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.
Whether 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'.
The 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?
@ 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.
I 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.
The 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.
1) 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.
http://www.chron.com/disp/story.mpl/ap/health/4523542.html
They just made the vaccine required in Texas.
Also 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.
Imagine 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..."
P.S. For those who don't recognize the quote;
http://en.wikipedia.org/wiki/Reaver_(Firefly)
You 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.
I 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...
Randy, 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?
Yes, 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.
I 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.
I 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.
The 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.
Boonton, 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.
dot,
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.
Boonton, 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?
dot - 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.
This 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.
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?
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). 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.
I 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.
Jane,
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.
Boonton, 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.
Good article on this topic from an ER physicians blog.
HPV 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.
Why 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?
Recent 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.
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.
Every bad idea has this kind of support.
Recent 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!"
Boonton,
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.
Gil - 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.
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.
You 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.
This 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?
"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.
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?
"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.
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.
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?
Here 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?
Maybe 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?
A 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...
You 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.
The 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?
To 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.
There 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.
If 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.
I'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.
Hmmm. 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.
The 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.
While 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.
Another 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.
Wow...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?
So 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.
To 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...
The 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?
The 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.
Ooh! Oooh! Thorley Winston has indirectly brought up a big philosophical issue:
Doesn't mandating this vaccine for all girls take away choice?
To 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.
Ooh! Oooh! Thorley Winston has indirectly brought up a big philosophical issue:
Doesn't mandating this vaccine for all girls take away choice?
Discuss....
And 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!".
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.
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.
Ellipsis, 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?
Ellipsis, 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.
Randy 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.
"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.
I 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.)
I 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?
and 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).
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?'
You could make a fair argument for mandatory underage abortion with logic like this. It would be a rather foolish argument, though.
I 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.
Cyall:
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.
In 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.
It 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...
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...
Boonton:
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. ;-)
If 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?
PS. 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.
Another 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.
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.
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...
Ryan 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.
Before 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.
The 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?
Well, 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.
Before 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.
I 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.
"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.
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. ;-)
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.
If 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.
Mark:
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.
Here'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.
Mark,
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.
Just a thought, but how is the "free rider problem" ever, by itself, a sufficient justification for eliminating freedom? Public health - maybe. Free riders - never.
Nor 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.
Jeffrey,
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?
You 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.
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NASA Astronaut Lisa Nowak Charged With Attempted Murder in Bizarre Love Triangle
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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?
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.
I 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.
The 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.
Why 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.
I'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.
Merck'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.
"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?
Tim 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.
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...
We 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.
Here 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 l