Friday, December 8, 2006
First in the nation: New Hampshire, HPV, and public health
BY NANCY BERLINGER

I gave a talk at a hospital in New Hampshire in mid-November. Residents of The Granite State are aware that getting in and out of northern New England can be a challenge, at the very least, especially when the weather turns cold. And so they graciously volunteer to drop off visitors at the airport, which turns out to be 75 miles away. You can learn a lot about the public health challenges in a rural state during a 75-mile drive when your driver is a senior faculty member with decades of knowledge about maternal and child health needs.

One thing I learned: New Hampshire is growing and diversifying through immigration. Community health workers in the rapidly urbanizing southern part of the state now offer services in eight or nine languages. (After my flight was cancelled, the hotel worker who drove me back to the airport at dawn was a young woman from Brazil.)

The news that New Hampshire will be the first state to make Gardasil available free of charge to all girls ages 11-18 reminded me of what I'd learned during my recent visit. The challenges of using Gardasil to prevent cancers caused by HPV, the most commonly sexually transmitted disease, are significant. The vaccine must reach adolescents and young adults, who may not be served by pediatricians responsible for the more familiar childhood immunizations. Immunization strategies must also account for women older than 18 who are at risk for HPV infection but who are not covered by the CDC's Vaccines for Children contract, which allows providers to purchase vaccines at government-negotiated discounts. (Gardasil was added to the contract in early November.)

These strategies must also account for immigrant women. Women in the developing world, who lack access to routine Pap smears, are at far greater risk of cervical cancer than are women in the U.S. Among women who participated in the National Health Interview Survey (NHIS) in 2000, "only 61% of recent immigrants reported having a Pap smear in the past 3 years as compared to 83% of women born in the United States." Even after emigrating, women may not catch up in terms of access to cancer screening and early detection. CDC researchers noted in a 2003 study that even as cervical cancer deaths among U.S.-born women had decreased during a recent ten-year period, they had increased among women who had emigrated to the U.S. As New Hampshire becomes more populous and diverse through immigration, and as its health care providers adapt to serve new immigrant communities, this state could also redress the scourge of cervical cancer globally by taking the lead in making a cancer-preventing vaccine available to the young immigrants who, like my Brazilian driver, are up at dawn, transforming its work force.

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