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HPV and influenza vaccinations: Methods to improve coverage rates
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Vaccination coverage levels targeting influenza virus and HPV in the pediatric population have fallen short in recent years. Coverage levels for other illness of the routine pediatric immunization schedule have generally been greater. How can we improve?
Influenza infection rates
Of all infectious diseases that can be prevented by immunization, influenza leads in pediatric morbidity (hospitalization) and mortality. Illness and death caused by influenza are increased in those aged at least 65 years, younger than 2 years and those with high-risk conditions. Children are also known to be highly associated with increased infection rates and transmission, more so than the adult population. Although the lay public may associate illness and death from influenza more with the elderly, infants and older children are also significantly affected.
Edward A.
Bell
Influenza-associated hospitalization rates for infants and young children (younger than 5 years) are similar to others considered at higher risk for influenza-related complications, such as adults aged at least 65 years. Since 2004, death due to influenza infection in children has been a nationally reportable condition. Annual pediatric deaths caused by influenza have ranged from 34 (2011-2012) to 348 (2009-2010). During this past influenza season (2012-2013), 164 children died of influenza. Many of these deaths (nearly 50%) occurred in children without recognized high-risk conditions, and most of these children had not received influenza vaccine.
Influenza vaccination rates low for children
For infants and children (aged 6 months to 17 years), preliminary results through February 2013 for 2012-2013 indicate 54.9% coverage (68.1% for those aged 6 months to 4 years; 57.2% for 5 to 12 years; 40.1% for 13 to 17 years). How does this compare with other pediatric immunizations, including diphtheria-tetanus-acellular pertussis, measles-mumps-rubella, pneumococcal conjugate vaccine and varicella?
Rates for 2012 for children aged 19 to 35 months were near or exceeded the Healthy People 2020 targets, as established by the Department of Health and Human Services: DTaP (≥4 doses) 82.5%; MMR (≥1 dose) 90.8%; PCV (≥4 doses) 81.9%; varicella (≥1 dose) 90.2%. However, influenza vaccination coverage is well below the target of 80% influenza vaccination coverage for all pediatric age groups.
The CDC has recommended enhancing access to vaccination services, increasing community demand for vaccinations, and enhancing provider-based interventions and system-based interventions. As individual health care providers, we can discuss these data with our patients and families, remind them of the potential dangers of influenza (including death), and recommend vaccination for all patients aged at least 6 months who do not have valid contraindications.
HPV
HPV is the most common sexually transmitted infection in the United States, with 14 million becoming infected with HPV each year. Most sexually active males and females will be exposed to HPV at some point in their lives. The CDC has estimated that of more than 110 million total (new and existing) STIs in the United States (2008), more than 79 million were due to infection with HPV. Of these, 26,000 HPV-related cancers will occur, with 17,000 occurring in females. In females, 4,000 will die annually of cervical cancer. Each year that HPV vaccine coverage remains at 30% instead of 80% (Healthy People 2020 goal), 1,400 future cervical cancer deaths will occur. Two HPV vaccines are available, Gardasil (targeting HPV types 6, 11, 16, 18) and Cervarix (targeting HPV types 16, 18). Gardasil (Merck) was licensed in 2006 and Cervarix (GlaxoSmithKline) in 2010 for females aged 9 to 26 years. Labeling for Gardasil was subsequently extended to males aged 9 to 26 years. Despite the availability of these vaccines, their use has lagged.
The CDC recently published data describing HPV vaccine coverage among girls aged 13 to 17 years from the 2007 to 2012 National Immunization Survey-Teen (NIS-Teen). This survey collects vaccination information from all states using random digit sample telephoning and medical record information provided by sampled teens’ providers (n=19,199). Coverage levels in 2012 did not differ significantly from 2011 — 53.8% coverage in 2012 vs. 53% coverage in 2011 (≥1 dose of either vaccine). Vaccine coverage for the completed HPV series (three doses) for 2012 was 33.4% vs. 34.8% for 2011. The percentage of unvaccinated girls with one or more missed opportunity for receipt of HPV vaccine was 84% in 2012.
However, when assessing administration of any vaccine at health care visits, had HPV been administered when other vaccines were given, HPV coverage would have been 92.6% in 2012. Clearly, these data indicate a need for improvement. Additional data collected from NIS-Teen included reasons parents provided for not administering HPV vaccine. The most common reasons given included: vaccine not needed (19.1%); vaccine not recommended (14.2%); vaccine safety concerns (13.1%); lack of knowledge about the vaccine or disease (12.6%); and daughter is not sexually active (10.1%).
Additional parental education needed
Recommendations given in this report include improving upon education of parents about HPV infection dangers and vaccine efficacy, improving strength of vaccine recommendation by health care providers, and reducing missed vaccination opportunities. Additional researchers have analyzed data from the NIS-Teen, evaluating reasons caregivers give for not vaccinating their adolescent children for HPV. Common reasons in these studies include parental concerns about vaccine safety, belief that immunization is not necessary when a child is not sexually active, and belief that HPV vaccine is not needed or necessary. Data from some of these studies demonstrate that health care provider recommendations are important in the parental decision process and increase the likelihood of HPV vaccination. These studies suggest that strategies to increase HPV vaccination coverage are likely to be multifactorial, including education of parents and adolescents about HPV epidemiology and disease; reducing parental concerns over HPV vaccine safety; improving the strength of health care provider recommendation; reducing missed opportunities for vaccination; and system improvements (such as reminder-recall systems). The CDC provides on its website an excellent information sheet that providers can use when speaking with parents and adolescents about HPV (www.cdc.gov/vaccines/who/teens/for-hcp-tipsheet-hpv.html).
Markowitz and colleagues from the CDC recently published data that demonstrate the effectiveness of HPV immunization. They evaluated cervicovaginal swab samples from females aged 14 to 59 years who participated in the National Health and Nutrition Examination Survey. HPV prevalence data were compared from the pre-vaccine era (2003-2006; n=4,150 samples) with the vaccine era (2007-2010; n=4,253 samples). Among females aged 14 to 19 years, vaccine-type HPV prevalence (6, 11, 16, 18) decreased by 56% (11.5% to 5.1%) from 2003-2006 to 2007-2010. The vaccine effectiveness of at least one dose of vaccine was 82%. HPV serotypes 16 and 18 are responsible for approximately 70% of cervical cancers. These data provide useful information for parents who may question the effectiveness of HPV vaccination.
There remains some belief by parents, as demonstrated in various surveys, that administration of HPV vaccine will increase adolescent sexual activity. A recently published analysis of electronic data from a managed care organization refutes these beliefs. Bednarczyk evaluated outcome data of a cohort of girls who received HPV vaccine at age 11 to 12 years (n=493 HPV vaccine-exposed; n=905 HPV vaccine-unexposed). Outcome measures included pregnancy/STI testing or diagnosis, and contraceptive counseling. After 3 years of follow-up, no difference was found in these measures between the HPV vaccine-exposed and HPV vaccine-unexposed groups, and the study researchers concluded that HPV vaccination was not associated with increased sexual activity-related outcome rates.
References:
Bednarczyk RA. Pediatrics. 2012;130:798-805.
For more information:
Edward A. Bell, PharmD, BCPS, is a professor of clinical sciences at Drake University College of Pharmacy, Blank Children’s Hospital, in Des Moines, Iowa. He is also a member of the Infectious Diseases in Children Editorial Board. He can be reached at: Drake University College of Pharmacy, 2507 University Ave., Des Moines, IA 50311; email: ed.bell@drake.edu.
Disclosure: Bell serves on the speakers’ bureau for Sanofi-Pasteur (Sklice) and MedImmune (FluMist Quad).