In June last year, the federal Food and Drug Administration (FDA) licensed a vaccine against human papillomavirus (HPV), thereby opening a debate in states over whether vaccination against HPV should be compulsory for girls entering sixth grade.

The vaccine, Gardasil, developed by the pharmaceutical company Merck, is considered a major public health development, since it protects against four strains of HPV, the most common sexually transmitted disease in the United States. Preventing HPV is of special importance because the infection is estimated to proceed to cervical cancer in as many as 10,000 women annually. And reasoning that the greatest benefit will occur if the vaccine is given before a female becomes sexually active, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) recommended that it be administered routinely to girls 11 or 12 years of age.

The committee took no position on whether vaccination should be required by law, leaving it to the states to make that determination. In September 2006, the Michigan state legislature became the first to propose adding HPV to the list of required childhood vaccinations, and it is expected that other states will follow Michigan’s lead.

Writing in the December 7 issue of the New England Journal of Medicine, author James Colgrove speculates that making the vaccination compulsory will “ignite a new round of polarizing debates.” He expects that opposition will come not only from religious conservatives who view the vaccine as a threat to teenage abstinence, but also from a growing number of parents and others who object to compulsory pediatric immunization in general, even against classic diseases such as polio, measles, and pertussis.

“Laws making vaccination compulsory raise unique ethical and policy issues,” Colgrove writes. On the one hand, “High levels of herd immunity protect all members of the community, including those who cannot receive vaccines because of medical contraindications. This protection is a justification for compulsion.”  On the other hand, bioethicists and parents who argue against compulsory immunization say that compulsion violates patient autonomy and the medical requirement for informed consent.

In the case of HPV vaccination, there is also opposition because HPV is not “casually transmissible” but only spreads through sexual contact. Similar concerns have been raised about school-based requirements for vaccination against hepatitis B, which spreads primarily among sexually active people and injection-drug users, leading some parents to argue that hep B vaccine should be given only to those groups rather than to all children.

Colgrove notes that “A large body of evidence demonstrates that school-based laws are an effective and efficient way of boosting vaccine-coverage rates. Requiring HPV vaccination by law will almost certainly achieve more widespread protection against the disease than will policies that rely exclusively on persuasion and education. A critical question is whether achieving a higher level of coverage justifies the infringement on parental autonomy that compulsory vaccination inevitably entails.”

“Any new vaccine that a state adds to its list of requirements must be judged in the context of both the increasingly lengthy and complex regimen of vaccines that children now receive and the possibility that additional mandates may inflame grassroots opposition, be it religious, philosophical, or ideological. Although issues of religion and adolescent sexuality have dominated the discussion, the move to require HPV vaccination raises broad questions about the acceptability of mandatory public health measures, the scope of parental autonomy, and the role of political advocacy in determining how preventive health measures are implemented.”

The article “The Ethics and Politics of Compulsory HPV Vaccination,” was published in the December 7, 2006, issue of the New England Journal of Medicine. Dr. Colgrove is an associate research scientist at the Center for the Ethics of Public Health in the Mailman School of Public Health at Columbia University.

See also:
Vaccine Will Protect Against Some Kinds of HPV
http://www.healthinschools.org/2006/june9_alert.asp