Perspective

Politics, Parents, and Prophylaxis — Mandating HPV Vaccination in the United States

R. Alta Charo, J.D.

N Engl J Med 2007; 356:1905-1908May 10, 2007DOI: 10.1056/NEJMp078054

Article

Audio Interview

Interview with Alta Charo on mandating HPV vaccination in the United States. (8:33)

• Listen
• Download

Cancer prevention has fallen victim to the culture wars. Throughout the United States, state legislatures are scrambling to respond to the availability of Merck's human papillomavirus (HPV) vaccine, Gardasil, and to the likely introduction of GlaxoSmithKline's not-yet-approved HPV vaccine, Cervarix, which have been shown to be effective in preventing infection with HPV strains that cause about 70% of cases of cervical cancer. At the Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP) has voted unanimously to recommend that girls 11 and 12 years of age receive the vaccine, and the CDC has added Gardasil to its Vaccines for Children Program, which provides free immunizations to impoverished or underserved children.

Yet despite this federal imprimatur, access to these vaccines has already become more a political than a public health question. Though the more important focus might be on the high cost of the vaccines — a cost that poses a genuine obstacle to patients, physicians, and insurers — concern has focused instead on a purported interference in family life and sexual mores. This concern has resulted in a variety of political efforts to forestall the creation of a mandated vaccination program. In Florida and Georgia, for example, efforts to increase adoption of the vaccine have been stalled by legislative maneuvering. The Democratic governor of New Mexico has announced that he will veto a bill that mandates vaccinations. And the Republican governor of Texas came under fire (and under legal attack from his own attorney general) when he issued an executive order to the same effect, mandating that all girls entering the sixth grade receive the vaccine; the policy was attacked as an intrusion on parental discretion and an invitation to teenage promiscuity. But all these measures included a parental right to opt out, whether on religious or secular grounds. The opposition seemed more about acknowledging the realities of teenage sexuality than about the privacy and autonomy of the nuclear family.

For more than a century, it has been settled law that states may require people to be vaccinated, and both federal and state court decisions have consistently upheld vaccination mandates for children, even to the extent of denying unvaccinated children access to the public schools. State requirements vary as to the range of communicable diseases but are often based on ACIP recommendations. School-based immunization requirements represent a key impetus for widespread vaccination of children and adolescents1 and are enforceable even when they allegedly conflict with personal or religious beliefs.2 In practice, however, these requirements usually feature exceptions that include individual medical, religious, and philosophical objections.

State Laws and Proposed Legislation Mandating HPV Vaccination.

HPV-vaccination mandates, which are aimed more at protecting the vaccinee than at achieving herd immunity, have been attacked as an unwarranted intrusion on individual and parental rights. The constitutionality of vaccination mandates is premised on the reasonableness of the risk–benefit balance, the degree of intrusion on personal autonomy, and, most crucial, the presence of a public health necessity. On the one hand, to the extent that required HPV vaccination is an example of state paternalism rather than community protection, mandatory programs lose some of their justification. On the other hand, the parental option to refuse vaccination without interfering in the child's right to attend school alters this balance. Here the mandates act less as state imperatives and more as subtle tools to encourage vaccination. Whereas an opt-in program requires an affirmative effort by a parent, and thus misses many children whose parents forget to opt in, an opt-out approach increases vaccination rates among children whose parents have no real objection to the program while perfectly preserving parental autonomy.

Opposition to HPV vaccination represents another chapter in the history of resistance to vaccination and, on some levels, reflects a growing trend toward parental refusal of a variety of vaccines based on the (erroneous) perception that many vaccines are more risky than the diseases they prevent. In most cases, pediatricians have largely restricted themselves to educating and counseling objecting families, since it is rare that the risks posed by going unvaccinated are so substantial that refusal is tantamount to medical neglect. In the case of HPV vaccine, parents' beliefs that their children will remain abstinent (and therefore uninfected) until marriage render it even more difficult to make the case for mandating a medical form of prevention. Even with an opt-out program, critics may argue that the availability of a simple and safe alternative — that is, abstinence — undermines the argument for a state initiative that encourages vaccination through mandates coupled with an option for parental refusal.

But experience shows that abstinence-only approaches to sex education do not delay the age of sexual initiation, nor do they decrease the number of sexual encounters.3 According to the CDC, though only 13% of American girls are sexually experienced by 15 years of age, by 17 the proportion grows to 43%, and by 19 to 70%.4 School-based programs are crucial for reaching those at highest risk of contracting sexually transmitted diseases, and despite the relatively low rate of sexual activity before age 15, the programs need to begin with children as young as 12 years: the rates at which adolescents drop out of school begin to increase at 13 years of age,1 and younger dropouts have been shown to be especially likely to engage in earlier or riskier sexual activity.

Another fear among those who oppose mandatory HPV vaccination is that it will have a disinhibiting effect and thus encourage sexual activity among teens who might otherwise have remained abstinent. This outcome, however, seems quite unlikely. The threat of pregnancy or even AIDS is far more immediate than the threat of cancer, but sex education and distribution of condoms have not been shown to increase sexual activity. Indeed, according to a study conducted by researchers at the University of Pennsylvania, it is the comprehensive sex-education approaches that include contraceptive training that “delay initiation of sexual intercourse, reduce frequency of sex, reduce frequency of unprotected sex, and reduce the number of sexual partners.”5 Opposition to the HPV-vaccination mandates, then, would seem to be based more on an inchoate concern: that to recognize the reality of teenage sexual activity is implicitly to endorse it.

Public health officials may have legitimate questions about the merits of HPV vaccine mandates, in light of the financial and logistic burdens these may impose on families and schools, and also may be uncertain about adverse-event rates in mass-scale programs. But given that the moral objections to requiring HPV vaccination are largely emotional, this source of resistance to mandates is difficult to justify. Since, without exception, the proposed laws permit parents to refuse to have their daughters vaccinated, the only valid objection is that parents must actively manifest such refusal. Such a slight burden on parents can hardly justify backing away from the most effective means of protecting a generation of women, and in particular, poor and disadvantaged women, from the scourge of cervical cancer. To lighten that burden even further, the governor of Virginia has proposed that refusals need not even be put in writing. Perhaps it is time for parents who object to HPV vaccinations to take a lesson from their children and heed the words of Nancy Reagan: Just say no.

An interview with Professor Charo can be heard at www.nejm.org.

Source Information

Professor Charo is a professor of law and bioethics at the University of Wisconsin, Madison.

References

References

1. 1

   Adolescent vaccination: bridging from a strong childhood foundation to a healthy adulthood. Bethesda, MD: National Foundation for Infectious Diseases, 2005. (Accessed April 19, 2007, at http://www.nfid.org/pdf/publications/adolescentvacc.pdf.)
   

2. 2

   Hodges J, Gostin L. School vaccination requirements: historical, social, and legal perspectives. Ky Law J 2001;90:831-890
   Medline

3. 3

   Trenholm C, Devaney B, Fortson K, Quay L, Wheeler J, Clark M. Impacts of four Title V, Section 510 abstinence education programs: final report. Princeton, NJ: Mathematica Policy Research, April 2007. (Accessed April 19, 2007, at http://www.mathematica-mpr.com/publications/PDFs/impactabstinence.pdf.)
   

4. 4

   Dailard C. Legislating against arousal: the growing divide between federal policy and teenage sexual behavior. Guttmacher Policy Rev 2006;9:12-16
   

5. 5

   Bleakley A, Hennessy M, Fishbein M. Public opinion on sex education in US schools. Arch Pediatr Adolesc Med 2006;160:1151-1156
   CrossRef | Web of Science | Medline

Citing Articles (39)

Citing Articles

1. 1

   Tami L. Thomas, Ora Strickland, Ralph Diclemente, Melinda Higgins. (2013) An Opportunity for Cancer Prevention During Preadolescence and Adolescence: Stopping Human Papillomavirus (HPV)-Related Cancer Through HPV Vaccination. Journal of Adolescent Health 52:5, S60-S68
   

2. 2

   C. In: Ferri's Clinical Advisor 2013. Elsevier, 2013:197-296.
   

3. 3

   Nathan W. Stupiansky, Gregory D. Zimet. STD Vaccine Acceptability in Sexually Transmitted Diseases. In: Sexually Transmitted Diseases. Elsevier, 2013:251-269.
   

4. 4

   Tami Lynn Thomas, Ora L. Strickland, Ralph DiClemente, Melinda Higgins, Michael Haber. (2012) Rural African American Parents’ Knowledge and Decisions About Human Papillomavirus Vaccination. Journal of Nursing Scholarship 44:4, 358-367
   

5. 5

   Lauri E. Markowitz, Vivien Tsu, Shelley L. Deeks, Heather Cubie, Susan A. Wang, Andrea S. Vicari, Julia M.L. Brotherton. (2012) Human Papillomavirus Vaccine Introduction – The First Five Years. Vaccine 30, F139-F148
   

6. 6

   Pieter Remes, Veronica Selestine, John Changalucha, David A. Ross, Daniel Wight, Silvia de Sanjosé, Saidi Kapiga, Richard J. Hayes, Deborah Watson-Jones. (2012) A qualitative study of HPV vaccine acceptability among health workers, teachers, parents, female pupils, and religious leaders in northwest Tanzania. Vaccine 30:36, 5363-5367
   

7. 7

   Kong-Nan Zhao, Jiezhong Chen. (2011) Codon usage roles in human papillomavirus. Reviews in Medical Virology 21:6, 397-411
   

8. 8

   Yin Ling Woo, Siti Z. Omar. (2011) Human papillomavirus vaccination in the resourced and resource-constrained world. Best Practice & Research Clinical Obstetrics & Gynaecology 25:5, 597-603
   

9. 9

   Catherine L. Mah, Raisa B. Deber, Astrid Guttmann, Allison McGeer, Murray Krahn. (2011) Another Look at the Human Papillomavirus Vaccine Experience in Canada. American Journal of Public Health 101:10, 1850-1857
   

10. 10

    Kelly Madden, Xiaoli Nan, Rowena Briones, Leah Waks. (2011) Sorting through search results: A content analysis of HPV vaccine information online. Vaccine
    

11. 11

    Jessica A. Kadis, Annie-Laurie McRee, Sami L. Gottlieb, Morgan R. Lee, Paul L. Reiter, Patricia J. Dittus, Noel T. Brewer. (2011) Mothers’ support for voluntary provision of HPV vaccine in schools. Vaccine 29:14, 2542-2547
    

12. 12

    Rebecca B. Perkins, Natalie Pierre-Joseph, Cecilia Marquez, Sandra Iloka, Jack A. Clark. (2010) Parents’ Opinions of Mandatory Human Papillomavirus Vaccination: Does Ethnicity Matter?. Women's Health Issues 20:6, 420-426
    

13. 13

    Emily L. McCave. (2010) Placing HPV Vaccination Within a Social Work Context: The Issue of Access to Care. Smith College Studies in Social Work 80:4, 377-394
    

14. 14

    Colgrove , James , Abiola , Sara , Mello , Michelle M. , . (2010) HPV Vaccination Mandates — Lawmaking amid Political and Scientific Controversy. New England Journal of Medicine 363:8, 785-791
    Free Full Text

15. 15

    Eloise Chapman, Pavithra Venkat, Emily Ko, Jorge P. Orezzoli, Marcela Del Carmen, Elizabeth I.O. Garner. (2010) Use of multimedia as an educational tool to improve human papillomavirus vaccine acceptability—A pilot study. Gynecologic Oncology 118:2, 103-107
    

16. 16

    Nava Yeganeh, Donna Curtis, Alice Kuo. (2010) Factors influencing HPV vaccination status in a Latino population; and parental attitudes towards vaccine mandates. Vaccine 28:25, 4186-4191
    

17. 17

    Archana Chatterjee, Catherine O’Keefe. (2010) Current controversies in the USA regarding vaccine safety. Expert Review of Vaccines 9:5, 497-502
    

18. 18

    Bruce Y. Lee, Donald S. Burke. (2010) Constructing target product profiles (TPPs) to help vaccines overcome post-approval obstacles. Vaccine 28:16, 2806-2809
    

19. 19

    Jennifer Keelan, Vera Pavri, Ravin Balakrishnan, Kumanan Wilson. (2010) An analysis of the Human Papilloma Virus vaccine debate on MySpace blogs. Vaccine 28:6, 1535-1540
    

20. 20

    Yin Ling Woo, Muriel van den Hende, Jane C. Sterling, Nicholas Coleman, Robin A.F. Crawford, Kitty M.C. Kwappenberg, Margaret A. Stanley, Sjoerd H. van der Burg. (2010) A prospective study on the natural course of low-grade squamous intraepithelial lesions and the presence of HPV16 E2-, E6- and E7-specific T-cell responses. International Journal of Cancer 126:1, 133-141
    

21. 21

    Gregory R. Moore, Richard A. Crosby, April Young, Richard Charnigo. (2010) Low rates of free human papillomavirus vaccine uptake among young women. Sexual Health 7:3, 287
    

22. 22

    Meaghan A. Leddy, Britta L. Anderson, Stanley Gall, Jay Schulkin. (2009) Obstetrician-gynecologists and the HPV Vaccine: Practice Patterns, Beliefs, and Knowledge. Journal of Pediatric and Adolescent Gynecology 22:4, 239-246
    

23. 23

    Mira L. Katz, Paul L. Reiter, Brenda C. Kluhsman, Stephenie Kennedy, Sharon Dwyer, Nancy Schoenberg, Andy Johnson, Gretchen Ely, Karen A. Roberto, Eugene J. Lengerich, Pamela Brown, Electra D. Paskett, Mark Dignan. (2009) Human papillomavirus (HPV) vaccine availability, recommendations, cost, and policies among health departments in seven Appalachian states. Vaccine 27:24, 3195-3200
    

24. 24

    Joseph E. Balog. (2009) The Moral Justification for a Compulsory Human Papillomavirus Vaccination Program. American Journal of Public Health 99:4, 616-622
    

25. 25

    Alberto E. Tozzi, Lucilla Ravà, D. Stat, Elisabetta Pandolfi, Maria G. Marino, Alberto G. Ugazio. (2009) Attitudes towards HPV immunization of Italian mothers of adolescent girls and potential role of health professionals in the immunization program. Vaccine 27:19, 2625-2629
    

26. 26

    J.A. Stockman. (2009) Quadrivalent Vaccine against Human Papillomavirus to Prevent High-Grade Cervical Lesions. Yearbook of Pediatrics 2009, 8-10
    

27. 27

    Thomas Q Gallagher, Craig S Derkay. (2008) Recurrent respiratory papillomatosis: update 2008. Current Opinion in Otolaryngology & Head and Neck Surgery 16:6, 536-542
    

28. 28

    Amanda F Dempsey, Gregory D Zimet. (2008) Human papillomavirus vaccine and adolescents. Current Opinion in Obstetrics and Gynecology 20:5, 447-454
    

29. 29

    Melissa Renee Conner, Miranda Merandi Collins. (2008) Human papillomavirus infection and the HPV vaccine: What are the facts?. Journal of the American Academy of Physician Assistants 21:10, 32-34
    

30. 30

    Randall Fisher, David H Darrow, Margene Tranter, Judith V Williams. (2008) Human papillomavirus vaccine: recommendations, issues and controversies. Current Opinion in Pediatrics 20:4, 441-445
    

31. 31

    Anthony T. Newall, Julia M. L. Brotherton, Helen E. Quinn, Peter B. McIntyre, Josephine Backhouse, Lynn Gilbert, Mark T. Esser, Joanne Erick, Janine Bryan, Neil Formica, C. Raina MacIntyre. (2008) Population Seroprevalence of Human Papillomavirus Types 6, 11, 16, and 18 in Men, Women, and Children in Australia. Clinical Infectious Diseases 46:11, 1647-1655
    

32. 32

    Cheryl A. Vamos, Robert J. McDermott, Ellen M. Daley. (2008) The HPV Vaccine: Framing the Arguments FOR and AGAINST Mandatory Vaccination of All Middle School Girls. Journal of School Health 78:6, 302-309
    

33. 33

    Thomas J. Herzog, Warner K. Huh, Levi S. Downs, Jennifer S. Smith, Bradley J. Monk. (2008) Initial lessons learned in HPV vaccination. Gynecologic Oncology 109:2, S4-S11
    

34. 34

    Gregory D. Zimet, Marcia L. Shew, Jessica A. Kahn. (2008) Appropriate Use of Cervical Cancer Vaccine. Annual Review of Medicine 59:1, 223-236
    

35. 35

    B.H. Thiers. (2008) Quadrivalent Vaccine against Human Papillomavirus to Prevent High-Grade Cervical Lesions. Yearbook of Dermatology and Dermatologic Surgery 2008, 147-148
    

36. 36

    B.H. Thiers. (2008) Quadrivalent Vaccine against Human Papillomavirus to Prevent Anogenital Diseases. Yearbook of Dermatology and Dermatologic Surgery 2008, 148-149
    

37. 37

    Paul Krogstad, James D. Cherry. (2007) Quadrivalent Human Vaccine-A Call to Action and for Additional Research. Pediatric Research 62:5, 527
    

38. 38

    Sara F Forman, Elizabeth R Woods. (2007) Human papilloma virus vaccine: a new frontier or political controversy?. Current Opinion in Pediatrics 19:4, 387-388
    

39. 39

    Baden , Lindsey R. , Curfman , Gregory D. , Morrissey , Stephen , Drazen , Jeffrey M. , . (2007) Human Papillomavirus Vaccine — Opportunity and Challenge. New England Journal of Medicine 356:19, 1990-1991
    Free Full Text