Applied Evidence

Bringing the HPV vaccination rate into line with other adolescent immunizations

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Use simple practice measures and counsel parents with compelling evidence to help correct the low uptake of this vital vaccine.

PRACTICE RECOMMENDATIONS

› Review vaccination status at every adolescent health care visit. C

› Give a clear, unambiguous, strong recommendation to vaccinate with human papillomavirus (HPV) to prevent infection; cervical, oropharyngeal, and other cancers; and genital warts. A

› Schedule follow-up appointments at checkout following initiation of HPV vaccination to help ensure completion of the series. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series


 

From The Journal of Family Practice | 2019;68(10):E1-E7.

References

Overall adolescent vaccination coverage is improving in the United States.1 But for adolescents up to 15 years of age, there’s a large gap between the rate of vaccination for human papillomavirus (HPV) and the higher rates of coverage for tetanus, diphtheria, and acellular pertussis (Tdap) and meningococcal conjugate (MenACWY) vaccines.1 Adopting or refining practice customs reviewed in this article can increase HPV vaccination rates and continue to improve coverage of all vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) for adolescents between the ages of 11 and 12.

The evolution of ACIP’s HPV vaccine recommendations

Before December 2016, ACIP recommended a 3-dose HPV series for all adolescents between the ages of 11 and 12, given on a 0, 1-2, and 6-month schedule.2 The series could be started at 9 years of age. It could be administered to females as old as 26 years, and to males through 21 years (or ages 22-26 years for those who wish to be vaccinated, who have certain medical conditions, or who are included in special populations—ie, gay and bisexual men, men who have sex with men, immunocompromised men, men with human immunodeficiency virus [HIV], and transgender men).

In 2016, ACIP revised its recommendation for adolescents who initiate vaccination before their 15th birthday: a 2-dose schedule is adequate, with the second dose given 6 to 12 months after the first dose. For those who initiate vaccination on or after their 15th birthday, and for those with certain medical conditions, the recommendation remains 3 doses on a 0, 1-2, and 6-month schedule.3

As of August 2019,4 ACIP now recommends that all women and men receive catch-up HPV vaccination through age 26. For individuals 27 to 45 years of age who have not been adequately vaccinated, HPV vaccine may be given based on shared clinical decision making with their physician.

How are we doing?

Overall, adolescent vaccination coverage is improving in the United States (see “Vaccination goals from ACIP and Healthy People 2020”1,5,6), but the rate of improvement of HPV coverage is lower than that for Tdap and MenACWY coverage by age 15 years (although completion of the ­MenACWY vaccine series is low). From 2015 to 2016, coverage increased for 1 or more doses of Tdap, from 86.4% to 88% among 17-year olds (87.9% for 15-year olds), and coverage for 1 or more doses of MenACWY increased from 81.7% to 83.5% among 17-year olds (80.4% among 15-year olds).1 Both Tdap and MenACWY coverage rates have surpassed Healthy People 2020 goals of 80%, and the focus now is on maintenance of coverage. Data from the 2016 National Immunization Survey ­(NIS)-Teen show that completion of the HPV vaccine series (applying updated HPV vaccine recommendations retrospectively) increased to 45.4% for 15-year-olds,1 still far below the Healthy People 2020 goal of 80%. Completion rates for 2 or more doses of MenACWY also increased from 33.3% to 39.1%.1

SIDEBAR
Vaccination goals from ACIP and Healthy People 2020

The Advisory Committee on Immunization Practices (ACIP) recommends that adolescents routinely receive several vaccines between the ages of 11 and 12 years: an annual influenza vaccine, Tdap, the first dose of MenACWY, and initiation of the HPV series. ACIP also advises a booster dose of MenACWY at age 16 years, and teens and young adults (16-23 years) also may be vaccinated with a multidose serogroup B meningococcal vaccine, preferably before age 18. For those adolescents not up to date with their childhood vaccines, ACIP recommends the following catch-up vaccinations: measles, mumps, rubella (MMR, 2 doses); hepatitis B (HepB, 3 doses); and varicella (VAR, 2 doses).5

Healthy People 2020. In December 2010, the US Department of Health and Human Services released Healthy People 2020, a wide-ranging initiative on health promotion and disease prevention that includes 10-year objectives of increasing coverage with Tdap, at least one dose of MenACWY, and completion of the HPV series among 80% of those ages 13 to 15 years.6 This initiative reflects extensive feedback from more than 2000 organizations and authorities in public health and prevention at federal, state, and local levels—as well as from the public. Adolescent vaccination coverage is estimated by the Centers for Disease Control and Prevention using data from the National Immunization Survey (NIS)-Teen annual survey conducted among parents and guardians of adolescents ages 13 to 17 years.1

Common barriers to improved vaccine coverage

Barriers to improved vaccination rates include a lack of regular assessment of vaccine status; limited use of electronic records, tools, and immunization registries; lack of health care provider knowledge on current vaccine recommendations; vaccine costs; missed opportunities; and patient/parent refusals.7,8 The Community Preventive Services Task Force outlines several well-established evidence-based ways that administrators and physicians can counter these barriers:

  • give a strong recommendation to vaccinate,9,10
  • incorporate an audit/feedback mechanism for health care providers who vaccinate,9,11
  • use electronic alerts to remind health care providers to vaccinate,9,12
  • use your state’s electronic immunization information systems (IIS),7,13
  • appoint a vaccine practice team/­vaccine champion,9,14 and
  • implement standing orders and ­reminder/recall systems.7,9,15

In 2016, 45.4% of 15-year-olds had completed the HPV vaccine series—far below the Healthy People 2020 goal of 80%.

The passage of the Affordable Care Act (ACA)—which mandates that certain preventive services, including ACIP-recommended immunizations, be covered as part of basic care at no cost-sharing—reduces the once-common financial barrier to vaccine uptake.16 A key contributor to low uptake of HPV vaccination by adolescents is parental refusal.17

Continue to: The threats posed by HPV

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