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., & Norn, 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-

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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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