In an expansion of North Carolina’s immunization program, public health officials aim to add five more vaccines to the list of universal immunizations that school-age girls receive. Among the newly added protections proposed for 9 to 12 year-old girls is Gardisill, which protects against the cervical cancer caused by human papillomavirus, or HPV.
To date, the vaccines recommended for the newly expanded list, like the flu vaccine, have generally been offered on an elective, fee-per-dosage basis. The state’s new plan would add immunizations against pneumonia and other respiratory diseases, rotavirus, bacterial meningitis, and HPV to vaccines in the universal program.
The Centers for Disease Control reports that roughly 3.1 million women are infected with HPV annually. The American Cancer Society estimates that in 2007, about 3,600, or one-third of the 11,000 women expected to be diagnosed with cervical cancer (from all causes), will die of their cancer. That means that 11 to 12 out of every 100,000 of the women who are infected with human papillomavirus could be expected to die of cervical cancer in 2007.
Given these statistics, should public health authorities in North Carolina add Gardisill to its list of universal vaccinations, and introduce the three-shot series to girls starting at age nine?
The introduction of Gardisill to the universal list is controversial for a number of reasons. The burden of the vaccine’s cost may fall on insurers, and thereby on insured patients as well as others. Higher premiums would hurt the insured without any assurance of better service or coverage. Ethical, financial and policy concerns, plus a loss of parental control over health decisions for their children, exist as well.
It’s important to note that the HPV virus is avoidable in a way that diseases on the current universal immunization list are not. The strains of HPV targeted by the Gardisill vaccine are the strains transmitted through sexual contact. With a nine-year-old age group scheduled for inoculation, concern runs high that reducing the incentive to eliminate risky behavior, particularly at a very young age, introduces a dangerous element of moral hazard into the equation.
But those who are inoculated don’t capture all of the benefits of the vaccine. An unavoidable spillover benefit also occurs whenever someone receives a vaccine—others benefit ‘for free.’ Every immunized person limits others’ exposure to a disease, creatinga positive spillover effect. The assumption that to few people will get the vaccination (and pay for it) if they can still be protected second-hand, through spillover from immunized parties, creates a market failure, according to the theory, and opens the door to government intervention into the process.
Finally, the growing number of required and recommended vaccines is already straining resources in third-party payments systems .
The fact that past immunization programs have been enormously beneficial doesn’t mean that every vaccination program is part of a sound policy. The public health policy toward immunizations in general should be separated from the recent controversy over administering the Gardisill vaccine to nine-year-olds. The Journal of the American Medical Association reports that mandatory human papillomavirus vaccination ‘has undermined public confidence and created a backlash among parents.’ If so, the idea that government, rather than parents or young adults should be responsible for the decision to vaccinate in this case deserves further discussion in public health and policy circles.