If patients are concerned about the potential cost, we advise them to check with their carriers. We also ask them to sign a waiver that will permit us to bill the patient herself if she is not covered.
In addition, we have set up an account for each of our practices with the vaccine manufacturer so we can order vaccine on fairly short notice. We have recommended that our divisions each stock a reasonable number of doses to ensure enough supply to meet the demand expected in the very near future. We have also recommended that our practices go ahead and schedule the 2- and 6-month booster visits at the time of the patient’s first vaccination and counsel the patient about the importance of receiving all 3 doses.
ACOG hopes to create better (and bigger) vaccinators
GALL: In general, ObGyns don’t do a very good job at vaccinating. The last CDC survey I saw indicated that less than 60% of ObGyns collect immunization and infection histories from their patients, and only two thirds offer even a single vaccine.
WRIGHT: You have been working for several years to help the ObGyn community with vaccine implementation. What is ACOG doing to help physicians in private practice?
GALL: ACOG has promoted the concept that ObGyns should, and need to, become better vaccinators. A working committee on immunization has developed a program for practicing ObGyns. The concept is simple: The HPV vaccine is an ObGyn vaccine, and we should embrace it with vigor. If the ObGyn office gets set up to administer the HPV vaccine, why not administer other important vaccines such as TIV, hepatitis B, Tdap, MCV4, and herpes zoster?
This working committee has prepared a number of materials that should be available by the next annual clinical meeting:
We also plan presentations for the district and annual clinical meetings.
Is there a future for cervical cancer screening?
WRIGHT: Dr. Levy, can you explain why we are going to need to continue screening once the vaccine becomes widely used?
LEVY: For the next 30 to 40 years we will have a large population of women—already over age 26—who have not received the vaccine. These women will require ongoing screening for cervical cancer precursors throughout their lives.
Although the vaccine protects against HPV types 16 and 18, which cause 70% of cancer cases, and types 6 and 11, which cause 90% of genital warts, immunity to these HPV types will not protect a woman against the other 11 high-risk HPV types. These 11 types are not as commonly associated with cervical cancer or its precursors, but they do lead to cancer in some women and can still infect the cervix in women who have received the vaccine. Even if we reach all at-risk young women with our vaccine program, they will still be at risk—albeit lower risk—for cervical cancer due to infection with other high-risk HPV types.
One other point: We do not yet know how long the immunity from these vaccines will last. So it seems clear that screening will still be required to detect cervical cancer precursors and prevent cervical cancer from developing—even in women who have received the HPV vaccine.
Do we risk increasing the cancer rate?
WRIGHT: I worry about vaccination coverage. In the absence of state school requirements for the HPV vaccine, we are unlikely to get a high coverage rate among adolescents in the US. In several European countries, such as Germany, that have both recommendations and funding for universal hepatitis B vaccination of adolescents, only about 30% of adolescents have been vaccinated. The reason? These countries lack school requirements for the vaccination and have no school-based vaccination program. With the high prevalence of HPV infections in young, sexually active women in the US, we could actually increase our cervical cancer rate if we recommend reduced screening without ensuring high levels of vaccination coverage.
Dr. Gall, what do you predict for the next decade?
GALL: The future looks bright. A bipartisan bill was just introduced in the Michigan state legislature to add the HPV vaccine as a requirement for entry into junior high school. I expect more states to follow.
In general, adolescents are a poorly served group when it comes to health care because many fall out of the system. The HPV vaccine provides a great opportunity for us to encourage patients to bring their adolescent daughters to the office for a consultation. During this visit, we will conduct an “about the umbilicus” (ie, non-pelvic) physical exam, provide immunization, and discuss a number of topics such as contraception, menstruation, nutrition, etc. A critical step is to get state health departments and Medicaid officials off the dime and supporting the HPV vaccine.