IN THE UNITED STATES, HPV VACCINE SHOULD NOT BE AN OPT-OUT SCHOOL-BASED PROGRAM

IN THE UNITED STATES, HPV VACCINE SHOULD NOT BE AN OPT-OUT SCHOOL-BASED PROGRAM

August 23, 2021

Introduction

Human papillomavirus (HPV) and its associated cancers are a serious public health threat around the globe1. In the United States, there were 79 million estimated cases of individuals infected with at least one type of HPV2 with types 16 and 18 being the most common contributing to more than 22,000 new cases of cancer each year3. HPV is responsible for almost all cervical cancers and will affect an estimated 12,900 US women in 2015 and lead to 4100 deaths4. Further, persistent HPV infections can also lead to other cancers in both men and women that include anogenital and oropharyngeal cancers5. Despite its morbidity and mortality, most HPV-associated cancers can be prevented through vaccination. Unfortunately, vaccination rates for HPV are abysmal with 2014 statistics revealing that only 40% of girls and 22% of boys among the 13 to 17 year old range complete their HPV vaccination series6. In the 2014 President’s Cancer Panel, a goal of 80% was set for HPV vaccination rates to prevent an additional 53,000 cases of cervical cancer in girls currently less than or equal to 12 years old1. Evidently, existing policy interventions have not been effective and new strategies should be considered. In light of existing literature on HPV vaccination trends, legislation for school-based programs without opt-out provisions should be enacted to address this public health issue.

Argument #1

First and foremost, while it is important to note that school-based HPV vaccination programs with opt-out provisions (as opposed to programs without opt-out provisions) decreased opposition from 54 to 21% in parents7, the primary reason for excluding opt-out provisions is because they have been shown to be ineffective in increasing vaccination rates8. In a 2015 study that compared HPV vaccination rates among states with and without school-entry and education mandates, they found that neither led to higher vaccine coverage8. Important to note, opt-out provisions were allowed in the school-entry mandates in Virginia and the District of Columbia and considered the main reason why this legislation failed. Additionally, the mere convenience of opting out was likely a contributing factor as to why vaccine rates did not differ among the groups as it takes more effort for parents to complete immunization schedules for school attendance7. Moreover, a potentially dangerous biproduct of adopting opt-out provisions may set a precedent in which parents refuse non-HPV vaccines and contribute to a culture of vaccination refusal7. 

Argument #2

Secondly, the effectiveness and safety profile of the HPV vaccine administered during the adolescent years as compared to older age groups warrant more aggressive legislation that precludes opt-out provisions. In the United States, the ACIP recommends the HPV vaccine for both females and males aged 11 or 12 years with the option to start the immunization series as early as 9 years old. Integration of vaccine legislation with school-programs, especially school-entry requirements, as an evidence-based strategy to increase vaccine coverage is also recommended by the Task Force on Community Preventative Services9. Thus, introduction of a school-based program without opt-out provisions will be an effective intervention that capitalizes on this narrow window of opportunity.

Argument #3

Third, while the removal of opt-out provisions may raise concerns about safety, the HPV vaccine has been shown to be both safe and effective10. Certainly, no drug is ever without side effects, but the recommendations from ACIP and the approval from the Food and Drug Administration (FDA) as it pertains to the HPV vaccine further support that the benefits outweigh the risks. Additionally, a population-based study that evaluated the administration of 600,000 doses of the HPV vaccine revealed that it did not significantly increase the risk of allergic reactions, syncope, anaphylaxis, seizure, stroke, or Guillain-Barre Syndrome10. Similar results were also confirmed in an analysis of the data from the US Vaccine Adverse Event Reporting System (VAERS) after the administration of 23 million doses.  

Conclusion

In conclusion, integrating vaccine legislation with school-based programs is an evidence-based strategy that should be considered by public policymakers. In light of low HPV vaccination rates and the ineffectiveness of programs with opt-out provisions, states should strongly consider enacting legislation that precludes the ability for parents to opt-out.

References

1.          National Cancer Institute T. Accelerating HPV Vaccine Uptake: Urgency for Action to Prevent Cancer The President’s Cancer Panel. Pres Cancer Panel. 2014. https://deainfo.nci.nih.gov/advisory/pcp/annualreports/hpv/PDF/PCP_Annual_Report_2012-2013.pdf.

2.          Satterwhite CL, Torrone E, Meites E, et al. Sexually Transmitted Infections Among US Women and Men. Sex Transm Dis. 2013;40(3):187-193. doi:10.1097/OLQ.0b013e318286bb53

3.          Centers for Disease Control and Prevention (CDC). Human Papillomavirus-Associated Cancers - United States, 2004-2008. MMWR Morb Mortal Wkly Rep. 2012;61(15):258-261. http://www.ncbi.nlm.nih.gov/pubmed/22513526.

4.          Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin. 2015;69(1):7-34. doi:10.3322/caac.21551

5.          De Martel C, Ferlay J, Franceschi S, et al. Global burden of cancers attributable to infections in 2008: A review and synthetic analysis. Lancet Oncol. 2012;13(6):607-615. doi:10.1016/S1470-2045(12)70137-7

6.          Reagan-Steiner S, Yankey D, Jeyarajah J, et al. National, Regional, States, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years - United States, 2014. Pediatr Infect Dis J. 2015;34(12):784-792. doi:10.1097/INF.0000000000000886

7.          Calo WA, Gilkey MB, Shah PD, Moss JL, Brewer NT. Parents’ support for school-entry requirements for human papillomavirus vaccination: A national study. Cancer Epidemiol Biomarkers Prev. 2016;25(9):1317-1325. doi:10.1158/1055-9965.EPI-15-1159

8.          Perkins RB, Lin M, Wallington SF, Hanchate AD. Impact of school-entry and education mandates by states on HPV vaccination coverage: Analysis of the 2009–2013 National Immunization Survey-Teen. Hum Vaccines Immunother. 2016;12(6):1615-1622. doi:10.1080/21645515.2016.1150394

9.          Task Force on Community Preventive Services, Briss PA, Rodewald LE, et al. Recommendations Regarding Interventions to Improve Vaccination Coverage in Children, Adolescents, and Adults. Am J Prev Med. 2000;18(1s):92-96. doi:10.1016/S0749-3797(99)00121-X

10.        Gee J, Naleway A, Shui I, et al. Monitoring the safety of quadrivalent human papillomavirus vaccine : Findings from the Vaccine Safety Datalink ଝ. Vaccine. 2011;29(46):8279-8284. doi:10.1016/j.vaccine.2011.08.106

11.        Burger EA, Campos NG, Sy S, Regan C, Kim JJ. Health and economic benefits of single-dose HPV vaccination in a Gavi-eligible country. Vaccine. 2018;36(32):4823-4829. doi:10.1016/j.vaccine.2018.04.061

12.        Buttenheim AM, Jones M, Mckown C, Salmon D, Omer SB. Conditional admission, religious exemption type, and nonmedical vaccine exemptions in California before and after a state policy change. Vaccine. 2018;36(26):3789-3793. doi:10.1016/j.vaccine.2018.05.050