HPV: Is adolescent consent sufficient?; Data on vaccine effectiveness post-infection

The August issue of Pediatrics included a commentary related to HPV vaccine ethics and policy that is worth noting, even several weeks after its publication. Ruth Farrell and Ellen Rome from the Cleveland Clinic offer a well-reasoned argument in favor of adolescent consent being sufficient for HPV vaccination in their commentary, "Adolescents' Access and Consent to the Human Papillomavirus Vaccine: A Critical Aspect for Immunization Success." (free extract).

The authors argue that HPV vaccination could reasonably be given the same status as other reproductive health matters among teenagers, for which parental consent is not required. They outline some of the reasons why teenagers might seek the vaccine without parental involvement or knowledge and note the missed opportunity that would occur if physicians postpone discussion of the vaccine or vaccination itself until a future visit with a parent present. They write:

"Lack of parental authorization, whether because the adolescent's mother or father may not be reachable or the adolescent truly seeks confidentiality in immunization, should not overshadow the chance to initiate or continue immunization administration. By the time the adolescent returns for health care (with or without a parent), she may have initiated sexual activity, with the vaccine losing its maximum potential efficacy."

While these authors are not the first to suggest waiving parental consent for HPV vaccination, the publication of their argument in the nation's premier journal for pediatric medicine is likely to influence the policy discussion in the coming months.

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Data that could be seen as supporting Farrell and Rome's argument could be found in an August issue of JAMA. There, Allan Hildesheim and colleagues explore the "Effect of Human Papillomavirus 16/18 L1 Viruslike Particle Vaccine Among Young Women With Preexisting Infection" (In layman's terms, "Does Gardasil Help if a Woman Already Has HPV?") At the risk of oversimplifying a nuanced study, the answer is an unsurprising "NO!" This finding confirms what had long been known about the vaccine (and the reason why vaccination is recommended for 11-12 year old girls prior to first sexual contact).

An accompanying editorial "HPV Vaccines--Prophylactic, Not Therapeutic" reinforces this point and explains how the vaccine's lack of therapeutic action shaped the ACIP recommendations.

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Finally, a new issue of HPV Today was released earlier this summer. Included in it are status reports on HPV vaccination in the U.S. and worldwide and a short paper explaining why HPV subtype replacement is unlikely to occur as a result of widespread vaccination with Gardasil or Cervarix.