Catching Up With the HPV Vaccine: Challenges and Opportunities in Primary Care

Andrew L. Sussman; Deborah Helitzer; Anzia Bennett; Angélica Solares; Marianna Lanoue; Christina M. Getrich

doi:10.1370/afm.1821

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Challenges to improving HPV vaccination coverage in adolescents
Rebecca B. Perkins, MD MSc

Published on: 04 August 2015
HPV Vaccine Bridge to Screening
Diane M Harper

Published on: 27 July 2015

Published on: (4 August 2015)
Page navigation anchor for Challenges to improving HPV vaccination coverage in adolescents
Challenges to improving HPV vaccination coverage in adolescents
Rebecca B. Perkins, MD MSc, Associate Professor of Obstetrics and Gynecology
Newly released data from NIS-Teen 2014 indicate that HPV vaccination rates continue to rise slowly--60% of girls and 42% of boys have received at least one dose.[1] Dr. Sussman and colleagues perform a relevant mixed-methods study to better understand clinicians' challenges to providing this adolescent vaccine. Although their data were collected between 2009-2011, the issues raised remain relevant.
One of the challenge...
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Newly released data from NIS-Teen 2014 indicate that HPV vaccination rates continue to rise slowly--60% of girls and 42% of boys have received at least one dose.[1] Dr. Sussman and colleagues perform a relevant mixed-methods study to better understand clinicians' challenges to providing this adolescent vaccine. Although their data were collected between 2009-2011, the issues raised remain relevant.
One of the challenges raised most frequently by providers was the difficulty providing vaccination during acute care visits. In contrast to young children, most of whom seek routine preventive care annually, many adolescents present only for acute problems.[2] Although not demonstrated in this study, other research has found a preference for vaccination at age 13 and older among some providers and parents,[3,4] which can lead to missed opportunities to vaccinate at the recommended ages of 11-12 if the adolescents are not seen for preventive care in their later teen years.
Clinicians also faced great difficulties with ensuring that their patients received all three doses of the vaccine. They estimated that only 9% of their patients completed the series within the recommended six-month timeframe, and explicitly stated that they did not have staff or systems in place to perform remind and recall patients for completion doses. In the future, the US may consider moving to a two-dose vaccination schedule at 0 and six months, with improved compliance being an important motivation for this change. However, existing systems will be no more capable of ensuring completion of two doses in six months than three doses, as reminder calls are necessary for any subsequent vaccinations. Thus greater emphasis must be placed on creating systems to support multi-dose adolescent vaccinations.
Sussman and colleagues also raised the question of informed consent when discussing the quadrivalent and bivalent vaccines. With the 9-valent HPV vaccine now replacing the quadrivalent vaccine over the next 18 months, the discussions will become more complex. Among HPV-naive women, the bivalent HPV vaccine appears to be 93% effective against CIN3+ caused by any HPV type[5] compared with 27% -75% effectiveness for the quadrivalent vaccine.[6,7] The effectiveness of the 9-valent HPV vaccine against all CIN3+ has not been published, though HPV prevalence studies indicate that up to 85% of CIN3+ should be prevented.[8] However, the bivalent vaccine is not FDA-approved or ACIP-recommended for boys, and is not stocked by many practices, limiting clinicians abilities and motivation to counsel patients about different vaccine options.
As the complexity of recommended preventive care for adolescents increases, more focus should be placed on supporting health system outreach functions to bring adolescents in for preventive healthcare, including vaccinations and screenings.
1. Reagan-Steiner S, Yankey D, Jeyarajah J, et al. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years - United States, 2014. MMWR Morb Mortal Wkly Rep. Jul 31 2015;64(29):784-792.
2. Rand CM, Shone LP, Albertin C, Auinger P, Klein JD, Szilagyi PG. National health care visit patterns of adolescents: implications for delivery of new adolescent vaccines Arch Pediatr Adolesc Med. Mar 2007;161(3):252-259.
3. Perkins RB, Clark JA, Apte G, et al. Missed opportunities for HPV vaccination in adolescent girls: a qualitative study Pediatrics. Sep 2014;134(3):e666-674.
4. Daley MF, Crane LA, Markowitz LE, et al. Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure. Pediatrics. Sep 2010;126(3):425-433.
5. Lehtinen M, Paavonen J, Wheeler CM, et al. Overall efficacy of HPV-16/18 AS04-adjuvanted vaccine against grade 3 or greater cervical intraepithelial neoplasia: 4-year end-of-study analysis of the randomised, double-blind PATRICIA trial Lancet Oncol. Jan 2012;13(1):89-99.
6. Group FIS. Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions N Engl J Med. May 10 2007;356(19):1915-1927.
7. Gertig DM, Brotherton JM, Budd AC, Drennan K, Chappell G, Saville AM. Impact of a population-based HPV vaccination program on cervical abnormalities: a data linkage study BMC Med. 2013;11:227.
8. Saraiya M, Unger ER, Thompson TD, et al. US assessment of HPV types in cancers: implications for current and 9-valent HPV vaccines J Natl Cancer Inst. Jun 2015;107(6):djv086.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (27 July 2015)
Page navigation anchor for HPV Vaccine Bridge to Screening
HPV Vaccine Bridge to Screening
Diane M Harper, Professor
Other Contributors:
Sussman et al have provided a thoughtful analysis of the poor Gardasil uptake in New Mexico.
The latest data suggest that placing HPV vaccination in a bridge position may be a better strategy. Optional HPV vaccination bridges adolescents until they are of cervical cancer screening age. Screening has become nearly 100% sensitive and nearly 100% specific with HPV testing either as a primary screen or in a co-te...
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Sussman et al have provided a thoughtful analysis of the poor Gardasil uptake in New Mexico.
The latest data suggest that placing HPV vaccination in a bridge position may be a better strategy. Optional HPV vaccination bridges adolescents until they are of cervical cancer screening age. Screening has become nearly 100% sensitive and nearly 100% specific with HPV testing either as a primary screen or in a co-testing fashion. This provides a 10 year span from age of vaccination until screening, allowing the onus of cancer prevention to be shed from HPV vaccination.
The shared decision making model then offers a choice of Gardasil9 (Gardasil) vs. Cervarix. Gardasil9 and Gardasil have identical 47% protection rates against CIN 3 regardless of HPV type (Joura E et al 2015 and FUTURE II et al 2007), and 100% protection against genital warts (Garland S et al 2007). Gardasil and Gardasil9 only have efficacy studies for the FDA approved 3 dose schedule, which 66% of women do not complete (Harper DM et al 2013). Cervarix has 93% protection against CIN 3 regardless of HPV type (Lehtinen M et al 2012), and 30% protection against genital warts (Szarewski A et al 2013). Cervarix has the same efficacy in one dose as it does in three doses (Kreimer AR et al 2015).
One dose, superior pre-cancer protection regardless of type, and some genital wart protection as a bridge from adolescents until women are of cervical cancer screening age offers real opportunity to decrease persistent infections. Yet most state Vaccine For Children programs do not even offer the physician the choice to offer patients Cervarix.
Do we as a society want to emphasize for our girls/women a three dose option that is hard to complete and offers inferior pre-cancer protection, yet good wart protection all because "it is too hard to stock two HPV vaccines, one for boys and one for girls"? As Sussman et al showed in their work, three doses is too high a bar to expect for adolescent vaccination, especially when the other adolescent vaccine can be a single dose vaccine. Girls and women deserve the option to have a single dose HPV vaccine should they choose to be vaccinated at all.
Joura EA, Giuliano AR, Iversen OE, Bouchard C, Mao C, Mehlsen J, Moreira ED Jr, Ngan Y, Petersen LK, Lazcano-Ponce E, Pitisuttithum P, Restrepo JA, Stuart G, Woelber L, Yang YC, Cuzick J, Garland SM, Huh W, Kjaer SK, Bautista OM, Chan IS, Chen J, Gesser R, Moeller E, Ritter M, Vuocolo S, Luxembourg A; Broad Spectrum HPV Vaccine Study.A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med. 2015 Feb 19;372(8):711-23.
FUTURE II Study Group.Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions. N Engl J Med. 2007 May 10;356(19):1915-27.
Garland SM, Hernandez-Avila M, Wheeler CM, Perez G, Harper DM, Leodolter S, Tang GW, Ferris DG, Steben M, Bryan J, Taddeo FJ, Railkar R, Esser MT, Sings HL, Nelson M, Boslego J, Sattler C, Barr E, Koutsky LA; Females United to Unilaterally Reduce Endo/Ectocervical Disease (FUTURE) I Investigators. Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases. N Engl J Med. 2007 May 10;356(19):1928-43.
Harper DM, Verdenius I, Ratnaraj F, Arey AM, Rosemergey B, Malnar GJ, Wall J. Quantifying clinical HPV4 dose inefficiencies in a safety net population. PLoS One. 2013 Nov 6;8(11):e77961.
Lehtinen M, Paavonen J, Wheeler CM, Jaisamrarn U, Garland SM, Castellsagu? X, Skinner SR, Apter D, Naud P, Salmer?n J, Chow SN, Kitchener H, Teixeira JC, Hedrick J, Limson G, Szarewski A, Romanowski B, Aoki FY, Schwarz TF, Poppe WA, De Carvalho NS, Germar MJ, Peters K, Mindel A, De Sutter P, Bosch FX, David MP, Descamps D, Struyf F, Dubin G; HPV PATRICIA Study Group. Overall efficacy of HPV-16/18 AS04-adjuvanted vaccine against grade 3 or greater cervical intraepithelial neoplasia: 4- year end-of-study analysis of the randomised, double-blind PATRICIA trial. Lancet Oncol. 2012 Jan;13(1):89-99.
Szarewski A, Skinner SR, Garland SM, Romanowski B, Schwarz TF, Apter D, Chow SN, Paavonen J, Del Rosario-Raymundo MR, Teixeira JC, De Carvalho NS, Castro-Sanchez M, Castellsagu? X, Poppe WA, De Sutter P, Huh W, Chatterjee A, Tjalma WA, Ackerman RT, Martens M, Papp KA, Bajo-Arenas J, Harper DM, Torn? A, David MP, Struyf F, Lehtinen M, Dubin G. Efficacy of the HPV-16/18 AS04-adjuvanted vaccine against low-risk HPV types (PATRICIA randomized trial): an unexpected observation. J Infect Dis. 2013 Nov 1;208(9):1391-6.
Kreimer AR, Struyf F, Del Rosario Raymundo MR, Hildesheim A, Skinner SR, Wacholder S, Garland SM, Herrero R, David MP, Wheeler CM, Harper DM for the Costa Rica Vaccine Trial and the PATRICIA study groups. Efficacy of Fewer than Three Doses of a HPV-16/18 AS04 adjuvanted Vaccine: a Meta Analysis of Data from the Costa Rica Vaccine Trial and the PATRICIA Trial. Lancet Oncology. 2015. Lancet Oncol. 2015 Jun 9. pii: S1470-2045(15)00047 -9. doi: 10.1016/S1470-2045(15)00047-9
Competing interests: None declared
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Competing Interests: None declared.