EXECUTIVE SUMMARY

There is widespread genital human papillomavirus (HPV) infection among all age groups of U.S. males; tellingly, HPV vaccination coverage is low among this population, according to a recent analysis of national data.

  • HPV infection is the most common sexually transmitted infection in the United States. The infection also can spawn several types of cancer.
  • Although male HPV vaccination programs have been available to the public since 2009, participation rates remain low. U.S. data indicate that as of 2014, 42% of boys have received at least one HPV vaccine injection, and 22% have completed the entire regimen.

Although overall genital human papillomavirus (HPV) infection prevalence appears to be widespread among all age groups of U.S. males, HPV vaccination coverage is low, according to a recent analysis of national data.1

HPV infection is the most common sexually transmitted infection in the United States and is a cause of several types of cancers.2 Although male HPV vaccination programs have been available to the public since 2009, U.S. vaccination rates remain low. National data indicate that as of 2014, 42% of boys have received at least one round of the HPV vaccine, while 22% have completed the entire regimen.3

To conduct the current analysis, researchers from the Womack Army Medical Center in Fort Bragg, NC, used data for 1,868 men from the 2013-2014 National Health and Nutrition Examination Survey (NHANES). What prompted the research team to analyze these particular data, a nationally representative sample of the U.S. non-institutionalized, civilian population?

“Our research team was familiar with NHANES data in looking at female HPV prevalence before and after [the] HPV vaccination era,” says Jasmine Han, MD, lead author of the current research paper. “It is a well-known data source to many researchers, because it is a well-designed systematic survey, conducted by CDC, that represents the U.S. population.”

Review the Results

To perform the analysis, researchers studied men 18-59 years of age who were examined in mobile exam centers during the NHANES 2013-2014 cycle. Scientists extracted DNA from self-collected penile swab specimens, and performed HPV genotyping by polymerase chain reaction amplification. Demographic and vaccination information was gathered via self-report during home-based standardized interviews, with binary multivariable logistic regression used to estimate the odds of HPV infection.

During the study period, the analysis indicated the overall genital HPV infection prevalence was 45.2% (95% confidence interval [CI], 41.3%-49.3%). The infection prevalence with at least one high-risk HPV subtype defined by DNA testing was 25.1% (95% CI, 23.0%-27.3%). In vaccine-eligible men, the prevalence of infection with at least one HPV strain targeted by the HPV quadrivalent vaccine and HPV 9-valent vaccine was 7.1% (95% CI, 5.1%-9.5%) and 15.4% (95% CI, 11.7%-19.6%), respectively. Among vaccine-eligible men, the HPV vaccination coverage was 10.7% (95% CI, 7.8%-14.6%).1

What’s the Next Step?

The CDC recommends two doses of HPV vaccine at least six months apart for 11- to 12-year-olds, rather than the previously recommended regimen of three doses. Patients who start the vaccine regimen later (15-26 years of age) still will require three doses of HPV vaccine to protect against HPV infection. The FDA has approved a two-dose schedule for the 9-valent HPV vaccine (Gardasil 9) for patients 9-14 years of age. The CDC encourages clinicians to implement the two-dose schedule right away to protect their young patients. (Contraceptive Technology Update reported on the issue; see “Just Two HPV Shots Recommended for Younger Teens,” January 2017, available at: http://bit.ly/2li1dma.)

Preteens generally receive the HPV vaccine along with whooping cough and meningitis vaccines. Two doses of HPV vaccine administered at least six months apart for patients 11 and 12 years of age will ensure long-lasting protection against HPV, according to the CDC. Patients 13-14 years of age also can receive the HPV vaccine on the two-dose schedule, the agency notes.

In January, the 69 National Cancer Institute (NCI)-designated cancer centers issued a consensus statement fully endorsing the revised recommendations. According to the statement, HPV vaccination represents a “rare opportunity” to prevent the nearly 40,000 cases of HPV-associated cancers diagnosed annually in the United States.4

Research indicates there are several barriers to improving vaccination rates, including few strong recommendations from providers as well as parents not understanding the HPV vaccine’s protective effects against not only HPV but also certain cancers. To overcome these barriers, NCI-designated cancer centers organized an ongoing series of national summits to share new research, discuss best practices, and identify collective action toward improving vaccination rates.

“We encourage all healthcare providers to be advocates for cancer prevention by making strong recommendations for childhood HPV vaccination,” the consensus statement reads. “We ask providers to join forces to educate parents, guardians, and colleagues about the importance and benefits of HPV vaccination.”

To increase HPV vaccine uptake, researchers at the University of North Carolina at Chapel Hill evaluated the effectiveness of training healthcare providers to presumptively announce the vaccine or engage in conversations with families. Study results indicate that only the announcement training produced a meaningful increase in vaccine initiation.5

In 2015, researchers conducted a six-month randomized, controlled trial made up of 30 pediatric and family medicine clinics in central North Carolina. Clinics either received no training (control group), announcement training, or conversation training. The training in announcements consisted of educating providers to share brief statements that assumed parents would be ready to vaccinate. Clinicians use similar presumptive announcements for other early childhood vaccines, according to the researchers.

The conversations training consisted of conditioning providers to talk with parents in an open-ended way that possibly could build rapport and perhaps increase their openness to HPV vaccination.

After completing the training, the North Carolina Immunization Registry collected data on 17,173 patients (11-12 years of age) who visited participating healthcare facilities during the next six months. At the end of the study period, researchers noted increases in HPV vaccination coverage were 5.4% higher for patients who received announcement training compared to patients in control clinics. The coverage rates did not change in clinics that received the conversation training, the researchers said.5

Based on these results, researchers recommended training healthcare providers to use presumptive announcements as a way to increase HPV vaccination among young patients.

Use CDC Resources

In talking to parents about the HPV vaccine, the CDC suggests clinicians present information about the HPV vaccine in the fashion and at the same time as all other adolescent vaccines. Practitioners could lead with a statement such as, “Now that your son is 11, he is due for vaccinations today to help protect him from meningitis, HPV cancers, and pertussis.” CDC experts urge clinicians to remind their patients’ parents of the follow-up shots their children need and ask them to make appointments before departing. (This provider fact sheet is available at: http://bit.ly/2ilIebN.)

Parents may be interested in the HPV vaccine, but still ask questions or express doubt. Some parents may need further reassurance from clinicians. To help answer questions and reassure worried parents and patients, the CDC offers more resources at: http://bit.ly/2iEChTn.

REFERENCES

  1. Han JJ, Beltran TH, Song JW, et al. Prevalence of genital human papillomavirus infection and human papillomavirus vaccination rates among US adult men: National Health and Nutrition Examination Survey (NHANES) 2013-2014. JAMA Oncol 2017; doi: 10.1001/jamaoncol.2016.6192. [Epub ahead of print.]
  2. Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: Incidence and prevalence estimates, 2000. Perspect Sex Reprod Health 2004;36:6-10.
  3. Reagan-Steiner S, Yankey D, Jeyarajah J, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years — United States, 2014. MMWR Morb Mortal Wkly Rep 2015;64:784-792.
  4. NCI-designated Cancer Centers Endorse Updated HPV Vaccination Recommendations. Available at: http://bit.ly/2lhbyy3. Accessed on Feb. 21, 2017.
  5. Brewer NT, Hall ME, Malo TL, et al. Announcements versus conversations to improve HPV vaccination coverage: A randomized trial. Pediatrics 2017; doi: 10.1542/peds.2016.2016-1764.