Q&A: Pandemic may hinder HPV vaccination efforts

The COVID-19 pandemic could reverse improvements made in recent decades toward HPV vaccination efforts, according to Mona Saraiya, MD, MPH.

Saraiya, a medical officer and team lead of the CDC’s Division of Cancer Prevention and Control’s Epidemiology and Applied Research Branch, and colleagues recently published research on U.S. vulvar, vaginal and anal precancer rates in the American Journal of Preventive Medicine.

They observed that precancer rates decreased or stabilized after the introduction of the HPV vaccine, Healio previously reported.

Further decreases in new precancer cases may occur with increases in HPV vaccination rates, Saraiya told Healio. However, vaccine hesitancy and a lack of patient-provider discussion hinders HPV prevention measures, and the pandemic adds another layer of difficulty to vaccination efforts.

Healio spoke with Saraiya to learn more about what is currently influencing HPV vaccine uptake in the U.S.

Healio: HPV vaccine uptake and awareness is low right now. What impact may this have on future precancer rates?

Saraiya: HPV vaccine awareness may be low, and studies suggest that some of the reasons that parents might be hesitant about giving their preteen the HPV vaccine are related to a lack of awareness about all the diseases it can prevent, worries about its safety, as well as the idea that their child is too young to get this vaccine.

However, we have seen a gradual increase in vaccination coverage among teens since the introduction of HPV vaccines in the U.S. HPV vaccination rates among those aged 13 to 17 years increased from 54% in 2019 to 59% in 2020 for teens who received all recommended doses. The percentage of teens who received one or more doses of HPV vaccine increased from 72% in 2019 to 75% in 2020. Among boys, the increase was from 70% to 73%, and among girls, it went from 73% to 77%.

Healio: Are current HPV vaccination efforts enough?

Saraiya: More than 135 million doses of HPV vaccine have been distributed since they were licensed, and data continue to show they are safe and very effective. However, there is still room for improvement.

The coverage rates are not nearly as high as the coverage rates for most other vaccines routinely recommended for those aged 11 to 12 years (Tdap and meningococcal conjugate), which are over 80%. The high coverage rates for the Tdap vaccine demonstrate that not only are most preteens and teens going to the doctor, but they are also receiving at least one of the recommended adolescent vaccines. 

Healio: How do you think the pandemic has helped or hindered HPV vaccination efforts?

Saraiya: The COVID-19 pandemic has the potential to reverse gains made in HPV vaccination coverage, and data from earlier in the pandemic show decreases in routine vaccination among all children, particularly older children.

We know that health care professionals play an important role in helping parents make the right decision through listening to their concerns and answering their questions confidently. Providers can take several steps to ensure that adolescents are up to date with recommended vaccines, including:

• Promote the importance of well-child and vaccination visits, even as the COVID-19 pandemic continues.
• Follow guidance on safely providing vaccinations during the COVID-19 pandemic and let families know what precautions are in place for safe delivery of in-person services.
• Leverage reminder and recall systems to remind parents of their teen’s upcoming appointment and recall those who missed appointments and vaccinations.
• Educate eligible patients and parents about free options for routine childhood vaccinations. CDC’s Vaccines for Children program helps provide vaccines at no cost to children whose parents or guardians may not be able to afford them.

The pandemic has also impacted screening efforts. We saw an 84% decline in the number of cervical cancer screening tests received by women through CDC’s National Breast and Cervical Cancer Early Detection Program during April 2020, as compared with the previous 5-year averages for that month. These screening declines coincided with the rapid increase of COVID-19 cases in Spring 2020. The good news is that the cervical cancer screening volume recovered by half in June 2020. It was 40% below the 5-year average for that month. However, it is important that we continue to encourage women to return to cancer screening services because over 60% of cervical cancer occurs among women who are never or rarely screened. Health care professionals can help by continuing routine cancer screening for women having symptoms or at high risk for cervical cancer.

Healio: How do social determinants of health impact vaccination rates and precancer/cancer diagnoses?

Saraiya: When talking about cancer, equity is when everyone has an equal opportunity to prevent cancer, find it early, and get proper treatment and follow-up after treatment is completed. However, social determinants of health such as the places where people live, learn, work and play can affect their chances of getting and dying from cancer.

For example, HPV vaccination rates among those aged 13 to 17 years increased in 2020, but lower vaccination rates were seen among teens living at or above poverty level in rural areas compared to those in urban areas, highlighting the need for continued efforts to ensure all teens have equal access to recommended vaccines.

We also know that HPV-associated conditions such as cervical cancer and precancer are more common among low-income groups and groups in certain racial-ethnic groups. Cervical cancer screening rates are also lower among certain racial/ethnic groups, rural area residents and those who are immigrant and those with limited English proficiency. Screening tests can find cervical, colorectal, breast and lung cancers early when treatment works best. However, for some people, it can be hard to get screened as recommended. For example, they may not be able to afford cancer screening tests and don’t have health insurance. People whose jobs don’t provide sick leave, people who live in rural or remote areas and people without reliable transportation may not be able to go to a doctor’s office.

Everyone deserves an equal opportunity to be as healthy as possible, and CDC works to eliminate cancer disparities to improve the health of all Americans. For example, CDC’s National Breast and Cervical Cancer Early Detection Program offers free or low-cost breast and cervical cancer screening tests nationwide.

Healio: Anything else to add?

Saraiya: HPV vaccines protect against the types of HPV that most often cause cervical, vaginal, vulvar, penile and anal precancers and cancers, as well as the types of HPV that cause most oropharyngeal cancers. HPV infections and cervical precancers have dropped since 2006, when HPV vaccines were first used in the U.S.

Infections with HPV types that cause most HPV cancers and genital warts have dropped 88% among teen girls, and 81% among young adult women. Among vaccinated women, the percentage of cervical precancers caused by the HPV types most often linked to cervical cancer has dropped by 40%.

CDC’s Division of Cancer Prevention and Control leads efforts to use cancer registry data to estimate how many HPV-associated cancers occur in the U.S. Each year, the most recent estimates of HPV-associated cancers at the national and state levels are published in U.S. Cancer Statistics Data Briefs.

Large international studies have confirmed that HPV vaccines are effective in preventing cervical cancer. In the U.S., we have also seen a reduction in cervical cancer among the youngest population after the introduction of HPV vaccines.

CDC’s Inside Knowledge About Gynecologic Cancer campaign raises awareness among women and health care providers about the five main types of gynecologic cancer: cervical, ovarian, uterine, vaginal and vulvar.

Reference:

Mix JM, et al. Am J Prev Med. 2022;doi:10.1016/j.amepre.2021.06.026.