The human papillomavirus (HPV) vaccine, newly approved by the FDA, should not be a mandatory vaccine for young girls for several critical reasons. The first reason pertains to safety, because this is a new vaccine that has undergone phase III clinical trials testing the efficacy of the vaccine among 17,500 young women (Merck, 2007). There are data about the short-term (2-4 years) efficacy of the vaccine, but there are no accumulated data on the long-term safety of the vaccine or its long-term immunogenic qualities. Although the side effects of this vaccine are reported as minimal, these reports are based on documented side effects that occurred among the women participating in the clinical trials. We have no idea what adverse responses may occur when administered to millions of young girls. A few years ago, a vaccine to prevent rotavirus gastroenteritis among infants was approved as a recommended vaccine after successful clinical trials, only to be pulled from the market after administration to hundreds of thousands of infants because of an association with an increased incidence of intussusception after immunization. In my opinion, effectiveness trials of the HPV vaccine should be conducted in the real world as opposed to the tightly controlled research environment of phase III trials to further establish safety and help to determine duration of antibody response before mandating that the vaccine be administered to all young girls.

Another reason to think twice about mandatory HPV vaccination is that not all young women are at risk for acquiring the particular types of HPV associated with genital warts, cervical dysplasia, and an increased risk of cervical cancer. There are more than 100 identified strains of HPV; this vaccine prevents the four most common types. For most young women who acquire HPV, there are no symptoms and the virus will clear from their immune systems in a short period of time (Hilliard & Kahn, 2005).

I do not suggest that young girls be counseled to avoid vaccination but rather that the immunization be voluntary. The decision whether to receive the vaccine should be made in consultation with their healthcare provider and parents. For young women who choose life-long abstinence for religious or other personal reasons, a mandated vaccine would violate their autonomy. There has also been discussion that public health nurses should administer the mandatory vaccine to young girls in the school setting. Even with parental consent, I believe that nurses would not be able to provide the necessary patient education under these circumstances.

Some proponents of mandating this vaccine have argued that other vaccines are already mandated, and adding another vaccine to the schedule would not be problematic. This view fails to recognize that all of the other childhood vaccines prevent communicable diseases that are easily spread from respiratory or casual contact routes and cannot be avoided. HPV is different; it is acquired through sexual contact. In my opinion, from a public health perspective, it is logical to mandate protection from diseases acquired through airborne transmission but not mandate a vaccine that prevents a disease transmitted through lifestyle choice.

A final reason for not mandating the vaccine is the economic cost. To be fully immunized, the HPV vaccine must be administered in a three-dose series, and estimates of costs to fully immunize all 11-year-old girls exceed $850 million per year (Elbasha, Dasbach, & Insinga, 2007). The government's Vaccine for Children Program would pay for the vaccine ($120/dose) for children who are uninsured or Medicaid eligible, and it is likely that most private insurers would cover the vaccine if mandated. For families who do not have health insurance that covers vaccines, however, affording the vaccine may be beyond their reach. The HPV vaccine should not be mandated for preadolescent girls until issues of safety, autonomy, and coverage for the uninsured are resolved.

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