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It’s time for more public schools to join the fight against cervical cancer
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Since the Advisory Committee on Immunization Practices first recommended routine use of the HPV vaccine in 2006, uptake has been discouragingly poor. In 2012, just 53.8% of girls aged 13 to 17 years had received a single dose of the HPV vaccine and only 38.4% had completed the full three doses. Immunization rates for boys are even more abysmal, with only 20.8% having received a single dose of the vaccine in its first year being routinely recommended for both sexes.
Even with such poor rates of administration, the vaccine has been shown to be effective at reducing the prevalence of oncogenic strains of HPV, indicating that universal vaccination could potentially lead to a dramatic decrease in HPV-related cancers. Of course, for the vaccine to be most effective, it must be provided before exposure to the virus. By the time they finish high school, one-quarter of all girls have already contracted a high-risk strain of HPV, underscoring the importance of widespread vaccination in the pre-teen years.
Underestimated risk for disease
Multiple studies suggest that parents who reject HPV vaccination for their children do so because of an underestimation of the prevalence of HPV and of their child’s risk for infection. According to the 2012 National Immunization Survey for teens, approximately 23% of parents said they did not intend to vaccinate their child against HPV in the coming year. Of these, 20% thought the vaccine was not necessary, and an additional 10% were delaying HPV vaccination because their child was not yet sexually active. Other authors have found parental concern for increased sexual promiscuity after receiving the vaccine to be another significant barrier to uptake.
As a consequence of the intrinsic link between HPV and sex, these statistics make it clear that many parents and even some physicians incorrectly assume that only kids labeled as bad or promiscuous are at risk of contracting the virus, whereas their innocent peers are safe and will suffer no negative outcomes by delaying immunization. Religious organizations that have outwardly opposed the development and distribution of the HPV vaccine also have perpetuated this message.
An opportunity for counseling
Counseling in the physician’s office is one important way to increase immunization and should counter such misunderstandings by including information on the high prevalence of HPV, the high likelihood of infection during teen and young adult years, and the convincing evidence that sexual activity is not affected by HPV vaccination. Nevertheless, counseling must be combined with thoughtful public policy to effect broad change in HPV immunization rates. Mandating HPV vaccination for public school attendance would accomplish this goal.
Although the HPV vaccine is routinely recommended for all patients aged 11 to 12 years by the ACIP, it is not required for admission to most US public schools: only Virginia and the District of Columbia require completion of the HPV series before the sixth grade. The lack of a school requirement not only undermines the message that HPV vaccination should be routine for pre-teen patients, it supports the notion that the vaccine may be appropriately reserved for high-risk adolescents.
This is in contrast to the status of the hepatitis B vaccine, which is required by public schools in all 50 states. In the case of the hepatitis B virus — also spread largely via high-risk behaviors such as sexual contact or needle sharing — initial strategies of immunizing only high-risk individuals were ineffective at inducing significant herd immunity. When hepatitis B became a school-required vaccine, immunization became destigmatized, and an ever-larger population gained protection from the virus.
Mandated vaccine for middle school entry
As with hepatitis B, it is likely that more widespread HPV vaccination will be required to maximize the reduction in cancers linked to the virus. Mandating HPV immunization would reduce the stigma of the HPV vaccine for pre-teen patients and would underscore for the public the medical profession’s consensus that the HPV vaccine is critical to child health. It could also rapidly increase the prevalence of vaccination: According to the CDC, simply providing the vaccine at the same time as other school-required immunizations would bring the proportion of vaccinated teens to more than 90%.
Immunization is, by definition, a preventive practice. Mandatory vaccination has been effective in dramatically reducing the risk for diphtheria, measles, meningitis and hepatitis B among school-aged populations by inducing immunity before children are exposed to disease. A similar requirement ensuring HPV vaccination before children are exposed to the virus is one of the most important steps we can take to prevent cancer: School-mandated HPV vaccination is good science, good medicine and good public policy.
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For more information:
Lawren D. Wellisch, MD, is a resident physician, department of pediatrics, Comer Children’s Hospital, The University of Chicago. Wellisch can be reached at: 5721 S. Maryland Avenue, Chicago, IL 60637; email: Lawren.Wellisch@uchospitals.edu.
Benjamin P. Brown, MD, is a second year resident from the University of Chicago Department of Obstetrics and Gynecology, The University of Chicago Medical Center.
Disclosure: The authors report no relevant financial disclosures.