HPV Vaccine Uptake Remains 'Unacceptably Low,' CDC Says

Roxanne Nelson

July 24, 2014

Uptake of the human papillomavirus (HPV) vaccine in teenage girls and boys remains unacceptably low, even though there was a slight increase in coverage from 2012 to 2013.

HPV coverage for girls increased 3.5%, from 53.8% in 2012 to 57.3% in 2013, according to data published in this week's Morbidity and Mortality Weekly Report (MMWR).

"We don't really have a really big news story teen vaccination results today, but in that case, no news is bad news for cancer prevention," said Anne Schuchat, MD, assistant surgeon general, US Public Health Service, and director of the National Center for Immunization and Respiratory Diseases, during a press briefing held today by the Centers for Disease Control and Prevention (CDC).

"It is a relief that we didn't continue to have flat-lining HPV coverage in 2013," said Dr. Schuchat. "There was absolutely no improvement from 2011 to 2012.

There is a substantial gap between the number of adolescents receiving tetanus, diphtheria, and pertussis (Tdap) vaccine and the number receiving HPV vaccine, according to the CDC. Current estimates are that only 57% of adolescent girls and 35% of boys received 1 or more doses of HPV vaccine. In contrast, nearly 86% had received 1 dose of the Tdap vaccine.

Missed Opportunities

These gaps in coverage indicate missed opportunities in the doctor's office, emphasized Dr. Schuchat. "If they would offer HPV at the same time an 11- or 12-year-old is getting other vaccines, we would have 91% coverage for HPV by the 13th birthday. We are urging clinicians to recommend HPV the same way and the same day as they recommend the others."

The increase from 2012 to 2013 was very small at the national level, and overall disappointing, she emphasized. However, there were 5 states that did have "impressive, significant HPV coverage" during this same time period. These states were New Hampshire, New Mexico, Illinois, South Carolina, and Michigan. These increases ranged from 12% in Illinois to 18.5% in South Carolina.

While these states have no commonalities on the surface, each one took some steps to focus on HPV and teen vaccination that might have led to greater progress, she explained. These steps included working intensely with physician organizations, immunization and cancer groups, outreach to parents, implementing peer-to-peer clinician office visits for HPV vaccination, and using systems approaches like reminder recall.

"In 2012 many other states were taking on these same kinds of activities, so we will see if that helps improve the national uptake," Dr. Schuchat said.

Uptake Lower in Boys

Since mid-2006, the Advisory Committee on Immunization Practices 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.

The vaccine results reported today are from the 2013 National Immunization Survey–Teen, which assessed vaccination coverage for adolescents aged 13 to 17 years in the 50 states, the District of Columbia, and other selected areas. The estimates for 2013 were based on parental/guardian telephone interviews for 18,264 adolescents (8710 girls and 9554 boys).

The survey showed that 1 or more HPV dose coverage was significantly higher among those aged 15 to 17 years as compared with younger adolescents. However, 1 or more HPV dose coverage for boys did not vary by age. Most vaccination coverage rates were similar by sex, but girls had greater vaccination coverage than boys for 1 or more, 2 or more, and 3 HPV doses and 3-dose HPV series completion.

Emphasis on Clinician Recommendation

The percentage of parents who reported receiving a recommendation for the HPV vaccine from their clinician was significantly higher in 2013 compared with 2012 for parents of both girls (64.4% vs 61.0%) and of boys (41.6% vs 28.0%).

"The data show that a recommendation from a healthcare professional is strongly associated with teens getting vaccinated," Dr. Schuchat noted. "One of the top 5 reasons parents gave for not getting their teen vaccinated was that it hadn't been recommended by the doctor."

More parents of vaccinated teens reported receiving a recommendation compared with parents of unvaccinated teens (girls, 73.7% vs 52.0%; boys, 71.7% vs 25.7%).

Other Barriers

One of the challenges of the HPV vaccine is that it's a 3-dose regimen, which requires 3 encounters with the healthcare system. Dr. Schuchat noted that some countries have switched to a 2-dose series if the vaccine is initiated before age 14, although in the United States it still remains a 3-dose schedule. One strategy is to have pharmacies offer the vaccine, which would allow more convenient time frames such as evenings and weekends.

Cost was not one of the top 5 reasons that parents cited for not getting the vaccine. "The HPV vaccine is part of the vaccine program, which provides free vaccines to the uninsured, and it should be covered under all insurance plans," she said.

Parents also reported safety concerns as a reason for not having their children vaccinated against HPV. The CDC reports that 67 million doses of HPV vaccine have been distributed in the United States, and no serious safety concerns have been linked to HPV vaccination. No new safety concerns have arisen since 2009 when the summary of the first 2.5 years of postlicensure reporting to the Vaccine Adverse Events Reporting System was published.

The Healthy People 2020 national targets for vaccination coverage among adolescents between the ages of 13 and 15 years are 80.0% for 1 or more Tdap doses, ≥1 or more meningococcal conjugate doses, 3 HPV doses (among girls), and 90.0% for 2 or more varicella doses.

MMWR. 2014;63:620-624.

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