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HPV vaccine coverage rates a call to action for providers
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HPV vaccine coverage data from the 2011 National Immunization Survey – Teen, conducted annually by the CDC, are disappointing and should serve as a call to action for all providers who care for older children and adolescents.
Although the HPV immunization rate for 13- to 17-year-old girls increased 4% during the prior year, only 53% had received one or more doses of HPV vaccine, and the rates were lower for younger teens. In addition, of girls who had begun the HPV vaccine series 6 or more months earlier, only 71% received all three required injections.
Joseph A. Bocchini
This survey was completed only a few months after the change in HPV vaccine recommendation for boys from permissive to routine by the CDC’s Advisory Committee on Immunization Practices. As such, one or more doses of HPV vaccine coverage for boys was low (8.3%). But, only 28% of boys who had begun the HPV vaccine series 6 or more months earlier had received all three doses, highlighting further the problem of compliance with the follow-up visits required to complete the series on schedule in this age group.
Other adolescent vaccinations
When compared with the other two vaccines routinely recommended at the 11- to 12-year-old visit, HPV uptake is falling behind. Tetanus-diphtheria-acellular pertussis vaccine coverage increased 9.5% in 2011 to 78.2% and meningococcal conjugate vaccine coverage increased by nearly 7.8%, to 70.5%.
These findings appear to be the result of a number of factors we as providers can effectively address. They include parental lack of knowledge, increasing concerns about vaccine safety, the belief that their child does not need the vaccine or is not sexually active, and a concern that giving the vaccine may result in an increased likelihood that the child will become sexually active. Some parents report that their child’s physician did not recommend HPV vaccine or that their physician provider did not give a strong recommendation, thus, in effect, delaying administration.
Recently published studies continue to show that many parents of young adolescents are unaware of the frequency of HPV infection and its consequences. Other parents feel it is safe to wait until their child gets older. However, parents underestimate whether their child is sexually active. Using the questions asked of parents in the 2011 National Immunization Survey (NIS)—Teen, investigators noted a significant increase in safety concerns from the first survey in 2008.
Also troubling is that some parents indicate that they would have considered giving HPV vaccine to their child if their physician had made them aware of HPV and had recommended it at that health visit. In all studies of the decision to vaccinate, parents indicate that the most important influence on their decision is a recommendation by their physician, who for most parents is their most trusted source of vaccine information.
HPV causes large disease burden
HPV is the most common sexually transmitted infection in the United States. The highest prevalence is in sexually active adolescents and young adults. Infection occurs soon after the onset of sexual activity. In the 2006-2008 National Survey of Family Growth, 21% of boys and 23% of girls aged 15 years reported having had vaginal sex; and by 18 years of age, the numbers increased to 59% and 56%, respectively. Recent studies indicate that non-intercourse–related sexual contact may also result in transmission of HPV. The lifetime risk for acquiring HPV is more than 50%. Although most infections are silent and resolve within 2 years, parents must be aware that HPV causes virtually all cases of cervical cancer and a significant percentage of cases of other anogenital and oropharyngeal cancers in females and males.
Despite cervical screening protocols, more than 11,000 women are diagnosed with cervical cancer each year in the United States. An estimated 25,000 HPV-associated cancers are diagnosed in the United States each year, and HPV types 16 and 18, which are in both licensed HPV vaccines, are responsible for more than 70% of cervical cancers and approximately 80% of all HPV-associated cancers.
Both of the licensed HPV vaccines are designed to prevent cancer, one also targets genital warts by including types 6 and 11. The routine recommendation from ACIP and AAP for HPV vaccines for 11- to 12-year-olds is based on the available data concerning their safety and efficacy and the epidemiology of HPV infection. Protection against HPV is greatest if the vaccine is given before the onset of sexual activity. Antibody titers post-immunization are highest in this age group. The safety of both HPV vaccines has been clearly demonstrated. Post-licensure monitoring of Vaccine Adverse Event Reporting System (VAERS) reports and prospective phase 4 safety studies have not demonstrated any safety signal or raised any safety concern.
In clinical trials, both vaccines were found to be highly efficacious in preventing cancer precursor lesions. Early data from Australia, where approximately 83% of 12- to 17-year-old girls and 55% of women aged 18 to 26 years received at least one dose of quadrivalent HPV vaccine (types 6, 11, 16 and 18) and 70% and 32%, respectively, completed the series from 2007 to 2009, indicate a marked reduction in cases of genital warts and HPV 16/18 genotype recovery from cervical specimens.
Adolescent immunization presents unique challenges. Adolescents are more likely to visit the office with an acute illness or injury rather than for routine preventive care. Every office visit should be used as an opportunity to review immunization status and update any patient who is behind schedule. The return visits required for completion of a three-dose immunization series is an additional challenge. Two recent articles indicate that the recall and reminder protocols that improve immunization rates in young children also may be helpful for adolescents.
We as providers can markedly influence the uptake of HPV vaccine. HPV vaccines give us a remarkable opportunity to protect our patients against another viral cause of cancer. As with hepatitis B vaccine, HPV vaccine must be given before exposure to be effective. Since the time of exposure cannot be predicted during adolescence, it is imperative that we educate parents on the importance of providing this vaccine to 11- to 12-year-old girls and boys. It is our responsibility to take the time to educate parents about the long-term consequences associated with HPV infection, correct misperceptions about HPV vaccine safety, make them aware of the data that HPV vaccination in the recommended ages is not associated with increased sexual activity, and make as strong a recommendation for giving HPV vaccine as we do for Tdap and MCV4. The CDC has numerous resources available to providers and parents.
Disclosure: Bocchini reports no relevant financial disclosures.