Shortly after Merck's HPV vaccine Gardasil was made available in the U.S. in 2006, Texas and Virginia decided to make the shots mandatory for all girls entering the sixth grade. The requirement didn't last long in either state -- the Texas legislature voted to overturn the executive order mandating the vaccine, while Virginia provided broad "opt-out" provisions for parents. But the debate rages on: should Gardasil be mandatory?
Gardasil protects against four strains of the human papillomavirus (HPV), two of which cause 70% of cervical cancer cases and two of which cause 90% of genital warts. It has also been linked to certain uncommon cancers in men, including anal and penile cancer. HPV is the most common sexually transmitted disease in the U.S., and cervical cancer causes a significant number of deaths worldwide. Gardasil (and GlaxoSmithKline's Cervarix, which is not yet approved in the U.S) is certainly a boon to public health, and particularly to women's health. But as lawmakers in Texas and Virginia belatedly realized, making it a mandatory vaccination is unnecessary.
Parents usually have the right to determine which medical treatments their children receive, including vaccinations. When not vaccinating children actively and immediately endangers those around them, however, parental rights become more complicated. The most applicable philosophy in this case is, "your rights ends where my nose begins." While parents may have the right to endanger their own children by not vaccinating them against a disease, they do not have the right to endanger another child's health because of it. That is why vaccines against measles and chicken pox are mandatory for school and day care attendance.
So the question becomes, does Gardasil provide vital protection against an immediate health threat, in which case mandating it would be justified and even necessary? The answer is no. An editorial in the Journal of the American Medical Association (JAMA) sums it up nicely: "the HPV vaccine is not immediately necessary to prevent harm to others." Its primary purpose is to protect women (and potentially men) from long-term risks -- ones that will never pose an immediate or urgent health threat to schoolchildren.
All of the other vaccines required for school attendance protect against diseases that can be transmitted through the air and are highly contagious, especially in population-dense situations like schools. HPV, on the other hand, is only transmitted sexually. It poses no immediate threat to a school's students and cannot be transmitted more quickly or dangerously in school environments. The virus' potential negative health effects don't emerge until years, if not decades, after exposure. And despite the fears of some socially conservative groups, studies have shown that vaccinating adolescent girls against HPV does not encourage promiscuity.
There is also new research suggesting that Gardasil may protect boys and young men against HPV as well. It appears to be particularly effective at reducing their risk of genital warts, but more research needs to be done to show if vaccinated males are less likely to transmit HPV to their sexual partners.
If Gardasil is indeed approved for use in boys, they should be just as strongly encouraged to get the vaccine as girls are now, and any school requirement mandating Gardasil would have to be expanded to include them -- which is an issue of fairness as much as health, as the JAMA editorial points out. But the same arguments against requiring the vaccine for girls also stand for boys. While parents and their adolescent children should take responsibility for protecting the upcoming generation against HPV and its complications, those children should not be required to receive a vaccine against a virus that does not immediately endanger the health and safety of other students at their schools.
Elizabeth Wade is a research intern at the American Council on Science and Health (ACSH.org, HealthFactsAndFears.com).
