Barriers to successful HPV vaccination in US adolescents

Human papillomavirus (HPV) is the most common sexually transmitted disease in the United States with a peak prevalence in adolescents and young adults. It is a viral infection that can persist in the body and lead to a significant risk of developing various types of cancer later in life. HPV infection is preventable thanks to the advent of vaccination. The current 9-valent HPV vaccine is proven to be safe, effective and successfully prevents morbidity and mortality associated with HPV-related diseases. Pediatricians, in particular, play a key role as providers of vaccination but also need to become leaders in HPV-vaccination education for children, adolescents and their parents.
Current guidelines from the Centers for Disease Control and Prevention (CDC) US Advisory Committee on Immunization Practices (UCIP) and the American Academy of Pediatrics (AAP) recommend initiating the 9-valent vaccine with 2-dose schedule at ages 11-12 (although can be started as early as age 9) and 3-dose schedule for those starting at ages 13-26. [2]
However, the HPV vaccination rate in the U.S. is still very low, particularly among adolescents, with less than two-thirds of adolescents ages 13-17 receiving at least one dose of the HPV vaccine. In Texas, low vaccination rates are even more prevalent in rural areas and border towns with higher Hispanic/Latino populations. Thus, Hispanic women in areas such as the Rio Grande Valley are at significantly higher risks for cervical cancer incidence and mortality than Hispanic women generally in the U.S. [1-3]
Under current Texas health law, adolescents can obtain health information on safe sexual practices, self-request pregnancy tests, contraception and STI tests confidentially with medical providers. HPV vaccination, however, is under immunization/vaccine law and thus requires parental consent for a teen to be vaccinated. Studies have shown that there is misinformation in the community regarding HPV vaccination, and that leads to parents declining HPV vaccination for their children. That in in turn leads to lower vaccination rates. Some barriers to vaccination cited include concerns about vaccine’s effect on sexual behavior, low perceived risk of HPV infection, social influence, irregular preventive care and concern for out-of-pocket costs. Interestingly, parents also cited healthcare professionals’ recommendations as one of the most important factors in their decision to vaccinate. [1]
Misinformation appears to be the key driving force behind suboptimal vaccination rates. This is in line with studies that have shown that parent/adolescent education and vaccination availability are key to addressing the issue. As an example, a single onsite school-based active vaccination program coupled with physician-led education on HPV and HPV vaccines for parents/guardians, school nurses and pediatric/family providers in a rural community in south Texas led to almost double HPV initiation and completion rates. [1,3]
Parents can find it complicated to navigate around all the misinformation around vaccinations, especially in a climate of a generalized sense of distrust geared toward the medical/pharmacological enterprise. Pediatricians and family medicine providers should clearly inform patients and their parents about the distinct benefits and safety regarding HPV vaccination, and the drastic, positive impact the vaccine provides in preventing HPV-associated cancer.
Cost should be less of a barrier, because the Patient Protection and Affordable Care Act requires insurance companies to cover ACIP-recommended vaccines without copays, and federal programs provide vaccines to Medicaid eligible children without cost. Finally, pediatricians should also establish strategic partnerships with schools and local health providers to develop active education programs and on-site vaccination programs. These steps can improve successful HPV vaccination rates and reduce risks for HPV-associated cancers.
1. Holman DM, Benard V, Roland KB, Watson M, Liddon N, Stokley S. Barriers to Human Papillomavirus Vaccination Among US Adolescents: A Systematic Review of the Literature. JAMA Pediatr. 2014 Jan; 168(1): 76–82.
2. Yang DY, Bracken K. Update on the new 9-valent vaccine for human papillomavirus prevention. Can Fam Physician. 2016 May; 62(5): 399–402.
3. Kaul S, Do TQN, Hsu E, Schmeler KM, Montealegre JR, Rodriguez AM. School-based human papillomavirus vaccination program for increasing vaccine uptake in an underserved area in Texas. Papillomavirus Res. 2019 Dec;8:100189.
B. CICERO WILLIS-PINEDA M.D.

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