On February 20, Merck & Company announced that it would suspend its aggressive campaign to persuade state governments to make Gardasil—the company's anti–cervical cancer vaccination—a requirement for preteen girls to attend school. Merck's about-face comes as states across the country consider such requirements, led by Texas, where Gov. Rick Perry (R) established one through an executive order. It also comes amidst backlash to such mandates from a diverse group of critics, ranging from proabstinence conservatives and vaccine skeptics to mainstream pub-lic health organizations.
Gardasil was approved in June 2006 as a highly effective, first-of-its kind vaccine for four strains of human papillomavirus (HPV): two that cause seven out of 10 cases of cervical cancer and two that cause nine out of 10 cases of genital warts. Public health experts see universal vaccination as key to reducing the 3,700 deaths from nearly 10,000 cases of cervical cancer in the United States each year, as well as the millions of abnormal Pap results and accompanying follow-up care. The Centers for Disease Control and Prevention (CDC) has recommended routine vaccination for all girls 11–12 (before they engage in sexual activity) and "catch-up" vaccination for ages 13–26. The vaccine is now included in the federal Vaccines for Children Program (VFC), which provides free vaccination for Medicaid recipients and the uninsured.
Research strongly suggests that school entry requirements for vaccination are the most effective tactic available, which is why more than 20 states in 2007 have considered such a step. That has not stopped some social conservatives from arguing that HPV vaccination will encourage promiscuity and that abstinence until marriage is the answer to preventing cervical cancer. As Perry asked in announcing his executive order, however, "If the medical community developed a vaccine for lung cancer, would the same critics oppose it claiming it would encourage smoking?" Critics also argue that because HPV is transmitted through sexual contact, it is not a threat for transmission in a school setting. This position ignores the fact that states require vaccination for several diseases that are not transmitted casually, including tetanus and Hepatitis B, to protect Americans throughout their lives and eradicate disease in the larger community (related article, Fall 2006, page 12).
Other arguments against school entry mandates revolve around parental autonomy (although almost every state allows parents to opt their children out of vaccinations on religious and sometimes even broader grounds), as well as concerns about the safety and long-term efficacy of a new vaccine. At a February 2007 conference, CDC officials presented data indicating that side effects have been overwhelmingly minor and rare.
Despite supporting widespread vaccination, some public health groups also have expressed unease over what they deem an unusually rapid call for a mandate and have emphasized a series of financial and logistical challenges to widespread vaccination uptake. Gardasil costs $360 for three shots over six months, which is extremely expensive by vaccine standards. In addition, providing the vaccine to adolescents may be difficult, as they are an age-group for whom there is no established protocol for regular health care visits. Health care advocates are arguing for enhanced public funding and private insurance coverage to prevent the VFC from being overwhelmed and to serve adults ineligible for public subsidies. They are also calling for public education campaigns to help parents better understand HPV and allay their concerns over vaccination.
Finally, advocates are stressing the continuing need for regular Pap smears—the widespread use of which is credited for the United States' relatively low cervical cancer rate. Without these steps, advocates fear that low-income and minority women, already facing serious disparities in Pap smear utilization and incidence of cervical cancer, will fall further behind. That said, it may well be that universal vaccination requirements for school entry are the surest way to protect these very women.
—Adam Sonfield
