Discussing the risks of the human papillomavirus and vaccinating teenage and young adult patients is no easy feat, but many gynecologic practices will find they can do it – and be “in the black” financially” – if they just appoint an office “vaccine advocate” to take charge of instituting national vaccination recommendations.
So says Dr. Stanley A. Gall, professor of obstetrics and gynecology at the University of Louisville (Ky.) and the American College of Obstetricians and Gynecologists' liaison to the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention.
Uptake of the vaccine has been slower and lower than it has been for other vaccines, he and other 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.
Pediatricians are vaccine experts and are used to low fees for vaccine administration, but in the case of HPV vaccine, they're challenged by their key age group: the 11- to 12-year-olds for whom the vaccine is recommended as part of the regular immunization schedule.
A recent survey of more than 1,500 parents 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).
Ob.gyns., on the other hand, are better positioned to discuss HPV infection as a sexually transmitted disease, but for many, vaccination requires a true “paradigm shift” in terms of practice values and resources.
HPV vaccination is recommended by ACIP on a “catch-up” basis for young women aged 13–26 years. Most private insurers cover vaccination, sources said, although coverage through some insurers diminishes in the 19- to 26-year age bracket. The public sector, Dr. Gall said, is now “catching up” with the private sector in covering HPV vaccination.
“Practices need to look at the reimbursement they're getting [or would get] from a handful of their insurers, and find out if they're in the black or the red,” said Dr. Gall, a member of ACIP's working group on HPV. “A lot of times, offices find that even though the amounts are small, they can make money.”
Success with HPV vaccine administration – as well as the administration of other vaccines – often comes with the appointment of a nurse or other practice member who “feels passionate” about the value of vaccination and can take charge of ordering and properly storing vaccines as well as teaching staff about proper vaccination indications, schedules, and techniques, said Dr. Gall.
“The physician shouldn't even have to think about it,” he said, noting that practices must institute standing orders for vaccines to be delivered in the physician's absence. “Take it out of their hands and make it a routine in the office.”
Even though the ob.gyn. practice staff may be more likely than pediatricians to find patients and parents more appreciative of HPV risks, it is still important to understand and anticipate the common reasons for refusal of the vaccine, Dr. Gall and other experts told this news organization.
For one, “there isn't as immediate a preventive effect” to 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 [teens] 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. HPV infection is the most commonly occurring STD. About 20% of adolescents are infected with HPV within 2 years of the onset of sexual activity, 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.
It is important to emphasize, however, that vaccination is not about sexual readiness or sexual activity but about preventing cervical cancer – and, sources said, it's important to give numbers.