National, state and international organizations sign-on to oppose the immigrant HPV vaccine requirement.

By admin
Published: Thursday, January 29th, 2009

January 26, 2009
Richard Besser, MD
Acting Director
Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30333

RE: HPV Vaccination Mandate for Immigrant Women and Girls

Dear Dr. Besser:

The undersigned immigrants’ rights, women’s rights, public health, medical, and reproductive justice organizations write to express our opposition to the newly-imposed requirement that female immigrants ages 11 to 26, seeking permanent residence or entry to the U.S. be immunized against the human papillomavirus (HPV).

We urge the Centers for Disease Control and Prevention (CDC) to retract its listing of HPV as a required vaccination for immigrants in the revised Technical Instructions to the Civil Surgeons for Vaccinations Requirements, and to direct the Advisory Committee on Immunization Practices (ACIP) to modify its recommendation to state that the HPV vaccination should not be mandated for immigrants. We also ask the CDC to direct the United States Office of Citizenship and Immigration Services (USCIS) to suspend the HPV vaccination requirement for immigrants applying to adjust their immigration status or to obtain visas for the U.S. In addition, we ask that the CDC re-examine and modify its current system of adding new vaccination requirements for immigrants to prevent future unintended additions to the list of mandatory vaccinations and undue burdens on immigrants. We outline the principal reasons for our objection to the mandated HPV vaccination below.

As you know, ACIP recommended in 2007 that Gardasil, the only FDA approved HPV vaccine, be administered to females ages 11 to 26 in the U.S. This recommendation became an automatic requirement for prospective immigrants when the government updated its vaccination list in July 2008. Unlike the other infectious diseases addressed on the list of required vaccinations, HPV does not pose an immediate threat to public health. Dr. Jon Abramson, former chairman ACIP, has said that Gardasil should not be mandatory because HPV, unlike measles or chicken pox, is transmitted only by sexual contact. Of the 14 required vaccinations for immigrants, 12 are intended to combat infectious diseases that are transmitted by respiratory route and are considered to be highly contagious. Gardasil and the only available vaccine for shingles, Zoster, are the only exceptions.

Furthermore, while the HPV vaccine is recommended for girls and women in the U.S., it is not currently required of U.S. citizens in any jurisdiction. We believe the mandatory use of a medical procedure on a targeted population, when it is not required by the general population, is discriminatory. Like their U.S. citizen counterparts, all prospective immigrant women should have the opportunity to make an informed decision about their use of the HPV vaccine, weighing both the potential costs and health benefits of this procedure. The HPV vaccination is not mandatory for U.S. citizens, and its inclusion as a required vaccine for immigrant women and girls raises tremendous concerns. The immigrant population also shares this sentiment. Immigration attorneys and on-the-ground advocates have received inquiries from immigrant women who question why this mandate impacts only them and their young daughters.

Moreover, the high cost of the HPV vaccine creates an unfair financial barrier for immigrant women. On average, the vaccine costs $120 per dose. The FDA approved regimen consists of three doses to be administered within six months, resulting in at least $360 in vaccine costs and several visits to the doctor or clinic. This is in addition to the cost of getting up to 13 other mandatory vaccinations, and application fees amounting to over $1,000. According to a recent survey of all designated civil surgeons in Maine that was conducted to determine the actual cost of receiving the series of Gardasil shots, the price of the series ranged from $600 to $1000.

Waiving the HPV vaccination requirement is also difficult and cost-prohibitive. While civil surgeons may apply a no-cost blanket waiver to the HPV vaccination under narrow circumstances, there is a mandatory waiver fee of $565 if an individual applicant is opposed to vaccinations in general based on her religious beliefs or moral convictions. We find the cost of the waiver unduly burdensome, and are also troubled that immigrants may resort to getting the vaccination in lieu of paying the even more expensive waiver fee. We are equally disturbed by the fact that some young immigrant women have decided to wait until they turn 27 years old to apply for adjustment of status so that they can age out of the vaccination requirement.

Finally, we have received accounts of the HPV vaccination being improperly administered. In one case, a pregnant woman received the vaccination even though the vaccine is not recommended for pregnant women by the CDC. While a pregnant U.S. citizen can decide whether or not to be vaccinated, a pregnant immigrant woman must be vaccinated without any opportunity to weigh the possible risks to herself and her pregnancy. Another case involved a woman who received the vaccine despite the fact that she was well over 26 years of age. These accounts reflect mistakes that could have been avoided if a more transparent and conscientious process was put in place during the implementation of the mandate.

Research that disaggregates data based on race and ethnicity show that cervical cancer has a disproportionate impact on certain immigrants, particularly Latinas and certain ethnic Asian groups including Vietnamese, Korean and Hmong women. However, the CDC’s and USCIS’s decision to mandate Gardasil for young immigrant women will not resolve these health disparities. For many immigrant women, the high expense of medical care, the lack of health insurance, and the difficulty in finding culturally competent services means that they forego routine preventive health care services such as pap smears. These inequalities in access contribute to the high rates of cervical cancer among immigrant women. While we support safe medical technologies that protect women’s health, mandating the use of medical procedures will not fully improve immigrant women’s lives.

We share your concern for the high rates of cervical cancer experienced by women of color and immigrant women, but we urge you to act quickly and retract your listing of HPV as a required vaccination in the revised Technical Instructions to Civil Surgeons for Vaccinations Requirements and to direct ACIP to modify their recommendation to state that the HPV vaccination should not be mandated for immigrants. We believe our focus should be on strengthening culturally-competent outreach efforts, increasing access to preventive health care services, such as Pap smears, for all groups of women facing a disproportionate risk of cancer. We also believe that all women should have the same right to informed decision-making over whether or not they want to be vaccinated against HPV.

Thank you for your consideration. We welcome the opportunity for further communication on this issue. Please contact Priscilla Huang at phuang@napawf.org, or (301) 270-4440, with questions or concerns.

Sincerely,

International Organizations

International Women’s Health Coalition

National Organizations

ACCESS/Women’s Health Rights Coalition

Advocates for Youth

American Immigration Lawyers Association

American Medical Student Association

American Social Health Association

Americans for Democratic Action

Asian American Justice Center

Asian & Pacific Islander American Health Forum

Black Alliance for Just Immigration

Black Women’s Health Imperative

Center for Human Rights and Constitutional Law

Center for Reproductive Rights

Center for Women Policy Studies

Choice USA

Church World Service, Immigration and Refugee Program

Community HIV/AIDS Mobilization Project (CHAMP)

Gynecological Cancer Foundation

Law Students for Reproductive Justice

Legal Momentum

Migrant Health Promotion

National Advocates for Pregnant Women

Native American Women’s Health Education Resource Center

National Asian American Pacific Islander Mental Health Association

National Asian Pacific American Families Against Substance Abuse

National Asian Pacific American Women’s Forum (NAPAWF)

National Coalition of STD Directors (NCSD)

National Council of Jewish Women

National Council of La Raza

National Health Law Program

National Immigration Law Center

National Institute for Reproductive Health

National Korean American Service & Education Consortium (NAKASEC)

National Latina Institute for Reproductive Health

National Network for Immigrant and Refugee Rights

National Network of Abortion Funds

Nonviolent Choice Directory

National Organization for Women

National Partnership for Women & Families

National Women’s Health Network

Nurse Practitioners in Women’s Health

OCA Embracing the Hopes and Aspirations of Asian Pacific Americans

Planned Parenthood Federation of America

Pro-Choice Public Education Project (PEP)

Project PAP (Prevention Awareness Program) National Group

Quirky Black Girls

Reproductive Health Technologies Project

SisterSong Women of Color Reproductive Health Collective

South Asian Americans Leading Together

Southeast Asia Resource Action Center (SEARAC)

The American College of Obstetricians and Gynecologists

The MergerWatch Project

The Praxis Project

United Methodist Church, General Board of Church and Society

Women of Color Resource Center

State/Local Organizations

Act for Women and Girls

African Services Committee

American Friends Service Committee, Philadelphia, Pa

Asian Law Caucus

Asian Pacific American Legal Center of Southern California

BARCA, Inc.

California Academy of Family Physicians

California National Organization for Women

Chicago Abortion Fund

Chicago Women’s Health Center

Coloradans For Immigrant Rights, a project of the American Friends Service Committee Colorado

Colorado Organization for Latina Opportunity & Reproductive Rights (COLOR)

Daya, Inc. (Texas)

Desis Rising Up and Moving (DRUM) (New York City)

Different Avenues

Entre Nosotras Foundation

Farmworker Legal Services of NY, Inc.

Feminist Women’s Health Center

Florida Coastal School of Law Immigrants Rights Clinic

HPV Awareness

Human Rights Initiative of North Texas, Inc.

Illinois Caucus for Adolescent Health (ICAH)

Immigrant Legal Advocacy Project

Immigration Services, Catholic Charities, Archdiocese of Atlanta

Indo-American Center (Illinois)

Jacksonville Area Legal Aid, Refugee Immigration Project

Justice Now

Just Neighbors

Kentucky Health Justice Network

Korean American Resource & Cultural Center (KRCC), Chicago, IL

Korean Resource Center (KRC), Los Angeles, CA

Law Office of Jacqueline Tapia

LUZ: A Reproductive Justice Think Tank

Miami International Latinas Organizing for Leadership and Advocacy (MI-LOLA)

Michigan Asian Indian Family Services (Michigan)

Mitch Factors Innovation in Health & Wellness

Mujeres Latinas en Accion

NARAL Pro-Choice Massachusetts

Narika

Nationalities Service Center

New Voices Pittsburgh: Women of Color for Reproductive Justice

New York City Latina Advocacy Network

Northwest Women’s Law Center

Our Bodies Ourselves

Pinay sa Seattle

Planned Parenthood Los Angeles

Planned Parenthood of New York City

Prax(us)

Refugee Forum of Orange County

Reproductive Justice Collective

Reproductive Justice Committee of the Unitarian Society of Ridgewood (NJ)

Robin H. Thompson & Associates

SisterLove, Inc.

Southwest Women’s Law

Tewa Women United

The Feminist Women’s Health Centers of California

The Institute of Women and Ethnic Studies

The New York Immigration Coalition

UCAN

Victims Resource Center

Women Who Care, Inc.

YWCA of the Sauk Valley

The Feminist Women’s Health Centers of California

The Institute of Women and Ethnic Studies

The New York Immigration Coalition

UCAN

Victims Resource Center

Women Who Care, Inc.

YWCA of the Sauk Valley

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