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Moving forward: HPV vaccination is only the beginning
Editor’s note: In this three-part series, Kenneth A. Alexander, MD, PhD, Chief of the Division of Infectious Diseases in the Department of Pediatrics at Nemours Children's Hospital in Orlando, reviews issues surrounding uptake of the HPV vaccine. Part three discusses his hopes for future vaccines and strategies for discussing HPV vaccination with patients and families.
The HPV vaccine is the first vaccine truly indicated for our adolescent patients. The HPV vaccine is not only important in its own right; it is also a bellwether for vaccines of the future. If clinicians made a list of vaccines that we wish we had, what would be on the list? I think we’d all agree that we want a vaccine for HIV. We’ve been working for decades on a vaccine against herpes. We’d love to have vaccines to prevent gonorrhea, chlamydia, hepatitis C, cytomegalovirus, group B streptococcus, breast cancer and prostate cancer. The list could still go on. Now, look at that list of vaccines we wish we had, and contemplate which ones would likely be administered among teenagers. The answer is: HIV, herpes, gonorrhea, chlamydia, group B streptococcus, CMV, , breast cancer and prostate cancer.
I have three comments about this list of vaccines we wish we had. First, it is important to remember that these are exciting times. The list of diseases that we will prevent by vaccination will continue to grow. Second, the face of immunization in the future is a teenager at the shopping mall who is texting his or her friends. Third, many of the diseases that we will prevent are, like HPV, associated with adult behaviors (read: sex). Given that the future of immunization is in teenagers, while also recognizing that HPV vaccines prevent diseases associated with adult behavior, we should view the HPV vaccine as an indicator of what’s to come, maybe even as a “dry run” on an HIV vaccine. We’re in for an exciting future of disease prevention, but if pediatricians are going to be prepared for that future we get past the idea that, if we bring up sexuality, parents are going to get angry. First, research shows that this notion is largely untrue. Second, even if parents did get angry, failing to advocate for vaccination is selling our patients short.
Of equal importance, the nuance of language is important. Providers must stop calling this a new vaccine. This vaccine is now 12 years old, or as old a child who is eligible for the HPV vaccine. This vaccine is no more a new vaccine than your 12-year-old is your new baby. In the , approximately 70 million doses have been administered. There have been more than 260 million doses given globally. Nearly 50,000 people have been enrolled in the clinical trials of this vaccine. It is one of the most studied vaccines in history. The efficacy, effectiveness and safety data on the HPV vaccine are voluminous.
All that said, I’m a glass-half-full guy. I am optimistic that the new, two-dose HPV vaccination schedule will increase vaccine acceptance. Individuals who administer the HPV vaccine need to be reminded that the two-dose regimen can be used as long as the first dose is given before the patient’s 15th birthday; the second dose should be given 6-12 months later. If the first dose is not given until after the patient’s 15th birthday, the patient should receive the three-dose regimen. The Advisory Committee on Immunization Practices recommends giving the vaccine to children between the ages of 11 and 12, so the question of using the three-dose regimen in children aged 15 years should be a nonissue.
If the number of vaccine doses means something to parents, pediatricians can point out that earlier vaccination requires only two doses, thereby saving an additional office visit and another dreaded needle stick. For some, that will be enough of an impetus to vaccinate early.
We have the data. We have shown that the HPV vaccine works and that it is safe. Now, we have to get our messaging right. Perhaps it is as simple as saying to parents, “OK, mom. It’s time for Mia’s HPV vaccine. Which arm?”
Disclosure: Alexander reports serving as a consultant and as a speaker for Merck and for MSD, the manufacturer of the 9-valent HPV vaccine.