HPV Vaccine Use Stalls in US Girls

Megan Brooks

July 25, 2013

Uptake of the human papillomavirus (HPV) vaccine among adolescent girls in the United States has stalled, according to new data released today by the Centers for Disease Control and Prevention (CDC).

"Today we have disappointing news: HPV vaccination coverage has not increased at all," CDC director Tom Frieden, MD, MPH, said during a media briefing. "We are dropping the ball. We are missing opportunities to give HPV vaccine, and that needs to change to protect girls from cervical cancer."

"We have not been very successful in protecting our adolescents against cervical cancer," added Thomas K. McInerny, MD, president of the American Academy of Pediatrics (AAP). "The AAP shares CDC's disappointment and concern that we are not providing this lifesaving vaccine at the same rates as we do with other immunizations."

The new data, published in the July 26 Morbidity and Mortality Weekly Report, stem from the 2012 National Immunization Survey-Teen (NIS-Teen), which the CDC uses to track vaccination coverage rates among adolescents.

Since mid-2006, the Advisory Committee on Immunization Practices (ACIP) has recommended routine vaccination of adolescent girls at ages 11 or 12 years with 3 doses of HPV vaccine. Healthcare providers are also urged to recommend the vaccine series to boys aged 11 or 12 years.

"Two HPV vaccines are available in the United States. Both the quadrivalent (HPV4 [Gardasil, Merck]) and bivalent (HPV2 [Cervarix, GlaxoSmithKline]) vaccines protect against HPV types 16 and 18, which cause 70% of cervical cancers and the majority of other HPV-associated cancers; HPV4 also protects against HPV types 6 and 11, which cause 90% of genital warts," according to the report.

Vaccine "Works Better Than Anticipated"

Vaccination coverage with at least a single dose of any HPV vaccine increased from 25.1% in 2007 to 53.0% in 2011, according to the report. However, coverage rates remained virtually unchanged in 2012, with only 53.8% of girls having received at least a single dose of HPV vaccine and only 33.4% receiving all 3 doses of the series.

"2012 is the first year with no observed increase," according to an accompanying editorial note. "We are use to seeing coverage increases of about 10% per year when a vaccine hits the market," Dr. Frieden added.

The new data are even more concerning, Dr. Frieden said, given a CDC study published last month that showed that HPV vaccination "works better than we anticipated." As reported by Medscape Medical News, the study found that vaccine-type HPV prevalence among adolescent girls aged 14 to 19 years has dropped by about half since 2006, despite low immunization rates.

Misinformation, Missed Opportunities

The 2012 NIS-Teen data also show that roughly one quarter of surveyed parents did not intend to vaccinate their daughters in the next 12 months: 19.1% felt the vaccine was unnecessary, 14.2% said the vaccine was not recommended by their healthcare provider, 13.1% had concerns about the safety of the vaccine or admitted not knowing about the vaccine or the diseases it prevents, and 10.1% said they would not seek the vaccine because their daughter was not sexually active.

Dr. Frieden said the data released today "reaffirms that the HPV vaccine is safe. Since 2006, about 57 million doses of HPV vaccine have been distributed in the US, and in the 7 years of HPV vaccine safety monitoring, no serious safety concerns have been identified."

The CDC says improving HPV vaccination coverage levels will require educating parents on its safety and benefits. Updated educational materials that address these issues are available from the CDC.

Dr. McInerny strongly encouraged clinicians to explain to parents that the HPV vaccine "works best when given before engaging in any type of sexual activity. Please explain that we don't wait for exposure to occur when giving many other vaccines."

The CDC urges healthcare providers to increase the consistency and strength of how they recommend HPV vaccine. The agency has developed a tip sheet, available on the CDC Web site, to help providers respond to parents' questions and communicate strong, clear HPV vaccination recommendations.

The agency also asks health providers to make an effort to reduce missed opportunities to administer the HPV vaccine. They define missed opportunities for vaccination as a healthcare encounter occurring on or after a girl's 11th birthday and on or after March 23, 2007 (the publication date of ACIPs HPV4 recommendation), during which a girl received at least 1 vaccine but did not receive HPV vaccine.

The data show that the percentage of unvaccinated girls with at least 1 missed opportunity for HPV vaccination rose from 20.8% in 2007 to 84.0% in 2012. In 2012, if all missed opportunities for HPV vaccination had been eliminated, coverage with at least a single dose of HPV vaccine could have reached 92.6%, the CDC said.

By increasing the 3-dose coverage to 80%, a Healthy People 2020 goal, an estimated additional 53,000 cases of cervical cancer could be prevented during the lifetimes of those aged 12 years and younger. "For every year that increases in coverage are delayed, another 4,400 women will go on to develop cervical cancer," according to the CDC.

"[A]pproximately 79 million persons in the United States are infected with HPV, and approximately 14 million will become newly infected each year," the agency estimates.

"[E]very health-care visit, whether for back-to-school evaluations or acute problems, should be used to assess teenagers' immunization status and provide recommended vaccines if indicated," the CDC advises.

Morb Mortal Wkly Rep. 2013;62:591-595. Full text

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