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 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 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.
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.
- Perkins RB, Clark JA, Apte G, Vercruysse JL, Sumner JJ, Wall-Haas CL, Rosenquist AW, Pierre-Joseph N. Missed Opportunities for HPV Vaccination in Adolescent Girls: A Qualitative Study. Pediatrics. 2014 August 17. doi: 10.1542/peds.2014-0442.
- Stokley S, Jeyarajah J, Yankey D, Cano M, Gee J, Roark J, Curtis RC, Markowitz L; Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC. Human papillomavirus vaccination coverage among adolescents, 2007-2013, and postlicensure vaccine safety monitoring, 2006-2014 – United States. MMWR Morb Mortal Wkly Rep. 2014 Jul 25;63(29):620-4. PubMed PMID: 25055185.