JAMA   
January 18, 2012, Vol 307, No. 3, pp 223-320
http://jama.ama-assn.org/current.dtl

Letters
Mandatory HPV Vaccination
Melissa B. Gilkey, Noel T. Brewer
JAMA. 2012;307(3):252-253.doi:10.1001/jama.2011.2018

Extract
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, …

Mandatory HPV Vaccination
Lynn C. Berger, Debra Blog, Guthrie S. Birkhead
JAMA. 2012;307(3):253-254.doi:10.1001/jama.2011.2019

Extract
To the Editor: Mr Gostin,1 in his Commentary, highlighted the unique issues and controversies surrounding the institution of a state vaccination law, or mandate, with regard to the HPV vaccine. The Commentary provided a much-needed focus on the undisputed safety and efficacy of the HPV vaccine in light of recent negative public attention.

We think, however, that it is important to clarify the author’s statement that “research on the effectiveness of mandates is unavailable.”1 While specific evidence does not yet exist regarding the effectiveness of school mandates on HPV vaccination rates, it is clear that school mandates have uniformly increased state vaccination rates for other vaccines. In 1999, the Task Force on Community Preventive Services concluded, after a review of all available studies on the effectiveness of school-entry vaccination laws, that these laws are both effective at reducing disease rates and outbreaks as well as increasing overall vaccination …

Mandatory HPV Vaccination
Lucija Tomljenovic, Christopher A. Shaw
JAMA. 2012;307(3):254.doi:10.1001/jama.2011.2020

Extract
To the Editor: Mr Gostin made an important point in his Commentary on mandatory HPV vaccination: “Above all, health policy must be driven by science.”1 However, the author’s recommendation that “if voluntary vaccination proves unsuccessful, states should seriously consider compulsory vaccination laws without generous exemptions” appears premature. As Gostin noted, clinical trial evidence has not demonstrated that  HPV vaccines can actually prevent invasive cervical cancer, let alone cervical cancer deaths.2,3 Because HPV vaccines were specifically developed to protect against cervical cancer, we conclude that in the absence of long-term data, their true benefits remain speculative. The Food and Drug Administration acknowledges that “It is believed that prevention of cervical precancerous lesions is highly likely to result in the prevention of those cancers.”4

Clinical trials show that HPV vaccine efficacy against persistent HPV infection and precancerous lesions only lasts for 8.4 and 5 years for Cervarix …

Mandatory HPV Vaccination—Reply
Lawrence O. Gostin
JAMA. 2012;307(3):254-255.doi:10.1001/jama.2011.2021

Extract
In Reply: This collection of 3 letters in response to my Commentary vividly demonstrates the political and social divisiveness of HPV vaccination, which sets it apart from most childhood immunizations. Each letter is thoughtful, and yet all 3 letters come to distinctly different policy conclusions. Drs Gilkey and Brewer find that health system factors such as cost and enhanced access are more effective than mandates; Dr Berger and colleagues urge immediate state adoption of HPV mandates with limited opt-outs; and Drs Tomljenovic and Shaw reject HPV mandates as a flawed policy. Each letter expresses strong agreement with my view, “Above all, health policy must be driven by science,” and yet each draws different conclusions based on the available scientific evidence. How is this possible?

Gilkey and Brewer cite studies showing strong parental support for mandates—either with generous opt-outs (84%-92%) or without (47%-59%). But these polls have underlying flaws. First, the …