Why boys are not getting HPV vaccine and how to fix this

Human papillomavirus (HPV) is the most common sexually transmitted virus in the United States.¹ According to the Centers for Disease Control and Prevention, 1 in 4 persons in the United States is currently infected with the virus, which is about 79 million people. Approximately 14 million individuals, including teenagers, are infected every year. Another shocking statistic is that almost every person who is sexually active will get HPV at some point in their lives if they don’t receive the vaccine,¹ and although 9 of 10 infections resolve on their own within 2 years and cause no symptoms or health problems, 1 in 10 infections persists and can progress to cancer.²

The HPV virus can cause cancer of the cervix, vulva, and vagina in women, cancer of the penis in men, and cancer of the anus and back of the throat, including the base of the tongue and tonsils, in both women and men.¹ Every year in the United States, HPV causes 33,700 cases of cancer in women and men despite the fact that HPV vaccination can provide nearly 100% protection against cervical precancers in women.³ If vaccination of both girls and boys can prevent the vast majority of these cancers, why are so many more girls than boys receiving the vaccine, and what can be done to increase vaccination rates?

Currently, the CDC and the Advisory Committee on Immunization Practices (ACIP) recommend that all girls and boys who are aged 11 or 12 years should get the recommended series of HPV vaccine, which is “2 doses for persons starting the series before their 15th birthday.”³ This has a 2-fold advantage. The earlier age is associated with a more robust immune system capable of mounting a protective immune response. The CDC also says studies have shown that 2 doses of HPV vaccine given at least 6 months apart to adolescents at age 9 to 14 years worked as well or better than 3 doses given to older adolescents starting the series at age 15 or older. Two vaccines instead of 3 also makes it more likely that children will complete the recommended schedule. Children aged 15 to 26 years still need the 3-dose regimen, as do children aged 9 to 26 years who are immunocompromised and would benefit from an extra dose. As of June 26th, 2019, the ACIP recommends “catch-up” vaccination⁴ for males through age 26 years (previously through age 21 years), in order to make sure that the vaccine is offered equally to both genders.

Vaccination rates and the gender gap

According to the CDC, most parents are choosing to get the HPV vaccine for their children, which is good news. In 2017, nearly half (49%) of adolescents were up-to-date on the HPV vaccine, and approximately two-thirds (66%) of adolescents aged 13 to 17 years received the first dose to start the series.⁵ On average, the percentage of adolescents who started the vaccine series increased by 5 percentage points each year over the past 5 years (2013-2017).

Despite the progress, there are several serious problems that cannot be ignored. For one, the 66% refers to the number of persons getting at least 1 dose.⁵ Only 49% of teenagers are up-to-date on all recommended doses, which means that only these 49% and not the 66% are actually protected against HPV infection and related cancers. Additionally, even though these numbers improve every year, there is still a long way to go, both in initially getting individuals vaccinated and in making sure they get the full 2- or 3-dose regimen for maximal protection.

One major positive is that the gender gap in vaccination rates continues to narrow, with 65% of girls receiving the first dose in 2016 compared with 56% of boys, according to the 2016 National Immunization Survey. The gap was 9 percentage points compared with 18 percentage points in 2014 and 13 percentage points in 2015.⁶

The low vaccination rate in males has largely been attributed to the common perception that HPV affects only girls. This makes sense given that the vaccine was initially advertised as a means to prevent cervical cancer. According to the Journal for Specialists in Pediatric Nursing, HPV infection is associated with 96% to 99% of cervical cancers compared with only 12% to 63% of oropharyngeal cancers and 36% to 40% of penile cancers.⁷ Cervical cancer is almost completely preventable with the HPV vaccine, whereas the cancers affecting men can be caused by other things, leading many to think of the vaccine as less important or effective in males. However, vaccinating boys and men aged 9 to 26 years against HPV can prevent more than 5 million cases of genital warts and 40,000 cancer-related deaths over the next century, while also saving $27,500 per quality-adjusted life year. In other words, the vaccine would not only prevent deaths but preserve people’s quality of life.

Many parents are hesitant to vaccinate their 11- or 12-year-old children against a sexually transmitted disease (STD) because they think that children cannot get an STD if they are not sexually active. However, the shot is not only most effective in younger kids because of their robust immune systems but specifically because they have not yet had sex. The CDC reports clinical trial data that show “no evidence of [vaccine] efficacy against disease caused by vaccine types with which participants were infected at the time of vaccination.”⁸ The idea is to get everyone vaccinated before they’ve actually been exposed. Making sure that most children are immunized also ensures that those who are unable to be immunized will still be partially protected through herd immunity.

Boys and girls should be equally informed

Another major issue is that boys simply don’t know that they should be getting vaccinated for HPV. Doctors appear to be far more encouraging of their female patients than their male patients, leading males to be less aware of vaccine benefits and less likely to seek out the vaccine. Last year, the American Journal of Managed Care reported that 1 in 5 parents of boys said the main reason for not vaccinating sons for HPV was because the parent didn’t receive a physician’s recommendation, compared with 1 in 10 parents of girls.⁹

Many parents assume that any necessary vaccine will be recommended to them by their doctor. The problem with HPV is that the vaccine is still relatively new, especially for boys, and some doctors still don’t explicitly recommend HPV vaccine to their male patients. This ultimately puts the responsibility on boys and boys’ parents to be proactive. The main takeaway is that HPV is about a lot more than sex and gender. Boys and girls should get vaccinated to protect themselves and to protect their future sexual partners and the community as a whole. Because HPV is a largely asymptomatic infection with reduction but not elimination of transmission with condom use, the importance of vaccination against HPV cannot be overstated.

Barriers to access

According to the Kaiser Family Foundation, 25 states and the District of Columbia have laws that either require HPV vaccination for school entry, provide funding to cover the costs of the vaccines, or support public education about HPV and the vaccine.¹⁰ In the other states, people with a lower socioeconomic status are much less likely to get the vaccine due to lack of awareness and/or cost. There are also small differences in state-specific regulations that allow for major differences in implementation.

For example, Washington, DC, and Virginia require the vaccine for girls to enter 6th grade but allow parents to opt out of the requirements for medical, moral, or religious reasons.¹⁰ Girls can easily opt out of getting the vaccine, despite the fact that it’s technically required by the state, and boys and their parents are not held accountable at all. Rhode Island is the only state that requires all 7th-grade students to be vaccinated.

It isn’t enough to simply label something as a requirement if there are so many exceptions to the rule. Federal regulations in addition to state regulations need to be in place to bridge the gap between the 29% of adolescents being up-to-date with HPV vaccination in Mississippi and the 78% being up-to-date in Washington, DC.¹⁰

According to the CDC, HPV vaccination rates are also lower in rural areas.⁵ The Journal for Specialists in Pediatric Nursing points out that primary care offices in many underserved areas limit requests for HPV vaccines from the state’s health department because the costs associated with stocking the vaccine must be offset by the amount of vaccine requested.⁷ Living in an urban area comes with greater proximity to major medical centers and free clinics, making it much easier for people to get the vaccine. In rural areas where HPV vaccine research has been conducted, boys and young men have to travel longer than an hour to access the vaccine. They have to be motivated to seek it out, making outreach efforts in those areas particularly critical. In lower income areas, a child might not be regularly seeing a doctor or have a doctor who is going to recommend the vaccine, but if the child and his or her parents are aware of the vaccine’s importance and free clinics where they could go to receive it, vaccine uptake would increase.

Strategies to Improve uptake of HPV vaccine

In thinking about ways to improve vaccination rates, the Journal for Specialists in Pediatric Nursing recommends a “family-centered approach.”⁷ This will increase parents’ knowledge of HPV and the vaccine, including current ACIP guidelines as well as benefits and risks. The journal also points out that many boys look specifically to their fathers for guidance in health and sex-related issues, and that father-focused health education interventions could lead to fewer misconceptions among young men about the vaccine and reduce some of the stigma associated with it. Educational efforts need to be targeted to underserved populations because geographic, economic, and cultural disparities all affect a boy’s awareness of HPV and his parents’ or caregiver’s decision and/or ability to get him vaccinated.

The CDC has noted some promising strategies that have been effective in increasing vaccination rates so far. The first is establishing links between cancer organizations and immunization groups to emphasize that HPV vaccination truly is cancer prevention.¹¹ Another strategy is for healthcare providers to recommend the HPV vaccine to both their female and male patients at the same time as the other 2 vaccines routinely given to 11- and 12-year-old patients-the quadrivalent meningococcal conjugate and Tdap vaccines. Getting all these vaccines done in 1 visit relieves parents of having to take their children to multiple appointments. Administering the vaccines at the same time also places equal importance on each vaccine.

In addition, state and local health departments should continue to assess how HPV vaccination coverage levels change over time and keep track of which strategies work and which do not in order to best target improvement efforts. To make information on HPV widely accessible, more public communication campaigns should be established, both in the form of online informal discussions and in more structured educational campaigns created by state and local health departments.

Another helpful recommendation by the CDC is to create “reminder recall interventions,”¹¹ which use immunization information systems to send reminders to parents about vaccinations. This is a quick and easy way to increase awareness and adherence.

In conclusion

The good news is that awareness of the importance of HPV prevention continues to grow, especially among the male population. Vaccination rates for boys are still lower than those for girls but they have been rapidly rising since 2011, and all healthcare professionals are responsible for ensuring that these numbers continue to rise. 

References:

1. Centers for Disease Control and Prevention (CDC). Human papillomavirus (HPV): HPV fact sheet. Available at: https://www.cdc.gov/std/hpv/stdfact-hpv.htm. Reviewed November 16, 2017. Accessed August 5, 2019.

2. Centers for Disease Control and Prevention (CDC). Human papillomavirus (HPV): About HPV. Available at: https://www.cdc.gov/hpv/parents/about-hpv.html. Reviewed April 29, 2019. Accessed August 5, 2019.

3. Centers for Disease Control and Prevention (CDC). Human papillomavirus (HPV) Questions and answers. Available at: https://www.cdc.gov/hpv/parents/questions-answers.html. Reviewed August 23, 2018. Accessed August 5, 2019.

4. Immunization Action Coalition. Ask the Experts. Human papillomavirus (HPV). Available at: http://www.immunize.org/askexperts/experts_hpv.asp. Accessed August 5, 2019.

5. Centers for Disease Control and Prevention (CDC). Human papillomavirus (HPV): HPV coverage data. Available at: https://www.cdc.gov/hpv/hcp/vacc-coverage/index.html. Reviewed August 23, 2018. Accessed August 5, 2019.

6. American Cancer Society. HPV vaccination rates are rising among American teens. Available at: https://www.cancer.org/latest-news/hpv-vaccination-rates-are-rising-among-american-teens.html. Published August 14, 2017. Accessed August 5, 2019.

7. Thomas TL, Snell S. Ask the expert: Vaccinate boys with the HPV vaccine? Really? J Spec Pediatr Nurs. 2013;18(2):165-169. Erratum in: J Spec Pediatr Nurs. 2014;19(1):101.

8. Centers for Disease Control and Prevention (CDC). Chapter 11: Human papillomavirus. In: The Pink Book. Epidemiology and Prevention of Vaccine Preventable Diseases. Available at: https://www.cdc.gov/vaccines/pubs/pinkbook/hpv.html. Reviewed May 16, 2018. Accessed August 5, 2019.

9. American Journal of Managed Care (AJMC) 2006-2019 Clinical Care Targeted Communications Group, LLC. Dr. Anna Beavis discusses gender differences in HPV vaccination. Presented at: Society of Gynecologic Oncology (SGO) 2018 Annual Meeting on Women’s Cancer; March 24-27, 2018; New Orleans, LA. Available at: https://www.ajmc.com/conferences/sgo-2018/dr-anna-beavis-discusses-gender-differences-in-hpv-vaccination. Published March 25, 2018. Accessed August 5, 2019.

10. Kaiser Family Foundation. The HPV vaccine: Access and use in the US. Available at: https://www.kff.org/womens-health-policy/fact-sheet/the-hpv-vaccine-access-and-use-in/. Published October 9, 2018. Accessed August 5, 2019.

11. Centers for Disease Control and Prevention (CDC). CDC Newsroom: Many adolescents still not getting HPV vaccine. Available at: https://www.cdc.gov/media/releases/2015/p0730-hpv.html. Reviewed July 30, 2015. Accessed August 5, 2019.