Provider messaging, lack of school requirements limit discussion of HPV vaccine

Kenneth Alexander
Kenneth A. Alexander

Editor’s note: In this three-part series, Kenneth A. Alexander, MD, PhD, Chief of the Division of Infectious Diseases in the Department of Pediatrics at Nemours Children's Hospital in Orlando, Florida, reviews issues surrounding uptake of the HPV vaccine. Part one of the series reviews how pediatricians frame the discussion of HPV vaccination with patients and their families and the lack of state requirements on HPV vaccination.

Increasingly, we are learning that the barriers to HPV vaccination are not what people and physicians believe them to be. Many of us, as physicians, believe that parents are concerned about safety; we think they’re concerned about a child’s sexual behavior and that somehow, if we immunize kids against HPV, they’re going to feel as though they have been granted permission to have sex. However, as it turns out, data from our colleagues at Harvard and at the University of North Carolina have shown that many doctors aren’t recommending HPV vaccination at all. In other cases, doctors are providing weak and ineffective recommendations. Thus, just as the old Walt Kelly cartoon character Pogo said, “We have met the enemy, and he is us.”

Talking about HPV vaccination “the wrong way”

In a national sample of pediatricians and family medicine physicians, Gilkey et al. found that approximately a third of individuals who supported immunization (immunizers) did not endorse HPV immunization or failed to deliver timely recommendations on its use. Another study by Gilkey and colleagues demonstrated that physicians, when they did discuss HPV immunization with families, presented adolescent vaccination against this virus as a low priority.

What we have learned from these studies is that physicians often say there are three vaccines recommended for adolescents. First, physicians will talk about Tdap, and then they discuss the meningococcal conjugate vaccine; after that, they introduce the idea of HPV vaccination. My concern with mentioning the HPV vaccine last is that it demonstrates, in effect, that doctors place a low value on HPV immunization.

Similarly, we’ve seen that it’s not unusual for a doctor to say, “It’s time for Ella’s Tdap and meningococcal vaccines, and then there’s this other vaccine, HPV,” during an adolescent visit. After that statement, the physician launches into a complex, protracted discussion about HPV epidemiology and vaccination. This extended discussion about the HPV vaccine may give parents the message that the HPV vaccine is, in some way, different from other vaccines. This undue (and likely unintentional) attention can lead parents to wonder if there is something unusual or risky about HPV immunization.

Given the data about how frequently physicians fail to recommend HPV vaccination effectively, the first step in increasing vaccination rates is to recognize that we’re not recommending HPV vaccination as often as we should. Much like the adage “You don’t get what you don’t ask for,” the vaccine that is not recommended is not given. The second step is to teach health care providers who immunize children to say less. When providers do talk about HPV vaccination, the research suggests that they often say too much and very often the wrong thing. Perhaps the best thing to say is as little as possible. Brewer and colleagues demonstrated the power of announcements, where providers announce that it’s time for an immunization, rather than offering an educational diatribe or having a discussion. Third, we must recognize that we, as pediatricians, often spout too many facts. Many families we serve don’t understand concepts like risk and effectiveness. For most of them, making a case for immunization by reciting technical data is like giving a nail to a man who has no hammer; it doesn’t work because parents don’t know what to do with the facts. As a result, rather than saying “Let’s talk about HPV vaccination” to parents, perhaps the best thing to say is ‘It’s time for your child’s HPV vaccine’ and make that the extent of the discussion.

If you must discuss the issue more after you’ve made your recommendation, talk to the heart and not to the head. Paul Offit once reminded me that immunization is, first and foremost, a gesture of love. We vaccinate our kids because we love them. Providers should help parents understand that HPV vaccination prevents cancer. Don’t fret over the fact that HPV is a sexually transmitted disease; this only confuses people and is marginal to the real issue of life-long cancer prevention.

Does no requirement equal not important?

School requirements for Tdap and meningococcal vaccines may also contribute to the lack of prioritization of HPV vaccination. In all 50 states, we require Tdap immunization among children aged 11 to 12 years for continued matriculation in public school. Similarly, in more than 35 states, we have meningococcal vaccine requirements. No states require HPV vaccination. To add to the confusion surrounding HPV vaccination, parents often say, “Give my child whatever vaccines are required,” equating what’s required with what’s important. Here’s the break in that logic. We require vaccines for school attendance, to prevent infections that children might acquire in school. I certainly don’t want to diminish the importance of protecting children against pertussis or meningococcal disease, but in the United States, an estimated 25 children a year, mostly babies, die of pertussis, and approximately 100 to 120 kids a year die of meningococcal disease. We added requirements in all 50 states for adolescent pertussis vaccination and in more than 35 states for meningococcal vaccination, all to prevent about 125 to 150 deaths. These requirements are good; I wholeheartedly support school requirements for Tdap and meningococcal conjugate, or MCV4.

Still, we must recognize that, in the U.S., we have more than 4,000 women dying each year of cervical cancer. We have another 1,000 to 2,000 women dying each year of vaginal and vulvar cancer and another 1,000 men and women dying of anal cancer. If we include people dying of head and neck cancer, we’ve easily accounted for 10,000 to 12,000 people dying each year of preventable, HPV-associated malignancies. However, despite these deaths, our HPV immunization rate of males and females in the U.S. is approximately 40%.

The tragedy happens when we imply to parents that Tdap and meningococcal vaccines are more important than HPV. In doing so, we turn our backs on one vaccine that could save as many as 10,000 lives annually in favor of two vaccines that together save 125 to 150 lives. I’m not recommending that we stop Tdap and MCV4 immunization in favor of HPV vaccination; I’m insisting that, if we want to save the maximal number of lives, we must deliver all three immunizations. We need to look beyond “what’s required” and do what’s right.

To be clear, I’m not advocating for a school requirement for HPV vaccination. That’s a different discussion. What I am advocating is that we make our HPV vaccination recommendations every bit as strident as school requirements make our Tdap and MCV4 recommendations.

References:

Brewer NT, et al. Pediatrics. 2017;doi:10.1542/peds.2016-1764.

Gilkey MB, et al. Cancer Epidemiol Biomarkers Prev. 2015;doi: 10.1158/1055-9965.EPI-15-0326.

Gilkey MB, et al. Prev Med. 2015;doi:10.1016/j.ypmed.2015.05.024.

Disclosure: Alexander reports serving as a consultant and as a speaker for Merck and for MSD, the manufacturer of the 9-valent HPV vaccine.

Kenneth Alexander
Kenneth A. Alexander

Editor’s note: In this three-part series, Kenneth A. Alexander, MD, PhD, Chief of the Division of Infectious Diseases in the Department of Pediatrics at Nemours Children's Hospital in Orlando, Florida, reviews issues surrounding uptake of the HPV vaccine. Part one of the series reviews how pediatricians frame the discussion of HPV vaccination with patients and their families and the lack of state requirements on HPV vaccination.

Increasingly, we are learning that the barriers to HPV vaccination are not what people and physicians believe them to be. Many of us, as physicians, believe that parents are concerned about safety; we think they’re concerned about a child’s sexual behavior and that somehow, if we immunize kids against HPV, they’re going to feel as though they have been granted permission to have sex. However, as it turns out, data from our colleagues at Harvard and at the University of North Carolina have shown that many doctors aren’t recommending HPV vaccination at all. In other cases, doctors are providing weak and ineffective recommendations. Thus, just as the old Walt Kelly cartoon character Pogo said, “We have met the enemy, and he is us.”

Talking about HPV vaccination “the wrong way”

In a national sample of pediatricians and family medicine physicians, Gilkey et al. found that approximately a third of individuals who supported immunization (immunizers) did not endorse HPV immunization or failed to deliver timely recommendations on its use. Another study by Gilkey and colleagues demonstrated that physicians, when they did discuss HPV immunization with families, presented adolescent vaccination against this virus as a low priority.

What we have learned from these studies is that physicians often say there are three vaccines recommended for adolescents. First, physicians will talk about Tdap, and then they discuss the meningococcal conjugate vaccine; after that, they introduce the idea of HPV vaccination. My concern with mentioning the HPV vaccine last is that it demonstrates, in effect, that doctors place a low value on HPV immunization.

Similarly, we’ve seen that it’s not unusual for a doctor to say, “It’s time for Ella’s Tdap and meningococcal vaccines, and then there’s this other vaccine, HPV,” during an adolescent visit. After that statement, the physician launches into a complex, protracted discussion about HPV epidemiology and vaccination. This extended discussion about the HPV vaccine may give parents the message that the HPV vaccine is, in some way, different from other vaccines. This undue (and likely unintentional) attention can lead parents to wonder if there is something unusual or risky about HPV immunization.

PAGE BREAK

Given the data about how frequently physicians fail to recommend HPV vaccination effectively, the first step in increasing vaccination rates is to recognize that we’re not recommending HPV vaccination as often as we should. Much like the adage “You don’t get what you don’t ask for,” the vaccine that is not recommended is not given. The second step is to teach health care providers who immunize children to say less. When providers do talk about HPV vaccination, the research suggests that they often say too much and very often the wrong thing. Perhaps the best thing to say is as little as possible. Brewer and colleagues demonstrated the power of announcements, where providers announce that it’s time for an immunization, rather than offering an educational diatribe or having a discussion. Third, we must recognize that we, as pediatricians, often spout too many facts. Many families we serve don’t understand concepts like risk and effectiveness. For most of them, making a case for immunization by reciting technical data is like giving a nail to a man who has no hammer; it doesn’t work because parents don’t know what to do with the facts. As a result, rather than saying “Let’s talk about HPV vaccination” to parents, perhaps the best thing to say is ‘It’s time for your child’s HPV vaccine’ and make that the extent of the discussion.

If you must discuss the issue more after you’ve made your recommendation, talk to the heart and not to the head. Paul Offit once reminded me that immunization is, first and foremost, a gesture of love. We vaccinate our kids because we love them. Providers should help parents understand that HPV vaccination prevents cancer. Don’t fret over the fact that HPV is a sexually transmitted disease; this only confuses people and is marginal to the real issue of life-long cancer prevention.

Does no requirement equal not important?

School requirements for Tdap and meningococcal vaccines may also contribute to the lack of prioritization of HPV vaccination. In all 50 states, we require Tdap immunization among children aged 11 to 12 years for continued matriculation in public school. Similarly, in more than 35 states, we have meningococcal vaccine requirements. No states require HPV vaccination. To add to the confusion surrounding HPV vaccination, parents often say, “Give my child whatever vaccines are required,” equating what’s required with what’s important. Here’s the break in that logic. We require vaccines for school attendance, to prevent infections that children might acquire in school. I certainly don’t want to diminish the importance of protecting children against pertussis or meningococcal disease, but in the United States, an estimated 25 children a year, mostly babies, die of pertussis, and approximately 100 to 120 kids a year die of meningococcal disease. We added requirements in all 50 states for adolescent pertussis vaccination and in more than 35 states for meningococcal vaccination, all to prevent about 125 to 150 deaths. These requirements are good; I wholeheartedly support school requirements for Tdap and meningococcal conjugate, or MCV4.

PAGE BREAK

Still, we must recognize that, in the U.S., we have more than 4,000 women dying each year of cervical cancer. We have another 1,000 to 2,000 women dying each year of vaginal and vulvar cancer and another 1,000 men and women dying of anal cancer. If we include people dying of head and neck cancer, we’ve easily accounted for 10,000 to 12,000 people dying each year of preventable, HPV-associated malignancies. However, despite these deaths, our HPV immunization rate of males and females in the U.S. is approximately 40%.

The tragedy happens when we imply to parents that Tdap and meningococcal vaccines are more important than HPV. In doing so, we turn our backs on one vaccine that could save as many as 10,000 lives annually in favor of two vaccines that together save 125 to 150 lives. I’m not recommending that we stop Tdap and MCV4 immunization in favor of HPV vaccination; I’m insisting that, if we want to save the maximal number of lives, we must deliver all three immunizations. We need to look beyond “what’s required” and do what’s right.

To be clear, I’m not advocating for a school requirement for HPV vaccination. That’s a different discussion. What I am advocating is that we make our HPV vaccination recommendations every bit as strident as school requirements make our Tdap and MCV4 recommendations.

References:

Brewer NT, et al. Pediatrics. 2017;doi:10.1542/peds.2016-1764.

Gilkey MB, et al. Cancer Epidemiol Biomarkers Prev. 2015;doi: 10.1158/1055-9965.EPI-15-0326.

Gilkey MB, et al. Prev Med. 2015;doi:10.1016/j.ypmed.2015.05.024.

Disclosure: Alexander reports serving as a consultant and as a speaker for Merck and for MSD, the manufacturer of the 9-valent HPV vaccine.