Stephanie Shine persisted, despite her 13-year-old daughter's resistance to getting the new vaccine against a sexually transmitted disease that can cause cervical cancer.
"For your safety? Your health? Your future?" Then Shine got creative: "What if you don't have to pay back the $20 you owe me?"
At that, daughter Cally - who hates needles - agreed to be immunized, even though it meant three shots across six months.
"I wanted to safeguard her as best I could against what can be a very pernicious lifelong worry," said Shine, co-president of the PTSA at Washington Middle School in Seattle.
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In contrast, Sue Hoverson, a substitute school nurse in Shoreline, talked frankly with her 12-year-old daughter about the vaccine and said: "It's not required. We won't be getting it."
Hoverson thinks not enough is known about the side effects. And, as a Christian, she promotes abstinence before marriage.
"We know the pressures are out there," Hoverson said. "But we want to set the bar really high for our kids. Then they don't have to worry about getting these STDs."
Across the nation, parents are starting to grapple with what to say to their young daughters about one of the hottest topics in public health: a childhood vaccine targeted at a potentially deadly disease - one caused by a virus that's contracted through sex.
The vaccine's introduction also is generating many questions and widespread debate among parents, providers and lawmakers: Where is it available? Who pays? Should vaccination be a mandatory condition of entrance to school? Will it be perceived as encouraging promiscuity?
"There's an unprecedented amount of attention to this vaccine," said Michele Perrin, a health-
promotion and communications manager with the state Department of Health. "It's a breakthrough vaccine in terms of women's health care and cancer prevention."
Last summer, the U.S. Food and Drug Administration licensed the use of Gardasil as the first and so far only vaccine to protect against four strains of HPV, or human papillomavirus.
Two of the HPV strains cause
70 percent of cervical cancers, and the other two strains cause 90 percent of genital warts.
The vaccine is recommended for girls and women ages 9 to 26, but especially for preadolescents who aren't sexually active. That's because the vaccine is preventive, rather than therapeutic, with the greatest benefit realized before exposure to HPV.
The recommendation was made by an advisory committee to the Centers for Disease Control and Prevention and will become final when it's published by the CDC.
The vaccine is not licensed for women older than 26 because it has not been tested in that population. Research is being conducted on the use of the vaccine in males.
The vaccine's side effects include pain and swelling, fever, nausea and dizziness.
In November, the CDC added HPV to its Vaccines for Children list.
About the same time, manufacturer Merck started its massive "One Less" national ad campaign - as in one less person who will battle cervical cancer. The campaign has forced the issue into homes on a major scale.
In Washington, Gov. Christine Gregoire's budget proposal requests $26.2 million for childhood vaccines, including the HPV vaccine. With lawmakers' approval, a state-sponsored HPV vaccine program would begin May 1. For girls ages 11 through 18, the shots would be offered at no cost, though providers could add a charge for an office visit or administrative fees.
Some doctors and pharmacists already make the vaccine available to privately insured patients or those willing to pay for it out of pocket. The manufacturer's list price is $120 per dose, which doesn't include add-on fees. Insurers covering the vaccine include Group Health Cooperative, Premera and Regence BlueShield. Swedish Medical Center is supplying the vaccine to low-income patients through a grant from its foundation.
Early in the legislative session, state Sen. Jeanne Kohl-Welles, D-Seattle, considered introducing a bill to make the vaccine mandatory for entrance to school. But state Board of Health officials relayed their preference that it was better for now to keep the vaccine as a budget issue rather than politicizing it.
"I am willing to do that and introduce legislation next year, if I determine it is warranted," Kohl-Welles said.
In 13 other states and the District of Columbia, lawmakers have sponsored bills to make the vaccine mandatory for entrance to school, according to Women in Government, a bipartisan group based in Washington, D.C., for female legislators. Such legislation was narrowly defeated in Michigan in December.
Women in Government has recommended that all girls entering middle school get the vaccine.
The American Academy of Pediatrics strongly supports HPV vaccination but thinks it's too early to consider school requirements. Other groups that support the vaccination but are against making it mandatory include The Catholic Medical Association, the nation's largest professional group for Catholic doctors.
Health officials say one of the biggest challenges ahead is public and provider education.
"There just isn't enough awareness of the importance of timing the vaccine before sexual activity begins," said Dr. Jeff Duchin, director of communicable disease control for Public Health - Seattle & King County.
Also, adolescents don't routinely go to the doctor for immunizations and preventive checkups as younger children and babies do, Duchin said. The other challenge is the requirement for three shots across six months.
But Duchin is optimistic: "The research out there suggests parents are supportive once they understand the link between cervical cancer and HPV."
If the state adds the vaccine to its list, the Health Department will begin sending educational materials to providers and making information available to parents.
Meanwhile, parents have begun to deal with the vaccine in vastly different ways.
Some are against it. Others feel there's no hurry, since their daughter isn't sexually active.
"It's new, and like anything that's new, sometimes they give it a little tweak and it's that much better," said Myra Adams, a Shoreline mother.
Mothers such as Joeline Watts are relying on the advice of the family doctor. Watts took her two daughters for a first dose last week at Swedish Medical Center, reasoning that other vaccines have worked well for her children.
"I trust what my doctor tells me," she said.
Still others believe getting the vaccine is the right thing to do but won't talk publicly about it or tell their daughters exactly what the vaccine is for.
A Seattle professional says she plans to advise a young woman in her family to get the vaccine. But she intends to give the advice privately, because she worries it could conflict with the beliefs of other family members and those of her church, which opposes premarital sex.
Another Seattle mother took her daughter to get the vaccine but explained only that it would prevent a virus that leads to cancer - no mention of STDs or exactly what kind of cancer.
"She's not a sophisticated girl," the mother said. "My daughter is very uncomfortable discussing anything physical."
Cally Shine, whose mom finally persuaded her to get the vaccine, doesn't mind talking about it one bit.
She even analyzed the Gardasil ad campaign in an eighth-grade class on propaganda and the media. The students determined that the ads don't reveal all of the vaccine's side effects, she said. That's another reason she was "iffy" about getting the shots.
Then again, it's better to get vaccinated "before. ... If they do after, it could be too late," Cally said. Cervical cancer: risk factors
What's the biggest risk factor? HPV, or human papillomavirus, is the most important risk factor for cervical cancer. HPVs are a group of more than 100 types of viruses. Some types cause genital warts; others cause cancer of the cervix. HPV is spread mostly through genital contact. Risk factors for HPV infection include having many sex partners, becoming sexually active at age 16 or younger and having a partner who has had several sex partners. At the same time, many people who contract the infection don't have these risk factors. The only sure way to prevent HPV is to abstain from all sexual activity.
How common is HPV? About 20 million men and women are infected with HPV. By age 50, at least 80 percent of women will have acquired genital HPV infection. Often the infection has no signs or symptoms and goes away on its own. It's possible to be exposed to HPV and not acquire the infection, but no data exist as to how common that is. Most with the infection don't get cervical cancer.
How many women get cervical cancer? The number of deaths from cervical cancer has dropped considerably since the mid-1950s, mainly because of the Pap test, which detects cancer, precancerous cells or other conditions such as infection and inflammation. Still, there will be an estimated 11,150 new cases of invasive cervical cancer in the United States this year, and about 3,670 women will die from it. For More information
The Centers for Disease Control's National Immuni–zation Program has an HPV home page: www.cdc.gov/nip/vaccine/hpv/default.htm.
The state Department of Health has an HPV fact-sheet link: www.doh.wa.gov/cfh/Immunize/documents/hpvvaccinefactsheet.pdf.
Reach the state Department of Health Immunization Program at 360-236-3595 or 866-397-0337.