Hell Just Froze Over – Mandatory HPV Vaccination in Texas?

Did hell just froze over because of Texas?

Yes my friends, apparently hell just froze over:

HOUSTON, Feb. 2 — Texas on Friday became the first state to require all 11- and 12-year-old girls entering the sixth grade to be vaccinated against a sexually transmitted virus that causes cervical cancer.

Averting a potentially divisive debate in the Legislature, Gov. Rick Perry, a Republican, signed an executive order mandating shots of the Merck vaccine Gardasil as protection against the human papillomavirus, or HPV, starting in September 2008.

Mr. Perry’s action, praised by health advocates, caught many by surprise in a largely conservative state where sexual politics is often a battleground.

“I had no idea; I was absolutely caught off guard,” said Representative Jessica Farrar, Democrat of Houston, who sponsored a bill to require the vaccinations starting this September. “Normally, the governor does not take things like this upon himself, although I’m glad he did.”

If you live in Texas and see some snow falling, it is not due to global warming, it is because Gov. Rick Perry – a stalwart conservative republican who is against abortion and stem-cell research – finally recognized that doing the right thing is not such a hard thing to do:

“Requiring young girls to get vaccinated before they come into contact with HPV is responsible health and fiscal policy that has the potential to significantly reduce cases of cervical cancer and mitigate future medical costs,” said Mr. Perry, who was re-elected to his second full term last November.

And it is official as well:

It is Republican Gov. Rick Perry who issued an executive order directing the state’s Health Human Services Commission (HHSC) to get ready to administer the HPV vaccine in girls at noted ages before they enter sixth grade.

The order, effective September 2008, also directs HHSC and the Department of State Health Services (DSHS) to “make the vaccine immediately available to eligible young females through the Texas Vaccines for Children program for young women ages 9 to 18, and through Medicaid for women ages 19 to 21,” says the statement of the governor’s office on its website.

See? It wasn’t that hard. Good for you, Gov. Perry. So every parent must vaccinate their school-aged girls with Gardasil, right? Wrong:

Under the order, girls and women from 9 to 21 eligible for public assistance could get free shots immediately. The governor’s office said parents could opt out of the school program “for reasons of conscience, including religious beliefs.”

Ahh, I see. So at least he didn’t completely screw over his conservative friends. I wonder what is the point of having a mandatory vaccination program if parents can opt out because of religious beliefs, but I digress. Time and education will eventually replace misinformation and stereotypes.

But I wonder, did Gov. Perry did this out of the goodness of his conservative heart, or because the scientific evidence finally convinced the guy? If by “scientific evidence” you mean “my former Chief-of-Staff, who is now a lobbyist for Merck, told me this would mean truckloads of money for them and for me”, then yes, he was convinced:

Is Perry’s order politically motivated? No one knows. But, USA Today has reported today that Perry has several ties to Merck, the maker of the HPV vaccine, and Women in Government, a not-for-profit organization comprised of state woman regulators, which some watchdog has claimed is too cozy with Merck.

Media has reported that Women in Government is quite active in promoting the Merck’s vaccine, which analysts say is positioned to make Merck more than billion dollars a year. According to USA Today, Mike Toomey, Perry’s former chief of staff, serves as one of the drug company’s three lobbyists in Texas. Perry’s current chief of staff’s mother-in-law, Texas Republican state Rep. Dianne White Delisi, is a head of Women in Government.

“Perry also received $6,000 from Merck’s political action committee during his re-election campaign,” USA Today says.

Ah, now everything seems to make sense. A conservative politician from Texas is opposed to everything this vaccine stands for, and knows he can lose his conservative base over this, but he can make up those votes from the other side, and make a ton of money for his friends at Merck in the process.

Now let me play Devil’s Advocate for a moment. Is there a conflict of interest here? Very likely. But are Gov. Perry’s actions regarding mandatory HPV vaccination wrong? Well, no. Merck does make the damn vaccine, and a generic will not become available in a long time. This vaccine represents a huge leap forward for women’s health. At around $400 for 3 shots over an 8-month period, it is expensive, and most health plans will NOT cover it. But while preventing cervical cancer is morally and medically correct, it is not exactly sound fiscal policy:

Mr. Perry says it makes sense to use the vaccine to prevent cervical cancer which would otherwise cause a large burden on medical expenditure. But does this mandatory inoculation of the HPV vaccine really save medical costs?

On average, a 5-year treatment for a case of cervical caner would cost $11,000, early studies show. For a 5-year span, about 5800 new cases of the disease are expected to be diagnosed in Texas, which means the medical cost for five years is 63.8 millions or 12.8 million a year.

In Texas, there are about 6.31 millions people now under age 18, meaning the number of girls who are required to receive the HPV vaccine each year is about 0.35 million. The total number of girls to receive the vaccine is 1.76 million, meaning that Merck can rake in 630 million dollars in five years or 126 million dollars in the vaccine sales in Texas alone with Mr. Perry’s order.

The cost for the first year would be double the price tag as girls both at age 11 and 12 will receive the vaccine. The calculation is based on the price of the vaccine at $360 per girl.

It seems that this state mandatory vaccination can save about 700 women’s lives a year in Texas at a cost of 126 million dollars a year spent on the preventive vaccine. These 700 women would otherwise need 7.7 million dollars for treatment of their cervical cancer.

Perry’s order can save some women’s lives, but it does not save money.

I am not saying that vaccinating women with Gardasil is not worth it – it is. It does make sense from a public health point of view, because cervical cancer it is the second most common cancer in women after breast cancer. Gardasil, the HPV vaccine, will definitely be most valuable in the developing world, where most women don’t have access to a yearly PAP smear. But the big fight, the one that will set the precedents for other countries to follow, is taking place in the United States and Texas, of all places, just landed a knockout blow.


11 Responses to Hell Just Froze Over – Mandatory HPV Vaccination in Texas?

  1. Mick says:

    There’s more to this than meets the eye. Yes, Merck is a huge contributor to Perry’s campaign war chest and that’s why he’s doing it. But “a huge leap forward for women’s health” is highly debatable. The fact is that Gardisil has been proven effective against a single fairly rare form of cervical cancer that afflicts a tiny percentage of women. Due to the Truth in Advertising laws, Merck’s own commercials have to include a disclaimer that says in the vast majority of women – well over 90% – HPV goes away by itself with no adverse affect on a woman’s health.

    I think there is a serious question here about mandatory vaccinations of nearly 100% of a given population in order to fight a “disease” that will only, if left untreated, affect 3-5% of that population. If you read the explanation on their own website carefully, what they actually claim is that HPV causes cervical cancer in 70% of the cases in which it doesn’t go away on its own. That’s 70% of 3-5%, or roughly 2 1/2-4% of women who contract the virus.

    It seems to me that this is very sophisticated fear campaign, and what Merck is doing is selling a vaccine to millions of people that in the normal course of events would only be needed by a small fraction of them. Maybe the vaccine is harmless but how do we know that with an FDA that’s in Bush’s – and therefore Merck’s – back pocket?

    I think this is a major Big Pharma scam along the lines of that other great scam, Zanax, wherein they set out to scare people about feeling bad or, in this case, contracting a minor disease with consequences for a small percentage of people, and then sell it to everybody who has a bad day or thinks it will help prevent cancer. I’d need to see some independent proof that HPV is anything like the threat they’re claiming it is. I don’t think it exists.

  2. Maggie Mahar says:

    Mick has the facts right.

    This is not (as commonly reported) a vaccine that protects against “most” of the viruses that cause cervical cancer. It protects against 70 percent of the viruses that cause cervical cancer. Of course 70 percent is more than 50 percent, so technically “most ” is correct. But the lanague is misleading. Girls who have been vaccinated are not “immune” (which is what vaccinated usually means). They are still vulnerable to 30% of hte viruses that cause the cancer.

    This is why Merck itself acknowledges that girls who receive the vaccine will still need regular Pap smears.

    The real danger is that girls who are vaccinated will think that they don’t need Pap Smears–or that Pap Smears aren’t that important becuase they’re “safe.’
    Just last week-end I saw a young girl in Texas on NBC saying that now that she had been vaccinated “this is one cancer that I won’t have to worry about fighting.”

    This is completely untrue. But no one contradicted her.

    Finally, thanks to Pap smears, less than 1 percent (.65%) of cancer deaths in the U.S. this year will be due to cerviccal cancer. Almost all of the women who die of this disease didn’t get regular Pap smears. What we need is a national campaign (perhaps through the schools) to persaude ALL girls to get in the habit of getting regular Pap smears (free at many clinics). That campaign would be a lot less expensive than vaccinating everyone.

    But of course, Merck wouldn’t make a profit on it. And Merck is in shaky financial shape right now. It sorely needs a blockbuster drug. That is what the campaign to make Gardasil mandatory is all about.

  3. truly.equal says:

    Thanks for all the comments. This is a topic in which we – and especially I as a future doctor – really need to play devil’s advocate with.

    Yes, Gardasil does not fit the usual definition for a vaccine because they are not truly “immune” but this needs some qualifying. The Human Papilloma Virus (HPV) has various serotypes, and it is usually 2 serotypes – 16 & 18 – that cause most types of cervical and penile cancer. Read that sentence again and see how many qualifiers there are. This does NOT mean that the other serotypes do not cause cancer. The mechanisms and interactions between the various serotypes and our genetic makeup is not well understood.

    There is a reason why Merck states the vaccine is most effective at ages 9-12, before most girls become sexually active: trial subjects who had already exposure to other common HPV serotypes showed higher rates of cervical neoplasia (that’s abnormal cancer cell precursors). This raises questions as to whether the vaccine impairs the immune response under such circumstances, or whether there were others factors in play.

    That being said, a vaccine that protects against the most common forms of HPV is a huge step forward for women’s health. It does not mean you won’t get infected with HPV, which is what most people don’t get… “but I thought I was vaccinated”… yes you are but it is not a cure all. Again, vaccines are not a cure all.

    The young girl that says “this is one cancer I won’t have to worry about fighting” is wrong but half-right. She won’t get infected with the usual HPV suspects, but keep having unprotected sex and you will get some other STDs, or other HPV serotypes. Then again, WHAT child knows what their vaccines can and cannot do? She is not a trained professional, you cannot take her statement at face value and claim “a-ha!” By the way, parents making a big fuss out of “what do we say to the children” are such hypocrites. Did they tell their kids what their polio vaccines were for? Rubeolla? Hepatitis B & C? You can get the last one by having sex as well. Read a proper health book, or consult a health professional, on how to properly approach a child about complicated issues.

    Ideally, every women should have access to a yearly PAP smear, but this does not happen, not even in the U.S. I am 100% for regular PAP smears – it should be the right of every women – but there is something people in the U.S. have missed.
    Worldwide, cervical cancer is the 2nd most common cancer in women (after breast cancer). This vaccine represents a HUGE step forward in women’s health worldwide, because another hurdle has been overcome somewhat. Yes, not fully, but partially. I will take that 70% anytime.

    Depending on the grade and staging of the cancer, there are treatments, most notably cryosurgery which is quite painful. In fact, most, if not all, cancer treatments are experimental and there are few, if any guarantees. Cervical cancer therapy is not a walk in the park… it is one of the most difficult therapies for a woman to face. Ask anyone who has a relative that has died of cervical cancer, and they’ll tell you something about side effects.

    I don’t trust Big Pharma… but there is a weird dance between the medical community and the drug makers. They make the drugs, and we need them just as much as they need us. I don’t approve of their shady practices, but do not let this make you think that this drug is a scam. Vaccines are more cost-effective in preventing cervical cancer than regular gynecological exams and routine Pap screening. Again, PAP smears are a healthcare “luxury” to most women in the world, don’t think that just because you can get one rather easily in the U.S. others can.

    Also, Merck is partnering with India’s Council of Medical Research to study Gardasil, and also has plans to collaborate with PATH and the Gates Foundation to facilitate introduction of Gardasil to impoverished nations.

  4. truly.equal says:

    By the way, are you that Maggie Mahar? Cool..

  5. Jim says:

    Hypothetically: Let’s say I have sex with a young Texan whose parents “opted out” of the vaccine and I contract HPV of the specific serotype Merck’s Miracle Medicine is designed to discourage. Can I sue them for recklessness/negligence?

  6. Jim says:


    Hoping you picked up on the (mostly) sarcastic inflection I was laying down there…

  7. truly.equal says:

    Unless you get married to her! I’m half-joking. I know – at least where I live – it is illegal to get married without a health certificate with complete VDRL results. In other words, you cannot get married and then find out after consumating the marriage that your wife had HIV/AIDS and did not tell you. That not only nullifies the marriage (not divorced, I mean null) but opens the other partner for a lawsuit because she knowingly infected you. The same is true for other diseases.

  8. […] all the brouhaha over HPV and Texas Governor Rick Perry’s order to implement a mandatory vaccination program for all school-…, I found an interesting nugget that has been largely ignored: First lady’s […]

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