HPV vaccination: No good reason to wait

Issue: October 2012

ByAmy Middleman, MD, MPH

If you examine the primary causes of morbidity and mortality among adolescents aged 15 to 24 years, infectious diseases are not at the top of the list. Instead, motor vehicle accidents top the list. Armed with this information, adolescent medicine providers (and most primary care providers) counsel their patients regarding the use of seat belts and safe driving practices. Of all of the behaviors we could change among youth, it is possible that this preventive strategy might affect the most lives. Unfortunately, motor vehicle accidents continue to kill our youth; the efficacy of our counseling may not be as high as we consistently hope it is.

HPV vaccine remains underutilized

Although infectious diseases are lower on the list of morbidity culprits, the efficacy of vaccines in the prevention of disease is quite high. To allow our adolescents to go without such an effective prevention strategy, when so few of our preventive health strategies reach this level of success, is unfortunate.

HPV vaccine represents a strategy that is currently being underutilized among our youth. The efficacy of this vaccine, whether you deliver the bivalent or quadrivalent product, is well into the 90% to 100% range. The morbidity it prevents has been shown to be significant; cost-effectiveness analysis for HPV vaccine has produced more favorable results over time; results are now similar to other childhood vaccines. Why are the rates of vaccination with this vaccine rising significantly slower than those of other vaccines?

Recommendations for the use of this vaccine have stirred very distracting debates pertaining to the mode of transmission of the target disease, and perhaps this is the reason rates are slower to improve. Although it is unfortunate that clear benefits regarding disease prevention have become confused by some with the “how-tos” and “where-fors” of disease acquisition (after all — many people are getting the disease regardless of our particular stance on when and how human sexuality should be explored), studies indicate that most parents support the use of the HPV vaccine for their children.

Amy Middleman

Maybe it is because HPV vaccine is considered by parents to be unsafe. Well, all vaccines have to run the gauntlet of public scrutiny, and the HPV vaccine has proven itself to be safe. With more than 46 million doses distributed, there are no significant adverse events associated with this vaccine. Therefore, it is unclear to me why this vaccine is not being accepted with the same fervor as other vaccines.

Role of the physician

One factor that is rarely discussed is the provider factor. We know that strong provider recommendation is a key component to parental acceptance of any vaccine. Studies have shown that providers recommend the HPV vaccine, but many report the vaccine is most appropriate for adolescents aged at least 15 years. I have heard from many of my patients that their primary care doctor has supported the use of the HPV vaccine, just “not right now.” Not right now? Is that really recommending the vaccine?

Data indicate that many teens have experienced their sexual debut before the age of 15 years, but, more importantly, sexual experimentation (digital and oral activities) that also puts children at risk of disease acquisition occurs some time before that. We must also face the fact that sexual debut may not be the patient’s choice. We know that immune response to the vaccine is more vigorous the younger the recipient. We know that duration of protection spans many years. Therefore, there is no reason to wait.

Some providers have noted that parents are concerned that administering the vaccine provides tacit approval for sexual activity. We have experience with school condom programs, availability of emergency contraception in pharmacies without a prescription and the use of contraception for medical indications that all indicate that such preventive interventions do not increase rates of sexual debut among young people. The decision to have sex is a developmental one. This type of reasoning raises questions regarding seat belt use encouraging adolescents to speed or administration of the tetanus-diphtheria-acellular pertussis vaccine encouraging contact with rusty nails.

Strong recommendations needed

As providers, we need to know the data ourselves and discuss these concerns with parents. Some providers may not want to discuss the mode of disease transmission with adolescents who may not be ready for such discussions. I would ask why you would discuss mode of transmission unless it represents an opportunity to enter a developmentally appropriate discussion about sexuality with an adolescent. Most physicians do not routinely discuss the mode of transmission of diphtheria before administering the Tdap vaccine. The same goes for mode of transmission for measles-mumps-rubella.

I would posit that most providers counsel their patients that these vaccines are important to prevent diseases that can cause illness and death. They are very effective, and we strongly recommend every adolescent receive them. These vaccines are a great way to protect our patients’ health. In addition, HPV is a disease that can cause illness and death. HPV vaccine is a great way to protect our patients’ health. We need to strongly recommend HPV vaccine to all of our patients at the specifically recommended age (eg, 11 to 12 years). Why hesitate? Why wait? And on the ride home from their shot, please counsel your patients to buckle up for safety.

For more information:

CDC. MMWR. 2011;60:1117-1149.
CDC. MMWR. 2012;61:1-162.
Chesson H. Vaccine. 2011;29:8443-8450.
Constantine NA. J Adolesc Health. 2007;40:108-115.
Daley M. Pediatr. 2006;118:2280-2289.
Elliott M. J Adolesc Health. 2007;41:616-619.
Gold M. J Pediatr Adolesc Gynecol. 2004;17:87-96.
Olshen E. J Adolesc Health. 2005;37:248-251.
Raine T. JAMA 2005;293:54-62.
Zimet G. J Adolesc Health. 2005;37:179-186.

Disclosure: Middleman reports no relevant financial disclosures.