In the fight against cancer, a vaccine is underused

Nan Feyler, chief of staff for the Philadelphia Department of Public Health, is a member of an expert panel intended to expand the breadth of The Public's Health.

By Nan Feyler

A vaccine against cancer? You would think people would be kicking down the doctor's door to get it. In fact, the existing HPV vaccine protects against cancer – and immunization rates are disappointing.

HPV, short for human papillomavirus, is the leading cause of cervical cancer in women. Each year about 12,000 women in the United States are diagnosed with cervical cancer and 4,000 will die of it. An additional 330,000 women annually undergo surgery to remove pre-cancerous lesions of the cervix, almost all of which are caused by HPV. Since 2006, an HPV vaccine has been available to prevent almost all cervical cancers, as well as vaginal and vulvar cancer in females and genital warts and anal cancer in both males and females, diseases also caused by HPV.

HPV is common, and it is easily spread during sexual activity. About 20 million Americans are infected, with an additional 6.2 million new infections each year. It is so common that at least 50 percent of sexually active men and women get it at some point.

It is possible to have HPV without knowing it and to then pass it on to someone else. In most people, the viral infection goes away on its own or remains in the body without symptoms. But the same virus can cause serious health conditions in some people. There is no cure for HPV.

The Centers for Disease Control and Prevention recommends that boys and girls between the ages of 11 and 12 receive the necessary series of three shots of HPV vaccine. That's because it is most effective before a person has engaged in any type of sexual activity. Vaccines are also recommended for females through age 26 and males through age 21 who have not been vaccinated previously or who have not completed the 3-dose series. Its safety and effectiveness has been well-documented.

The vaccine is only six years old and recommendations on who should get it are even newer. Still, experts worry that teens are less likely to get HPV vaccines than any other recommended immunizations for their age group. In 2011, only 35 percent of girls between 13 and 17 nationwide had the necessary series of three shots; just 53 percent of girls received one shot. The vaccine was recommended for boys more recently, and fewer have been immunized – 8.3 percent had one shot and 1.3 percent had three shots in 2011. We have had more success in Philadelphia: 49 percent of teenage girls in the city had the complete series; 76 percent of girls and 19 percent of boys received at least one shot. Clearly, more work is needed to protect adolescents against HPV-related cancers.

Why not mandate the HPV vaccine for school entry? Requiring vaccines for school enrollment has been proven to increase immunization coverage, reduce the spread of diseases and narrow racial disparities in both vaccination rates and vaccine-preventable diseases. African American and Latino women develop cervical cancer more frequently and are more likely to die of it than white women, making it especially important that young people of color are vaccinated. The government's interest in increasing uptake of this life-saving vaccine combined with the benefit of reducing the cost of cancer arguably justifies any intrusion on a parent's autonomy.

All states permit parents to opt out from vaccination requirements for medical reasons, and nearly all include a religious exemption as well. About 18 states also allow exemptions based on personal, moral or philosophical beliefs that could be part of any HPV mandate. Definitions vary from state to state.

Pennsylvania law doesn't use the word "personal" but its religious exemption is expansively worded: "Children need not be immunized if the parent, guardian or emancipated child objects in writing to the immunization on religious grounds or on the basis of a strong moral or ethical conviction similar to a religious belief." New Jersey, on the other hand, makes crystal clear that it does not permit a personal or philosophical exemption.

Opponents argue that mandating a vaccine to prevent a sexually transmitted infection strays into decision making that is better left to parents. In a recent, small study of parental attitudes toward requiring HPV vaccination, parents expressed enthusiasm for vaccines in general and all but one parent vaccinated their daughters against HPV. But they were split over whether the government should mandate the vaccine for school enrollment or leave the decision to each family. Some had no problems with mandating the vaccine because of its importance in preventing cancer. Others felt that mandates should be limited to vaccines that protect school children from diseases like measles, which can be spread through casual rather than sexual contact.

School entry immunization mandates raise complicated ethical, public health and political challenges, perhaps more so when issues of adolescent sexual activity and parental authority are involved. Within a year after the Food and Drug Administration first approved an HPV vaccine, bills for compulsory HPV immunization were introduced in 24 states. By 2008, however, lawmakers had soured on the idea. Gov. Rick Perry's initial support for a mandate in Texas got him in hot water during the Republican presidential primaries. Currently, only Virginia and Washington, D.C. require HPV vaccines for school entry, and both have provisions that allow parents to refuse to have their child vaccinated.

What should be done to encourage more adolescents to be vaccinated against HPV? Should the government mandate the vaccine for school enrollment or leave it up to parents to decide? What do you think?

Here's more information about HPV and the vaccine.

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