug on February 8, 2007 11:30 AMI also daresay that you or I do not know the prevalence of PCR-type testing for HPV out there in the general medical community. I invite any knowledgeable physicians (or MLTs or RNs) to comment.
Posted by: Klug on February 8, 2007 11:39 AMThat's the best option if money grew on trees. Since it doesn't a more limited mandate could accomplish the same thing for a fraction of the cost.
Oh, I guess money only grows on my tree then. Since I have four daughters, three of which will be affected by this mandate, I get the foot the bill for your great leap forward. Thank you for reaching into my pocket for me and letting me know how best to spend my money.
And cost/benefit analysis still does not explain the state of Texas' compelling interest in ordering this. Unlike, TB, HPV is not highly contagious and does not have major outbreaks. Unlike mumps, measles and rubella, HPV does not cause brain damage in children and is not communicable in a social setting such as a school building. Unlike all the other vaccines that I have given my children, the HPV vaccine does not have a proven track record nor is the current sample size and study period been enough to consider putting it in all of our children.
When my three daughters who are affected by this mandate are ready in 6 to 9 years, I very likely will have it administered to them, if over the next 6 to 9 years it is proven safe and effective. Right now, the data is just not there to convince me that we should be using it on our children.
Posted by: kbiel on February 8, 2007 11:54 AMFor the record, what Texas is doing is simply saying you have to vaccinate UNLESS you get off your ass and fill out a paper saying you object to vaccinating. So you still have your 'personal freedom' only you have to do a little bit of work.
Wow. That's a great form of liberty. Perhaps we can restrict people from watching TV, "UNLESS [they] get off [their] ass and fill out a paper" saying that they object to not being able to watch TV. Or we could restrict people from eating junkfood "UNLESS [they] get off [their] ass and fill out a paper" saying that they object to eating only healthy food. Better yet, let's restrict people from attending the church of their choice "UNLESS [they] get off [their] ass and fill out a paper" saying that they object to being atheist or agnostic.
Posted by: kbiel on February 8, 2007 12:05 PMHPV is not casually communicable among prepubescent schoolchildren the way that polio, measles or mumps are. How is this a difficult concept for you?
The vaccine is most effective when administered to prepubescents. How is that a difficult concept for you?
Posted by: Mark on February 8, 2007 1:21 PMI'm sorry to see that the debate is being framed in terms of the question: Is madatory vaccinations a good thing or a bad thing? I think getting sucked into that debate deflects for more important long term issues.
Let's step back for a moment. Due to dramatic advances in science in the last few years, there will soon be many vaccines available to cure cancers and other diseases.
So let's look at how this particular vaccine debate has come about, shall we? First the drug company ran a huge national campaign to enlighten (some say scare) us about the dangers of cervical cancers caused by HPV. Second they ran a huge $$ national campaign ad of sisterly love saying they could cure it (glossing over the fact that their vaccine only covers 4 of the 100+ viruses that cause it and thus only a very small percentage of people's lives will be spared. Then Merk hired mega $$ PR firms to lobby congress and on every talk show in America and bloggers and radio, etc., etc. to tell us how critical this particular vaccine is to our overall public health.
Clearly they expect their mega million PR effort to pay off. And it has. We are all suddenly aware that we can avoid this particular death - however small the risk. So we grab our pitch forks and demand that our government spend whatever tax billions neccessary RIGIHT NOW! to spare us from this particular death.
What bothers me most about the way this debate is how it is profitable for Merk to create this hysteria over a relatively remote possibility of an untimely death. And why is Merk doing this? It is because Merk's pattent only lasts for five years after which time then we could all be vaccinated for probably $15 a pop instead of $300 - or whatever it will be. Let's be honest, this debate isn't really about the best use of our tax dollars to save lives, it is about making sure Merk gets a big return on their patent.
I have no problem with Drug companies getting a good return on their research investment. But do we really want to make it so profitable for them to do so by hyping something to the hysterical proportions that this particular issue has been hyped into? Wouln't you prefer it was MORE profitable for Merk to take those same PR millions and pump it back into their R&D?
This debate should really focus on this question: Is this the best use of billions of our tax dollars, or would more lives be saved spening the same amount of money for health screening or improving roads or air quality or whatever? Let's be real, the only reason we are focusing on this vaccine is because we have been hyped into it by a mega million doallar Merk campaign. Are you comfortable shilling for that?
Besides, what bothers me the most is the road we are traveling. It is not a good idea for the government to make it enormously profitable for a drug company to create a panic for their patented cure.
Merk has done a good thing by creating this vaccine and should be rewarded for it. But if it is so profitable to create a hysteria through a media campaign, is it not even more profitable to create an illness or mold or fungus that only their patent can cure?
IN SHORT:
We are not far off from that possiblity and we should do all that we can to limit the financial incentives for patent holders to create a panic for their product - either through media hype or worse possible scenarios.
Given the number of sexual contacts is so much higher in some parts of the gay male community, I don't think that population should be ignored.
You're right that gay men won't enjoy the herd immunity, but all women and all heterosexual men will. That's 98.5% of the population.
Posted by: Dan on February 8, 2007 2:09 PMOne more data point:
There is a commercialized test for HPV. It does not tell you which strain you have, but it can tell you whether you have the high risk ones. More information at thehpvtest.com.
Appears to be readily available to physicians and marketed by Digene, Inc., whoever that is.
Posted by: Klug on February 8, 2007 2:36 PMP.S. This HPV test is not a Pap smear, but (I assume) based on PCR techniques. It is not available to men. [Interestingly, the website basically suggests that men don't have anything to worry about from HPV.]
Posted by: Klug on February 8, 2007 2:45 PMJust one more case of the government going after something related to sex that kills 400 people a year instead of something like drunk driving or tobacco use that each kill tens of thousands.
The vaccine may have more serious long-term consequences than the disease it allegedly prevents. More study is needed.
The Governor is bypassing the Legislature, a possible Constitutional issue.
And the opt-out process is complicated and must be repeated every year...
Posted by: jtb on February 8, 2007 3:12 PMI think that the HPV vaccine should be mandatory for all Texas Governors.
Posted by: LuLu on February 8, 2007 3:16 PMI re-emphasize, the 34% number is from a study of 312 teen girls in Atlanta. 95% of them were African-American. At the risk of being un-PC, I don't think that you can extrapolate from this one study; the authors refer to this population as high risk.
Sorry Klug, although I'm curious as to what would be a good rule of thumb to use? Teen girls in Atlanta may be high risk but the girls with 34% only had one partner which is not exceptionally risky or unusual compared to the entire nation IMO. I'd love to know how much lower the rate would be for single partner girls in their late teens elsewhere. I'd be surprised if the rate was a lot lower than, say, 20% or so.
kbiel
Oh, I guess money only grows on my tree then. Since I have four daughters, three of which will be affected by this mandate, I get the foot the bill for your great leap forward. Thank you for reaching into my pocket for me and letting me know how best to spend my money.
So making your neighbor pay to vaccinate his four boys does what exactly to reduce your medical bill? I'm sorry you're going to have to lay out money 4 times to handle a vaccination whose primary benefit is for women but that's sort of goes along with having four girls. You'll also have to buy 4 prom dresses and hopefully fund 4 weddings (if you're old school where the bride's parents pay).
On the other hand if someone invents a vaccine that prevents testicular cancer you'll be able to save your money and laugh at your neighbor with four boys.
When my three daughters who are affected by this mandate are ready in 6 to 9 years, I very likely will have it administered to them, if over the next 6 to 9 years it is proven safe and effective. Right now, the data is just not there to convince me that we should be using it on our children.
Fair enough. Out of curiousity what type of data would you require? Are you talking about actual studies you would like to see done or do you just want to wait a few more years to see if news reports start popping up about problems with the vaccination?
Wow. That's a great form of liberty. Perhaps we can restrict people from watching TV, "UNLESS [they] get off [their] ass and fill out a paper" saying that they object to not being able to watch TV. Or we could restrict people from eating junkfood "UNLESS [they] get off [their] ass and fill out a paper" saying that they object to eating only healthy food. Better yet, let's restrict people from attending the church of their choice "UNLESS [they] get off [their] ass and fill out a paper" saying that they object to being atheist or agnostic.
Yea well we aren't talking about your liberty here but the liberty of your kids to be provided with proper medical care. That's not a liberty to you but a duty. People can and are charged as criminals all the time for failing to provide for their children's medical care. I can agree that you can reasonably disagree with whether this vaccine should be considered necessary or optional but I don't think you can really argue the state has no business here.
Becky
Clearly they expect their mega million PR effort to pay off. And it has. We are all suddenly aware that we can avoid this particular death - however small the risk. So we grab our pitch forks and demand that our government spend whatever tax billions neccessary RIGIHT NOW! to spare us from this particular death.
No no no. We're not demanding that gov't spend billions of tax dollars. We want to spend kbiel's dollars!!! :)
Seriously, Merk's advertising in my opinion is not hysterical. Cervical cancer is real and is a risk and their vaccine does greatly diminishes that risk. If everyone had the vaccine before becoming infected by HPV cervical cancer rates would fall by about 70%. Yes other cancers are more common than cervical cancer. For example, in terms of risk you'd probably rather have your daughter be infected with HPV than pick up smoking. Sadly there is no vaccine for lung cancer but that doesn't mean one for cervical cancer can be laughed away as too trivial to worry about.
Like all pharmaceuticals Merk's advertising is watched over carefully by the FDA. I can tell you from working in pharma marketing that the FDA is very strict and uses a very free hand to censor pharmaceutical advertising in ways that would never be tolerated among other products. Not too long ago, I believe Roche got in trouble because it promoted its AIDS drugs with inspiring images of people climbing mountains, riding bikes, swimming etc. The FDA cracked down on them, it felt that the ads were giving people the impression that if you had AIDS you could feel so healthy that you could do such fun things if you were on Roche's medication.
Posted by: Boonton on February 8, 2007 3:16 PMJust one more case of the government going after something related to sex that kills 400 people a year instead of something like drunk driving or tobacco use that each kill tens of thousands.
Hmmm, tobacco is taxed to death on top of the massive 'settlement' tobacco companies had to pay the states. Drunk driving punishments are severe. Both have gone from being socially accepted to socially taboo and if you look at the rates of both you'll see that they have fallen like rocks over the last 20 years or so.
The vaccine may have more serious long-term consequences than the disease it allegedly prevents. More study is needed.
What study is needed? Would you know it if it hit you? If you just want to wait a few years then say that but don't pretend that you have actual studies in mind that you would read if published.
And the opt-out process is complicated and must be repeated every year...
Good, all the more reason to opt out only if you have good reasons.
It's like a diet where you can't eat any fat or sweets and if you slip up even once the whole thing will fail.
Bzzzzzt. If a person's self-control over their sexual activity is so lax that it can be analogized by a basic life process that typically must take place 2+ times a day for any normal health maintenance, then that person is about to learn a very cruel lesson regarding the relationship between action and consequences (of which HPV will be among the least of those consequences).
Posted by: anony-mouse on February 8, 2007 3:39 PMIf a person's self-control over their sexual activity is so lax that it can be analogized ...
Here we were talking about a person who had maybe one sexual partner as a teenager and marries a person who also had one other sexual partner in their lifetime.
I see most of the commentors here get a lot less action than they probably should...even for Internet geeks!
Posted by: Boonton on February 8, 2007 3:43 PMGotta love America where the power of the state can require you to stick a needle with toxins or viruses into your kid, or force you to go through a complicated process to opt out, but if they say the pledge of allegiance in the classroom and give you the right not to even say it the consitutionality is questioned.
Posted by: love america on February 8, 2007 5:42 PMGiven that unwed mothers are costing this country a fortune, one could argue that the government should issue a mandate requiring that all girls of a certain age take birth control pills. I assume all of us would say that's none of the government's business. It ain't about the money, no matter what y'all say. It's about the government overstepping its bounds.
Posted by: dkbaby on February 8, 2007 5:49 PMI see most of the commentors here get a lot less action than they probably should...even for Internet geeks!
Sowing, reaping, etc. Personally, I'm impressed that some of the commentors here have attached such an enormous emotional payload to the vaccine, even in defiance of all areligious scientific and economic knowledge regarding the scope of the disease (small) and the costs (high) of the alleged cure (unproven).
It's almost as though said commenters channeled all their will into denying the actions/consequences link into promoting Merck's corporate interests for some odd reason, even though this is one of the least likely STD problems that will ever be encountered (and is one of the most benign for any woman who undergoes regular health checkups).
Posted by: anony-mouse on February 8, 2007 6:56 PMBoonton: I have to disagree. Did you see the ad campaign? I find it very offensive that Merk ran the first announcement as some sort of public service announcement. "Tell someone you know that they have a risk of dying of cervical cancer." Yeah right. I make it a habit of running around saying, "Did you know you have a X% chance of getting cervical cancer or TB or dying from a miscarriage?" Then after they whipped up the scare, their next ad campaign gets to the point - tell your Dr, your senator, your best friend and everyone you know to buy our vaccine.
You said, "I can tell you from working in pharma marketing.." Ahhh. Yes. I see. And since I'm not a regular visitor to this site, I can't help but wonder .... considering all of the millions Merk is spending on this current PR media campaign in lobbying and advertisments, it certainly makes sense to hire staff to go out and respond to popularly linked blogs that support their position and keep up the scare.
There are lots of things we can spend our tax dollars that will be a better use of money to extend our life spans.
I stand by my previous comments above.
Posted by: Becky on February 8, 2007 7:10 PMAnony-mouse:
For the first time in a long, long time in the comments, I have to disagree with you. (although it could be by degrees) I'm going to guess that low-risk HPV strains are very common in terms of overall infections. From reading the literature, I gather that what you and I would consider a comprehensive study (1000's of women, randomly selected) of HPV infection has yet to be done. However, the smaller studies that have been done of specific populations have uncomfortably high rates. Let me reach over to the 2 reviews I've printed out and read you the percentages as they come: 40, 24, 32, 18, 12, 8, 27, 20, 35%.
This link from NIH (http://www.niaid.nih.gov/factsheets/stdhpv.htm) says that HPV is actually the most common STD out there.
I actually agree with you about the relative lack of danger from high-risk HPV as opposed to AIDS. However, for a certain percentage, it's just as deadly.
Becky:
I've been reading this blog a long time. Boonton has been commenting for a long, long time on this board. I'm sorry. On that one, you're wrong.
Posted by: Klug on February 8, 2007 7:35 PMOk - my apologies to Boonton then.
Regardless of the merits or lack thereof of this particular issue, I think it is a very, very, very, dangerous trend to allow corporations who have patents for disease or disease resistent foods to be allowed to overhype a scare, as Merk has done in this case. It is very obvious that their ultimate goal is to get the masses to focus on this issue (which is low on the list of what is most likely to kill you) and demand that their Senators to force everyone to be vaccinated with their vaccine before the patent runs out.
We should be asking how can our limited tax dollars be best spent for the public as a whole. That should be the discussion. Their are many ways to improve the overall health and longevity of the public. This particular issue is mega money for a very, very small overall result. If we allow Merk to succeed with this PR campaign, then you can expect that in the future all Corporations will be far more willing to spending much more of their budget whipping up a scare in the hopes of getting the legislature to force the use of their product. It will easily provide them a far greater return on their money than the money they spend in R&D.
JMHO
Posted by: Becky on February 8, 2007 8:34 PM"mandatory" is my problem. If they want to offer it, advertise the availability or even do like the flu shot a few times a year, I have no problem
The problem is that one more "mandatory" thing you folks want the government to tell us to do. Back off. This country is to be about freedom. This "manditory" thing for one thing leads to fokls now runing for Presidential office to state they "will take things away from you for your own good."
Posted by: Noelie on February 8, 2007 9:56 PMBecky - It is very obvious that their ultimate goal is to get the masses to focus on this issue (which is low on the list of what is most likely to kill you) and demand that their Senators to force everyone to be vaccinated with their vaccine before the patent runs out.
I don't mind people advertising advertising one bit. I'm thrilled that there's another vaccine for another harmful disease (assuming that it's effective for a long enough time) as long as the advertising is honest. There have been far more damaging fads and trends. Can we address the advertising as a separate issue from the governmental mandates?
Ryan - I understand your point - however the point I'm trying to make is the ONLY reason that the government is going to MANDATE spending so much money for a vaccine that has such a nominal effect on decreasing the public mortality rate is BECAUSE Merk is spending millions to scare us into thinking that this is a health risk of the utmost importance and we must have this vaccine this risk no matter what the cost.
Compared to other places our money could be spent in public health,- this vaccine at $360 a pop for every girl in America is waaay down the list of things that the government could do to increase our chances of not dying before our time.
Please hear my point. I'm not against the vaccine. It's great. I'm not against Merk advertising their product. I'm not against Merk making a big profit on their great vaccine. I AM against Merk spending millions to get the public scared into demanding that the government give them this vaccine no matter what the cost benefit is.
And that's what my complaint is. We are not having this discussion due to our risk of getting cervical cancer. We are having this discussion because Merk has whipped the public up into a frenzy over these 4 (out of 100+) HPV's - versus the other much more serious health and saftey threats that will surely kill far more of us and where our tax dollars could save far more people.
So - from my point of view the advertising can not be separated from the issue of government mandate. Without the mega PR campaign there would be no government mandate.
Posted by: Becky on February 8, 2007 11:29 PMLet me get this straight: HPV is too minor of a problem for people to actually change their behavior, but HPV is such a major problem that we need a government mandate for vaccination.
Shouldn't someone say something for revealed preferences?
HPV and the related cervical cancer risk are well-known risks of sexual activity. No one cares about these risks--they're too remote for anyone to change their behavior. Conservative moralists have tried for a generation to point out these particular risks--hyping them just as Merck now is doing--and they've been slapped down. Sure, it's a risk, and one that condoms don't effectively eliminate, but so what?
Now there's a vaccine, and we're supposed to force this on everyone? What's the rationale, again?
Posted by: anon on February 9, 2007 2:34 AMPart of the problem is that many parents refuse to admit that their "precious" is sexually active. This is similar to the response many parents have when their child is arrested "precious would *never* do that!"
Part of the problem is that religious fanatics believe that there must be some punishment for sex: disease or pregnancy. Anything that reduces that punishment must be eliminated, no matter whether it is condoms, vaccines or contraceptives.
If we were a society that didn't circumcise boys, then we'd have a higher incidence of penile cancers. And HPV would figure prominently in those.
Women end up getting pap smears for most of their adult life (usually about $40-80 plus office visit). Some docs want those to start annualy at 18, other every other year at about age 30. The pap smear is a screening test. It doesn't say if you have something or not. It just says "look at her more closely." Diagnostic tests (usually about $200-$1k) can include coloscopy and biopsies. Frequently, hysterectomies are performed (usually about $5k-$10k) as an early stage method of prevention/remediation. The US leads the world in number of hysterectomies performed. Catching cervical cancer (like most cancers) at an early stage gives a very high survival rate.
In the article I linked (click my name):
Vaccination against high-risk HPV saved 2.8 life days and 4.0 quality-adjusted life days per person. In comparison, vaccinations against measles, mumps, rubella, and pertussis each save 2.7, 3.0, 0.3, and 3.3 life days, respectively.
That's about the same as other diseases we compel students to receive before attending schools.
The "70%" number that people bandy about is that this vaccine protects the recipient from several strains of HPV, those strains represent 70% of the HPV infections.
Posted by: Peter on February 9, 2007 10:13 AMYou said, "I can tell you from working in pharma marketing.." Ahhh. Yes. I see. And since I'm not a regular visitor to this site, I can't help but wonder .... considering all of the millions Merk is spending on this current PR media campaign in lobbying and advertisments, it certainly makes sense to hire staff to go out and respond to popularly linked blogs that support their position and keep up the scare.
I wouldn't be shocked if some PR company hired bloggers to write positive stuff but no not me. I work in finance (watching marketing budgets) and not for Merk but for a competitor whose main products are for cancer drugs and cardiovascular drugs. Before that I worked at an advertising agency but Merk wasn't one of their clients but I can tell you medical advertising is closely watched.
I know cervical cancer is not the biggest health problem in the world but what do you expect Merk to do?. They have a vaccine that does a good job of preventing cervical cancer. Are they not supposed to advertise that because they didn't invent a vaccine that prevents breast cancer? And the ad I saw doesn't say "tell your Senator" but only says to talk about the vaccine with your doctor which is what basically all drug ads say. Really if you're going to question whether or not an ad is medically necessary you should probably start with 'restless leg syndrom' rather than cervical cancer.
I'll admit that I may have some bias because I work for a pharma company. At the same time I also have a some real life perspective too. I don't get paid or rewarded for sticking up for 'big pharma' here...if anything I'd probably get dinged for goofing off during work!
Compared to other places our money could be spent in public health,- this vaccine at $360 a pop for every girl in America is waaay down the list of things that the government could do to increase our chances of not dying before our time.
This IMO is probably your strongest argument. Comparing the cost versus saving a few thousand lives (but also add in your also saving those who do not die from cervical cancer the illness as well, needless to say fewer genital warts are always a good thing) this is probably very borderline. I have no doubt that there are numerous environmental and safety regulations whose cost benefit analysis works out to hundreds of thousands of dollars per life saved. On the other hand the cost probably would come down with a universal vaccination program for reasons I already wrote about so to me I suspect it is just a few notches within the line of being acceptable froma cost-benefit POV.
anon
Let me get this straight: HPV is too minor of a problem for people to actually change their behavior, but HPV is such a major problem that we need a government mandate for vaccination.
Actually the problem is that the behavioral changes needed to avoid HPV are probably too radical to work from a cost-benefit perspective. As I pointed out it seems you don't need a very wild sex life to end up with a very high chance of getting HPV.
Shouldn't someone say something for revealed preferences?
HPV and the related cervical cancer risk are well-known risks of sexual activity. No one cares about these risks--they're too remote for anyone to change their behavior.
Well we know that sexual behavior has changed in relation to risks. Birth control and the ability to treat older STD's like sysphilus lead to an increase in sexual activity. AIDS has created radical changes in the reverse. Some conservatives probably like like abstinance but also others like the rise of oral sex among teens being treated as casually as French kissing...
But the problem with 'behavior change' in relation to HPV is that there is no bang for the buck...pardon the pun. Just altering your behavior a little bit can dramatically lower your risk of AIDS. No such luck with HPV, since many have it you need a radical behavioral change to really make any impact on your risk.
What really costs more? Radically changing your lifetime sexual activities or taking 3 shots of a vaccine at an age when you're already getting vaccinated for other things?
Posted by: Boonton on February 9, 2007 10:30 AMWomen end up getting pap smears for most of their adult life (usually about $40-80 plus office visit). Some docs want those to start annualy at 18, other every other year at about age 30. The pap smear is a screening test. It doesn't say if you have something or not. It just says "look at her more closely." Diagnostic tests (usually about $200-$1k) can include coloscopy and biopsies. Frequently, hysterectomies are performed (usually about $5k-$10k) as an early stage method of prevention/remediation. The US leads the world in number of hysterectomies performed. Catching cervical cancer (like most cancers) at an early stage gives a very high survival rate.
A good post Peter. This is something else that should be added to the benefit column. If you prevent a hysterectomy you save $10,000 which covers the cost of 27 or so vaccinations. If we could make pap smears less necessary and hold them off until age 30 rather than age 18 you have saved $40 * 12 years = $480. If you could make pap smears every two years rather than annually after 30 you further cut that cost in half. (I know no one has suggested that yet but if the cancer causing HPV infections are cut by 70% in the general population that may become practical). (I know, discounting these figures to present value is needed)
From this perspective it seems even on the individual level there's a positive payout over time to getting the vaccination and laying our $400 for it.
Peter - do you know the mortality rate from that 70%? I think the number is low - compared to other diseases that will kill you. You said that catching cervical cancer early (like most cancers) results in a high survival rate. I wonder how much lower the mortality rate would be if we demanded the government pay for annual pap smears instead of the $360 vaccine.
Peter you said that religious fanatics want to punish kids for having sex. Do you really believe that is what is driving most people to question the cost or safety of mandating this vaccine? That seems a huge stretch to me.
Posted by: Becky on February 9, 2007 10:55 AMPeter and Boonton:
The factlet that we lead the world in # of hysterectomies is essentially meaningless without context, other than the fact that n>0 is a tragedy.
With the vaccines in hand, Pap smears are still strongly suggested. That may be legal CYA, but it is there nonetheless.
Posted by: Klug on February 9, 2007 11:00 AMBoonton - your expertise on this subject is welcome.
You said, " If we could make pap smears less necessary and hold them off until age 30 rather than age 18 you have saved $40 * 12 years = $480"
And that gets to the meat of my point. We should be looking at this in terms of a cost benefit and best use of tax dollars.
I'm no expert, but having women hold off to get their pap smears until the age of 30 could actually cause more deaths from cervical cancer. Remember - this virus only protects from 4 of the 100 HPVs. So even if you vaccinated every woman in the world....
Secondly, we are only talking about asking the government to wait 5 years, until the patent wears off before the pick up this tab when the vaccine will be much cheaper. So we are really talking about the actual number of women who will contract these 4 HPV's that will result in cancer.
And then of course, I get back to my main point, this frantic rush to get everyone vaccinated RIGHT NOW (before the patent expires) seems to be a result of Merk's aggressive scare campaign rather than a wish to find the most comprehensive plan to help decrease the incidence of mortality from cervical cancer.
Posted by: Becky on February 9, 2007 11:09 AMBecky,
I'm no expert, but having women hold off to get their pap smears until the age of 30 could actually cause more deaths from cervical cancer. Remember - this virus only protects from 4 of the 100 HPVs. So even if you vaccinated every woman in the world....
All things being equal you are probably right but in a world of mass vaccination the risk goes down dramatically. Economically speaking nothing is free. Pap smears not only cost $40-$80 but they also carry other costs such as false positives that result in unneeded, costly, and probably unpleasent diagnostic tests that themselves have small but real risks.
Pap smears are therefore endured today because despite these costs the benefits of catching and treating cervical cancer outweigh those costs. But if numerous cervical cancer cases can be simply prevented with a vaccination then the equation probably changes allowing us to have fewer smears.
I'm not an expert here but you cannot get away from human nature. There are only so many tests you can do in an office visit. And if people are supposed to do a check up once a year there are so many who will do it every two, three, five or worse number of years.
Because of this limit, the pap smear test has probably bumped some other test that is useful but is just a little less useful than the pap smear test. If a breakthrough made the pap smear less needed than that other test can be considered. Yes there are other HPV's but only certain ones seem to cause cervical cancer and the vaccine seems to do a good job on most of those ones.
In perspective the high patent price of the vaccine now is, IMO, no big deal. How much cheaper will it get when it is off patent? 50% off maybe? Spread over many years this $100 or $200 in initial cost has, I suspect, less of an impact on the equation than it appears at first glance. Plus assuming the benefits outweigh the costs NOW even with the higher patent price it would be good policy to implement vaccination now rather than waiting 5 years. By waiting 5 years you are in the long run incurring more costs than savings...plus you have the bad precedent of killing some of the profit incentive to develop new vaccines. Don't you think other pharma companies are trying to formulate their own HPV vaccines that are better than Merk's? In three or four years you may have a vaccine that does a great job on 90% of the cancer causing HPV strains and covers 45 of the 100 HPV strains overall. Then will we say 'let's wait another 5 or 7 years' till the new and improved vaccine goes off patent? If nothing else the patent price is spurring incentives to other companies to match Merk's vaccine with their own versions.
Another economic perspective...there's no distinction here between taxpayer dollars or just individual dollars... it's dollars. Either this is worth our dollar or it isn't. Whether the vaccine should be paid for by your individual dollars (due to a 'mandate') or by the taxpayer is a different issue. The first question is "is it worth it to spend $360 per girl to reap the benefits of this vaccine"? It seems like the answer is yes. If it is then who is going to pay $360 is another debate.
I haven't made any conclusions about what I think about this as public policy, etc.
But Boonton is right on one issue: if you are a young woman that is thinking about having a really fun sex life (lifetime sexual partners >= 5), this is a great investment. I'm not judging, but you'd think that this product would be pretty popular if you were rational.
Posted by: Klug on February 9, 2007 1:19 PMOr another way of putting it;
If you're a young woman and you're not willing to bet your health on your ability not to make a single mistake for the next 30 years AND to pick partners who are equally as good..then this is a good investment.
Posted by: Boonton on February 9, 2007 2:06 PMBoonton, HPV is pretty contagious. It's not the frickin' superflu here. Let's get some perspective.
Posted by: Klug on February 9, 2007 2:09 PMGranted, I admit this is on the line here. If the vaccine cost $1,000 or was very difficult to administer or only covered, say, 50% of the viruses that cause cancer I'd probably say it didn't feel like it would be worth a mass vaccinate mandate.
Posted by: Boonton on February 9, 2007 2:24 PMBoonton: You said, "Pap smears are therefore endured today". LOL! You must be a guy.
Let's agree to disagree. We really don't have any real facts or numbers to work with here. Just feelings, beliefs and wild hunches. Pretty tough to come to any real sort of rational conclusions since we don't if this multi-billion dollar mass vaccination will save 2 lives, 2,000 lives or 2,000,000.
I stand by stance that I think we should put a little bit more effort in determining the cost benefit before we invest BILLIONS of dollars on a vaccine just because Merk is spending millions to focus and scare the public on this issue.
Thanks for the discussion. Stay safe and stay away from high fats and busy intersections :-)
Posted by: Becky on February 9, 2007 3:24 PMThanks to instapundit, here are some facts:
http://ww2.scripps.com/cgi-bin/archives/denver.pl?DBLIST=rm07&DOCNUM=2664
Posted by: Becky on February 9, 2007 11:35 PMAs someone who had a hysterectomy at age 22 because of a "safe and effective" Dalkon Shield (and that was the good news; I almost died) - put me down as someone who thinks it is frightening to mandate this at this stage.
While this vaccine may end up to be everything that the supporters believe it to be, let's give it a decade or two before we force all girls to get it.
Call me a skeptic. But - I've got one hell of a reason to be.
Posted by: Peg on February 9, 2007 11:49 PMElipsis - Please be so kind as to read back up the thread, where the costs of inaction were described. ...Yet you seem to think it a good idea for every pre-pubescent girl on the planet to become a lab-test rat for Merck.
As long as we're talking about reading the thread (which I'd already done) please quote me where I said "It's a good idea for every pre-pubescent girl on the planet to become a lab-test rat for Merck." You seem to be fabricating this strawman out of whole cloth. My posts have been answering specific objections. A cost benefit analysis should be done separately from making any decision, no?
Posted by: Ryan on February 10, 2007 1:13 PMRyan, do you know what the words "seem to think" mean? So far as I can tell, you seem to think that mandatory vaccination of prepubescent girls is a good idea.
Your posts have avoided many specific objections, such as:
* Long term effects on fertility
* Effects upon prepubescent girls when no testing has been done at all to show safety
* Effects when given to pregnant women
Do you believe that government is infallible, or not? Have you bothered to actually read the cost/benefit discussion up thread or not?
Why is cost/benefit not to be included in a decision?
Posted by: ellipsis on February 10, 2007 4:19 PMEntering the discussion late.
1 - I have a male friend who almost died due to HPV-related rectal cancer. If he'd gone much longer without a diagnosis, he would have. As it was, it wrecked his life.
2 - For those who think that the vaccine can be targetted to women and homosexual men - you do know, don't you, that many women get HIV from men who "aren't gay" but who engage in homosexual behavior. "Brothers on the down-low" is the term I have read. These men are NOT going to self-identify as gay and they are NOT going to get that vaccine if it is targetted at gay men.
3 - Herd immunity isn't going to happen if only girls are immunized. Some girls won't get immunized, some will but the vaccine won't take. I refuse to believe that any vaccine is 100% effective.
4 - I have been married for 24.5 years. I promise that I have had sex - I have a (grown) child to prove it. For whatever reason, I suppose my personal body chemistry, I have to repeat PAP smears every so often. They always come back OK the second time. The last time it happened I complained to my GYN, who ordered an HPV biopsy. It came back negative, thus allowing us to relax a little about all those rechecks. The point is, it simply is not true that only virgins don't have HPV.
5 - We did not have a Thalidomide tragedy in this country like they did in Europe, because the FDA refused to approve it. This was before fast-tracking, of course.
Posted by: Laura(southernxyl) on February 10, 2007 8:50 PMPeg
As someone who had a hysterectomy at age 22 because of a "safe and effective" Dalkon Shield (and that was the good news; I almost died) - put me down as someone who thinks it is frightening to mandate this at this stage.
I'm sorry for your experience but you certainly must know the difference between what a modern drug or vaccine must do to prove its worthiness and what the Dalkon Shield had presented as 'evidence' of its safety before it began marketing itself.
I don't see an argument for waiting a 'decade or two'. Assuming 2,000 lives a year that is 20,000-40,000 deaths all for the purpose of accumulating a bit more data. It's perfectly fair for you to bring your experience with a medical device that was brought to market without proper study. However it's short sighted to pretend that the call to wait and wait and wait for ever more data will inflict its own type of cost on lives that are every bit worthy as your own.
Posted by: Boonton on February 10, 2007 11:41 PMRyan, do you know what the words "seem to think" mean?
In this case, it means you've drawn a conclusion with no basis in my posts.
Your posts have avoided many specific objections, such as:
* Long term effects on fertility
Lets address that. There are three basic, reasonable possibilities for why HPV or other pathogens influence infertility. The first is some direct action by the pathogen, in which case the vaccine will improve fertility (assuming immunity still holds when infection occurs.) The second possibility is that loss of fertility in people with current HPV infection is due to some aspect of the inflammation reaction which occurs in response to an infection. There's some evidence for this. If the second is true, the vaccine might actually impact infertility as you suggest. But the response would occur in reaction to viral strains with the L1 capsid protein, which tend to be oncogenic. If someone is actually one of the rare few infected with an oncogenic strain, a little infertility should be the least of their worries.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15212683&query_hl=2&itool=pubmed_docsum
Posted by: Ryan on February 11, 2007 12:20 AMThe third possibility is that HPV might generate some form of autoimmune reaction in women.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16849513&query_hl=13&itool=pubmed_docsum
I don't know of any HPV infected women whose fertility mimic the linked response.
Effects when given to pregnant women
Effects upon prepubescent girls when no testing has been done at all to show safety
Posted by: Ryan on February 11, 2007 12:21 AM
The vaccine is being given before anyone receiving it is likely to be pregnant, as was previously discussed. That seems to answer the pregnancy objection pretty well. Secondly, there's been some representation of Gardasil as a novel vaccine. But it works in a manner similar to other vaccines, in that it uses proteins that stimulate an immune response. Could there be a reaction to the aluminum hydroxyphosphate sulfate that this stuff is carried in? Maybe. But why wouldn't that come out in earlier tests.
HPV is prevalent enough that if there were going to be catastrophic effects from the active ingredients in this vaccine, they would have already been noted in HPV carriers.
Do you believe that government is infallible, or not?
The government is quite fallible, of course. I'm not going to take a drug just because it's been FDA approved. I've tried to address the individual costs and benefits using available evidence. For me, the issue of thalidomide is about whether this vaccine might be administered to women who are currently pregnant. It won't be. I also intended to point out that after the thalidomide problem, testing on drugs which might be administered to pregnant women increased, helping to close the specific loophole which caused the thalidomide problem. But this vaccine isn't being administered to pregnant women. I pointed out that the FDA never approved thalidomide because... the FDA never approved thalidomide. I saw no harm in making a statement which was factually true to clarify another which might have been mislead some.
Have you bothered to actually read the cost/benefit discussion up thread or not?
If you'd read my posts, you'd know that I have. Your condescension is unwarranted.
To repost my earlier comment, since you seem to have missed or misinterpreted it;
While I question this being mandatory since I think people have a right to control their own bodies, I think it makes a lot of sense.
I am discussing the individual points that people have raised. My stance has nothing to do with deferring to the government, so asking whether or not I think the government is falliable is a red herring.
Posted by: Ryan on February 11, 2007 12:43 AMI think there's a good argument in favor of some people using this vaccine. I don't think that it's for everyone since some people will be better off applying the money to some other end, and should be allowed to. And some people/populations might be less likely to need it. That should be their parent's choice, even if it means that their parents choose badly, and even if there's a good argument for a more widespread vaccination. I don't think it should be mandatory either, for reasons that have been mentioned and others. I do think that comparisons of gardasil to thalidomide are way over the top.
Hopefully that clears up what I do and don't believe.
Posted by: Ryan on February 11, 2007 2:55 AMRyan, this last comment is the first time I have read anything by you in this thread that even hints or suggests that you don't support mandatory vaccination. Thanks for spelling that out.
Posted by: ellipsis on February 11, 2007 3:52 PMI don't see an argument for waiting a 'decade or two'. Assuming 2,000 lives a year that is 20,000-40,000 deaths all for the purpose of accumulating a bit more data. It's perfectly fair for you to bring your experience with a medical device that was brought to market without proper study. However it's short sighted to pretend that the call to wait and wait and wait for ever more data will inflict its own type of cost on lives that are every bit worthy as your own.
***********************************
I'm not saying we should wait to use the vaccine. Anyone and everyone who thinks it is sensible to use now should get it - and have their daughters get it.
I'm only saying that it ought not to be mandatory. Huge difference.
Let people decide for themselves the risks and rewards.
Posted by: Peg on February 11, 2007 5:44 PMBut do we do this with all vaccines? Wait, let's back up...
First 'mandatory' here simply means that if you don't want it you have to do a little bit of work. Essentially filling out a form.
Second, defaults make a big deal of different. Many times people will not do anything to alter a default. This has been observed with 401K's. If employees are told their 401K's will begin with a 4% contribution unless they elect otherwise they mostly will leave it be. But if employees default at 0% and have to notify their admin. what they want to contribute many will leave it at 0%.
If the default is for vaccination those who have good reasons to be against it will be able to easily avoid it. Those that have no real feelings about it will go with the flow either to vaccinate if that's 'normal' or not if it's seen as 'special'.
Posted by: Boonton on February 11, 2007 9:22 PMBecky, Medicare pays about $10 for a pap smear. And since that's what medicare pays, that's what most insurance providers will cover. You might have better than average insurance. Or you might be like tens of millions of American women: no insurance at all.
Caught early, cervical cancer has a more than 95% five-year-survival rate. If you wait until it is a stage 4 cancer, then the five-year-survival rate drops to around 50%. Currently, about 3500 women die each year from cervical cancer.
Pap smears are a screening test. If they are suspicious, then you do other diagnostic tests. Those other diagnostic tests also have costs.
The vaccine is a preventative measure. People vaccinated won't be spreading the three strains of HPV that it protects against. There are several other strains of HPV that this vaccine doesn't protect against. I don't have kids, but if I did, they'd be getting this vaccination. Boys too.
It is a first shot against the disease. In the future, I'm sure the producers of this vaccine will add more of the strains to what can be protected against. Kind of like that line "you go with the army you do have, not the army you want to have."
I think it is far better to prevent the disease than catch it after the fact. Abstinence doesn't work. Well, maybe it does, but all those teens seem to lie about it, since teens that swear to remain abstinent until marriage get pregnant at a higher rate than those that make no such pledges. You can't lock your kids up until they reach 30. No matter how much you want to do so.
I also believe, but cannot prove, that more of the illnesses that we suffer from are a result of hostile bacteria and/or viruses. Decades ago, the prevailing wisdom for ulcers was along the line of "its what's eating you that's eating you." I.E. that stress was the cause of ulcers. It took a long time to prove that a simple bacteria was the cause. And a simple treatment of antibiotics cured it. You didn't need to spend hundreds of dollars per month on lifestyle drugs for the rest of your life. BigPharma took a massive hit in the wallet when this finally got out. And now, that most cervical cancers are caused by a virus, which can be protected from by a vaccine. What other diseases are going to be like this? Tinfoil hats, shiny side in? Or shiny side out?
Posted by: Peter on February 12, 2007 1:34 PM