Final Reflection

As future nurse graduates, we have become actively involved in the discussion surrounding this blog and have taken steps toward political activism in our field. We have sent letters to our local congressional leaders and the program Director of Virginia Vaccines for Children Program with an invitation to join us in the discussion about this bill. We are still awaiting their reply, but the steps have been taken.        

With our blog project, we have learned that nurses can create change and have an important place in advocating for healthcare policy. By forming an opinion on a specific subject and contacting key stakeholders, we understand how to go gain access into the political realm. Changes in health policy directly impact our career, our nursing practice, and most importantly our community we serve. The nursing profession is constantly changing based on the needs of society and staying current as well as active with policy is crucial to nursing success and efficiency. It will be important to follow the issue of HPV vaccination after this project is complete. As future nurses, parents, and friends, knowing the impact of HPV will be significant information for us to know.

Contacting Key Stakeholders and Updates

We have contacted delegate Dickie Bell of the city Staunton, Virginia, delegate Steve Landes of Waynesboro, Virginia, and delegate Tony Wilt of Harrisonburg, Virginia, the Central Shenandoah Health District, and Crista Sullivan, the Program Director of Virginia Vaccines for Children Program (VVFC). We have reached out to these key stakeholders regarding our opinion of this bill because they are who has a direct tie to the surrounding communities of James Madison University. Due to the fact that these individuals represent our area of locality, our group figured it would be the best rationale to refer local congressional leaders to our blog. It is our hope this will lead to action and direct representation of constituent opinion about HPV vaccination requirements.

While there are no new updates in the bill, a recent development in healthcare law has had a dramatic affect on the response to mandated HPV vaccination. Abrahams’s Law, a law passed in Virginia in February 2010, allows parents to refuse certain medical treatments for their children without fear of accusations of neglect or any other reprisal. The conditions are that the decision must be made jointly with the child, the child must be mature enough to make such a decision, other treatment options must be considered, and parents must believe the decision is in the best interests of the child. Although this law intends to protect the family’s right to their own decisions in healthcare, some parents say they should not have to go through any red tape just because they do not want their children to receive the vaccine and that mandatory vaccination circumvents parents' rights to make medical decisions for their children. However, our group still thinks that the benefits of the giving the vaccine, such as the resulting lower prevalence of HPV and cervical cancer, outweigh the objections by some parents. In fact, the Abraham Law may actually help those parents who still feel uncomfortable about having their adolescent daughters receive the mandatory vaccine, after being fully educated on the subject, feel comfort in that if they truly object that they are not being punished or belittled for their objections or forced into something that they do not believe in.

Position, Key Stakeholders, and Legislators

After much review and thought concerning this bill, our group has decided that no longer requiring HPV vaccination is not something we support. As nursing students, we have learned that vaccination is often a necessity in preventing the spread of disease. We feel that if girls are no longer required HPV vaccination by the 6^th grade then the risk of contracting HPV will rise.

The chance that adolescents can choose to be sexually active and thus transmit HPV is too great of a consequence to no longer require vaccination. In regards to safety and decreasing cervical cancers associated with HPV, our group believes that HPV vaccination should be required to protect those individuals in the case that they do become sexually active and have a chance of exposure to HPV.

Our political involvement in countering this bill is important. Our group plans to write letters to district congressional leaders expressing our opinions about this bill and encourage them to review our blog, which shows evidence-based information about why we believe this bill is detrimental to public health.

Demspey and Patel write that “Data accrued from clinical and epidemiologic studies thus far provide reassurance regarding the safety and efficacy of currently available HPV vaccines. While vaccination against HPV has the potential to reduce both morbidity and mortality from HPV-associated disease, this will ultimately depend upon utilization of HPV vaccines among those at risk”. If this bill is passed, it may further deteriorate the attitude about and rate of vaccine. By allowing schools to continue the mandated vaccinations, which have “shown in clinical trials to have nearly 100% efficacy in females against persistent infection with vaccine-targeted types of HPV”, HPV and HPV associated cervical cancers may begin to be less prevalent in the future (Dempsey & Patel, 2010).

Stakeholders (people or groups who affect or who would be affected by the outcome of this bill) include:

Adolescent girls

Parents/guardians

Health insurance companies

Clinicians/primary care providers/school nurses

Religious figures

The state health department

Merck and Co, the vaccine Gardasil’s manufacturer

We encourage our readers to join us by taking a step to further this cause. Make your voice heard by sending your opinion about the HPV vaccine to your local legislator in the VA House of Delegates.

The 3 main legislators that our group will contact are all associated with our current surrounding districts; Rockingham, and Augusta County.

Contact information is below:

The Potential Impact of a Required HPV Vaccine

            HPV vaccination requirement is a multifaceted issue left to each individual state to decide. There is a tracked history of this debate that started in 2006. Upon introduction, Gardasil was well received by the United States Health Administration. However, debates against the vaccine began early as the media exposed that several strong political supporters had direct financial ties to Merck, one of the companies producing Gardasil. This fueled questions and opposition to the governmental mandate of the HPV vaccine and opened the door to different political influences to debate and question the US Governments position on mandating the vaccine.

Political influences against mandating the vaccine include: social conservatives, including religious groups, parent groups, and advocates for disadvantaged groups. Religious and parental groups believe that national vaccination would encourage girls to become sexually active at an earlier age. An article in the New England Journal of Medicine starts by explaining the religious disagreement with the initial proposed vaccine requirement: “Controversy over the product began before it was licensed, when some religious conservatives expressed concern that the availability of a vaccine against a sexually transmitted disease would undermine abstinence-based prevention messages (Colgrove, 2006).” Allowing vaccination is thought to cause less focus on abstinence education, thus undermining religious views. If a child was forced to undergo vaccination, this would then counter their family’s religious view. Another opposing viewpoint is the idea that vaccination contributes to conditions such as austism, diabetes, and multiple sclerosis (Colgrove, 2006). Often parents are concerned that this may lead to genetic abnormalities or health complications down the road. However, this issue is deeper and more complicated. The ethical and political dilemmas that arise involve questioning the power use of the state to override individuality beliefs regarding healthcare.

            Some believe that there should be requirement for vaccine due to the detrimental health effects HPV can have on a woman’s health.  The government’s overall objectives for the HPV vaccination program are to reduce the morbidity and mortality rate associated with cervical cancer.  They believe that mandating the vaccine in all school age girls would be an effective way to minimize the widespread disease.An article in the New England Journal of Medicine states, “Data show that schools with exemption rates as low as 2 to 4% are at increased risk for disease outbreaks and that children who have been exempted from vaccine requirements have a much greater risk of acquiring infectious diseases than their vaccinated peers (Colgrove, 2006).” Certainly this issue has been debated for years and continues today. With a strategy to allow parents to opt their children out of the vaccination program, exemption rates have shown to contribute to a greater risk of spread of disease. This research data supports the opinion of those who believe that vaccination should be a requirement to protect the health of the public.

Accoding to the CDC, a survey of students in 2009 found that 46% of United States high school students have been sexually active and 14% have already had four or more sexual partners. As students engage in sexual intercourse, there becomes a risk for those students to acquire sexually transmitted diseases (STDs). The CDC also states that of new STDs reported each year, about half are among adolescents 15-24 years old ("Sexual risk behavior:," 2011).

For females, HPV is becoming a prevalent STD, which can later result in cervical cancer. In the article Examining Future Adolescent HPV Vaccine Uptake With and Without a School Mandate, they suggest that "if widely implemented, HPV vaccines could drastically reduce the prevalence of HPV-related diseases” (Dempsey & Mendez, 2010), while another article adds that "If all young women were vaccinated, it is projected that the HPV vaccine could reduce the lifetime risk of cervical cancer by 20 to 66%" (Ishibashi et. al., 2010). While this is the obvious impact of the vaccine, there are also other impacts for the females required to get the vaccine and their parents who, if given the option, chose whether or not to opt out of the vaccine.   

Middle schools are targeted as the starting age for receiving the vaccine because it is recommended that ideally girls receive the vaccine before becoming sexually active. As previously discussed, some who oppose vaccination don’t agree with the assumed increase in sexual promiscuity after the child receives the vaccine. Physician and nursing recommendations can positively influence parents’ attitudes towards the vaccine. Education and creating awareness in the community is important for healthcare professionals. If parents and children are aware of what HPV is and the risks, preventative interventions, like vaccination, can be taken to decrease prevalence of the virus. While many physicians can advocate for use of the vaccine, they must also alert children and parents of the risks of getting it. Also, if parents or children refuse vaccination then education of the possible transmission of HPV and associated risks are important measures for healthcare professionals to follow.

This policy change could potentially have a large impact on nursing and the healthcare system. Along with the elimination of the requirement for females to start the HPV vaccine series before entering the sixth grade, the provisions about how a parent can opt out of the vaccination would also be eliminated. Having these requirements in school is a simple and highly effective way for nurses and the healthcare system to educate people of all walks of life about the risks of HPV and its related complications. The policy requiring the vaccines is so effective because everyone receives educated about HPV, even when they choose to opt out of the vaccination, and hopefully most will become vaccinated. If school cannot be used as a wide-reaching vehicle to promote knowledge and change, the healthcare systems and the nurses within them will have to work much harder to reach not nearly as many people. An endeavor such as this would take precious time away from the already busy healthcare practitioners, and take money that could be going towards helping more people away from the healthcare budget to finance far-reaching educational promotion.

House Bill 1419 and the HPV Vaccine

House Bill 1419 is a proposed bill in the Virginia House of Delegates for the elimination of the Human Papilloma Virus (HPV) vaccination requirement for females prior to entering sixth grade. Since 2006, Virginia has been one of about 20 states that have enacted legislation to make financial support, teaching, and the vaccine for HPV mandatory for these 11-12 year old girls and in 2007, Virginia passed the requirement for the vaccine. The previously introduced Bill had a requirement that the first dose had to be completed upon entering the sixth grade in the Virginia private or public school system, the vaccine was required for girls age 11 or older and parents had the ability to opt out, the vaccine would be added as part of the mandatory scheduled vaccination for 11 year old girls, and that the vaccine would be covered by insurance. The amendment to be passed will no longer require vaccination for Human Papilloma Virus. An additional revision is that with the removal of the requirement, there is no longer a need for parents or guardians to opt out of their child receiving vaccination. However, this will also remove the provision of educational services about the link between vaccination and prevention of cervical cancer that was required when the parents or guardians elected for their child to not receive vaccination for HPV.

So, what is the HPV vaccine? There are two HPV vaccines, Cervarix (made by GlaxoSmithKline) and Gardasil (made by Merck), which are licensed by the Federal Drug Administration (FDA) and recommended by the Center for Disease Control (CDC) for prevention of certain strains of HPV infection. Both vaccines are made with very small parts of the human papilloma virus, which can cause the body to form immunity but cannot cause infection or treat existing HPV infections.

The vaccines have different adjuvants, which are the substances added to the vaccine to increase the body's immune response. While both of the vaccines are very effective against HPV types 16 and 18, which cause most cervical cancers, only Gardasil has been proven to protect against HPV types 6 and 11, which cause most genital warts in both females and males. Gardasil has also been tested and shown to protect against cancers of the vulva, vagina, and anus. The CDC states that Cervarix and Gardasil are licensed, safe, and effective for females ages 9 through 26 years, and recommends that all girls aged 11-12 years old receive the vaccination.

Gardasil has been tested and licensed as safe and effective for use in males ages 9 through 26, but the CDC did not add this vaccine to the recommended immunization schedule for males because studies suggest the best way to prevent the spread of HPV is to vaccinate as many females as possible.  Both vaccines are given as shots and require 3 doses, the second dose given one to two months after the first, and the third dose given six months after the first dose. Both vaccines were tested in thousands of people around the world, and the studies showed no serious safety concerns. Common, mild adverse events reported during these studies include pain where the shot was given, fever, dizziness, and nausea. As with all vaccines, the CDC and FDA continue to monitor the safety of these vaccines very carefully.