Some people would argue that if people choose not to get vaccinated, than it's their own fault if they get a preventable illness. To an extent, I agree. I would not support, for example, a mandatory HIV vaccine in the United States. In general, HIV is preventable with reasonable precautions, and I think most at-risk individuals recognize the gravity of their risk and would get vaccinated. It's also substantially less common than HPV, and the young women at the heart of the HPV vaccine controversy are less likely to be exposed. It's those young women, however, who may be particularly powerless in the fight against HPV.
One of the most vocal arguments against mandating the HPV vaccine is that it will encourage young girls to have sex. Parents, who control their children's healthcare, don't want the vaccine because they don't want to be seen as advocating sex. All well and good, except that teenagers are already having sex. They're just not getting caught.
According to the Youth Risk Behavior Survey, a very well constructed national survey of high school students in the U.S.:
- Almost half of all high school students have had intercourse.
- More than 1 in 10 high school students have had intercourse with 4 or more partners.
- Even though, in 2005, 60% of students had used condoms at last intercourse, condoms aren't 100% protective against HPV, and 40% of students weren't protected at all.
If the vaccine isn't mandatory, these sexually active young women may not be able to get it. Even if they want it, parents are the gateway to healthcare access for most teenagers, and a teenager who is hiding her sexual activity is unlikely to ask for a vaccine that her parents associate with sex. So they're not going to get the vaccine, and by the time they're 18 and able to make decisions for themselves as many as half of them will already have been exposed to one or more forms of HPV and the vaccine won't be able to do as much good. Mandating the vaccine takes sex out of the question. The vaccine becomes something that is required for school, and the girls who need it... will get it. Whenever vaccines are mandated there are opt-out procedures for safety concerns, or religious beliefs, and parents who don't want the vaccine may need to jump through some hoops for their daughters not to get it, but it will, in the end, be the parents' choice. The government, in the public interest, is just making it harder for them to make that choice.
There are many excellent arguments for why the HPV vaccine should not be made mandatory. It is a new vaccine. It has not been around long enough for its long term safety to be established. I'll even stipulate that the big push for mandating it is, in part, to put a lot of money in the manufacturer's pockets. On the other hand, the vaccine could help stamp out the 4 major strains of HPV in the U.S. that cause 70% of cervical cancers and 90% of genital warts. There's no real other way to do that, except complete abstinence until life-long marriage to another untouched soul, since condoms are not 100% protective and such a large portion of the population is infected.
The other arguments, those that revolve around a belief that providing the vaccine will encourage promiscuity, hold less water. Providing condoms in schools has conclusively been shown not to encourage kids to have sex. It's unlikely that giving them some shots for a disease that most of them aren't even worried about will.
As a public health professional, I have been convinced of the benefits of opt-out systems instead of opt-in for health and sexuality related decisions. In general, I believe they give people better care. If you look at research on condom provision in public schools, where parents are asked to opt-out of allowing their children to participate in the system very few do. Kids get access to condoms if, and when, they need them, and there is very good research that having the condoms available doesn't increase the likelihood that they will engage in sex. On the other hand, when parents are required to opt-in to the system, many of them don't. They have to make the effort to allow the school to do something they're not crazy about, and they are unwilling. With no effort involved, as in an opt-out system, they'd be fine with it, but having to go the extra mile is asking too much. Similarly, when doctors say "we screen all pregnant women for syphilis," they catch cases that they wouldn't if they asked each woman "would you like to be screened for syphilis." Women still have the ability to opt out of the test, but de-stigmatizing it makes it easier to accept, and it saves children's lives.
Should the HPV vaccine be mandated? Absolutely.
Should it be mandated right now? I don’t know.
The lack of (non manufacturer-controlled) long-term safety information is the closet thing to a compelling argument against mandating the vaccine. Merck may have years of clinical trial data on vaccine safety, on over 20,000 girls, but I suspect the population at large will feel much better about the vaccine after it has been available for a few years with no major problems. People will be more comfortable with Gardasil after they see that those who choose to be vaccinated have had no serious side effects. So far that has certainly been the case.
The vaccine should be safe. There is no viral DNA in the vaccine, so there is no way for it to be infectious, and the other components of Gardasil have been used in other vaccines. Nonetheless, there are reasons that, in the past, the government has waited years before requiring a vaccine. Is there, in this case, a compelling reason to rush?
Maybe. Maybe not. But I would have been the first person in line to get this vaccine if I were within the age limits for which it has been approved. When they expand the age range for the vaccine to include women over 30, I'll get my shots. And if one day I have a daughter... she’ll be vaccinated too.
