This story is part of a partnership between MedPage Today and VICE News.
Although many vaccines become mandatory for school-aged children about eight years after the CDC's Advisory Committee on Immunization Practices recommends them, vaccines for human papillomavirus (HPV) have fallen far behind, new research shows.
HPV is the most common sexually transmitted infection in the United States, with about 14 million new cases every year. But despite being recommended by the CDC in 2007, HPV vaccination is only required in Virginia, Rhode Island, and Washington, DC.
In contrast, a research letter by Princeton University bioethicist Jason Schwartz that was published on Tuesday in the Journal of the American Medical Association notes that the CDC recommended that all children get the chicken pox vaccine in 1996. Eight years later, 39 states required children to be vaccinated against the chickenpox before entering public school, and today all 50 states and Washington, DC, require it.
Schwartz and his team also examined immunization requirements for hepatitis B and meningococcal diseases, and found a similar pattern.
'Lots of parents were saying this may be appropriate for that child down the street, but not for mine.'
"I think part of this is the fact that this vaccine had a controversial history," Schwartz told VICE News. "Critics of the vaccine in general were very effective at raising anxiety, raising concern about safety of the vaccine, about the value, about consequences, about adolescent sexual behavior after receiving the vaccine.… That really may have left a bitter taste in the mouths of state legislatures and state health officials."
Shortly after HPV vaccines were licensed, people focused on how the virus was sexually transmitted rather than the fact that the vaccine prevented a virus that caused cervical cancer, according to Dr. William Schaffner, chair of preventive medicine at Vanderbilt University in Nashville, Tennessee, who was not involved in Schwartz's study. Fears of encouraging promiscuity among young people trumped concerns about public health.
"With attention devoted to the mode of acquisition of the virus, that raised all the issues of sex in young people," Schaffner told VICE News. "Lots of parents were saying this may be appropriate for that child down the street, but not for mine."
Hepatitis B is also sexually transmitted. Schwartz points out that the hepatitis B vaccine is mandatory in 47 states and Washington, DC, where it is given to newborns.
Schaffner said that when the hepatitis B vaccine was first introduced in the 1980s, it was administered to adolescents and sparked the same fears about influencing sexual behavior. This anxiety faded in time because studies disproved a link between the vaccine and sexual behavior, and it was added to the newborn immunization schedule.
In 2010, the federal Healthy People program announced a goal to have 80 percent of children between 13 and 15 vaccinated for HPV by 2020. But CDC data show that only 37.6 percent of adolescent girls and 13.9 percent of adolescent boys had completed the three-dose series of HPV vaccination in 2013.
"When you think about how this is a vaccine that is remarkably safe and remarkably effective, that's not a good record," Schaffner said, referring to the data. "In fact, it's appalling."
Although Dr. Kimberly Gecsi, an OB/GYN at University Hospitals Case Medical Center in Cleveland, Ohio, is unsurprised that HPV vaccination hasn't been widely administered, she said that Schwartz's research letter offered a compelling comparison and made her think about why we rely on schools to enforce vaccine coverage in the first place.
"You can argue that schools want to require communicable vaccines like the measles and the chicken pox… but you're not going to get HPV just by being at the school with somebody with HPV," she said. "The same thing is true with hepatitis B. With hepatitis B, you're trying to change the behavior by requiring it."
Texas became the first US state to require HPV vaccines in 2007, when Gov. Rick Perry issued an executive order mandating that all girls entering the sixth grade be vaccinated against HPV. But Texas legislators quickly passed a bill to override the executive order, which Perry declined to veto.
That same year, Virginia and DC passed HPV immunization requirements for middle school girls that are still in effect today. DC has since extended the requirement to boys. In July 2014, Rhode Island passed a similar bill, and it will go into effect for boys and girls this August.
Some communities have achieved high HPV immunization coverage without mandatory school requirements, a spokesman for the National Center for Immunization and Respiratory Diseases told VICE News. Although Rhode Island's mandate doesn't go into effect until next month, he noted that 77 percent of adolescent girls in the state have already had at least the first shot in the series.
School requirements mostly help communities that already have high vaccination rates by ensuring that "stragglers" who've fallen behind on their immunizations are able to catch up before starting school.
"However, if the community has very low coverage — say, 50 percent — the school requirement may not be as effective since there may be other issues that is keeping coverage down," he said. "We need to have realistic expectations of what school requirements can do."
Hanneke Weitering is an intern at MedPage Today.
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