HPV Vaccine Access and Use in the US

Running head: HPV VACCINE: ACCESS AND USE IN THE US 1
HPV Vaccine: Access and Use in the US
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HPV VACCINE: ACCESS AND USE IN THE US 2
HPV Vaccine: Access and Use in the US
Abstract
Human papillomavirus (HPV) vaccines offer great potential to prevent oropharyngal, vaginal,
penile, anal, and cervical cancers and are currently the primary and only immunogens that
protect both men and women against the various forms of cancer that are related to the HPV
strains. In America, the CDC recommends the vaccination of pre-teen girls and boys aged
between eleven and twelve years not only to make certain that they are protected prior to being
exposed to HPVs, but also because HPV vaccines tend to produce better immune responses in
minors of this age compared to older adolescents. The Department of Health and Human
Services, through the Healthy People 2020 program, has set a goal for full-course completion of
HPV vaccination by 80 percent of boys and girls aged between thirteen and fifteen years.
However, notwithstanding the availability of HPV vaccines, vaccination rates in America remain
low relative to other recommended vaccines and in comparison the projected HPV vaccination
rates. This paper examines the state of access to and utilization of HPV vaccination in the US.
Key words: HPV, vaccination, access, use, United States
HPV VACCINE: ACCESS AND USE IN THE US 3
Introduction
The development of HPV (human papilloma virus) vaccines is regarded as one of the
greatest public health accomplishments of the 21st century because it offers great potential to
prevent oropharyngal, vaginal, penile, anal, and cervical cancers. The US FDA (Federal Food
and Drug Administration) approved the first HPV vaccine in 2006, with the latest nonavalent
vaccine that is, vaccine that function through the stimulation of the body’s immune response
against antigens being approved in 2015 (Keim-Malpass et al., 2017). HPV vaccines are
currently the primary and only immunogens that protect both men and women against the
various forms of cancer that are related to the HPV strains. Since being introduced in the United
States in 2006, many changes have occurred with regard to the dosing regimen and the range of
protection that HPV vaccines provide.
Many states introduced laws that, if implemented, would have included the vaccine
among those required for attending school. In 2007, the Governor of Texas issued an executive
order mandating HPV vaccine for 6th grade girls, even though the Texas legislature later
overturned the order. Currently, three jurisdictions namely Virginia, Rhode Island, and District
of Columbia have made HPV vaccination mandatory for school attendance. It is not difficult to
see the significance of this policy to the nursing profession since nurses play an important role in
promoting the health and wellbeing of the population. This paper presents an overview of the
HPV vaccination policy at the state level, and discusses the interventions that the policy
proposes, as well as how it will help in promoting health by preventing cases of HPV-caused
cancer.
An Overview of the Policy
HPV VACCINE: ACCESS AND USE IN THE US 4
At the state level, the debate as to whether to require boys and girls to be vaccinated
against HPV, which is often linked to almost all genital warts and cervical cancer cases,
continues to rage. This state-level activity springs from 2006 ACIP (Advisory Committee on
Immunization Practices) recommendation that regular vaccination is advised for girls and boys
aged between eleven and twelve years. Even with the ACIP recommendations, state legislatures
still decide school vaccination requirements. It is worth noting that certain states, such as Rhode
Island, have granted power to regulatory bodies the power to mandate vaccines, although the
legislature is still required to provide the requisite funding. Currently, District of Columbia,
Virginia, and Rhode Island require HPV vaccines as a prerequisite for school attendance. The
Rhode Island Department of Health declared in 2015 that HPV vaccination would be mandatory
for seventh graders beginning September 2015. The department has the capacity to enforce this
without the need for legislative action.
Interventions Proposed by the Policy
It is mandatory for seventh grade students in Rhode Island to receive HPV vaccine. HPVs
refer to a class of related viruses that number more than 200, out of which more than forty are
transmittable through sexual contact. These viruses usually move from the mucus membrane and
skin of the infected individual to the mucus membrane and skin of the sexual partner, often
spread through oral, anal, or vaginal sex. Other types of HPV are known to cause non-genital
warts, although these cannot be transmitted through sexual contact. It is worth noting that
sexually transmitted HPVs can be broadly categorized into low- and high-risk HPVs. Low-risk
HPVs are not known to cause cancer, although they can result in skin warts on or in the region of
the anus and genitals. For instance, two strains of HPV, namely strains 6 and 11, are responsible
to 90 percent of all genital warts cases (Newton, 2011).
HPV VACCINE: ACCESS AND USE IN THE US 5
Rhode Island requires both girls and boys entering the seventh grade to have received
HPV vaccine. The only other states that has mandates such vaccination to block strains of HPV
that are known to cause certain types of cancer later in life is Virginia. High-risk HPVs have
been established as being among the major causes of cancer. For example, two strains of high-
risk HPVs, namely strains 16 and 18, are responsible for nearly seventy percent of cervical
cancer cases, and indeed for most cancers caused by human papillomaviruses. Zenilman and
Shahmanesh (2012) and Sweet and Gibbs (2015) observe that HPVs are the most prevalent STIs
(sexually transmitted infections) in the US, with an estimated 6.2 million human papillomavirus
infections every year. In fact, according to the CDC (Centers for Disease Control and
Prevention), in excess of eighty and ninety percent of women and men respectively (who are
sexually active) will contract no less than one kind of HPV during their lifetime (Chesson et al.,
2014). It has also been established that nearly 50 percent of these infections involve high-risk
HPVs (Hariri et al., 2011).
HPV Vaccines in the US
As already noted, HPV vaccines protect both men and women against infection by HPV
types. These vaccines are typically available for protection against up to nine HPV types, with all
vaccines protecting against at least types 16 and 18, which are responsible for causing cervical
cancer. Research suggests that HPV vaccines may prevent vulvar, vaginal, anal, cervical, and
possibly mouth cancers (De Vuyst et al., 2009). Takes et al. (2015) found prophylactic
vaccination to be effectual in preventing anogenital HPV infections, as well as precursor anal
and cervical lesions. HPV vaccines also prevent certain forms of genital warts, with HPV 4 and
HPV 9 vaccines providing better protection. As per the World Health Organization (WHO)
recommendations, HPV vaccination ought to be included (together with preventive measures) as
HPV VACCINE: ACCESS AND USE IN THE US 6
part of every country’s routine vaccination programs. As a rule, the vaccination of girls aged
between nine and thirteen years is encouraged. These vaccines protect vaccinated persons for at
least five to ten years and are usually administered as three shots over a period of six months.
In the United States, the CDC recommends the vaccination of pre-teen girls and boys
aged between eleven and twelve years not only to ensure that they are protected prior to being
exposed to HPVs, but also because HPV vaccines tend to produce better immune responses in
this group compared to older adolescents (CDC, 2017). For girls and women, HPV vaccines
protect not only against genital warts, but also from cancers of the anus, moth, vulva, and vagina
while for boys and men, the vaccines protect against genital warts, as well as cancers of the
throat/mouth, penis, and anus. Two HPV vaccines became available following FDA approval in
2006, all of which are already licensed in the US. These include Gardasil and Cervarix. The
former protects against four HPV types, which include HPV 6, HPV 11, HPV 16, and HPV 18. It
was initially approved for females aged between nine and twenty-six years. In 2010, this
approval was extended to males of the same age, as well. The latter vaccine, which was approved
in 2010, protects against HPVs 16 and 18 and is used exclusively in females aged between nine
and twenty-five years. In other words, while both vaccines can be used in females, only Gardasil
can be used in males. Many studies have found these vaccines to be effectual against the targeted
HPV types, in addition to providing a modest degree of cross-protection against other types of
non-targeted HPV strains.
Advocating for the Health Policy as a Professional Nurse
Despite the availability of HPV vaccines, vaccination rates in the United States remain
low relative to other recommended vaccines and in comparison the projected HPV vaccination
rates. It is also worth noting that while the US was among the early adopters of HPV vaccine,
HPV VACCINE: ACCESS AND USE IN THE US 7
coverage remains low in comparison to other industrialized nations, such as the United Kingdom
and Australia. The latest available data from the CDC indicates full-course coverage for boys to
be 22 percent in 2014 compared to 13 percent in 2013 while for girls; it was 40 percent in 2014,
which was only a marginal increase from 38 percent in 2013 (CDC, 2017). These figures
indicate a slower rate of coverage than projected. The Department of Health and Human
Services, through the Healthy People 2020 program, has set a goal for full-course completion of
HPV vaccination by 80 percent of boys and girls aged between thirteen and fifteen years (The
President’s Cancer Panel, 2014).
Barriers to the Uptake of HPV Vaccination
Several studies have been carried out on vaccine acceptance trends in the US, including
the trends in HPV vaccination, as well as the possible causes for the comparatively low uptake.
Some authors have reported that parents are more likely to reject HPV vaccine or ask for
alternative schedule (Carney, 2016). Other studies have also found widespread
misunderstandings and negative attitudes by parents towards the HPV vaccine, particularly when
it comes to the vaccination of boys (Ferrer et al., 2014; Holman et al., 2014). The low
vaccination completion rates have also been attributed to a lack of discussion with or
recommendation from primary care providers, although timidity to talk about vaccination is also
common among pediatricians. Overall, literature on vaccination completion among female and
male adolescents identifies several barriers faced by parents, care providers, and underserved
groups that affect the access and use of HPV vaccines.
The main themes in the literature are that parents frequently vaccinate their children out
of the direct recommendation of physicians, that the cost of vaccination and parental concerns
make the provision of HPV vaccine difficult, and that some healthcare providers and parents did
HPV VACCINE: ACCESS AND USE IN THE US 8
not deem it necessary to vaccinate boys (Ferrer et al., 2014). Another prominent theme is that
parents who start their children on HPV vaccine often forget or do not know that the children
should receive a series of three vaccination doses. Aside from these factors, misinformation and
hearsay about HPV vaccine perpetuated through online platforms, particularly on social media,
have also contributed to the low uptake of the vaccine. Nevertheless, it should be noted that
concerns about HPV vaccination abound in medical literature, as well. Some of the safety signals
include responses resembling autoimmune reactions, chronic fatigue syndrome, POTS (postural
orthostatic tachycardia syndrome), and CRPS (complex regional pain syndrome) (Chandler et al.,
2017). Some of the safety concerns could account for the timidity among pediatricians to talk
about vaccination and the decision by some physicians not to recommend HPV vaccination.
Advocating for HPV Vaccination Policy
While most vaccine-preventable diseases have become extinct in the US, nurses have a
duty to increase the population’s understanding that herd immunity might not be sufficient to
protect unimmunized children. Nurses can advocate for the HPV vaccination policy by paying
attention to and addressing the concerns of parents regarding immunization. In this manner, they
can dissipate any misconceptions and change the perception of parents regarding the risks
associated with HPV vaccination. The primary guiding principal for nurses is that of caring,
which can be demonstrated in a variety of ways, with the most notable being patient advocacy. It
is uncontested that nurses operate on a wellness approach, which seeks to promote health by
preventing diseases. Vaccination is among the safest and most effectual ways of promoting
health. Nurses can play an important role in promoting vaccination by stopping biased reporting
and using every available opportunity to respond to any misinformation and propaganda with
evidence-based science supporting safe and effectual vaccines.
HPV VACCINE: ACCESS AND USE IN THE US 9
Conclusion
HPVs infect an estimated fourteen million people in the United States every year. These
viruses can cause different types of cancer, including vaginal, vulvar, and cervical in females and
cancer of the penis in men. In addition to causing cancers of the anus and throat in men and
women, HPVs is also a recognized cause of genital warts. Therefore, HPV vaccines protect both
men and women against infection by various HPV types. Despite the availability of HPV
vaccines, vaccination rates in the United States remain low. Widespread misunderstandings and
negative attitudes by parents towards the HPV vaccine, particularly when it comes to the
vaccination of boys, are some of the factors that have led to the low uptake. Others are a lack of
discussion with or recommendation from primary care providers, the cost of vaccination and
parental concerns, and misinformation and hearsay about HPV vaccine perpetuated through
social media platforms. Taken together, these factors explain the low vaccination rates currently
being experienced in the US with regard to HPVs.
HPV VACCINE: ACCESS AND USE IN THE US 10
References
Carney, J. K. (2016). Controversies in public health and health policy. Burlington, MA: Jones &
Bartlett Learning.
CDC. (2017). HPV vaccine for preteens and teens. Retrieved 12 November 2017 from
https://www.cdc.gov/vaccines/parents/diseases/teen/hpv.html
Chandler, R. E., Juhlin, K., Fransson, J., Caster, O., Edwards, I. R., & Norn, G. N. (2017).
Current safety concerns with human papillomavirus vaccine: A cluster analysis of reports
in VigiBase®. Drug Safety, 40(1), 81-90.
Chesson, H. W., Dunne, E. F., Hariri, S., & Markowitz, L. E. (2014). The estimated lifetime
probability of acquiring human papillomavirus in the United States. Sexually Transmitted
Diseases, 41(11), 660-664.
De Vuyst, H., Clifford, G. M., Nascimento, M. C., Madeleine, M. M., & Franceschi, S. (2009).
Prevalence and type distribution of human papillomavirus in carcinoma and
intraepithelial neoplasia of the vulva, vagina and anus: A meta-analysis. International
Journal of Cancer, 124(7), 1626-1636.
Ferrer, H. B., Hickman, M., Audrey, S., & Trotter, C. (2014). Barriers and facilitators to HPV
vaccination of young women in high-income countries: A qualitative systematic review
and evidence synthesis. Bmc Public Health, 14(1), 1-22.
Hariri, S., Unger, E. R., Sternberg, M., Dunne, E. F., Swan, D., Patel, S., & Markowitz, L. E.
(2011). Prevalence of Genital Human Papillomavirus Among Females in the United
States, the National Health and Nutrition Examination Survey, 2003-2006. Journal of
Infectious Diseases, 204(4), 566-573.
HPV VACCINE: ACCESS AND USE IN THE US 11
Holman, D. M., Benard, V., Roland, K. B., Watson, M., Liddon, N., & Stokley, S. (2014).
Barriers to human papillomavirus vaccination among us adolescents: A systematic review
of the literature. Jama Pediatrics, 168(1), 76-82.
Keim-Malpass, J., Mitchell, E. M., DeGuzman, P. B., Stoler, M. H., & Kennedy, C. (2017).
Legislative activity related to the human papillomavirus (HPV) vaccine in the United
States (2006-2015): A need for evidence-based policy. Risk Management and Healthcare
Policy, 10, 29-32.
Newton, D. E. (2011). Sexual health: A reference handbook. Santa Barbara, CA: ABC-CLIO.
Sweet, R. L., & Gibbs, R. S. (2015). Infectious Diseases of the Female Genital Tract.
Philadelphia, PA: Wolters Kluwer.
Takes, R. P., Wierzbicka, M., D’Souza, G., Jackowska, J., Silver, C. E., Rodrigo, J. P., Dikkers,
F. G., ... Ferlito, A. (2015). HPV vaccination to prevent oropharyngeal carcinoma: What
can be learned from anogenital vaccination programs?. Oral Oncology, 51(12), 1057-
1060. Page 1057
The President’s Cancer Panel. (2014). Accelerating HPV vaccine uptake: Urgency for action to
prevent cancer. Retrieved 12 November 2017 from
https://deainfo.nci.nih.gov/advisory/pcp/annualreports/HPV/Part1.htm
Zenilman, J. M., & Shahmanesh, M. (2012). Sexually transmitted infections: Diagnosis,
management, and treatment. Sudbury, MA: Jones & Bartlett Learning.

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