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Lack of Progress in HPV Vaccination: A Crisis of Missed Opportunities for Cancer Prevention

Anne Schuchat, MD, RADM
Assistant Surgeon General, United States Public Health Service
Director, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

National goals should focus efforts on reducing the gap between today’s reality and a desired future.  Nowhere in the U.S. immunization program is the gap between current performance and the impact achievable with existing tools greater than for Human papillomavirus (HPV) immunization of teens.  The National Vaccine Plan report on Goal 4 could highlight various successes: sustained high coverage of early childhood immunization; impressive local, state and federal responses to resurgent pertussis; maintenance of measles elimination despite numerous importations of the virus; or improving health care worker influenza vaccination.  Instead, this commentary shines a harsh spotlight on where we are failing.  

Our nation’s deplorable performance with HPV vaccination is at first difficult to comprehend.  HPV vaccines are highly effective and safe, their supply is ample, and financing secure through the Vaccines for Children program and private insurance, reinforced by the Advisory Committee on Immunization Practices’ recommendation for routine use and by provisions of the 2010 Affordable Care Act.  HPV infections are common and the consequences of persistent infection are severe.  Despite a strong rationale and enabling environment, the 2012 National Immunization Survey - Teen found that only 53.8 percent of girls 13–17 years of age had initiated the series and only 33.4 percent had received three doses.  There was no improvement in HPV coverage in girls from 2011 to 2012.  Modeling suggests that about 50,000 girls who are under 12 today will develop cervical cancer during their lifetimes if we do not raise coverage to the target of 80 percent for the three-dose series.  Each year we remain at current levels, another 4,400 of these girls will develop cervical cancer.  Raising coverage will prevent additional cancers in both women and men.  

What accounts for our nation’s failure?  Adolescents are in the doctor’s offices.  We have achieved high coverage with other routinely recommended vaccines (e.g., Tdap and meningococcal conjugate) and if every time a teenaged girl received another vaccine she also received HPV, first dose coverage would exceed 90 percent.  Access is not our problem.  Clinicians are.

Clinician recommendation is the leading influence on a family’s decision to vaccinate.  Recent qualitative research found clinicians are giving weak or no recommendation for HPV vaccination of teen-aged patients.  The Centers for Disease Control and Prevention’s National Immunization Survey-Teen for 2012 found that parents who did not intend to vaccinate their daughters described lack of a provider recommendation as the most common factor influencing their plans.  The disparity between HPV and other teen vaccination reflects clear missed opportunities.  The last time our country faced a national crisis of missed opportunities was 1989–90  when measles resurgence killed over 100 children and caused illness in 55,000.  Clinicians reduced missed opportunities, and raised coverage among pre-school aged children, and by 2000 the United States had eliminated indigenous measles.  Pediatric caregivers recognized they had the responsibility and means to prevent measles and its associated complications. We need clinicians caring for teenagers to realize that future cervical and other HPV-associated cancers are their responsibility too.  A generation of young people is depending on them.