document_title: Procedures of the Supreme Court of the United States

question_text: when does the supreme court begin a new term

text: Terms and sittings[edit]

text: A term of the Supreme Court commences on the first Monday of each October, and continues until June or early July of the following year. Each term consists of alternating periods of approximately two weeks known as "sittings" and "recesses." Justices hear cases and deliver rulings during sittings; they discuss cases and write opinions during recesses.

text: The Court's authority to hear cases[edit]

text: Appellate jurisdiction[edit]

text: In nearly all of the cases heard by the Supreme Court, the Court exercises the appellate jurisdiction granted it by Article III of the Constitution. This authority permits the Court to review—and affirm or overturn—decisions made by lower courts and tribunals. Procedures for bringing cases before the Supreme Court have changed significantly over time. Today, cases are brought before the Supreme Court by one of several methods, of which the first two account for the overwhelming majority of cases decided:

text:
By petition for a writ of certiorari, filed by a party to a case that has been decided by one of the United States courts of appeals or by the United States Court of Appeals for the Armed Forces.
By petition for writ of certiorari with respect to a decision of one of the territorial or state courts, after all state appeals have been exhausted, where an issue of federal constitutional or statutory law is in question. The writ is usually issued to a state supreme court (including high courts of the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa), but is occasionally issued to a state's intermediate appellate court for cases where the state supreme court denied certiorari or review and thereby refused to hear the appeal.
By petition for certiorari before judgment, which permits the Court to expedite a case pending before a United States court of appeals by accepting the case for review before the appellate court has decided it. However, Supreme Court Rule 11 provides that a case may be taken by the Court before judgment in a lower court "only upon a showing that the case is of such imperative public importance as to justify deviation from normal appellate practice and to require immediate determination in this Court."
By appeal from certain decisions of United States district courts in certain cases involving redistricting of congressional or state legislative districts, or when specifically authorized in a particular statute.
By a certified question or proposition of law from one of the United States Courts of Appeals, meaning that the Court of Appeals requests the Supreme Court to instruct it on how to decide the case. This procedure was once common but is now rarely invoked; the last certificate accepted for review was in 1981.
By petition for an "extraordinary writ" such as mandamus, prohibition, or habeas corpus. These writs are rarely granted by the Supreme Court though they are more frequently granted by lower courts.

text: Original jurisdiction[edit]

text: Certain cases that have not been considered by a lower court may be heard by the Supreme Court in the first instance under what is termed original jurisdiction. The Supreme Court's authority in this respect is also derived from Article III of the Constitution, which states that the Supreme Court shall have original jurisdiction "in all cases affecting ambassadors, other public ministers and consuls, and those in which a state shall be party." The original jurisdiction of the Court is set forth in 28 U.S.C. § 1251. This statute provides further that, in the case of disputes between two or more states, the Supreme Court holds both original and exclusive jurisdiction and no lower court may hear such cases.

text: The number of original jurisdiction cases heard by the court is small; generally only one or two such cases are heard per term. Because the nine-member Supreme Court is not well-suited to conducting pretrial proceedings or trials, original jurisdiction cases accepted by the Court are typically referred to a well-qualified lawyer or lower-court judge to serve as special master, conduct the proceedings, and report recommendations to the Court. The Court then considers whether to accept the special master's report or whether to sustain any exceptions filed to the report.

text: Although jury trials are in theory possible in the Court's original jurisdiction cases, there has not been one since Georgia v. Brailsford in 1794.[1] In 1950, in the case United States v. Louisiana, the state of Louisiana moved for a jury trial, but the Court denied the motion, ruling that the suit was an equity action and not an action at law, and that therefore the Seventh Amendment guarantee of a jury trial did not apply. If a matter involving an action at law did come before the court, however, a jury would likely be empaneled and would hear the case alongside the justices of the Court.[2]

text: Selection of cases[edit]

text: Since the Judiciary Act of 1925 ("The Certiorari Act" in some texts), the majority of the Supreme Court's jurisdiction has been discretionary.[3] Each year, the court receives approximately 9,000–10,000 petitions for certiorari, of which less than 1% (approximately 80–100), are granted plenary review with oral arguments, and an additional 50 to 60 are disposed of without plenary review.[4][5]

text: The Court strictly enforces its requirements for the preparation and timely filing of certiorari petitions, in order to manage such a massive caseload. This occasionally results in harsh consequences, as Justice Thomas acknowledged in a 2007 opinion: "Just a few months ago, the Clerk, pursuant to this Court’s Rule 13.2, refused to accept a petition for certiorari submitted by Ryan Heath Dickson because it had been filed one day late ... Dickson was executed on April 26, 2007, without any Member of this Court having even seen his petition for certiorari. The rejected certiorari petition was Dickson’s first in this Court, and one can only speculate as to whether denial of that petition would have been a foregone conclusion."[6]

text: In theory, each Justice's clerks write a brief for the Justice outlining the questions presented, and offering a recommendation as to whether certiorari should be granted; in practice, most Justices (all of the current court, except Justices Alito and Gorsuch) have their clerks participate in the cert pool.[7][8][9]

text: During the Justices' regular conference, the Justices discuss the petitions, and grant certiorari in less than five percent of the cases filed. (During the 1980s and 1990s, the number of cases accepted and decided each term approached 150 per year; more recently, the number of cases granted has averaged well under 100 annually). Before each conference, the Chief Justice prepares a list of those petitions he believes have sufficient merit to warrant discussion. Any other Justice may also add a case to the "discuss list"; cases not designated for discussion by any Justice are automatically denied review. The Court or a Justice may also decide that a case be "re-listed" for discussion at a later conference; this occurs, for example, where the Court decides to request input from the Solicitor General of the United States on whether a petition should be granted.[10]

text: The votes of four Justices at Conference (see Rule of four) will suffice to grant certiorari and place the case on the court's calendar. If the Supreme Court grants certiorari (or the certified question or other extraordinary writ), then a briefing schedule is arranged for the parties to submit their briefs in favor of or against a particular form of relief. During this time, an individual or group having an interest in a case but not a party to the case may submit a motion to appear before the court as amicus curiae ("friend of the court"). Except for certain specific categories (such as lawyers for state and local governments) or where all parties to the case consent, it is in the Court's discretion whether such motions are granted.

text: The grant or denial of certiorari petitions by the Court are usually issued as one-sentence orders without explanation.

text: Cases that fall within the Court's original jurisdiction are initiated by filing a complaint directly with the Supreme Court, and normally are assigned to a special master appointed by the Court for the taking of evidence and making recommendations, after which the Court may accept briefs and hear oral arguments as in an appellate case.

text: Hearing cases[edit]

text: Filing briefs[edit]

text: Before oral arguments, the parties to a case file legal briefs outlining their arguments. An amicus curiae may also submit a brief in support of a particular outcome in the case if the Court grants it permission. Formal rules govern every aspect of these briefs; Chief Justice William Rehnquist described the rules thus:

text: Oral arguments[edit]

text: Thereafter, if the Court chooses to hold a hearing, each side has thirty minutes to present its case orally. In exceptional and controversial cases, however, the time limit may be extended. In the Court's early years, attorneys might argue a single case for hours or even days; but as the judicial workload increased, the time available for argument has been restricted. The late Chief Justice Rehnquist was noted for his especially strict enforcement of the argument time limits.

text: To file pleadings or to argue a case, an attorney must be a member of the bar of the Court. (The primary requirement for admission to the Bar is that the attorney must have been admitted to practice in the highest court of a state or territory for at least the past three years.) Justices are allowed to interrupt the attorney speaking in order to ask him or her questions, and particularly since the arrival of Justice Antonin Scalia in 1986, do so often.[12]

text: The Court began recording Oral Arguments in October 1955.[13] Beginning in October 2010, the Supreme Court began the practice of posting recordings and transcripts of the oral arguments made during the preceding week on Fridays on the Court's website.

text: In an interview for C-SPAN, former Justice Scalia, speaking for himself, noted that by the time the Justices hear oral arguments, having read the submissions by the parties and amici, it is "very rare, though not unheard of", for the discussion during the oral arguments to change his view of a case in which he has already made up his mind based on the submissions and his research about the case. However, he also made the point that it is "quite common" for him to go into Oral Arguments with his mind not made up yet, as the cases are usually very hard and difficult, and that in those situations a persuasive attorney can make the difference for him.[14]

text: Forming opinions[edit]

text: The conference: assignment of opinions[edit]

text: At the end of a week in which the Court has heard oral arguments, the Justices hold a conference to discuss the cases and vote on any new petitions of certiorari. The Justices discuss the points of law at issue in the cases. No clerks are permitted to be present, which would make it exceedingly difficult for a justice without a firm grasp of the matters at hand to participate.[15] At this conference, each justice—in order from most to least senior—states the basis on which he or she would decide the case, and a preliminary vote is taken.

text: Former Justice Scalia professed frustration that there is little substantive discussion,[16] while former Chief Justice Rehnquist wrote that this makes the conference more efficient.[17] The votes are tallied, and the responsibility for writing the opinion in the case is assigned to one of the justices; the most senior Justice voting in the majority (but always the Chief Justice if he is in the majority) makes the assignment, and can assign the responsibility to him- or herself.

text: Circulating draft opinions and changing of views[edit]

text: The justice writing the opinion for the court will produce and circulate a draft opinion to the other justices. Each justice's law clerks may be involved in this phase. In modern Supreme Court history only a few justices, such as former Justice Antonin Scalia, have regularly written their own first drafts.[18] Once the draft opinion has been reviewed, the remaining Justices may recommend changes to the opinion. Whether these changes are accommodated depends on the legal philosophy of the drafters as well as on how strong a majority the opinion garnered at conference. A justice may instead simply join the opinion at that point without comment.

text: Votes at conference are preliminary; while opinions are being circulated, it is not unheard of for a justice to change sides. A justice may be swayed by the persuasiveness (or lack thereof) of the opinion or dissent, or as a result of reflection and discussion on the points of law at issue.

text: The evolution of the justices' views during the circulation of draft opinions can change the outcome of the case; an opinion that begins as a majority opinion can become a dissenting opinion, and vice versa. At the conference for Planned Parenthood v. Casey, Justice Kennedy is said to have initially voted with Chief Justice Rehnquist, but then changed his mind, feeling unable to join Rehnquist's draft opinion.[19] While working for the Justice Department, present-day Chief Justice John Roberts—a former Rehnquist law clerk—wrote an analysis of Wallace v. Jaffree[20] in which he indicated his belief (based on the length and structure) that Rehnquist's dissent had started out as an opinion for the court, but lost its majority; similar speculation is often heard of Justice O'Connor's dissent in Kelo v. New London.[21] Justice Kennedy is known within the Court for changing his mind subsequent to the conference, and Justice Thomas is known for having the tendency to lose a majority.[22] Justices may change sides at any time prior to the handing down of the Court's opinion. Generally, the Court's decision is the opinion which a majority (five or more) of justices have joined. In rare instances, the Court will issue a plurality opinion in which four or fewer Justices agree on one opinion, but the others are so fractured that they cannot agree on a position. In this circumstance, in order to determine what the decision is lawyers and judges will analyze the opinions to determine on which points a majority agrees. An example of a case decided by a plurality opinion is Hamdi v. Rumsfeld.

text: A justice voting with the majority may write a concurring opinion; this is an opinion where the justice agrees with the majority holding itself, but where he or she wishes to express views on the legal elements of the case that are not encompassed in the majority opinion. Justices who do not agree with the decision made by the majority may also submit dissenting opinions, which may give alternative legal viewpoints. Dissenting opinions carry no legal weight or precedent, but they can set the argument for future cases. John Marshall Harlan's dissent in Plessy v. Ferguson set down for the majority opinion later in Brown v. Board of Education.

text: After granting a writ of certiorari and accepting a case for review, the justices may decide against further review of the case. For example, the Court may feel the case presented during oral arguments did not present the constitutional issues in a clear-cut way, and that adjudication of these issues is better deferred until a suitable case comes before the court. In this event the writ of certiorari is "dismissed as improvidently granted" (DIG)—saying, in effect that the Court should not have accepted the case. As with the granting or denial of cert, this dismissal is customarily made using a simple per curiam decision without explanation.[23]

text: Customarily, justices who were not seated at the time oral arguments were heard by the Supreme Court do not participate in the formulation of an opinion. Likewise, a justice leaving the Court prior to the handing down of an opinion does not take part in the Court's opinion. Should the composition of the Court materially affect the outcome of a pending case, the justices will likely elect to reschedule the case for rehearing.

text: Tied votes and lack of quorum[edit]

text: If not all of the nine justices vote on a case, or the Court has a vacancy, then a tied vote is possible. If this occurs, then the decision of the court below is affirmed, but the case is not considered to be binding precedent. The effect is a return to the status quo ante. No opinions (or voting alignments) are issued in such a case, only the one-sentence announcement that "[t]he judgment is affirmed by an equally divided Court." Omega S.A. v. Costco Wholesale Corp. is an example of such a case. The court tries to avoid such rulings when possible: After the retirement of Justice O'Connor in 2006 three cases would have ended with a tie. All cases were reargued to allow the newly appointed Samuel Alito to cast a decisive vote.

text: A quorum of justices to hear and decide a case is six. If, through recusals or vacancies, fewer than six justices can participate in a case, and a majority of qualified justices determines that the case cannot be heard in the next term, then the decision of the court below is affirmed as if the Court had been equally divided on the case. An exception exists when this situation arises in one of the now-rare cases brought directly to the Supreme Court on appeal from a United States District Court; in this situation, the case is referred to the U.S. Court of Appeals for the corresponding circuit for a final decision there by either the Court of Appeals sitting en banc, or a panel consisting of the three most senior active circuit judges.[24]

text: Announcement of opinions[edit]

text: Throughout the term, but mostly during the last months of the term—May, June, and, if necessary, July—the Court announces its opinions. The decision of the Court is subsequently published, first as a slip opinion, and subsequently in the United States Reports. In recent years, opinions have been available on the Supreme Court's website and other legal websites on the morning they are announced. Since recording devices have been banned inside the courtroom, the fastest way for decisions of landmark cases to reach the press is through the Running of the Interns.[25]

text: The opinion of the Court is usually signed by the author; occasionally, the Supreme Court may issue an unsigned opinion per curiam. The practice of issuing a single opinion of the Court was initiated during the tenure of Chief Justice John Marshall during the early 19th century. This custom replaced the previous practice under which each Justice, whether in the majority or the minority, issued a separate opinion. The older practice is still followed by appellate courts in many common law jurisdictions outside the United States.

text: Reporting and citation of cases[edit]

text: Supreme Court decisions are typically cited as in the following example: "Roe v. Wade, 410 U.S. 113 (1973)." The court citation consists of the names of the opposing parties; the volume number; "U.S." (signifying United States Reports, the official reporter of Supreme Court decisions); the page number on which the decision begins; and the year in which the case was decided. The names of the opposing parties are listed in the format "Petitioner v. Respondent" or "Appellant v. Appellee." The Reporter of Decisions is responsible for publication of the Court's rulings. Two other widely used citation formats exist: the Supreme Court Reporter and the Lawyers' Edition, corresponding to two privately published collections of decisions. Citations to cases in the Supreme Court Reporter would be structured as follows: Snowden v. Hughes, 64 S. Ct. 397 (1944). Citations to cases in the Lawyers' Edition would be as follows: Snowden v. Hughes, 88 L. Ed. 497 (1944). Judicial opinions often use the citation from all three sources (the United States Reports, Supreme Court Reporter, and Lawyers' Edition), as seen here: Martin v. Texas, 200 U.S. 316, 26 S. Ct. 338, 50 L. Ed. 497 (1906). Since the 1930s, prior to publication of the decisions in these reporters, they are available from the United States Law Week (U.S.L.W.). In more recent years, opinions have been available electronically soon after they appeared on commercial sites such as Lexis or Westlaw, on Internet sites such as FindLaw and on the Court's own website.[26]

text: The Reporter of Decisions is the court official responsible for the publication of the Court's opinions and orders. The current Reporter of Decisions is Christine Luchok Fallon.

text: Decisions of the Supreme Court are precedents that bind all lower courts, both federal and state. The Supreme Court generally respects its own precedents, but has in some cases overturned them.


document_title: Wand'rin' Star

question_text: who sang i was born under a wondering star

root

text: Wand'rin' Star

text: This article needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (March 2014) (Learn how and when to remove this template message)

tag: table

text:
"Wand'rin' Star"

Single by Lee Marvin

A-side
"Wand'rin' Star"

B-side
"I Talk to the Trees"
(Clint Eastwood)

Released
1970 (1970)

Format
7"

Songwriter(s)

Alan J. Lerner (lyrics)
Frederick Loewe (music)

text: "Wand'rin' Star" was a number one single in the UK and Ireland for Lee Marvin for three weeks in March 1970.[1]

tag: p

text: It was originally written by Alan J. Lerner (lyrics) and Frederick Loewe (music) for the stage musical Paint Your Wagon in 1951. When the film of the musical was made in 1969, Lee Marvin took the role of prospector Ben Rumson. Not a natural singer, Marvin nevertheless sang all of his songs in the film, rejecting the idea of miming to another singer's voice. Despite the film being a box office flop, the soundtrack became a success. Orchestrated and arranged by Nelson Riddle, Marvin's version of the song "Wand'rin Star" became a number-one single in Ireland and the UK, keeping The Beatles at number two in the UK with their single "Let It Be". Marvin never released a follow-up single, so he is considered a one-hit wonder.

text: A sound-alike cover appeared on the 1970 album Top of the Pops, Volume 10, with one reviewer using terms like "laryngitic croak" and "gargling gargoyles" to describe how he felt about the cover. [2]

text: "Wand'rin' Star" was covered by English comedian and novelist Julian Clary; his version was released as a single in the United Kingdom in 1990, backed with the self-penned track "Uncanny and Unnatural".

text: The song was covered by Shane MacGowan and The Popes on their 1997 album The Crock of Gold.

text: The song was mentioned in the words of "Build A Fire" by The KLF. The last lines are, "We'll stop for lunch, in some taco bar./Lee Marvin on the jukebox, 'Wand'rin' Star.'"

text: Sample[edit]

text:
sample of "Wand'rin' Star" by Lee Marvin

Problems playing this file? See media help.


document_title: Seat belt legislation

question_text: when did seat belts become mandatory in nsw

text: Seat belt legislation

text: National comparisons[edit]

text: Australia[edit]

text: In Australia, after the introduction of mandatory front outboard mounting points in 1964, the use of seat belts by all vehicle passengers was made compulsory in the states of Victoria and South Australia in 1970 and 1971, respectively.[1] By 1973, the use of fitted seat belts by vehicle occupants was made compulsory for the rest of Australia and some other countries during the 1970s and 1980s. The subsequent dramatic decline in road deaths is generally because of seat belt laws and subsequent road safety campaigns.[2][3][4] Seat belts are not required for bus occupants, reversing drivers, and those driving some slow moving vehicles. The laws for these differ depending on the state or territory with jurisdiction.

text: Canada[edit]

text: All provinces in Canada have primary enforcement seat belt laws. In 1976, Ontario was the first province to pass a law which required vehicle occupants to wear seat belts.[5]

text: United Kingdom[edit]

text: In the United Kingdom, seat belts must be worn at all times if they are fitted to a vehicle unless reversing. Passengers may be exempt from wearing a seat belt for different reasons. Since September 18, 2006, children travelling in the UK must also use an appropriate child seat in addition to the standard seat belt, unless they are 12 years old and/or have reached at least 135 centimetres (53 in) in height.[6]

text: In the UK, a requirement for anchorage points was introduced in 1965, followed by the requirement in 1968 to fit three-point belts in the front outboard positions on all new cars and all existing cars back to 1965.[citation needed] Successive UK Governments proposed, but failed to deliver, seat belt legislation throughout the 1970s. Front seat belts were compulsory equipment on all new cars registered in the UK from 1972, although it did not become compulsory for them to be worn until 1983. Rear seat belts were compulsory equipment from 1986 and became compulsory for them to be worn in 1991. However, it has never been a legal requirement for cars registered before those dates to be fitted with seat belts.[7] In one such attempt in 1979 similar claims for potential lives and injuries saved were advanced. William Rodgers, then Secretary of State for Transport in the Callaghan Labour Government (1976–1979), stated: "On the best available evidence of accidents in this country - evidence which has not been seriously contested - compulsion could save up to 1000 lives and 10,000 injuries a year."[8]

text: United States[edit]

text: In the United States, seat belt legislation varies by state. The state of Wisconsin introduced legislation in 1961 requiring seat belts to be fitted to the front outboard seat positions of cars.[9] Seat belts have been mandatory equipment since the 1968 model year per Federal Motor Vehicle Safety Standard 208.

text: New York State passed the first law in the US mandating the use of seat belts in 1984 under the leadership of John D. States, an orthopedic surgeon who dedicated his career to improving automotive safety.[10] Depending on which state a driver is in, not wearing a seat belt in the front seat is either a primary offense or a secondary offense, with the exception of New Hampshire, which does not have a law requiring people over age 18 to wear a seat belt. In the front seat, the driver and each passenger must wear a seat belt, one person per belt. In some states, such as New York, New Hampshire, and Michigan, belts in the rear seats are not mandatory for people over the age of 16, though it is extremely advised. The driver and front-seat passengers aged 16 or older can be fined up to $50 each for failure to buckle up. In California, you must be 15 years or older to accompany the driver in the front seat. Children 14 and younger must sit in the rear seat until they reach the age of 15.Template:DMV.org

text: A primary offense means that a police officer can pull a driver over for the seat belt law violation alone, and secondary offense indicates that one can be punished for a seat belt law violation only if they are already pulled over for another reason. By January 2007 25 states and the District of Columbia had primary seat belt laws, 24 had secondary seat belt laws, and New Hampshire had no laws.[11] In 2009, Public Health Law Research published several evidence briefs summarizing the research assessing the effect of a specific law or policy on public health. One stated, "Safety belt laws work, but there is strong evidence to support that primary enforcement safety belt laws are more effective than secondary enforcement laws in increasing seat belt use and reducing crash injuries."[12]

text: Another found that "there is strong evidence that enhanced seat belt enforcement interventions can substantially increase seat belt use and its associated benefits."[13]

text: Developing countries[edit]

text: In many developing countries, pedestrians, cyclists, rickshaw operators and moped users represent the majority of road users.

text: In India, all cars manufactured after March 25, 1994 are equipped with front seat belts. The rule was extended for rear seats in 2002. The usage of seat belts is to be implemented by the respective states, with most states making seat belt usage for front seat passengers mandatory in 2002. Older vehicles that did not originally have seat belts were exempted. However, enforcement is weak in most parts of the country.

text: In Indonesia, belts are only mandatory for front seats. Many low entry car models are not equipped with rear seat belts.[14]

text: In Malaysia, the first stage of safety belt laws was implemented in 1979. This was expanded in January 2009 to include rear passengers. Passenger vehicles registered prior to January 1, 1995, and those weighing more than 3.5 tons are exempted from this rule. The third and fourth stages, which will deal with baby and child seats and the number of passengers in a vehicle, have not taken effect.[15]

text: In the Philippines, a seat belt law, Republic Act No. 8750, was approved in August 5, 1999. The law took effect in 2000 and requires all public and private vehicles, except motorcycles and tricycles, to have their front seats equipped with seat belts. Front seats as defined by the law includes the first row of seats behind the driver for public utility buses. Those below the age of six are prohibited to occupy the front seats of motor vehicles even if wearing a seat belt. Jeepneys are only required lap belts for the front seat passengers and the driver.[16][17]

text: The table below gives an overview of when seat belt legislation was first introduced in different countries. It includes both regional and national legislation.

text:
Country
Compulsory wearing
Compulsory fitting
Source

Cars
Bus passengers
Cars
Buses

Driver
Front passengers
Rear passengers

 Argentina
1994

1994
1994 (First row only, all in school buses)
[18]

 Australia
1970 (Victoria) 1971 (NSW) 1972 (national) 1986 (child restraints)

1969, 1970 (back seat, Victoria) 1971 (back seat)
1983 (≤3.5 tonnes)
[19][20]

 Canada
1976

 Czech Republic
1966 (outside cities)
1990 (all)
1976
1990
2004
1968

[21]

 European Union
1993

[22]

 Finland
1975
1982
1987
2006

 France
1973 (outside cities), 1975 (cities at night), 1979 (all)
1990
2003
1967, 1978 (back seat)
2003
[22]
[23]

 Germany
1976
1984
1999
1970, 1979 (back seat)
1999
Angurtpflicht

 Hungary
1976

1993

[19]

 Hong Kong
1983
1983
1996
2004 (minibuses)
1996 (back seat)
2004 (minibuses)

[24]

 India

1994 (front seats), 2002 (rear seats)

 Ireland
1979

1992

1971 (front seats), 1992 (rear seats)

[25]

 Italy
1989
1990 (where available)‡
2006‡
1988 (new vehicles); 1989 (all*, front seats); 1990 (new vehicles, back seats); 2000 (all*, back seats)
2006
[26]

 Japan
1971† (1985)
1971 (no fines), 1985 (fines on freeway), 1993 (all)
2008
2008
1969

[22]

 Myanmar
2017
2017
2017
2016 (motorway buses enforced)

 Netherlands
1976
1992

1975 (front) 1990 (rear)

 New Zealand
1972
1972 (15 years and over), 1979 (8 years and over)
1989♣

1972 (vehicles registered after 1965), 1975 (after 1955)

[27]

 Philippines
2000 (those below 6 years prohibited to occupy front seats)

2000 (first row beside the driver's seat only)
2000
[28]

 Singapore
1973
1973
1993
2008 (small buses)
1973

 Spain
1975

 Sri Lanka
2011
2011

 Sweden
1975
1986
1969 (front) 1970 (rear)
2004
[22][29]

 Thailand
1996
2009

 United Kingdom
1983
1991
2006
1967 (front) 1987 (rear)

[30]

 United States
1984 (New York; seat belt use law is jurisdiction of individual states)

Wisconsin, 1961. Federally, front lap 1965 model year; front shoulder & rear lap 1968; 3-point front 1974

[22]

text:
* - actually only vehicles registered after 15 June 1976; in previous registered vehicles fitting is optional
† - required by the law, but no penalty for violation at the time
‡ - required by the law, but low enforcement
♣ - definitely introduced by this date, possibly earlier

text: Effects[edit]

text: Studies by road safety authorities conclude that seat belt legislation has reduced the number of casualties in road accidents.

text: Experiments using both crash test dummies and human cadavers also indicated that wearing seat belts should lead to reduced risk of death and injury in car crashes.

text: Studies of accident outcomes suggest that fatality rates among car occupants are reduced by between 30 and 50 percent if seat belts are worn. The US National Highway Traffic Safety Administration (NHTSA) estimates that death risks for a driver wearing a lap-shoulder seat belt are reduced by 48 percent. The same study indicated that in 2007, an estimated 15,147 lives were saved by seat belts in the United States and that if seat belt use were increased to 100 percent, an additional 5024 lives would have been saved.[31]

text: An earlier statistical analysis by the NHTSA claimed that seat belts save over 10,000 lives every year in the US.[32]

text: According to a more recent fact sheet produced by the NHTSA:

text: By 2009, despite large increases in population and the number of vehicles, road deaths in Victoria had fallen below 300, less than a third of the 1970 level, the lowest since records were kept, and far below the per capita rate in jurisdictions such as the United States. This reduction was generally attributed to aggressive road safety campaigns beginning with the seat belt laws.[34][35]

text: A 2008 study in the Journal of Health Economics found that mandatory seat belt laws in the U.S. "significantly increased seatbelt use among high school age youths by 45-80%" and "significantly reduced traffic fatalities and serious injuries resulting from fatal crashes by 8 and 9%, respectively."[36] The authors note that these "results suggest that if all states had primary enforcement seatbelt laws then regular youth seatbelt use would be nearly universal and youth fatalities would fall by about 120 per year."[36]

text: Opposition[edit]

text: A number of groups and individuals are opposed to seat belt legislation. The most common grounds for opposition are:

text:
The view that laws requiring the wearing of seat belts are an infringement of individual liberty.
Claims that official estimates of the number of lives saved by seat belts are overstated or fail to take into account additional risks for other road users.

tag: ul

text: Risk compensation and other theories[edit]

text: The most common basis for disputing estimates of the benefits of seat belts is risk compensation and risk homeostasis, advanced by researchers John Adams and Gerald Wilde. The idea of this theory is that, if the risk of death or injury from a car crash is reduced by the wearing of seat belts, drivers will respond by reducing the precautions they take against crashes.

text: Along with many others[who?], Adams accepts the hypothesis that wearing seat belts improves a vehicle occupant’s chances of surviving a crash.[37]

text: In order to explain the disparity between the agreed improvement in crash survival and the observed results, Adams and Wilde argue that protecting someone from the consequences of risky behaviour may tend to encourage greater risk taking. Wilde states, "to compel a person to use protection from the consequences of hazardous driving, as seat belt laws do, is to encourage hazardous driving. A fine for non-compliance will encourage seat belt use, but the fact that the law fails to increase people's desire to be safe encourages compensatory behaviour." [38]

text: Studies and experiments have been carried out to examine the risk compensation theory. In one experiment subjects were asked to drive go-karts around a track under various conditions. It was found that subjects who started driving belted did not drive any slower when subsequently unbelted, but those who started driving unbelted did drive consistently faster when subsequently belted.[39] A study of habitual non-seat belt wearers driving in freeway conditions found evidence that they had adapted to seat belt use by adopting higher driving speeds and closer following distances.[40] In another study, taxi drivers who were habitual non-wearers were timed over a route with passengers who did, and others who did not, insist on the driver wearing a belt. They completed the route faster when belted.[41]

text: In addition to risk compensation, Adams has suggested other mechanisms that may lead to inaccurate or unsupportable predictions of positive benefits from seat belt legislation.

text:
Case-control studies based on voluntary use of safety aids can attribute to the aid benefits that actually come from the risk-averse nature of those likely to use them voluntarily (confounding), particularly early adopters.
Fatality rates are subject to considerable stochastic noise, and comparison of single years or short periods can be misleading.

text: Individual liberty[edit]

text: Opponents have objected to the laws on libertarian principles.[42] Some do so on the grounds that seat belt laws infringe on their civil liberties. They argue[where?] that not wearing seat belts is a victimless crime as the only person harmed is the one making that decision for himself about his own life.

text: The counterpoint to the libertarian view toward seat belt laws is that mandatory usage may reduce injuries and deaths (while possibly increasing the number of accidents) but also reduces the economic cost to society.[citation needed] Another notable scenario is of rear-seated passengers being forced forward in a crash and thus inadvertently harming the driver or front passenger. A University of Wisconsin study demonstrated that car accident victims who had not worn seat belts cost the hospital (and the state, in the case of the uninsured) on average 25% more.[43]

text: Side-effects of seat belts[edit]

text: Neck injuries can be caused by the deceleration from a high speed. The passengers head continues to move forward while the body is restrained, potentially causing paralyzing injuries. A study of such injuries notes, "Seatbelts save lives. However, they may cause injury to adjacent structures and when they malfunction can cause injury to the abdominal viscera, bony skeleton and vascular structures. The motor industry has attempted to reduce these injuries by modification of vehicle design and safety equipment."[44]


document_title: Gwildor

question_text: who played wildor in masters of the universe

text: Gwildor

text: Development[edit]

text: Gwildor was created as a stand-in for Orko, whose features (floating and legless) were considered impractical for depiction in a live-action movie.

text: In the film, "Billy Barty, as Gwildor, is given a hobbit-like look. Storyboard coordinator Joe Griffith designed Gwildor..."[1]

text: Character profile[edit]

text: The movie[edit]

text: Gwildor was introduced into the mythology with his appearance in the 1987 live action film starring Dolph Lundgren. Played by Billy Barty, he was created specially for the movie to as a substitute for Orko,whose design was too complex for the studio to produce in live action with its limited budget. Frederick S. Clarke explains that Gwildor was "reportedly a stand-in for Orko...In the series Orko has no feet or legs and is always seen floating or flying, a difficult concept to film live..."[2]

text: As Cinefantastique reveals, veteran "midget actor Billy Barty plays Gwildor, an innocent locksmith/inventor thrown into the adventure when an invention he creates inadvertently gives Skeletor his power."[3] Thus, Gwildor's role in the movie is key to the central plot. He is introduced into the film when rescued by He-Man from Skeletor's soldiers. He then explains how he was tricked by Skeletor's sidekick Evil-Lyn into giving his prize creation The Cosmic Key to the forces of evil, and thus allowing them to enter Castle Grayskull and take over Eternia. As the unwitting cause of Grayskull's defeat, Gwildor endeavors to help He-Man overcome Skeletor by using a prototype Cosmic Key. When the heroes find themselves overwhelmed by Skeletor's army, Gwildor uses the Cosmic Key to help them escape, and the heroes are transported to Earth, leaving Gwildor faced with the task of finding the correct programming on the Key to transport them back before Skeletor gains the power of the universe.

text: Gwildor is presented as absent-minded and quite bumbling, but also wise, intelligent and good-hearted, with little fear. His Cosmic Key, meanwhile, is a complex device with numerous switches and buttons, which can be used to programme sonic waves, sounds, music and light patterns which serves to transport its users to the location of their choice.

text: In earlier drafts of the movie's script, Gwildor's character was slightly different. He was initially described as being even smaller and unable to walk long distances, meaning he had to be carried on Man-At-Arms' back for most of the story. He also had a fearful side to his character similar to that normally associated with the character of Cringer, and frequently becoming scared easily and cowering away from danger.

text: Other media[edit]

text: After the release of the movie, Gwildor was incorporated into the toy line with his own action figure, complete with Cosmic Key. A life-size Cosmic Key was also planned by Mattel, but the toy line was cancelled before it could be made.

text: He appears in the accompanying mini-comic "The Cosmic Key", which once again puts Gwildor and his creation in the spotlight, but this comic has no continuity with the movie, telling a radically different story of how He-Man came to meet Gwildor, instead having him summoned by The Sorceress to aid He-Man against an evil force.

text: Gwildor and the Cosmic Key also appear in numerous comics published after the movie, including those by Marvel Comics and various European comic series.

text: In January 2011, a new version of the Cosmic Key was released in the Masters of the Universe: Classics toyline. The Cosmic Key came with "Preternia Disguise He-Man", and was detailed to look like the version shown in the movie (with a few minor differences). A new Gwildor action figure (with prototype Cosmic Key) was released in November 2014.

text: Reception[edit]

text: The actor's "'comic flair added a great deal to the role.' Barty proved to be inventive on the set, improvising dialogue and action not found in the script."[4]


document_title: HPV vaccines

question_text: when did the hpv vaccine come out in us

question_tokens: when did the hpv vaccine come out in us

text: HPV vaccines

text: Medical uses[edit]

text: HPV vaccines are used to prevent HPV infection and therefore cervical cancer.[1] They are recommended for women who are 9 to 25 years old who have not been exposed to HPV. However, since it is unlikely that a woman will have already contracted all four viruses, and because HPV is primarily sexually transmitted, the U.S. Centers for Disease Control and Prevention has recommended vaccination for women up to 26 years of age.

text: Since the vaccine only covers some high-risk types of HPV, cervical cancer screening is recommended even after vaccination.[1][12] In the US, the recommendation is for women to receive routine Pap smears beginning at age 21. Additional vaccine candidate research is occurring for next generation products to extend protection against additional HPV types.

text: Males[edit]

text: HPV vaccines are approved for males in several countries, including Canada, Australia, South Korea, Hong Kong (SAR of China), the United Kingdom, New Zealand and the United States.

text: Gardasil has been shown to also be effective in preventing genital warts in males.[13][14] On 9 September 2009, an advisory panel recommended that the FDA licence Gardasil in the United States for boys and men ages 9–26 for the prevention of genital warts.[15] Soon after that, the vaccine was approved by the FDA for use in males aged 9 to 26 for prevention of genital warts[13][14] and anal cancer.[16] While Gardasil and Gardasil-9 vaccines have been approved for males, the third HPV vaccine, Cervarix, is not administered to males. Unlike the Gardasil-based vaccines, Cervarix does not protect against genital warts.[17]

text: On October 25, 2011, an advisory panel for the Centers for Disease Control and Prevention (CDC) voted to recommend that the vaccine should be given to boys ages 11–12. The panel's recommendation is intended to prevent genital warts and anal cancers in males, and possibly prevent head and neck cancer (though the vaccine's effectiveness against head and neck cancers has not yet been proven).[18] The Committee also made the vaccination recommendation for males 13 to 21 years who have not been vaccinated previously or who have not completed the three-dose series.[13][19]

text: In males, Gardasil may reduce their risk of genital warts and precancerous lesions caused by HPV. This reduction in precancerous lesions might be predicted to reduce the rates of penile and anal cancer in men. Since penile and anal cancers are much less common than cervical cancer, HPV vaccination of young men is likely to be much less cost-effective than for young women.[20]

text: From a public health point of view, vaccinating men as well as women decreases the virus pool within the population, but is only cost-effective if the uptake in the female population is extremely low.[21] In the United States, the cost per quality-adjusted life year is greater than $100,000 for vaccinating the male population, compared to the less than $50,000 for vaccinating the female population.[21] This assumes a 75% vaccination rate. In early 2013 the two companies who sell the most common vaccines announced a price cut to less than $5 per dose to poor countries, as opposed to $130 per dose in the US.[22]

text: As with females, the vaccine should be administered before infection with the HPV types covered by the vaccine occurs. Vaccination before adolescence, therefore, makes it more likely that the recipient has not been exposed to HPV.

text: Gardasil is in particular demand among men who have sex with men, who are at higher risk for genital warts, penile cancer, and anal cancer.[23]

text: Harald zur Hausen's support for vaccinating boys (so that they will be protected and thereby women) was joined by professors Harald Moi and Ole-Erik Iversen in 2011.[24]

text: Older women[edit]

text: When Gardasil was first introduced, it was recommended as a prevention for cervical cancer for women that were 25 years old or younger. New evidence suggests that all HPV vaccines are effective in preventing cervical cancer for women up to 45 years of age.[25]

text: In November 2007, Merck presented new data on Gardasil. In an investigational study, Gardasil reduced the incidence of HPV types 6, 11, 16 and 18-related persistent infection and disease in women through age 45. The study evaluated women who had not contracted at least one of the HPV types targeted by the vaccine by the end of the three-dose vaccination series. Merck planned to submit this data before the end of 2007 to the FDA, and to seek an indication for Gardasil for women through age 45.[26]

text: Efficacy[edit]

text: HPV vaccines have been shown to prevent cervical dysplasia from the high-risk HPV types 16 and 18 and some protection against a few closely related high-risk HPV types.[1] However, there are other high-risk HPV types that are not affected by the vaccines.[27] The protection against HPV 16 and 18 has lasted at least 8 years after vaccination for Gardasil[28] and more than 9 years for Cervarix.[28] It is thought that booster vaccines will not be necessary.[29]

text: Gardasil also protects against low-risk HPV types 6 and 11, which are much less likely to cause cancer, but do cause genital warts.

text: A recent analysis of data from a clinical trial of Cervarix found that this vaccine is just as effective at protecting women against persistent HPV 16 and 18 infection in the anus as it is at protecting them from these infections in the cervix. Overall, about 30 percent of cervical cancers will not be prevented by these vaccines. Also, in the case of Gardasil, 10 percent of genital warts will not be prevented by the vaccine. Neither vaccine prevents other sexually transmitted diseases, nor do they treat existing HPV infection or cervical cancer.[30][31]

text: HPV types 16, 18 and 45 contribute to 94% of cervical adenocarcinoma (cancers originating in the glandular cells of the cervix).[32] While most cervical cancer arises in the squamous cells, adenocarcinomas make up a sizable minority of cancers.[32] Further, Pap smears are not as effective at detecting adenocarcinomas, so where Pap screening programs are in place, a larger proportion of the remaining cancers are adenocarcinomas.[32] Trials suggest that HPV vaccines may also reduce the incidence of adenocarcinoma.[32]

text: Two doses of the vaccine may work as well as three doses.[33] The CDC recommends two doses in those less than 15 and three doses in those over 15.[34]

text: A study with 9vHPV, a 9-valent HPV vaccine that protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58, came to the result that the rate of high-grade cervical, vulvar, or vaginal disease was the same as when using a quadrivalent HPV vaccine.[35] A lack of a difference may have been caused by the study design of including women 16 to 26 years of age, who may largely already have been infected with the five additional HPV types that are additionally covered by the 9-valent vaccine.[36]

text: Public health[edit]

text: The National Cancer Institute states "Widespread vaccination has the potential to reduce cervical cancer deaths around the world by as much as two-thirds if all women were to take the vaccine and if protection turns out to be long-term. In addition, the vaccines can reduce the need for medical care, biopsies, and invasive procedures associated with the follow-up from abnormal Pap tests, thus helping to reduce health care costs and anxieties related to abnormal Pap tests and follow-up procedures."[12]

text: Current preventive vaccines protect against the two HPV types (16 and 18) that cause about 70% of cervical cancers worldwide.[37] Because of the distribution of HPV types associated with cervical cancer, the vaccines are likely to be most effective in Asia, Europe, and North America.[37] Some other high-risk types cause a larger percentage of cancers in other parts of the world.[37] Vaccines that protect against more of the types common in cancers would prevent more cancers, and be less subject to regional variation.[37] For instance, a vaccine against the seven types most common in cervical cancers (16, 18, 45, 31, 33, 52, 58) would prevent an estimated 87% of cervical cancers worldwide.[37]

text: Only 41% of women with cervical cancer in the developing world get medical treatment.[38] Therefore, prevention of HPV by vaccination may be a more effective way of lowering the disease burden in developing countries than cervical screening. The European Society of Gynecological Oncology sees the developing world as most likely to benefit from HPV vaccination.[39] However, individuals in many resource-limited nations, Kenya for example, are unable to afford the vaccine.[40]

text: In more developed countries, populations that do not receive adequate medical care, such as poor or minorities in the United States or parts of Europe also have less access to cervical screening and appropriate treatment, and are similarly more likely to benefit.[32] Comments made by Dr. Diane Harper, a researcher for the HPV vaccines, were interpreted as indicating that in countries where Pap smear screening is common, it will take vaccination of a large proportion of women in order to further reduce cervical cancer rates.[41] She has also encouraged women to continue pap screening after they are vaccinated and to be aware of potential adverse effects.[42]

text: According to the CDC, as of 2012, use of the HPV vaccine had cut rates of infection with HPV-6, -11, -16 and -18 in half in American teenagers (from 11.5% to 4.3%) and by one third in American women in their early twenties (from 18.5% to 12.1%).[43]

text: Side effects[edit]

text: While the use of HPV vaccines can help reduce cervical cancer deaths by two thirds around the world,[44] not everyone is eligible for vaccination. There are some factors that exclude people from receiving HPV vaccines. These factors include:[45]

text:
People with history of immediate hypersensitivity to vaccine components. Patients with a hypersensitivity to yeast should not receive Gardasil since yeast is used in its production.
People with moderate or severe acute illnesses. This does not completely exclude patients from vaccination, but postpones the time of vaccination until the illness has improved.[46]

text: Pregnancy[edit]

text: In the Gardasil clinical trials, 1,115 pregnant women received the HPV vaccine. Overall, the proportions of pregnancies with an adverse outcome were comparable in subjects who received Gardasil and subjects who received placebo.[47] However, the clinical trials had a relatively small sample size. Currently, the vaccine is not recommended for pregnant women.[47][48] The long-term effects of the vaccine on fertility are not known, but no effects are anticipated.

text: The FDA has classified the HPV vaccine as a pregnancy Category B, meaning there is no apparent harm to the fetus in animal studies. HPV vaccines have not been causally related with adverse pregnancy outcomes or adverse effects on the fetus. However, data on vaccination during pregnancy is very limited and vaccination during the pregnancy term should be delayed until more information is available. If a woman is found to be pregnant during the three-dose series of vaccination, the series will be postponed until pregnancy has been completed. While there is no indication for intervention for vaccine dosages administered during pregnancy, patients and health-care providers are encouraged to report exposure to vaccines to the appropriate HPV vaccine pregnancy registry.[45][46][49]

text: Safety[edit]

text: HPV vaccines are approved for use in over 100 countries, with more than 100 million doses distributed worldwide. Extensive clinical trial and post-marketing safety surveillance data indicate that both Gardasil and Cervarix are well tolerated and safe.[50]

text: A cohort study of approximately 1 million girls found no evidence supporting associations between exposure to quadrivalent human papillomavirus vaccine and autoimmune, neurological, and venous thromboembolic adverse events.[51]

text: Gardasil is a 3-dose (injection) vaccine. As of 8 September 2013[update] there have been more than 57 million doses distributed in the United States, though it is unknown how many have been administered.[52] There have been 22,000 Vaccine Adverse Event Reporting System (VAERS) reports following the vaccination.[53] Ninety-two percent were reports of events considered to be non-serious (e.g., fainting, pain and swelling at the injection site (arm), headache, nausea and fever), and 9 percent were considered to be serious (death, permanent disability, life-threatening illness and hospitalization). There is no proven causal link between the vaccine and serious adverse effects; VAERS reports include any effects whether coincidental or causal. The CDC states: "When evaluating data from VAERS, it is important to note that for any reported event, no cause-and-effect relationship has been established. VAERS receives reports on all potential associations between vaccines and adverse events."[53]

text: As of 1 September 2009[update], there have been 44 U.S. reports of death in females after receiving the vaccine.[53] None of the 27 confirmed deaths of women and girls who had taken the vaccine were linked to the vaccine.[53] There is no evidence suggesting that Gardasil causes or raises the risk of Guillain–Barré syndrome. Additionally, there have been rare reports of blood clots forming in the heart, lungs and legs.[53] A 2015 review conducted by the European Medicines Agency's Pharmacovigilance Risk Assessment Committee concluded that evidence does not support the idea that HPV vaccination causes complex regional pain syndrome or postural orthostatic tachycardia syndrome.[54]

text: As of 8 September 2013[update] the CDC continues to recommend Gardasil vaccination for the prevention of four types of HPV.[53] Merck, the manufacturer of Gardasil, has committed to ongoing research assessing the vaccine's safety.[55]

text: According to the Centers for Disease Control and Prevention (CDC) and the FDA, the rate of adverse side effects related to Gardasil immunization in the safety review was consistent with what has been seen in the safety studies carried out before the vaccine was approved and were similar to those seen with other vaccines. However, a higher proportion of syncope (fainting) were seen with Gardasil than are usually seen with other vaccines. The FDA and CDC have reminded health care providers that, to prevent falls and injuries, all vaccine recipients should remain seated or lying down and be closely observed for 15 minutes after vaccination.[31] The HPV vaccination does not appear to reduce the willingness of women to undergo pap tests.[56]

text: Mechanism of action[edit]

text: The HPV vaccines are based on hollow virus-like particles (VLPs) assembled from recombinant HPV coat proteins. The virus possesses circular double stranded DNA and a viral shell that is composed of 72 capsomeres. Every subunit of the virus is composed of two proteins molecules, L1 and L2. The reason why this virus has the capability to affect the skin and the mucous layers is due to its structure. The primary structures expressed in these areas are E1 and E2, these proteins are responsible for the replication of the virus.[57] E1 is a highly conserved protein in the virus, E1 is in charge of the production of viral copies is also involved in every step of replication process.[57] The second component of this process is E2 ensures that non-specific interaction occurs while interacting with E1.[57] As a result of these proteins working together it assures that numerous copies are made within the host cell. The structure of the virus is critical because this influences the infection affinity of the virus. Knowing the structure of the virus allowed for the development of an efficient vaccine, such as Gardasil and Cervarix. The vaccines target the two high-risk HPVs, types 16 and 18 that cause the most cervical cancers. Gardasil's proteins are synthesized by the yeast Saccharomyces cerevisiae. Its protein makeup allows it to target four types of HPV. Gardasil contains inactive L1 proteins from four different HPV strains: 6, 11, 16, and 18. Each vaccine dose contains 225 µg of aluminum, 9.56 mg of sodium chloride, 0.78 mg of L-histidine, 50 µg of polysorbate 80, 35 µg of sodium borate, and water. The combination of ingredients totals 0.5 mL.[58] Together, these two HPV types currently cause about 70 percent of all cervical cancer.[37] Gardasil also targets HPV types 6 and 11, which together currently cause about 90 percent of all cases of genital warts.[59]

text: Gardasil and Cervarix are designed to elicit virus-neutralizing antibody responses that prevent initial infection with the HPV types represented in the vaccine. The vaccines have been shown to offer 100 percent protection against the development of cervical pre-cancers and genital warts caused by the HPV types in the vaccine, with few or no side effects. The protective effects of the vaccine are expected to last a minimum of 4.5 years after the initial vaccination.[27]

text: While the study period was not long enough for cervical cancer to develop, the prevention of these cervical precancerous lesions (or dysplasias) is believed highly likely to result in the prevention of those cancers.[60]

text: History[edit]

text: The vaccine was first developed by the University of Queensland in Australia and the final form was made by researchers at the University of Queensland, Georgetown University Medical Center, University of Rochester, and the U.S. National Cancer Institute.[61] Researchers Ian Frazer and Jian Zhou at the University of Queensland have been accorded priority under U.S. patent law for the invention of the HPV vaccine's basis, the VLPs.[62] In 2006, the FDA approved the first preventive HPV vaccine, marketed by Merck & Co. under the trade name Gardasil. According to a Merck press release,[63] in the second quarter of 2007, it had been approved in 80 countries, many under fast-track or expedited review. Early in 2007, GlaxoSmithKline filed for approval in the United States for a similar preventive HPV vaccine, known as Cervarix. In June 2007 this vaccine was licensed in Australia, and it was approved in the European Union in September 2007.[64] Cervarix was approved for use in the U.S. in October 2009.[65]

text: Harald zur Hausen, a German researcher who initially suspected and later helped to prove that genital HPV infection can lead to cervical cancer, was awarded half of the $1.4 million Nobel Prize in Medicine for his work. Verification that cervical cancer is caused by an infectious agent led several other groups (see above) to develop vaccines against HPV strains that cause most cases of cervical cancer. The other half of the award went to Françoise Barré-Sinoussi and Luc Montagnier, two French virologists, for their part in the discovery of HIV.[66]

text: zur Hausen went against current dogma and postulated that oncogenic human papilloma virus (HPV) caused cervical cancer.[31] He realized that HPV-DNA could exist in a non-productive state in the tumours, and should be detectable by specific searches for viral DNA.[66] He and others, notably workers at the Pasteur Institute, found HPV to be a heterogeneous family of viruses. Only some HPV types cause cancer.[31]

text: Harald zur Hausen pursued his idea of HPV for over 10 years by searching for different HPV types. [3] This research was difficult due to the fact that only parts of the viral DNA were integrated into the host genome. He found novel HPV-DNA in cervix cancer biopsies, and thus discovered the new, tumourigenic HPV16 type in 1983. In 1984, he cloned HPV16 and 18 from patients with cervical cancer.[66] The HPV types 16 and 18 were consistently found in about 70% of cervical cancer biopsies throughout the world.[31]

text: His observation of HPV oncogenic potential in human malignancy provided impetus within the research community to characterize the natural history of HPV infection, and to develop a better understanding of mechanisms of HPV-induced carcinogenesis.[31]

text: In December 2014, the United States' Food and Drug Administration (FDA) approved a vaccine called Gardasil 9 to protect females between the ages of 9 and 26 and males between the ages of 9 and 15 against nine strains of HPV.[67] Gardasil 9 protects against infection with the strains covered by the first generation of Gardasil (HPV-6, HPV-11, HPV-16, and HPV-18) and protects against five other HPV strains responsible for 20% of cervical cancers (HPV-31, HPV-33, HPV-45, HPV-52, and HPV-58).[67]

text: Vaccine implementation[edit]

text: In developed countries, the widespread use of cervical "Pap smear" screening programs has reduced the incidence of invasive cervical cancer by 50% or more. Current preventive vaccines reduce but do not eliminate the chance of getting cervical cancer. Therefore, experts recommend that women combine the benefits of both programs by seeking regular Pap smear screening, even after vaccination.[68] The European Centre for Disease Prevention and Control (ECDC) has recommended all European teenage girls to be vaccinated; however Bulgaria, Cyprus, Czech Republic, Estonia, Lithuania, Poland, Slovakia, and Turkey currently do not have a vaccination program in place.[citation needed]

text: Africa[edit]

text: With support from the GAVI Alliance, a number of low-income African countries have begun rollout of the HPV vaccine, with others to follow. In 2013 Ghana, Kenya, Madagascar, Malawi, Niger, Sierra Leone, and the United Republic of Tanzania begin implementation of the vaccine. In 2014, Rwanda will begin nationwide rollout, and demonstration programs will take place in Mozambique and Zimbabwe.[69]

text: Australia[edit]

text: In April 2007, Australia became the first country to introduce a government-funded National Human Papillomavirus (HPV) Vaccination Program to protect young women against HPV infections that can lead to cancers and disease.[70] The National HPV Vaccination Program is listed on the National Immunisation Program (NIP) Schedule and funded under the Immunise Australia Program.[71] The Immunise Australia Program is a joint Australian, State, and Territory Government initiative to increase immunisation rates for vaccine preventable diseases.

text: The National HPV Vaccination Program for females was made up of two components: an ongoing school-based program for 12- and 13-year-old girls; and a time-limited catch-up program (females aged 14–26 years) delivered through schools, general practices, and community immunization services, which ceased on 31 December 2009.

text: During 2007–2009, an estimated 83% of females aged 12–17 years received at least one dose of HPV vaccine and 70% completed the 3-dose HPV vaccination course.[70] Latest HPV coverage data on the Immunise Australia website show that by 15 years of age, over 70% of Australian females have received all three doses. This has remained steady since 2009.[72]

text: Since the National HPV Vaccination Program commenced in 2007, there has been a reduction in HPV-related infections in young women. A study published in The Journal of Infectious Disease in October 2012 found the prevalence of vaccine-preventable HPV types (6, 11, 16 and 18) in Papanicolaou test results of women aged 18–24 years has significantly decreased from 28.7% to 6.7% four years after the introduction of the National HPV Vaccination Program.[70] A 2011 report published found the diagnosis of genital warts (caused by HPV types 6 and 11) had also decreased in young women and men.[73]

text: In October 2010, the Australian regulatory agency, the Therapeutic Goods Administration, extended the registration of the quadrivalent vaccine (Gardasil) to include use in males aged 9 through 26 years of age, for the prevention of external genital lesions and infection with HPV types 6, 11, 16 and 18.

text: In November 2011, the Pharmaceutical Benefits Advisory Committee (PBAC) recommended the extension of the National HPV Vaccination Program to include males. The PBAC made its recommendation on the preventative health benefits that can be achieved, such as a reduction in the incidence of anal and penile cancers and other HPV-related diseases. In addition to the direct benefit to males, it was estimated that routine HPV vaccination of adolescent males would contribute to the reduction of vaccine HPV-type infection and associated disease in women through herd immunity.[74]

text: On 12 July 2012, the Australian Government announced funding to extend the National HPV Vaccination Program to include males, with implementation commencing in all states and territories in February 2013.[75]

text: Updated results were reported in 2014.[76]

text: From February 2013, free HPV vaccine is being provided through school-based programs for:

text:
males and females aged 12–13 years (ongoing program); and
males aged between 14–15 years – until the end of the school year in 2014 (catch up program).

text: Further information is available on the HPV Vaccination Program website at www.australia.gov.au/hpv

text: Canada[edit]

text: In July 2006, human papillomavirus vaccine against 4 types of HPV was authorized in Canada for females 9 to 26 years. In February 2010, use in males 9 to 26 years of age for prevention of genital warts was authorized.[77]

text: Currently, all Canadian provinces and territories fund HPV school-based immunization programs for females.[78] Three provinces have implemented HPV immunization programs for males: Prince Edward Island, Alberta,[78] and Saskatchewan.[79]

text: Canada has approved use of Gardasil.[80] Initiating and funding free vaccination programs has been left to individual Province/Territory Governments. In the provinces of Ontario, Prince Edward Island, Newfoundland and Labrador, and Nova Scotia,[81] free vaccinations to protect women against HPV were slated to begin in September 2007 and will be offered to girls ages 11–14. Similar vaccination programs are being planned in British Columbia and Quebec.[82][83][84]

text: China[edit]

text: GSK China announced on July 18, 2016, that Cervarix (HPV vaccine 16 and 18) had been approved by China Food and Drug Administration (CFDA), therefore became the first approved HPV vaccine in China. Cervarix is registered in China for girls aged 9 to 25, adopting 3-dose program within 6 months. Cervarix is expected to be marketed in China in early 2017.[85]

text: On the same day, China Food and Drug Administration (CFDA) also announced that the import registration application of Human Papillomavirus Absorbed Vaccine (Cervarix), the preventive biological product manufactured by GlaxoSmithKline, had been approved on July 12, 2016. The approval of this vaccine will provide a brand-new effective method to prevent cervical cancers.[86]

text: Colombia[edit]

text: The vaccine was introduced in 2012, approved for 9 aged girls.[87][88] The HPV vaccine begins to delivered to girls aged 9 and older and are attending fourth grade of school. Since 2013 the age of coverage was extended to girls in school from grade four who have reached the age of 9 to grade 11th independent of age; and no schooling from age 9–17 years 11 months and 29 days old.[89]

text: Europe[edit]

text:
Country
Date of introduction
Gender(s)
Target age group
Financed by
Policy

Austria
2006
M/F
10–12
Fully financed by national health authorities[90]

Belgium
2007

10–13
Financed 75% by national health authorities

Croatia
20 May 2016
M/F
12
Fully financed by national health authorities
Voluntary immunization for women not yet sexually active

Denmark[91]
1 January 2009
F
12
Fully financed by national health authorities
Part of the Danish Childhood Vaccination program

Finland[92]
21 November 2013
F
12
Fully financed by national health authorities
Part of the Finnish National Vaccination program

France[93]
11 July 2007
F
14–23
Financed 65% by national health authorities
Voluntary immunization for women not yet sexually active

Germany[94]
26 March 2007

Greece[95][96]
12 February 2007
F
12–26
Fully financed by national health authorities
Mandatory for all girls entering 7th grade

Hungary[97]
2014
F
12
Fully financed by national health authorities. In addition subsidised by local councils for 13- and 14-year-olds.

Iceland
2011

12
Fully financed by national health authorities

Ireland
2008

12–13
Fully financed by national health authorities

Italy[94]
26 March 2007
F
12

Latvia
2009

12
Fully financed by national health authorities

Luxembourg
2008

12
Fully financed by national health authorities

Macedonia
2009
F
12
Fully financed by national health authorities
Mandatory; part of the national immunization schedule

Netherlands
2009
F
12–13
Fully financed by national health authorities

Norway
2009
F
12–13

Part of the national immunization program

Portugal
2007
F
13
Fully financed by national health authorities
Part of the national immunization program

Romania
November 2008
F
10–11

Slovenia
2009

11–12
Fully financed by national health authorities

Spain
2007

11–14
Fully financed by national health authorities

Sweden[98]
1 January 2010
F
10–12

Switzerland
2008

11–14
Fully financed by national health authorities

UK
September 2008
M/F
M:9–15
F:9–26
Fully financed by national health authorities for girls only

text: Israel[edit]

text: Introduced in 2012. Target age group 13–14. Fully financed by national health authorities only for this age group. For the year 2013–2014, girls in the eighth grade may get the vaccine free of charge only in school, and not in Ministry of Health offices or clinics. Girls in the ninth grade may receive the vaccine free of charge only at Ministry of Health offices, and not in schools or clinics.[99] Religious and conservative groups are expected to refuse the vaccination.[100]

text: Japan[edit]

text: Introduced in 2010, widely available only since April 2013. Fully financed by national health authorities. In June 2013, however, Japan's Vaccine Adverse Reactions Review Committee (VARRC) suspended recommendation of the vaccine due to fears of adverse events. This directive has been criticized by researchers at the University of Tokyo as a failure of governance since the decision was taken without presentation of adequate scientific evidence.[101]

text: Kenya[edit]

text: Both Cervarix and Gardasil are approved for use within Kenya by the Pharmacy and Poisons Board. However, at a cost of 20,000 Kenyan shillings, which is more than the average annual income for a family, the director of health promotion in the Ministry of Health, Nicholas Muraguri, states that many Kenyans are unable to afford the vaccine.[40]

text: Laos[edit]

text: In 2013 Laos began implementation of the HPV vaccine, with the assistance of the Gavi Alliance.[69]

text: Mexico[edit]

text: The vaccine was introduced in 2008 to 5% of the population. This percentage of the population had the lowest development index which correlates with the highest incidence of cervical cancer.[102] The HPV vaccine is delivered to girls 12 – 16 years old following the 0-2-6 dosing schedule. By 2009 Mexico had expanded the vaccine use to girls, 9–12 years of age, the dosing schedule in this group was different, the time elapsed between the first and second dose was six months and the third dose 60 months later.[103] In 2011 Mexico approved a nationwide use of HPV vaccination program to include vaccination of all 9-year-old girls.[103]

text: New Zealand[edit]

text: The publicly funded New Zealand HPV Immunisation Programme began on 1 September 2008. Gardasil is available free for New Zealand girls, usually through a school-based program in Year 8 (approximately age 12), but also through general practices and some family planning clinics. While it is recommended at age 12, it is free for young women before their 20th birthday. Over 200,000 New Zealand girls and young women have received HPV immunization as at November 2015, around 60% of eligible girls.[104]

text: Panama[edit]

text: The vaccine was added to the national immunization program in 2008, to target girls in the population aged 10.[102] The vaccine is being administer by clinics and schools.[103]

text: South Africa[edit]

text: Cervical cancer represents the most common cause of cancer-related deaths—more than 3,000 deaths per year—among women in South Africa because of high HIV prevalence, making introduction of the vaccine highly desirable.[105] A Papanicolaou test program was established in 2000 to help screen for cervical cancer, but since this program has not been implemented widely, vaccination would offer more efficient form of prevention.[106] In May 2013 the Minister of Health of South Africa, Aaron Motsoaledi, announced the government would provide free HPV vaccines for girls aged 9 and 10 in the poorest 80% of schools starting in February 2014 and the fifth quintile later on.[107] South Africa will be the first African country with an immunisation schedule that includes vaccines to protect people from HPV infection, but because the effectiveness of the vaccines in women who later become infected with HIV is not yet fully understood, it is difficult to assess how cost-effective the vaccine will be. Negotiations are currently underway for more affordable HPV vaccines since they are up to 10 times more expensive than others already included in the immunization schedule.[105][107]

text: South Korea[edit]

text: On July 27, 2007, South Korean government approved Gardasil for use in girls and women aged 9 to 26 and boys aged 9 to 15.[108] Approval for use in boys was based on safety and immunogenicity but not efficacy.

text: Since 2016, HPV vaccination has been part of the National Immunization Program, offered free of charge to all children under 12 in South Korea, with costs fully covered by the Korean government.[109]

text: For 2016 only, Korean girls born between 1 January 2003 to 31 December 2004 are also eligible to receive the free shots as a limited time offer. From 2017, the free shots will be available to those under 12 only.[110]

text: Trinidad and Tobago[edit]

text: Introduced in 2013. Target Group 9–26. Fully financed by national health authorities. Administration in schools currently suspended owing to objections and concerns raised by the Catholic Board, but fully available in local health centers.

text: United Kingdom[edit]

text: In the UK the vaccine is licensed for girls aged 9 to 15, for women aged 16 to 26, and for boys aged 9–15.[111]

text: HPV vaccination with Cervarix was introduced into the national immunization program in September 2008, for girls aged 12–13 across the UK. A two-year catch-up campaign started in Autumn 2009 to vaccinate all girls up to 18 years of age. Catch up vaccination will be offered to:

text:
girls aged between 16 and 18 from autumn 2009, and
girls aged between 15 and 17 from autumn 2010.

text: By the end of the catch-up campaign, all girls under 18 will have been offered the HPV vaccine.

text: In September 2012, Gardasil replaced Cervarix as the HPV vaccination of choice due to its added protection against genital warts.

text: It will be many years before the vaccination program has an effect on cervical cancer incidence so women are advised to continue accepting their invitations for cervical screening.[112]

text: Boots UK made its private HPV vaccination service to boys and men aged 12–44 years in April 2017 at a cost of £150 per vaccination. Children aged 12–14 years require two vaccinations, while those aged 15–44 years require a course of three.[113]

text: United States[edit]

text: Adoption[edit]

text: As of late 2007[update], about one quarter of US females age 13–17 years had received at least one of the three HPV shots.[114] By 2014[update], the proportion of such females receiving a vaccination had risen to 38%.[115] The government began recommending vaccination for boys in 2011; by 2014[update], the vaccination rate among boys (at least one dose) had reached 35%.[115]

text: According to the US Centers for Disease Control and Prevention (CDC), getting as many girls vaccinated as early and as quickly as possible will reduce the cases of cervical cancer among middle-aged women in 30 to 40 years and reduce the transmission of this highly communicable infection. Barriers include the limited understanding by many people that HPV causes cervical cancer, the difficulty of getting pre-teens and teens into the doctor's office to get a shot, and the high cost of the vaccine ($120/dose, $360 total for the three required doses, plus the cost of doctor visits).[30][116] Community-based interventions can increase the uptake of HPV vaccination among adolescents.[117]

text: A survey was conducted in 2009 to gather information about knowledge and adoption of the HPV vaccine. Thirty percent of 13- to 17-year-olds and 9% of 18- to 26-year-olds out of the total 1,011 young women surveyed reported receipt of at least one HPV injection. Knowledge about HPV varied; however, 5% or fewer subjects believed that the HPV vaccine precluded the need for regular cervical cancer screening or safe-sex practices. Few girls and young women overestimate the protection provided by the vaccine. Despite moderate uptake, many females at risk of acquiring HPV have not yet received the vaccine.[118] For example, young black women are less likely to receive HPV vaccines compared to young white women. Additionally, young women of all races and ethnicities without health insurance are less likely to initiate vaccine uptake.[119]

text: Since the approval of Gardasil in 2006 and despite low vaccine uptake, prevalence of HPV among teenagers aged 14–19 has been cut in half with an 88% reduction among vaccinated women. No decline in prevalence was observed in other age groups, indicating the vaccine to have been responsible for the sharp decline in cases. The drop in number of infections is expected to in turn lead to a decline in cervical and other HPV-related cancers in the future.[120][121]

text: Legislation[edit]

text: Shortly after the first HPV vaccine was approved, bills to make the vaccine mandatory for school attendance were introduced in many states.[122] Only two such bills passed (in Virginia and Washington DC) during the first four years after vaccine introduction.[122] Mandates have been effective at increasing uptake of other vaccines, such as mumps, measles, rubella, and hepatitis B (which is also sexually transmitted).[116] However most such efforts developed for five or more years after vaccine release, while financing and supply were arranged, further safety data was gathered, and education efforts increased understanding, before mandates were considered.[122] Most public policies including school mandates have not been effective in promoting HPV vaccination while receiving a recommendation from a physician increased the probability of vaccination.[123]

text: State-by-State[edit]

text: The National Conference of State Legislatures periodically issues summaries of HPV vaccine related legislation.[124]

text: Almost all pieces of legislation currently pending in the states that would make the vaccine mandatory for school entrance have an "opt-out" policy.[124]

text: In July, 2015, Rhode Island added an HPV vaccine requirement for admittance into public school. This mandate requires all students entering the 7th grade to receive one dose of the HPV vaccine starting in September, 2015.[125][126] No legislative action is required for the Rhode Island Department of Health to add new vaccine mandates. Rhode Island is the only state that requires the vaccine for both male and female 7th graders.[127][128]

text: Other states are also preparing bills regarding the HPV Vaccine.[124]

text:
State
Proposal
Status

Alabama
HB 42 would allow parents the option of immunizing female students entering the sixth grade, and requires the Department of Health and Senior Services to directly mail age appropriate information to parents or guardians to those students regarding the connection between HPV and cervical cancer and the availability of the immunization.
Passed

Alaska
Voluntary vaccination program
Passed

Florida
SB 1116 Would require the Department of Health to adopt a rule adding HPV/cervical cancer to the list of communicable diseases for which immunizations are recommended; requires that schools provide the parents or guardians of certain public school students information regarding the disease and the availability of a vaccine; requires the department to prescribe the required information.
Not passed

Georgia
HB 736 Would require public Schools to provide parents or guardians of sixth grade female students information concerning the infection and the immunization against the human papillomavirus.

Hawaii
HCR 71 Would request the Department of Health to make human papillomavirus immunization available to indigent patients and through the teen VAX program, and urging insurers to offer coverage for human papillomavirus immunization to female policyholders eleven to twenty-six years of age.
Not Passed

Iowa
SSB 3097 Would create a study bill for a HPV public awareness program and make appropriations for the public awareness program, provision of vaccinations, and cervical cancer screenings.
In committee

Kansas
HR 6019 Resolution would urge the FDA to use caution in approving new vaccines such as Gardasil which has had a number of health problems including some deaths associated with the use of this vaccine.
In committee

Kentucky
HR 80 Would urge females ages 9 to 26 and males ages 11 to 26 to obtain the Human papillomavirus (HPV) vaccination and all citizens to become more knowledgeable about the benefits of HPV vaccination.
Passed

Maryland
HB 411 Would require the Statewide Advisory Commission on Immunizations to study the safety of the human papillomavirus (HPV) vaccine; requires the Commission to include specified components in the study, make recommendations, and report the results of its study.
Passed

Minnesota
HF 1758 Would require the commissioner of health to prepare informational materials on vaccines including the HPV vaccines and encourages public and private schools with students in grades 6-12 to provide this information to parents in a cost-effective and programmatically effective manner. (Introduced 3/16/09)

Michigan
SB 1062 and SB 1063 Each would require health insurers to provide coverage for human papillomavirus screenings for cervical cancer.
In committee

Mississippi
HB 1512 Would require health benefit plans to cover HPV screenings.
Not Passed

Missouri
HB 1935 Would require health insurers to provide coverage for human papillomavirus screenings for cervical cancer.
In committee

New Jersey
S 1163 Would require health insurers and State Health Benefits Program and SEHBP to provide coverage for screening for cervical cancer, including testing for HPV. (Sent to Committee 1/23/12)
A 2185 Would require insurers and State health care coverage programs to cover cost of HPV vaccine.

In committee

New York
SB 98 (same as AB 2360) Would encourage voluntary, informed vaccination against human papillomavirus (HPV). (Amended in Senate Committee on Health 1/5/12)
AB 699 Would require immunization against HPV for children born after Jan. 1, 1996. (Sent to Assembly Committee on Health 1/5/11) AB 1946 Would require insurance companies to provide coverage for the vaccine against human papilloma virus. (Sent to committee 1/12/11) AB 2360 Would encourage voluntary, informed vaccination against human papillomavirus (HPV) for school-aged children and their parents or guardians. (Sent to committee 1/18/11) SB 4708 Would require insurance companies to cover HPV vaccine.

In committee

Oregon
HB 2794 Would require health benefit plans to provide coverage of human papillomavirus vaccine for female beneficiaries who are 11 years of age or older.
Passed

Pennsylvania
HB 524 Would require health insurance policies to provide coverage for vaccinations for human papilloma virus.
In committee

South Carolina
HB 4497 Would enact the Cervical Cancer Prevention Act and allow the Department of Health and Environmental Control to offer the option of an HPV vaccine series to female students entering the seventh grade at the request of their parent or guardian pending state and federal funding.
In committee

Texas
HB 2220 Would allow the Executive Commissioner of the Health and Human Services Commission to require immunization against human papillomavirus or other immunizations for a person's admission to elementary or secondary school.
In committee

Virginia
HB 1419 Would repeal the HPV vaccination requirement for female children. (Passed House 1/21/11, Indefinitely passed by the Senate Committee 2/17/11)
HB 65 Would repeal the requirement for children to receive the HPV vaccination for school attendance. (Left in committee 2/14/12) HB 824 Would require that the Commonwealth shall assume liability for any injury resulting from administration of the human papillomavirus vaccine. HB 1112 Would eliminate the requirement for vaccination against human papillomavirus for female children.

Passed House and sent to Senate

text: Source: National Conference of State Legislatures

text: Immigrants[edit]

text: Between July 2008 and December 2009, proof of the first of three doses of HPV Gardasil vaccine was required for women ages 11–26 intending to legally enter the United States. This requirement stirred controversy because of the cost of the vaccine, and because all the other vaccines so required prevent diseases which are spread by respiratory route and considered highly contagious.[129] The Centers for Disease Control and Prevention repealed all HPV vaccination directives for immigrants effective December 14, 2009.[130]

text: Coverage[edit]

text: Measures have been considered including requiring insurers to cover HPV vaccination, and funding HPV vaccines for those without insurance. The cost of the HPV vaccines for females under 18 who are uninsured is covered under the federal Vaccines for Children Program.[131] As of 23 September 2010, vaccines are required to be covered by insurers under the Patient Protection and Affordable Care Act. HPV vaccines specifically are to be covered at no charge for women, including those who are pregnant or nursing.[132]

text: Medicaid covers HPV vaccination in accordance with the ACIP recommendations, and immunizations are a mandatory service under Medicaid for eligible individuals under age 21. [1][citation needed] In addition, Medicaid includes the Vaccines for Children Program. [1][citation needed] This program provides immunization services for children 18 and under who are Medicaid eligible, uninsured, underinsured, receiving immunizations through a Federally Qualified Health Center or Rural Health Clinic, or are Native American or Alaska Native.[1][citation needed]

text: The vaccine manufacturers also offer help for people who cannot afford HPV vaccination. GlaxoSmithKline's Vaccines Access Program[133] provides Cervarix[134] free of charge 1-877-VACC-911[135] to low income women, ages 19 to 25, who do not have insurance.[136] Merck's Vaccine Patient Assistance Program 1-800-293-3881[137] provides Gardasil free to low income women and men, ages 19 to 26, who do not have insurance, including immigrants who are legal residents.[138]

text: Opposition in the United States[edit]

text: Insurance companies[edit]

text: There has been significant opposition from health insurance companies to covering the cost of the vaccine ($360).[139][140][141]

text: Religious and conservative groups[edit]

text: Opposition due to the safety of the vaccine has been addressed through studies, leaving opposition focused on the sexual implications of the vaccine to remain. Conservative[142][who?] groups in the U.S. have opposed the concept of making HPV vaccination mandatory for pre-adolescent girls, asserting that making the vaccine mandatory is a violation of parental rights. They also say that it will lead to early sexual activity, giving a false sense of immunity to sexually transmitted disease. (See Peltzman effect) Both the Family Research Council and the group Focus on the Family support widespread (universal) availability of HPV vaccines but oppose mandatory HPV vaccinations for entry to public school.[143][144][145][146] Parents also express confusion over recent mandates for entry to public school pointing out that HPV is transmitted through sexual contact, not through attending school with other children.[147]

text: Conservative groups are concerned children will see the vaccine as a safeguard against STDs and will have sex sooner than they would without the vaccine while failing to use contraceptives.[147] However; Many organizations such as the American Academy of Pediatrics disagree with the argument that the vaccine increases sexual activity among teens.[148] Dr. Christine Peterson, director of the University of Virginia's Gynecology Clinic, said "The presence of seat belts in cars doesn't cause people to drive less safely. The presence of a vaccine in a person's body doesn't cause them to engage in risk-taking behavior they would not otherwise engage in."[149][150]

text: Parental opposition[edit]

text: Many parents opposed to providing the HPV vaccine to their pre-teens agree the vaccine is safe and effective, but find talking to their children about sex uncomfortable. Dr. Elizabeth Lange, of Waterman Pediatrics in Providence, RI, addresses this concern by emphasizing what the vaccine is doing for the child. Dr. Lange suggests parents should focus on the cancer prevention aspect without being distracted by words like 'sexually transmitted'. Everyone wants cancer prevention, yet here parents are denying their children a form of protection due to the nature of the cancer—Lagne suggests that this much controversy would not surround a breast cancer or colon cancer vaccine. The HPV vaccine is suggested for 11-year-olds because it should be administered before possible exposure to HPV, yes, but also because the immune system has the highest response for creating antibodies around this age. Dr. Lange also emphasized the studies showing that the HPV vaccine does not cause children to be more promiscuous than they would be without the vaccine.[147]

text: Controversy over the HPV vaccine remains present in the media. Parents in Rhode Island have created a Facebook group called "Rhode Islanders Against Mandated HPV Vaccinations" in response to Rhode Island's mandate that males and females entering the 7th grade, as of September 2015, be vaccinated for HPV before attending public school.[147]

text: Physician impact[edit]

text: The effectiveness of a physician's recommendation for the HPV vaccine also contributes to low vaccination rates and controversy surrounding the vaccine. A 2015 study of national physician communication and support for the HPV vaccine found physicians routinely recommend HPV vaccines less strongly than they recommend Tdap or meningitis vaccines, find the discussion about HPV to be long and burdensome, and discuss the HPV vaccine last, after all other vaccines. Researchers suggest these factors discourage patients and parents from setting up timely HPV vaccines. In order to increase vaccination rates, this issue must be addressed and physicians should be better trained to handle discussing the importance of the HPV vaccine with patients and their families.[151]

text: Research[edit]

text: There are high-risk HPV types, that are not affected by available vaccines.[27] Ongoing research is focused on the development of HPV vaccines that will offer protection against a broader range of HPV types. One such method is a vaccine based on the minor capsid protein L2, which is highly conserved across HPV genotypes.[152] Efforts for this have included boosting the immunogenicity of L2 by linking together short amino acid sequences of L2 from different oncogenic HPV types or by displaying L2 peptides on a more immunogenic carrier.[153] [154] There is also substantial research interest in the development of therapeutic vaccines, which seek to elicit immune responses against established HPV infections and HPV-induced cancers.[155]

text: Therapeutic vaccines[edit]

text: In addition to preventive vaccines, such as Gardasil and Cervarix, laboratory research and several human clinical trials are focused on the development of therapeutic HPV vaccines. In general, these vaccines focus on the main HPV oncogenes, E6 and E7. Since expression of E6 and E7 is required for promoting the growth of cervical cancer cells (and cells within warts), it is hoped that immune responses against the two oncogenes might eradicate established tumors.[156]

text: There is a working therapeutic HPV vaccine. It has gone through 3 clinical trials. The vaccine is officially called the MEL-1 vaccine but also known as the MVA-E2 vaccine. In a study it has been suggested that an immunogenic peptide pool containing epitopes that can be effective against all the high-risk HPV strains circulating globally and 14 conserved immunogenic peptide fragments from 4 early proteins (E1, E2, E6 and E7) of 16 high-risk HPV types providing CD8+ responses.[157][158][159][160][161]

text: Therapeutic DNA vaccine VGX-3100, which consists of plasmids pGX3001 and pGX3002, has been granted a waiver by the European Medicines Agency for pediatric treatment of squamous intraepithelial lesions of the cervix caused by HPV types 16 and 18.[162] According to an article published 16 Sep 2015 in The Lancet, which reviewed the safety, efficacy, and immunogenicity of VGX-3100 in a double-blind, randomized controlled trial (phase 2b) targeting HPV-16 and HPV-18 E6 and E7 proteins for cervical intraepithelial neoplasia 2/3, it is the first therapeutic vaccine to show efficacy against CIN 2/3 associated with HPV-16 and HPV-18.[163] In June, 2017, VGX-3100 entered a phase 3 clinical trial called REVEAL-1 for the treatment of HPV-induced high-grade squamous intraepithelial lesions.[164] The estimated completion time for collecting primary clinical endpoint data is August, 2019.[165]

text: Awards[edit]

text: In 2009 as part of the Q150 celebrations, the cervical cancer vaccine was announced as one of the Q150 Icons of Queensland for its role in "innovation and invention".[166]

text: In 2017, National Cancer Institute scientists Douglas R. Lowy and John T. Schiller received the Lasker-DeBakey Clinical Medical Research Award for their contributions leading to the development of HPV vaccines. [167]