A mandate in Texas: the story of a compulsory vaccination and what it means.(PUBLIC POLICY)

ON February 2, Texas became the first state to require that young girls be vaccinated against some sexually transmitted viruses. This happened when Gov. Rick Perry issued an executive order requiring that students receive a new vaccine before entering the sixth grade. Perry's order has met with criticism from state legislators who object to his unilateral action, medical groups that welcome the breakthrough vaccine but oppose a mandate, and parents who believe that such coercion usurps their authority. The vaccine's manufacturer is aggressively lobbying other state legislatures to back mandates, and legislation to require the new vaccine is pending in over a dozen states.

Last June, the Food and Drug Administration approved Merck & Co.'s Gardasil vaccine for females aged 9 to 26. When administered to girls before they become sexually active, the vaccine can protect against two of the strains of the human papillomavirus (HPV) that cause about 70 percent of cervical cancers. Within a few weeks of the approval, the vaccine was added to the federal list of recommended routine immunizations for eleven- and twelve-year-old girls. The duration of immunity for the three-dose vaccine series, at a cost of about $360, is not yet known. The federal, means-tested Vaccines for Children program will now include the HPV vaccine, and insurance companies are expected to begin covering its costs.

There is little controversy over the recommendation that the vaccine be broadly used. HPV is the most common sexually transmitted infection, with about half of those who are sexually active carrying it at some point in their lives and about 6.2 million infected annually. The number of sexual partners is the most important risk factor for genital HPV infection. There are no treatments to cure HPV infections, but most are cleared by the immune system, with 90 percent disappearing within two years. Some infections do persist, causing genital warts, cancers of the cervix, and other types of cancer. Each year, over 9,000 new cases of cervical cancer are diagnosed, and the disease kills 3,700 women. Routine Pap tests have dramatically reduced the incidence of cervical cancers over the past 50 years, and it is recommended that even those immunized with the new vaccine continue to be tested, as the vaccine doesn't guard against eleven other high-risk strains of HPV that cause cancer.

Governor Perry recognized that "the newly approved HPV vaccine is a great advance in the protection of women's health" in a "whereas" clause on the way to his "therefore" order that rules be adopted to "mandate the age appropriate vaccination of all female children for HPV prior to admission to the sixth grade." In turning a federal recommendation into a state mandate, Perry has thrilled the vaccine manufacturer while acting against the balance of medical opinion. And critics object to an opt-out provision that puts the onus on parents to file an affidavit seeking approval of their objection.

The American College of Pediatricians opposes requiring the vaccination for school attendance, saying that such a mandate would represent a "serious, precedent-setting action that trespasses on the rights of parents to make medical decisions for their children as well as on the rights of the children to attend school." The chairman of the American Academy of Pediatrics Committee on Infectious Diseases, Dr. Joseph A. Bocchini, believes a vaccine mandate is premature. "I think it's too early," he said. "This is a new vaccine. It would be wise to wait until we have additional information about the safety of the vaccine." The Texas Medical Association also opposes the mandate, expressing concerns over liability and costs.

Mandatory-education laws create a responsibility to make sure that children are ...