A federal panel of scientists recommended Thursday (June 29) that all 11- and 12-year-old girls get a vaccine that could prevent 70 percent of cervical cancer cases. Now discussion moves to state capitols, where legislators will decide whether to make the three-shot treatment mandatory before girls enter certain grades.
The recommendation by the Advisory Committee on Immunization Practices means that the federal government will likely pick up the tab for vaccinating poor women. The suggestions can also influence insurance coverage.
The issue for states will be whether to add the vaccine for the most dangerous strains of Human Papillomavirus (HPV), which causes cervical cancers in women, to the list of shots such as measles, mumps, polio and whooping cough required for admittance at school.
An estimated 9,700 American women are diagnosed with cervical cancer every year; 3,700 die of the disease. Worldwide, cervical cancer is the second most common cancer among women, afflicting 470,000 women and leading to 233,000 deaths a year, according to the Food and Drug Administration.
But unlike other contagious childhood diseases, HPV is a sexually transmitted disease. The distinction already is spurring some conservative groups to say states shouldn't mandate that girls get the vaccine, because the only way to catch the cancer-causing disease is through sexual contact.
Linda Klepacki, an analyst on sexual health for Focus on the Family, which promotes abstinence until marriage, said the reason for inoculating schoolchildren for diseases like measles doesn't apply to the cervical cancer vaccine.
"HPV cannot be communicated by sitting in a public school classroom. It's communicated only by sexual behavior. Because of that reason, we believe that parents should be the primary decision makers. … It's not something you can catch, but it's something you really have to go out and get," she said.
Klepacki acknowledged that women who remain celibate until marriage still could be at risk, if their husbands contracted the virus earlier.
Massachussetts state Rep. Gale Candaras (D), along with a national bipartisan group of state legislators called Women in Government, are waging a national education campaign against cervical cancer and are promoting the vaccine. Candaras already is working with Merck, which manufactures the vaccine, and her state's public health officials to ensure that low-income women can get access to the vaccines.
"I'm sure there are fringe groups that will try to make this about the issue of sexual abstinence, but the fact of the matter is that, whatever the cause of the disease, having an STD (sexually transmitted disease) is one thing, having a cancer is another. We're talking about curing or obliterating or eradicating the first gynecological cancer,"
Candaras said. Candaras also noted that the vaccine could help men, because HPV can lead to penile cancer and warts. Merck is still studying how effective its vaccine, called Gardasil, is in preventing those conditions in men.
Forty-seven states already require school children to be inoculated for hepatitis B, a disease that affects the liver and is transmitted through blood, contaminated needles or sexual activity.
HPV infects a quarter of people ages 15 to 24. The Centers for Disease Control and Prevention estimate that 80 percent of women contract the virus by the time they're 50.
Most people who get the virus don't show any symptoms. But some strains can lead to cervical cancer and genital warts. Gardasil protects against four strains of the virus - two that cause 70 percent of cervical cancer cases and two that are responsible for 90 percent of genital warts.
Regular testing, such as through Pap smears, can detect the precursors of cervical cancer, which are easier to treat than the cancer itself.
Besides 11- and 12-year-old girls, the federal scientific panel said young women up to 26 who haven't been inoculated should receive it, too. Its stance clears the way for the federal government to pay for the cervical cancer vaccines for poor and uninsured children. Each dose of the vaccine normally costs $120, and patients must take three doses over six months.
The FDA had approved the vaccine on June 8, and the first batches are already being shipped to doctors around the country.
States do not necessarily have to follow the suggestions of the federal panel of scientists.
State legislators and, in some cases, public health agencies determine whether to mandate treatment. That process varies by state. Many times it's up to legislators to write the requirements into law. But it can also be done administratively.
In Pennsylvania, for example, the secretary of health could recommend that the cervical cancer vaccine be required for school attendance. If he did, it would trigger an administrative process that can take six months to two years. Legislators would be part of that review process, as would the governor and attorney general.
Even mandatory immunization policies usually have exceptions. A survey of the 50 states in March 2004 by the National Network for Immunization Information (NNII) found that all states allowed exemptions for medical reasons, 48 provided for exceptions for religious reasons and 20 also let patients opt out on philosophical grounds.
Debbie Saslow, a spokeswoman for the American Cancer Society, said her group will push states to find ways to pay for vaccines for women who don't receive free shots from the government and who don't have insurance.
The cancer society hasn't decided whether to advocate making the vaccine a requirement for school entrance, although Saslow said those mandates have proved to be one of the most effective ways to ensure children are inoculated. But schools could also ensure that parents learn about the vaccine, she added.
Dr. Louis Z. Cooper, a past president of the American Academy of Pediatrics and an NNII board member, said the importance of state mandatory immunization policies has decreased over the years.
In the 1970s, state laws requiring schoolchildren to be inoculated led to "remarkable success," he said. But now, he said, the medical community is leading the way. Pediatricians started widespread inoculation for pneumococcal disease - a bacterial infection that can lead to meningitis, pneumonia and other complications - before states started mandating it, Cooper said.
"The people who deliver 85 percent of vaccines are doctors in their offices. They don't need states to take action at all," he said.