Mais sobre o HPV: os limites da liberdade

O mapa americano ao lado mostra os estados em magenta onde foi aprovada a vacinação obrigatória para o papilomavírus para meninas entre 11 e 12 anos porque isso preveniria câncer de colo uterino. Em marrom, onde a proposta foi recusada e em verde onde há discussão. No momento há somente uma apresentação comercial, o Gardasil da Merck e, em breve haverá o Cervarix da Glaxo Smith Wellcome. Nessa semana, The New England Journal of Medicine - de onde esse mapa foi retirado - está debatendo (clique no título do post) a questão sob o ponto de vista ético, visto que o editorialista aceita a versão técnica do Center of Disease Control favorável à inclusão da vacina no calendário de imunização. Por sinal, decisão facilmente constestável novamente do ponto de vista técnico, vide o editorial - aqui reproduzido - da semana passada em JAMA. O debate que está florescendo nos Estados Unidos é sobre a liberdade dos pais em vacinarem ou não filhos e, principalmente da iniciação sexual. Porém, o mais importante é que ao contrário das reações históricas de todas as sociedades contra vacinas, nesse caso não porque exigir que a aluna confirme estar vacinada para algo que somente é transmitido sexualmente e, cujo impacto em outro indivíduo será remoto.

Explicando melhor com exemplos: (1) ao não vacinar seu filho contra sarampo - fato corriqueiro em famílias progessistas com médicos homeopatas nos anos 80 em São Paulo - esses pais colocaram de fato em risco a vida do filho e de seus colegas, porque o colega vacinado não necessariamente estava imunizado ( eficácia vacinal é de 95%), ou seja há risco de infecção mesmo em quem for vacinado. Por isso torna-se obrigatório reduzir a circulação de vírus na população infantil. Nesse caso, a imposição faz todo sentido, porque a sua liberdade não pode causar mal a terceiros, lembrando Stuart-Mill. (2) não vacinar uma menina para o papilomavírus aos 12 anos, não sigficará nada para a sociedade, para terceiros por vários motivos e, para ela própria. Por vários motivos, cujas variáveis, nem ela, nem os pais, nem niguém consegue estabecer, como ela se manterá virgem ou terá poucos parceiros ou mesmo infectada fará exames citológicos de prevenção ou uma enorme de chances outras. Lembro que o Gardasil cobre 70% dos tipos de papiloma associados ao câncer.

Ou seja há tantos condicionais, que há necessidade de se verificar quais são os grupo de "alta vulnerabilidade" e, aí sim atuar de forma decisiva e, obviamente com a força do estado aplicado a vacina gratuitamente.

O boicote à vacina contra a pólio na Nigéria.

Na Plos Medicine desse mês há um relato muito interessante sobre o boicote à vacinação contra a poliomielite em cinco estados da região norte da Nigéria. O tema é interessante para verificar que não bastam recursos financeiros, mas sim uma rede mínima - social, política, cultural - para permitir políticas de saúde pública.

O texto completo está em http://medicine.plos.org. Abaixo, um resumo.

Community Prevent Further Boycotts?
The vaccine boycott in Nigeria was influenced by a complex interplay of factors. These factors included lack of trust in modern medicine, political and religious motives, a history of perceived betrayal by the federal government, the medical establishment, and big business, and a conceivably genuine—albeit misplaced and ineffective—attempt by the local leadership to protect its people. A recent editorial in The Lancet argued that “few data exist on the best way to stop the spread of false information” . One lesson from the Kano boycott is that research is needed to investigate why people have concerns and fears about vaccination, and what steps should be taken to avoid boycotts in the future. Other lessons are discussed below.
Governments should be sensitive to local politics, especially as they affect health-care delivery
Immunization campaign programs should be a participatory event involving state and local governments, community leaders, and parents. There are three types of community leaders in northern Nigeria—traditional rulers, political leaders, and religious leaders. Traditional rulers acquire their status through succession and their authority is rooted in traditions and customs [40–42]. Political leaders acquire their status through the political process and religious leaders do so on a religious basis. Among the three, the traditional ruler is best placed to represent the interests of children. Community leaders may contribute to the success or failure of health research and delivery .
Public awareness campaigns about vaccination are crucial.
These should stress the value of immunization and involve the media. Reaching the community requires radio, television, and folk media (such as local music, theatre, and festivals). Immunization messages can be packaged into songs by local musicians and can be communicated through drama in the language that local people understand.
Research ethics committees should be established in each local government.
These committees would examine and approve or reject health research in its sphere of influence. Members of these community-based ethics committees should include volunteers who are ready to undergo basic ethics training relevant to their duties. The committees should be under the supervision of, and funded by, the local government's councils, and the committees should work with local medical associations. They should choose their own chairperson and determine their own agenda in line with the national ethics code. Barriers to the formation of local ethics committees include inadequate capacity, funding, and communication.

Merck Sharp & Dhome forçava a barra para impor a vacina para o HPV.

Notícia do The Wall Street Journal (abaixo) revela a ação da empresa Merck (no Brasil, Merck Sharp & Dhome) em forçar que os Estados americanos tornassem o Gardasil, vacina para o HPV, fator de risco para o câncer de colo uterino, obrigatório para adolescentes. A reação dos pais e educadores foi grande o suficiente para que a empresa suspendesse o lobby nos Estados.

Aqui, haverá uma reportagem de capa em um das semanais, uma reportagem de duas páginas em um dos três grandes jornais e, um hospital jetset irá abrir uma clínica de HPV. Aguardem.

Já foi dito aqui que a vacina será disponível em Brasília, mas não em Brasília Teimosa em Recife.

Merck Suspends Campaign to MakeGardasil Vaccination Mandatory
By JOHN CARREYROU and SARAH RUBENSTEINFebruary 20, 2007 6:39 p.m.
Merck & Co. said it would stop lobbying states to pass laws requiring that preteen girls be vaccinated against cervical cancer in the face of a growing backlash among parents, physicians and consumer advocates.
Merck's aggressive lobbying campaign was intended to boost sales of its Gardasil vaccine, which received Food and Drug Administration approval last year. Gardasil provides protection against two strains of the human papillomavirus that are thought to cause the majority of cervical-cancer cases.
But unlike a number of other diseases that U.S. schoolchildren are required to be vaccinated against, HPV isn't an airborne virus that can spread easily in a group setting. Rather, it is sexually transmitted. Gardasil also stands apart from other vaccines that are compulsory because of its high cost: $360 for a three-dose regimen.
In recent weeks, opposition to state mandates has grown among parents who want the freedom to make such a medical decision on their own and are worried about exposing their children to the unforeseen side effects of a new vaccine. Physicians and consumer advocates have also questioned the need to immunize young girls against a disease that is no longer very prevalent in the U.S. and doesn't develop until much later in life.
Merck's lobbying efforts have become a distraction from the company's goal of immunizing as many women as possible against cervical cancer, said Richard Haupt, Merck's executive director of medical affairs. Merck has "decided at this point not to lobby for school laws any further."
More than 20 states have drafted bills that would make vaccination of pre-teen girls against HPV compulsory. Earlier this month, Texas Gov. Rick Perry issued an executive order mandating that the vaccine be administered to all girls entering the 6th grade in the state as of September 2008. One of Merck's lobbyists in Texas is Gov. Perry's former chief of staff, and Merck's political action committee contributed $6,000 to the governor's re-election campaign.
Merck has also been funding Women In Government, a Washington, D.C.-based advocacy group made up of female state lawmakers. An executive from Merck's vaccine division, Deborah Alfano, sat on Women In Government's business council last year, and a number of the bills across the country have been introduced by members of the group.
A spokesman for Merck, Ray Kerins, declined to say how much money the company had spent on the lobbying campaign. Merck is eager to build Gardasil's sales quickly to offset patent expirations on some of its bestselling drugs and its mounting legal costs over its withdrawn painkiller Vioxx.
"It's a good decision because I think it's true that the discussion about mandates was a distraction -- it is a distraction," said Joseph Bocchini, chairman of the committee on infectious diseases of the American Academy of Pediatrics. Dr. Bocchini said he was concerned that parents would decide against vaccinating their children because of the controversy when they might have otherwise opted to do so. Merck recently asked Dr. Bocchini about his opinion on the controversy, he added.
Dr. Bocchini noted that state mandates are usually passed to control the spread of a highly infectious disease like chicken pox. The focus with Gardasil at this point should be on educating patients about the vaccine and cervical cancer, and making sure that patients can afford the vaccine, he said.
Merck's marketing campaign for Gardasil has emphasized that cervical cancer is the second-leading cancer among women around the world. But screening with Pap smears has dramatically reduced the disease's incidence in the U.S. The American Cancer Society estimates that 3,670 American women will die from cervical cancer this year, the equivalent of 0.65% of U.S. cancer deaths. Cervical cancer is a much bigger problem in the developing world.
Moreover, inoculation with Gardasil won't obviate the need for regular Pap tests because some 30% of cervical cancers are thought to be caused by other HPV strains not covered by the vaccine.