Seventh-graders in Rhode Island started school this year under a new mandate rarely seen in the country: Girls and boys must be vaccinated against HPV — the human papillomavirus — a sexually transmitted disease that can cause cancer.
The move sparked protests from parents, who resented a school requirement to immunize against a disease that spreads through sex rather than anything that could be transmitted in the classroom.
Despite the uproar, public health officials in Massachusetts are watching Rhode Island’s move. If it succeeds, Massachusetts may want to take the same route to boost the use of a vaccine that has long been a hard sell, said Kevin Cranston, director of the state’s Bureau of Infectious Disease.
“We’re going to be very intrigued by the Rhode Island mandate experience,” Cranston said.
So far, that experience has included a protest rally, a 2,400-member Facebook group fighting the mandate, a local School Committee asking for repeal, and complaints from across the ideological spectrum — with both the American Civil Liberties Union and a local conservative group in opposition. One opponent’s online video was deemed so threatening that the health director canceled the last two informational forums at the end of August.
But Rhode Island health officials have held firm, believing they can increase the HPV vaccination rate in a state that already boasts the highest rate in the nation.
“Our goal is that, over time, parents will become comfortable and familiar with the benefits of this vaccine,” said Dr. Nicole Alexander-Scott, Rhode Island’s health director. She noted that the hepatitis B vaccine, given to babies, also protects against a sexually transmitted disease.
Until now in Rhode Island, the HPV vaccine was the only immunization recommended by the federal government but not required for school attendance.
As with all required immunizations, Rhode Island parents can exempt their children from the HPV vaccine by signing a form. But even with this opt-out, linking school attendance to vaccination has been shown to increase immunization rates because it encourages visits and discussions with pediatricians, said Alexander-Scott.
HPV can cause cancers of the cervix, anus, head, or neck — but usually not until adulthood. Doctors want to give the vaccine before children are at risk of being infected and when their young immune systems can generate the most robust protection.
Jennifer Gallant of Tiverton, R.I., was incensed when she learned of the HPV requirement, which the Rhode Island Health Department adopted after little-noticed public hearings last year.
“I didn’t like the state telling me that I have to do this vaccine,” she said. “I don’t think that should be their concern.”
Still, Gallant has nothing against the vaccine, saying her own research found it to be safe and beneficial, and her teenage daughters are getting vaccinated.
Like most parents, Gallant also doesn’t object to the school requirement for the other two vaccines recommended for adolescents: meningitis and diphtheria-tetanus-pertussis. Those were mandated in 2009 without controversy.
Still, in Rhode Island, as elsewhere, the number of teenagers who get the HPV vaccine lags far behind the other two vaccines recommended for that age group.
The HPV vaccine has always stood apart.
“From early on, this vaccine was sort of carved out from other vaccines and treated a little differently because it’s for a sexually transmitted infection,” said Gregory D. Zimet, an Indiana University School of Medicine psychologist who has studied attitudes toward the HPV vaccine.
Additionally, Zimet said, “You’re vaccinating 11- and 12-year-olds to prevent something that might not become an issue for 10, 20, 30 years. It’s hard for people to see the connection and feel it as strongly.”
It doesn’t help that Gardasil, the trade name for the HPV vaccine, launched amid controversy.
In 2006, the US Centers for Disease Control and Prevention recommended the vaccine for 11- and 12-year-old girls, as three doses given six months apart. (Boys were added in 2009.) But when Texas Governor Rick Perry required HPV vaccination for girls entering middle school, the state Legislature overturned it — after it was revealed that Gardasil’s manufacturer had contributed to Perry’s reelection campaign and lobbied legislators.
Meanwhile, in 2007, 24 state legislatures and Washington, D.C., considered requiring HPV vaccines for school attendance, but only Washington, D.C., and Virginia enacted a mandate, and no other state had done so since. In Virginia, the rule applies only to girls, and it specifies that parents “may elect for the child not to receive the HPV vaccine,” no form needed. Washington, D.C., has a requirement similar to Rhode Island’s.
When parents decide whether to vaccinate their children, a strong recommendation from their children’s doctor can make all the difference, said Melissa Gilkey, a behavioral scientist in Harvard Medical School’s Department of Population Medicine, who studies adolescent health and cancer prevention. But a 2013 survey found that health care professionals recommended the HPV vaccine to barely two-thirds of girls’ parents and fewer than half of boys’ parents.
“Our research suggests that some providers find the conversation uncomfortable,” Gilkey said. “They don’t recommend the vaccine with the same strength as they would other adolescent vaccines.”
Alexander-Scott said she’s not convinced most Rhode Islanders oppose the vaccine, despite the protests. The state, which buys childhood vaccines at no cost to parents, has long had one of the highest childhood immunization rates in the country.
“The overall sense is that parents support vaccines and want their children to be healthy,” Alexander-Scott said.
Amid the protests, others came out in support.
Dr. Katina Robison, a women’s cancer specialist with Women and Infants Hospital in Providence, spoke out about the toll of cervical cancer, even when it’s caught early.
Dr. Richard K. Ohnmacht, a Cranston, R.I., pediatrician who wrote an op-ed piece in the Providence Journal in favor, said in an interview that his very few patients refuse the vaccine at his practice.
But news of the mandate created a platform for vaccine opponents, who told stories of illnesses they linked to the vaccine, despite data showing side effects to be extremely rare.
Karen Ferris, of Portsmouth, R.I., followed her pediatrician’s advice. Before she even knew there would be a school requirement, her daughter, 12, received the first two doses. But some of the opponents’ arguments made sense to her and now she’s questioning whether her daughter should get the final dose.
“A 12-year-old is not going to be going out and having sex and contracting an STD,” Ferris said.
Will the Rhode Island mandate backfire? It could, said Zimet, the Indiana University psychologist, but his money is on success.
“I think it will work,” he said. “If the policy stays in place, it will become routine and some of the heat will go away.”
Felice J. Freyer can be reached at firstname.lastname@example.org. Follow her on Twitter @felicejfreyer.