Am Fam Physician. 2015 Sep 15;92(6):449-454.
Related article: Update on Routine Childhood and Adolescent Immunizations
Related editorial: Navigating the Changes in Pneumococcal Immunizations for Adults
In this issue of American Family Physician, Ackerman and Serrano provide a concise and well-referenced summary of the recommended immunizations for children and adolescents.1 The immunization schedule is designed to create the best immunologic response and achieve maximal disease prevention. However, full adherence to the schedule is jeopardized by the fears of some parents and physicians who have concerns about the safety of and need for certain immunizations, and subsequently refuse or delay vaccination.
The acceptance rate for most immunizations is high (80% to 90%), especially for more well-established vaccines.2 However, the acceptance rate is much lower for human papillomavirus (HPV) vaccine, with 57.3% of females and 34.6% of males initiating the series2 and only 38% of females and 14% of males receiving all three doses.3 Because HPV vaccination has the potential to significantly reduce rates of cervical and oropharyngeal cancers,4 the low immunization rate is a public health failure. Which parental and physician impediments prevent the HPV vaccination rate from reaching appropriate levels?
Some parents are concerned that the HPV vaccine is unsafe or that administration may encourage sexual activity, thereby increasing their child's risk of a sexually transmitted infection (STI).5,6 Parental safety concerns about the HPV vaccine increased from 4.5% in 2008 to 16% in 2010,7 although the reported adverse effects have been minor (e.g., injection site reactions, syncope, dizziness, nausea, headache).3 Studies have shown that adolescents who receive the HPV vaccine do not initiate sexual activity earlier,8,9 nor is their risk of acquiring an STI increased.10
Some parents and physicians think the HPV vaccine should be delayed until the child is likely to have initiated sexual activity or until a visit when the child is not receiving other adolescent vaccinations.11 This approach is problematic; to be effective, the HPV vaccine must be given before exposure to covered serotypes. However, parents often do not know when their child has initiated sexual activity.12 Additionally, vaccines that are delayed are often never received because they are forgotten or no subsequent physician visit occurs.11
Impediments originating with physicians are multifactorial. Some have been reluctant to recommend HPV vaccination at the suggested age based on information obtained by profiling their patients about sexual activity.5 Some do not see the need for HPV vaccination because cervical cancer screening, detection, and treatment are effective.11 Some give parents the perception that the vaccine is optional11; in fact, many parents report that their physician never offered the vaccine.11
To improve acceptance of immunizations, physicians must be knowledgeable about vaccine safety and effectiveness, and non-judgmental about parents' beliefs. The non-judgmental approach does not condemn parents, nor does it minimize their concerns. Although randomized trials have not shown significant improvement in vaccine acceptance after face-to-face discussions between physicians and parents,13 listening to the parents' concerns and giving evidence-based answers is a first step in helping parents understand the need for vaccination. An unequivocal recommendation from the physician is associated with improved acceptance of vaccinations by hesitant parents14; a recommendation from their child's physician is the reason most often given by parents who agree to immunizations.15,16 Rather than focusing too much attention on the HPV vaccine, it may be better to address it in the same routine, matter-of-fact way that other vaccines are recommended.17
Specific approaches have been shown to improve HPV vaccination rates.18 Instead of discussing the vaccine as a means of STI prevention, physicians can present it as a way to prevent cervical cancer in women and oropharyngeal cancer in men. They can mention that immunologic response is greater in younger adolescents, so earlier immunization is prudent.19 Physicians should encourage HPV vaccine administration at the same time that other adolescent vaccines are given. They should review immunization status at every visit, and administer the HPV vaccine at any time—including during sick visits.18 It is estimated that if these procedures had been followed, the HPV vaccination rate could have reached 91.3% for 13-year-old girls who were born in 2000.3
Several other strategies may be helpful. Finding a way to address parental social networks has been beneficial.7 Hesitant parents may respond to the CASE method: the physician corroborates the parents' concerns, talks about his or her own experience with the vaccine, summarizes the science about vaccine effectiveness and safety, and explains advice in terms of the child's health.20
One other barrier may be more difficult to overcome: cost. The older HPV vaccines, Cervarix and Gardasil, cost about $500 for three doses; the new nonavalent vaccine, Gardasil 9, currently costs about $1,100 for three doses.21
We have an opportunity to significantly reduce rates of cervical and oropharyngeal cancers with a safe and effective HPV vaccine. We should listen and address parental concerns, but also strongly recommend all childhood immunizations and use every opportunity to administer them.
REFERENCESshow all references
1. Ackerman LK, Serrano JL. Update on routine childhood and adolescent immunizations. Am Fam Physician. 2015;92(6):460–468....
2. Elam-Evans LD, Yankey D, Jeyarajah J, et al.; Immunization Services Division, National Center for Immunization and Respiratory Diseases; Centers for Disease Control and Prevention (CDC). National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years—United States, 2013. MMWR Morb Mortal Wkly Rep. 2014;63(29):625–633.
3. Stokley S, Jeyarajah J, Yankey D, et al.; Immunization Services Division, National Center for Immunization and Respiratory Diseases; Centers for Disease Control and Prevention (CDC). Human papillomavirus vaccination coverage among adolescents, 2007–2013, and postlicensure vaccine safety monitoring, 2006–2014—United States. MMWR Morb Mortal Wkly Rep. 2014;63(29):620–624.
4. Graham DM, Isaranuwatchai W, Habbous S, et al. A cost-effectiveness analysis of human papillomavirus vaccination of boys for the prevention of oropharyngeal cancer. Cancer. 2015;121(11):1785–1792.
5. Bednarczyk RA. Human papillomavirus vaccine and sexual activity: how do we best address parent and physician concerns? JAMA Intern Med. 2015;175(4):624–625.
6. Darden PM, Thompson DM, Roberts JR, et al. Reasons for not vaccinating adolescents: National Immunization Survey of Teens, 2008–2010. Pediatrics. 2013;131(4):645–651.
7. Jacobson RM, Roberts JR, Darden PM. Parents' perceptions of the HPV vaccine: a key target for improving immunization rates. Expert Rev Clin Immunol. 2013;9(9):791–793.
8. Bednarczyk RA, Davis R, Ault K, Orenstein W, Omer SB. Sexual activity-related outcomes after human papillomavirus vaccination of 11- to 12-year-olds. Pediatrics. 2012;130(5):798–805.
9. Liddon NC, Leichliter JS, Markowitz LE. Human papillomavirus vaccine and sexual behavior among adolescent and young women. Am J Prev Med. 2012;42(1):44–52.
10. Jena AB, Goldman DP, Seabury SA. Incidence of sexually transmitted infections after human papillomavirus vaccination among adolescent females. JAMA Intern Med. 2015;175(4):617–623.
11. Perkins RB, Clark JA, Apte G, et al. Missed opportunities for HPV vaccination in adolescent girls: a qualitative study. Pediatrics. 2014;134(3):e666–e674.
12. Mollborn S, Everett B. Correlates and consequences of parent-teen incongruence in reports of teens' sexual experience. J Sex Res. 2010;47(4):314–329.
13. Kaufman J, Synnot A, Ryan R, et al. Face to face interventions for informing or educating parents about early childhood vaccination. Cochrane Database Syst Rev. 2013;(5):CD010038.
14. Opel DJ, Heritage J, Taylor JA, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics. 2013;132(6):1037–1046.
15. Smith PJ, Kennedy AM, Wooten K, Gust DA, Pickering LK. Association between health care providers' influence on parents who have concerns about vaccine safety and vaccination coverage. Pediatrics. 2006;118(5):e1287–e1292.
16. Sturm LA, Mays RM, Zimet GD. Parental beliefs and decision making about child and adolescent immunization: from polio to sexually transmitted infections. J Dev Behav Pediatr. 2005;26(6):441–452.
17. Rubin R. Why the “no-brainer” HPV vaccine is being ignored. JAMA. 2015;313(15):1502–1504.
18. Perkins RB, Zisblatt L, Legler A, Trucks E, Hanchate A, Gorin SS. Effectiveness of a provider-focused intervention to improve HPV vaccination rates in boys and girls. Vaccine. 2015;33(9):1223–1229.
19. Markowitz LE, Dunne EF, Saraiya M, et al.; Centers for Disease Control and Prevention (CDC). Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2014;63(RR-05):1–30.
20. Jacobson RM, Van Etta L, Bahta L. The C.A.S.E. approach: guidance for talking to vaccine-hesitant parents. Minn Med. 2013;96(4):49–50.
21. GoodRx. http://www.goodrx.com. Accessed June 30, 2015.
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