Breaking Down Barriers
By Kara Nuzback Texas Medicine April 2014

Battling Texas' Low HPV Vaccination Rate

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Public Health Feature — April 2014

By Kara Nuzback

Tex Med. 2014;110(4):35-39.

Physicians face major hurdles in administering a vaccine that protects against human papillomavirus (HPV)-related cancers. Cervical, genital, and head and neck cancers are preventable, but physicians say the stigma surrounding the vaccine, its high cost, and its voluntary status are keeping vaccination rates in Texas low.

Two HPV vaccines — Merck's Gardasil and GlaxoSmithKline's Cervarix — are currently on the market, and the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommends a three-dose series of vaccine injections within a six-month period for 11- and 12-year-old boys and girls. ACIP guidelines state vaccination can begin as early as age 9 and should be completed by age 26.

The National Immunization Survey reports that in 2012 about 30 percent of Texas females aged 13 to 17 had received all three doses of HPV vaccine. The national rate is only slightly higher at 33 percent for the same year.

The fact that the vaccine is voluntary is a major barrier, says Lisa Swanson, MD, a Mesquite pediatrician and member of the Texas Medical Association Committee on Child and Adolescent Health.

"It's been a very tough sell," she said.

Dr. Swanson says she administers most required vaccinations to patients at age 12, before the patient enters seventh grade. Those adolescent patients often receive two or three shots per visit. 

"It's difficult for patients to talk themselves into an extra shot that's not required," she said.

Gov. Rick Perry signed an executive order in 2007 that would have required HPV vaccination of all sixth-grade girls in Texas. The Texas Legislature overturned the order. 

HPV is the most common sexually transmitted infection (STI) in the United States, with about 40 different strains of the genital virus, according to CDC. 

The vaccine has made an impact since it hit the market in 2006. A study in the Aug. 1, 2013, issue of The Journal of Infectious Diseases shows preventable strains of HPV decreased 56 percent in girls aged 14 to 19 in the four years following the vaccine's introduction. But physicians say it's difficult to immunize patients in the ACIP-recommended target age range.

Dr. Swanson says that in her experience, by age 12, most adolescents stop visiting the doctor regularly. Of those who do visit regularly, only about one in five agrees to HPV immunization. 

"It's just hard to talk people into getting it," she said. "Teenagers don't like vaccines; they don't like shots."

TMA can help physicians deliver the HPV vaccine to more adolescents through its Be Wise — ImmunizeSM campaign. Be Wise provides education and funding resources for physicians who want to help improve vaccination rates in Texas. (See "TMA Program Helps Doctors Spread the Word.")

Physician Recommendation Matters

ACIP modified its HPV vaccine recommendation in January, stating the third dose should be administered at least 12 weeks after the second dose and at least 24 weeks after the first dose. The committee recommends only the quadrivalent HPV vaccine for boys; girls can receive either the bivalent or quadrivalent version.  

A health care professional's recommendation to vaccinate against HPV is a powerful motivator for patients, according to CDC.

Keller pediatrician Jason Terk, MD, past chair of the TMA Council on Science and Public Health and a member of the Be Wise — Immunize Advisory Panel, says the most significant limitation on administering the vaccine is the lack of broad affirmative promotion on the part of physicians. 

"We know that a strong physician endorsement of this vaccine will increase adoption and provision of HPV vaccine more broadly," Dr. Terk said. "As long as it is stated or implied to be merely optional, the full promise of this important cancer-preventing vaccine will remain unfulfilled."

A 2008 TMA survey and a study published this year in the American Journal of Preventive Medicine (AJPM) show physicians recommend HPV vaccination only about half of the time.

TMA's statewide survey, conducted by the former Physician Oncology Education Program and published in the August 2009 issue of Cancer Epidemiology, Biomarkers & Prevention, revealed fewer than half of 1,122 participating Texas physicians always recommended the vaccine to 11- and 12-year-old girls. Sixty-eight percent of physicians surveyed said they were likely to recommend the vaccine to 11- and 12-year-old boys, and about 42 percent agreed vaccination should be mandatory.

"Physicians' Human Papillomavirus Vaccine Recommendations, 2009 and 2011," a study in the January 2014 issue of AJPM, shows similar results nationally, and the instance of doctors recommending the vaccine to patients rose only slightly over a two-year period.

Of the physicians who participated in the survey reported in AJPM, 35 percent in 2009 said they always recommended the vaccine to 11- and 12-year-old boys and girls. In 2011, the rate jumped to 40 percent. 

The recommendation rate for patients aged 13 to 17 was 53 percent in 2009 and 55 percent in 2011. For patients aged 18 to 26, the recommendation rate increased from 50 percent in 2009 to 52 percent in 2011, according to the study.

Dr. Terk says physicians who administer other lifesaving vaccines to adolescents should give the HPV vaccine equal weight. 

"HPV is so common that one cannot avoid it by virtue of his or her own good choices after becoming sexually active," he said. "We need to approach this as a cancer-preventing vaccine, not as an STI-preventing vaccine."

In the 2008 TMA survey, doctors said parents were often the No. 1 barrier to administering the HPV vaccine because they worried that vaccination would encourage adolescents to engage in sexual behavior.

A study published in February in Pediatrics, the official journal of the American Academy of Pediatrics, debunks many parents' assumption that HPV vaccination would lead to sexual activity in adolescents.

The survey questioned young women aged 13 to 21 about their sexual behavior after receiving the HPV vaccine. According to the study, the lower risk of HPV infection did not cause the girls to engage in riskier sexual behavior during the next six months. 

Though the vaccine can be administered to patients as young as 9, Dr. Swanson says she is often unsure whether the child's parents or teachers have talked to them about sex. 

"At age 9, sometimes the kids are very naive," she said.

Communication Is Key

Dr. Swanson says patients who are knowledgeable about the HPV vaccine before entering her office are more likely to get vaccinated. She says vaccination rates could be higher if teachers mentioned inoculations in school or during health class. 

The high cost of the vaccine is another barrier for many physicians.

"The HPV vaccine is one of the most expensive vaccines that physicians must contend with," Dr. Terk said. According to CDC, Gardasil costs about $140 per dose, and Cervarix costs about $130 for physicians to purchase. 

He says the vaccine's high price tag causes physicians to assume financial risk. Some patients' health plans won't cover the full amount physicians pay to keep the vaccine in stock.

According to Chris Van Deusen, spokesperson for the Texas Department of State Health Services, all physicians who participate in the Texas Vaccines for Children program carry the HPV vaccine. 

"Privately insured patients can call their local pharmacies or medical providers if their doctor doesn't have the vaccine," Mr. Van Deusen said.

Dr. Swanson says a television commercial or a social media advertisement that teens could access through YouTube would be a prime way to target the age group recommended for HPV vaccination. An HPV vaccine that requires fewer than three doses would also make patients more likely to get immunized, she says. 

"If you could cut it down to two doses, it would help," Dr. Swanson said.

A study released in the May 1, 2013, issue of the Journal of the American Medical Association suggests two doses of the HPV vaccine could protect against genital warts, but no evidence shows two doses could prevent cervical cancer.

Dr. Terk says it's important for physicians to learn how to communicate with parents and teens who are hesitant about HPV immunization. 

"They need to understand their audience's world view and their potential preconceptions in order to effectively address their concerns and successfully overcome them," he said. 

Dr. Terk says he commonly encounters parents who are hesitant about many vaccines — not just HPV — because of the alleged connection between vaccines and autism spectrum disorder. He says parents are also concerned about the safety of vaccine ingredients and about the number of vaccinations recommended for their children. (Read "The Truth About Shots," January 2014 Texas Medicine, pages 31-36.)

"The first thing I do is ask for specific reasons a parent has concerns and what resources the parent used to create the concern or reinforce it. Requiring specifics is important because it allows me to understand what information I might need to call upon to answer the concern. It also requires the parent to cognitively clarify what may be a nebulous fear," he said.

Dr. Terk says it's easier to be a reliable resource for the parent if he understands their concerns, and the conversation allows him to disprove any unreliable, non-evidence-based information the parent brings to the table.

Parents and physicians who are skeptical about vaccinating young adults against HPV should also remember a teen doesn't always choose to become sexually active, Dr. Terk says. 

"One of the most effective things I tell my parents is that, unfortunately, not all of our children will willingly consent to their first sexual experience," he said. "Our job as parents is to protect our children as well as we can, and this is a very important way to do that." 

HPV Disparities Exist

HPV vaccination is crucial in the fight against cervical cancer. Some studies suggest women of color could be at greater risk of developing cancer as a result of HPV infection. 

Research from the Carolina Women's Care Study presented at the 2012 meeting of the American Association for Cancer Research (AACR) suggests African-American women's bodies have more difficulty clearing HPV compared with women of European descent. 

University of South Carolina professor Kim E. Creek, PhD, the lead author of the study, told attendees at the AACR meeting that African-American women are 40 percent more likely to get cervical cancer and twice as likely to die from the disease. 

The study shows the incidence of infection was about the same among all women surveyed, but black women were one-and-a-half times more likely to test positive for strains of HPV that can lead to cancer. The study indicates the infection typically lasts about 12 months in white women and 18 months in African-American women.

A study reported in the October 2011 issue of AJPM showed white women also were more likely to complete the three-dose series than their Hispanic and African-American counterparts.

Vincent Fonseca, MD, a San Antonio preventive medicine specialist and member of the TMA Council on Science and Public Health, says he sees an ethnic disparity in HPV vaccination firsthand, especially in women aged 19 to 26. Dr. Fonseca says no one knows exactly why the ethnic disparity exists. 

"But it does seem to be related to sociodemographic factors that help to explain other health disparities," he said.

At-home testing kits, which could target uninsured patients or women who don't receive regular Pap tests, are available in the United Kingdom but not in the United States. 

A study from the Unit of Cancer Epidemiology at the Scientific Institute of Public Health in Brussels shows at-home tests were only about 11-percent less sensitive in identifying precancerous growth than a test administered by a health care professional. But Dr. Fonseca says at-home tests are not the answer to reduce HPV-related health disparities. 

"This would just add additional burden to the patient and an additional cost to society," he said. "Let's first try to put as much effort in adolescent and young adult immunization as we do for infants."

Dr. Fonseca says it's every physician's duty to recommend the vaccine to patients to help reduce health disparities and prevent HPV-related cancers. 

"The risk for teenagers and young adults is extremely high. That is why there is a universal recommendation for both boys and girls, women and men," he said. 

Kara Nuzback can be reached by telephone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.


TMA Program Helps Doctors Spread the Word

TMA supports the American Congress of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention, the Advisory Committee on Immunization Practices, the National Institutes of Health, and the American Academy of Pediatrics in recommending three doses of the human papillomavirus (HPV) vaccine for females and males aged 9 to 26.

Be Wise — ImmunizeSM is a TMA program that works with physicians, medical students, and TMA Alliance members to improve vaccination rates in Texas through education and hands-on immunization clinics. It is made possible thanks to a grant from the TMA Foundation's top donors, H-E-B and the TMF Health Quality Institute, as well as gifts from physicians and their families.

The program's fact sheets can help you implement or enhance vaccination practices in your office. Be Wise toolkits for physicians contain best practice guidelines, vaccine safety information, complete details about ImmTrac, and information about the Texas Vaccines for Children program.

The Be Wise adolescent toolkit also offers tips specifically on how to talk about HPV vaccination with parents and encourages physicians to explain the safety and effectiveness of HPV vaccines. The toolkit features talking points for countering parents' objections.

To download the child and adolescent toolkits, visit the Be Wise webpage and click on What Does Be Wise — Immunize Offer for Physicians?

Through Be Wise — Immunize, you can also host a low-cost or free vaccination clinic. Be Wise offers local impact grants to assist in funding a local vaccination event. Grants of $500 to $2,000 are available to county medical societies, TMA Alliance chapters, medical student chapters, and TMA member-physician practices and clinics.

Be Wise — Immunize is a service mark of the Texas Medical Association.

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May 13, 2016

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