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Week of 2.23.07

A Vaccine Expert's Perspective

Gary Freed Gary Freed is a professor of pediatrics and of health policy at the University of Michigan and also serves as the chairman of the National Vaccine Advisory Committee. NOW spoke with Dr. Freed to find out his views on the new vaccine against the sexually transmitted virus that causes cervical cancer.

This is an edited transcript of our interview with Dr. Freed.

NOW: How serious is human papillomavirus (HPV)?

Freed: There are probably over a hundred different strains of HPV. A significant portion of these strains can actually be pre-cancerous lesions which will lead to cervical cancer in women. If you get a strain that can cause cancer, that's a very serious issue.

"If the ability to opt out of this particular vaccine and the pathway to opt out is very easy, parents may then choose to opt out of all vaccines simply because they don't have the time to take a child for vaccines."
NOW: How serious of a disease is cervical cancer?

Freed: In the United States there are about 10,000 new cases of cervical cancer each year and around 4,000 deaths from the disease.

NOW: How significant is the new HPV vaccine?

Freed: This new vaccine prevents the infection of HPV associated with 70 percent of cervical cancer in the United States. By extension, this is a vaccine that can actually prevent cancer in women, which is a remarkable new opportunity in the ability to prevent disease for the children of the U.S. and the world. If we have the ability to prevent any cancer deaths, much less a significant number of cancer deaths that affect a segment of our population that historically have not been necessarily as well served as they could have been, then I think it's incumbent upon society to make sure that we're able to prevent these cancers.

NOW: What do you think of mandating the vaccine for girls entering the sixth grade?

Freed: In this country, we've historically had a lot of mandates for vaccines. We're also used to thinking that our children need to get certain vaccines before they start school. People have, for the most part, voluntarily complied with these mandates because they understood the need to prevent disease and the transmission of certain viruses or bacteria. In the United States, probably close to 99 percent of kids get vaccinated by the time they hit school.

It's a different world when we're talking about mandating a vaccine for children in middle school or perhaps high school. It presents some new issues that we've not dealt with before with mandates.

NOW: What new issues do you see?

Funding, for one. To have a mandate where you're going to require children to have a particular vaccine to enter school, but not provide the funding to make sure that children who either can't afford it or whose insurance doesn't cover it will mean having children barred from school. This sends a very disheartening message from where I sit in terms of our educational priorities in this country. So we have to absolutely make sure there are no financial barriers to children getting this vaccine. To my knowledge, none of the bills that have been introduced so far contains specific funding to make sure that all girls will have the ability to receive this vaccine.

Also, the ability to have middle schools or high schools track a three-vaccine series, which the HPV vaccine is, will create a new administrative burden that the schools haven't had to undertake thus far. There is no provision to provide funding or administrative support to the schools that are now going to be tasked with following these immunization rates. I don't think the legislation has really tried to delve into how schools are going to 'operationalize' this program.

"This is a vaccine that can actually prevent cancer in women, which is a remarkable new opportunity in the ability to prevent disease for the children of the U.S. and the world."
NOW: Are there any other issues?

Freed: The other issue deals with what I would call the potential for a new culture of vaccine refusal. If the ability to opt out of this particular vaccine and the pathway to opt out is very easy, parents may then choose to opt out of all vaccines simply because they don't have the time to take a child for vaccines. This is not to say, by any stretch, that parents should not have a choice in how their kids get vaccinated or what types of medical care their children receive. I firmly believe that parents have to have a role in that. But what I don't want to see is the ability to refuse vaccine or almost the encouragement to refuse the vaccine.

NOW: Do you think the vaccine should be mandated by the state?

Freed: I think that any mandate that doesn't address the three issues that I mentioned—the financing, the school issues and the way in which refusals are handled—has the potential to do more harm than good. If those issues can be addressed in an effective fashion, then I would be very supportive of a mandate.

NOW: What is the real difference between having the vaccine mandated or not?

Freed: If we don't have a mandate, my guess is there will be less of an impetus for states to commit funding to make sure that children who can't afford the vaccine can get the vaccine. Also, if it's not mandated, I don't think the issue of this vaccine is likely to get in front of parents and children as easily as it would otherwise. Children at this age—11, 12, 13, 14—don't go to the doctor as frequently as young children do.

NOW: Some people who oppose the mandate have said they prefer an educational approach instead. What would you say to them?

Freed: I'm for getting the word out and for publicity campaigns. But I'm also for trying to get as many young women for whom this vaccine is recommended to get the vaccine to help prevent them ever having cervical cancer in their lifetime.

NOW: Do you think it's possible to eradicate cervical cancer?

Freed: By itself, this vaccine will not end cervical cancer, nor will it end the need for pap smears. But by immunizing these young girls at ten, at 11 or 12 years of age, we're able to make sure, no matter what their life brings them, that we're able to prevent the 70 percent of the viruses that can cause cervical cancer. Period. No matter what their eventual behaviors or actions or healthcare status is going to be.

NOW: Is the vaccine safe?

Freed: It's my belief that the vaccine is very safe. It's been approved by the U.S. Food and Drug Administration as safe and effective. It's been tested in over 30,000 girls, worldwide, and has had an exceedingly great safety profile.

"There's really no compelling evidence that [preventing a sexually transmitted disease] would have any impact whatsoever on an adolescent's behavior."
NOW: Some people have said 'This is a sexually transmitted disease and it's not an immediate threat to sixth graders, so why mandate it?'

Freed: The time to immunize is before exposure to prevent the disease. The vaccine won't do any good once people are already infected with the strain of the virus that's going to cause them to get cancer. By the time they're graduating high school or moving into college age, there's a significant likelihood that over half of them will already have been exposed to the virus.

NOW: Some people are concerned about having to discuss sexually-transmitted diseases with their children earlier than they would want to. What do you think of that concern?

Freed: I think by the time girls are 11 or 12 years old, those types of discussions are happening either with or without their parents. I would think it would be a healthy opportunity for parents to begin having those discussions if they hadn't had them already.

NOW: Do you think giving the vaccine to young girls will influence their behavior?

Freed: There is certainly no evidence that preventing a sexually transmitted disease has any influence on future adolescent sexual behavior. And there certainly is evidence to say that the fear of disease has no impact on behavior. So there's really no compelling evidence that that would have any impact whatsoever on an adolescent's behavior. The only impact we're going to have is preventing cervical cancer.