CE/CME

How to Increase HPV Vaccination Rates

Clinician Reviews. 2017 September;27(9):40-46

References

1. Juckett G, Hartsman-Adams H. Human papillomavirus: clinical manifestations and prevention. Am Fam Physician. 2010;82(10):1209-1213.
2. Markowitz LE, Dunne EF, Saraiya M, et al. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2014;63(RR-05):1-30.
3. Viens LJ, Henley SJ, Watson M, et al. Human papillomavirus-associated cancers—United States, 2008-2012. MMWR Morb Mortal Wkly Rep. 2016;65(26):661-666.
4. American Cancer Society. Cancer facts and figures 2016. Atlanta: American Cancer Society; 2016.
5. Holman DM, Benard V, Roland KB, et al. Barriers to the human papillomavirus vaccination among US adolescents: a systematic review of the literature. JAMA Pediatr. 2014;168(1):76-82.
6. American College of Obstetricians and Gynecologists. Human papillomavirus vaccination. Committee Opinion. Number 704. June 2017. www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Human-Papillomavirus-Vaccination. Accessed August 17, 2017.
7. Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination—updated recommendation of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405-1408.
8. Mulcahy N. GSK’s HPV vaccine, Cervarix, no longer available in the US. Medscape Medical News. October 26, 2016. www.medscape.com/viewarticle/870853. Accessed June 11, 2017.
9. Reagan-Steiner S, Yankey D, Jeyarajah J, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years—United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(29):784-792.
10. Muncie HL, Lebato AL. HPV vaccination: overcoming parental and physician impediments. Am Fam Physician. 2015;92(6):449-454.
11. Bratic JS, Seyferth ER, Bocchini JA Jr. Update on barriers to human papillomavirus vaccination and effective strategies to promote vaccine acceptance. Curr Opin Pediatr. 2016;28(3):407-412.
12. Rahman M, Laz TH, McGrath CJ, Berenson AB. Provider recommendation mediates the relationship between parental human papillomavirus (HPV) vaccine awareness and HPV vaccine initiation and completion among 13- to 17-year-old US adolescent children. Clin Pediatr. 2015;54(4):371-375.
13. Sussman AL, Helitzer D, Bennett A, et al. Catching up with the HPV vaccine: challenges and opportunities in primary care. Ann Fam Med. 2015;13(4):354-360.
14. Clark SJ, Cowan AE, Filipp SL, et al. Parent perception of provider interactions influences HPV vaccination status of adolescent females. Clin Pediatr. 2016;55(8):701-706.
15. Ackerman LK, Serrano JL. Update on routine childhood and adolescent immunizations. Am Fam Physician. 2015;92(6):460-468.
16. Tom A, Robinett H, Buenconsejo-Lum L, et al. Promoting and providing the HPV vaccination in Hawaii: barriers faced by health providers. J Community Health. 2016;41(5):1069-1077.
17. Young JL, Bernheim RG, Korte JE, et al. Human papillomavirus vaccination recommendation may be linked to reimbursement: A survey of Virginia family practitioners and gynecologists. J Pediat Adolesc Gynecol. 2011;24(6):380-385.
18. Thomas R, Higgins L, Ding L, et al. Factors associated with HPV vaccine initiation, vaccine completion, and accuracy of self-reported vaccination status among 13- to 26-year-old men. Am J Mens Health. 2016;1-9.
19. Laz TH, Rahman M, Berenson AB. Human papillomavirus vaccine uptake among 9-17 year old males in the United States: the National Health Interview Survey, 2010. Hum Vaccin Immunother. 2013;9(4):874-878.
20. Perkins RB, Zisblatt L, Legler A, et al. Effectiveness of a provider-focused intervention to improve HPV vaccination rates in boys and girls. Vaccine. 2015;33:1223-1229.
21. Smulian EA, Mitchell KR, Stokley S. Interventions to increase HPV vaccination coverage: a systematic review. Hum Vaccin Immunother. 2016;12:1566-1588.
22. Walling EB, Benzoni N, Dornfeld J, et al. Interventions to improve HPV vaccine uptake: a systematic review. Pediatrics. 2016;138(1).
23. CDC. Overview of AFIX. www.cdc.gov/vaccines/programs/afix/index.html. Accessed August 17, 2017.
24. CDC. Human papillomavirus (HPV). www.cdc.gov/hpv/. Accessed August 17, 2017.
25. Fu LY, Bonhomme LA, Cooper SC, et al. Educational interventions to increase HPV vaccination acceptance: a systematic review. Vaccine. 2014;32(17):1901-1920.
26. Kennedy A, Sapsis KF, Stokley S, et al. Parental attitudes toward human papillomavirus vaccination: evaluation of an educational intervention, 2008. J Health Commun. 2011;16(3):300-313.
27. Spleen AM, Kluhsman BC, Clark AD, et al; ACTION Health Cancer Task Force. An increase in HPV-related knowledge and vaccination intent among parental and non-parental caregivers of adolescent girls, ages 9-17 years, in Appalachian Pennsylvania. J Cancer Educ. 2012;27(2):312-319.
28. Conroy K, Rosenthal SL, Zimet GD, et al. Human papillomavirus vaccine uptake, predictors of vaccination, and self-reported barriers to vaccination. J Womens Health (Larchmt). 2009;18(10):1679-1686.
29. National Vaccine Advisory Committee. Overcoming barriers to low HPV vaccine uptake in the United States: recommendations from the National Vaccine Advisory Committee. Public Health Rep. 2016;131(1):17-25.
30. Aragones A, Bruno DM, Ehrenberg M, et al. Parental education and text messaging reminders as effective community based tools to increase HPV vaccination rates among Mexican American children. Prev Med Rep. 2015;2:554-558.
31. Chao C, Preciado M, Slezak J, Xu L. A randomized intervention of reminder letter for human papillomavirus vaccine series completion. J Adolesc Health. 2015;56(1):85-90.
32. Community Preventive Services Task Force. The community guide—guide to community preventive services: increasing appropriate vaccinations. Atlanta, GA: Community Preventive Services Task Force; 2016
33. Kelminson K, Saville A, Seewald L, et al. Parental views of school-located delivery of adolescent vaccines. J Adolesc Health. 2012;51(2):190-196.

Although human papillomavirus (HPV) vaccine is a safe and effective means of preventing most HPV-related cancers, HPV vaccination rates lag well behind those of other vaccines recommended for children and adolescents. Understanding the barriers to HPV vaccine acceptance and effective strategies for overcoming them will improve vaccine uptake and completion in adolescents.

Human papillomavirus (HPV) infection is the most common sexually transmitted infection in the United States.^1,2 HPV causes approximately 30,700 new cancer cases in the US annually.³ It is the primary cause of cervical cancer, which resulted in more than 4,000 deaths in the US in 2016.⁴ HPV is also associated with some vaginal, vulvar, penile, anal, and oropharyngeal cancers and causes anogenital warts.³

Although HPV vaccines are available to protect against infection with the HPV types that lead to these sequelae, HPV vaccination rates remain low compared with other routinely administered vaccines.⁵ Reasons for these lower rates include vaccine cost, lack of patient and provider education, providers’ failure to recommend, stigmas related to sexual behavior, and misconceptions about the vaccine, such as concerns about harm.⁵ This article discusses these barriers to better educate providers about the HPV vaccine and encourage them to assist in increasing vaccination rates.

EPIDEMIOLOGY

Approximately 79 million Americans are currently infected with HPV, and 14 million new cases are reported each year.² In the US, the prevalence of HPV is highest among sexually active adolescents and young adults, especially those ages 20 to 24.² Of the more than 150 types of HPV that have been identified, 40 infect the genital area. HPV genital infections are mainly spread through sexual intercourse but can also be spread through oral-to-genital contact.²

The genital HPV types are categorized as low-risk and high-risk based on their association with cervical cancer.² High-risk types 16 and 18 are the most troublesome, accounting for 63% of all HPV-associated cancers, with HPV 16 posing the highest risk for cancer.³ High-risk types HPV 31, 33, 45, 52, and 58 account for another 10% of these cancers.³ Low-risk types, such as HPV 6 and 11, can cause low-grade cervical intraepithelial lesions, and HPV 6 and 11 account for more than 90% of genital warts.²

Most HPV infections, whether with high- or low-risk types, do not cause symptoms and resolve spontaneously in about two years.² Persistent high-risk HPV infection is necessary for the development of cervical cancer precursor lesions—and therefore, once the infection has cleared, the risk for cancer declines.²

HPV VACCINES

Three HPV vaccines are licensed for use in the US: bivalent (Cervarix), quadrivalent (Gardasil), and 9-valent (Gardasil 9) vaccines (see Table 1).^2,6,7 The bivalent, Cervarix, has recently been removed from the US market due to a decrease in product demand.^6,8

To ensure optimal protection, the vaccines must be administered in a series of scheduled doses over six to 12 months. The Advisory Committee on Immunization Practices (ACIP) recently updated their recommendations to include a two- or three-dose series based on age (see Table 2).⁷

HPV vaccines are recommended for males and females between the ages of 9 and 26 years, but the ACIP and the American College of Obstetricians and Gynecologists (ACOG) strongly promote a targeted age range for vaccination between 11 and 12 years for both genders.^6,7 Earlier vaccination is preferred because clinical data show a more rapid antibody response at a younger age, and because the vaccines are more effective if administered before an individual is exposed to or infected with HPV (ie, before the start of sexual activity).^6,7

LOW VACCINATION RATES

HPV vaccination rates in the US are significantly lower than rates for other regularly administered vaccines; furthermore, they do not meet the Healthy People 2020 national goal of 80% for all vaccines.⁹ Immunization rates for most childhood vaccines range from 80% to 90%, but in 2015 only 28.1% of males and 41.9% of females ages 13 to 17 had completed the entire HPV vaccine series.^9-11

The total HPV vaccination rates for male and female adolescents combined were 56.1% for one dose or more, 45.4% for two or more doses, and 34.9% for all three doses.⁹ In comparison, coverage rates for the meningococcal and Tdap (tetanus, diphtheria, and pertussis) immunizations, also recommended at the same age range as the HPV vaccine, were 81.3% and 86.4%, respectively.⁹

In addition to variation by gender and age, factors such as race, insurance coverage, and socioeconomic status influence vaccination rates.¹¹ For the HPV vaccine specifically, Hispanic, non-Hispanic black, and American Indian/Alaska Native adolescents have higher rates of receiving each of the vaccine doses and higher rates of completing the vaccine series, compared to non-Hispanic white adolescents.⁹ Adolescents with Medicaid insurance and those living below the federal poverty level have better HPV vaccination coverage compared with adolescents with commercial insurance plans or those living at or above the poverty level.^9,11

The HPV vaccine series completion rates in 2015 for males and females ages 13 to 17 living below the poverty level were 31.0% and 44.4%, respectively, compared to 27.4% and 41.3% for those living at or above the poverty level.⁹ One reason for increased rates among those living in lower-income households may be their eligibility for vaccinations at no cost through the Vaccines for Children (VFC) program, a federal program that provides vaccines to children who might otherwise forgo vaccination because of inability to pay.⁹

References

Common Variable Immunodeficiency: A Clinical Overview

How to Increase HPV Vaccination Rates

References

EPIDEMIOLOGY

HPV VACCINES

LOW VACCINATION RATES

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