Vaccination is the Most Effective Strategy for HPV Prevention

Human Papillomavirus (HPV) remains the most commonly sexually transmitted-infection (STI) in the world. During 2013 to 2014, the prevalence of genital infection with any HPV type was 42.5% among adults aged 18 through 59 years in the United States.¹ Although many will be asymptomatic, most sexually active people will be infected with one of the 40 types known to infect the genital area in their lifetime. HPV types are not equally dangerous. Types 16 and 18 are known to be highly oncogenic and cause a wide range of cancers including cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers and precancers, but a number of additional strains (types 31, 33, 45, 52, and 58) are known to be oncogenic as well.^2,3 While HPV types 7 and 11 do not appear to cause cancer they account for nearly 90% of genital warts and cause other medical issues like respiratory papillomatosis.^2,3

Vaccination is the Most Effective HPV Prevention Strategy

As skin-to-skin contact is all that is necessary to transmit HPV, abstaining from sexual intercourse and consistent use of latex condoms does not completely eliminate the risk of infection. Vaccination is a safe and effective method of preventing infection with the HPV types most likely to cause cancers and genital warts. Despite the vaccine’s effectiveness, four out of ten adolescent girls and six out of ten adolescent boys have not started the HPV vaccine series, and remain vulnerable to cancers caused by HPV infections.⁴ In Delaware, 40% of all adolescents completed their first HPV shot in 2016 (up from 26% in 2013); however, we continue to struggle with vaccine series completion.⁴ Approximately 17% of teens received the third dose of HPV vaccination in 2016, which represents an increase from 7.3% in 2013. Needless to say, we have a lot of work to do to reach the Healthy People 2020 goal of 80%.⁵

ACIP Recommendation for HPV Vaccination

The Advisory Committee on Immunization Practices (ACIP) is the committee that reviews immunization data and makes recommendation to the Centers for Disease Control and Prevention (CDC) about immunization schedules. HPV vaccination appears on both the infant, child and adolescent and adult schedules. HPV is routinely recommended for adolescents at ages 11-12 years old.² One major benefit to providing the vaccine on time is the use of a two-dose series (0, 6-12 months). If the first dose of HPV vaccination is provided before the 15^th birthday, only one additional dose is required to complete the series. The vaccine can be given as early as 9 years old, and catch-up vaccination can occur up to age 21 years in men (26 years amongst men who have sex with men) and 26 years in women.² Older adolescents and young adults starting the series after 15 years old should continue to receive the traditional three dose series (0, 1-2, 6 months). Recently the 9vHPV vaccine was approved by the US Food and Drug Administration for administration to adults up to age 45 years; however, no recommendation has been made from the ACIP yet.⁶

Strategies to Improve HPV Vaccination Rates

Make a Strong Recommendation

There are some key strategies for communicating a strong recommendation. Firstly, use a presumptive approach: expect that the patient is open to hearing your recommendation rather than anticipating there will be a disagreement or resistance. Use clear language and consider employing a bundled approach to clearly delineate that you are recommending HPV vaccine the same way as other adolescent vaccinations. Aim to have a recommendation that stresses administration of vaccines on the same day. Common wording that has been shown to be effective includes “I strongly recommend 3 shots during today’s visit: Tdap, HPV and Meningitis,” or “You are due for 3 shots today - TdaP, HPV and Meningitis. I strongly recommend you receive all three.” The CDC has a series of videos called “How I Recommend” that you may find valuable as you develop your personal recommendation style.⁷

Address Concerns about Side Effects and Safety

While there is a robust national conversation about vaccines, some of this information is inaccurate. Parents and teens may have concerns or fears about the safety of a vaccine and/or potential exposure to harm. You should be prepared to answer common questions about vaccine side effects and safety. CDC resources are available to assist in the education of teens and their guardian(s).⁸ Additionally, the CDC campaign website for “You are the Key to Cancer Prevention” includes resources for health care professionals and patients.⁹ Some clinicians may overreact to minor questions with defensiveness or the provision of massive amounts of safety data. This is not an ideal approach as it overwhelms the parent and teen and, at times, leads to delays or refusals for immunization.

Leverage the Wisdom of your Practice Team

Immunizations should not be limited to the clinician domain. Office staff can be incredibly supportive and instrumental in creating an atmosphere of vaccine acceptance. Consider selecting an Immunization Champion for your practice. This champion can serve as the point person who organizes your practice workflow around vaccinations, stays up-to-date on changes and recommendations, and ultimately helps your practice excel in immunization delivery. Encourage administrative staff to remind patients of upcoming immunizations through reminder-recall strategies (for example, sending post cards to remind patients of appointments or using patient portals to recall them back to the office when the time for the next dose has passed) or when scheduling routine appointments. Institute a standing order policy to reduce barriers to immunizing during rooming (and saving the patient the 15 minute wait at the end of the visit). Some practices even leverage daily huddles and care gap reviews to identify and encourage vaccination during visits. The National HPV Roundtable has a resource library and a dedicated provider education resource page that includes a variety of tools to help you improve your HPV vaccination rates, including a set of action guides with targeted approaches that have been shown to be effective.¹⁰

Conclusion

HPV vaccination represents an opportunity to prevent not only a STI but to prevent cancer. Delaware has the opportunity to be a leader in the nation by continuing to increase our immunization rates among males and females. We can all play a major role by stocking, strongly recommending, and advocating for on time HPV vaccine at 11 and 12 years old. Use the wide variety of resources to educate yourself and your patients about HPV. If you find that you have questions about 9vHPV (or any other vaccine), the CDC welcomes you reaching out to them at NIPINFO@cdc.gov.