HPV vaccination mandates--lawmaking amid political and scientific controversy.

The June 2006 licensure of Merck’s human papillomavirus (HPV) vaccine, Gardasil, and the recommendation of the Advisory Committee on Immunization Practices that it be routinely given to girls starting at 11 or 12 years of age set off a f lurry of state-level policymaking. The vaccine protects against four strains of HPV, the most common sexually transmitted infection in the country and the major cause of cervical cancer. Within a year, legislators in 41 states had proposed measures intended to increase uptake of the vaccine, including educational campaigns, public subsidies, and insurance-coverage requirements.1 The most contentious proposals were those to make the vaccine mandatory for girls attending school. Bills to make HPV vaccination compulsory were introduced in 24 states, and one state governor imposed a school mandate by executive order (Table 1). Between 2006 and 2008, however, policymakers turned decisively away from the idea that the vaccine should be required for school attendance. As of February 2010, only Virginia and Washington, D.C., had enacted mandates, and Virginia’s legislation included an opt-out provision so broad that it may be a misnomer to refer to the law as a mandate.2 Immunization requirements, like all compulsory health measures, are politically and ethically sensitive because they intrude on individual autonomy.3-5 Mandate proposals for HPV vaccination are particularly fraught because they lie at the intersection of two highly charged policy areas: immunization safety and adolescent sexuality. Weighed against these concerns is the success of mandates at achieving high levels of immunization coverage.6 The debate over compulsory HPV immunization represents a case study in public health lawmaking amid political and scientific controversy. Given the centrality of compulsory immunization to the control of vaccine-preventable diseases, it is critical to understand the determinants of policy in this area. We analyzed the policymaking process in a sample of states to identify the factors that were most influential in determining how states acted on the issue of mandates.