Which Adolescents Are Receiving the HPV Vaccine?

Since its introduction in 2006, the human papillomavirus (HPV) vaccine has had trouble gaining traction among adolescents, parents, and even some health care providers. The Advisory Committee on Immunization Practices (ACIP), a division of the Centers for Disease Control and Prevention (CDC), has recommended that girls and boys aged 11 and 12 receive the HPV vaccine, although the recommendation for boys was given in 2009, three years after the recommendation for girls. Administration of this vaccine in the United States continues to lag behind the administration of two other universally-recommended adolescent vaccines, those for tetanus-diphtheria-acellular pertussis (Tdap) and meningococcal disease (MenACWY).

Looking to discern patterns of use of recommended adolescent vaccines, researchers at the University of North Carolina in Chapel Hill conducted a study consisting of nearly 1,700,000 American adolescents nationwide whose information had been entered into insurance-claims databases between 2009 and 2014, following up for a mean duration of 16 months. The team found that only slightly more than half of the adolescents (56.1%) had received any of the recommended vaccinations at all, with just 18.4% receiving at least one dose of HPV vaccine. Of those who received any vaccinations, only one-fourth received all three recommended vaccines.

Clear geographical patterns emerged upon further study. Adolescents who resided in rural areas were less likely to have received the HPV vaccine, with the exception of rural residents of the Northeast, who were more likely to receive the HPV vaccine than rural dwellers in the South, West, and North Central parts of the United States were. Overall, adolescents who lived in western states were more likely to receive the HPV vaccine, and those who lived in urban areas were more likely to receive it as well.

Other findings: Girls were more likely to get the vaccine than boys were (21.9% vs. 15.1%), and to get it earlier—the mean age at first dose was 11.7 years for girls and 12 years for boys. HPV vaccination rates increased with age, with later birth cohorts of both sexes reporting larger numbers of adolescents receiving the vaccine and an increase in coadministration of all three recommended vaccines.

According to the authors, many missed opportunities exist for HPV vaccination, including during visits with health care providers during which other vaccines are administered. In their report, they noted that their study showed a full 43% of adolescents who received the HPV vaccine who received their first dose during the same year in which they became sexually active, or even afterwards. “While ACIP recommends catch-up vaccination for adolescents older than 12 years, HPV vaccine effectiveness is highest before sexual debut,” they wrote. The authors also cited a recent study that tracked 1,139 urban-dwelling girls and found that delaying the HPV vaccine until after age 15 was linked to an increased risk of high-grade cervical lesions.

Why are so many adolescents missing out on necessary vaccinations? A number of possibilities exist. One is that some parents are wary of vaccines due to a fear of side effects or a belief that vaccines cause autoimmune diseases or autism. They also may object to vaccines on religious or moral grounds, particularly when it comes to the HPV vaccine, which protects against sexually transmitted infections. For some parents, cost and a lack of transportation come into play. The authors noted that barriers to vaccination in rural areas need to be studied, and suggested that the rural Northeast being an exception to the lower rates of HPV vaccination in rural areas may be a result of the region’s small size, among other factors. One determinant of vaccine administration may be the type of health care provider adolescents see. “[Rural] adolescents are more likely to receive care from a family physician rather than a pediatrician and thus may be less likely to receive recommendations for HPV vaccination,” the authors wrote.

To increase vaccination rates, the authors maintain that all health care providers who treat adolescents need to be educated about CDC-recommended vaccines and learn how to explain their benefits to reluctant caregivers and patients alike, as well as adequately convey the risks of skipping them.