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Changing focus of HPV vaccine discussion could increase immunization rates
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Missed opportunities for HPV vaccination are related to parents’ and physicians’ assumptions about the timing of vaccination relative to onset of sexual activity, according to study findings in Pediatrics.
Rebecca B. Perkins, MD, MSc, of Boston University School of Medicine in Boston, and colleagues conducted parent and physician interviews at an inner-city public clinic and three private practices between September 2012 and August 2013. The study cohort included 124 parents who accompanied their daughters, aged 11 to 17 years, to pediatric well-child visits or problem visits, 30 primary care providers and seven nurses. Interviews determined parental and provider views on why eligible girls did or did not receive HPV vaccination.
Rebecca B. Perkins
Providers’ individual estimates of HPV vaccine initiation rates ranged from 20% to 95%. The mean rate for HPV vaccine initiation for providers at private practices was 67%, compared with 80% at the public clinic.
Review of electronic medical records indicated 54% of females aged 11 to 21 years initiated HPV vaccination at private practices vs. 77% at the public clinic.
Fifty-three girls did not initiate HPV vaccination during the study period. The most common reason for non-vaccination, reported by parents, was never being offered the vaccine (44%). Many parents said they would have accepted the vaccine if offered, according to researchers. Girls who were not offered vaccination were younger than those whose parents declined vaccination when offered.
Another common reason parents reported not initiating vaccination was their perception that HPV vaccination was optional or not recommended. Some parents said the provider indicated HPV vaccination was unnecessary before a patient was sexually active.
Many parents said they declined HPV vaccination for their daughter because of lacking information (21%). Additional reasons included belief that their daughter was too young (13%); safety concerns (11%); belief that vaccination was unnecessary due to abstinence (5%); or concerns that vaccination may promote unsafe sexual behavior (3%).
All providers agreed on the importance of HPV vaccination and that its benefits included reducing cancer rates and health care costs. No providers had safety concerns about the HPV vaccine.
Self-reported rates of HPV vaccination and the age at which vaccination was recommended varied significantly according to provider and site. More private practice providers were concerned about vaccinating at age 11 years and coadministering HPV vaccines with other recommended immunizations than providers from the public clinic. Providers at private practices reported more parental resistance to vaccination than those from the public clinic. In both practice settings, some providers strongly recommended HPV vaccination while others did not, as indicated by the variety of self-reported vaccination rates.
Providers at the public clinic preferred to administer all recommended shots during one visit because many patients did not return annually for care.
“Because HPV is transmitted sexually, and neither parents nor providers want children to be sexually active in their preteen or early teen years, providers often tacitly supported parents’ belief that delaying HPV vaccination is a good idea,” the researchers wrote.
Most providers and parents who delayed vaccination at age 11 or 12 years reported they intended for the child to receive the vaccine later, but that did not happen in many cases.
Ten providers reported that more than 80% of their patients receive the HPV vaccine and said that recommending coadministration of HPV, tetanus, and meningococcal vaccines, with an emphasis on cancer prevention, increased uptake.
Preventing cancer was the primary motivator for most parents, according to providers.
“Many missed opportunities for HPV vaccination occur not because parents and providers feel vaccination is unimportant but because both parties tacitly agree to delay vaccination until there is a perception that girls are at risk for sexual activity. Although in theory this option should still result in timely vaccination, determining the onset of sexual activity in practice is problematic, and many girls remain at risk for vaccine-preventable cancers,” the researchers concluded.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Joseph A. Bocchini Jr., MD, FAAP
Increasing adolescent HPV vaccination rates is a public health issue and a high priority. This study adds to the evidence that a strong recommendation from the provider to give HPV vaccine to 11 and 12-year-olds is the most important way we can increase HPV vaccine uptake to match the other vaccines given to this age group. Parents trust their children’s medical provider and the provider’s recommendation is the reason most parents choose to have their children vaccinated.
HPV vaccine is not an optional vaccine and it makes no sense to delay its administration. As with all other vaccines, the best effect is achieved if the vaccine is given before exposure. The message is clear: HPV vaccine prevents cancer and it needs to be given to girls and boys at the 11-12 year old visit to have the greatest impact. HPV vaccine needs to be recommended with the same strength as Tdap and MCV4 (Menactra, Sanofi-Pasteur).
Co-administration with these vaccines has been shown to be safe and well tolerated. Over 60 million doses of HPV vaccine have been distributed in the US and to this date, the safety profile is no different than in the clinical trials which led to licensure. Protection is long lasting. The vaccine is proving to be very effective. Providers should take a leadership role in improving HPV vaccination rates to reduce the burden of cancers in the lifetime of the adolescents they care for in their practices.
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