Ideally, Myers says, the vaccine companies would like to see the vaccine added to the recommended pediatric immunization schedule. According to Eliav Barr, who heads Mercks clinical research program on the HPV vaccine, both the U.S. Centers for Disease Control and Preventions Advisory Committee on Immunization Practices and the American Academy of Pediatrics have expressed intense interest in the HPV vaccines. Barr also believes that making the inoculation part of the series required for school entry could be the most effective way to ensure widespread vaccination. These requirements are set by each state individually, usually in accordance with guidelines established by the Advisory Committee on Immunization Practices. The key thing with vaccinations is reaching the hard to reach, he says. Middle-school entry and high-school entry requirements have been extremely effective at boosting coverage [for other vaccines] to levels really consistent with the best benefits available.
Opponents of such a requirement note that it wouldn’t hurt Merck’s or Glaxo’s bottom line. This thing is motivated by money as usualand in a worldview that not everyone subscribes to, says Leslee Unruh, founder of the Abstinence Clearinghouse. Unruh believes that abstinence-only sexual education offers a better approach to preventing the spread of all sexually transmitted diseases. Other Christian values groups, such as Concerned Women for America and the Family Research Council, echo her point of view.
We know that there is what could easily be called an epidemic of HPV infection, and that needs to be taken seriously, says Pia de Solenni, an ethicist who serves as director of life and women’s issues at the Family Research Council. However, our concern would be that [a vaccine] really isn’t comprehensive, especially when you’re talking about administering it to 12-year-olds. It’s important to focus on abstinence. Abstinence, Solenni notes, would prevent not just HPV, but an array of other sexually transmitted infections, including gonorrhea, chlamydia, and HIV.
Many find the idea of incorporating the vaccine into school-entry requirements particularly troubling. We need to look at this with a serious moral perspective and talk about it some more instead of just imposing it on every parent and every child, says Wendy Wright, senior policy director of Concerned Women for America . We’re not saying don’t make this vaccine available. But, she adds, giving the vaccine at an early age sends a message. What they’ve done is told this 12-year-old, You can now become sexually active,’ she says. Perhaps they could adjust this vaccine so that it could be taken at a later age. Solenni concurs, saying that although she still wouldn’t endorse it, the vaccine would best be offered only to people who are at least 18 years old. The only form of prevention she supports is abstinence from any sex outside marriage.
As a public health policy, delaying vaccination until age 18, an age before which many girls have become sexually active, fails. In our study, we found that effectiveness was OK until age 15; then it decreased, says Duke’s Myers. It’s clear that waiting until 18 would reduce the overall benefits of the vaccine by a substantial proportion. I strongly doubt that those teens who aren’t having sex are being held back by a fear of HPV, and that being vaccinated would suddenly change behavior.
One notable exception to the abstinence only refrain of the family-values groups is Focus on the Family. Reginald Finger, a public health physician and the medical issue analyst for the organization , serves on the CDC’s Advisory Committee for Immunization Practices. If three doses of HPV vaccine is going to produce efficacy over a young-adult lifetime, then [age 12] might be a good time to reach them, just because they’re easier to reach and you can implement a system for doing that with the adolescent visit, he says. I do not think that you necessarily need to infer that if you’re giving it to 12 year olds, that 12 year olds are suspected to be at risk right then. HPV, he notes, can be a long-lasting infection, to the point that it may be a risk even to people who have been abstinent until marriage. With HPV, you could have a person in their 20s, never sexually active before marriage, marrying someone who has had a sexual history in their teens, who has turned around their lifestyle and had been abstinent for eight years, he says. Then all of a sudden, you have a situation where it’s possible HPV could be an issue.
Both Merck’s Barr and Dartmouth ‘s Harper are optimistic that education may help change the perspectives of some of the more conservative groups. The key thing is that neither Merck nor any other organization is interested in promoting sexual activity among adolescents, but we are interested in promoting the public health, says Barr. Although HPV is transmitted sexually, it is as common as any other disease for which people are vaccinated, with approximately 5.5 million cases in the United States every year; the lifetime risk of HPV infection approaches 70 percent.
Ultimately, Barr says, I think that parents, regardless of their political, religious, or cultural background, want to prevent cancer in their kids. While that is undoubtedly true, a divide remains about whether vaccination or teaching only abstinence is the best way to do that.