Human Papillomavirus Vaccination Practices
Abstract & Commentary
By Hal B. Jenson, MD, FAAP, Professor of Pediatrics, Tufts University School of Medicine, and Chief, Academic Officer, Baystate Medical Center, Springfield, MA, is Associate Editor for Infectious Disease Alert.
Dr. Jenson reports no financial relationships relevant to this field of study.
Synopsis: A survey of physicians showed that the vast majority of pediatricians and family physicians offer human papillomavirus vaccine, though frequently at a later age than recommended. Physicians reported financial and other obstacles to HPV vaccination.
Source: Daley MF, et al. Human papillomavirus vaccination practices: A survey of US physicians 18 months after licensure. Pediatrics. 2010;126:425-433.
A nationwide survey conducted in March 2008 of 429 pediatricians and 419 family physicians in the United States with response rates of 81% and 79%, respectively, showed that 98% of pediatricians and 80% of family physicians were administering HPV vaccine in their offices. Fewer physicians strongly recommended HPV vaccine for 11- to 12-year-old female patients than for older female patients (pediatricians: 57% for 11- to 12-year-old patients and 90% for 13- to 15-year-old patients; p < 0.001; family physicians: 50% and 86%, respectively; p < 0.001).
The survey assessed physician attitudes regarding adolescent health care and HPV vaccination. For the statement, "It is hard to establish continuity of care with female adolescent patients," 5% of pediatricians strongly agreed and 38% somewhat agreed; corresponding proportions for family physicians were 9% and 42%, respectively. For the statement, "Female adolescents are coming in for preventive health visits to receive HPV vaccine," 15% of pediatricians strongly agreed and 53% somewhat agreed; corresponding proportions for family physicians were 11% and 40%, respectively. The vast majority of respondents (84% of pediatricians and 89% of family physicians) reported feeling comfortable discussing sexuality with female adolescent patients, with 42% of pediatricians and 54% of family physicians considering it necessary to discuss sexuality before recommending HPV vaccine. Few physicians thought that vaccination against a sexually transmitted infection would encourage earlier and riskier sexual behavior among recipients, although almost one-half of physicians reported that parents had this concern.
Gaps in physician knowledge were identified, with only 43% of pediatricians and 58% of family physicians correctly identifying that different HPV types cause genital warts and cervical cancer. Only 69% of family physicians knew that a pregnancy test was not required before administering HPV vaccination.
The most frequent barriers to HPV vaccine included patient cost and lack of insurance coverage ("Definitely a Barrier" by 26% of pediatricians and 36% of family physicians; "Somewhat a Barrier" by 21% of pediatricians and 28% of family physicians). Other factors reducing HPV vaccination rates included having requisite discussions of sexuality before recommending HPV vaccine (adjusted risk ratio: 1.27 [95% CI: 1.07-1.51]), parents of younger vs. older adolescents (adjusted risk ratio: 2.09 [95% CI: 1.66-2.81]), and the time it takes to discuss HPV vaccination with parents (adjusted risk ratio: 1.30 [95% CI: 1.04-1.58]). Parent acceptance was important, with 18% of pediatricians and 29% of family physicians reporting that at least one-fourth of parents of 11- to 12-year-old patients refused HPV vaccine, and 45% of pediatricians and 49% of family physicians reporting that at least one-fourth of parents of this age group deferred HPV vaccine.
Commentary
This survey was conducted 21 months after licensure of the quadrivalent HPV vaccine (types 6, 11, 16, and 18) in the United States in June 2006 for female patients 9 to 26 years of age. A bivalent (types 16 and 18) HPV vaccine was licensed in October 2009. HPV vaccination is recommended currently for all 11- to 12-year-old females, with catch-up vaccination recommended for unimmunized 13- to 26-year-old females. In May 2010, the Advisory Committee on Immunization Practices issued guidance that the three-dose series of quadrivalent HPV vaccine "may be given" to males aged 9 through 26 years to reduce their likelihood of acquiring genital warts, though this indication is generally not currently covered by insurance.
This survey indicates that almost all pediatricians and most family physicians in the United States are strongly recommending the vaccine for their adolescent patients, especially older adolescents. Despite the encouraging finding of widespread recommendation by primary care providers of HPV vaccination, there remain opportunities for improvement in physician knowledge about HPV, and in patient and parent acceptance of HPV vaccination. Infectious disease specialists should identify, and help create, opportunities to provide continuing education about HPV infection and vaccination to primary care providers.
In addition, primary care providers need to develop processes to provide education about HPV vaccination earlier to patients and especially parents to increase the acceptance of the vaccine at 11-12 years of age rather than deferring vaccination to older adolescence. In the United States, the median age of first sexual intercourse is 17 years, with 13% of girls initiating sexual activity before 15 years of age and 4% before 13 years of age. Delaying HPV vaccination after the recommended 11-12 years of age adversely and unnecessarily reduces the potential impact to decrease the lifelong risk for oncogenic HPV infection and cervical cancer. Approximately half of physicians consider discussion of sexuality necessary before recommending HPV vaccine. It is important for us to develop systems to provide parental education and ensure these discussions, at least with the child's parents, well before the child's 11th birthday in order to facilitate greater acceptance of HPV vaccination at the recommended age.
A nationwide survey conducted in March 2008 of 429 pediatricians and 419 family physicians in the United States with response rates of 81% and 79%, respectively, showed that 98% of pediatricians and 80% of family physicians were administering HPV vaccine in their offices.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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