The HPV Vaccine Works. So Why Aren't We Vaccinating All Teens?

A recent report by Laurie Markowitz, et al from the CDC looked at the prevalence of HPV among girls and women 3 years before and 3 years after the introduction of the HPV vaccine. Despite the fact that only 1/3 of the girls age 13-17 received the full vaccine course, there was a drop of more than 50% in the incidence of HPV recovered from vaginal washings. Imagine if we were actually vaccinating ALL of our girls. Imagine if we vaccinated our BOYS too. In a generation, we could see the incidence of HPV related disease plummet to near zero. So why are we not vaccinating our children?

Despite the evidence of huge potential health benefits, Australia is the only nation with a comprehensive HPV vaccination program. In 2007, a national, school based vaccination program was begun in which the Gardasil vaccination was administered free of charge for all girls, and as of 2013, all boys, aged 12-13 years of age.  A recent analysis of Australian HPV surveillance data collected between January 2004 and December 2009 showed a decrease of about 59 per cent in the frequency of genital warts among young Australian females and an additional a 28 per cent decrease in heterosexual males, presumably because of herd immunity. A 2011 study published in Vaccine estimated that the introduction of a male vaccination program in Australia that achieves similar coverage to the female program could prevent up to an additional 24 per cent of new HPV infections.

And yet, despite such striking evidence from our own national experience and that of Australia, we continue to have suboptimal HPV vaccination rates. Why?

The fear of vaccines is a widespread American phenomenon. In fact in the NEJM in 2012 Dr. Saed Omer documented that the rates of vaccine exemptions for child hood vaccinations from 2005-2011 were rising. The rates of parents choosing “alternative vaccination schedules” for routine childhood immunizations have been going up as well. Research is ongoing in an attempt to identify the barriers to vaccination in the United States. Many studies have found that parents are profoundly lacking in knowledge about vaccines in general, and about the diseases they prevent. They are acutely aware of the huge number of shots their little ones get in rapid succession during the first years of life, the pain and discomfort they cause, and often feel that their health care providers don’t take enough time to explain why the vaccines and the proper timing of administration are important.

In my own practice I often hear that patients or parents are worried about the safety of vaccination and about the possible association of vaccines with autism. With respect to HPV vaccine in particular, they often just don’t think its “time yet”. They may be willing to entertain the idea of HPV vaccination, but believe that it isn’t necessary until their child is sexually active. Patients and their parents have also “heard bad things” about the HPV vaccine from unreliable sources. These barriers to HPV vaccination are reflected in the litterature as well. Specifically Mills, et al, earlier this year, showed that among women in rural Kentucky, there are three primary barriers to HPV vaccination: women are both uninformed and misinformed about cervical cancer, HPV, and the HPV vaccine; women consult questionable information sources; and financial/social difficulties all of which contribute negatively to vaccination decisions.

So, in short, it is imperative that we, as health care providers, talk to our patients about the importance of vaccination in general, and specifically about HPV vaccination. We should not be addressing just the adolescent patients and their parents, but also our older patients who are mothers (or grandmothers) of young girls and boys. We have an opportunity here to dramatically decrease rates of genital, anal, head and neck cancers for the next generation. While it takes time and effort out of our already overburdened clinical lives, we must step up to the plate and face this challenge for the good of our grandchildren.

References:

Lauri E Markowitz, et al Reduction in Human Papillomavirus (HPV) Prevalence Among Young Women Following HPV Vaccine Introduction in the United States, National Health and Nutrition Examination Surveys, 2003–2010 J. infectious Disease, August 1, 2013 208 (3).

Douglas J. Opel, MD, MPH; Edgar K. Marcuse, MD, MPH The Enigma of Alternative Childhood Immunization Schedules: What Are the Questions? JAMA Pediatr. 2013;167(3):304-305. doi:10.1001/jamapediatrics.2013.786.

Mills LA, Head KJ, Vanderpool RC. HPV Vaccination Among Young Adult Women: A Perspective From Appalachian Kentucky. Prev Chronic Dis 2013;10:120183. DOI: http://dx.doi.org/10.5888/pcd10.120183.

MMWR Morb Mortal Wkly Rep. 2011 Aug 26;60(33):1117-23. National and state vaccination coverage among adolescents aged 13 through 17 years--United States, 2010. Centers for Disease Control and Prevention (CDC).

Brotherton JM, Fridman M, May CL, Chappell G, Saville AM, Gertig DM. Early effect of the HPV vaccination programme on cervical abnormalities in Victoria, Australia: an ecological study. Lancet. 2011 Jun 18;377(9783):2085-92. doi: 10.1016/S0140-6736(11)60551-5.

Ali H, Guy RJ, Wand H, Read TR, Regan DG, Grulich AE, Fairley CK, Donovan B. Decline in in-patient treatments of genital warts among young Australians following the national HPV vaccination program. BMC Infect Dis. 2013 Mar 18;13:140. doi: 10.1186/1471-2334-13-140.