SEARCH

SEARCH BY CITATION

Keywords:

  • federal programs;
  • HPV;
  • immunization;
  • Vaccines for Children;
  • National Breast and Cervical Cancer Screening Program

Abstract

  1. Top of page
  2. Abstract
  3. THE NATIONAL BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAM (NBCCEDP)
  4. THE VACCINES FOR CHILDREN AND SECTION 317 IMMUNIZATION GRANT PROGRAMS
  5. ECONOMIC BENEFITS
  6. FUTURE DIRECTIONS
  7. CONCLUSION
  8. REFERENCES

Three federal programs with the potential to reduce cervical cancer incidence, morbidity, and mortality, especially among underserved populations, are administered by the Centers for Disease Control and Prevention (CDC): the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), the Vaccines for Children (VFC) Program, and the Section 317 immunization grant program. The NBCCEDP provides breast and cervical cancer screening and diagnostic services to uninsured and underinsured women. The VFC program and the Section 317 immunization grant program provide vaccines, including human papillomavirus (HPV) vaccine, to targeted populations at no cost for these vaccines. This article describes the programs, their histories, populations served, services offered, and roles in preventing cervical cancer through HPV vaccination and cervical cancer screening. Potential long-term reduction in healthcare costs resulting from HPV vaccination is also discussed. As an example of an initiative to vaccinate uninsured women aged 19-26 years through a cancer services program, a state-based effort that was recently launched in New York, is highlighted. Cancer 2008;113:(10 suppl):3004–12. Published 2008 by the American Cancer Society.

Persistent human papillomavirus (HPV) infections are necessary for development of cervical cancer precursor lesions.1 Prevention, through vaccination, of cervical cancer precursors that stem from persistent infection with HPV types 16 and 18 is expected to decrease needs for excisional or ablative treatments and risks for developing HPV16-associated and HPV18-associated cervical cancer.2 Among previously unexposed women, vaccination against HPV types 16 and 18 will prevent future infection, potentially decreasing 16% of all abnormal Papanicolaou (Pap) tests.3 It is projected that HPV vaccination will reduce the number of vaccinated women who will require colposcopy, biopsy and cervical treatment for precancerous cervical lesions.3 Among women who have already been exposed to HPV types 16 and 18 before vaccination, little or no impact is expected on either the number of abnormal Pap tests or the need for diagnostic or follow-up procedures.

Populations in the United States that would benefit most from HPV vaccination are those that suffer the greatest morbidity and mortality due to cervical cancer (ie, those of low socioeconomic status, recent immigrants, and members of racial and ethnic minorities).2, 4, 5 However, members of these US populations may not have continuous health benefits from private or public payers.6–8 Consequently, they may not have access to preventive services, including HPV vaccination and routine Pap test screening, which are recommended for timely prevention and detection of cervical cancer.2, 9 Three federal programs with the potential to reduce cervical cancer incidence, morbidity, and mortality are administered by the Centers for Disease Control and Prevention (CDC) as follows: the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), the Vaccines for Children Program (VFC), and the Section 317 immunization grant program (aka, the 317 Program). This article describes these programs, their histories, populations served, services offered, and each program's role in preventing cervical cancer through HPV vaccination and screening. Although other publicly funded programs (eg, Title X, Comprehensive Cancer Control Programs) and government agencies (eg, the Centers for Medicare & Medicaid Services, the Health Resources Service Administration) will continue to contribute to reducing the burden of cervical cancer, the current article emphasizes the 3 federal programs specified, so that programmatic features may be presented in detail. Potential cost savings that may result from HPV vaccination for the NBCCEDP and the US population are also discussed. As an example of an initiative to vaccinate uninsured women aged 19-26 years through a cancer services program, a state-based effort that was recently launched in New York is highlighted.

THE NATIONAL BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAM (NBCCEDP)

  1. Top of page
  2. Abstract
  3. THE NATIONAL BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAM (NBCCEDP)
  4. THE VACCINES FOR CHILDREN AND SECTION 317 IMMUNIZATION GRANT PROGRAMS
  5. ECONOMIC BENEFITS
  6. FUTURE DIRECTIONS
  7. CONCLUSION
  8. REFERENCES

The NBCCEDP was established in 1991, after being authorized by Congress in 1990, to provide free or low-cost screening and diagnostic services to low-income, uninsured, and underinsured women aged 40-64 years for breast cancer services and aged 18-64 years for cervical cancer services.10 A total of 68 grantees, representing all 50 states, the District of Columbia, 12 tribes and tribal organizations, and 5 territories, receive NBCCEDP funding. The funds are administered by CDC's Division of Cancer Prevention and Control through cooperative agreements with grantees.11 As a screening program, the provision of vaccines is beyond the NBCCEDP's scope.10

Programmatic efforts are focused on persons who are at greatest risk for cervical cancer because they have never or have rarely been screened or because they are older than age 40 years. The ways in which individual grantees provide clinical services and manage the administrative aspects of their programs vary widely. In some settings, small tribal programs operate out of 1 clinic with a small number of providers and office staff. In others, large, decentralized programs contract with thousands of individual providers in a variety of clinical settings. Some programs in isolated areas of Alaska and the Pacific Islands fly providers to villages to provide services. Budget awards to individual grantees range from <$100,000 to >$8 million annually.

From 1991 through mid-2006, the NBCCEDP served more than 3 million women, provided more than 7.2 million screening examinations, and diagnosed more than 31,000 breast cancers, 100,000 precursor cervical lesions, and nearly 2000 cervical cancers.11 Clients of the NBCCEDP have little or no health insurance, have income at or below 250% of the Federal Poverty Level, and often lack a primary care provider. Approximately 60% are members of minority racial and ethnic populations, and some women are geographically isolated from existing services.

Most NBCCEDP providers are primary care physicians, nurse practitioners, or obstetrician/gynecologists.12 They provide clinical services in private offices and public health settings such as health departments, Federally Qualified Health Centers (FQHCs), and Indian Health Service (IHS) facilities. Many participating providers report seeing patients younger than 13 years of age (7% of patients) and between the ages of 13-18 years (18%) in office visits independent of the NBCCEDP.12

The NBCCEDP has a strong framework of systems and policies to ensure the quality of clinical services. Individual programs are required to have a Medical Advisory Committee comprised of providers and experts in the community. Committee members develop clinical guidelines on the basis of recommendations from professional organizations such as the American Society for Colposcopy and Cervical Pathology and the American College of Radiology. “Minimum Data Elements” (MDEs) are collected and entered into a CDC database for every NBCCEDP patient encounter. These data are measured against quality benchmarks, at the grantee level as well as the national level. For example, programs are expected to follow women with abnormal Pap tests to ensure that a final diagnosis is reached for no fewer than 90% of these patients. At the program level, analysis of the MDEs allows grantees to identify providers or clinical sites with “best practices,” as well as those where standards are not met. Such analyses facilitate development and delivery of interventions.

The NBCCEDP funds professional educational activities through its grantees and their local and state partners. The goal of these educational activities is to improve the ability of healthcare providers to screen for and diagnose breast and cervical cancer so that women receive appropriate and high quality screening and diagnostic services. CDC also provides professional education training directly to its grantees—for example when national guidelines for screening or management of cervical cancer abnormalities are changed. Grantees then update their program staff and providers. More general clinical updates are provided to grantee program directors during their annual meetings. In addition, periodic professional educational teleconferences, face-to-face conferences, and Webcasts are provided.

Significant racial and ethnic disparities in cervical cancer screening have been observed in the United States,13 resulting in inequalities in health outcomes among certain groups.14–16 The NBCCEDP has been able to reach populations (eg, African Americans, Hispanics, and American Indians/Alaska Natives) whose rates of screening fall far below national averages. A variety of successful recruitment strategies has made inroads in educating women about the importance of screening, explaining the services available, removing barriers to screening, and motivating women to complete screening exams as part of their routine healthcare.17 The ultimate goal of these recruitment strategies is to identify and enroll program-eligible women who are members of priority populations, thereby reducing disparities in cervical cancer detection and mortality.

Because programs vary widely, each grantee assesses its own populations and their needs, and then develops feasible recruitment strategies. An example of a successful recruitment intervention to low-income and minority communities has been the use of faith-based initiatives, such as “Pink Ribbon Sunday” in which African-American churches identify a Sunday service to discuss and highlight health issues (particularly breast and cervical health). All women, not simply those who are program-eligible, benefit from efforts such as these.

THE VACCINES FOR CHILDREN AND SECTION 317 IMMUNIZATION GRANT PROGRAMS

  1. Top of page
  2. Abstract
  3. THE NATIONAL BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAM (NBCCEDP)
  4. THE VACCINES FOR CHILDREN AND SECTION 317 IMMUNIZATION GRANT PROGRAMS
  5. ECONOMIC BENEFITS
  6. FUTURE DIRECTIONS
  7. CONCLUSION
  8. REFERENCES

Through safe and effective vaccination, the mission of CDC's immunization program is to prevent disease, death, and disability among children, adolescents, and adults.18 The program targets diseases and conditions caused by 16 pathogens, including HPV.19, 20 CDC activities related to the immunization program are conducted principally in the National Center for Immunization and Respiratory Diseases (NCIRD) and the Immunization Safety Office, respectively.

To achieve its mission, CDC partners with 64 federal immunization grantees, which include the 50 states, 6 cities, and 8 US territories and affiliated jurisdictions. In collaboration with the grantees, CDC administers immunization programs with 2 distinct sources of funding as follows: VFC Program funds and Section 317 funds.18 By using allocated VFC program, 317 program, and grantee funds (if appropriated in a given state or locality), CDC and grantee officials manage not only public purchase of vaccines through negotiated federal contracts, but also distribution of the purchased vaccines to public and private providers in grantee public health jurisdictions nationwide. Together, CDC and grantee officials manage more than half of the national pediatric vaccine supply, which represents approximately $3 billion in annual vaccine purchases through federal contract agreements and use of VFC program, 317 program, and grantee funds, respectively.21

Grantees' capacities to use negotiated federal contracts allow procurement of vaccines at reduced prices. Historically, federal contract discounts from manufacturers' catalog prices averaged approximately 50%. However, for HPV vaccine and other more recently recommended vaccines, federal contract discounts have been reduced and have been observed to be approximately 20% less than catalog prices.22 Savings to grantees who use federal contracts for vaccine purchases with VFC program, 317 program, and grantee funds allow grantees to use public funds to buy more vaccine doses for the populations served than would otherwise be possible.

A federal entitlement program launched in 1994, VFC was designed to foster vaccination by primary care providers.23 Private and public providers who participate in the VFC program in over 47,000 sites18 vaccinate eligible children with federally purchased VFC vaccines as approved through resolutions by CDC's Advisory Committee on Immunization Practices (ACIP).23, 24 Children aged 18 years and younger who are Medicaid eligible, uninsured, and/or American Indian or Alaska Native (as defined by the Indian Health Care Improvement Act) are eligible to receive vaccine from providers through the VFC program.25 Children in this age group who are categorized as “underinsured” (because their health plans do not include coverage for recommended vaccinations) may receive VFC vaccines if they are served by a rural health clinic (RHC) or Federally Qualified Health Center (FQHC).23, 25

The VFC program helps families of children who may not otherwise have access to vaccines by providing vaccines at no purchase cost to physicians who serve them. Grantees participating in the VFC program enroll providers who administer vaccines to eligible patients. In 2006, there were 47,435 VFC-enrolled providers (Table 1). Although the majority of these providers practice in the private sector, almost all public health department clinics, RHCs, and FQHCs (which include Community Health Centers, and Migrant Health Centers) are enrolled in the program. Starting in 2007, grantees have been encouraged to expand their VFC provider networks to include clinicians caring for adolescents in complementary vaccination settings (eg, school-based health centers, juvenile detention centers, obstetrician/gynecologists' offices, family planning clinics). It is expected that expanding the provider network will promote more rapid uptake not only of the HPV vaccine but also of other vaccines that have been recently recommended for adolescents.26–29

Table 1. Vaccines for Children (VFC) Enrolled Providers by Type, 2006*
Provider TypeNo. Enrolled
  • Public Health Department clinic is defined as a state, district, county or city public health clinic where immunizations are administered; Indian Health Service (IHS), primary care clinics for American Indians and Alaska Natives, including outpatient clinics in IHS hospitals. HIS/Tribal health clinics may have multiple sites; Federally qualified health center, primary care clinics partially funded by the Bureau of Primary Health Care (BPHC); Other public, any other public clinic that provides immunization, such as a publicly funded nonprofit.

  • *

    Adapted from: 2006 VFC Management Survey [database on the Internet]. Atlanta: Centers for Disease Control and Prevention; 2006 (updated 2007 October 30). Accessed February 20, 2008. Available from: http://www2a.cdc.gov/nip/irar/grantee/vfcprovider06.asp

Public Health Department clinic4633
Indian Health Service (IHS)265
Federally qualified health center5229
Other public2997
Private34,311
Total47,435

Although the VFC and 317 programs differ in several important aspects, they are similar in that they provide vaccines at no cost to targeted populations. The 317 program was created in 1962 by the Vaccination Assistance Act24 and initially allowed use of discretionary funds for vaccine purchase and programmatic activities (eg, outbreak control, disease surveillance, program administration, planning, and evaluation). Additional 317 program funding was allocated 30 years later in the aftermath of a measles epidemic, and, for the first time, resources were directed to support infrastructure and direct service delivery.30 In contrast to the VFC program, which operates in varied settings including private offices, most vaccines purchased with 317 program funds are delivered through public health departments. The 317 program also differs from the VFC program in that grantees have discretion to use 317 vaccine funds for any population. Specifically, there are no federal eligibility requirements that recipients must meet to receive vaccine purchased with 317 funds as there are for recipients of vaccines purchased with VFC funds. Also, in contrast to those of the VFC entitlement program, 317 program funding levels are determined through annual federal appropriation and historically have not increased with the introduction of new vaccinations or expanded recommendations. In addition, grantees have broad decision-making capacity to determine what diseases should be prioritized for prevention and control and which age groups and/or high-risk groups should receive vaccinations through the 317 program's limited funding. The selected populations receiving vaccinations have historically included the underinsured, with children being prioritized. As funding has allowed, adolescents and adults have been served through the 317 program, but these populations have received far fewer vaccinations through the program than have children.18

Adolescents and adults who are not eligible to receive publicly purchased vaccines and who do not have access to public or private insurance covering all costs associated with vaccination face the greatest financial barriers to being immunized consistent with national recommendations. In 2006, ACIP recommended routine vaccination with 3 doses of quadrivalent HPV vaccine for girls aged 11-12 years. In addition, catch-up HPV vaccination is recommended for females aged 13-26 years who have not been vaccinated previously or who have not completed the full vaccine series.9 Females aged 19-26 years for whom HPV vaccination is recommended are not eligible for the VFC program and, depending on the public health priorities and resources of grantees, may not be eligible for vaccine publicly purchased with 317 program funds. If not otherwise publicly or privately insured, young women in this age group are confronted with not only paying the full private sector purchase cost (now exceeding$375) for the vaccine series31 but also with paying other costs (eg, office visit fees, administration fees, and transportation costs), which can approach or surpass the expense of the vaccine series alone. Thus, the comparatively high price of a complete series of HPV vaccine, along with other costs, may pose considerable financial barriers and may impede achievement of high HPV vaccination coverage among all persons for whom the vaccine is recommended.

Principally because of the achievement and maintenance of high childhood vaccination coverage rates in the United States, the US incidence of most vaccine-preventable diseases is now at an all-time low.32 However, although childhood vaccination coverage levels are at or near record highs, data from the 2006 National Immunization Survey indicate that there are statistically significant differences in immunization rates between black and white children nationwide.33 Analyses suggest that these observed findings are attributable to disparities in coverage by poverty level as well as to differences in income distributions among black and white populations.33 Although the VFC program and the 317 program are recognized as having contributed to the achievement of high national vaccine coverage levels among children,24, 33, 34 barriers to vaccination remain. The 2008 National Immunization Survey will include a module of questions that will be used to gain understanding of barriers to vaccination affecting socioeconomically disadvantaged groups as well as racial/ethnic populations.33

In addition to activities such as procurement and distribution of recommended vaccines, CDC, federal grantees, and other partners provide important information, technical assistance, and resources to promote achievement of high vaccination coverage rates. Resources for provider training related to immunization are extensive; they include a comprehensive resource that addresses the important topic of vaccine storage and handling. Patient education materials have been developed, and states or regions may request a 2-day onsite course related to vaccine-preventable diseases. Continuing education credits are available for many of the education and training materials (all materials are available at www.cdc.gov/vaccines/ed/default.htm). VFC providers also benefit from guidance and information shared during site visits that are conducted as part of the VFC program.

ECONOMIC BENEFITS

  1. Top of page
  2. Abstract
  3. THE NATIONAL BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAM (NBCCEDP)
  4. THE VACCINES FOR CHILDREN AND SECTION 317 IMMUNIZATION GRANT PROGRAMS
  5. ECONOMIC BENEFITS
  6. FUTURE DIRECTIONS
  7. CONCLUSION
  8. REFERENCES

Because long-term cost reductions in diagnosing and treating cervical cancer and precancer are expected to result from increased expenditures by the VFC and 317 programs, the public health integration of immunization and screening efforts, as described by Castle et al in this Supplement,35 should yield economic benefits.36, 37 Provision of prophylactic HPV vaccine, in conjunction with continued emphasis on cervical cancer screening among vaccinated and unvaccinated women, is expected to reduce the prevalence of precursor lesions and cervical cancer and to be cost effective.36–39 In addition, HPV vaccination could reduce the psychosocial burden and healthcare costs associated with abnormal Pap test results while also decreasing the number of women who require follow-up care like colposcopy, biopsy, and other treatment for precancerous cervical lesions.40, 41 Sanders et al.42 estimated a 21% reduction in the incidence of low-grade Pap test abnormalities over the lifetime of a vaccinated cohort of females aged 12 years. Nationally, between $2.3 billion to $6 billion are spent each year on direct medical costs for the evaluation and management of abnormal Pap test results and other low-grade lesions,43–45 the majority of which would regress without intervention. Estimated US unit costs of cervical cancer screening and follow-up testing are summarized in Table 2.

Table 2. Estimated Unit Costs for Cervical Cancer Screening and Follow-up Testing Employed in 4 Economic Studies, United States, 1999–2008*
ParameterAverageMinimumMaximumReferences
  • *

    These unit costs are expressed in 2004 dollars and are inflated by using the Medical Care component of the Consumer Price Index for All Urban Consumers.56

  • Pap test costs were calculated by averaging data in 3 studies.52, 53, 55

  • Colposcopy costs were calculated by averaging data in 3 studies.53–55

Pap test$61.11$35.00$90.0052-54
Abnormal pap test$84.00$42.00$120.0054, 55
Colposcopy without biopsy$164.95$100.20$348.0054, 55
Colposcopy with biopsy$275.06$104.00$416.0055

The majority of abnormal Pap test results in the NBCCEDP occur in young women between the ages of 18 to 29 years,46–48 despite the finding that the women served by the program are predominantly aged 40 to 64 years. These results are explained, at least in part, by the finding that cervical changes are often seen among females who have recently initiated sexual activity and have become infected with HPV.49 The NBCCEDP findings among women aged <30 years are consistent with the higher HPV prevalence rates observed among young women nationally.50

Costs associated with the management of abnormal cytology are high. In 2005, approximately 2925 colposcopies, at an average cost of $164, were performed in the NBCCEDP for women between the ages of 18 and 29 years, at a total cost of $479,700. In the face of these expenditures, we believe that facilitating the appropriate vaccination of girls and young women who may become NBCCEDP-eligible in the future is a sound economic decision. By doing so, the program could realize savings in the form of reduced numbers of Pap test abnormalities, colposcopies, as well as decreased indications for other costly medical procedures. The program would not anticipate any impact on cervical cancer screening services required by women who have not received the HPV vaccine series.

FUTURE DIRECTIONS

  1. Top of page
  2. Abstract
  3. THE NATIONAL BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAM (NBCCEDP)
  4. THE VACCINES FOR CHILDREN AND SECTION 317 IMMUNIZATION GRANT PROGRAMS
  5. ECONOMIC BENEFITS
  6. FUTURE DIRECTIONS
  7. CONCLUSION
  8. REFERENCES

Because currently available vaccines do not provide protection against all oncogenic HPV types, vaccinated women will still require screening to achieve maximal reduction in cervical cancer incidence.2 Vaccination and cervical cancer screening must be considered inseparable,40, 51 and the 3 programs described in the current article will be integral to US efforts to reach the uninsured and underserved populations. In addition, unvaccinated women will continue to need screening services.

The idea of strengthening ties between immunization delivery and screening service delivery is an appealing public health approach. Although a comprehensive discussion is beyond the scope of this article, 1 state-based effort that was recently launched in New York provides a useful example of an initiative to vaccinate uninsured women aged 19 to 26 years through a cancer services program. This effort is notable because of the integrated capacity for vaccination and cervical cancer screening delivery and because it benefits a population of females recommended by ACIP to receive HPV vaccination but who are not covered by the VFC program.

The New York State Department of Health delivers its breast and cervical cancer screening services for uninsured and underinsured women through a decentralized system called the Cancer Services Program (CSP). The services of this program are provided with both state funds and federal NBCCEDP dollars. On September 15, 2007, the CSP expanded its services and began reimbursing CSP providers for vaccinating women aged 19 to 26 years against HPV, using solely state funds. The initiative to seek appropriations and reimburse CSP providers arose because providers in New York began administering HPV vaccine shortly after its approval by the US Food and Drug Administration in June 2006 and because Medicaid and private insurers also moved quickly to cover the vaccine. New York sought to cover those women without health insurance who were already receiving breast and cervical cancer screening services through the CSP. The program's first year goal was to support delivery of 36,000 doses of vaccine to 12,000 women aged 19 to 26 years. During the initiative's first year, CSP-provider reimbursement costs for HPV vaccine purchase and administration were anticipated to be approximately $5 million. Many CSP providers also participate in the VFC program and provide HPV vaccine purchased with VFC program funds to their eligible female patients aged 9 to 18 years.

CONCLUSION

  1. Top of page
  2. Abstract
  3. THE NATIONAL BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAM (NBCCEDP)
  4. THE VACCINES FOR CHILDREN AND SECTION 317 IMMUNIZATION GRANT PROGRAMS
  5. ECONOMIC BENEFITS
  6. FUTURE DIRECTIONS
  7. CONCLUSION
  8. REFERENCES

The 3 federal programs discussed here share many common attributes that will be important to achieving needed reductions in cervical cancer incidence, morbidity, and mortality in the United States. All of these programs strive to remove cost as a barrier to care and to provide services to populations most in need and at risk of infection and disease. They are built upon established infrastructures that support public and professional educational efforts. In addition, the NBCCEDP and VFC programs are mature programs that have comprehensive systems in place to ensure the quality of their services.

Differences among the programs do exist. Most notably, the respective ages of eligibility for the NBCCEDP and the VFC program make their client populations almost exclusive of one another. Simultaneous eligibility for both programs occurs only for females aged 18 years (Fig. 1).

thumbnail image

Figure 1. These are age-eligibility requirements for NBCCEDP, VFC and the 2006 ACIP HPV Vaccine Recommendations. CDC indicates Centers for Disease Control and Prevention; ACIP, Advisory Committee on Immunization Practices; VFC, Vaccines for Children program; HPV, human papillomavirus; NBCCEDP, National Breast and Cervical Cancer Early Detection Program.

Download figure to PowerPoint

The overviews of the NBCCEDP, VFC program, and the 317 program provided here are intended not only to complement this Supplement's related articles but also to facilitate dialogue and, conceivably, collaboration among readers and their colleagues. Some readers may be familiar with 1 federal program's role in a community but may have been previously unaware of the existing or potential role of 1 or more of the other federal programs described. Through complementary activities, these 3 federal programs offer prevention and screening services at no cost to females who belong to the US populations most vulnerable to developing and dying from cervical cancer. Greater awareness of programs and services available to the underserved in communities across the United States may be 1 of the most important steps in the fight for diminishing health disparities and reducing the burden of cervical cancer.

REFERENCES

  1. Top of page
  2. Abstract
  3. THE NATIONAL BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAM (NBCCEDP)
  4. THE VACCINES FOR CHILDREN AND SECTION 317 IMMUNIZATION GRANT PROGRAMS
  5. ECONOMIC BENEFITS
  6. FUTURE DIRECTIONS
  7. CONCLUSION
  8. REFERENCES
  • 1
    Munoz N,Bosch FX,De Sanjose S, et al. Epidemiologic classification of human papillomavirus types associated with cervical cancer. N Engl J Med. 2003; 348: 518527.
  • 2
    Wheeler CM. Advances in primary and secondary interventions for cervical cancer: human papillomavirus prophylactic vaccines and testing. Nat Clin Pract Oncol. 2007; 4: 224235.
  • 3
    Huh WK, and the Quadrivalent HPV Vaccine Phase IIb/IIIb Investigator. Impact of quadrivalent human papillomavirus (HPV) types 6/11/16/18 L1 virus-like particle vaccine on the incidence of abnormal pap tests and cervical procedures [abstract]. Gynecol Oncol. 2008; 108( suppl 1): s11. Abstract presented at Annual Meeting of Society of Gynecology Oncologists, March 9, 2008, Tampa, Florida.
  • 4
    Singh GK,Miller BA,Hankey BF,Edwards BK. Persistent area socioeconomic disparities in U.S. incidence of cervical cancer, mortality, stage, and survival, 1975-2000. Cancer. 2004; 101: 1051107.
  • 5
    U.S. Cancer Statistics Working Group. United States Cancer Statistics: 2002 Incidence and Mortality. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2005.
  • 6
    Adams SH,Newacheck PW,Park JM,Brindis CD,Irwin CE. Health insurance across vulnerable ages: Patterns and disparities from adolescence to the early 30s. Pediatrics. 2007; 119: e1033e1039.
  • 7
    Cohen RA,Martinez ME. Health insurance coverage: early release of estimates from the National Health Interview Survey. Clin Exp Obstet Gyn. 2006;(document posted 2007 June 25, website updated 2007 July 9, cited 2007 July 12). Available at: http://www.cdc.gov/nchs/nhis.htm Accessed July 12, 2007.
  • 8
    Dubard CA,Massing MW. Trends in emergency Medicaid expenditures for recent and undocumented immigrants. JAMA. 2007; 297: 10851092.
  • 9
    Markowitz LE,Dunne EF,Saraiya M,Lawson HW,Chesson H,Unger ER. Quadrivalent human papillomavirus vaccine: recommendations of the advisory committee on immunization practices (ACIP). MMWR. 2007; 56(RR-2): 124.
  • 10
    Public Law 101-354. Title 42. The Public Health and Welfare. Chapter 6a, The Public Health Service. Preventive Health Measures with Respect to Breast and Cervical Cancers 42. U.S.C. § 300k, US Congress 1990.
  • 11
    Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program. Page last updated: February 25, 2008. Available at: http://www.cdc.gov/cancer/nbccedp/about.htm Accessed on July 29, 2008.
  • 12
    Saraiya M,Irwin KL,Carlin L, et al. Cervical cancer screening and management practices among providers in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Cancer. 2007; 110: 10241032.
  • 13
    Swan J,Breen N,Coates R,Rimer B,Lee N. Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey. Cancer. 2003; 97: 15281540.
  • 14
    Benard V,Coughlin SS,Thompson T,Richardson LC. Cervical cancer incidence in the United States by area of residence, 1998-2001. Obstet Gynecol. 2007; 110: 681686.
  • 15
    McDougall J,Madeleine MM,Daling JR,Li C. Racial and ethnic disparities in cervical cancer incidence rates in the United States, 1992-2003. Cancer Causes Control. 2007; 18: 11751186.
  • 16
    Saraiya M,Ahmed F,King J, et al. Cervical cancer incidence in a pre-vaccine era—United States, 1998-2002. Obstet Gynecol. 2007; 109: 360370.
  • 17
    Centers for Disease Control and Prevention. Recruitment. The National Breast and Cervical Cancer Early Detection Program Manual. Atlanta, Georgia: US Department of Health and Human Services; 2007.
  • 18
    Centers for Disease Control and Prevention. Report to Congress on 317 Immunization Program. Atlanta, Georgia: US Department of Health and Human Services; 2007.
  • 19
    Centers for Disease Control and Prevention. Recommended immunization schedules for persons aged 0-18 years—United States, 2008. MMWR. 2008; 57: Q1Q4.
  • 20
    Centers for Disease Control and Prevention. Recommended adult immunization schedule—United States, October 2007-September 2008. MMWR. 2007; 56: Q1Q4.
  • 21
    Centers for Disease Control and Prevention. Vaccine Management Business Improvement Project; (document dated 2007 February, website updated 2007 April 9, cited 2007 October 4). Available at: http://www.cdc.gov/vaccines/about/pibs/downloads/vmbip.pdf Accessed October 4, 2007.
  • 22
    Orenstein WA,Mootrey GT,Pazol K,Hinman AR. Financing immunization of adults in the United States. Clin Pharmacol Ther. 2007; 82: 764768.
  • 23
    Santoli J,Rodewald L,Maes E,Battaglia M,Coronado V. Vaccines for Children Program, United States, 1997. Pediatrics. 1999; 104: e15.
  • 24
    Orenstein WA. The role of measles elimination in development of a national immunization program. Pediatr Infect Dis J. 2006; 25: 10931101.
  • 25
    Centers for Disease Control and Prevention. Which children are eligible for the VFC Program? 2008. Available at: http://www.cdc.gov/vaccines/programs/elig-scrn-rec.doc-req.htm Accessed on July 29, 2008.
  • 26
    Centers for Disease Control and Prevention. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2005; 54(RR-7): 121.
  • 27
    Centers for Disease Control and Prevention. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2006; 55(RR-3): 143.
  • 28
    Centers for Disease Control and Prevention. Adolescent immunization. In: 2008-2012 Immunization Program Operations Manual (document posted 2007 April 10, website updated 2007 October 2, cited 2008 February 1). Available at: http://www.cdc.gov/vaccines/vac-gen/policies/ipom/downloads/chp-06-adolescent-iz.pdf
  • 29
    Centers for Disease Control and Prevention. Notice to Readers: revised recommendations of the Advisory Committee on Immunization Practices to vaccinate all persons aged 11-18 years with meningococcal conjugate vaccine. MMWR. 2007; 56: 794795.
  • 30
    Orenstein WA. Testimony on the immunization grant program of the PHS Act, 1997. Available at: http://www.hhs.gov/asl/testify/t970506a.html. Accessed archive page April 25, 2008.
  • 31
    Centers for Disease Control and Prevention. CDC vaccine price list; 2008. Available at: http://www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm (updated 2008 February 5). Accessed February 20, 2008.
  • 32
    Roush SW,Murphy TV, and the Vaccine-Preventable Disease Table Working Group. Historical comparisons of morbidity and mortality for vaccine-preventable diseases in the United States. JAMA. 2007; 298: 21552163.
  • 33
    Wooten KG,Darling N,Singleton JA,Shefer A. National, state, and local area vaccination coverage among children aged 19-35 months—United States, 2006. MMWR. 2007; 56: 880885.
  • 34
    Rein DB,Honeycutt AA,Rojas-Smith L,Hersey JC. Impact of the CDC's Section 317 Immunization Grants Program Funding on childhood vaccination coverage. Am J Public Health. 2006; 96: 15481553.
  • 35
    Castle PE,Solomon D,Saslow D,Schiffman M. Commentary. Predicting the effect of successful HPV vaccination on existing US cervical cancer prevention programs. Cancer. 2008; 113(10 suppl): 30313035.
  • 36
    Dasbach EJ,Elbasha EH,Insinga RP. Mathematical models for predicting the epidemiologic and economic impact of vaccination against human papillomavirus infection and disease. Epidemiol Rev. 2006; 28: 88100.
  • 37
    Goldie SJ,Kohli M,Grima D, et al. Projected clinical benefits and cost-effectiveness of a human papillomavirus 16/18 vaccine. J Natl Cancer Inst. 2004; 96: 604615.
  • 38
    Kulasingam SL,Myers ER. Potential health and economic impact of adding a human papillomavirus vaccine to screening programs. JAMA. 2003; 290: 781789.
  • 39
    Taira AV,Neukerman CP,Sanders GD. Evaluating human papillomavirus vaccination programs. Emerg Infect Dis. 2007; 10: 19151923.
  • 40
    Schiffman M. Integration of human papillomavirus vaccination, cytology, and human papillomavirus testing. Cancer. 2007; 111: 145153.
  • 41
    Steinbrook R. The potential of human papillomavirus vaccines. N Engl J Med. 2006; 354: 11091112.
  • 42
    Sanders GD. Cost effectiveness of a potential vaccine forhuman papillomavirus. Emerg Infect Dis. 2003; 9: 3748.
  • 43
    Follen M,Richards-Kortum R. Emerging technologies and cervical cancer. J Natl Cancer Inst. 2000; 92: 363365.
  • 44
    Insinga RP,Dasbach EJ,Elbasha EH. Assessing the annual economic burden of preventing and treating anogenital human papillomavirus-related disease in the US: analytic framework and review of the literature. Pharmacoeconomics. 2005; 23: 11071122.
  • 45
    Schiller JT. Delivering on the promise: HPV vaccines and cervical cancer. Nat Rev Microbiol. 2004; 2: 343347.
  • 46
    Benard VB,Eheman CR,Lawson HW, et al. Cervical screening in the National Breast and Cervical Cancer Early Detection Program, 1995-2001. Obstet Gynecol. 2004; 103: 564571.
  • 47
    Benard VB,Lawson HW,Eheman CR,Anderson C,Helsel W. Adherence to guidelines for follow-up of low-grade cytologic abnormalities among medically underserved women. Obstet Gynecol. 2005; 105: 1323138.
  • 48
    Centers for Disease Control and Prevention (CDC). The National Breast and Cervical Cancer Early Detection Program: 1991-2002 National Report. Atlanta, Georgia: Department of Health and Human Services; 2005.
  • 49
    Winer RL,Lee S-K,Hughes JP,Adam DE,Kiviat NB,Koutsky LA. Genital human papillomavirus infection: Incidence and risk factors in a cohort of female university students. Am J Epidemiol. 2003; 157: 218226.
  • 50
    Dunne EF,Unger ER,Sternberg M, et al. Prevalence of HPV infection among females in the United States. JAMA. 2007; 297: 813819.
  • 51
    Newall AT,Beutels P,Wood JG,Edmunds WJ,MacIntyre CR. Cost-effectiveness analyses of human papillomavirus vaccination. Lancet Infect Dis. 2007; 7: 289296.
  • 52
    Ekwueme DU,Gardner JG,Subramanian S,Tangka FK,Bapat B,Richardson LC. Cost analysis of the National Breast and Cervical Cancer Early Detection Program—selected states. Cancer. 2008; 112: 626635.
  • 53
    Helms LJ,Melnikow J. Determining costs of health care services for cost-effectiveness analyses: the case of cervical cancer prevention and treatment. Med Care. 1999; 37: 652661.
  • 54
    Myers ER,Mccrory DC,Subramanian S,Mccal N,Nanda K, et al. Setting the target for a better cervical screening test: characteristics of a cost-effective test for cervical neoplasia screening. Obstet Gynecol. 2000; 96: 645652.
  • 55
    Kulasingam SL,Kim JJ,Lawrence WF, et al. Cost effectiveness analysis based on the Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesion Triage Study (ALTS). J Natl Cancer Inst. 2006; 98: 92100.
  • 56
    US Bureau of Labor and Statistics. Consumer price indexes: Bureau of Labor and Statistics, 2003. Washington, DC: US Bureau of Labor and Statistics; 2003. Available at: http://www.bls.gov/cpi/ Accessed August 27, 2007.