Providers Are the Key: Making a Strong HPV Recommendation
by Sherrie Flynt Wallington, PhD
Human papillomavirus (HPV) is very common among both men and women. HPV has been found to be associated with several types of cancer: cervical, vulvar, vaginal, penile, anal, and oropharyngeal. Reports from the Centers for Disease Control and Prevention (CDC) show that in the U.S., HPV causes about 17,000 cancers in women and about 9,000 cancers in men each year.
There are two vaccines approved by the Food and Drug Administration (FDA) targeting HPV and routinely recommended for girls and women ages 9 to 26 years. One of the vaccines is approved and recommended for males ages 9 to 21 years. Administration of either vaccine consists of three doses administered at 0, 2, and 6 months. Research shows that health provider recommendation has a strong correlation with rates of uptake and completion of the vaccine series, which are disappointingly low. Nationally, although HPV vaccination initiation coverage is increasing, overall vaccine completion rates are at suboptimal levels and below the U.S. Department of Health and Human Services’ Healthy People 2020 initiative target of 80%.
CDC’s National Immunization Survey (NIS-Teen) from 2013 indicates that 64.5% of females and 42.9% of males in the District of Columbia (DC) have received one or more doses of HPV. Furthermore, 43.3% of females and 10.4% of males have received three doses. D.C.’s HPV vaccination rates are slightly to moderately higher than NIS-reported national rates except for rates in males, which are approximately 3% lower.
Lagging HPV vaccination initiation and completion rates continue to dampen the promise of HPV vaccines. Multiple factors affect HPV vaccination compliance, including the roles of parents, adolescents, and physicians. Physicians and other healthcare providers play a critical role in vaccine initiation and completion. The likelihood of HPV vaccination is strongly linked to a provider’s recommendation. The strength of the recommendation plays a significant role in the decision to be vaccinated, with some studies indicating a four-fold greater likelihood of vaccination from a strong recommendation versus one that was not strong. Consequently, HPV vaccination message-framing takes on an extremely important role.
Physicians and healthcare providers need to stress the importance of completing all three vaccine doses to their patients. Most public health and cancer experts agree that a cancer prevention message rather than a sexually transmitted disease message is key. The emphasis on a cancer prevention message has to do with the fact that the primary scientific endpoint of HPV vaccination is to prevent cancer – specifically cervical cancer, but other cancers as well. Here are some suggested communication strategies recently presented at the D.C. Department of Health, Immunization Office’s HPV Stakeholder Trainings:
- Frame your communication and discussion around “cancer prevention” rather than the sexually transmitted aspect of the virus.
- Provide parents with both oral and written HPV and HPV vaccine information, particularly about vaccine safety, so parents can make an informed decision about HPV vaccination.
- Give a strong HPV recommendation to both males and females. Discuss the HPV vaccines as you would any vaccinations recommended under the Advisory Committee on Immunization Practices (ACIP).
- Use gender-neutral messages so that parents and adolescents do not think vaccination is for females only.
- Encourage questions; interpret them as natural caution, not refusal.
- Be cognizant of the cultural, religious, and linguistic barriers to HPV vaccination.
- Use the Cancer Registry to send reminder recall and notifications for all vaccines.
In addition, be sure that everyone in your office who has patient contact receives training on HPV vaccination. It is important that clinical office personnel know their roles in immunization communication. Remember to arrange for subsequent doses and to give the Vaccine Information Statement (VIS) with each dose. HPV vaccines represent an important evidence-based finding in the translation of cancer prevention to all populations, particularly those at greatest risk for HPV-associated cancers. Providers play a critical role in this translation.
For more information about HPV vaccines and other ACIP-recommended vaccines, call the D.C. Department of Health, Immunization Office, at 202-578-7130, the D.C. AAP office at 301/655-4767, or visit the CDC web page at http://www.cdc.gov/vaccines/who/teens/for-hcp/hpv-resources.html.
Sherrie Flynt Wallington, PhD. is an Assistant Professor of Oncology and Program Director of the Health Disparities Initiative at Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, D.C.