NEJM: Competing Visions for U.S. Health Policy, Evolocumab for Pediatric Familial Hypercholesterolemia, and the Cervical Cancer Vaccine

A recent commentary (M Fiedler. NEJM 2020; 383: 1197-99. Competing Visions for the Future of Health Policy) describes two competing approaches to U.S. healthcare policy.

  • The current administration has supported legislation which would repeal or sharply curtail many of the Affordable Care Act’s (ACA’s) coverage provisions and is “asking the U.S. Supreme Court to strike down the entire ACA.”  Their approach views “existing federal coverage programs, particularly those serving lower-income people, [as] too expansive.”
  • The main alternative approach aims for expanded insurance coverage and deep subsidies to cover low- and moderate-income individuals.
  • Areas of potential agreement include encouraging competition to lower costs as well as making prices more transparent to encourage patients to seek out lower-priced alternatives.

My take: Overall, I favor more expansive health care coverage.


RD Santos et al. NEJM 2020; 383: 1317-1327. Evolocumab in Pediatric Heterozygous Familial Hypercholesterolemia

Methods: In this 24-week, randomized, double-blind, placebo-controlled trial with pediatric patients (n=157) with heterozygous familial hypercholesterolemia, patients 10 to 17 years of age were treated with evolocumab.  All had been receiving lipid-lowering treatment before screening and had LDL cholesterol level of 130 mg/dL.

Key finding: At week 24, the mean percent change from baseline in LDL cholesterol level was −44.5% in the evolocumab group and −6.2% in the placebo group.

My take: Long-term data are needed.  However, in high risk patients who have not responded to other intensive treatment, evolocumab may be worthwhile.


J Lei et al. NEJM 2020; 383: 1340-1348. HPV Vaccination and the Risk of Invasive Cervical Cancer

Methods: We used nationwide Swedish demographic and health registers to follow an open population of 1,672,983 girls and women who were 10 to 30 years of age from 2006 through 2017.

Key findings:

  • After adjustment for all covariates, the incidence rate ratio was 0.12 (95% CI, 0.00 to 0.34) among women who had been vaccinated before the age of 17 years and 0.47 (95% CI, 0.27 to 0.75) among women who had been vaccinated at the age of 17 to 30 years.

My take: HPV vaccine (aka ‘Cervical Cancer Vaccine’) may lower the risk of cancer by 88% in those vaccinated before the age of 17 years.

From The Onion

Briefly noted: Autism Spectrum Prevalence

A recent study (G Xu et al. JAMA Pediatr 2019; 173: 153-9) uses a nationwide, population-based, cross-sectional survey to provided updated estimates of autism spectrum disorder (ASD) prevalence. The authors include more than 43,000 children (3-17 yrs).

Key findings:

  • The weighted prevalence of ever-diagnosed and current ASD was 2.79% and 2.50% respectively
  • State-level prevalence varied considerably with ever-diagnosed ASD of 1.54% in Texas to 4.88% in Florida.
  • 29.5% of those with current ASD did not receive either behavioral or medication treatment.

My take: This study documents the high rates of ASD in the pediatric population and shows that many are not receiving potentially beneficial treatment.

Also, in the same issue, there are three unrelated commentaries regarding vaccine policy (thanks to Ben Gold for these references):

  • New York City Childcare Influenza Mandate (YT Yang, J Colgrove. JAMA Pediatr 2019; 173: 119-20)
  • Lessons from California’s Discipline of a Popular Physician for Vaccination Exemptions Without Medical Cause (RD Silverman, YT Yang. JAMA Pediatr 2019; 173: 121-2)
  • Requiring Human Papillomavirus Vaccination for School Entry  (MJ Bayefsky, LO Gastin. JAMA Pediatr 2019; 173: 123-4)

The first of these commentaries discusses the implications of NYC influenza 2013 mandate for infants/children 6 mo-59 months.  After implementation, there was an increase in vaccination rates by 11.4% which dropped back after a legal challenge. The second commentary discusses the California State Board’s discipline of a vaccine skeptic, Dr. ‘Bob’ Sears. The final commentary calls for mandating the HPV vaccine. (Related post: HPV Vaccine Eliminating Cervical Cancer)

View from Ryan Mountain, Joshua Tree National Park

Prevent HPV

The CDC currently recommends HPV vaccine at 11-12 years of age.  HPV Vaccine Information

Here’s why: NY Times: Close to Half of Americans with HPV

An excerpt:

More than 42 percent of Americans between the ages of 18 and 59 are infected with genital human papillomavirus, according to the first survey to look at the prevalence of the virus in the adult population.

The report, published on Thursday by the National Center for Health Statistics, found that high-risk strains of the virus — a cause of cervical and vaginal cancers, and cancer of the penis, as well as cancers of the anus and throat in both sexes — infect 25.1 percent of men and 20.4 percent of women.

The virus is transmitted by skin to skin contact; people who are infected may pass the virus to sexual partners…

“If we can get 11- and 12-year-olds to get the vaccine, we’ll make some progress,” Dr. McQuillan said. “You need to give it before kids become sexually active, before they get infected. By the time they’re in their mid-twenties, people are infected and it’s too late. This is a vaccine against cancer — that’s the message.”

Related blog post: Latest Vaccine Recommendations