Discussing the risks of the human papillomavirus and the value of HPV vaccination is no easy feat for physicians who are seeing preteen and teenage girls and trying to institute national vaccination recommendations.
Especially in the 11- to 12-year-old population – the age group for whom the vaccine is recommended as part of the regular immunization schedule – how to best address HPV risk is still "a million dollar question," said Dr. Charles Wibbelsman, chief of adolescent medicine at Kaiser Permanente in San Francisco and a former member of the American Academy of Pediatrics' committee on adolescents.
Uptake of the vaccine has been slower and lower than it has been for other vaccines, experts say, and both surveys and interviews with physicians around the country indicate that physicians face a host of moral, ethical, and safety concerns from parents, even though almost 5 years have passed since Gardasil – the first of two HPV vaccines – was licensed.
A survey of more than 1,500 parents published last April, for instance, showed that the HPV vaccine was the most commonly refused pediatric vaccine. Almost 80% of the parents who refused said they believed there had not been enough research on it, 51% said it challenged their belief systems, 59% said they believed their children were at low risk for contracting the sexually transmitted disease, and 37% said they did "not believe the vaccine is effective in preventing the disease" (Pediatrics 2010:125:654-9).
Physicians who spoke with this news organization said that understanding and anticipating these common reasons for refusal of the vaccine are key to an efficient and meaningful discussion of HPV risks. So is the use of affirmative, matter-of-fact statements about HPV vaccination.
Dr. Michael E. Pichichero
"If you approach it by saying 'It's time to receive your HPV vaccine,' there's often no need to go any further, other than providing parents with the appropriate information pamphlet" from the Centers for Disease Control and Prevention, said Dr. Michael E. Pichichero, director of the Rochester (N.Y.) General Hospital Research Institute and a pediatrician in private practice in that city.
"If you start out, on the other hand, by saying 'It's time to discuss the possibility of your daughter receiving the HPV vaccine,' immediately that sends a very different message," said Dr. Pichichero, who has served as a consultant for both Merck and GlaxoSmithKline, the manufacturers of Gardasil and Cervarix, respectively.
"Parents have never heard this type of approach used with a vaccine before," he said.
It is important to tailor one's approach to the fact that "there isn't as immediate a preventive effect that parents can appreciate, compared with other vaccines," said Dr. Gary L. Freed, immediate past chairman of the National Vaccine Advisory Committee and director of the division of general pediatrics and the child health evaluation and research unit at the University of Michigan in Ann Arbor.
"We can do better at being straightforward in addressing the issues of HPV, with both children and their parents," he said.
The following are some of the suggestions offered and experiences shared by these physicians and others:
• The "Why Now" Factor. As with other sensitive issues, clinicians have to tailor the depth of discussion about HPV infection to the maturity of the child and values of the family.
"But when a parent [of an 11- to 12-year-old] says, 'I want to have this discussion 2 years from now,' I think it's our responsibility to share data about the risk, and to convey the fact that we want to provide universal protection at an age when we know the child will respond effectively to the vaccine by developing a strong immune response ... and at an age that is prior to the risk," said Dr. Joseph Bocchini, immediate past chairman of the American Academy of Pediatrics' committee on infectious diseases and chairman of the department of pediatrics at the Louisiana State University Health Sciences Center in Shreveport.
Both parents and clinicians underestimate the likelihood that their child or patient is sexually active or about to become sexually active, said Dr. Bocchini, who also serves on the HPV working group of the CDC's Advisory Committee on Immunization Practices (ACIP).
In all, 20% of adolescents are infected with HPV within 2 years of the onset of sexual activity, he said, which for the majority of girls occurs during their teenage years.
Although physicians should not shy away from discussing HPV infection as a sexually transmitted disease – indeed, it is the most commonly occurring STD – they should nevertheless take care to emphasize the overall goal of vaccination: the prevention of cervical cancer.