States propose laws requiring HPV vaccine

Some doctors worry about the high costs for the new immunization.

By Kevin B. O’Reilly — Posted Jan. 29, 2007

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Over the objections of social conservatives and parents opposed to forced immunizations, politicians in at least six states are pushing laws that would require girls entering middle school to receive the human papillomavirus vaccine.

Physicians see the new vaccine as a breakthrough in preventing cervical cancer but are split on how society should proceed. Many doctors support school-entry mandates, while some say lawmakers eager to require the vaccine should proceed with caution, given the cost.

In December 2006, Michigan fell just three votes shy of becoming first to mandate the HPV vaccine for girls entering sixth grade. The bill has been reintroduced there, and lawmakers in Texas, California, Kentucky and Washington, D.C., are considering similar legislation. A bill is expected to be introduced in Illinois soon. The bills would allow parents who object to the vaccine on religious, moral or philosophical grounds to opt out of having their children immunized.

Supporters note that mandates dramatically increase uptake of a vaccine and broaden the protection as widely as possible. It also is best to get to girls before they become sexually active, according to Carolyn Johnston, MD, a gynecologic oncologist at the University of Michigan Comprehensive Cancer Center.

"The point of making it mandatory is that a lot of people don't think about girls that young having sex, nor do they think that cervix cancer starts early," Dr. Johnston said. "But it's pretty clear that if you prevent infection with the HPV vaccine that you can reduce the precursor lesions of cervical cancer."

Vaccine found effective

The American Cancer Society says nearly 10,000 women are diagnosed with cervical cancer annually and the disease kills about 3,700 women every year. The new vaccine is 100% effective against four strains of HPV associated with 70% of all cervical cancer cases and 90% of all genital warts cases, according to the Centers for Disease Control and Prevention.

Earlier this month, the Advisory Committee on Immunization Practices finalized its recommendation that females 12 to 26 should get the HPV vaccine, which Merck & Co. markets as Gardasil, approved by the Food and Drug Administration in June 2006. The American Academy of Family Physicians, the American Academy of Pediatrics and the AMA all have policy supporting the recommendations, though none has gone on record in favor of state mandates. The Christian Medical and Dental Assns. has no objection to vaccine mandates as long as they allow parents to opt out, a spokeswoman said.

Socially conservative groups such as the Family Research Council have come out against the proposed mandates, arguing they could undermine parents' communication with children about abstinence being the best way to avoid sexually transmitted diseases. Other groups, worried about potential adverse events and protective of parental authority, say the vaccine mandate is unwarranted.

"There's nothing about a school environment for an 11-year-old girl that would predispose her to exposure to HPV," said Dawn Richardson, president of Texas-based Parents Requesting Open Vaccine Education. "School mandates were put in place to protect children from communicable diseases. This is an abuse of the policy."

Some physicians, meanwhile, worry the HPV vaccine's cost -- $360 for the three-dose series, not including administration fees -- could put it out of reach for underinsured families. While the federal Vaccines for Children program covers the uninsured and those on or eligible for Medicaid, insurer coverage for the immunization so far is spotty. These doctors added that given the cost, it might be wiser to spend state funds to improve the availability of cervical cancer screening.

On the other hand, mandates can ease doctors' concerns about ordering vaccine, according to Renee Jenkins, MD, president-elect of the American Academy of Pediatrics.

"You don't want to lay out that much money for supply unless people are going to ask for it," Dr. Jenkins said during a Kaiser Family Foundation Webcast about the vaccine.

"If it's not mandated, smaller practices, especially, may have to decide whether to take that risk financially -- whether to purchase the vaccine or not," she said.

The CDC's goal is for 90% of girls and women in the recommended age group to have received the vaccine within the next five years.

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What the CDC says

Once the Advisory Committee on Immunization Practices recommends that a vaccine be added to the childhood immunization schedule, states often follow by mandating its use as a condition of entering school. Below is ACIP's final recommendation on the HPV vaccine, published this month in the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report.

  • Recommended for girls ages 11 and 12 and can be given to girls as young as 9.
  • Should be administered in a three-dose schedule, with the second and third shots coming two and six months after the first dose.
  • Can be administered during the same visit along with other age-appropriate immunizations such as the meningococcal vaccine and the tetanus, diphtheria and pertussis vaccine.
  • A catch-up vaccination for girls and women ages 13 to 26 is recommended.
  • Girls and women who receive the HPV vaccine should still be screened, as recommended, for cervical cancer.

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