Mandatory HPV Vaccination

To the Editor: Mr Gostin's Commentary questioned whether mandates for human papillomavirus (HPV) vaccination are effective enough to risk alienating the public.¹ Data in studies he cites address this matter. In the 2 places that have adopted mandates, Virginia and the District of Columbia, coverage remains modest. Compared with 49% of female adolescents nationwide, just 54% of those in Virginia and 58% of those in the District of Columbia had received 1 or more doses of HPV vaccine by 2010 according to medical records.² Existing mandates include generous opt-out provisions that, in the case of the District of Columbia, more than 40% of parents used to circumvent the policy.

Gostin suggested widespread educational campaigns and mandates without generous opt-outs as a last resort, but we think this focus on the public is likely misguided. Numerous surveys indicate that many people already agree with HPV vaccination mandates. Most recently, studies found that 47% to 59% of parents agreed with mandates that did not specify an opt-out provision.^{3 - 4} When opt-out provisions were included, agreement increased dramatically to 84% to 92%.^{3 - 4} Thus, the very thing that undermines the effectiveness of mandates, an opt-out clause, is what makes them palatable. Weakly effective interventions like education are neither likely to resolve this paradox nor substantially increase vaccine uptake.

By contrast, interventions that address the factors of health care systems such as cost and clinician recommendation show considerable promise. For example, voluntary provision of no-cost HPV vaccine is a strategy that 3 states, including South Dakota and Washington, currently use. With 69% of adolescent girls having received at least 1 dose, these 2 states have attained among the highest HPV vaccine initiation rates in the nation.² Evidence from abroad indicates that combining universal coverage with a school-based approach may be particularly effective; a voluntary, no-cost, school-based program in England, for example, has achieved vaccine initiation levels as high as 90%.⁵ Because the Affordable Care Act will provide nearly universal coverage for vaccination costs, such an approach may be increasingly feasible in the United States.

Gostin concluded, “Above all, health policy must be driven by science.”¹ Although we are far from having conclusive evidence, an emergent literature indicates that cost and access are more important barriers to HPV vaccination than public opinion. Further study of voluntary, no-cost programs in schools to improve HPV vaccine uptake among adolescents in the United States is warranted.