The ‘Crisis’ of Low HPV Vaccination Rates: A Conversation with Dr. Noel Brewer

February 2, 2016, by NCI Staff

Last week, all 69 NCI-Designated Cancer Centers released a consensus statement on human papillomavirus (HPV) vaccination in the United States. The statement describes the continued low rates of HPV vaccination as “a serious public health threat,” recommends that parents have their children vaccinated, and urges clinicians “to be advocates for cancer prevention by making strong recommendations for childhood HPV vaccination.”

In this interview, Noel Brewer, Ph.D., of the University of North Carolina Lineberger Comprehensive Cancer Center and chair of the National HPV Vaccination Roundtable, discusses the issue and some of the key actions that can help to improve HPV vaccination rates.

You've called the poor uptake of the HPV vaccine a crisis. Why?

That’s definitely a strong way to describe the problem. But we’ve been so successful with other adolescent vaccines, Tdap and meningitis, and yet we’ve failed to get high levels of coverage for HPV vaccination. There will be a clear cost in terms of deaths from cervical and other cancers that we could prevent.

In my view, it should be simple to solve this problem and save lives from cervical and other cancers, and yet we’re not doing it. So I think calling it a “crisis” is fair.

What do you see as the primary reasons for low HPV vaccination rates?

It’s straightforward: Health care providers recommend the vaccine late, half heartedly, or not at all. Those are the problems.

Although parent concerns and other factors can play a role, providers have been the main sticking point. Even if parents have concerns, they look to physicians and other health care professionals for advice and guidance, and parents often take that advice.

Why have clinicians been reluctant to recommend the HPV vaccine?

One of the big issues is that clinicians don’t want to talk about sex. They expect an uncomfortable conversation. And, because they’re very busy, they worry that these conversations will take a long time.

There are efficient ways for primary care providers to make recommendations for HPV vaccination that take almost no time at all. A widely accepted approach is to let the parent know during the visit that their child is due for three vaccines, putting HPV in the middle of the list, and then say the child will get the vaccines at the end of the visit. 

These types of announcements are used routinely in clinical care for children, adolescents, and adults, so clinicians are used to delivering them. If parents raise concerns, such as about safety or timing, the provider can address them.

What if a parent does express concerns?

A promising practice that we’ve seen is to acknowledge the parent’s main concern and then address it directly, but always finish with a strong recommendation for HPV vaccination at that visit.

An important message is that HPV vaccination is key to cancer prevention because it also protects against other cancers. I think it’s the right message because it applies to both boys and girls.

Are there any notable disparities in vaccine uptake?

There’s actually evidence of what you might call “reverse disparities,” with Hispanics and African Americans more likely than other population groups to get the first dose. And that’s true for boys and girls. Among those who do initiate the vaccine series, however, national data show few or no racial and ethnic disparities in vaccination completion—that is, getting all three doses.

What is far more important are the large geographic disparities, with some states having half the rates of HPV vaccine completion of other states. This is one of my biggest concerns, because as Jennifer Moss, Paul Reiter, and I recently showed, states with low HPV vaccination rates tend to have high rates of cervical cancer.

For example, Mississippi has among the lowest HPV vaccine initiation rates among adolescent girls, and it has the highest rate of cervical cancer death in the nation.

In your opinion, what are the biggest priorities for improving vaccination rates?

The first priority is to support physicians in recommending vaccination to every adolescent aged 11 to 12. We can do that by giving health care providers better communication tools and helping them implement quality improvement measures. 

For example, the Centers for Disease Control and Prevention funds state health departments to visit vaccine providers every few years and show them their vaccination rates. Seeing these rates can be a surprise for many provider and can help them prioritize improvements in vaccination. 

We also need to establish alternative settings for vaccination, including pharmacies and schools. Outside of the U.S., school-located vaccination programs have been very effective. In parts of Canada, Australia, and the U.K., schools with HPV vaccination programs have achieved 90 percent completion rates within the first year. In the U.S., we may want to focus on pharmacies because they have better systems for storage and billing.

There is emerging evidence that two doses of the HPV vaccine, or perhaps even one, may be sufficient. What kind of impact could that have?

A two-dose schedule will help busy providers and parents get HPV vaccine for adolescents. It’s also important that the money we save on that third dose can go toward reaching the many communities that do not have adequate vaccination services.

What do you hope the consensus statement from the NCI-Designated Cancer Centers will accomplish? Will it simply raise awareness, or can it do more?

The consensus statement is important because it reminds parents and policymakers that the HPV vaccine is for cancer prevention.

It’s also very important that we keep reminding the public of the many good things about HPV vaccination, because there is a lot of misinformation about the vaccine, particularly on social media. It’s our job to shed light and truth in these dark corners of the Internet.