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T h e n e w e ng l a n d j o u r na l o f m e dic i n e Mandating HPV Vaccination — Private Rights, Public Good
To the Editor: Those who oppose mandating lice power” granted to states under the Consti-
vaccination against human papillomavirus (HPV) tution’s 10th Amendment permits all jurisdictions as a condition for school entry generally open the to legislate to “protect the public health and the debate with two fundamental questions. First, public safety.”1 Thus, the Court said, Massachu- how can the government interfere in the medical setts was acting within its appropriate authority decisions parents make for their children by when requiring persons to submit to vaccination compelling immunizations for school entry? Sec- against smallpox and when imposing sanctions ond, how can the HPV vaccine be a good candi- for noncompliance. Seventeen years later, the date for school mandates when HPV infection is Court affirmed a Texas mandate that required transmitted only through intimate contact, not documentation of the receipt of certain vaccina- through casual encounters, as with other diseas- tions before children could enter school.2 es that are preventable with vaccines? In fact, re- Today, all states and the District of Columbia quiring vaccination against HPV for school entry have instituted immunization requirements for is firmly rooted in American jurisprudence.
school entry and all jurisdictions provide a pro- The Supreme Court, when first adjudicating cedure for parents to opt out of the requirements. compelled vaccination, recognized that the “po- These mandates have proved to be the most ef- fective tool ever devised for increasing access to recommended vaccines for our children. Indeed, this week’s letters
the national coverage rate for most childhood vac- 1998 Mandating HPV Vaccination — Private Rights,
Public Good
vaccination contends that because the infection 1999 Treatment of Infertility in the Polycystic Ovary
is not casually communicable, the traditional justi- Syndrome
fications outlined in previous judicial decisions do not apply. However, the mode of transmission is 2001 GM-CSF Autoantibodies in Pulmonary Alveolar
a distinction without meaningful difference, and Proteinosis
the result is the same. Twenty million persons are currently infected with HPV; 6 million more 2003 Interleukin-12/23 Monoclonal Antibody
become infected each year. The threat to the for Psoriasis
public’s health, at least with respect to vaccine- 2003 Communicating about Dying in the ICU
related strains, is preventable with the vaccine.
Legal precedent, although established before 2005 The Incidentally Discovered Adrenal Mass
the introduction of the new vaccine against a vi- rus that is transmitted through intimate contact, 2006 Urine Fluorescence in Ethylene Glycol Poisoning
will nevertheless serve as the nexus for decisions 2007 Superior Athletic Performance Two Decades
about the future. If courts are ever called on to after Cardiac Transplantation
review the appropriateness of mandating vacci- nation against HPV, the traditional underlying n engl j med 356;19 www.nejm.org may 10, 2007 Downloaded from www.nejm.org on May 9, 2007 . For personal use only. No other uses without permission. Copyright 2007 Massachusetts Medical Society. All rights reserved. principles set forth to justify vaccine mandates Dr. Stewart reports working under a contract from Merck could easily outweigh concerns about the mode (with the Department of Health Policy at George Washington University Medical Center, which has conducted research on ac- of transmission. Courts must rely on and respect cess to vaccines among the underserved) to study Medicaid cov- the established precedent on which immuniza- erage of the HPV vaccine. No other potential conflict of interest 1. Jacobson v. Massachusetts, 197 US 11 (1905) at 25.
2. Zucht v. King, 260 US 174 (1922) at 175.
George Washington University Medical Center 3. Orenstein WA, Hinman AR. The immunization system in
the United States — the role of school immunization laws. Vac- Treatment of Infertility in the Polycystic Ovary Syndrome
To the Editor: In their report on the treatment modification in polycystic ovary syndrome. Trends Endocrinol
of infertility in women with the polycystic ovary Metab 2002;13:251-7.
3. Palomba S, Orio F Jr, Falbo A, et al. Prospective parallel
syndrome, Legro et al. (Feb. 8 issue)1 do not men- randomized, double-blind, double-dummy controlled clinical tion lifestyle interventions, although a significant trial comparing clomiphene citrate and metformin as the first- proportion of the women in their study were line treatment for ovulation induction in nonobese anovulatory women with polycystic ovary syndrome. J Clin Endocrinol Metab obese. Many studies have shown that weight re- 2005;90:4068-74.
duction normalizes ovulation, improves hyper- 4. Clark AM, Thornley B, Tomlinson L, Galletley C, Norman
androgenism, and ultimately increases rates of RJ. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. conception among women with the polycystic Hum Reprod 1998;13:1502-5.
ovary syndrome.2 In fact, ovulation rates similar 5. Matalliotakis I, Kourtis A, Koukoura O, Panidis D. Polycystic
to those achieved in the two recent trials with ovary syndrome: etiology and pathogenesis. Arch Gynecol Ob- metformin1,3 have been previously reported in association with lifestyle interventions.4 In addition to infertility in anovulatory women, To the Editor: Legro et al. assert that the infe-
the polycystic ovary syndrome is associated with riority of metformin in achieving live births is in- metabolic disorders that are linked to insulin re- consistent with the findings of previous studies, sistance and central obesity.5 The administration which show the benefits of metformin in stimu- of clomiphene alone does not target these abnor- lating ovulation. However, in the previous stud- malities, and in the study by Legro et al. it actu- ies, subjects received metformin in an immediate- ally led to increases in weight and insulin resis- release form, whereas the subjects in the study by tance. In contrast, weight loss has been associated Legro et al. received metformin in the extended- with a significant reduction of visceral fat, lead- release form, which may not be as efficacious in lowering insulin, androgen, and sex hormone– On the basis of this evidence, we believe that binding globulin levels.
lifestyle modifications — increased exercise, a Clinical experience with extended-release met- properly supervised diet, and smoking cessation formin suggests that it is not as effective as the — should be the first and are probably the most immediate-release form for glycemic control. The important steps in the therapeutic approach to nonsignificant decreases in the levels of glucose, the polycystic ovary syndrome in obese women. insulin, proinsulin, and insulin resistance as de-Dimitrios Panidis, M.D., Ph.D. termined by homeostasis model assessment as- sociated with metformin in the study by Legro and colleagues provide support for this impres- sion. In an initial study of immediate-release 1. Legro RS, Barnhart HX, Schlaff WD, et al. Clomiphene, met-
metformin, reported by Nestler and Jakubowicz,1 formin, or both for infertility in the polycystic ovary syndrome. sex hormone–binding globulin levels increased 2. Norman RJ, Davies MJ, Lord J, Moran L. The role of lifestyle by 187.5% (vs. a 12.0% increase with extended-
n engl j med 356;19 www.nejm.org may 10, 2007 Downloaded from www.nejm.org on May 9, 2007 . For personal use only. No other uses without permission. Copyright 2007 Massachusetts Medical Society. All rights reserved.

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