Friday, January 30, 2009

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

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, or (301) 270-4440, with questions or concerns.

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
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)
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 Partnership for Women & Families
National Women’s Health Network
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
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
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
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
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
Victims Resource Center
Women Who Care, Inc.
YWCA of the Sauk Valley

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