By Anita Brakman, MS
Senior Director of Education, Research and Training
Physicians for Reproductive Health
New York City
Taylor Rose Ellsworth, MPH
Manager, Education, Research and Training
Physicians for Reproductive Health
Melanie Gold, DO, DABMA, MQT, FAAP, FACOP
Medical Director
School-Based Health Centers
New York-Presbyterian Hospital
Columbia University Medical Center
New York City
Healthcare professionals need to be familiar with all of the indications for the human papillomavirus (HPV) vaccine, make strong recommendations for receiving vaccine at ages 11 or 12, and be aware of systems that can improve practice vaccination rates.
In 2014, the Food and Drug Administration (FDA) approved a vaccine designed to prevent nine high-risk strains of human papillomavirus.1 In 2015, the Advisory Committee on Immunization Practices (ACIP) added the new 9-valent HPV vaccine (9vHPV or Gardasil 9) to its recommendations for the routine vaccination of adolescents.2
HPV is the most common U.S. sexually transmitted infection, so much so that nearly all sexually active people who aren’t vaccinated will contract it at some point.3 An estimated 79 million Americans are infected with HPV, with 14 million new cases each year, and the highest burden falls on adolescents and young adults under age 25.4
Most HPV infections are asymptomatic, transient, and resolve on their own. However, those infections that don’t resolve can lead to cancers, as well as genital warts. An estimated 27,000 people are diagnosed annually with cancer attributed to HPV. Most are cervical cancers, but cancer of the vagina, vulva, penis, or anus, and oropharyngeal cancers also are caused by oncogenic strains of HPV.5
The bivalent and quadrivalent HPV vaccines that were FDA approved in 2006 and 2009, respectively, already offered protection against two strains, types 16 and 18, which cause 64% of HPV-associated cancers. The quadrivalent vaccine also protects against two strains that cause genital warts: types 6 and 11. The 9vHPV shot protects against all of these, plus five additional strains (HPV 31, 33, 45, 52, and 58). These additional strains cause about 10% of HPV-associated cancers, including about 15% of cervical cancers.5
The recommendation from ACIP is that HPV vaccines should be routinely given for females and males at ages 11 or 12, though it can be given as early as age 9. Vaccination for females ages 13-26 and males ages 13-21 also are recommended if they have not completed the three-dose series. Also, vaccination is recommended up to age 26 for men who have sex with men, as well as immunocompromised males.2
The availability of the new 9HPV vaccine might cause confusion about which vaccine to use, especially if patients have started and not yet finished the complete three-dose series. If a female patient has started the series, she can complete it with the 9vHPV or with the bivalent or quadrivalent versions. Males also can start the series with the quadrivalent and finish with 9vHPV, or vice versa, but the bivalent vaccine is not approved for use in males. For all, the benefit of vaccinating in a timely way with any of the three options outweighs the risk of delaying vaccination to obtain 9vHPV.6
If a patient has completed the series, it is not recommended that they obtain a dose of 9-valent vaccine.
In 2014, 87.6% of adolescents ages 13-17 were vaccinated with tetanus, diphtheria, and acellular pertussis (Tdap), and 79.3% were vaccinated with meningococcal conjugate (MenACWY). In contrast, only 60% of females and 42% of males received one dose of an HPV vaccine series. Only 40% of females and 22% of males received the complete three-dose series. Although HPV vaccination rates have increased since the vaccine was introduced, they still lag far behind the other routine adolescent vaccines.7
Studies consistently show that a provider’s recommendation is the single best predictor of vaccination.8 Yet, in a recent study of family physicians and pediatricians, 25% failed to make a timely recommendation for girls; 40% failed to recommend it for boys. Sixty percent of the providers polled used a risk-based approach to decide when to recommend the HPV vaccination, rather than offering it routinely as per ACIP guidelines.9
After conducting focus groups with parents, the Centers for Disease Control and Prevention (CDC) has created materials for providers to help them discuss HPV vaccination with parents. They recommend bundling the HPV vaccination with other adolescent vaccines on the same day and giving them equal weight and importance. The CDC also recommends that providers emphasize that HPV vaccination is cancer prevention and one’s personal belief in the benefit of their son or daughter receiving the vaccine.10 Integrating routine recommendations for the HPV vaccine in practice can significantly impact parental and patient decisions and improve vaccine rates to be more in line with other routine adolescent vaccines.
REFERENCES
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Food and Drug Administration. Dec 10, 2014 Approval letter — Gardasil 9. Silver Spring, MD: Department of Health and Human Services, Food and Drug Administration; 2014. Available at http://1.usa.gov/1YwUeBe.
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Markowitz LE, Dunne EF, Saraiya M, et al. Centers for Disease Control and Prevention (CDC). Human papillomavirus vaccination: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2014; 63(No. RR-05):1-30.
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Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: Preva-lence and incidence estimates, 2008. Sex Transm Dis 2013; 40(3):187-193.
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Jemal A, Simard P, Dorell C, et al. Annual report to the nation on the status of cancer, 1975–2009, featuring the burden and trends in human papillomavirus (HPV) — Associated cancers and HPV vaccination coverage levels. J Natl Cancer Inst 2013; 105:175-201.
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Centers for Disease Control and Prevention. Human papillomavirus (HPV)-associated cancers. Atlanta: Department of Health and Human Services, CDC; 2015. Available at http://1.usa.gov/1BUtB3U.
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Petrosky E, Bocchini JA, Hariri S, et al. Use of 9-valent human papillomavirus (HPV) vaccine: Updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2015; 64(11):300-304.
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Reagan-Steiner S, Yankey D, Jeyarajah J, et al. National, regional, state and selected local area vaccination coverage among adolescents aged 13-17 years — United States, 2014. MMWR 2015; 64:784-792.
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Stokley S, Jeyarajah J, Yankey D, et al. Human papillomavirus vaccination coverage among adolescents, 2007–2013, and postlicensure vaccine safety monitoring, 2006–2014 — United States. MMWR 2014; 63(29):620-624.
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Gilkey MB, Talo TL, Shah PD, et al. Quality of physician communication about human papillomavirus vaccine: Findings from a national survey. Cancer Epidemiol Biomarkers Prev 2015; 24(11):1673-1679.
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Centers for Disease Control and Prevention. Tips and time savers for talking with parents about HPV vaccine. Available at http://1.usa.gov/1phjRrM.
