Don't rush to mandate HPV vaccine

February 08, 2007|By Arthur Allen

Sometimes, good policy is a question of good timing. The human papilloma virus (HPV) vaccine - which Texas required for its sixth-grade girls last week, and which state legislatures around the country, including Maryland's, have been considering - is a good case in point.

By all accounts, the new vaccine against cervical cancer, developed by Merck Co., can provide an important advance in health. In scientific trials, it proved 100 percent effective in preventing infections with the two types of HPV that cause 70 percent of the 3,500 deaths by cervical cancer in this country every year. The vaccine also seemed safe, although only about 5 percent of the 25,000 patients who got it in the trial were preteen girls, the targeted group.

The vaccine seems like a good candidate for mandatory administration to sixth-grade girls. After all, the fact that HPV is sexually transmitted should have no bearing on whether we take a step to protect girls and women from a deadly infectious disease. We require vaccination of babies against hepatitis B, a disease mainly spread, in the U.S., through sex and hypodermic needle sharing.

Seat belts don't cause car crashes, and vaccines against viruses spread by sex don't cause sex. HPV is a very common virus that most women will be exposed to at some point. Years of experience with vaccination campaigns have shown that they reach those who need them only when parents are forced to either vaccinate their kids or keep them out of school. In the case of HPV, the women who get cervical cancer are often from the same socioeconomic groups that don't get regular medical care.

For all these reasons, the Texas government's decision to impose the HPV vaccine sounded, on its face, like good public policy. And it would be, perhaps, if the government had waited for a year or two - and if the legislature had made the decision.

But public health's coercive function is a delicate instrument and one that needs to be wielded carefully. By ordering mandatory HPV vaccination without getting the legislature's support, Gov. Rick Perry may have blundered in a way that could end up hurting the success of the fight against HPV and other infectious diseases.

In the past, public health authorities usually waited several years before requiring children to get a new vaccine. For example, Merck's chickenpox vaccine, licensed in 1995, did not become mandatory in many states until 1999. The time between licensing and requirement allowed vaccine authorities to view the safety and effectiveness record of the vaccine before they ordered children to receive it. Even Jonas Salk's celebrated polio vaccine, licensed in 1955, was not immediately required by any state - though almost the entire country viewed polio as a menace to be battled together.

But when Merck's HPV vaccine was licensed in June, the company quickly began a marketing campaign designed to introduce the vaccine to the public. In the past several months, the company has been actively lobbying state governments and legislatures to make the vaccine mandatory. State public health officials, who usually take the lead in such campaigns, were taken by surprise.

Because Merck competitor GlaxoSmithKline is coming out with a similar vaccine in about six months, it raises the presumption that Merck is cramming its vaccine down our throats (or rather, into our arms) in order to grab market share before the competition gets going.

Such a strategy is dangerous for a couple of reasons. First, public health departments around the U.S. do not have the cash to pay for this vaccine, which they will be obliged to do when it becomes mandatory. Because most of these departments can barely afford their current vaccine obligations, they aren't too happy about Merck's push. Second, and perhaps most important, people don't like to be told what to do by the government. And when they're being told what to do under conditions like these, it inspires skeptical questions, along the lines of, "Why is the government in such a big hurry to vaccinate my 11-year-old against a sexually transmitted disease?" and "Why do I have to hurry up and pay $360 to Merck?"

In Texas, and in many other states, people can opt out of vaccination if they object for "philosophical" reasons. With his rushed imposition of the HPV vaccine, Mr. Perry threatens to mobilize people who, under normal circumstances, would simply do what they were told, assuming it was best for them. This is not the best way to gain trust in an important public health measure.

Arthur Allen is the author of "Vaccine: The Controversial Story of Medicine's Greatest Lifesaver." His e-mail is

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