EXECUTIVE SUMMARY

Current estimates suggest that four out of 10 adolescent females and six out of 10 adolescent males are unvaccinated for human papillomavirus (HPV). Approximately 79 million Americans currently are infected with the virus, and about 14 million people become infected each year.

  • Routine HPV vaccination is recommended for all adolescents at age 11 or 12 years, and is recommended for females ages 13-26 and males ages 13-21 who were not adequately vaccinated when they were younger. HPV vaccination also is recommended for males ages 22-26 who have certain immunocompromising conditions; gay, bisexual, and other men who have sex with men; and transgender individuals who were not adequately vaccinated previously.
  • Clinicians can recommend the HPV vaccine series the same way they recommend the other adolescent vaccines in talking with parents about the shot.

While more than 29,000 cases of cancer each year could be prevented with human papillomavirus (HPV) vaccination, many parents may be hesitant to have their young teens vaccinated. What can clinicians do to overcome barriers to widespread implementation of HPV vaccination in their current practice?

The Washington, DC-based Association of Reproductive Health Professionals has just released a webinar on increasing HPV vaccine uptake to help providers review evidence-based information on the subject. The webinar focuses on provider education, access, consent to care, confidentiality, and administrative issues.(Review the webinar at http://bit.ly/2DFM6ik.)

HPV is the most common sexually transmitted disease in the United States, notes Beth Kruse, MS, CNM, ARNP, webinar co-presenter and lead clinician for the Family Planning Program at Public Health Seattle King County. Nearly all sexually active people will get HPV at some point in their lives.1 According to data from the Centers for Disease Control and Prevention (CDC), approximately 79 million Americans currently are infected with the virus, and about 14 million people become infected each year.2

“It should be noted that these numbers are estimates from the pre-vaccine era; the current incidence/prevalence is likely much lower with uptake of the HPV vaccine, especially in persons less than 25 years old,” she notes.

Most new infections of HPV occur in individuals in their teens and early 20s, says Kruse.

Why Vaccination Is Important

The CDC analyzed data from the National Program of Cancer Registries and the National Cancer Institute’s Surveillance, Epidemiology, and End Results program to calculate the incidence of HPV-associated cancers. Its analysis indicates that during the period of 2008-2012, an average of 38,793 cancers associated with HPV were diagnosed yearly, including 23,000 (59%) among females and 15,793 (41%) among males.3

By multiplying these amounts by the percentages attributable to HPV, the CDC estimated that about 30,700 new cancers were attributable to HPV, including 19,200 among females and 11,600 among males, states Kruse.

In looking at the 38,793 cancers that occur each year in the United States at anatomic sites associated with HPV, about 30,700 can be attributed to HPV. Approximately 28,500 are attributable to HPV types that are high-risk and that are included in the 9-valent HPV vaccine. Some 24,600 cancers are attributable to HPV types 16 and 18, which are included in all of the currently available HPV vaccines.3

Push for Early Vaccination

Current estimates suggest that four out of 10 adolescent females and six out of 10 adolescent males are unvaccinated for HPV, says Craig Roberts, PA-C, MS, clinical assistant professor emeritus at University of Wisconsin-Madison.

To be effective, HPV vaccines should be given before exposure to HPV, so there is no reason to wait until a teenager is having sex to offer them HPV vaccination, notes Roberts, who served as webinar co-presenter. The HPV vaccine produces a higher immune response in preteens than in older adolescents, he explains.

“Preteens should receive all doses of the HPV vaccine series long before they begin any type of sexual activity and are exposed to HPV,” notes Roberts. “Most individuals get HPV infections shortly after becoming sexually active for the first time.”

Routine HPV vaccination is recommended for all adolescents at age 11 or 12 years, and is recommended for females 13-26 years of age and males 13-21 years of age who were not adequately vaccinated when they were younger. For people who initiate vaccination before their 15th birthday, the recommended schedule is two doses of HPV vaccine. For people who initiate vaccination on or after their 15th birthday, the recommended schedule is three doses of HPV vaccine, says Roberts. Vaccination continues to have benefit up to at least 26 years of age for persons at risk. HPV vaccination also is recommended for males ages 22-26 who have certain immunocompromising conditions; gay, bisexual, and other men who have sex with men; and transgender individuals who were not adequately vaccinated previously.

Focus on Herd Immunity

A recent national analysis of HPV vaccine impact measured via the National Health and Nutrition Examination Survey shows that HPV types 6, 11, 16, and 18 (4vHPV-type) prevalence in sexually active 14- to 24-year-old females decreased by 89% among those who were vaccinated, and by 34% among those who were never vaccinated, over the two time periods studied (2003-2006 vs. 2011-2014).4

Among 14- to 19-year-olds, 4vHPV-type prevalence decreased from 11.5% (95% confidence interval [CI], 9.1%-14.4%) in 2003-2006 to 3.3% (95% CI, 1.9%-5.8%) in 2011-2014, when one or more dose coverage was 55%. Among 20- to 24-year-olds, prevalence decreased from 18.5% (95% CI, 14.9%-22.8%) in 2003-2006 to 7.2% (95% CI, 4.7%-11.1%) in 2011-2014, when one or more dose coverage was 43%.

This decrease in prevalence of the virus types included in the original vaccine among unvaccinated females suggests herd protection, says Roberts.

“In other words, as the overall prevalence of the virus declines in their population (due to vaccination), even unvaccinated adolescents are benefiting, since the probability of becoming infected is directly correlated with prevalence,” states Roberts.

Talk With Parents

Several barriers have been identified that contribute to low HPV vaccination rates among adolescents. When it comes to parental barriers, data from the 2010 National Health Interview Survey suggest that parents of unvaccinated girls who were not interested in vaccinating their daughters mentioned reasons such as not knowing enough about the vaccine, belief that the vaccine was not needed, and concerns about safety.5 Not receiving the recommendation from a healthcare professional, belief that one’s child is too young to receive the vaccination, and cost of the vaccine are other parental barriers that have been cited in the literature, notes Roberts.

There is still work to be done to help dispel parental fears and to confirm facts about the HPV vaccine, notes Roberts. Use some of the straightforward statements offered by the American Cancer Society in 2016 to counsel parents about the HPV vaccine:

  • It is effective and can prevent cervical and other cancers.
  • The primary side effect is pain at the injection site, and the HPV vaccine causes no long-term side effects.
  • The HPV vaccine does not cause fertility problems.
  • The HPV vaccine does not contain harmful ingredients.
  • Getting the HPV vaccine does not encourage youth to become sexually active.
  • The HPV vaccine is approved for both males and females.
  • The HPV vaccine offers long-lasting protection against cancer.

“Studies of HPV vaccine-hesitant parents show that the single most effective strategy to improve vaccination rates in adolescents is for the health care provider to give a direct, strong recommendation to be vaccinated,” says Roberts. “Patients and their parents trust their provider to give them good advice-regularly review all routinely recommended immunizations with patients, and provide updates when needed.”

Clinicians can recommend the HPV vaccine series the same way they recommend the other adolescent vaccines, states Roberts. “For example, you can say, ‘Your child needs these shots today,’ and name all of the vaccines recommended for the child’s age,” says Roberts.

REFERENCES

  1. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: Prev-alence and incidence estimates, 2008. Sex Transm Dis 2013;40:187-193.
  2. Centers for Disease Control and Prevention. Genital HPV infection. Fact sheet. Available at: http://bit.ly/2gCyxk8. Accessed Jan. 23, 2018.
  3. Viens LJ, Henley SJ, Watson M, et al. Human papillomavirus-associated cancers—United States, 2008–2012. MMWR Morb Mortal Wkly Rep 2016;65:661-666.
  4. Oliver SE, Unger ER, Lewis R, et al. Prevalence of human papillomavirus among females after vaccine introduction — National Health and Nutrition Examination Survey, United States, 2003-2014. J Infect Dis 2017;216:594-603.
  5. Holman DM, Benard V, Roland KB, et al. Barriers to human papillomavirus vaccination among US adolescents: A systematic review of the literature. JAMA Pediatr 2013;168:79-82.