The pervasive and frequently symptom-free sexually transmitted disease Human Papillomavirus Virus (HPV) kills. HPV is the cause of 99 percent of cervical cancer cases in the United States, and every year cervical cancer takes the lives of more than 3,700 of the 9,710 women affected by it, according to the Center for Disease Control (CDC). Priced at $360 dollars, the vaccine Gardisil®, manufactured by Merck, protects against 4 types of HPV including strains 16 and 18 which alone are responsible for causing 70 percent of cervical cancers in the United States.
The FDA has recently approved Gardisil®, declaring it effective in combating the spread of HPV. This action led to a recommendation of the Center for Disease Control (CDC)?s Advisory Committee on Immunization Practices (ACIP) that the HPV Vaccine be routinely administered to girls between the ages of 11 and 12 years of age and approved for as-needed administration for women up to age 26. Accordingly, Gardasil® becomes the first gender-based vaccine to prevent a cancer-causing sexually transmitted infection to be included on the list of all immunizations that young girls should receive.
Another important outcome of the ACIP recommendation is that Gardasil® must be covered by the federal Vaccines for Children Program (VFC) which provides no-cost immunizations to children covered by Medicaid, Alaska-Native and American Indian children and some uninsured and underinsured children up to age 18.1 Children and their physicians receive vaccines at no cost through VFC. In 2004, the VFC program purchased approximately 40 percent of the total number of doses of routinely recommended pediatric vaccines distributed in the United States.2 Thus the ACIP recommendation is critical to ensuring the promise of the Gardasil® vaccine to low-income communities and communities of color which have an increased risk of developing cervical cancer.
HPV and Public Health Programs
Will the HPV vaccine reach those populations most in need? The United States has long battled the disparity that exists in administering vaccines between those individuals with higher incomes and health insurance, compared to those with lower-incomes and no health insurance. In response to this, the Vaccination Assistance Act of the Public Health Service Act was implemented in 1962 in response to incomplete and unequal coverage of childhood vaccines. It was not until 1989 that Medicaid law specifically codified immunizations as a mandatory component of the Medicaid program for individuals under 21 and specified coverage in accordance with ACIP standards. VFC was later created in 1993.
If the ACIP and corresponding VFC recommendations are followed, the HPV vaccine will be available to many adolescent girls in low-income families, as part of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, Medicaid?s pediatric benefits package.3Early detection and prevention are the hallmarks of the EPSDT program.4 EPSDT requires that medical screens must include appropriate immunizations according to age and health history. Vaccines are to be administered by ?program-registered providers? who are entitled to receive the vaccine without charge for either the vaccine or for its delivery. Providers then distribute the vaccines at no cost to children. Program-registered providers can provide vaccines in accordance with state law without regard to whether the provider otherwise participates in Medicaid.5
Although providers cannot deny administration of a pediatric vaccine to a vaccine-eligible child because the parent cannot pay, the provider is not required to administer a vaccine to every child who seeks one. As is always the case with Medicaid law, the extent of participation is left to the provider as providers do not have to participate in the Medicaid program, however, if they choose to, they must adhere to the requirements of the EPSDT program. In these instances however, the child is entitled to receive the vaccine.
Another program that administers vaccines to children of low-income families is the State Children?s Health Insurance Program (SCHIP), which provides health insurance to children of ?near-poor? families who are ineligible for Medicaid. Like Medicaid, SCHIP mandates that all state plans cover the cost and administration of childhood vaccines. Gardisil® should be administered by state SCHIP programs as well.
Despite government efforts in the United States to eliminate the barriers low-income children face in receiving immunizations and vaccines through the Medicaid and SCHIP programs, 9 million children in this country still go without any form of health insurance. Although the VFC does serve some uninsured children, it is these children that may go without receiving the HPV vaccine, thus maintaining the current level of the risk of getting cervical cancer, while the risk is greatly decreased for those with insurance.
Among those who are uninsured, children of color are disproportionately represented, as twenty percent of Hispanic children are uninsured, compared to 9 percent of African-American children and 6 percent of non-Hispanic white children.6 Thus, cervical cancer disparities among women of color will persist unless uninsured girls have access to the vaccine and uninsured women (among whom women of color also are overrepresented) have access to appropriate preventive services.
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