Parental knowledge, physician support key to HPV vaccine uptake

Parental knowledge and provider support are key factors in increasing acceptance and uptake of the human papillomavirus (HPV) vaccine among parents of boys, according to a new report.

Although HPV vaccine uptake generally remains below the desired level, vaccination rates are particularly low among boys, for whom recommendations for the vaccine came later than for girls.

The study, published in Clinical Pediatrics, found that a lack of knowledge about diseases caused by HPV and the vaccine created to protect against that virus was a major factor in parents’ choosing not to have the vaccine administered to their sons. Additionally, physicians don't routinely recommend the vaccine to boys.

Human papillomavirus is the most common sexually transmitted infection in the United States with an estimated 14 million new infections annually--roughly half of those in adolescents and young adults aged 15 to 24 years. Although most HPV cases are asymptomatic, some can result in genital warts or a variety of cancers.

The HPV vaccine was first licensed for use in women aged 9 to 26 years in 2006 to protect against 4 serotypes of HPV, and approval for men aged 9 to 26 years followed in 2009 to provide protection against genital warts. The recommendation for men was updated to include HPV-related cancers, and men are particularly advised to receive the vaccine if they are immunocompromised or have sex with other men, according to the report.

The Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP) currently recommends routine use of the HPV vaccine in boys and men aged 11 to 26 years, particularly among older men who are immunocompromised or have sexual relations with other men.

Vaccine uptake remains low

Despite recommendations in favor of the vaccine from a number of national advisory bodies and organizations, uptake of the full course of the vaccine remains low. According to the 2014 National Immunization Survey, 41.7% of males aged 13 to 17 years received 1 dose of the vaccine, but just 21.6% received the recommended 3 doses for full coverage.

Studies on trends in HPV vaccination among boys and men revealed that parents of teenaged boys had high levels of vaccine acceptance but low levels of knowledge about HPV and therefore low intention to vaccinate their sons. However, most parents polled stated that even with their limited knowledge about the HPV vaccine, they would choose it for their sons if it was recommended by their physician.

Tina Q. Tan, MD, attending physician in the Division of Infectious Diseases and medical director of the International Patient Services Program at the Ann and Robert H. Lurie Children’s Hospital of Chicago, Illinois, professor of Pediatrics (Infectious Diseases) at Northwestern University Feinberg School of Medicine, Chicago, and lead author of the report, says pediatricians need to be proactive about providing the HPV vaccine to both male and female patients.

“Parents trust the recommendations of their healthcare providers and most will act on their recommendations. However, pediatricians need to discuss, strongly recommend, and administer HPV vaccine to their patients,” Tan says.

That being said, physician attitudes about the vaccine also play a role with uptake. According to the study, only 12% of pediatric and family medicine practitioners recommended the vaccine when it was first made available. Those who did not recommend the vaccine cited concerns about safety, low perception about the severity of diseases caused by HPV, lack of school mandates for the vaccination, and policies preventing the administration of the HPV vaccine alongside other vaccines.

The report also cites a 2014 study that found that many healthcare providers were still uncomfortable with recommending the HPV vaccine, with just 10.8% always recommending the vaccine to boys aged 11 to 12 years, 12.9% recommending the vaccines for boys aged 13 to 17 years, and 13.2% recommending the vaccine for men aged 18 to 26 years. A quarter of the physicians that participated in the study stated that they did not strongly endorse the HPV vaccine, and 60% recommended the vaccine based on individual risk factors rather than as a routine vaccination. More recent studies suggest that around half of primary care and pediatric practitioners are recommending the HPV vaccine, but it remains unclear as to which factors work best in increasing uptake and acceptance of the vaccine among patients and their parents.

It’s time for ‘the talk’

Researchers found that parents who used private pediatric offices were significantly more likely to have been educated about HPV and its vaccine. However, despite these parents’ increased knowledge about the vaccine, there was little difference in vaccinate rates among parents who used private pediatric practices and those who used public health clinics. The study also found little variation in vaccination rate based on parent education or income level. Overall, 44.35% of parents who used private clinics opted for vaccine administration compared with 45.1% of parents who used public health clinics.

Tan says she was surprised to find that parental knowledge and level of education had little influence on whether they chose to vaccinate their sons against HPV. “Providers need to talk to their patients about the vaccine and recommend it,” she says.

Both public and private pediatricians polled about vaccination rates reported that a lack of knowledge about HPV and the vaccine was a major barrier to uptake, and that physician recommendations in favor of the vaccine carry a lot of weight in terms of increased compliance.

"This really emphasizes the need for intensive education of primary healthcare providers who provide care to boys aged 9 to 18 years on the importance and benefits of the HPV vaccine in males and the need to proactively discuss and administer the vaccine," the researchers note. "The message that this vaccine would directly benefit males by not only being preventive against genital warts but also as an anticancer vaccine that could prevent a significant percentage of HPV-related cancers that occur among males is one that should be emphasized."

The researchers recommend routine suggestions by providers in favor of the HPV vaccine, and promoting administration of the vaccine alongside other routine vaccinations in order to increase uptake.

As to why there is resistance against the HPV vaccine in boys compared with girls, Tan says the reasons are multifactorial and not clear. A study conducted by the CDC found that parental reasoning for why not to administer the HPV vaccine varied in rank depending on whether the child was a boy or a girl. Parents of girls first cited lack of knowledge, followed by not feeling the vaccine was necessary, safety concerns about adverse effects, the fact that their daughter was not sexually active, and that the vaccine was not recommended by the provider or school as reasons to avoid the vaccine. For parents of boys, the top reason for skipping the vaccination was not being recommended by the provider or school, following by not feeling the vaccine was necessary, lack of knowledge, that the child was not sexually active, and safety concerns and adverse effects.