What is your practice for HPV vaccinations?
Results from a new national review indicates that while the vast majority of pediatricians and family physicians are offering the human papillomavirus (HPV) vaccine, fewer physicians are encouraging it for 11- to 12-year-old girls.1
To perform the current review, analysts looked at results of a 2008 survey administered to 429 pediatricians and 419 family physicians. Ninety-eight percent of pediatricians and 88% of family physicians said they were offering the vaccine; however, fewer pediatricians (57%) and family physicians (50%) strongly recommended HPV vaccination for 11- to 12-year old girls than for girls ages 13-15 (90% of pediatricians, 86% of family physicians).
While HPV immunization rates among females are increasing, there is room for improvement. A September 2010 report issued by the Centers for Disease Control and Prevention shows 44.3% of teens ages 13-17 had received just one dose in 2009, while 26.7% had received all three recommended doses.2
Why is HPV vaccination recommended at 11 to 12 years of age? The policy decision to target this age group was based upon HPV-specific as well as broader health care delivery considerations, says Matthew Daley, MD, a pediatrician and a researcher at the University of Colorado School of Medicine and the Kaiser Permanente Institute for Health Research in Denver. Daley served as lead author for the new national review.
While the median age of sexual intercourse in the United States is 17 years, 13% of females initiate sexual activity prior to 15 years of age and 4% prior to age 13 years, says Daley. HPV vaccination does not protect against HPV types to which women have already been exposed; therefore, vaccination at 11 to 12 years as opposed to older ages increases the likelihood that immunization occurs prior to any sexual activity, Daley explains.
Efforts have been made to synchronize HPV vaccine delivery with other adolescent vaccines and with recommended well-adolescent visits, a concept referred to as the "adolescent immunization platform," Daley notes. "The intent has been to coordinate delivery of adolescent vaccines with delivery of preventive care, thereby creating mechanisms for achieving high adolescent immunization coverage while enhancing broader health care provision to adolescents," he states.
The American College of Obstetricians and Gynecologists (ACOG) has just issued updated recommendations on HPV vaccination.3 Girls ages 11 to 12 should receive either of the two Food and Drug Administration-approved vaccines (Gardasil, Merck and Co., and Cervarix, GlaxoSmithKline) to prevent cervical cancer, ideally before they become sexually active, the guidance states.
Play "catch-up"
Clinicians are encouraged to discuss the potential benefit of the HPV vaccine, as well as offer vaccination to females ages 13-26 who have not received it or completed the series. This group of women, who fall into the "catch up" group, are in the age range often seen by many family planning providers, says Susan Wysocki, WHNP-BC, FAANP, president and chief executive officer of the Washington, DC-based National Association of Nurse Practitioners in Women's Health. All family planning providers should inquire about their patients' HPV vaccine status and provide and encourage vaccination, she states.
There are many misperceptions about vaccination after sexual debut, particularly if the woman has had multiple sexual partners, says Wysocki.
"However, the data show that the vast majority of women even those who have been treated for HPV related disease have not been exposed to all the types covered by the vaccines," notes Wysocki. "It is very much worth it to encourage future protection."
What about men?
The Food and Drug Administration gave approval in 2009 for use of Gardasil in the prevention of genital warts (condyloma acuminata) due to HPV types 6 and 11 in boys and men, ages 9-26.
It might be too early to obtain an estimate of HPV vaccination use in young men, as the recommendations for usage are still "pretty fresh," says Kevin Ault, MD, associate professor of gynecology and obstetrics at Emory University in Atlanta and an investigator in the university's Emory Vaccine Center. Gardasil has been available for use in U.S. females since 2006. With the recent news that about 44% of teens had gotten their first HPV shot, it mighty take a couple of years before there is a clear picture about uptake in men, says Ault.
HPV vaccination in women can make an impact on men. In Australia, where HPV vaccination of females has been in force for some time, data indicates there is less incidence of genital warts in young men, probably due to "herd immunity," says Ault. The study, which looked at immunization records from 2004 to 2009, indicated a 60% drop-off in genital warts among women under age 27. Heterosexual men experienced a decline of just more than 30%.4
Data presented at the 2010 XVIII International AIDS Conference in Vienna indicates that Gardasil can reduce the risk of cancerous and non-cancerous varieties of anal and penile lesions in men.5 The study demonstrated a reduction in the number of pre-cancerous anal lesions caused by HPV, notes Ault. Such data might be reviewed at the next meeting of the Advisory Committee on Immunization Practices, says Ault.
References
- Daley MF, Crane LA, Markowitz LE, et al. Human papillomavirus vaccination practices: survey of US physicians 18 months after licensure. Pediatrics 2010; 126:425-433.
- Centers for Disease Control and Prevention. National, state, and local area vaccination coverage among adolescents aged 13-17 years United States, 2009. MMWR 2010; 59:1,018-1,023.
- American College of Obstetricians and Gynecologists. Committee Opinion #467. Human papillomavirus vaccination. Obstet Gynecol 2010; 116:800-803.
- Fairley C, Hocking J, Gurrin L, et al. Continued rapid decline in warts after national quadrivalent HPV vaccine program. Presented at the 26th International Papillomavirus Conference. Montreal, July 2010.
- Jessen H, Giuliano A, Palefsky J, et al. Quadrivalent HPV vaccine efficacy against HPV 6/11/16/18 infection and disease in men. Presented at the XVIII International AIDS Conference. Vienna; July 2010.
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