Dr.Ayoubreport

What is wrong with the HPV vaccine mandate in Illinois?

Prairie Collaborative for Immunization Safety, An Illinois not-for-profit organization

David Ayoub, MD, Director and Founder

Karen McDonough, Director

Teresa Conrick, Director

Christina Blakey, Director

Springfield, Illinois

(217) 691-3298

raypoke@mac.com

Summary:

1) It will not be known whether this vaccine prevents cervical cancer for another 15-20 years of further long-term follow-up. Until then, access to Pap smears will prevent nearly all cases of invasive cancer. It is far too premature for an HPV vaccine mandate.

2) The chairman of the CDC’s Advisory Committee of Immunization Practices Dr. Jon Abramson recently stated; “It shouldn’t be mandated”. The CDC’s suggested age target is 11-12 year-old. Why are Illinois legislators pushing mandate legislation against the CDC’s recommendation and why does the recent amendment of HB115 target 10 year-olds?

3) Targeting 11-12 year-old girls is unwise since only a few hundred girls this age have been studied. Merck executive director Richard Haupt stated: “In the 9 to 15 year-old age group, we could not do an efficacy study”.

4) There have already been reports of several instances of vaccine failures including HPV infections, genital warts and even invasive cervical cancer following vaccination.

5) The HPV vaccine suffers a significant adverse reaction rate (90%) as reported in published trials and also in VAERS. There are no long-term safety studies yet over 900 reports (as of February 28, 2007) of adverse reactions have already been reported to the FDA including life-threatening reactions.

6) Merck has funded most HPV vaccine clinical trials. Over 40% of study co-authors are Merck employees and 81% had received money from Merck. At least 2 members of the FDA committee that approved Gardasil were former Merck employees. This is a similar pattern of bias seen in past Vioxx research.

7) Since influenza kills ten-times as many individuals as cervical cancer yet flu vaccination is not mandated, HPV mandates can’t be just about “saving more lives”. The HPV mandate appears to be a triumph of Merck’s marketing, not science.

Updated March 14, 2007

Thank you for considering a bill that will potentially reduce a dangerous cancer in women. Based upon our review of the safety and effectiveness of the HPV vaccine, we cannot support this legislation and that the available data suggests that use of the HPV vaccine in Illinois should be highly restricted to IRB-approved, closely supervised clinical trials.

A review of the facts about cervical cancer raises doubts about the role of preventative immunization. There are only about 3,700 annual cervical cancer deaths in the United States, less than 1% of all total cancer deaths and the 14^th leading cause of cancer deaths in women. Furthermore, there have already been sharp declines in the incidence of cervical cancer. Hospitalization rates have dropped 36% since 1994.[1] According to the National Cancer Institute, mortality rates have declined 75% since the Pap test was widely implemented over 50 years ago and recent studies indicate mortality rates are still declining.[2]^,[3] Nearly all cervical cancer deaths are preventable by a simple Pap test and appropriate follow-up. In Illinois there are only about 200 annual cervical cancer deaths but nearly 20% of women in our state do not receive recommended Pap screening.[4]^,[5]Therefore, simply improving access to Pap tests can further reduce cervical cancer in Illinois. The HPV immunization series would cost at least $360 but doctors may charge up to three-times that to patients. A Pap test costs about $50. The annual cost of Pap smears, about $1.6 billion in the U.S., is about three-times lower than the projected sales for Gardasil. Other risk factors for cervical cancer such as tobacco and birth control pill use and sexual promiscuity represent modifiable risks. Therefore, risk education and promoting abstinence, monogamy or condom use can further reduce HPV transmission.

The rationale to prevent cervical cancer is based upon its association with Human Papillomavirus (HPV) infection. Although most women will at some time become infected with HPV the overwhelming majority will not progress to invasive cancer. It is easy to question the rationale of mandatory vaccination of 80,000-90,000 11 year-old Illinois school girls (at a cost of at least $28 million) against a sexually transmitted disease that affects adult women.

Effectiveness of the HPV vaccine unproven. The Gardasil product insert states that the goal of vaccination is to prevent the development of pathological changes in the cervix that are known precursors to invasive carcinoma; however, the length of time required to develop invasive cancer after identification of precursor lesions averages between 8.1 to 12.6 years and may require up to 40 years.[6] Since published vaccine trials have assessed long-term outcomes no longer than two years post-vaccination, the claim of cervical cancer prevention is highly optimistic. By the time a vaccinated child turns 18 years-old they will be well beyond Merck’s testing period for known protection and still two-three decades younger than when cervical cancer typically develops.

Not all cervical cancers are related to HPV. Since the vaccine currently targets only four HPV viruses that are known to cause about 70% of all cervical cancers, prevention of all cases of HPV-related cancer is highly unlikely. There are 30 known high-risk HPV strains but the vaccine targets only two. Only 3.4% of women are infected with any one of the of HPV strains in Gardasil, even fewer when considering only the high-risk HPV strains.[7]

This novel type of vaccine even possesses the potential to increase cervical cancer. If HPV virus types compete to colonize the cervix, then the prevalence of competing strains not targeted by the vaccine could increase. If these virus types are more aggressive, cervical cancer could still develop or worse develop into a more lethal form. NIH researcher Dr. Joseph DeSoto stated similar concerns: “These are incomplete vaccines which will not do what they are supposed to do and that’s prevent cervical cancer.”[8]

Even though Merck claims that Gardasil is virtually 100% successful in preventing HPV infection, a recent report filed in the Vaccine Adverse Event Reporting System (VAERS) described the development of cervical infection with a “high-risk” HPV vaccine strain only three years after Gardasil immunization and seroconversion.[9] So far VAERS has reported 12 vaccination failures, including three reports of genital warts, six cases of abnormal Pap smears and three HPV infections. Merck executive director of medical affairs, Richard Haupt has recently admitted, “In the 9 to 15 year-old age group, we could not do an efficacy study.”[10]

Major concerns about Gardasil vaccine safety. Because vaccine effectiveness is not established and methods do exist to prevent cervical cancer, tolerance for vaccination risk should be very low. The vaccine package insert assures that Merck’s HPV vaccine failed to detect adverse outcomes, including reproductive harm, in experimental animal studies. Unfortunately, HPV is only pathogenic to humans and the applicability of animal studies is problematic. The National Vaccine Information Center (NVIC) is a consumer vaccine safety organization tracking adverse vaccine events reported to the FDA’s Vaccine Adverse Event Reporting System (VAERS). These reports may represent as few as 1% of the true incidence of reactions due to the passive nature of the reporting requirements. NVIC’s recent analysis of VAERS reports revealed an alarming and increasing number of complications since the FDA approved Gardasil for use on June 8^th, 2006.[11] There was a disproportionately large percentage of reports involving women ≤ 16-years old (38%), an age group that represented only about 5% of all vaccine trial participants. Five reactions were life threatening and six were “disabling”. Two-thirds of reports described the necessity for additional medical care including hospitalization (12). The majority of reported reactions occurred within 24 hours of vaccination leaving little doubt about causation. There are now over 900 reports over an 8-month period ending February 28, 2007. Frequently reported events included syncope/fainting (79), seizures (13), menstrual irregularities (9), visual disturbances (9) and Guillain-Barre Syndrome (5). It is disturbing that an HPV vaccine researcher recently raised major questions about unproven vaccine efficacy and safety, claiming Merck was aware of more than 40 cases of Guillain-Barre Syndrome in young vaccine recipients.[12] It is uncertain why Merck or VAERS have failed to disclose these life-threatening side effects.

Total adverse events from Gardasil are more than 15 times more prevalent than events following influenza vaccination, and loss of consciousness, more than 239 times more common among Gardasil recipients.[13]According to a pre-licensure data presented to the FDA, spontaneous abortions occurred in nearly 25% of women who became pregnant following vaccination.[14] Although this was a similar rate in the aluminum-containing placebo group, the rate far exceeds the typical background rates of 10% implying that both vaccine and adjuvant may be abortifacients.

The aluminum concern. Gardasil contains an aluminum adjuvant that assists in development of a proper immune response but it is also a known neurotoxin with little safety testing. At least one study found no significant difference in immune response to vaccines with or without aluminum rendering its role doubtful.[15] The concentration of aluminum in Gardasil is 450 mg/L or 18,000 times higher than what the FDA considers safe in injectable products.[16] Aluminum has been shown to cause behavior and memory impairment associated with death of motor neurons in animals at doses of 10-11 micrograms/kg.[17] The Gardasil immunization series will expose 11 year-old girls to approximately 17 micrograms/kg, doses above that known to be neurotoxic in animals. Reports of neurological events following immunization with Gardasil are therefore not surprising if not predictable.

Published papers touting vaccine safety and efficacy are not credible. Bias in Gardasil research authorship is strong. Review of five major studies published in peer-reviewed journals indicated that all studies were funded by Merck and Co.[18] Of the 69 listed co-authors, 81% had financial connections to Merck, 42% were actual Merck employees, presumably holding stock/options and therefore were positioned to financially benefit from their own favorable reporting. In four of five papers a co-author was actually a Gardasil patent holder. Merck has outsourced many of its clinical trials to Contract Research Organizations (CRO’s) operating in many underdeveloped countries. CRO’s have also been criticized for their own built-in conflicts of interest, often receiving royalties for reporting favorable outcomes.[19]

There are several striking and disturbing parallels between Merck’s missteps with Vioxx research and the current research surrounding Gardasil. Vioxx was introduced by Merck in 1999 as a safe alternative to non-steroidal anti-inflammatory drugs but was later withdrawn due to serious cardiovascular complications, including as many as 100,000 deaths over five years. The details are summarized in a recent feature article in the British Medical Journal (January 20^th, 2007):

-Merck had prior knowledge of potential cardiovascular reactions to Vioxx but intentionally designed subsequent studies to obscure such risks.

-Merck financed and produced nine studies touting Vioxx safety and effectiveness having establishing influence over data analysis, safety monitoring and reporting. Design flaws included small sample sizes, selection of low-risk patients, short follow-up and pooling of data.

-A major journal editor condemned published studies, claiming Merck had withheld critical data, obscuring serious complications. Companies hired by Merck had ghostwritten some publications.

-Merck faces nearly 30,000 legal claims due to serious and undisclosed drug complications.

Merck’s behaviors could be better classified as criminal than biased. Following a similar pattern to Merck’s Vioxx research, Gardasil researchers designed studies of women who were low-risk for HPV transmission and followed them for only two years or less. Despite reporting adverse events in 90% of vaccine recipients (approximately 40% were systemic reactions), they minimized the significance by reporting similar reaction rates in placebo groups that had inappropriately received high doses of aluminum rather than conventional saline.

Financial pressures against the pharmaceutical giant are now even greater. Besides facing up to a $10 billion in legal losses from Vioxx they now anticipate a nearly $6 billion tax charge as the result of multiple reporting violations.[20] Is a company that already has spent millions of dollars on an advertising campaign for Gardasil capable of telling the truth when they are more financially desperate today than ever before? It has been estimated that HPV mandates could generate as much as $5 billion annually for Merck, who now has little liability in vaccine injuries that may ensue thanks to the CDC’s decision to distribute Gardasil through the Vaccine for Children Program. Any Gardasil-related legal claims will be addressed in the no-fault system of the U.S. Court of Federal Claims rather than state and federal courts. Thus, taxpayers and consumers will pay for children’s injuries, not Merck. Limited liability further undermines Merck’s motivation to be forthright about vaccine problems.

Government healthcare agencies serve industry. FDA approval should not garner confidence in Gardasil. At least two FDA advisory committee members were former Merck employees who had voted to approve Gardasil after having been granted conflict-of-interest waivers.¹⁵ Prior FDA biases and failures are well documented. In a November 18^th, 2004 testimony before Congress, FDA drug safety officer Dr. David Graham, commenting on Merck’s Vioxx debacle and the FDA’s role in concealment of cardiovascular complications and failure to withdraw the drug earlier, stated, “I would argue that the FDA, as currently configured, is incapable of protecting America against another Vioxx. We are virtually defenseless.”[21] We can only be grateful that Vioxx was not a mandated drug.

Four years prior this problem was foreshadowed in a Congressional investigation reviewing conflicts of interest among healthcare agencies that reported too close of ties between FDA and CDC advisory committee members and the drug industry.[22] This included the placement of patent holders on advisory committees who were allowed to vote in approval for their own vaccine. Four of six members of a 1999 FDA advisory who approved Vioxx were granted waivers from the conflict-of-interest rule.

Harsh criticisms of the FDA continue today.[23] On February 13, 2007 the House Energy and Commerce Committee’s Subcommittee on Oversight and Investigations opened hearings lambasting the FDA regarding the safety of drugs. Chairman John Dingell (D-MI) opened, “It is clear … that the FDA is badly broken. I expect that before we finish this investigation, which is just getting underway, we will discover whether the problems we have found are due to the work of scoundrels, irrational penny-pinching, or because the doors to the FDA “hen house” have been thrown open to foxes.” Testimony by Charles Grassley (R-IA) painted a picture of a rogue agency with near complete disregard for the law, intentionally exposing Americans to known peril while actively covering the trail while working in partnership with Big Pharma.

Many legislators and physicians may find it impossible to believe that America’s healthcare governance is broken, but consider the evidence. According to a recent shocking report by the international group Save The Children, the United States has one of the highest rates of newborn mortality of all the "industrialized" nations in the world.[24] Of the 33 developed nations reviewed, the U.S. ranked 32^nd in infant mortality. The CIA Factbooks has recently failed to rank the United States in the top 40 nations for either infant mortality or life expectancy.[25] Children in the United States suffer from increasing rates of autism, asthma, obesity and other chronic childhood illnesses yet are among the world’s most vaccinated populations.

Who is promoting the HPV mandate-medicine or Merck? The efforts to pass legislation mandating this vaccine appear to more about marketing and influence than about science. After Texan Governor Perry issued an executive order on February 2^nd,2006, mandating the HPV vaccine, the Associated Press reported he had taken campaign contributions from Merck and his former chief of staff was a Merck lobbyist.[26] Merck provides an undisclosed amount of money to Women in Government (WiG), an advocacy group comprised of female state lawmakers including cosponsors of both the senate and house versions of the Illinois’ HPV mandate as well as members of each committee assign to consider the legislation. WiG has come under intense criticism for catering to Merck’s efforts to direct state legislation, leading some members to resign.¹⁵

Little legislative support appears to be coming from healthcare agencies and organizations. Even the chairman of the CDC’s Advisory Committee of Immunization Practices Dr. Jon Abramson recently stated; “It shouldn’t be mandated”, echoing similar positions taken by the AAP and the AAFP.[27] Why should Illinois bypass recommendations from these organizations and agencies?

Conclusion. Mandating a vaccine against sexually transmitted diseases in 11 year-old children is unwise. This age group is likely being targeted to take advantage of the leverage of the threat to block entry into 6^th grade and maximizing drug sales, not because of valid science. Merck’s own trials only enrolled a few hundred 11-12 year olds so we know less about vaccinating children this age than any other age group. Cervical cancer is an uncommon cancer in women and we already have a means of prevention. The real science indicates the greatest risk groups for HPV transmission are sexually active adults, not children. Since regulatory agencies urge vaccination before HPV infection is established and nearly 97% of adult women do not possess the strains in Gardasil, the overwhelming majority of women are candidates for vaccination. Therefore, I certainly hope that legislators, healthcare officials and physicians will also be willing to roll up their own sleeves in order to “prevent” cervical cancer. Somehow, I think very few would have the courage to take their own advice in lieu of the many unanswered questions about a drug marketed by a company who’s moral compass is obviously broken. An HPV vaccine mandate is more about marketing than rational science. The HPV vaccine mandate may be a good idea someday, but please not today.

Lifetime risk (%) of developing cancer (invasive) by site, FEMALES, all Race/Ethnicity

SEER Cancer Statistics 2001-2003

Modified from Table I-14

http://seer.cancer.gov/csr/1975_2003/results_merged/topic_lifetime_risk.pdf

Lifetime risk (%) of dying from cancer (invasive) by site, FEMALES, all Race/Ethnicity

SEER Cancer Statistics 2001-2003

Modified from Table I-15

American Cancer Society

2006 Cancer Incidence Statistics-New Cases

http://www.cancer.org/downloads/stt/CAFF06EsCsMc.pdf

Researcher blasts HPV marketing

BY CINDY BEVINGTON

cindyb@kpcnews.net (Created: Wednesday, March 14, 2007 9:04 AM EDT)

LEBANON, N.H. — A lead researcher who spent 20 years developing the vaccine for humanpapilloma virus says the HPV vaccine is not for younger girls, and that it is "silly" for states to be mandating it for them.

"Giving it to 11-year-olds is a great big public health experiment," said Diane M. Harper, who is a scientist, physician, professor and the director of the Gynecologic Cancer Prevention Research Group at the Norris Cotton Cancer Center at Dartmouth Medical School in New Hampshire.

"It is silly to mandate vaccination of 11- to 12-year-old girls There also is not enough evidence gathered on side effects to know that safety is not an issue."

Internationally recognized as a pioneer in the field, Harper has been studying HPV and a possible vaccine for several of the more than 100 strains of HPV for 20 years - most of her adult life.

"This vaccine should not be mandated for 11-year-old girls," she reiterated. "It's not been tested in little girls for efficacy. At 11, these girls don't get cervical cancer - they won't know for 25 years if they will get cervical cancer.

"Also, the public needs to know that with vaccinated women and women who still get Pap smears (which test for abnormal cells that can lead to cancer), some of them will still get cervical cancer."

For months, Harper said, she's been trying to convince major television and print media to listen to her and tell the facts about the usefulness and effectiveness of this vaccine.

"But no one will print it," she said.

So far more than 40 cases of Guillian-Barre syndrome - a dangerous immune disorder that causes tingling, numbness and even paralysis of the muscles have been reported in girls who have received the HPV vaccine in combination with the meningitis vaccine.

"To mandate now is simply to Merck's benefit, and only to Merck's benefit," she said.

(COMMENTARY-ONLY 5 CASES OF Guillan-Barre are reported on VAERS-Merck has not reported these in their studies to the FDA or to peer-review)

Excerpt provided by David Ayoub, MD 217 691-3298

WHY THE HPV VACCINE MANDATE IS WRONG:

ILLLINOIS SB 10 and HB 115 NOT SUPPORTED BY SCIENCE OR THE CDC

4) There have already been reports of several instances of vaccine failures including HPV infections, genital warts and even invasive cervical cancer following vaccination.

5) The HPV vaccine suffers a significant adverse reaction rate (90%) as reported in published trials and also in VAERS. There are no long-term safety studies yet over 600 reports of adverse reactions have already been reported to the FDA including life-threatening reactions.

7) Since influenza kills ten-times as many individuals as cervical cancer yet flu vaccination is not mandated, HPV mandates can’t be just about “saving more lives”.

David Ayoub, MD-Springfield

217 691- 3298

WHY THE HPV VACCINE MANDATE IS WRONG:

ILLLINOIS SB 10 and HB 115 NOT SUPPORTED BY SCIENCE OR THE CDC

“In the 9 to 15 year-old age group, we could not do an efficacy study”.

Merck executive director of medical affairs, Richard Haupt

“It shouldn’t be mandated”.

Dr. Jon Abramson, chairman of the CDC’s Advisory Committee of Immunization Practices

"Giving it to 11-year-olds is a great big public health experiment,"

"It's not been tested in little girls for efficacy. At 11, these girls don't get cervical cancer - they won't know for 25 years if they will get cervical cancer.

"To mandate now is simply to Merck's benefit, and only to Merck's benefit,"

Diane M. Harper, HPV vaccine scientist, physician and the director of the Gynecologic Cancer Prevention Research Group at Dartmouth Medical School in New Hampshire.

The vaccine list price of $360 translates into a cost for parents of 3 days off work office, drug and injection charges easily exceeding $1,000. To file an exemption will still cost parents time-off from work and office visit expenses.

Even the Illinois Chapter of the American Academy of Pediatrics is not supporting the HPV mandate. Who are Illinois legislators listening to?

David Ayoub, MD

Springfield, Illinois

217 691 3298

[1]Hospital Stays for Cervical Cancer. M Milenkovic, et al. 2004 Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality Statistical Brief #22, Jan 2007. Available at http://www.hcupus.ahrq.gov/reports/statbriefs/sb22.pdf

[2] Excess Cervical Cancer Mortality: A Marker for Low Access to Health Care in Poor Communities. Freeman HP, Wingrove BK. Rockville, MD: National Cancer Institute, Center to Reduce Cancer Health Disparities, May 2005. NIHPub. No. 05–5282. Available online http://crchd.cancer.gov/attachments/excess-cervcanmort.pdf

[3] Cervical cancer incidence in a prevaccine era in the United States, 1998-2002. Saraiya M et al. Obstet Gynecol. 2007 Feb;109(2 Pt 1):360-70.

[4] Cervical cancer mortality in Illinois, 1986 to 1998. JV Campbell and T Shen. EPI Updates, Illinois Department of Public Health, Spring 2000. Available online at: www.idph.state.il.us/cancer/pdf/Eupcerinc.pdf

[5]Chronic Diseases: The Leading Causes of Death Illinois Profiling the Leading Causes of Death in the United States. Heart Disease, Stroke and Cancer. CDC, Atlanta, GA. at: http://www.cdc.gov/nccdphp/publications/factsheets/ChronicDisease/illinois.htm

[6] Management of abnormal cervical cytology and histology. ACOG Practice Bulletin No. 66. American College of Obstetricians and Gynecologist. Obstet Gynecol 2005; 106: 645-64.

[7] Prevalence of HPV infection among females in the United States. Dunne et al. JAMA. Feb 27, 2007; 297(8): 813-819.

[8] Grindley Productions. 2007. NVIC HPV Vaccine Video. Accessed Feb 20, 2007 http://nvic.org/Diseases/HPV/HPVHOME.htm

[9] VAERS ID # 267418. Available online at: http://www.medalerts.org/vaersdb/showrecord.php?rec=267418

[10] Merck says Gardasil is safe for patients to use. By John Wilen. Mar 2, 2007. PhilyBurbs.com

[11]Human papilloma virus vaccine safety Analysis of Vaccine Adverse Events Reporting System Reports: Part II National Vaccine Information Center. February 18, 2007 Available at www.nvic.org/Diseases/HPV/HPVREPT2.htm

[12] Researcher blasts HPV marketing. By Cindy Bevington. March 14, 2007. Available at: http://www.kpcnews.com/articles/2007/03/14/features/columnists/cindy_bevington/doc45f7fd0f5a229535548238.txt

[13] Based upon review of VAERS database through Jan 31, 2007; accessed March 11, 2007. Based upon distribution of 115 million doses of influenza (2006-07) and 2 million doses of Gardasil.

[14] Presentation by Nancy Miller, MD, CBER, FDA May 18, 2006, Vaccines and Related Biological Products Advisory Committee Meeting.

[15] Safety and immunogenecity trial in adult volunteers of a Human Papillomavirus 16L1 virus-like particle vaccine. Harro et al. J Natl Cancer Inst 2001;93:284-92.

[16] §201.323 Aluminum in large and small volume parenterals used in total parenteral nutrition. Federal Register/Rules and Regulations. Vol 68 (106) Tuesday June 3, 2003. Page 32981

[17] Aluminum adjuvant linked to Gulf War Illness induces motor neuron death in mice. MS Petrik, et cl. Neuromolecular Medicne 2007; 9(1):83-100.

[18] LA Koutsky et al NEJM 2002. SL Block et al Pediatrics, 2006. GP Poland et al, Mayo Clinic Proceedings 2005. LLVilla et al, Lancet-Oncology 2005. C Mao et al. Obstetrics & Gynecology 2006. Abstracts available online at www.pubmed.com

[19] Merck’s murky dealings: HPV vaccine lobby backfires. By Terry Allen, Special to CorpWatch. Mar 7^th, 2007.

[20] Merck tax disputes could cost $5.58 billion Potential liabilities disclosed amid lawsuits over painkiller Vioxx. The Associated Press. Nov 8, 2006. Available at http://www.msnbc.msn.com/id/15621917/

[21] Statement of David Graham, M.D., Associate Director, Office of Drug Safety, U.S. Food and Drug Administration before the Committee on Finance, United States Senate, November 18, 2004. Available at http://www.senate.gov/~finance/hearings/testimony/2004test/111804dgtest.pdf

[22] Conflicts of Interest in Vaccine Policy Making Majority Staff Report Committee on Government Reform U.S. House of Representatives August 21, 2000. Available at: www.vacineinfo.net/issues/conflictsofinterest/conflictsofinteresthearings/shtml

[23] Drug safety-the eleventh hour is now! By Byron J. Richards, CCN February 21, 2007. NewsWithViews.com

[24] State of the World's Mothers 2006: Saving the Lives of Mothers and Newborns. Available online at www.savethechildren.com

[25] CIA Factbook. Available online at: www.cia.gov/publications/factbook

[26] Texas Governor orders anti-cancer vaccine. Liz Austin Peterson, Associated Press Writer. Feb 2, 2007.

[27] CDC opposes law for vaccine. By Gregory Lopes, Washington Times. February 27, 2007.