OK, why aren’t kids getting vaccinated with Gardasil?

Cervical-cancer-This is my 48th article about Gardasil, following by just a few hours, my 47th. After my 50th, I get a watch made from the gold hidden in the subterranean vaults of the Big Pharma overlords who generates bundles of cash from vaccines. Oh, I keep forgetting–that’s not true.

Despite the overwhelming evidence that the HPV quadrivalent vaccine, also known as Gardasil (or Silgard in Europe) can prevent human papillomavirus (HPV) infection, the most common sexually transmitted infection (STI) in the USA, which is linked to cervical, anal, vulvar, vaginal, oropharyngeal and penile cancer, HPV vaccine uptake is not as high as other vaccines. A recent report from the CDC, published in Morbidity and Mortality Weekly Report, states that only 57% of girls and 35% of boys, aged 13-17 years, have received at least one of the three recommended doses of the HPV vaccine. This is far short of the goal of Healthy People 2020, the CDC’s initiative to set clear objectives and strategies to improve the health of Americans, that 80% of American teens have received all three doses of the HPV vaccine by 2020.

Currently in the United States, the Advisory Committee on Immunization Practices (ACIP) recommends that preteen girls and boys aged 11 or 12 are vaccinated against HPV. The immunization is also recommended for teenage girls and young women up to the age of 26 who did not receive it when they were younger, and teenage boys and young men up to the age of 21.

In a new study, by Rebecca Perkins, MD, et al., published in Pediatrics, attempted to identify the rationale of parents and guardians or healthcare providers for either delaying or administering the HPV vaccine to girls. The research was performed through qualitative interviews with the parents and guardians accompanying vaccine-eligible 11-17 year old girls to visits to their physicians. The interviews goal was to probe vaccine decision-making from the point view of both parents/guardians and the healthcare provider.

The researchers interviewed 122 parents and guardians, the vast majority were the mother of the girl (although a few fathers were included), from a broad demographic range, including income, education, ethnicity, and other factors. The researchers also interviewed 30 healthcare providers who were involved with the decision making for the HPV vaccination. The study included both public clinics and private practices.

With such small numbers, it is difficult to obtain statistically solid results, but there were a lot of comments from both the parents and the providers that can give a strong clue as to barriers to HPV vaccination, along with successful techniques to get these kids vaccinated.

Below is a summary of some of  barriers to HPV immunization:

Parents

  • Parents are not offered vaccination–“I agree that I think the vaccine is a good idea so I would likely accept it if offered.”–White father of 13-year-old, private practice.
  • Parents perceive vaccine as optional or unnecessary at that time–“If we had said yes it would have been fine, if we had said no it would have been fine. Very optional.”–White mother of 12-year-old, private practice. “[We didn’t vaccinate because] she was kind of low risk…in terms of sexually activity, that sort of thing.”–African-American mother of 14-year-old, public clinic.
  • Parents perceive that their providers discouraged vaccination–“We changed doctors in this process and in fact I was rather distressed that [daughter’s name]’s previous doctor recommended avoiding HPV vaccination for a couple of years which troubled me…. this would have been when she was twelve, thirteen, maybe even fourteen….He just recommended waiting for more studies and I thought the evidence was pretty conclusive already…. [We brought it up] multiple times and were fended off.”–White mother of a 15-year-old, private practice. “I brought [HPV vaccination] up because I thought this was something that was being recommended and I had said, ‘Do you feel that my daughter should get it?’ And they felt, ‘No, she doesn’t really need to have it at this time.’ And I didn’t give it a second thought…I just kinda went with what the doctor said.”–White mother of a 13-year-old, private practice.
  • Parents want information about vaccine safety–“I would like to see studies about what the risk level is more accurately, I understand things on the Internet can be a little bit sensationalist, you know ‘people did this and they died!’ it’s like yes, well people drive and they die too.“–White mother of 13-year-old, private practice. “I’d rather have my child die of cervical cancer then her die of me giving her a vaccine.”–White mother of 16-year-old, private practice. “I think it is important [to vaccinate] before they are sexually active. Like I said the more information I get in terms of the side effects will determine my ultimate decision.”–African-American mother of 14-year-old, public clinic.
  • Parents do not understand the reason to vaccinate at 11 to 12 years of age–“I thought that it didn’t really make any difference as long as they had the three vaccines before their 20’s.”–White mother of 12-year-old, private practice “It’s like blaming a kid before they even get a chance to do anything.”—African-American mother of 11-year-old, public clinic

Providers

  • Providers are reluctant to give multiple shots at 1 visit–“The 11 and 12 year olds I don’t usually recommend it then just because they’re getting other vaccines.”–Pediatrician in private practice. “So, we’re supposed to give it 11 but I tend to give it at 12 just because they’re getting two other shots at 11 and if there’s any real need to be giving it at 11 because they’re sexually active then we have a much bigger problem than HPV.”–Pediatrician in private practice.
  • Providers introduce HPV vaccination at age 11 years but do not recommend it strongly–“At [the 11 year old] visit generally I anticipate that they’re not going to do it and I talk to them about it.”–Pediatrician in private practice. “I’d honestly say it’s rare that I spend more than 20 seconds on it at 11…So few 11 year olds are physically mature to be sexually active that it’s, I find it’s almost sort of an awkward conversation.”–Pediatrician in private practice.
  • Providers recommend vaccination based on their estimation of sexual activity–“I rarely give it at 11 or 12. I most commonly give it in the like 8th, 8th to 10th grade range when sexual activity would put them at risk, rather than just an age. This is what I tell parents: it’s very different than other vaccines because you can quantify your risk by what you’re doing.”–Pediatrician in private practice. “I don’t think about that consciously, but when I think about it unconsciously when I see this skinny little upper middle class kid here, with parents, and they talk and they’re barely doing anything, and I’d be shocked if they became sexually active at a really young age and to bring all this up with the parents have 20 other things they want to talk about, it seems low down on the list.”–Pediatrician in private practice.
  • Providers have limited experience with HPV disease and underestimate risk–“I don’t get as scared of cervical cancer just because…the Pap test is another screening method. So the other things just feel more dramatic to me….. and it’s not like HPV is going to kill the boys.”–Pediatrician in private practice. “It probably is more likely that they would die from meningococcal meningitis then die from cervical cancer.”–Pediatrician in private practice.
  • Providers perceive HPV as more emotionally charged than other vaccines–“If you have an 11-year-old boy and I’m supposed to talk about HPV, they’re going to ask me why I’m recommending it, ‘Well when your son grows up, you know, he, it’ll prevent him from giving cervical cancer to his partner and it’ll prevent them fromgetting penile warts.’ This is a big discussion to have in front of a little 11- year-old, I don’t even know what word they use for penis at 11.”–Pediatrician in private practice. “Eleven feels really young. That being said, there’s nothing to say it’s not safe that young but I do, I kind of understand why parents want to wait a couple years. But I don’t have…any specific safety concerns…I mean I’d probably do it [for my child]. Well I think I would almost do it more grade than age…. So, I would say 7th and 8th grade. I think that’s more appropriate.”–Pediatrician in private practice.
  • Both providers and parents know they are often unaware of timing of sexual debut–“It’s probably only maybe 20% of the sexually active teens their parents know.”–Pediatrician in private practice “I feel like a lot of [teens], either say they’re not doing anything or they’re using condoms 100% of the time… but I’ve had a couple of pregnancies.”–Nurse practitioner in private practice. “I know how kids are, you know? For what it’s worth, I was sexually active from age 14 on and that was a long time ago.”–White father of a 14-year-old, public clinic. “From what I understand the vaccine is safe, efficacious and I’d be a fool and also have amnesia to believe that high schoolers do not engage in unwise sexual practices at times.”–White father of a 12-year-old, private practice.
  • Delaying vaccination leads to non-vaccination–“A lot of teenagers don’t think they need to come in because there are no real required shots after 11 and after 16 they feel kind of invincible.”–Pediatrician in private practice. “That’s an argument for doing it at 11 and 12 is that the child is more, the child’s schedule is more under the parent’s control at 11 and 12 than it is at 14, 15.”– Pediatrician in private practice.

The mother who said, “I’d rather have my child die of cervical cancer then her die of me giving her a vaccine,” is the one that drives me crazy. The danger of cervical cancer is measurable and known. There is simply no evidence that anyone ever died of Gardasil–unless you enjoy VAERS dumpster diving, which is kind of smelly.

Cervical-Cancer-Statistics

Again, although I am unsure of any statistical significance of this information, what is remarkable is that even providers have some rumor-based beliefs about the HPV, especially about the various risks of HPV and underestimating the sexual behavior of their patients. In fact, it seems that the parents do look to the providers as to when to start Gardasil vaccinations, and if the provider is confused or unsure about the vaccine, then that transfers to the parents. That becomes a major barrier to vaccination.

On the other hand, the research did uncover some successful tactics from providers and parents that are effective in convincing parents to have their children immunized against HPV:

  • Parents want to prevent cancer–“It’s important for her to get the HPV vaccine cause it can prevent cervical cancer. I just wanted my daughter to have every chance to not get HPV. And also to protect her from cervical cancer. She’s still a virgin thank god! But if she ever did have sex with multiple partners, to be able to protect her from that.”–African-American mother of 15-year-old, public clinic. “Just thinking in the long run, anything that would protect from any cancer down the road just seemed to make sense to me.”–White mother of 14-year-old, private practice.
  • Parents trust provider recommendations–“Because her doctor knows, just like I know. Because her doctor has been with her since she was born.” – African-American mother of 16-year-old, public clinic. “I trust my doctor’s advice and I also think there has been enough research to prove that the vaccine is effective so I felt that it was important to go ahead.”–White mother of 15-year-old, private practice.
  • Parents think benefits outweigh risks–“It’s a harmless vaccine and could have life-saving qualities.”–White parent of 15-year-old, public clinic. “Since I can’t control everything I thought I’d rather have her protected”–Latino parent of 17-year-old, private practice.
  • Parents want a strong recommendation–“I want someone to say to me ‘you need to do this for your daughter, you’re doing the right thing.’ Because people are unsure and they’re afraid and they don’t want to make a decision that’s going to hurt their child.”–White mother of 12-year-old, private practice.
  • Providers emphasize cancer prevention–“I also point out this is pretty much the only vaccine we have that prevents a kind of cancer. That’s something that is a big deal.”–Pediatrician in private practice. “My husband knew somebody who had mouth and throat cancer too… maybe if that person had the HPV vaccine it would have protected them.”–Pediatrician in private practice. “I’ll start a conversation by saying, ‘In your experience with your health right now, you may be screened for cervical cancer by means of a Pap smear…because cervical cancer can obviously be something that can be life-threatening but if caught soon, it can be taken care of, and this is how your health is impacted by this virus right now. Well, children now have the option of getting this vaccine which is actually very effective at reducing the risk for contracting that same virus.’”– Pediatrician at the public clinic.
  • Providers normalize the HPV vaccine/coadminister with other vaccines–“What I’ve been doing is saying to them, “Okay, after the first push in the first two years of life when babies get vaccines at every visit, the next big push is at 4 and the next big push is at 11” and so that they’re, they know this is when I’m going to be doing it. I think that’s helpful…Most of the time I don’t get questions. I give a little, tiny spiel about each of them so that they’re all seen as kind of equal.”–Pediatrician at public clinic.
  • Providers give a strong recommendation–“In my experience, it’s the confidence with which I make the recommendation that seems to be the most convincing because my patients know me, and so if I say, ‘You need this,’ they say, ‘Okay, if you say I need it, I need it.’”–Pediatrician at public clinic. “Maybe [age 13–14 is] subconsciously where I flip the switch, and maybe I’m not doing a hard enough sell at 11.”–Pediatrician at private practice.

If there’s anything to understand from this study is that the physician, the pediatrician in this case, has a significant opportunity to provide important information to parents about the HPV vaccine. They can say that it is safe. They can say it is effective in preventing cancer. They can say that it’s part of the vaccinations that should be given to children, just like MMR or DtaP. People still trust physicians (well, outside of the lunatic fringe), and they don’t have to defer to a mother who gets her information from the internet, and who even then, wonders if she’s got accurate information from the internet.

The authors concluded that:

Many missed opportunities for HPV vaccination occur not because parents and providers feel that vaccination is unimportant but because both parties tacitly agree to delay vaccination until there is a perception that girls are at risk for sexual activity. Although in theory this option should still result in timely vaccination, determining the onset of sexual activity in practice is problematic, and many girls remain at risk for vaccine-preventable cancers. A commitment by providers to strongly recommend HPV as a cancer prevention vaccine, and to recommend coadministration with tetanus booster and meningococcal vaccines routinely at age 11 years, has the potential to greatly decrease missed opportunities (emphasis mine).

Based on emails and Disqus comments I’ve read, I know that a lot of pediatricians read this blog. I am confident that you all can convert my snarky dismissal of the anti-science crowd to a kind, gentle, comforting approach to parents to get them to get the HPV vaccine. It prevents cancer. And it’s absolutely safe (much safer than cancer). Go get ’em. You have the power.

Visit the Science-Based Vaccine Search Engine.

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The Original Skeptical Raptor
Chief Executive Officer at SkepticalRaptor
Lifetime lover of science, especially biomedical research. Spent years in academics, business development, research, and traveling the world shilling for Big Pharma. I love sports, mostly college basketball and football, hockey, and baseball. I enjoy great food and intelligent conversation. And a delicious morning coffee!
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  • Boris Ogon

    I’m going to leave a comment to test a bit of Disqustink markup syntax and then delete it. I hope this isn’t too much of a nuisance.

    • Guest

      @boris_ogon:disqus This is the test comment.

  • SteveCA7

    In the UK there are many thousands of serious adverse reactions to this vaccine
    (x100 more than other common vaccines) including my daughter who has been
    severely disabled for over 3 years. But the UK Health Service tells us these
    are all a coincidence. On their web page they tell us: the FDA recently
    reported that ‘Gardasil continues to be safe and effective’. But on the FDA
    webpage: http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM111263.pdf you can find:

    6.2 Post Marketing Experience

    The following adverse events have been spontaneously reported during post-approval use of GARDASIL. Because these events were reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency or to establish a causal relationship to vaccine exposure.

    Blood and lymphatic system disorders:
    Autoimmune hemolytic anemia, idiopathic thrombocytopenic purpura,
    lymphadenopathy. Respiratory, thoracic and mediastinal disorders: Pulmonary
    embolus. Gastrointestinal disorders: Nausea, pancreatitis, vomiting. General
    disorders and administration site conditions: Asthenia, chills, DEATH, fatigue, malaise. Immune system disorders: Autoimmune diseases, hypersensitivity reactions including anaphylactic/anaphylactoid reactions, bronchospasm, and urticaria. Musculoskeletal and connective tissue disorders: Arthralgia, myalgia. Nervous system disorders: Acute disseminated encephalomyelitis, dizziness, Guillain-Barré syndrome, headache, motor neuron disease, paralysis, seizures, syncope (including syncope associated with tonic-clonic movements and other seizure-like activity) sometimes resulting in falling with injury, transverse myelitis. Infections and infestations: cellulitis. Vascular disorders: Deep venous thrombosis.

    See also http://www.sanevax.org and https://www.youtube.com/watch?v=hD5TnDtGKYw before you choose this vaccine.

    • Your information is misleading and, in fact, isn’t even information at all.

      There have been several large post-licensure studies in the UK which shows the vaccine is safe and effective. What happened to your daughter may or may not have been related to the vaccine, but it’s most probably a coincidence. It’s human nature to presume their anecdote is somehow superior to scientific study. Kind of arrogant of you.

      You’re quoting a package insert. Only those without real clinical evidence use it as a scare tactic, which is kind of sad. Read this, unless you only read anti-vaccination shill sites:

      http://www.skepticalraptor.com/skepticalraptorblog.php/vaccine-package-inserts-debunking-myths/

      Not much else to say about your information. It’s pulled from anti-science websites. Very useless with this crowd who accepts meta reviews and large scale clinical trials which negate everything you say. Oh well.

      • voxvot

        “Post-licence studies” are subject to human error, confirmation bias, vested interest and incompetence.

        What’s your “probability” estimation based on?

        It’s “human nature” to raise concern when their personal experiences conflicts with official narratives.

        To say that your information is pulled from “anti-science websites” is the genetic fallacy; imagine that, a skeptic employing a fallacy of logic, tut, tut…really.

        The problem with these post-licence studies is that, as you rightly point out, there can be a multiplicity of explanations for events that take place within the same time frame being non-causally related. Your problem is that you extrapolate from this that any apparently causally connected events that cannot be definitively proven to be causally related are, ipso facto, non-causally related.

        In reality, by the very virtue of the fact of many possible alternative explanations, the statistical possibility of probable causal connectivity will only become apparent over the long term.

        It is simply not possible for a short term analysis of case studies or cohort studies to contain enough data to make meaningful conclusions.

        In layman’s terms what you are doing is basing your analysis of the outcome of a marathon by looking at how the runners are placed at the one mile marker.

        • Don’t care about human nature. Humans once thought dragons were at the edge world. They thought that Jews carried disease. They thought that star patterns predicted future.

          What you call “human nature” I call cognitive biases. What you call “official narratives” I call evidence based science. To claim that all post-license studies are subject to human error, confirmation bias, vested interest and incompetence also indicates cognitive bias.

          Anti-science websites are frankly filled with ignorance, lies, and slander. So, you’re kind full of bullshit to accuse me of a genetic fallacy with your condescension. There is nothing more frustrating than a pseudo intellectual pulling crap out of his ass to make himself feel superior.

          Yes, and if you cannot show causality, it simply does not exist. And I won’t fall for any of your Arguments from Ignorance. You see, I actually know what that is.

          • voxvot

            Whoa! Try a little practice with your preach sister. The “human nature” that you “don’t care” about was in quotation marks because, like YOU raised the subject that you, apparently “don’t care” about?

            And straight from that hysterical outburst you launch into a strawman (illogical, pre-rational bullshit) about Dragons and Jews, hysterical.

            You call it “evidence based science”? I call it conclusions drawn from the limited evidence available which then passes through a selection process organized by people with a uniform perspective, outlook and background; garbage in, garbage out.

            To claim that cognitive bias is not a universal pitfall that can afflict any area of research, is to make an implicit claim that ant argument made from a certain ideological outlook is free from any normal human failings and evinces a transcendent and unquestioning truth; sounds more like the ravings of the Catholic church than rational discourse
            to me.

            “Anti-science websites”, oh dear! The cult of skepticism waffles on about logical fallacies ad nauseum, but you’ve segued from strawman to ad hom without skipping a heartbeat. I was expecting a more rational response from a high priestess of reason, instead I got the kind of flaky response you’d expect from a scientologist.

  • I don’t get it: How the feck is it that they think the only way to get the virus is to have sex? They’re doctors!

    Also, “They’re getting two other vaccines at 11. I think it’s better to get it at 12.” What the actual fuck?! If I heard a doctor say that, I’d respond with, “You asshole. You fucking know that kids could get every vaccine at once, and they’d only cry about the number of sticks, and redness! You’d best give my child that damned vaccine!”

    Grrr

    • I’m one of those “get ’em all done at once, so I don’t have to worry about it.”

      I know that the authors cherry picked the most outrageous comments, and I don’t think it’s a representative sample of pediatricians, but the fact that any think like this just baffles me.

      • I’m certain they did, too. But the point is: How can any doctor think this way? I mean, weren’t vaccines part of the curriculum in med school?

  • motek42

    As a pediatrician, the provider quotes really piss me off. The physicians should know better!!!! I would like to note that many of us do.

    Also, a penis is called a penis at every age. No need for cutesy names, even with a toddler. See my blogpost on “private parts” for more information on that. What kind of doctor can’t say the word penis to his patient??? FFS.

    • When I saw that comment, I was wondering if they just talked to some uptight doctors. An 11 year old girl has heard much worse watching HBO.

      • notation

        Actually, I’ve heard worse FROM 11-year-old girls.

  • Robert Haile

    People are not able to pay attention long enough in this digital world other than to repeat an unproven sound bite. it began with the rigged autism-vaccination hoax study that was retracted from the british medical journal.. Over 20 million children studied to prove autism is not related to vaccinations, and still there are parents who raise this issue. People are too distracted to think ahead and our society still has minsogynst tendencies decreasing the incidence of male HPV vaccinations. Stop treating children as babies, and for the pediatrician wondering what 11 year olds call a penis: hot off the press-penis may be called a dick. “. Your dick could grow warts or give your {rtf1ansiansicpg1252
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