From NEJM: Ethics and Politics of HPV Mandates

This week's New England Journal of Medicine includes a commentary titled "The Ethics and Politics of Compulsory HPV Vaccination" by James Colgrove, an Associate Research Scientist at Columbia's Center for the History and Ethics of Public Health.

Colgrove -- a contributor to our Ethics of Vaccines Project -- does an excellent job outlining the many competing considerations that will influence states' decisions regarding possible mandates of HPV vaccination as a condition of school or day-care attendance. While there is not much new in the essay (particularly for regular visitors to this site), Colgrove's essay is, by far, the best available synopsis of the topic in print to date. Thanks to the folks at NEJM, its full text is available for free.

One problem (perhaps the only one) with the essay is Colgrove's simplistic characterization of the perspectives of bioethicists on the topic, a description that comes perilously close to caricature. He writes:

"Bioethicists, who generally hold the values of patient autonomy and informed consent to be preeminent, tend to be skeptical about compulsory vaccination laws. Not surprisingly, some have expressed wariness about or opposition to mandating HPV vaccination."

Colgrove surely must be aware that any attempt to describe how "bioethicists tend" to think about a specific policy issue is about as useful as trying to capture in one sentence what "politicians tend to think" about Iraq or what "judges tend to believe" about civil liberties, as though a single, dominant position exists on these topics. In fact, many bioethicists, particularly those coming from a public health background, are quite comfortable with state vaccine mandates, including those for HPV vaccination.

As for the "some" bioethicists expressing wariness, Colgrove cites only two papers on ethical aspects of HPV vaccination, one of which is written by Pitt's Richard Zimmerman (a paper we previously discussed here). While Zimmerman has written frequently on ethical topics in journals of the vaccinology community, it is a stretch to identify him as a bioethicist, let alone as one of two who represent how the discipline as a whole tends to think about vaccine mandates.

These criticisms aside, Colgrove's essay is well worth reading for anyone thinking seriously about the appropriateness of HPV mandates.

Op-ed on health care worker flu vaccination

Our colleagues Art Caplan and David Curry wrote an editorial in Tuesday's San Jose Mercury News on the disturbingly low influenza vaccination rates among physicians and other health care workers. Here's an excerpt from the piece, declaratively titled "Make sure your health care workers got flu shot":

"The roughly 40 percent rate of flu vaccination for health care workers means that two in three of the people caring for her are not vaccinated. Do you have the right to ask that health care workers who interact with your parent get the flu vaccine? Why not? You should ask those providing health care: 'Did you get your flu shot this season?' And don't forget the person who brings the food tray, changes the bedding or installs the cable TV. Asking may be embarrassing, but it will remind health care workers to do the right thing.

It is time to move public policy in the direction of mandatory flu vaccines for all appropriate health care employees. Choice is a key value for us all, but spreading infection among the sick is too high a price to pay for that choice. We should not have to wonder whether the person taking care of us, our newborn or our elderly parent has gotten a flu shot."

Survey of physician attitudes on HPV vaccination in Pediatrics

The December 6 issue of the journal Pediatrics includes an interesting paper titled, "A National Survey of Pediatrician Knowledge and Attitudes Regarding Human Papillomavirus Vaccination." (Vol. 118 No. 6 December 2006, pp. 2280-2289 -- free abstract, subscription required for full text. The survey was conducted by researchers at the University of Colorado at Denver, Children's Hospital in Denver, and the CDC.

A national sample of 431 physicians was surveyed "to determine physician characteristics, knowledge, and attitudes associated with an intention to recommend human papillomavirus vaccination," quoting from the abstract. Among the reported results:

"46% of respondents would recommend vaccination for 10- to 12-year-old females, 77% for 13- to 15-year-old females, and 89% for 16- to 18-year-old females. Corresponding rates for males were 37%, 67%, and 82%, respectively. Whereas 60% of respondents thought that parents would be concerned that human papillomavirus vaccination may encourage risky sexual behaviors, 11% reported that they themselves had this concern."

The main issue complicating attempts to assess the value of this data is that the survey in question occurred between August and October of 2005, long before HPV vaccines entered the public spotlight (and likely well before many practicing pediatricians gave the vaccine serious thought). There's no way to know what impact the events of the last six months (particularly the significant public support that seems to exist in favor of vaccination) has had on physician attitudes. Still, the paper is a helpful contribution to vaccine implementation efforts.

$200m in GAVI funding for rotavirus and pneumococcal vaccines

Our hometown newspaper, The Philadelphia Inquirer, reports today on the $200 million pledge made late last week by GAVI to support vaccination against rotavirus and pneumococcus in the developing world. Here's the GAVI press release about the announcement.

The Inquirer story quotes GAVI's estimates of the potential worldwide benefit of each vaccine in the coming years: 370,000 deaths and 14 million hospitalizations due to rotavirus could be prevented by 2015, as could 447,000 deaths attributable to pneumococcus.

The Inquirer story explains:

"GAVI said it would coordinate with the World Health Organization and UNICEF to acquire and distribute vaccines first in 'countries where the vaccines have shown efficacy. As new and more effective vaccines come on the market, and as political support grows for introducing them in other GAVI countries, we will scale up to meet demand.'"

CDC releases updated "General Recommendations on Immunization"

Every few years, the Advisory Committee on Immunization Practices releases an updated version of its "General Recommendations on Immunization." The new document released Friday is an update to the previous version released in 2002.

As the title suggests, it is a series of recommendations that are not specific to a particular vaccine, addressing issues such as vaccine handling, administration, spacing, contraindications, and vaccination of specific populations (such as pregnant women or those with altered immune systems). Coupled with 200+ references to the medical literature, it's an excellent resource for those looking for a synopsis of a particular topic and directions for further study.