Increases in vaccination rates for human papillomavirus, or HPV, vaccine are lagging far behind the two other vaccines -- tetanus, diphtheria and pertussis, or Tdap, and quadrivalent meningococcal conjugate vaccine, or MCV4 -- specifically recommended for teens and preteens.
Melinda Wharton, M.D., deputy director of the CDC's National Center for Immunization and Respiratory Diseases said in an Aug. 25 news conference(www.cdc.gov) that one reason for the disparity is that some young patients and their parents are not getting a strong recommendation for HPV vaccine from their family physicians and pediatricians.
"When we first recommended the vaccine, we looked forward to seeing strong and steady increases in coverage over time like we've seen following the introduction of other vaccines," Wharton said of HPV vaccine, which was approved by the FDA in 2006. "But not enough of our nation's girls are receiving this lifesaving vaccine as they should. If we don't do a much better job, we're leaving another generation vulnerable to cervical cancer later in life."
- The CDC's 2010 teen vaccination survey reveals that coverage rates for at least one dose of both tetanus, diphtheria and pertussis vaccine and quadrivalent meningococcal conjugate vaccine in teens ages 13-17 were greater than 60 percent and increased by more than 9 percent compared with 2009 rates.
- Coverage with at least one dose of human papillomavirus, or HPV, vaccine, however, was less than 50 percent and increased by less than 5 percent compared with 2009.
- Only 32 percent of adolescent girls had completed the entire three-dose HPV series.
- The CDC is urging physicians to make a strong recommendation for the HPV vaccine, which protects against precancerous cervical lesions and genital warts.
Twelve thousand U.S. women are diagnosed with cervical cancer each year, and 4,000 die of the disease, according the CDC. About 6 million Americans become infected with HPV each year, the agency said.
The 2010 version of the CDC's National Immunization Survey-Teen was published in a recent Morbidity and Mortality Weekly Report(www.cdc.gov). The survey found that the proportion of adolescents ages 13-17 who had received at least one dose of HPV vaccine increased from 44.3 percent in 2009 to 48.7 last year. The proportion of teens who had completed the series increased from 26.7 percent to 32.0 percent. By comparison, coverage with at least one dose of Tdap increased from 55.6 percent to 68.7 during the same period, while MCV4 coverage increased from 53.6 percent to 62.7 percent.
Doug Campos-Outcalt, M.D., M.P.A., a member of the CDC's Advisory Committee on Immunization Practices, or ACIP, and chair of the department of family and community medicine at the University of Arizona College of Medicine, Phoenix, said the fact that full HPV immunization requires three shots creates particular challenges.
"It is three shots," he said, "and it's not a readily apparent disease. I don't think the risk of HPV is very well understood. There also are unfounded concerns about the safety of the vaccine, and all those things add up."
HPV vaccine is recommended(5 page PDF) for girls beginning at age 11. Wharton acknowledged that vaccinating for a sexually transmitted disease at such a young age is a barrier for many parents.
At least 90 percent of U.S. children ages 19-35 months have been immunized against poliovirus and varicella; have received at least one dose of the measles, mumps, and rubella vaccine; and have received the full series of hepatitis B vaccine, according to the CDC's 2010 National Immunization Survey.
The survey, which was published Sept. 2 in a Morbidity and Mortality Weekly Report(www.cdc.gov), looked at children born between January 2007 and July 2009. Notably, that time frame overlapped with a shortage of Haemophilus influenzae type b, or Hib, vaccine that lasted from December 2007 through June 2009.
The CDC survey found that coverage with the primary series of Hib vaccine remained stable at 92.2 percent, indicating that physicians complied with an interim recommendation to defer the booster dose while continuing to vaccinate children with the primary series. The proportion of children completing the Hib series increased to 66.8 percent -- up 12 percent compared with 2009 -- indicating that children were given the booster dose after supplies returned to normal.
Meanwhile, other vaccines showed the following increases from 2009 to 2010:
- the percentage of children who received at least four doses of pneumococcal conjugate vaccine increased from 80.4 percent to 83.3 percent;
- the percentage of infants who received the birth dose of hepatitis B vaccine increased from 60.8 percent to 64.1 percent;
- the percentage of children who received at least two doses of hepatitis A vaccine increased from 46.6 percent to 49.7 percent; and
- the percentage of children immunized with rotavirus vaccine increased from 43.9 percent to 59.2 percent.
"Part of this, I'm sure, has to do with the perception that this age is just too young, that girls aren't sexually active at that age and therefore they don't need the vaccine," she said. "Of course, that's why we recommend the vaccine at this age. This is a preventive vaccine, not a therapeutic vaccine. It won't work unless it's given prior to onset of sexual activity."
Campos-Outcalt said the age of the patient should not be a barrier for vaccination to prevent a sexually transmitted disease. "There's no other vaccine we think about this way, and we have to get away from that kind of thinking," he told AAFP News Now. "We give hepatitis B vaccine as a routine immunization for infants. It's a good time to give it. It provides protection right away, though patients are most likely to be exposed later in life."
Campos-Outcalt said cost should not be a barrier, either, because HPV vaccine is covered by the Vaccines for Children Program(www.cdc.gov), which provides free vaccine to health care professionals for administration to children younger than 19 years who are eligible for Medicaid, are American Indians or Alaska Natives, or who don't have health insurance. In addition, most insurers cover the series in girls and young women.
Wharton said physicians can make "an enormous impact on parents' decision to vaccinate" by providing a strong recommendation for the vaccine.
In addition to that step, the CDC recommended the following strategies for physicians:
- create a standard operating procedure to check the vaccination status of your adolescent patients at every visit, including acute-care visits;
- administer all recommended vaccines during a visit;
- if a parent declines a vaccine, ask why and document it in the chart, which can reinforce offering again at follow-up visits;
- for patients who start the HPV series, schedule the next two doses before the patient leaves the office;
- send reminder/recall notices to parents;
- find out how many adolescents are in your practice and how many of those have been immunized, and use this information to help improve vaccine delivery; and
- report vaccines that are administered to the state/local immunization registry.
HPV coverage estimates varied by state, ranging from 28.8 percent in Idaho to 73 percent in Rhode Island. Coverage for all three recommended adolescent vaccines was significantly lower among adolescents living in the southeastern United States compared with those in other regions. Mississippi, for example, had the lowest coverage rates for both Tdap (29 percent) and MCV4 (26 percent).
Related ANN Coverage
Vaccines and Immunizations Special Report
CDC: Provider Resources for Vaccine Conversations with Parents(www.cdc.gov)