Doctors say Perry's vaccine mandate for girls is premature

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From, among others, the Texas Medical Association and the American Academy of Pediatrics, many doctors are saying it's too early to mandate the vaccine, which was approved for use last June. It protects against four strains of the human papillomavirus that cause 70 percent of cervical cancers.



"We support physicians being able to provide the vaccine, but we don't support a state mandate at this time," said Dr. Bill Hinchey, a San Antonio pathologist and president-elect of the TMA, which represents 41,000 physicians. "There are issues, such as liability and cost, that need to be vetted first."



Other reasons cited by doctors in Texas and across the country include the vaccine's newness; supply and distribution considerations; the possibility opposition could snowball and lead to a reduction in other immunizations; the possibility it could lull women into not going for still-necessary cervical cancer screenings; gender-equity issues; and the tradition of vaccines starting as voluntary and becoming mandatory after a need is demonstrated.



Hinchey said that TMA leadership expressed their concerns to Perry on Tuesday. He said the TMA arrived at its position after debating the issue in committees in recent days.



A spokeswoman for Perry reiterated Tuesday that the governor stands by the order. She said he is listening to the discussion but thinks the vaccine is safe and effective.



Unexpected opposition

Perry touched off a firestorm Friday when he issued the order, which requires girls receive the three-shot vaccination to enter sixth grade, starting in September 2008. Social conservatives said a mandate makes sex seem permissible. Others complained Perry was circumventing the legislative process, where bills to make the vaccine mandatory had been filed.



Opposition from doctors was less expected. Virtually all hail the vaccine as a great breakthrough and call for the highest possible proportion of girls and women — and boys and men, eventually — to get immunized in hope of one day eliminating the virus.



"But education needs to come first," said Dr. Joseph Bocchini, chairman of the AAP's committee on infectious disease. "Much of the public doesn't know about HPV and its link to cervical cancer and other diseases. You can't put a mandate ahead of that."



HPV is the most common sexually transmitted infection in the United States, infecting 6.2 million new people a year. Though the immune system usually clears the infection, it can lead to cervical cancer, cancer of the penis and anus, and genital warts. Although cervical cancer is declining in the United States, there are 9,710 new cases a year and 3,700 annual deaths attributed to it. Worldwide, it's the second most common cancer in women, resulting in 233,000 deaths a year.



Point of contact an issue

The 60,000-member AAP circulated a statement last week that lays out many concerns about a mandate. The statement, written before Perry's order, notes that 24 states and the District of Columbia have introduced or prefiled legislation requiring adolescent girls to get the vaccine.



Among the statement's points is that mandating a vaccine for a disease not spread by casual or occupational contact — and currently only available to one gender — represents a departure from past practice. Such school immunization requirements came into existence, it says, to protect schoolchildren from outbreaks of contagious disease in that setting, not to compel vaccination. (The quickest a vaccine has gone from approval to mandatory in Texas was the chickenpox vaccine, which took 5 1/2 years.)



The statement also says the costs of such a program will further strain state vaccine programs already short on resources. It says states that choose to add the HPV vaccine to school entry programs should provide additional funding and insurance coverage.



Perry's order said the vaccine would be covered under the federal Vaccine for Children program, which supplies vaccines to those uninsured, underinsured or on Medicaid or the Children's Health Insurance Program. The order said nothing about coverage by private insurers, many of whom aren't yet including the shot in their popular plans. The vaccine costs from $120 to $200 a shot.



Reaction from doctors

Dr. Patricia Sulak, a professor of obstetrics-gynecology at the Texas A&M Health Science Center College of Medicine, said health-care providers she knows were shocked by the order. "It's such a new vaccine — they haven't had time to explain it to patients," said Sulak. "I think everyone was happy with the CDC's Advisory Committee for Immunization Practices' recommendation that it be routinely given. But this makes it seem like it's being shoved down people's throats."



Hinchey and others emphasized that although the vaccine is considered safe, there are questions of whether there is enough experience with it to warrant a mandate. They say that some girls eventually may experience rare adverse effects not yet identified.



One medical ethicist was willing to give Perry's order a chance.



"Perry gave a classic public-health-ethics rationale for the program," said Laurence McCullough, a professor in Baylor College of Medicine's Center for Ethics and Health Policy. "But he needs to present to the legislature a cost analysis and funding source so other priorities are not displaced."



McCullough added that Perry likely would have avoided controversy if he'd signed on to proposed legislation and led public debate rather than issuing an executive order.



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