Human Papillomavirus: Updated Coverage Rates and Obstacles to Vaccine Uptake
The human papillomavirus (HPV) vaccine is highly protective against cervical cancer and can prevent other cancers as well, including head and neck cancers. Clinicians are in a strong position to educate families about HPV infection and the vaccine that prevents it.
Professor of Pediatrics
“I think that we, as practitioners, can continue to have a positive impact on HPV vaccination rates.”
The HPV vaccine has been available for more than 10 years in the United States. Originally developed to prevent cervical cancer, for which it is highly protective, we now know that the HPV vaccine can also prevent a number of head and neck cancers, vaginal cancers, rectal cancers, and penile cancers. So, I consider and present the HPV vaccine as an incredibly effective vaccine that prevents cancer. It is also very effective at preventing genital warts, which people do not often think of as being a big issue. However, genital warts can have a significant psychological impact on the patient, are painful to treat, and often recur.
One important issue limiting HPV vaccine uptake is that people associate HPV infection with sexual activity, with some individuals believing that receiving the vaccine will promote sexual activity. While this may be a concern among some parents, it is important to be clear that vaccines do not make someone sexually active; there is no evidence that receiving the HPV vaccine is associated with an increase in sexual activity. So, I think that it is important to frame the conversation about HPV vaccination in terms of cancer prevention and protection.
With regard to coverage rates, we are still not where we need to be with HPV. Pingali et al used the 2021 National Immunization Survey–Teen data to estimate rates, showing that coverage with at least 1 dose of HPV was 76.9% in 2021, and the percentage of adolescents who were completely up to date on HPV vaccination was only 61.7%. By comparison, for example, coverage with at least 1 dose of the tetanus, diphtheria, and pertussis (Tdap) vaccine was 89.6% in 2021.
I think that we, as practitioners, can continue to have a positive impact on HPV vaccination rates. For example, if a patient is in the office to get the Tdap and the meningococcal vaccines, they can also get the HPV vaccine at the same visit. And it is important that we put the HPV vaccine on equal footing with other vaccines. We can say something like, “We have 3 vaccines that you need to get today: meningococcal, Tdap, and HPV,” instead of saying something like, “You need to get the Tdap and the meningococcal vaccines today, and—if you want it—you can also get the HPV vaccine.” When the HPV vaccine is separated out from the other vaccines in this way, we run the risk of people thinking that it is somehow different, perhaps not as fully endorsed, or perhaps something to be more concerned about.
Families and adolescents should understand that the HPV vaccine is prophylactic, not therapeutic. Once a person has been infected with HPV, the vaccine will not work retroactively. However, the vaccine offers protection against 9 different types of HPV, so that, going forward, there would be protection against newly encountered strains. We do not know when children and adolescents are going to become sexually active, and the risk of HPV transmission increases with the number of sexual partners. Thus, the thought is that if you wait until adolescents are college-aged to administer the vaccine, it may be too late for some of them to be protected.
The Centers for Disease Control and Prevention reports that vaccination coverage rates are rising every year, but the slope of the increase in HPV vaccination rates is not very steep. In fact, it is significantly lower than the slope of the increase in meningococcal vaccination rates, and the meningococcal vaccines have not been around for much longer than the HPV vaccine.
Health care providers are in a strong position to improve coverage rates because they are still a trusted source of information about health. Families go to their providers looking for answers, so it is essential that we dispel unfounded concerns about HPV vaccination and foster an appreciation of the long-term benefits.
Bednarczyk RA, Davis R, Ault K, Orenstein W, Omer SB. Sexual activity-related outcomes after human papillomavirus vaccination of 11- to 12-year-olds. Pediatrics. 2012;130(5):798-805. doi:10.1542/peds.2012-1516
Boakye EA, McKinney SL, Whittington KD, et al. Association between sexual activity and human papillomavirus (HPV) vaccine initiation and completion among college students. Vaccines (Basel). 2022;10(12):2079. doi:10.3390/vaccines10122079
Goldfarb JA, Comber JD. Human papillomavirus (HPV) infection and vaccination: a cross-sectional study of college students' knowledge, awareness, and attitudes in Villanova, PA. Vaccine X. 2022;10:100141. doi:10.1016/j.jvacx.2022.10014
HPV vaccine schedule and dosing. Centers for Disease Control and Prevention. Reviewed November 2, 2021. Accessed June 7, 2023. https://www.cdc.gov/hpv/hcp/schedules-recommendations.html#:~:text=Immunogenicity%20studies%20show%20that%20two,older%20adolescents%20or%20young%20adults
Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination—updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405-1408. doi:10.15585/mmwr.mm6549a5
Pingali C, Yankey D, Elam-Evans LD, et al. National vaccination coverage among adolescents aged 13-17 years—National Immunization Survey-Teen, United States, 2021. MMWR Morb Mortal Wkly Rep. 2022;71(35):1101-1108. doi:10.15585/mmwr.mm7135a1
Rosenblum HG, Lewis RM, Gargano JW, Querec TD, Unger ER, Markowitz LE. Declines in prevalence of human papillomavirus vaccine-type infection among females after introduction of vaccine—United States, 2003-2018 [published correction appears in MMWR Morb Mortal Wkly Rep. 2021;70(13):502]. MMWR Morb Mortal Wkly Rep. 2021;70(12):415-420. doi:10.15585/mmwr.mm7012a2