Despite widespread availability of the human papillomavirus vaccine over the last 11 years, vaccination rates continue to lag behind national targets and are far behind other vaccines routinely administered in adolescence, such as the meningococcal and tetanus vaccines.
Better collaboration among pediatricians and obstetrician-gynecologists to promote the HPV vaccine may be one answer to turning the tide, said David W. Kimberlin , MD, codirector of the division of pediatric infectious diseases at the University of Alabama at Birmingham and president of the Pediatric Infectious Diseases Society.
“Prevention of HPV-related cancers is in the pediatric period, but the disease being prevented [occurs] in women and men who are well into adulthood,” Dr. Kimberlin said in an interview. “We have to work together to raise awareness so that lives can be saved. Every patient encounter is an opportunity to do so, thereby the coordination between ob.gyn. and pediatrics that we are advocating is all the more important.”
As of 2015, just 63% of eligible U.S. girls completed the first dose of the HPV vaccination, 52% completed two doses, and 42% finished the three-dose series, according to a recent “Call to Action” paper in the American Journal of Obstetrics and Gynecology ( doi: 10.1016/j.ajog.2017.02.026 ). Although the HPV vaccine has been recommended for boys since 2011, just half of eligible boys completed the first dose, 39% completed two doses, and 28% finished the full series. By contrast, 86% of adolescents received the tetanus, diphtheria, and acellular pertussis vaccine, and 81% received the first dose of the meningococcal vaccine. The federal government’s Office of Disease Prevention and Health Promotion aims for an 80% HPV vaccination completion rate for girls and boys aged 13-15 years by 2020.
The CDC now recommends that 11- to 12-year-olds get two doses of the HPV vaccine, rather than three, with the second dose given 6-12 months after the first ( MMWR. 2016;65:1405-8 ).
The common ways in which the HPV vaccine is introduced to parents likely contributes to the low vaccination rates, said Beth Auslander , PhD, a clinical psychologist and associate professor in the department of pediatrics at the University of Texas Medical Branch in Galveston. Some pediatricians may tell parents about school-mandated vaccines first and then as a side note, mention the HPV vaccine.
“The way it’s presented at times is being separate from the other vaccines,” Dr. Auslander said. “Sometimes it sounds optional.”
Parents often are uncertain about the safety and efficacy of the HPV vaccine, she added, and some wrongly assume the vaccine will lead to sexual activity among their children.
Both ob.gyns. and pediatricians could do a better job of giving stronger recommendations about the HPV vaccine, said Jennie Yoost , MD, a Huntington, W.Va.–based pediatric and adolescent gynecologist and a member of the American Congress of Obstetricians and Gynecologists’ (ACOG) Immunization Expert Work Group.
“Sometimes it can take a little longer to talk about,” Dr. Yoost said in an interview. “A lot of times, parents will bring up questions or concerns about the HPV vaccine. If physicians aren’t comfortable talking about those topics, they may not give the best recommendation. Pediatricians are not dealing with cervical cancer, so they may have a harder time recommending a vaccine based on outcomes they don’t deal with.”
Ob.gyns. are in a unique position to reach out to their pediatric counterparts and discuss strategies for catching more patients eligible for the HPV vaccine, said Sarah Dilley, MD, a gynecologic oncology fellow at the University of Alabama at Birmingham and the lead author of the recent Call to Action paper.
“We offer a unique perspective in that we are treating the conditions that the HPV vaccine is preventing, so we have more of a sense of urgency and an understanding of why that is so important,” Dr. Dilley said in an interview. “Obviously, pediatricians understand this as well, but it’s not something they see every day in their practice. We, as ob.gyns., have the opportunity to talk to our pediatric colleagues about the importance and really how devastating these conditions can be and how important it is to prevent them.”
In the recent paper, Dr. Dilley and her colleagues recommend that ob.gyns. speak to pediatricians and primary care physicians in their community to promote the vaccine and encourage them to view the Centers for Disease Control and Prevention’s You Are the Key presentation. The CDC resources include tips for how to discuss the burden of HPV-related diseases and effective communication with parents, an update on state vaccination rates, and the latest HPV vaccination recommendations.
Dr. Dilley encourages ob.gyns. and pediatricians to find different opportunities and venues to discuss the HPV vaccine. Ask about the pediatrician’s current approach to the vaccine, the doctor’s communication with parents, and how such practices could be improved, she said.
“People like to hear from their colleagues,” Dr. Dilley said. “Hearing from ob.gyns. [about] their experiences could be really helpful, whether it’s doing lunch and learns, formal education, grand rounds, or even more informal talks at the hospital.”
Ob.gyns. and pediatricians also need to better coordinate their messaging so that there is more consistent emphasis during each patient encounter about the need of the HPV vaccination, Dr. Kimberlin said. There needs to be a renewed focus on the vaccine as a cancer vaccination, he said.
“The nuances of HPV and the way that HPV is acquired, namely sexually transmitted, has taken too much of a front row consideration in the conversations that parents sometimes want to have with their child’s health care providers,” Dr. Kimberlin said. “We have to stress this is a cancer vaccine. This is a vaccine that prevents that deaths of thousands of women and men. We simply need to get that message out more forcefully.”
In addition, there’s a need for joint action to debunk myths about the vaccine and work toward eliminating the stigma surrounding it, Dr. Dilley said.
“I talk to a lot parents about the HPV vaccine and there’s so much misinformation online,” she said. “But a lot of patients do look at websites of their ob.gyn. or their pediatrician, [and] if they see something reputable coming from one of those sites, they might listen. We have a lot of patients who are mothers or grandmothers of kids; that’s also an opportunity for us to say, ‘Hey while we’re screening you for cervical cancer, let’s talk about the HPV vaccine.’ That’s a really good opportunity to help our [pediatric] colleagues out.”
5 steps to increase HPV vaccination
Melissa Kottke, MD, director of the Jane Fonda Center for Adolescent Reproductive Health at Emory University offered her practice steps for increased HPV vaccination rates.
1. Be clear about your recommendation. For example, “I recommend the HPV vaccine. It can help prevent cancer.”
2. Do not delay. From an immune response and potential HPV exposure standpoint, receiving the vaccine at a younger age is better than receiving it at an older age.
3. Educate the entire clinical team (front desk staff, nursing, medical assistants, etc.) about the HPV vaccine so there is consistent messaging and delivery.
4. Establish streamlined systems. The vaccine recommendation, order, and follow-up should be streamlined and automated, if possible. Systems should also ensure documentation of vaccine receipt.
5. Make time for conversations with patients who are mothers and grandmothers. Recommend the HPV vaccine for males and females aged 9-26 years old. Encourage parents/grandparents to follow-up with the child’s doctor or offer to provide the vaccine in your office.
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