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Public Health or State Intrusion? Some Opinions on an HPV Vaccine for School Girls
Over the past two years, a heated public-health debate has played out in state capitals across the country. At issue is legislation concerning a vaccine against human papillomavirus (HPV), a primary cause of cervical cancer that is usually transmitted sexually. Whether states should encourage or even mandate its use has proven deeply controversial. The laudable goal of preventing cancer deaths has clashed with parents’ rights, resistance to state mandates and vaccines generally, and allegations of flawed or rigged medical studies, and of drug companies greasing the legislative process with targeted campaign contributions.
In July 2006, the FDA approved Gardasil ®, a Merck product, for sale and marketing to girls and women ages nine to 26. The Center for Disease Control soon after voted unanimously to recommend that girls ages 11 and 12 receive the vaccine. A number of groups quickly mounted intense campaigns against the use of the drug, arguing, for instance, that the clinical studies were flawed and that the probability of seriously harmful side-effects was not yet understood.
By the end of 2007, about half the states had seen bills mandating an HPV vaccine program in schools. As of spring 2008, legislators in more than 40 states have introduced legislation to require, fund or educate the public about HPV vaccines, and about one-third of the states have enacted some legislation. At time of writing, however, bills are still pending in most cases. In April 2008, Michigan passed a law requiring that any schools that provide information about vaccinations to families include details about HPV vaccines, a much scaled-back measure compared to the mandatory immunizations for sixth-grade girls that had been proposed months earlier. Illinois likewise saw the introduction of bills mandating vaccination introduced in both the House and Senate in 2007, but has, to date, passed only a far milder law. As of August 2007, insurance companies must provide coverage for the HPV vaccine, and the department of health must cover girls under 18 who are not covered by another provider (Public Act 095-0422 (2007).
Texas, briefly, had the distinction of being the only state on course to implement the aggressive course of requiring vaccination for young girls. In February 2007, Governor Rick Perry, a conservative Republican, issued an executive order requiring vaccination of sixth-grade school girls as of September 2008. By April, however, opponents, many from within his own party, had foiled the plan, with a bill that bars the state from ordering any vaccinations to take place until 2011. The final-passage vote in the Texas House was a jaw-dropping 135-2, and Perry admitted defeat by not bothering to veto the bill (since his veto would certainly have been over-ridden).
We were interested in whether an HPV vaccination program could still gain support in Illinois. The trend, of late, appears to be that large-scale vaccination programs are being shelved in favor of information dissemination. But proponents of vaccination are still pushing for more aggressive programs, which they say can save lives at minimal cost. A great many bills are still pending.
We asked respondents to the January Illinois Opinion Monitor a question referencing the original Texas program. Depending on their answer, we asked a follow-up question introducing one counter-argument. Our results were as follows:
Table 1. HPV Questions
Beginning in September 2008, Texas girls ages 11 and 12 will automatically be vaccinated against HPV, a sexually transmitted virus that can cause cervical cancer. Parents who object can file an affidavit to exclude their daughters from vaccination. Should Illinois implement a similar program?
Yes 48.3 %
No 35.6 %
Don’t know 16.1 %
If YES: Would your answer change if some doctors argued that it is too early to know if this is an effective vaccine?
Yes 44.4 %
No 37.6 %
Don’t know 18.1 %
If NO: Would your answer change if the program were not mandatory (that is, if parents were required to opt in, not opt out)?
Don’t know 9.1%
Initially, there was more support than opposition. We were surprised by how rare was the “don’t know” response, and perhaps we had under-estimated how much media coverage the subject had received. At the same time, we did not find majorities locked into either support or opposition. Looking at the follow-up questions, sizeable numbers were willing to change their position when confronted with only one modification or rebuttal. The proportions that changed from Yes to No and vice versa were about the same, but fewer of the initial Yes respondents were certain they would not change away from Yes. If we thus breakdown our respondents according to the combined questions, we have the following distribution.
Table 2. Overall Breakdown of Respondents
|IL should implement even if doctors say it is too early||18 %|
|IL should implement, maybe not if doctors say too early||9 %|
|IL should implement unless doctors say it is too early||22 %|
|Don’t know if IL should implement or not||16 %|
|IL should not implement except as an opt-in||16 %|
|IL should not implement, except maybe as an opt-in||3 %|
|IL should not implement even as an opt-in||17 %|
For the general public, the initial response to the program is more positive than negative, but there is clear polarization. The 27% at the top of the scale either stick with their support or waffle on whether or not doctor doubts could shift their view; only 20% dug in their heels in opposition or were not sure they could switch to support if the program were voluntary. With most respondents lying in between, we infer that both opponents and proponents have ground to cover if they hope to win the public-opinion battle in this state.
To be clear, we did not confront all respondents with both counter-arguments, so we cannot say anything definite about the levels of support for an opt-in program or a program that an unspecified number of doctors say is too early. But it seems clear from Texas and elsewhere that making a program mandatory is highly controversial, and many of our respondents who were disinclined to back a hypothetical mandatory vaccination program warmed up to it once it was voluntary.
We undertook a parallel sampling of expert opinion on this question by inviting health care specialists to answer a similar question. Since early 2007, we have been assembling a panel of experts in various policy areas who are willing to answer periodic surveys. Some of those who were chosen for expertise in health policy were asked the following question in the fall of 2007.
|Beginning in September 2008, Texas girls ages 11 and 12 will automatically be vaccinated against HPV, a sexually transmitted virus that can cause cervical cancer. Parents who object can file an affidavit to exclude their daughters from vaccination. Should Illinois implement a similar program?|
|Yes, this is a sound public-health program.||26%|
|Yes, but the vaccination should be done at a later age||0%|
Yes, but it should not be mandatory. Parents should be required to opt in, not opt out.
|No, it is too early to know if this is an appropriate vaccine.||9%|
No, vaccination programs should be limited to highly contagious disease that can be contracted in public settings like schools.
No, health care decisions should be made by individuals and families, not governments.
Our experts are not a random sample from any identifiable population, and one cannot have the same kind of confidence in results for 20-30 respondents as for 1000, even when the questions asked of respondents are identical. Thus, we take the responses above with a large grain of salt. They are merely suggestive of the opinions of some hospital administrators and members of interest groups with an interest in health care. Nonetheless, we find the comparison intriguing. By far the most popular response was support for the program, but on an opt-in basis. Some of the expert respondent did fear that it is too early to implement an HPV vaccination program, and others appear to disagree on principle with public vaccination in this context. But most of the respondents with backgrounds in health care policy were generally supportive of the program, albeit not as a mandatory program from which parents must withdraw their daughters.
Nothing in these results is meant to convey support or opposition to an HPV vaccination. Our interest was in measuring support at a point when most of the debate is in fairly early stages, or is confined to experts. The results above would strongly suggest that if proponents are to succeed in passing a measure, they would be wise to make it an opt-in program, and they should expect a robust debate on the health merits of the vaccine, and on the philosophy motivating public vaccination against sexually transmitted disease, particularly when administered to young children.