HPV Vaccine: Personal Choice or School Mandated?

Katie Couric HPV Vaccine Video:

http://www.cbsnews.com/video/watch/?id=2423068n

What is the HPV vaccine and how is it effective?

HPV is the most commonly transmitted sexual disease in the world. The virus is spread through sexual and genital contact. It is most commonly transmitted in the teenage and young adult years, when individuals are most sexually active, and because many people are unaware they have HPV or their partner does due to its symptomless appearance. Also, condoms do not necessarily protect from HPV –HPV can infect areas that are not covered by a condom. Some forms of HPV may cause cervical cancer for women and different types genital cancers (mouth, neck, anal, penal). Other types of HPV can cause genital warts. Each year, there are about 12,000 women diagnosed with cervical cancer and about 4,000 die from this disease in the U.S The vaccine targets the types of HPV strains which do cause cervical cancer. It is still important for women to get regular pap exams and to lower their risk with possible infected persons by using protection. The vaccine’s protection is projected to last a long time and is most effective in preventing HPV in women who have not previously been exposed to any forms of the disease, which is why testing at a young age is suggested. The vaccine does not treat current HPV infections or the diseases they may cause; it can only prevent HPV before a person gets it.

"Clinical trials have shown the vaccine to be highly immunogenic, safe, and well tolerated in females 9 through 26 years of age. Antibody responses are highest in girls 9 to 15 years old. In sexually active females 16 to 26 years of age, protection has been demonstrated against persistent infection, precancerous lesions, and genital warts caused by HPV types within the vaccine." -CDC

Some Statistics:

---Among teen girls in California aged 13 to 17, about 378,000 out of 1,468,000 (26 percent) reported receiving at least one dose of the vaccine. Among California females aged 18 to 26, about 262,000 out of 2,273,000 (12 percent) reported receiving at least one dose of the vaccine in 2007.

---76 percent of teen girls aged 13 to 17 and 60 percent of young adult women aged 18 to 26 reported an interest in getting the HPV vaccine themselves, while 57 percent of parents of age-eligible girls reported an interest in getting the HPV vaccine for their daughters.

(Source: Science Daily Online)

How Safe & Affordable Is It?

The vaccine had been licensed by the FDA and approved by the CDC as safe and effective. It has been studied in thousands of females around the world, ages 9 through 26, and it continues to be monitored by the FDA and CDC. Studies have not found any serious or adverse reactions or side effects to the vaccine and the most commonly reported symptom is pain at the injection site. For more information, please visit this site:

http://www.cdc.gov/vaccinesafety/concerns/human_papillomavirus_vaccine.htm

A common problem with the HPV vaccine is that many insurance companies do not offer full coverage of the pricey, $360 some estimate for all three shots. This is usually because a patient is over the age of 18 and because the vaccine has not been in practice long enough to foresee the long-term benefits and outcomes. However, there are also public health clinics that will offer the shots for very reduced costs (even Ingham Health Center in the Lansing area offers them for $24 if you are uninsured).

Should the vaccine be MANDATORY for school?

School mandates on vaccines are considered a huge public health success, credited with compliance rates near 100% for 5-year-olds. Schools and health departments are responsible for enforcement and school mandates in the adolescent population have been particularly successful given the poor compliance with routine vaccination in this age range.

On September 12, 2006, Michigan State Senator Beverly Hammerstrom introduced the first bill requiring vaccination of girls aged 11-12 prior to entry into the sixth grade. Since this time, school mandates have been considered or are being considered in 24 states, including:

• Governor Rick Perry of Texas issued an executive order requiring vaccination for sixth-grade girls in Texas
  in February 2007
• Virginia is the only state to have signed a bill into law requiring HPV vaccination of girls prior to entry into the sixth grade. This bill initially required a parent's signature but was altered such that a verbal opt-out is sufficient. All of the HPV vaccine mandate bills introduced thus far have a clause regarding parental opt-out separate from the states' current vaccination exemption laws.

“The HPV vaccine has sparked ethical debate along many lines, including the utility of compulsory vaccination. Currently, the vaccine is approved only for use in females and, therefore, herd immunity in the truest sense is unable to be achieved at the moment. Further, given the prevalence of HPV in the general population, the greatest benefit to each person receiving the vaccine is to the individual in protection against the 4 viral types in the current quadrivalent vaccine. Therefore, given the individual benefit and the assumed individual risk, autonomy of the person or parents of the child receiving the vaccine becomes the larger consideration.” - California Health Interview Survey

Additionally, many parents feel that their rights are being violated when the vaccine is mandatory and that it only encourages an immoral lifestyle, and sexual activity. Further, HPV could be prevented by a monogamous lifestyle or through abstinence. Religious and cultural values come into play here and public schools should not be allowed to force families and parents to have to vaccinate for something can be seen as a personal choice protection vaccine. Parents could instead become more aware and educated by the school system about the prevalence of HPV and the risks it poses, so that they may best decide as to how to inform their daughters (and sons) and whether or when to go to the vaccine. While Virginia schools took a public health approach to try and mitigate the prevalence of HPV in society, it should be remembered that this is not a disease in which the transmission of infection is like that of traditional communicable diseases for which we have childhood vaccinations (measles, mumps, rubella, chickenpox). Since research has already discerned that the age group most at risk for HPV is the teens and early twenties, perhaps the shot, if it is to be mandated, should be for adolescents entering high school or college. Parent opinion has actually favored this:

“In a survey of nearly 10,000 parents, only 49 percent said they intended to vaccinate their daughter if she were 9 to 12 years old. Meanwhile, 68 percent and 86 percent intended to vaccinate their 13-15-year-old and 16-18-year-old daughters, respectively.” (Source: Jennifer Young, MD, MPH)

Ethical Principles Involved

Utilitarianism: Getting vaccinated requires an individual to accept the risk of an immunization for the good of the society in the form of "herd immunity." It is unlikely that the individual will suffer from the disease itself because the particular diseases vaccines target are rare in the general population. Immunizations are more of a benefit to the "greater good" of society. Certain vaccinations are important for people of all ages, and it is important that children are immunized so as to not harm pregnant mothers.

Compulsory Vaccination: Currently, the vaccine is only approved for use in females, which hinders the concept of "herd immunity." Given its prevalence of HPV in the population, the greatest benefit each person receives is protection against the 4 strains most likely to cause cervical cancer and genital warts. Because the individual benefits, and is also at risk for a drug with few long-term studies, the autonomy of the girl (and her parents involvement in) receiving the shot is a much greater consideration.

Argument in favor of Vaccination: A Utilitarian Approach

Utilitarianism is the theory that an action or practice is right when it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences and thereby minimizes harms and maximizes benefits. Utilitarian’s see moral rules as fulfilling individual needs as well as achieving wide-ranging, social goals. Vaccinations are a means of eliminating and preventing infectious diseases that once killed or harmed many infants, children, adolescents, and adults. Vaccines are intended to help bolster our immunity against certain viruses such as the flu, which is constantly changing in form and severity. The viruses and bacteria that cause vaccine-preventable disease still exist and can be passed on to those who are not protected by a shot. Vaccine-preventable disease can have many social and economic costs to society. These include sick children missing school, parents missing work to take care of the child, increased family stress and responsibility, lowered quality of life for the afflicted individual, and increased doctor’s visits, hospitalizations, costs, and premature death. Overall, vaccine policies and guidelines adhere to maximize the good (our society’s overall health and a lower disease and death rate), maintain the standard of goodness (the happiness, health and freedom to a better life), minimize consequentialism (the good of the action outweighs the very low percentage who have adverse reactions to vaccines), and to be impartial /universal without regard to people’s race, sex, nationality or economic circumstances.

Additionally, without immunizations, an individual is more likely to infect others in the community, creating more harm. People who are not vaccinated can pass diseases on to babies who are too young to be completely immunized, are a threat to children and adults who cannot be vaccinated for medical reasons (those with Leukemia, Cancer, HIV/AIDS, or receiving chemotherapy, radiation therapy), and can affect the small proportion of children whose vaccinations "did not take."

Examples of How Important Vaccinations are to Longevity (U.S.):

~Before the Polio vaccine was available, 13,000-20,000 cases of paralytic polio were reported each year in the United States

~If vaccinations were halted for Measles, 2.7 million people could be estimated to die of measles each year worldwide (before the immunization was available, nearly everyone in the U.S. had measles and 450 died/year)

~The Hib Meningitis vaccine has reduced the incidence of Hib by 98%; this form of bacterial meningitis once killed 600 children/year & left many survivors with deafness, seizures, Mental Retardation

~Before the Pertussis vaccine (whooping cough), 150,000-200,000 cases were reported each year with up to 9,000 deaths; It has also been found that incidence rates surge 10-100 times in countries where immunization coverage is reduced

~Each year, Tetanus kills 300,000 newborns and 30,000 birth mothers who were not vaccinated

~Before the pneumococcal vaccine was available for children, there were 63,000 cases and 6,100 deaths per year from Pneumonia; since the vaccine, this incidence has been reduced by 75%

~Prior to the varicella (chickenpox) vaccine, the virus caused an est. 4 million cases, 11,000 hospitalizations, and 100 deaths per year; cases have decreased by over 90%

~Around 5,000 people will die each year from Hepatitis-B related liver infections resulting in over $700 million in medical and work loss costs

[Source: Centers for Disease Control & Prevention]

How Vaccines Are Made, What They Are Made of, and How They Work

How They Work

Many people are vaccinated each day against various diseases and viruses, however the majority of these people may not know how these vaccinations actually work. The link posted below is a video that gives a description of how vaccinations work in the body.






How They Are Made

Depending on the particular vaccination, the actual product is made in several different ways using various ingredients. The Children's Hospital of Philedelphia provides a list of ways vaccines are made and the pros and cons to each approach.

“Weaken the virus

Using this strategy, viruses are weakened so that they reproduce themselves very poorly once inside the body. The measles, mumps, German measles (rubella) and chickenpox (varicella) vaccines are made this way. Viruses usually cause disease by reproducing themselves many times in the body. Whereas natural viruses reproduce themselves thousands of times, vaccine viruses usually reproduce themselves fewer than 20 times. Because vaccine viruses don't reproduce themselves very much, they don't cause disease, but
vaccine viruses replicate well enough to induce “memory B cells” that protect against infection in the future. The advantage of live, "weakened" vaccines is that one or two doses provide immunity that is life long. The limitation of this approach is that these vaccines usually cannot be given to people with weakened immune systems (like people with cancer or AIDS).

Inactivate the virus
Using this strategy, viruses are completely inactivated (or killed) with a chemical. By killing the virus, it cannot possibly reproduce itself or cause disease. The inactivated polio, hepatitis A, influenza, and rabies vaccines are made this way. Because the virus is still “seen” by the body, cells of the immune system that protect against disease are generated. The strength of this approach is that the vaccine cannot possibly cause even a mild form of the disease that it prevents and can be given to people with weakened immune systems. The limitation of this approach is that several doses must be given to achieve immunity.

Use part of the virus
Using this strategy, just one part of the virus is removed and used as a vaccine. The hepatitis B vaccine is the only vaccine that is made this way. The vaccine is composed of a protein that resides on the surface of the virus. This strategy can be used when an immune response to one part of the virus (or bacteria) is
responsible for protection against disease. The hepatitis B vaccine can be given even to people with weakened immunity and the vaccine appears to
induce long-lived immunity after three doses.

Use part of the bacteria
Some bacteria cause disease by making a harmful protein called a toxin. Several vaccines are made by taking toxins and inactivating them with a chemical (the toxin, once inactivated, is called a toxoid). By inactivating the toxin, it no longer causes harm. The diphtheria, tetanus and pertussis vaccines are made this way. Another strategy to make a bacterial vaccine is to use part of the sugar coating (or polysaccharide) of the bacteria. Protection against infection by certain bacteria is based on immunity to this sugar coating (and not the whole bacteria). However, because young children don't make a very good immune response to the sugar coating alone, the coating is linked to a harmless protein (this is called a "conjugated polysaccharide" vaccine). The Haemophilus influenzae B (or Hib) and pneumococcal vaccines are made this way. A conjugate vaccine to prevent meningococcal infections should be available soon. Just like for inactivated viral vaccines, bacterial vaccines can be given to people with weakened immune systems, but often require several doses to induce adequate immunity.”

Children’s Hospital of Philadelphia
A Pediatric Healtcare Network
www.chop.edu

What They Are Made Of

The Center For Disease Control (CDC) has a significant amount of information on various topics of vaccination. They also have a list of ingredients of 49 common vaccinations and facts about these components available on their website. The following is the link to this information:

http://www.cdc.gov/vaccines/vac-gen/additives.htm

Smallpox Eradication: A Milestone in Modern Medicine

http://www.bt.cdc.gov/agent/smallpox/smallpox-images/smallpox1.htm

• Previous to the mass vaccination campaign, smallpox had been causing epidemics for over 3,000 years. Many well known historical figures have died from smallpox.
• Kills 1 in 4, can cause blindness and scarring in survivors.
• It has two fatal forms: hemorrhagic which causes hemorrhage in the skin, and malignant which causes lesions that do not develop into pustules and remain soft and flat.
• Spreads by air droplets or contact with infected clothing or bedding.
  
• In the 1950's, 50 million cases of smallpox existed. The figure fell to 10-15 million in 1967 after the introduction of the vaccine.
• Vaccine administration:
• 

http://www.who.int/mediacentre/factsheets/smallpox/en/

• There are some potential serious side effects including eczema and encephalitis which can result in death. However, a study was done using 14 million vaccinated people and only 9 deaths occured.
  
• In 1967 WHO launched a global eradication campaign and the last natural case of smallpox was in 1977. The disease was declared eradicated in 1980.
  

This is an excellent example of how effective vaccines are and why we should continue to use them. I posted this in case anyone wanted to use it as evidence when making their ethical arguments. I think that because this happened over 30 years ago, people are starting to forget about the smallpox vaccine and its importance. It is now on the list as a potential biological warfare weapon because millions of people have never been vaccinated against it or may no longer be protected from it.

Source: WHO
Pictures: CDC, WHO

Basic Vaccine History

Vaccines were developed mainly in the 19th and 20th centuries as preventative medicine for bacterial and viral diseases. The first vaccine was developed by Edward Jenner for cattle. Smallpox was a fatal disease that was becoming an epidemic during this time. He noticed that milkmaids who did were exposed to cowpox in cattle did not acquire the disease. He then inoculated cattle with the smallpox vaccine from human subjects and they developed immunity to cowpox. The Latin root vacca or cow is responsible for the name- vaccination.

Immunity develops when a weak form of a disease is inoculated. Antibodies are produced by the immune systems as well as other factors that are said to develop the immune response and prevent the disease from invading the body in the future.


Louis Pasteur developed the rabies vaccine by injecting 15 day old spinal fluid of a rabies-infected rabbit into a patient, and continuing to inject the patient with fresher samples on a daily basis. Immunity was built stronger and stronger each day until the patient was completely immune to the rabies virus as the injections increased in virility.




As vaccinations became more advanced and widespread, the ethics of policies became controversial. Individual immunity originally was available to the rich, and then became more widespread throughout the population to include more people and produce herd immunity. Herd immunity for certain population or areas of the world led to the possibility of completely disease eradication. The immunity of the entire world population to certain diseases, for example smallpox and measles, mumps, and rubella became more accepted and expected.

The problem with widespread immunity is that the disease becomes so uncommon that people will overlook the risk The lower perceived risk can reduce the chances that people will become vaccinated and have their families vaccinated. Lower perceived risk of not getting vaccinated, medical safety concerns, political or religious reasons, and concern about excessive government or institutional power over the individual have contributed to resistance to vaccination. This is obviously a risk to all of society, because the virus could adapt and a new strain could be resistant.


As a result of this, some vaccines have become required by law. In 1853, the smallpox vaccination became required in England and Wales. In the 1905, the US Supreme Court ruled that certain vaccinations for individuals become required. Many policy issues arise by vaccination requirements because there is a compromise between the health of society and the freedom of the individual. Vaccinations are required for children enrolling in public school, for those enlisting in the military, and for citizens with green cards. Exemptions are allowed for school aged children who have compromised immune systems, have allergies to immunizations, and those whose parents hold religious or personal objections. Physicians are required discuss the decision and inform the parents of the potential harm of not getting their children vaccinated. They are required to respect the decision of their patients, but if the child is at risk for immediate or serious harm child protective services can be notified. A medical neglect form is filled out by the physician and it is possible that the child may be forced to be immunized.

Moral Obligation to the Public

When deciding whether or not to vaccinate their children, parents must consider the possible impact their choice has on their community. Vaccination is not simply a personal choice in which only the individual will benefit or suffer from. Parents not only have an obligation to keep their children safe from deadly diseases, they have an obligation to protect other people from being harmed by these diseases.

If your child is not vaccinated they may pass the disease onto other members of the community who are not vaccinated.

Some people may not be able to receive vaccines because of medical reasons; these people are reliant on herd immunity. Herd immunity cannot be established if many members of a community are not vaccinated. For example, the influenza vaccine is not recommended for pregnant women and children under 6 months.

A couple of people deciding not to get vaccinated in a low risk community is not the present issue. The issue comes when too many people decide not to get vaccinated and the risk of disease in the community increases. Of course, it is not fair to force some into getting vaccinated while letting others decide for themselves. The only way to for this to be fair is for all healthy, able people to become vaccinated.

Is the moral obligation so strong that parents ought to be legally liable when their unvaccinated children spread disease?

Arguments justifying this:

• Their children are a direct cause of injury in another person. The other person is harmed unfairly and of no fault of their own.
• This would increase rates of vaccination because people would be motivated to avoid unnecessary legal trouble.
• Follows with negligence claims-- harm, duty, breach of duty and causation.
• We need to protect those that cannot be vaccinated.
  

Arguments against this:

• Extremely difficult to trace a disease back to someone.
• There are medical risks (even if they are very unlikely) to getting vaccinated.
• Could create panic, especially those that truly do not believe in vaccinations.
• Vaccine policies need to maintain the most amount of personal liberty possible.

Also, there is no way to draw definitive lines, there are simply too many holes that might allow for abuse of the law. For example, what about an unvaccinated child giving a disease to another unvaccinated child? I believe that both parents are at fault for this and one should not be legally responsible for making the same decision the other made.

I found the Michigan Law Review to be a really source for this, they had a lot of articles looking at the legal and ethical side of vaccine liability.

Case Study – Vaccination as a Choice

Amy Roehl


Amy Roehl is a 22 year old senior at Michigan State University who will be graduating with a degree in communicative disorders and sciences this May. She grew up in Beverly Hills, Michigan with her Mother, Father, and brother Craig. Amy is also one of the many people who have not had childhood as well as adult vaccinations and who remains an objector to the practice along with her mother. However this has not always been the case. When Amy was born her mother saw no objection to the regular vaccinations and she received the first immunization in a series of shots for Hepatitis B. Her mother, like many parents saw little to no harm in vaccinating her children and knew she was only helping them. The minimum age for some other child vaccinations are around 2-6 months of age and it was around this time when Amy’s mother took her to get these recommended routine vaccinations, which included the DPT vaccination. DPT protects against Diptheria, Pertussis, and Tetanus. According to the CDC it is given at 2, 4, 6, and 15-18 months of age with a booster between ages 4-6. In childhood vaccines it is known as DTap and the adolescent and adult booster is known as Tdap. After Amy was given a dose of the DPT vaccine she had a very serious adverse reaction. Amy started to convulse and display seizure-like symptoms. The cause for the significant negative reaction was the pertussis part of the vaccine. According to the FDA, “the pertussis component of DTP causes more adverse reactions than any other vaccine. Most common are fever, soreness at the site of the shot, and irritability. In rare cases, the vaccine causes very high fever and convulsions.” After this experience Amy’s mother wasn’t taking any more chances and Amy never completed any other vaccinations with the exception of the Hepatitis B. This means Amy has never had a tetanus booster shot, a flu shot, or even the highly recommended meningitis vaccination when coming to college. As a child Amy’s mother said she had some difficulty with after school or day care places that wouldn’t let Amy enroll there because she had not had the recommended vaccinations. However her elementary school as well as high school just asked her mother sign a waiver saying she had not had them. Because of the negative side effects she experienced after the DPT shot, she decided against the recommended but not mandatory Meningococcal Meningitis vaccine. I asked Amy if the university gave her any trouble when she objected to the immunization and how she went about doing that. She said they just made her sign a waiver, as she had to do in previous schools, saying this was her choice not to get the vaccine. The university registrar and health center also kept sending her emails and contacting her about getting the shot but that was pretty much the extent of it. It has now been four years since she decided against the meningitis vaccination and she says if presented with the situation again, she would make the same choice.