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Most parents support school-entry HPV vaccination requirements if opt-outs exist

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August 19, 2016

A majority of parents supported laws that would make HPV vaccination mandatory for school entry if their state offered opt-out provisions, according to results of a national study.

Although including opt-out provisions nearly tripled parents’ acceptance of HPV vaccination requirements, such provisions might make vaccination laws less effective, according to the researchers.

William A. Calo

“HPV vaccination saves lives. We have an unprecedented opportunity to prevent thousands of HPV–associated cancers through vaccination and, unfortunately, we are missing that opportunity,” William A. Calo, PhD, JD, postdoctoral research associate in the department of health policy and management at University of North Carolina Gillings School of Global Public Health, said in a press release. “Any process for requesting an opt-out should have an education component and encourage parents to carefully consider their decision.”

The CDC recommends boys and girls receive three-dose HPV vaccination at age 11 or 12 years; however, only 40% of girls and 22% of boys aged 13 to 17 years had completed the vaccine series in 2014.

Previous research has shown that school-entry requirements increased uptake of hepatitis B, Tdap and MMR vaccines. Although half of U.S. state legislatures have introduced measures to add HPV to the required vaccination list since 2006, only Virginia, Rhode Island and the District of Columbia require the HPV vaccine for school entry with laws that provide opt-out provisions. Parental disapproval and ethical, political and legal concerns prevented the passage of measures in other states.

Because limited data exist regarding parents’ support of these laws, Calo and colleagues conducted a web-based survey of a national sample of 1,501 parents between November 2014 and January 2015. All of the parents had a child aged 11 to 17 years living in their home (median age, 14 years; 51% boys).

When asked about their attitudes regarding HPV vaccination, 23% of parents said they thought the HPV vaccine could cause lasting health problems, 32% thought vaccination was pushed by drug companies to make money, and 32% said they did not have enough information regarding HPV vaccination to make a decision whether their child should receive the vaccine. Forty percent of parents said they thought the vaccine effectively prevented cervical cancer and 51% said the HPV vaccine was as important or more important than Tdap vaccination.

Overall, 21% of parents stated laws requiring HPV vaccination for school entry were a “good idea,” whereas 54% disagreed. When opt-out provisions were included, acceptance of HPV vaccination requirements increased to 57%, and the disagreement rate decreased to 21%.

Noel Brewer

“It would be hard for law makers to enact a policy that has 21% support,” Noel Brewer, PhD, member of UNC Lineberger Comprehensive Cancer Center and associate professor in UNC Gillings School of Global Public Health, said in a press release. “School-entry requirements are highly acceptable to parents, but only when implemented in a way that makes them ineffective. Opt-outs lead to a large number of parents choosing not to vaccinate their children, and that makes requirements ineffective in raising vaccination rates.”

Acceptance of HPV vaccination laws without opt-out provisions was more common among parents who were Hispanic (OR = 1.53; 95% CI, 1.05-2.22), who believed HPV vaccination was as important or more important than other adolescent vaccines (OR = 2.76; 95% CI, 1.98-3.83), or who believed HPV vaccination was effective for preventing cervical cancer (OR = 2.55; 95% CI, 1.93-3.37).

Parents were less likely to support these laws if they believed HPV vaccines were being pushed by drug companies (OR = 0.47; 95% CI, 0.32-0.69) or if they lived in Midwest states compared with Northeast states (OR = 0.64; 95% CI, 0.42-0.98).

The researchers acknowledged they only asked about hypothetical school-entry requirements and did not describe the scope of opt-out provisions, which could have limited these findings.

“Given the many challenges to enacting HPV vaccine requirements, it’s unlikely that a large number of states will pass these laws in the near future,” Calo said. “Physicians and other health care providers are key to improving HPV vaccination uptake.” – by Alexandra Todak

Disclosure: The study was funded by the Mark Sharp & Dohme Investigator Studies Program. Brewer reports HPV vaccine–related grants from and paid advisory board roles with Merck Sharp & Dohme and Pfizer. Calo and the other researchers report no relevant financial disclosures.

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Carolyn Y. Fang

These findings suggest that, at present, there is limited parental support for school-entry requirements for HPV vaccination of students entering the sixth grade. It is unclear whether this is due to parental discomfort with mandating this requirement for this age group (children aged 11 to 12 years). It may be worth exploring whether a greater proportion of parents would be amenable to school-entry requirements for HPV vaccination for older students (eg, high school students, or for students aged 16 to 17 years if they have not been vaccinated yet).  Because Advisory Committee on Immunization Practices guidelines indicate that females can be vaccinated through 26 years (and males through 21 years), it is possible that parents desire to have control over the age at which to vaccinate their children. 

Approximately 25% of parents neither agreed nor disagreed with HPV vaccine school-entry requirements, and some had concerns about vaccine safety. Thus, it may be helpful to focus on public health efforts to address parents’ informational needs and to alleviate their concerns about the vaccine.

Carolyn Y. Fang. PhD

Fox Chase Cancer Center

Disclosure: Fang reports no relevant financial disclosures.