A decade after the Food and Drug Administration approved a vaccine for sexually transmitted HPV, many parents remain doubtful about the worthiness of the shot and the message it sends to children about sex.
More than a third of girls in the target middle-school age and half of boys had not been given the vaccine as of last year, according to the Centers for Disease Control and Prevention, which is shooting for a rate of 80 percent by the end of the decade.
State lawmakers are trying to add pressure. Virginia in 2008 became the first state to require schoolchildren to be vaccinated for human papillomavirus. The District of Columbia followed suit in 2009, and Massachusetts and other states have forged ways to make the shots free to anyone who wants them, without requiring it for students.
Yet 10 states in the past year alone tried and failed to pass bills that would mandate the vaccine or educate parents about it, and Rhode Island’s health department continues to face backlash from state lawmakers and parents who say its mandatory vaccination of seventh-graders starting in fall 2015 amounts to executive overreach.
A coalition that opposes the mandate says parents should be able to discuss sex-related issues on their terms and that the spread of HPV in particular falls outside of the school system’s purview.
“You’re not going to spread it in the classroom. It would have to be intimate contact,” said Aimee Gardiner, director of Rhode Island Against Mandated HPV Vaccine. “We have bigger problems if there’s intimate contact in the school.”
The CDC says all girls and boys should be immunized against HPV, which infects an estimated 14 million Americans per year and can cause certain types of cancer. The CDC says the target age for the shots is 11 or 12 because the vaccine produces a “more robust” immune response during the preteen years by establishing protection before sexual activity.
But researchers said the proportion of adolescents vaccinated against HPV appears to be plateauing, even while other vaccines’ use is growing.
Tony Yang, an associate professor at George Mason University in Virginia who co-authored a paper on the subject in Public Health Reports, said parents are sometimes wary because of the virus’ link to sexual activity.
“Some believe that use of this vaccine will increase sexual activity despite research evidence that proves that to be false,” he said. “Parents may believe that their child will not participate in sexual activity until marriage and therefore does not need the vaccine.”
In Rhode Island, Ms. Gardiner argued that the mandate requires parents to talk to their children about sex on the state’s timeline, instead of their own.
Her group is championing a Republican-led push to bar the health department from imposing vaccination requirements on diseases that are “not transmissible in a school environment.”
The bill was tabled for further study this year but could be refiled next year.
Though it took effect only in the final months of 2015, the Rhode Island requirement appears to have driven a spike in vaccine use among adolescents.
The proportion of girls ages 13-17 who took at least one dose jumped from 76 percent in 2014 to 88 percent in 2015. The proportion of males with one dose increased from 69 percent to 81 percent, according to the CDC.
Rhode Island’s rates were relatively static from 2013 to 2014 by comparison.
State health department spokesman Joseph Wendelken said Rhode Island is “extremely encouraged” by the results and that a state program providing free vaccines has contributed to the jump.
He also said the route to imposing the requirement, “which included a public comment period, was the same exact process that is followed for all vaccines.”
Virginia’s rate of adolescents with at least one dose steadily rose from 51 percent for girls and 12 percent for boys in 2012 to 61 percent and 40 percent, respectively, in 2015. That is still behind the national average of 63 percent for girls and 50 percent for boys.
Dr. Yang said Virginia’s mandate includes a broad exemption that allows parents to opt out if they review a set of educational materials, decide they are still opposed and sign a waiver.
A national survey released by the University of North Carolina in August found that only one in five parents think the HPV vaccine requirement for school enrollment is a good idea, though support balloons to nearly 60 percent when an opt-out clause is introduced.
“School entry requirements are highly acceptable to parents, but only when implemented in a way that makes them ineffective,” Noel Brewer, a professor of health behavior at UNC Gillings School of Global Public Health, said in a press release on the findings. “Opt-outs lead to a large number of parents choosing not to vaccinate their children, and that makes requirements ineffective in raising vaccination rates.”
Rhode Island provides exemptions for religious and medical reasons, though Ms. Gardiner still feels parents shouldn’t be forced to come up with objections.
“I have a big issue with the government doing anything that oversteps boundaries,” she said.
In 2007, Texas Gov. Rick Perry became the first state leader to require girls entering the seventh grade to get the vaccine. State lawmakers overturned his decision amid an outcry from conservatives, however, and Texas still does not require the vaccine for school entry.
Several years on, some states are forgoing the intricacies of a mandate in favor of simply making the HPV vaccine more accessible.
Massachusetts decided in November to tap its childhood vaccine trust fund to make the HPV immunization available to anyone who wants it.
More recently, it received a $500,000 CDC grant to “increase the acceptance of HPV vaccine by parents,” said Kevin Cranston, assistant commissioner at the state health department.
“Our approach,” he said, “has focused on making HPV vaccination easy and routine for health care providers and their patients.”
Merck, the drugmaker responsible for the best-known HPV vaccine, Gardasil, said no vaccine or medicine is “completely without risk” but that leading health organizations have reviewed its vaccine’s safety requirements and continue to recommend its use.
“Merck continues to support efforts and policies designed to help improve access to HPV vaccination, which are endorsed by policymakers and public health leaders throughout the country,” company spokeswoman Pamela L. Eisele said. “We will continue to provide information about the efficacy and safety of Gardasil to the public health experts, legislators and other policymakers who make the determination of what is best for their state.”