Boosting Uptake of the HPV Vaccine

TON July 2015 Vol 8 No 4 - Best Practices
Alice Goodman

The United States lags behind other developed countries in uptake of the human papillomavirus (HPV) vaccine, and nurses and other healthcare providers can improve the situation. Only 33% of the US population has had the HPV vaccine, whereas the goal of uptake is 80%.

“The HPV vaccine is cancer prevention, and you are the key,” Betsy Shenkman, RN, PhD, told nurses and advanced practice nurses at the recent annual congress of the Oncology Nursing Society.

Shenkman was joined by 2 panelists with extensive experience in studying how best to improve uptake of the HPV vaccine nationwide: Electra D. Paskett, PhD, Ohio State University, Columbus, and Mildred Maldonado-Molina, PhD, University of Florida, Gainesville.

Scope of the Problem
There are 26 million girls under the age of 18 in the United States. If none of them are vaccinated, 168,000 will develop cervical cancer and 54,000 will die.

“For each year that we stay at 30% coverage, an additional 4400 cases of HPV infection will not be prevented nor will 1400 deaths from HPV-associated cancer,” Paskett said.

Most Americans will be infected with some type of HPV during their lifetime. HPV infection is often asymptomatic and only discovered on routine Pap smear. Of the many types of this virus, the HPV 16 and 18 genotypes are most often associated with cancer.

HPV infection and associated cancers affect both males and females. The most prevalent type of HPV infection in both sexes is genital warts. The major risk with HPV infection in women is HPV-associated cervical cancer. In men, oropharyngeal cancer is the most common HPV-associated cancer.

The HPV vaccine is now recommended for females and males between the ages of 11 and 12; males can be vaccinated up to age 21 and females up to age 26. Three doses of the vaccine are recommended for full coverage.

Addressing Barriers with Parents
“The main point to emphasize in conversation with patients is that the vaccine is safe, effective, and provides lasting protection,” Maldonado-Molina stated. This has been shown by many studies, she added.

In one study, 13% of parents of teenagers said that they did not plan to have their child/children vaccinated because “it was not recommended.” Although the HPV vaccine is not mandated or required by law, parents need to know that it is recommended by every large healthcare organization, including the Institute of Medicine, National Cancer Institute, Centers for Disease Control and Prevention, World Health Organization, and the American Cancer Society, as well as many others.

To address this problem, panelists suggested that nurses and doctors “bundle” vaccine recommendations; tell parents that all 3 vaccines—HPV, Tdap, and meningococcal are recommended for preteens.

“The timing and strength of the recommendation [to parents] are important,” Maldonado-Molina emphasized. At a routine checkup, parents should be told: “Your child needs 3 shots today. This will protect her/him against tetanus, diphtheria, pertussis (Tdap), meningitis (meningococcal vaccine), and HPV-associated cancer. Many parents accept this bundled recommendation.”

Parents often state that they won’t vaccinate their child because he/she is too young and is not sexually active. They need to know that the vaccine is not a green light for sexual activity; it is to be given before exposure to HPV when the immune system is at its most robust. Studies show that sexual activity is not increased after being vaccinated for HPV. In fact, a large study conducted by Kaiser Permanente showed no increase in sexual activity or unintended pregnancy years later in girls vaccinated between the ages of 11 and 13.

“Change the focus from fears about vaccination at a young age and sexual activity to cancer prevention. This message resonates. Research shows that mothers were influenced to vaccinate because of cancer prevention, history of cancer, or personal experience with cervical cancer,” she said.

Parents do not understand how common and prevalent HPV infection is, and they are unclear about what the vaccine protects against, the panelists agreed.

“It’s so common that 79 million Americans are currently infected and 14 million new infections occur each year. Even if your child waits until marriage to have sex or only has one partner, her partner was probably exposed,” Maldonado-Molina said.

The personal factor should come into discussions with parents. If they know that your children have been vaccinated, this helps to make parents feel more secure, she continued.

Fears of side effects should be addressed with parents. They need to know that after 67 million doses in the United States, there are no major safety concerns other than minor side effects. The vaccine does not have adverse effects on fertility. “It is ironic that the HPV vaccine does not affect fertility, but HPV infection does compromise fertility. Parents need to be informed about that,” Paskett said.

Reminders are important, because the HPV series involves 3 shots. Before the patient leaves the room, remind the parents and child that 3 doses are needed to provide full protection. Sending postcards or electronic reminders can be helpful.

The take-home messages for discussions with parents are:

  • HPV cancers are devastating to men and women, especially for cancers not routinely screened (ie, vaginal, vulvar, penile, anal).
  • We finally have a vaccine for cancer prevention—the HPV vaccine.

“Make a strong recommendation, start the conversation early, and focus on cancer prevention. Offer a personal story. Welcome questions from parents, especially about safety,” Maldonado-Molina emphasized.

Paskett ED, Shenkman B. Healthy people vaccinate: improving HPV vaccine uptake. Presented at: Oncology Nursing Society 40th Annual Congress; April 22-26, 2015; Orlando, FL.

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Last modified: July 29, 2015