To the Editor: In his Perspective article on the ethics andpolitics of compulsory vaccination against human papillomavirus(HPV) (Dec. 7 issue),1 Colgrove highlights the perception thatHPV vaccination is a women's health issue, yet he also alludesto the question of how much herd immunity may be necessary toprotect unvaccinated women from cervical cancer. Explorationof the question of herd immunity exposes HPV vaccination asa men's health issue as well — that is, men are responsiblefor half the cases of transmission of the virus, and vaccinatingmen, if found to be effective in reducing the transmission ofHPV to women, could be an important mechanism for reducing theburden of cervical cancer. At least one recent study involvingboys has reported noninferior immunogenic responses to all fourtypes of HPV covered by the quadrivalent vaccine.2 We have insufficientdata to evaluate how great an effect vaccinating boys couldhave on reducing transmission to women. Therefore, the possibilityof vaccinating persons of both sexes should be further evaluatedif we are to consider all policy options for preventing cervicalcancer.
Sanjay Basu, M.Sc. Yale University School of Medicine New Haven, CT 06510
References
Colgrove J. The ethics and politics of compulsory HPV vaccination. N Engl J Med 2006;355:2389-2391. [Free Full Text]
Block SL, Nolan T, Sattler C, et al. Comparison of the immunogenicity and reactogenicity of a prophylactic quadrivalent human papillomavirus (types 6, 11, 16, and 18) L1 virus-like particle vaccine in male and female adolescents and young adult women. Pediatrics 2006;118:2135-2145. [Free Full Text]
To the Editor: The political implications of compulsory HPVvaccination deserve further attention. Unfortunately, Colgroveonly briefly mentions Michigan's proposed legislation regardingHPV vaccination, and he erroneously describes it as compulsoryvaccination. What Michigan's proposed legislation actually requiresis that parents receive information on the connection betweenHPV and cervical cancer before making an informed decision aboutHPV vaccination for their adolescent daughters.1 This broadallowance for informed refusal — for any reason —is clearly outside the realm of traditional programs of compulsoryvaccination, which permit only religious or medical exemptions.By allowing informed refusal, Michigan's ingenious proposedlegislation not only respects individual liberties but alsoensures that all adolescent girls will be offered the vaccineand eliminates the opportunity for passive omission by parentsand physicians. Other states considering HPV-vaccination legislationshould take a serious look at Michigan's proposed legislationand follow its lead in balancing individual liberties with thelegitimate health concerns raised by HPV and cervical cancer.
Britnye T. Segraves, J.D. Boston University School of Public Health Boston, MA 02118 bgodwin{at}bu.edu
References
Michigan Senate bill 1417 (as passed on Sept. 20, 2006).
The author replies: Basu makes an important point about theindirect effect that vaccinating boys against HPV might haveon the incidence of cervical cancer among women. A policy ofvaccinating one segment of the population for the primary purposeof reducing the incidence of a disease in another segment wasalso undertaken in the case of the rubella vaccine, which isroutinely given to all children for the primary purpose of reducingthe incidence of congenital defects in infants born to womenwho contract rubella during pregnancy.1
Segraves is incorrect in stating that a vaccination law allowinginformed refusal for any reason "is clearly outside the realmof traditional programs of compulsory vaccination, which permitonly religious or medical exemptions." Almost half the statesthat allow exemptions for medical or religious reasons alsopermit exemptions for personal or philosophical concerns. Itis true that a law such as Michigan's that contains an opt-outprovision does not represent compulsion in a strict sense,2but as used in common parlance, the term "compulsory" appliesto school-based vaccination policies in the United States. Somestates place administrative burdens on parents who seek exemptions— such as requirements to obtain a form from a local healthdepartment, to write a letter explaining their decision, orto renew the exemption annually — that may in practicemake it difficult to claim an exemption.3,4
James Colgrove, Ph.D., M.P.H. Columbia University New York,NY 10032
References
Fulginiti VA. Controversies in current immunization policy and practices: one physician's viewpoint. Curr Probl Pediatr 1976;6:3-25. [CrossRef][Medline]
Feinberg J. Harm to self. New York: Oxford University Press, 1986.
Salmon DA, Omer SB, Moulton LH, et al. Exemptions to school immunization requirements: the role of school-level requirements, policies, and procedures. Am J Public Health 2005;95:436-440. [Erratum, Am J Public Health 2005;95:551.] [Free Full Text]
Rota JS, Salmon DA, Rodewald LE, Chen RT, Hibbs BF, Gangarosa EJ. Processes for obtaining nonmedical exemptions to state immunization laws. Am J Public Health 2001;91:645-648. [Abstract]
Previous
