HPV vaccines in New England Journal of Medicine

As Nick Anthis, over at The Scientific Activists points out, the New England Journal of Medicine (NEJM) has a lot of articles about HPV vaccines.

Instead of linking all the articles, I'll refer you to either the frontpage of New England Journal of Medicine or Anthis' post.

Anthis sums up the content of the articles thus:

In short, the vaccine is safe, and it is effective. It's no surprise that it's not 100% effective at preventing cervical cancer, given its limited scope. The fact that it prevents at least 17% of cases of cervical cancer should make its distribution a major public health priority. Given that its effectiveness decreases dramatically if there has been prior exposure to HPV, mandating it for sixth grade females is entirely justified. Also, given that HPV is so strongly linked to throat cancer, and given that males transmit HPV to females, vaccination in males as well should be a priority in the near future.

One of the articles in the NEJM is a perspective piece by R. Alta Charo. It's very interesting even for those of us with no medical training, and it makes some good points.

HPV-vaccination mandates, which are aimed more at protecting the vaccinee than at achieving herd immunity, have been attacked as an unwarranted intrusion on individual and parental rights. The constitutionality of vaccination mandates is premised on the reasonableness of the risk–benefit balance, the degree of intrusion on personal autonomy, and, most crucial, the presence of a public health necessity. On the one hand, to the extent that required HPV vaccination is an example of state paternalism rather than community protection, mandatory programs lose some of their justification. On the other hand, the parental option to refuse vaccination without interfering in the child's right to attend school alters this balance. Here the mandates act less as state imperatives and more as subtle tools to encourage vaccination. Whereas an opt-in program requires an affirmative effort by a parent, and thus misses many children whose parents forget to opt in, an opt-out approach increases vaccination rates among children whose parents have no real objection to the program while perfectly preserving parental autonomy.

Opposition to HPV vaccination represents another chapter in the history of resistance to vaccination and, on some levels, reflects a growing trend toward parental refusal of a variety of vaccines based on the (erroneous) perception that many vaccines are more risky than the diseases they prevent. In most cases, pediatricians have largely restricted themselves to educating and counseling objecting families, since it is rare that the risks posed by going unvaccinated are so substantial that refusal is tantamount to medical neglect. In the case of HPV vaccine, parents' beliefs that their children will remain abstinent (and therefore uninfected) until marriage render it even more difficult to make the case for mandating a medical form of prevention. Even with an opt-out program, critics may argue that the availability of a simple and safe alternative — that is, abstinence — undermines the argument for a state initiative that encourages vaccination through mandates coupled with an option for parental refusal.

But experience shows that abstinence-only approaches to sex education do not delay the age of sexual initiation, nor do they decrease the number of sexual encounters.3 According to the CDC, though only 13% of American girls are sexually experienced by 15 years of age, by 17 the proportion grows to 43%, and by 19 to 70%.4 School-based programs are crucial for reaching those at highest risk of contracting sexually transmitted diseases, and despite the relatively low rate of sexual activity before age 15, the programs need to begin with children as young as 12 years: the rates at which adolescents drop out of school begin to increase at 13 years of age,1 and younger dropouts have been shown to be especially likely to engage in earlier or riskier sexual activity.

I hope that these, now demonstrately safe, vaccinations will soon be widely available.

Dr. Charles has more, as does Shelley Batts and Carl Zimmer.