How you can remove HPV vaccination barriers
By Anita Brakman, MS
Senior Director of Education, Research & Training
Physicians for Reproductive Health
New York City
Melanie Gold, DO, FAAP
Clinical Professor of Pediatrics
University of Pittsburgh School of Medicine
University of Pittsburgh Student Health Service
In June 2013, researchers reported that the vaccine for human papillomavirus (HPV) effectively reduces infection with high risk strains of the virus among female adolescents ages 14-19. The study reveals that since the first vaccine was introduced in 2006, vaccine-type HPV prevalence among this population of young women has decreased by 56%.1 Despite this encouraging news, the introduction of a second vaccine, and recommendations for routine vaccination of young females and males starting at ages 11 or 12, many adolescents and young adults remain unprotected.
The 2012 National Immunization Survey — Teen found that a little more than half (54%) of U.S. females ages 13-17 had received at least one dose of vaccine and only 33% had completed all three doses in the series. Coverage was worse among males in the same age group compared to females, with only 21% starting the series and 7% completing three doses.2
A November 2013 review in JAMA Pediatrics examined why coverage remains low and identified several key barriers that contribute to lower vaccination coverage rates compared to other vaccines recommended for adolescents. The review included articles published between 2009 and 2012 with the sole focus being barriers to HPV vaccine initiation or series completion among U.S. adolescents ages 11-17. Most of the articles addressed barriers experienced by parents, and the authors also assessed barriers experienced by healthcare professionals, historically underserved populations, and males.3
Most parents in the included studies were aware of the vaccine but desired more information and reported knowledge gaps as a barrier. Many studies found parents were concerned about the vaccines' relative newness and potential adverse effects or safety, but it was not clear if these concerns actually inhibited uptake. A small group of parents across studies reported concerns about the vaccines' potential to increase sexual activity among adolescents, though this fear has not been proven to be true. In 2012, a retrospective cohort study of nearly 1,400 female adolescents found no increase in testing or diagnosis of sexually transmitted infections or pregnancy and no increase in requests for contraceptives among those who initiated vaccination compared to unvaccinated teens.4 The review found mixed results when looking at parental religious beliefs as a barrier to vaccination.
What influences parents?
Factors that were associated with vaccine acceptance among parents included receiving a doctor's recommendation, perceived risk of HPV-related disease, belief that the vaccine was part of a social norm, as well as a history of seeking other preventive services. Additionally, not receiving a doctor's recommendation was associated with non-initiation.3
Articles examining healthcare professionals found a variety of barriers in place. Several studies found clinicians reported a lack of knowledge about the relationship between HPV and urogenital or oral cancers, which indicates an ongoing need for medical education on this topic. Additionally, many providers reported recommending the vaccine only to select populations. Some offered vaccination only to those they perceived as high risk (often low income and/or patients of color). Others reported age or gender biases and only vaccinated older teens or females, but not males. Some questioned the cost effectiveness of vaccinating young males.3
While increasing vaccine coverage among females is a more efficient strategy than vaccinating males overall, providing the vaccine to young men is cost effective when vaccine coverage rates among young women are low and when all potential HPV vaccine-related benefits are included in analysis. Considering reductions in oropharyngeal cancers, penile cancer and recurrent respiratory papillomatosis in addition to reduced cervical, vaginal, vulvar, and anal cancers, and genital warts when analyzing benefits of the vaccine will demonstrate more significant cost benefits to the expanded recommendation for routine vaccination for both young females and males.5
One other significant barrier for clinicians was cost to patients and to providers, including lack of insurance coverage and lack of reimbursement. This barrier was less evident among providers who participated in the Vaccines for Children (VFC) program. Increased participation in the VFC program, combined with enhanced insurance coverage as healthcare reform implementation continues, might mitigate these factors.3
A lack of routine and consistent approaches to vaccination among healthcare providers was reflected in the studies examining underserved populations and males. Black and Hispanic, as well as low-income females, were more likely to receive a recommendation and initiate vaccination. Unfortunately, they were less likely to complete the series than white or higher income peers.3
Where do you come in?
Understanding this data makes it clear that clinicians have a significant role to play in increasing HPV vaccination rates to further decrease prevalence of high risk HPV strains. Educating ourselves, our patients, and their parents, as well as making clear, routine recommendations that are in line with Centers for Disease Control and Prevention guidelines regardless of perceived risk, race, gender, or socioeconomic status, can have a significant effect on parents' and patients' decisions to protect themselves from HPV and its associated negative health outcomes. Adolescents see clinicians less often than younger children or adults, and they are likely to present more often for acute care or athletic and driver's physicals. Any visit with a young adolescent is an opportunity to discuss and offer this safe and effective tool for prevention.
- Markowitz LE, Hariri S, Lin C, et al. Reduction in human papillomavirus (HPV) prevalence among young women following HPV vaccine introduction in the United States, National Health and Nutrition Examination Surveys, 2003-2010. J Infect Dis 2013; 208(3):385-393.
- National and State Vaccination Coverage Among Adolescents Aged 13-17 Years — United States, 2012. MMWR 2012; 62(34):685-693.
- 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 Nov 25; doi:10.1001/jamapediatrics.2013.2752.
- Bednarczyk RA, Davis R, Ault K, et al. Sexual activityrelated outcomes after human papillomavirus vaccination of 11- to 12-year-olds. Pediatrics 2012; 130(5):798-805.
- Chesson HW, Ekwueme DU, Saraiya M, et al. The cost-effectiveness of male HPV vaccination in the United States. Vaccine 2011; 29(46):8,443-8,450.