Gotham Gazette

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Access to the HPV Vaccine in NYC

Young mothers whisk by pushing baby strollers heading toward the pediatric floor at the Gouverneur healthcare facility on the outskirts of Manhattan's Chinatown.

Even on a slower than usual Monday, mothers and children clutter the waiting area, where signs promote a brand new vaccine and urge parents to ponder "how (their) daughter could become one less affected."

At Gouverneur and other medical care facilities within the city's Health and Hospitals Corporation, check-ups for girls as young as 11 years old can now include a vaccine aimed at wiping out four types of a virus that causes 70 percent of all cervical cancers - the Human Papillomavirus or HPV.

The Food and Drug Administration has approved only one vaccine for the virus – Merck's Gardasil. Both the Health and Hospitals Corporation as well and the Department of Health and Mental Hygiene say they are pushing immunization for girls between the ages of 11 and 18 and are making it more accessible, both physically and financially, across the five boroughs. But others say the city is not doing enough.

A Campaign Against Cancer

Approximately 11,000 new cases of cervical cancer are reported every year of which 3,000 are fatal, according to the American Cancer Society. The vast majority are caused by HPV - the most common sexually transmitted disease in the country that is known to cause genital warts. Approved by the Food and Drug Administration last summer, Gardasil, administered over six months in three doses, protects against four types of HPV.

Gardasil is increasingly in demand in the city - thanks to a tailored media campaign by Merck, medical professionals said. But although the vaccine has been applauded by medical professional far and wide, access has been an issue due to its exorbitant cost – estimated at nearly $400 for the entire immunization.

The cost can deter women of lower incomes from perusing the vaccination. This poses a particular problem in New York City, where minority women are screened far less for cervical cancer than other women. By skipping an annual Pap test – an exam that screens for cervical cancer – women are less likely to catch the disease early on before it is to late. In 2004, according to a survey by the health department, 41 percent of Asian women said they had not had a Pap screening in the last three years.

The national Centers for Disease Control and Prevention has recommended the vaccine be given to girls age 11 and 12 and that older females, from ages 13 to 26, be given a "catch up" vaccination. The vaccine is licensed for women ages 9 through 26 and is aimed at younger populations to catch them before they become sexually active.

It is estimated that 80 percent of women will be exposed to the virus by age 50, and 6.2 million new infections occur annually throughout the country.

Access in NYC

A report released in March by Gotbaum found that just over half of the child and teen clinics within the Health and Hospitals Corporation offered the vaccine. The corporation contends this figure is flawed and inaccurate (it blamed uneducated phone operators). In a statement, the corporation said it had always provided the vaccine at its facilities.

Gotbaum’s report also took issue with the health department, which it found did not offer the vaccine at any of its sexually transmitted disease walk-in clinics or its immunization clinics. Most of these facilities cater to uninsured, low-income or minority populations that otherwise would not be able to afford the vaccine.

Public Health Post-Study

The hospitals corporation now provides the vaccine at its 11 hospitals and its community based healthcare centers. For families that meet income qualifications, which apply to individuals with an income below 400 percent of the federal poverty level, the cost of the vaccine is integrated into the cost of a visit. This means uninsured patients who qualify for the corporation's financial assistance program would not have to pay an extra fee to receive the vaccine. A visit can typically cost between $15 and $60, depending on income and family size.

The health department is now offering the vaccine at its four, year-round immunization clinics. The health department's assistant commissioner who heads the bureau of immunization, Dr. Jane Zucker, said that since the department started offering the vaccine in May, it has administered 150 shots at its immunization clinics.

Since this spring, through the federal Vaccines for Children program, the department has also distributed 75,000 free doses for eligible children 18 years old and under to an array of health care providers throughout the city. The department, Zucker said, is also pushing to make the vaccine available for children through their primary care physicians.

"The most important thing is to make sure that kids have access through their doctor's office," said Zucker. "The most important thing is to make sure that all providers… that all venues have access to the vaccine."

The department is not offering the vaccine at its sexually transmitted disease walk-in clinics, because the clinics are not meant to provide routine medical care, officials said. Based on its experience with the Hepatitis B vaccine, health officials said it is unlikely a patient would return to the clinic for all three doses. Without all of the doses, the effectiveness of the vaccine is questionable.

Gotbaum’s report recommended the inclusion of the HPV vaccine in immunization services provided at the sexually transmitted disease walk-in clinics. Another recommendation – providing information about the vaccine on the city's non-emergency hotline 311 – has been implemented, health officials said.

Reaching Women Over 18

Some community-based clinics are struggling with whether, or even how, to provide the vaccine to women over 18 who are uninsured, sexually active and are not eligible for the free vaccines under the Vaccines for Children program. Although the vaccine is recommended for young women who are not yet sexually active, the Centers for Disease Control and Prevention did not disregard its positive effects on women up to 26 years old.

Elizabeth Howell of the nonprofit healthcare provider, Community Healthcare Network, said it currently provides the vaccine only to those less than 18 years old. Howell said there is no system to get their patients – who are low income and uninsured - to come back for multiple doses.

"We’re in a catch 22," she said. "We can't offer it freely. We don’t have the resources to offer it to anyone off the street."

Planned Parenthood does not provide the vaccine. Neither does the Medical and Health Research Association of New York City, which is dedicated to researching and providing health care to underserved populations.

A Popular Shot

Unlike community or nonprofit clinics, physicians and nurses in the Department of Pediatrics at Gouverneur see Gardasil increasingly becoming a routine step in preventative medicine. They have worked with private providers of Gardasil to vaccinate women above 18 years old, regardless of sexual history.

"Professional medicine is the key to this whole HPV (prevalence)," said assistant director of pediatrics Lily Yiu. Yiu's own 18-year-old daughter will soon be taking her third and final dose of the vaccine.

The director of the pediatric department, Dr. Felix Santiago, said the vaccine has been integrated into the medical center's immunization processes and has been classified as a "recommended" vaccination. (Medical professionals interviewed at Gouverneur would not explicitly back Gardasil as a mandate).

Health professionals who interact with young girls everyday are seeing the popularity of the vaccination first hand. Gloria Perez, a pediatric nurse practitioner at Gouverneur, said most of her patients come in knowing about Gardasil, and some college-aged girls make specific visits in just for it.

"It's in their teen magazines. It's in the subways," Perez said of Merck's advertisements. "It's part of your wealth visits. It's part of your health maintenance visits, just like any of the other shots are."

Since it was introduced in the center in December, nearly 100 percent of patients have opted for the vaccine when offered, the director added.

The Public Perspective

Gardasil has taken the nation by storm and sparked heated debates in legislatures across the country. But with any political storm, usually comes a thunderous backlash.

In Texas, the legislature rescinded an executive order by Governor Rick Perry that mandated the vaccine for all young girls. Some parents and advocates have claimed a requirement would encourage young girls to have sex, while others objected for religious reasons.

Since then, 25 states, including New York, have considered mandating the vaccine. Assemblywoman Amy Paulin of Scarsdale introduced a bill this past legislative session that would have required the vaccine for school-aged girls, although it would have allowed parents to opt out for religious reasons. The measure was unsuccessful and never received a co-sponsor in the Senate, but Paulin intends on introducing it again in hopes of improving access to the vaccine for all socioeconomic classes.

"With a vaccine like this, one that requires three dosages, you often see families go for the first one, maybe even the second one and forget the third one," said Paulin. "(A mandate) also closes the socioeconomic gap. Poor children do not get vaccines unless they are mandated."

Although the City Council has held hearings on the subject, Councilmember Helen Sears, chair of the Women's Issues Committee, said the council is currently taking a wait and see position on the vaccine. Sears said she hopes to work with the health department and monitor the vaccine's success and popularity since its recent implementation in some of the walk-in clinics.

"The big thing is that they’re starting it," she said.

[Further reading: Human Papillomavirus (HPV)]

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