EXECUTIVE SUMMARY
Results of a recent study indicate that conflicting expectations between parents and medical providers about who is responsible for scheduling follow-up appointments is resulting in young girls failing to receive the full complement of HPV shots.
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Fewer than two-thirds of adolescents who begin the HPV vaccine series complete all three doses, which may put them at risk for HPV-related disease, because three doses are associated with maximum effectiveness.
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Strategies to boost completion rates include scheduling follow-up appointments as the child receives the first dose; implementing clinic reminder and recall systems, such as phone calls, educational brochures, and text messages; having patients receive reminders directly from state immunization registries; and offering vaccines at alternative sites that are more convenient for parents, such as schools and pharmacies.
(Editor’s note: News of this research was published first at reliasmedia.com, the web page of Contraceptive Technology Update’s publisher. To keep up with breaking healthcare news as it occurs, go to reliasmedia.com.)
Once you administer that first shot of the human papillomavirus (HPV) vaccine, what are you doing to ensure that patients receive all three doses? Results of a recent study indicate that conflicting expectations between parents and medical providers about who is responsible for scheduling follow-up appointments is resulting in a failure of young girls to receive the full complement of shots.1
Fewer than two-thirds of adolescents who begin the HPV vaccine series complete all three doses, which may put them at risk for HPV-related disease, because three doses are associated with maximum effectiveness.2 There are three available HPV vaccines:
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the bivalent Cervarix, manufactured by GlaxoSmithKline;
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the quadrivalent vaccine, Gardasil, manufactured by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co.;
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the 9-valent Gardasil 9, also manufactured by Merck Sharp & Dohme Corp.
Each of the three vaccines is a noninfectious, virus-like particle vaccine.
The bivalent, quadrivalent, and 9-valent HPV vaccines each target HPV 16 and 18, types that cause about 66% of cervical cancers and most other HPV-associated cancers in women and men in the United States. The 9-valent HPV vaccine also targets five more cancer-causing types (HPV 31, 33, 45, 52, 58), which account for about 15% of cervical cancers. Quadrivalent and 9-valent HPV vaccines also protect against HPV 6 and 11, which are types that cause anogenital warts. The quadrivalent and 9-valent HPV vaccines are licensed for use in females and males; bivalent HPV vaccine is licensed for use in females. (To read more on the 9-valent shot, see the Contraceptive Technology Update March 2015 article, “New HPV vaccine covers 9 types of HPV,” which can be accessed at http://bit.ly/1UQp5M3.)
Check study results
The study, conducted by Boston Medical Center scientists, involved interviews with parents and providers to determine why patients are not receiving all three doses.
“We undertook this study because in the U.S., currently fewer than two-thirds of boys and girls who start the series complete the recommended three doses,” says Rebecca Perkins, MD, MSc, a physician in obstetrics and gynecology at Boston Medical Center and lead author of the research. “Many studies have looked at reasons why adolescents do or do not begin the series, but we know much less about why adolescents who start the series do not complete it.”
Over a one-year period, researchers interviewed 65 parents whose daughters received at least one dose of the HPV vaccine, and they divided them into groups whose daughters had completed the series (28) and those who had not (37). Of the group whose daughters did not finish the series, 65% said they expected the clinic to contact them regarding scheduling additional doses. About one-fourth of parents said inconvenience, such as long commutes to the clinic, led to failure to complete the series, while only four parents made a conscious decision to halt the series.
The researchers also polled 27 providers about their specific plans to ensure patients completed the series. More than half (52%) said they informed parents about when the next doses were due, but they said they relied on the parents to schedule the follow-up visits. Forty-one percent said they planned on scheduling the second dose when the first dose was given, and 7% hoped to immunize patients when they returned for a different appointment. A lack of reminder systems was the cause of most failures to complete the series, providers noted.
How can vaccination completion rates be increased? Researchers suggested actions such as scheduling follow-up appointments as the child receives the first dose; implementing reminder and recall systems in clinics, such as phone calls, educational brochures, and text messages; having patients receive reminders directly from state immunization registries, which are independent from individual medical practices; and offering vaccines at alternative sites that are more convenient for parents, such as schools and pharmacies.1
Give voice to vaccinations
Research indicates that a recommendation from a healthcare provider is one of the best influences on patient acceptance of immunization.3 Look to the Centers for Disease Control and Prevention’s “You Are the Key” web portal (http://1.usa.gov/1eGPIdM), which includes resources to give clinicians guidance on how to provide a strong and effective recommendation for the HPV vaccine.
Current recommendations state that HPV vaccines should be given routinely to females and males at ages 11 or 12, though it can be given as early as age 9. Vaccination for females ages 13-26 and males ages 13-21 also is recommended if they have not completed the three-dose series. Additionally, vaccination is recommended up to age 26 for men who have sex with men, as well as immunocompromised males.4
As women’s health providers, obstetrician-gynecologists are uniquely positioned as a source of information and recommendations on immunization and reducing morbidity and mortality from a range of vaccine-preventable diseases. The American College of Obstetricians and Gynecologists (ACOG) has issued a new Committee Opinion, Integrating Immunizations Into Practice, which outlines the steps providers can take to educate and vaccinate their patients.5 It also has a site that offers information for providers and patients located at http://immunizationforwomen.org.
“Helping our patients make informed decisions about vaccination is an essential part of our specialty,” says Martin Tucker, MD, member of ACOG’s Immunization Expert Work Group and lead author of the Committee Opinion. “We must embrace this role, increase awareness, and work to enhance immunization uptake.”
The Committee Opinion calls on providers to speak with each patient directly and strongly recommend indicated immunizations. The use of prompts, either paper or electronic, can remind physicians and staff which patients need to be immunized. Many electronic medical record systems have these prompts available. Electronic medical records that use reminder systems can improve opportunities to immunize when patients are in the office for regularly scheduled appointments, the Opinion notes. (CTU reported on such prompt systems in the March 2015 article that is linked earlier.)
REFERENCES
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Vercruysse J, Chigurupati NL, Fung L, et al. Parents’ and providers’ attitudes toward school-located provision and school-entry requirements for HPV vaccines. Hum Vaccin Immunother 2016; doi:10.1080/21645515.2016.1140289.
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World Health Organization. Evidence Based Recommendations on Human Papilloma Virus (HPV) Vaccines Schedules Background paper for SAGE Discussions 2014. Accessed at http://bit.ly/26pyUEO.
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Stokley S, Jeyarajah J, Yankey D, et al. Human papillomavirus vaccination coverage among adolescents, 2007–2013, and postlicensure vaccine safety monitoring, 2006–2014 — United States. Morb Mortal Wkly Rep. 2014; 63(29):620-624.
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Markowitz LE, Dunne EF, Saraiya M, et al. Centers for Disease Control and Prevention (CDC). Human papillomavirus vaccination: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2014; 63(No. RR-05):1-30.
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Committee Opinion No. 661: Integrating immunizations into practice. Obstet Gynecol 2016; 127(4):e104-e107.
