Time to boost numbers for HPV vaccination

Bivalent and quadrivalent human papillomavirus (HPV) vaccines are safe and effective, with the potential to prevent a large burden of cancers and diseases. However, while national adolescent vaccination rates have continued to climb for vaccines for tetanus-diphtheria-pertussis and meningococcal infection, for the third year in a row, the rise in coverage for HPV vaccine is half of the increases seen for the other two vaccines.1 (Contraceptive Technology Update reported on the statistics in “HPV vaccine rates trail teen vaccines,” November 2011, p. 126.)

It is critical that providers improve communication with parents and patients to strengthen their HPV vaccine recommendations by providing accurate, overall messages about the HPV vaccine and anticipating and preparing to respond to specific concerns from parents, said Amy Middleman, MD, MSEd, MPH, associate professor and director of the Adolescent and Young Adult Immunization program at Texas Children’s Hospital Center for Vaccine Awareness and Research in Houston. Middleman served as a panel member of a February 2013 Centers for Disease Control and Prevention (CDC) Public Health Grand Rounds presentation, “Reducing the Burden of HPV-associated Cancer and Disease through Vaccination in the U.S.” (Clinicians can access a video of the presentation at http://1.usa.gov/X1MlrR.)

Providers also can use clinical practice strategies shown to improve immunization rates such as recall systems, screening tools, and standing orders to help boost immunization numbers, said Middleman.

In a 2012 study, adolescents who received reminder recall messages experience higher coverage rates for adolescent vaccines, including an approximately 73% higher rate for HPV vaccines, than those who did not receive such messages, Middleman noted.2

“Quick visits” can help

What are some other ways that providers can help? Check the following tips offered by Lauri Markowitz, MD, another panel member and team leader of the Epidemiology and Statistics Branch in the CDC’s Division of STD Prevention’s National Center for HIV, Viral Hepatitis, STD and TB Prevention.

• Arrange for “quick visits” in which patients come in, get the vaccine, and leave, with no appointment necessary.

• Let parents and teens know that the HPV vaccine is an anti-cancer vaccine that is safe and effective.

Results of a 2011 paper indicate a provider’s recommendation is the single most important factor in the decision by adolescents and parents to initiate and complete the HPV vaccination series.3

There are two, if not more, issues with uptake of the HPV vaccine, observes Susan Wysocki, WHNP-BC, FAANP, president & chief executive officer of iWomansHealth in Washington, DC, which focuses on information on women’s health issues for clinicians and consumers. One issue centers around whether providers offer the vaccine onsite. Some providers might not stock the vaccine, because overhead costs range from about 17% to 28% of the cost of the vaccine, according to a 2010 published report.4

Another issue is the convenience to the patient to complete the series, notes Wysocki.

“If it is possible, as it is in some states, to offer initial or series completion at local pharmacies with a provider’s script, it is worth the effort,” states Wysocki. According to the American Pharmacists Association, 43 states have regulations allowing pharmacists to administer the HPV vaccine. Visit http://bit.ly/Y0T7Rv to see the listing.

“Anything that makes things easier for the patient and the provider is a step in the right direction,” says Wysocki.

Why parents hesitate

Just-published results from a national survey show more than two in five parents surveyed believe the HPV vaccine is unnecessary, and a growing number worry about potential side effects.5

Previous research has examined the top five reasons parents have cited for not vaccinating their daughters with the HPV shot. About one-quarter (23.2%) said it was not needed or necessary; about one-fifth (19.5) said their daughters were not sexually active; and 19.3% cited safety concerns regarding side effects. Lack of knowledge was cited by 15.2%; and about 10% said it had not recommended by their provider.6

Clinician interaction is going to play an important role in uptake of the HPV vaccine in young males. In 2009, the quadrivalent HPV vaccine was approved and permissively recommended for U.S. males ages 9-26 to protect against genital warts. The recommendation was moved to routine use in 2011. (See “Finally! HPV male shot routinely recommended,” January 2012, p. 6.) Data from the 2010 National Health Interview Survey were obtained to assess vaccination status uptake among males ages 9-17 during the first year following the permissive recommendation. Overall, just 55% of parents with sons were aware of the HPV vaccine. Only 2.0% and 0.5% of males ages 9-17 initiated one or more doses and completed the vaccine series, respectively.7

Given the brief amount of time allotted for counseling during patient visits, what are the most important things providers should cover regarding the HPV vaccine?

The most important area to emphasize is that the HPV vaccine is an anti-cancer vaccine that is one of medicine’s most effective vaccines, said Markowitz. It is recommended for boys and girls at 11 or 12 years, which is a great age to give the vaccine, she stated.

“We know the immune response to the vaccination is very good at this age, and it can be delivered before any potential exposure to the virus,” stated Markowitz.


1. Centers for Disease Control and Prevention (CDC). National and state vaccination coverage among adolescents aged 13 through 17 years – United States, 2010. MMWR 2011; 60:1,117-1,123.

2. Suh CA, Saville A, Daley MF, et al. Effectiveness and net cost of reminder/recall for adolescent immunizations. Pediatrics 2012; 129(6):e1,437-1,445.

3. Dorell CG, Yankey D, Santibanez TA, et al. Human papillomavirus vaccination series initiation and completion, 2008-2009. Pediatrics 2011; 128(5):830-839.

4. American Academy of Pediatrics. The Business Case for Pricing Vaccines. Accessed at http://bit.ly/ZrjTwx.

5. Darden PM, Thompson DM, Roberts JR, et al. Reasons for not vaccinating adolescents: National Immunization Survey of Teens, 2008–2010. Pediatrics 2013. Doi: 10.1542/peds.2012-2384.

6. Daley MF, Crane LA, Markowitz LE, et al. Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure. Pediatrics 2010; 126(3):425-433.

7. Laz TH, Rahman M, Berenson AB. Human papillomavirus vaccine uptake among 9-17 year old males in the United States: The National Health Interview Survey, 2010. Hum Vaccin Immunother 2013; 9(4): http://dx.doi.org/10.4161/hv.23190.