A Report to the President of the United States 

from the Chair of the President’s Cancer Panel

HPV VACCINATION FOR 

CANCER PREVENTION:

Progress, Opportunities, and a 

Renewed Call to Action

November 2018
THE PRESIDENT’S CANCER PANEL

CHAIR

Barbara K. Rimer, DrPH

Dean and Alumni Distinguished Professor

Gillings School of Global Public Health

The University of North Carolina at Chapel Hill

Chapel Hill, NC

This report is submitted to the President of the United States in fulfillment of the obligations of the President’s 

Cancer Panel to appraise the National Cancer Program as established in accordance with the National Cancer 

Act of 1971 (P.L. 92-218), the Health Research Extension Act of 1987 (P.L. 99-158), the National Institutes of Health 

Revitalization Act of 1993 (P.L. 103-43), and Title V, Part A, Public Health Service Act (42 U.S.C. 281 et seq.).

Printed November 2018

For further information on the President’s Cancer Panel or additional copies of the report, please contact: 

Abby Sandler, PhD

Executive Secretary

President’s Cancer Panel

9000 Rockville Pike

Building 31, Room B2B37, MSC 2590

Bethesda, MD 20892

(240) 781-3430

PresCancerPanel@nih.gov 

https://prescancerpanel.cancer.gov 
HPV Vaccination 

for Cancer Prevention:

Progress, Opportunities, and 

a Renewed Call to Action

A Report to the President of the United States 

from the Chair of the President’s Cancer Panel

Suggested citation:

HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to 

Action. A Report to the President of the United States from the Chair of the President’s Cancer 

Panel. Bethesda (MD): President’s Cancer Panel; 2018 Nov. 

A web-based version of this report is available at: 

https://prescancerpanel.cancer.gov/report/hpvupdate 

The President

The White House

Washington, DC 20500

Dear Mr. President,

Today, there are safe and effective vaccines against human papillomavirus (HPV), a group of viruses that cause six 

cancers and other diseases. This extraordinary tool could prevent hundreds of thousands of cancers globally. 

The President’s Cancer Panel concluded in its 2012-2013 report that underuse of HPV vaccines is a serious but 

correctable threat to progress against cancer and identified several goals and objectives to help increase HPV 

vaccine uptake in the United States and globally. This report describes the notable progress made over the past 

five years and presents priorities and strategies to speed progress toward goals identified in the previous report. 

Although vaccine uptake has improved in recent years, the fact remains that less than 50% of boys and girls in 

the United States are fully vaccinated against HPV. We are still far short of the government’s Healthy People 2020 

goal of 80% of age-eligible adolescents. This target is achievable with the continued work and support of federal 

agencies, organizations, healthcare providers, and researchers. 

Cancer and immunization partners have risen to the challenge of accelerating HPV vaccine uptake. They have 

raised awareness among the general public of the importance of HPV vaccination, supported healthcare 

providers and systems in delivering the HPV vaccine, and contributed to global efforts to promote HPV 

vaccination. However, much work remains to maximize the cancer prevention potential of HPV vaccination. 

It is critical that partnerships and collaborations are supported and expanded to drive further increases 

needed in HPV vaccine coverage.

The United States and stakeholders across the globe should renew their commitment to prioritize HPV 

vaccination. We have a chance to prevent cancers caused by HPV, an opportunity that should not be missed. 

Our children and future generations are counting on us to act now to protect them from deadly vaccinepreventable cancers. This is a win for individuals and families. I hope that you and your administration will 

encourage uptake of HPV vaccines.

Sincerely,

PRESIDENT’S CANCER PANEL

Barbara K. Rimer, DrPH

Chair 

President’s Cancer Panel

PRESIDENT’S CANCER PANEL

ACKNOWLEDGEMENTS

The Panel Chair would like to thank the many people who contributed to this report. She is particularly 

grateful to Noel Brewer, PhD, Professor of Health Behavior, Gillings School of Global Public Health, and 

Member, Lineberger Comprehensive Cancer Center, University of North Carolina; in his role as Special 

Advisor to the Panel Chair, he generously shared his time and extensive expertise on this topic. 

Many others, listed below, reviewed whole or partial drafts of the report or provided valuable insights into the 

changing landscape of HPV vaccination. Acknowledgment of the important role of these individuals should not 

be interpreted as endorsement of the Panel Chair’s positions or recommendations.

Lauren Chambers, MPH, Public Health Analyst, 

National Vaccine Advisory Committee Manager, 

National Vaccine Program Office

Sara Comstock, MSW, Senior Director, Hospital 

Systems, North Region, American Cancer Society

Robert Croyle, PhD, Director, Division of Cancer 

Control and Population Sciences and Interim Director, 

Center for Global Health, National Cancer Institute

Kalina Duncan, MPH, Lead Public Health Analyst, 

Center for Global Health, National Cancer Institute

Aimée Kreimer, PhD, Senior Investigator, Division of 

Cancer Epidemiology and Genetics, National Cancer 

Institute

Douglas Lowy, MD, Deputy Director,

National Cancer Institute

Lauri Markowitz, MD, Associate Director for Science, 

HPV, Division of Viral Diseases, National Center for 

Immunization and Respiratory Diseases, Centers for 

Disease Control and Prevention

Jennifer Nkonga, MS, Director, Health Systems and 

Provider Engagement, National HPV Vaccination 

Roundtable

Kristin Oliver, MD, MHS, Assistant Professor, 

Department of Environmental Medicine and Public 

Health, Department of Pediatrics, Icahn School of 

Medicine at Mount Sinai

Jill Roark, MPH, Director, Public Relations, American 

Cancer Society

Debbie Saslow, PhD, Senior Director, HPV-Related 

and Women’s Cancers, American Cancer Society

Margot Savoy, MD, MPH, Chair, Family and 

Community Medicine and Associate Professor, Family 

and Community Medicine, Temple University, Lewis 

Katz School of Medicine

Norman Sharpless, MD, Director, National Cancer 

Institute

Angela Shen, ScD, MPH, Designated Federal Official, 

National Vaccine Advisory Committee; Senior Science 

Policy Advisor, National Vaccine Program Office

Jennifer Sienko, MPH, Director, Communications 

and Public Engagement, National HPV Vaccination 

Roundtable 

Lisa Stevens, PhD, Deputy Director, Center for Global 

Health, National Cancer Institute

Shannon Stokley, DrPH, Associate Director for 

Science, Immunization Services Division, National 

Center for Immunization and Respiratory Diseases, 

Centers for Disease Control and Prevention

Edward Trimble, MD, MPH, Senior Advisor, Office of 

the Director, National Cancer Institute

Melinda Wharton, MD, MPH, Director, Immunization 

Services Division, National Center for Immunization 

and Respiratory Diseases, Centers for Disease Control 

and Prevention and Acting Director, National Vaccine 

Program Office

The Chair also acknowledges the efforts and contributions of Abby Sandler, PhD, who serves as the Panel’s 

Executive Secretary, as well as those of Panel staff and support staff: 

Rachel Hanisch, PhD, MPH

Randi Hays

Erin Milliken, PhD

Benjamin Neal

Katherine Nicol, MS

Lisa Paradis, MPH

Rachel Wojnilower

Dana Young, JD
PRESIDENT’S CANCER PANEL
PRESIDENT’S CANCER PANEL

TABLE OF CONTENTS

EXECUTIVE SUMMARY.............................................................................................................................. i

PREFACE .............................................................................................................................. iii

THE CURRENT LANDSCAPE OF HPV CANCERS AND 

HPV VACCINATION .............................................................................................................................. 1

HPV Cancers Affect Thousands of U.S. Women and Men ............................................................................ 1

Vaccines Protect Against Cancer-Causing HPV Types ................................................................................... 2

Two Vaccine Doses Are Sufficient to Protect Younger Adolescents ............................................................. 3

HPV Vaccines Are Safe and Effective .............................................................................................................. 3

U.S. HPV Vaccine Uptake: Progress and Continuing Challenges................................................................... 4

GOALS AND OPPORTUNITIES

TO INCREASE HPV VACCINE UPTAKE ................................................................................................... 9

Goal 1: Reduce Missed Clinical Opportunities to Recommend 

and Administer the HPV Vaccine. ..................................................................................................................... 11

Strong Provider Recommendations Are Needed .........................................................................................12

Systems-Level Efforts Facilitate Vaccination .................................................................................................13

Goal 2: Increase Parents’ Acceptance of HPV Vaccination. ..........................................................................16

Goal 3: Maximize Access to HPV Vaccination Services. ................................................................................18

Coverage for HPV Vaccination Costs Must Be Maintained ..........................................................................18

Alternative Settings May Expand Access to HPV Vaccination in Some Situations .....................................18

Goal 4: Promote Global HPV Vaccine Uptake. ...............................................................................................21

HPV Vaccination Is Low in Countries with Most Cervical Cancer Cases and Deaths .................................21

HPV Vaccination Is Feasible in Low-Resource Settings ................................................................................22

U.S. Support Is Needed to Promote Global HPV Vaccination .....................................................................23

CONCLUSIONS .............................................................................................................................. 25

REFERENCES .............................................................................................................................. 27

APPENDIX: ACRONYMS ........................................................................................................................ 37

PRESIDENT’S CANCER PANEL

EXECUTIVE SUMMARY

Human papillomaviruses (HPV) cause six types of cancer—cervical, oropharyngeal, anal, penile, vulvar, and 

vaginal—and several other diseases. HPV vaccination provides a compelling opportunity to protect against 

infection with HPV and prevent cancers and other diseases. The President’s Cancer Panel concluded in its 2012-

2013 report to the White House, Accelerating HPV Vaccine Uptake: Urgency for Action to Prevent Cancer, that 

underuse of HPV vaccines was a serious but correctable threat to progress against cancer. That report identified 

several goals and objectives to increase HPV vaccine uptake in the United States and globally. 

Substantial progress in HPV vaccine uptake has been achieved in recent years—the percentage of adolescents 

who started the HPV vaccine series increased an average of 5 points each year between 2013 and 2017. However, 

HPV vaccine coverage is still too low to achieve its cancer prevention potential. As of 2017, less than half of U.S. 

adolescents were fully vaccinated, far below the Healthy People 2020 goal—full vaccination of 80 percent of 

adolescents aged 13-15 years. In addition, HPV vaccines are not included in the national vaccine programs of 

many low- and middle-income countries, where the vast majority of cervical cancer cases and deaths occur.

In this report, the Panel Chair provides an overview of progress made over the past five years and presents priorities 

and strategies to speed progress toward goals identified in the previous report. Several research priorities also are 

highlighted.

Goals and Opportunities to Increase HPV Vaccine Uptake

The Panel’s 2012-2013 report identified three goals to increase HPV vaccine uptake in the United States. A fourth 

goal was to promote global HPV vaccine uptake. Research and discussions with key stakeholders on the current 

landscape of HPV cancers and HPV vaccination led the Panel Chair to conclude that the goals outlined in the 

previous report are still relevant. Priorities and strategies that will help achieve these goals are outlined below.

Partnerships and Collaborations Are Essential

The coalescence of a critical mass of dedicated stakeholders has created momentum and 

opportunity to achieve the goals outlined in this report. The Panel Chair urges continued 

stakeholder collaborations and partnerships in implementing proven strategies to increase 

vaccination rates among all populations to target levels.

Executive Summary i

Goal 1: Reduce Missed Clinical Opportunities to Recommend and Administer the HPV Vaccine.

Communication strategies and systems changes are essential to ensure that all eligible adolescents and young 

adults are offered the HPV vaccine when they visit their healthcare providers. Provider- and systems-level 

changes hold the greatest potential for eliminating missed clinical opportunities, normalizing HPV vaccination, 

and ensuring that U.S. adolescents and future generations are optimally protected from HPV cancers. As such, 

the Panel Chair urges healthcare providers to strongly recommend HPV vaccination for all eligible adolescents. In 

addition, health system leaders should make HPV vaccination a high, measurable priority.
Goal 2: Increase Parents’ Acceptance of HPV Vaccination.

Communication campaigns and promotion of the HPV vaccine by a growing number of healthcare providers have 

contributed to recent progress in vaccination rates. However, more must be done to ensure that parents have 

access to clear, accurate information about the HPV vaccine. The Panel Chair encourages the Centers for Disease 

Control and Prevention, American Cancer Society, and other trusted organizations to continue to develop and 

deploy evidence-based communication campaigns to increase parents’ acceptance of HPV vaccination.

Goal 3: Maximize Access to HPV Vaccination Services.

Ensuring that HPV vaccination is affordable and convenient for all U.S. adolescents will support optimal vaccine 

uptake. National, regional, and local efforts are needed to understand and address existing and potential 

barriers to access. While sources of private and public financing currently ensure that the vaccine’s cost is 

covered for most adolescents, the Panel Chair asserts that insurance coverage for preventive services must be 

maintained to ensure that cost does not limit U.S. adolescents’ access to HPV vaccination.

Goal 4: Promote Global HPV Vaccine Uptake.

The potential impact of HPV vaccination is greatest in less developed countries, where the vast majority of 

cervical cancer cases and deaths occur and HPV vaccination rates are disproportionately low. The Panel Chair 

urges the United States to continue to support implementation and sustainability of HPV vaccination programs 

around the world, particularly in low- and middle-income countries.

A Renewed Call to Action 

Progress and momentum built over the past half decade have created a compelling opportunity to further 

increase HPV vaccine uptake and dramatically reduce—and perhaps eventually largely eliminate—the 

preventable burden of HPV cancers. Cancer and immunization stakeholders worldwide must renew their 

collective commitment to achieving HPV vaccination targets. All should rally without hesitation around the 

ultimate goal of cancer prevention.

Research Priorities

 Establish natural history of oral HPV infections and develop tools to detect precancers.

Understand and address inequities among populations with high rates of HPV cancers. 

dentify ways to harness social media to communicate about HPV and HPV vaccination.

Determine efficacy and duration of protection of a single HPV vaccine dose.

PRESIDENT’S CANCER PANEL

ii HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action
PRESIDENT’S CANCER PANEL

PREFACE

The President’s Cancer Panel (the Panel), established by 

the National Cancer Act of 1971 (P.L. 92-218), is charged 

with monitoring progress of the National Cancer 

Program and identifying barriers to its fullest and most 

rapid implementation. The Panel investigates topics of 

high importance to the National Cancer Program and 

presents findings and recommendations in reports to 

the President of the United States. 

In 2012-2013, the Panel held a series of meetings on 

human papillomavirus vaccination. At that time, the 

Panel concluded that underuse of HPV vaccines was 

a serious but correctable threat to progress against 

cancer and identified several goals and objectives to 

increase HPV vaccine uptake in the United States and 

globally. Many stakeholders have worked resolutely 

to make progress toward these goals and to achieve 

the ultimate goal of preventing HPV cancers. The 

2012-2013 Panel report is frequently cited as a seminal 

resource on HPV vaccination. In response to several 

stakeholders who have expressed interest in the Panel 

revisiting this topic, the Panel Chair has assessed the 

current landscape of HPV cancers and vaccination 

through consultations with experts about the state 

of the field, selective review of the literature, and 

additional research. In this report, the Panel Chair 

provides an overview of progress made over the past 

five years and presents priorities and strategies to 

speed progress toward goals identified in the 2012-

2013 report. 

While Panel reports are submitted to the President, 

they also are intended for use by a larger group 

of stakeholders, public and private, that comprise 

the National Cancer Program. As the Panel is 

advisory, implementation of Panel recommendations 

depends on actions of these stakeholders. Over 

the past five years, numerous organizations and 

agencies—including, but not limited to, the National 

Cancer Institute (NCI); NCI-designated cancer centers; 

Centers for Disease Control and Prevention; American 

Cancer Society; National HPV Vaccination Roundtable; 

American Academy of Pediatrics; American Academy 

of Family Physicians; World Health Organization; and 

Gavi, the Vaccine Alliance—have devoted substantial 

resources and voiced strong support for HPV 

vaccination. Progress to date is a testament to the 

dedicated efforts, strategic focus, and persistence of 

these organizations and their partners throughout the 

United States and globally. The United States and its 

global partners must seize the opportunity to build 

on this momentum to eliminate both the barriers to 

HPV vaccine uptake and the unnecessary burden of 

preventable HPV cancers. 

Preface iii
iv HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action

PRESIDENT’S CANCER PANEL
PRESIDENT’S CANCER PANEL

The Current Landscape of HPV Cancers and HPV Vaccination 1

THE CURRENT LANDSCAPE 

OF HPV CANCERS AND 

HPV VACCINATION

Human papillomaviruses cause nearly 630,000 cases of 

cancer worldwide each year. The majority—530,000—

are cervical cancers, but HPV also is responsible for 

about 100,000 cancers at five other sites, including the 

oropharynx, anus, penis, vulva, and vagina.1*

* de Martel et al. include cancers of the oral cavity and larynx in their estimate of HPV-attributable cancers. The U.S. Centers for 

Disease Control and Prevention has concluded that HPV causes some cancers of the oropharynx, but that the evidence that HPV 

causes cancers of the oral cavity and larynx is insufficient. Thus, numbers in this report include estimates for oropharyngeal but 

not oral cavity and laryngeal cancers.

 In 2006, 

the first HPV vaccine was approved, making available 

a powerful new tool for preventing cancers and other 

diseases caused by these viruses. Two additional HPV 

vaccines were approved in 2009 and 2014. Despite 

extensive evidence that these vaccines are remarkably 

effective and safe, early uptake was slow in the United 

States and some other countries. 

In its 2012-2013 report, Accelerating HPV Vaccine 

Uptake: Urgency for Action to Prevent Cancer, the 

President’s Cancer Panel concluded that underuse of 

HPV vaccines was a serious threat to progress against 

cancer and recommended several steps to increase 

vaccination in the United States and globally.2 Other 

high-profile reports—including 2015 and 2018 reports 

from the National Vaccine Advisory Committee3,4 and 

2016 reports from the Cancer Moonshot Blue Ribbon 

Panel5 and Cancer Moonshot Task Force6—echoed 

the Panel’s call for action.

This report of the Panel Chair provides an update on 

the landscape of HPV cancers and HPV vaccination. 

Substantial progress in HPV vaccine uptake has 

been achieved in recent years—the percentage of 

adolescents who started the HPV vaccine series 

increased an average of 5 percentage points each year 

between 2013 and 2017.7 This is a testament to the 

hard work and dedication of the many stakeholders 

who have come together to promote HPV vaccination. 

However, the United States and many other countries 

still fall far short of target vaccination rates. 

On average, the percentage of adolescents 

who started the HPV vaccine series 

increased 5 percentage points each year 

between 2013 and 2017.

HPV Cancers Affect Thousands of U.S. 

Women and Men 

There are more than 150 strains, or types, of HPV. In 

the United States, about 79 million people currently 

are infected with HPV, and about 14 million will 

become newly infected with HPV each year. Most 

sexually active men and women will be infected with 

HPV at some point in their lives if they do not receive 

the HPV vaccine.8 The majority of HPV infections go 

away without treatment and do not cause health 

problems. In some cases, however, HPV infections 

persist and cause cancer and other diseases. 

In the United States, HPV causes nearly 34,000 cases of 

cancer each year (Figure 1).9 In addition, about 300,000 
2 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action

Figure 1. Numbers of U.S. Cancers Caused by HPV

10,800

Oropharynx

Anus

10,700 2,200

Cervix

Vagina

Vulva

Penis 800

600

2,700

1,900 4,000

FEMALE

MALE

PRESIDENT’S CANCER PANEL

Source: Centers for Disease Control and Prevention. How many cancers are linked with HPV each year? 

[Internet]. Atlanta (GA): CDC; [updated 2018 Aug 22; cited 2018 Aug 26]. Available from: https://www.cdc.gov/

cancer/hpv/statistics/cases.htm. 

U.S. women undergo invasive treatment for cervical 

precancers caused by HPV.10,11 Women are more likely 

than men to be diagnosed with HPV cancers, but the 

burden of HPV cancers among men is increasing. This 

trend is driven largely by increases in HPV-positive 

oropharyngeal cancers over the past three decades, 

particularly among men, even as incidence rates of 

other head and neck cancers and many other cancers 

are decreasing.12-15 The number of oropharyngeal 

cancers attributed to HPV is now higher than the 

number of cervical cancers in the United States.9,16

Vaccines Protect Against 

Cancer-Causing HPV Types

When the 2012-2013 Panel report on HPV vaccination 

was released, two HPV vaccines were approved for 

use in the United States—Cervarix and Gardasil. Both 

vaccines are designed to protect against the two most 

common cancer-causing types of HPV—HPV 16 and 

HPV 18—which together account for about two-thirds 

of cervical cancers. Gardasil also protects against 

HPV 6 and 11, which cause genital warts and recurrent 

respiratory papillomatosis, a rare but debilitating 

disease characterized by noncancerous growths in the 

respiratory tract. Cervarix provides cross-protection 

against three additional cancer-causing HPV types (HPV 

31, 33, and 45) that are related to HPV 16 or HPV 18.17

In 2014, the U.S. Food and Drug Administration 

(FDA) approved a third HPV vaccine—Gardasil 9—

which protects against HPV 16, 18, 6, 11, and five 

additional cancer-causing HPV types (HPV 31, 33, 

45, 52, 58).18 The HPV types covered by Gardasil 9 

cause the vast majority of HPV-associated diseases 

in the United States and worldwide.19 Since January 

2017, only Gardasil 9 has been available in the United 

States. Cervarix and Gardasil are still used in some 

other countries.
The Current Landscape of HPV Cancers and HPV Vaccination 3

Two Vaccine Doses Are Sufficient to 

Protect Younger Adolescents

The Advisory Committee on Immunization Practices 

(ACIP) recommends routine HPV vaccination of 

girls and boys at 11 or 12 years of age.20 Initial 

recommendations for girls (in 2006) and boys (in 

2011) called for a three-dose series.21-23 In 2016, 

ACIP updated its recommendation to indicate that 

adolescents who initiate the vaccine series before 

15 years of age need only two doses (separated by 

6-12 months).20 This update, which aligns with the 

World Health Organization recommendation,24 was 

based on evidence that two doses of the vaccine in 

younger adolescents produced an immune response 

similar to or higher than the response in young adults 

who received three doses.25 ACIP also recommends 

vaccination for females through age 26 and for males 

through age 21 who were not adequately vaccinated 

previously. Vaccination for some special populations is 

recommended through 26 years of age.20†

HPV Vaccines Are Safe and Effective

HPV vaccines are safe. All three vaccines have excellent 

safety profiles based on clinical trials and postapproval 

monitoring and evaluation in the United States and 

other countries.26-28 As of 2017, more than 270 million 

HPV vaccine doses had been distributed worldwide,26 

including over 100 million in the United States.28 More 

than 100 studies that included 2.5 million people in 6 

countries have found no serious adverse effects of HPV 

vaccination beyond what is typical for other adolescent

vaccines.27 The Centers for Disease Control and 

Prevention and the FDA continue to monitor the safety 

of these vaccines, as for all vaccines. 

HPV vaccines are highly effective. In clinical trials, 

among women who were not previously infected 

with HPV, the vaccines provided nearly complete 

protection against persistent HPV infection and 

cervical, vaginal, and vulvar precancers caused 

by vaccine-targeted HPV types.29-32 Women who 

were vaccinated as part of a clinical trial also had 

lower prevalence of oral HPV infections than did 

participants in the trial who were not vaccinated.33

Rates of vaccine-type cervical HPV infections and 

HPV cervical precancers have declined in the United 

States (Figure 2) and many countries following 

implementation of HPV vaccination programs.17, 34-43

Early evidence suggests that HPV vaccination may 

be contributing to recent declines in cervical cancer 

incidence among young females,44,45 although further 

studies are needed to confirm these findings. In 

addition, lower rates of oral HPV infections have 

been documented among vaccinated compared 

with unvaccinated U.S. men and women (Figure 2).46

Reductions in genital warts also have been observed 

in the years following introduction of the vaccine;34 it is 

predicted that genital warts will be nearly eliminated in 

Australia as a result of HPV vaccination.47

Research Priority: Natural History of Oral HPV Infections

HPV vaccines are not currently approved for prevention of HPV-associated oropharyngeal 

cancers, but based on what is known about the biology of these cancers, it is highly likely the 

vaccines will be protective. To test whether HPV vaccination prevents oropharyngeal cancer, 

the natural history of oral HPV infections must be further elucidated and tools must be 

developed to allow detection of precancers. 

† FDA recently expanded the approved use of Gardasil 9 to include men and women aged 27-45 years. An ACIP decision on 

whether to expand the recommended ages for vaccination is expected to occur in the future. Source: U.S. Food and Drug 

Administration. FDA approves expanded use of Gardasil 9 to include individuals 27 through 45 years old [News Release]. Silver 

Spring (MD): FDA; 2018 Oct 5. Available from: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm622715.htm

PRESIDENT’S CANCER PANEL
4 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action

Figure 2. Prevalence of Cervical HPV Infection, Cervical Precancers, and 

Oral HPV Infection in the HPV Vaccine Era



(

Oral HPV Infections

Males and Females, 18-33 years old

Unvaccinated Vaccinated

88%

lower

71%

decrease

Cervical HPV Infections

Females, 14-19 years old

Cervical Precancers

Females, 15-19 years old

2003-2006 2011-2014 2007 2014

59%

decrease

PRESIDENT’S CANCER PANEL

Note: Cervical and oral infection data represent prevalence of HPV 16/18/6/11 among select National 

Health and Nutrition Examination Survey (NHANES) participants. Oral HPV infection prevalence is based 

on cross-sectional data from NHANES 2011-2014. Cervical precancer data represent prevalence of 

cervical intraepithelial neoplasia grades 2 and 3 among privately insured U.S. female adolescents and 

women. Sources: Oliver SE, Unger ER, Lewis R, et al. Prevalence of human papillomavirus among females 

after vaccine introduction-National Health and Nutrition Examination Survey, United States, 2003-2014. 

J Infect Dis. 2017;216(5):594-603; Flagg EW, Torrone EA, Weinstock H. Ecological association of human 

papillomavirus vaccination with cervical dysplasia prevalence in the United States, 2007-2014. Am J Public 

Health. 2016;106(12):2211-8; Chaturvedi AK, Graubard BI, Broutian T, et al. Effect of prophylactic human 

papillomavirus (HPV) vaccination on oral HPV infections among young adults in the United States. J Clin 

Oncol. 2018;36(3):262-7.

U.S. HPV Vaccine Uptake: 

Progress and Continuing Challenges

When the Panel’s 2012-2013 report on HPV 

vaccination was released, the most recent data 

indicated that only one-third of 13- to 17-yearold females and fewer than 7 percent of males 

had received the recommended three doses.48 

Fortunately, there has been notable progress over 

the past five years. 

HPV vaccination has increased overall. In 2017, 

among those 13 to 17 years old, over half of females 

53%) and more than one-third of males (44%) were 

up to date with respect to HPV vaccination (at least 

two doses for those who received their first HPV 

vaccine dose before age 15 and at least three doses 

for others; Figure 3). More than 65 percent of 

adolescents in this age group had received at 

least one dose of the vaccine, an increase over 

earlier years.7
The Current Landscape of HPV Cancers and HPV Vaccination 5

 HPV vaccination of males has increased.

When the Panel’s 2012-2013 report was released, 

vaccination coverage among adolescent boys 

lagged far behind that of girls, at least in part 

because the ACIP recommendation for boys 

was not issued until 2011. However, this gap is 

narrowing (Figure 3). Large increases in male 

vaccination rates have occurred across every 

stratum of age, race/ethnicity, and poverty level.49

HPV vaccination has increased dramatically in 

some states and regions. In 2017, more than 80 

percent of adolescents in two states (Rhode Island 

and Massachusetts) and the District of Columbia 

initiated the HPV vaccine series.7 Between 2013 and 

2017, the percentage of adolescents who received 

their first dose of the HPV vaccine doubled or nearly 

doubled in four states (Utah, Arkansas, Virginia, 

and Montana). An additional 25 states increased 

one-dose coverage by more than 50 percent during 

this time period.7

Specific examples of successful efforts and programs 

are described later in the report (see Quality 

Improvement Initiative Improves HPV Vaccine Initiation 

and Completion on page 14, Rapid Adoption of the 

HPV Vaccine within a Health System on page 15, and 

School Program Increases HPV Vaccination in Rural 

North Dakota on page 21). Despite this progress, 

U.S. HPV vaccination rates do not meet the Healthy 

People 2020 goal—full vaccination of 80 percent 

of adolescents aged 13-15 years.50 Several statistics 

highlight the need to increase HPV vaccination rates 

throughout the United States. 

Figure 3. Vaccine Uptake Among U.S. Adolescents Aged 13-17 Years, 2006-2017 Percentage Vaccinated

10

20

30

40

50

60

70

80

90

100

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

HPV

Males ACIP Recommendation HPV

Females

Tdap (≥1 dose)

HPV–Females

(≥3 doses)

HPV–Females 

(up to date)

MenACWY (≥1 dose)

HPV–Males

(≥ 3 doses)

HPV–Males

(up to date)

PRESIDENT’S CANCER PANEL

Note: Adolescents were considered to be up to date for HPV if they had received ≥3 doses, or if all of the 

following applied: 1) they had received two doses; 2) the first dose was received before the 15th birthday; and 

3) the interval between the first and second doses was ≥5 months minus 4 days, the absolute minimum interval 

between the first and second doses. NIS-Teen implemented a revised adequate provider definition in 2013 and 

retrospectively applied this definition to 2013 data, which causes a shift in trendlines in 2013. Source: Walker 

TY, Elam-Evans LD, Yankey D, et al. National, regional, state, and selected local area vaccination coverage 

among adolescents aged 13-17 years—United States, 2017. MMWR Morb Mortal Wkly Rep. 2018;67(33):909-17.
6 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action

 HPV vaccination coverage remains lower than 

that of other adolescent vaccines. HPV is one 

of three vaccines recommended for adolescents 

at age 11-12 years—the other two are the tetanus, 

diphtheria, and acellular pertussis vaccine (Tdap) 

and the meningococcal conjugate vaccine 

(MenACWY). In 2017, nearly 90 percent 

of 13- to 17-year-old adolescents received the 

Tdap vaccine, and 85 percent received the initial 

dose of MenACWY vaccine; however, only 49 

percent had received all recommended doses 

of the HPV vaccine.7



HPV vaccination coverage in the United States 

emains lower than in other countries. In 

Australia, in 2016, 79 percent of females and 73 

percent of males had received three doses of the 

HPV vaccine by 15 years of age.51,52 In the United 

Kingdom, in 2016-2017, 83 percent of 13- to 14-yearold females had completed the two-dose HPV 

vaccination series.53 In the United States, however, 

among 13- to 17-year-olds, only 53 percent of 

females and 44 percent of males had received all 

recommended doses.7

HPV vaccine uptake is uneven across the 

United States. HPV vaccination coverage 

varies substantially by state (Figure 4)—rates of 

up-to-date HPV vaccination range from a low of 

29 percent in Mississippi to a high of 78 percent 

in the District of Columbia.7 No state or region 

has achieved the nation’s goal of full vaccination 

of 80 percent of adolescents. HPV vaccination 

rates are particularly low in rural areas, despite 

high uptake of other adolescent vaccines; over 

half of adolescents in urban areas are up to 

date on their HPV vaccination compared with 

only 42 percent in rural areas.7 There also are 

differences in vaccine uptake by race/ethnicity, 

socioeconomic status, and insurance status. The 

reasons for differences between populations are 

not fully understood.

Research Priority: Understanding and Addressing Inequities

Research is needed to elucidate factors that contribute to lower HPV vaccination rates among 

populations with disproportionately high rates of HPV cancers (e.g., rural). Investments in 

implementation research could inform development and scale-up of interventions targeting 

these populations.

PRESIDENT’S CANCER PANEL
The Current Landscape of HPV Cancers and HPV Vaccination 7

Figure 4. Rates of Up-to-Date HPV Vaccination Among U.S. Adolescents

Aged 13-17 Years, 2017

★

As of 2017, overall HPV vaccine coverage among U.S. adolescents 

was 49%. No state had reached the Healthy People 2020 goal of 

full vaccination of 80% of adolescents aged 13-15 years.

55% 

55% 

53% 

49% 

44%

49% 

31% 

54% 

37% 

48% 53% 

40% 

41% 

34% 

58% 

45% 

58% 

47% 

52% 

50% 

54% 

35% 

40% 

53% 

40% 

39% 

54% 

53% 

54% 

VT 65% 

46% 

42% 

29% 

38% 

43%

52% 

MD 53% 47% DE 58% 

41% 44% 

NJ 50% 

CT 58% 

MA 66% 

59% 

RI 78% 

59% 

NH 60% 

DC 78% 

55% 

43% 

≥ 60% 

40-49% 

≤ 39% 

50-59% 

PRESIDENT’S CANCER PANEL

Source: Walker TY, Elam-Evans LD, Yankey D, et al. National, regional, state, and selected local area vaccination 

coverage among adolescents aged 13-17 years—United States, 2017. MMWR Morb Mortal Wkly Rep. 

2018;67(33):909-17.
8 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action

PRESIDENT’S CANCER PANEL
PRESIDENT’S CANCER PANEL

GOALS AND OPPORTUNITIES

TO INCREASE HPV VACCINE 

UPTAKE

The Panel’s 2012-2013 report identified three goals 

to increase HPV vaccine uptake in the United 

States: reduce missed clinical opportunities for HPV 

vaccination, increase parents’ acceptance of the 

vaccine, and maximize access to HPV vaccination. 

A fourth goal was to promote global HPV vaccine 

uptake. While there has been progress toward these 

goals, HPV vaccine coverage is still too low to achieve 

its cancer prevention potential. The benefits of HPV 

vaccination have become even more evident over 

the past five years. Several organizations—including 

the World Health Organization, American Cancer 

Society (ACS), NCI-designated cancer centers, and 

International Papillomavirus Society—have concluded 

that HPV vaccination could dramatically reduce or even 

eliminate cervical cancer as a public health problem 

when used in combination with cancer screening.54-58 

Research and discussions with key stakeholders on the 

current landscape of HPV cancers and HPV vaccination 

led the Panel Chair to conclude that the goals outlined 

in the 2012-2013 report are still relevant. The following 

sections describe priorities and strategies—informed 

by research and real-world experiences over the past 

five years—that will help achieve these goals. Several 

research priorities also are highlighted throughout the 

report, complementing research gaps that have been 

identified by others.59

The coalescence of a critical mass of dedicated 

stakeholders (see Partnerships and Collaborations 

Are Essential to Promote HPV Vaccine Uptake on 

page 10), accumulation of data on the benefits of 

HPV vaccination, and increasing awareness and 

acceptance of the vaccines among healthcare 

providers and the public has created momentum 

and opportunity to achieve the goals outlined in this 

report. This opportunity must be seized to accelerate 

HPV vaccine uptake and achieve the potential of 

vaccination to reduce dramatically the number of HPV 

cancers in the United States and around the world. 

Efforts to increase HPV vaccination should consider 

the changing landscape of healthcare delivery in the 

United States. Trends such as the increasing popularity 

of retail clinics60 and the consolidation of providers 

within larger healthcare systems61 may present both 

challenges to and opportunities for increasing 

HPV vaccination.

Goals and Opportunities to Increase HPV Vaccine Uptake 9
Partnerships and Collaborations Are Essential to Promote HPV Vaccine Uptake 

In its earlier report, the Panel stated that increasing HPV vaccine levels would require concerted action by 

multiple organizations and individuals. Since that time, many key stakeholders have forged or enhanced 

collaborations and partnerships to identify and take concrete steps to address barriers to HPV vaccination. 

These have included unprecedented partnerships among cancer control and immunization experts. A 

few examples of partnerships and collaborations—catalyzed, in part, by the 2012-2013 Panel report—are 

described below. 

The Panel Chair urges continued stakeholder collaborations and partnerships in implementing proven 

strategies to increase vaccination rates among all populations to target levels. Local and regional 

partnerships will be particularly important for identifying local barriers and solutions to HPV vaccine uptake. 

Partner organizations should include state immunization and cancer control programs, state cancer plans, 

providers and provider organizations, survivors, advocacy organizations, vaccine manufacturers, and others. 

The Centers for Disease Control and Prevention (CDC), National Cancer Institute (NCI), and other funding 

organizations should continue to support partnerships and collaborations aimed at HPV vaccination. 

National HPV Vaccination Roundtable

The National HPV Vaccination Roundtable—hosted by the American Cancer Society and funded in large part 

by CDC—was formed in 2015 to convene stakeholders, facilitate information exchange, identify gaps, and 

catalyze efforts to increase U.S. HPV vaccine coverage. More than 75 organizations representing public health, 

academia, advocacy organizations, professional societies, industry, and state and federal agencies participate in 

the Roundtable. Task groups bring together member organizations to work on key topics, such as provider 

training and state HPV coalitions. The Roundtable also maintains a resource library with materials for a variety of 

stakeholders and audiences. 

NCI-Designated Cancer Centers

The NCI Cancer Centers Program provides support for 70 centers across the country that meet rigorous 

standards for transdisciplinary research programs focused on developing new and improved approaches 

for cancer prevention, diagnosis, and treatment. In July 2014, NCI provided supplemental funding to 18 

NCI-designated cancer centers to help address HPV vaccination in their respective catchment areas. Each 

cancer center conducted an environmental scan to identify local barriers and facilitators to HPV vaccination 

and developed linkages with existing coalitions and programs in the state or region (e.g., healthcare providers, 

health departments, immunization coalitions). 

Although funding was for only one year, the cancer centers have maintained their commitment to increasing 

HPV vaccination. Each year since 2015, a different cancer center has hosted a meeting to enable centers to learn 

from and work with one another. State and regional coalitions formed during the funding period—including the 

Alabama HPV Vaccination Coalition and the Intermountain West HPV Vaccination Coalition—are still active. NCI 

provided funding to an additional 12 cancer centers in 2017 to promote HPV vaccine uptake.

Sources: Saslow D, Sienko J, Nkonga JLZ, Brewer NT. Creating a National Coalition to Increase Human Papillomavirus 

Vaccination Coverage. Acad Pediatr. 2018;18(2S):S11-S3; National HPV Vaccination Roundtable. Home page [Internet]. 

Atlanta (GA): the Roundtable; [cited 2018 Jul 6]. Available from: http://hpvroundtable.org/; National Cancer Institute 

Division of Cancer Control and Population Sciences. Administrative supplements for NCI-designated cancer centers to 

support collaborations to enhance HPV vaccination in pediatric settings: a summary report. Bethesda (MD): NCI DCCPS; 

2016 Jun. Available from: https://healthcaredelivery.cancer.gov/hpvuptake/DCCPS_HPVvax-report_FINAL_508compliant.

pdf; National Cancer Institute. HPV vaccine uptake in cancer centers [Internet]. Bethesda (MD): NCI; [cited 2018 Jul 6]. 

Available from: https://healthcaredelivery.cancer.gov/hpvuptake

PRESIDENT’S CANCER PANEL

10 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action
Goal 1

Reduce Missed Clinical 

Opportunities to Recommend 

and Administer the HPV Vaccine.

In its 2012-2013 report, the Panel recommended 

development of communication strategies and systems 

changes to ensure that all eligible adolescents and 

young adults were offered the HPV vaccine when 

they visited their healthcare providers. Since that 

time, the Centers for Disease Control and Prevention 

(CDC) launched a multipronged campaign aimed at 

improving clinicians’ practices, recognizing HPV vaccine 

champions, and supporting health systems.62-64 The 

American Academy of Pediatrics (AAP), American 

Academy of Family Physicians (AAFP), and other 

health professional associations have urged their 

members to recommend vaccination strongly 

and developed resources to support increases in 

uptake (see Professional Organizations Urge Strong 

Recommendations below).65-69 Several interventions 

targeting provider HPV vaccine knowledge and 

practices also have been developed.70,71

The commitment of these groups and the efforts 

of many healthcare providers undoubtedly have 

contributed to increases in HPV vaccination observed 

in recent years. Their roles in progress achieved 

to date should be commended. Yet, too many 

adolescents continue to leave their doctors’ offices 

without receiving the HPV vaccine, even when they 

have received other recommended vaccines.7,72-74 One 

study of girls who had not received the HPV vaccine 

by 13 years of age found that 80 percent had had 

healthcare encounters during which another vaccine 

was administered.73 If the HPV vaccine had been 

given at all of these visits, HPV vaccine initiation rates 

would have reached nearly 90 percent. The Panel 

Chair emphasizes strongly that provider- and 

systems-level changes hold the greatest potential 

for eliminating missed clinical opportunities, 

normalizing HPV vaccination, and ensuring that 

U.S. adolescents and future generations are 

optimally protected from HPV cancers.75 

CDC, AAP, AAFP, and others have 

effectively promoted HPV vaccination 

through provider education, training, and 

resource development.

Professional Organizations Urge Strong Recommendations 

In 2014, several health professional organizations—the American Academy of Family 

Physicians, American Academy of Pediatrics, American College of Obstetricians and 

Gynecologists, and American College of Physicians—partnered with the Centers for 

Disease Control and Prevention and Immunization Action Coalition to urge their members 

to firmly and strongly recommend HPV vaccination to their patients. Many providers 

reported improving their HPV vaccine communication after receiving information from their 

professional organizations. 

Sources: American Academy of Family Physicians, American Academy of Pediatrics, American College 

of Obstetricians and Gynecologists, American College of Physicians, Centers for Disease Control and 

Prevention, Immunization Action Coalition. Letter to: Colleagues 2014. Available from: http://www.

immunize.org/letter/recommend_hpv_vaccination.pdf; Hswen Y, Gilkey MB, Rimer BK, Brewer NT. 

Improving physician recommendations for human papillomavirus vaccination: the role of professional 

organizations. Sex Transm Dis. 2017;44(1):42-7.

PRESIDENT’S CANCER PANEL

Goals and Opportunities to Increase HPV Vaccine Uptake 11
Strong Provider Recommendations 

Are Needed

Provider recommendation is one of the strongest 

predictors of adolescent HPV vaccine uptake, even 

stronger than often-studied factors such as race/

ethnicity, insurance status, knowledge of HPV, and 

perceptions about HPV vaccine effectiveness and 

safety.76,77 Most physicians who provide care for 

adolescents say they recommend HPV vaccination,78,79

and surveys of parents suggest that providers are more 

likely to recommend the HPV vaccine now than in the 

past.80,81 However, too many parents of age-eligible 

adolescents do not recall receiving a recommendation 

from their children’s healthcare providers.77,80,81

How the vaccine is recommended is important. Studies 

have found that providers often deliver weak or unclear 

recommendations for the HPV vaccine (e.g., presenting 

the vaccine as being optional, less important, or less 

urgent than other adolescent vaccines).76,77,82,83 These 

recommendations may be sufficient for parents who 

already hold favorable views of HPV vaccination, but they 

are less likely to convince parents who have questions or 

uncertainties to vaccinate their adolescents.

CDC urges providers to deliver a clear, concise, 

and strong recommendation for same-day HPV 

vaccination.62 The vaccine’s efficacy in preventing 

cancer should be emphasized.77 Children of parents 

who received high-quality recommendations aligned 

with these guidelines are more likely to initiate and 

complete the HPV vaccine series than those of parents 

who received a low-quality or no recommendation.77

The Panel Chair urges health care providers to 

strongly recommend HPV vaccination for all eligible 

adolescents. Recommendations are most likely to be 

effective if providers:

 Use announcement language. Brief statements 

that assume parents are ready to vaccinate are 

associated with higher vaccine uptake than are 

open-ended, conversational approaches.84-87

Announcements may be particularly effective 

for parents who are ambivalent or uncertain 

about HPV vaccination because these types of 

statements present vaccination as the social norm 

and affirm the provider’s confidence in safety 

and effectiveness of the vaccine.75 Open-ended 

discussions should be reserved for instances in 

which parents raise specific questions or concerns.

 Bundle with other adolescent vaccines. The HPV 

vaccine should be recommended at the same 

time and in the same way as other recommended 

adolescent vaccines, with HPV cancer prevention 

in the middle of the list (your son/daughter is due 

for vaccinations to help protect him/her from 

meningitis, HPV cancers, and whooping cough).62,88

 Focus on vaccination of young adolescents. 

Although ACIP recommends routine HPV 

vaccination of 11- and 12-year-olds, providers are 

more likely to recommend the vaccine strongly 

to older adolescents.77 Providers should strongly 

recommend same-day HPV vaccination for all 

of their 11- and 12-year-old patients unless it is 

contraindicated. If parents suggest delaying 

vaccination, providers should emphasize that the 

vaccine is most effective when administered well 

before HPV exposure.89 Additionally, younger 

adolescents exhibit strong immune responses 

following vaccination,90 and those who initiate the 

series before 15 years of age require only two doses 

instead of three. Providers also should recommend 

the vaccine to older adolescents and young adults 

who have not completed the recommended series.

 Promote vaccination of boys and girls equally. 

Providers are less likely to consistently and 

strongly recommend HPV vaccination of 

boys than of girls,77-79 and parents of boys 

are more likely than those of girls to cite lack 

of provider recommendation as a reason for 

nonvaccination.80,81 Providers should deliver strong 

recommendations for both girls and boys to 

ensure that recent increases in vaccine coverage 

among boys continue. Males account for a growing 

proportion of HPV cancers in the United States 

due to the increasing incidence of HPV-associated 

oropharyngeal cancers.16,91,92

PRESIDENT’S CANCER PANEL

12 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action
 Repeat recommendations as needed. Some 

parents respond to a provider’s recommendation 

with hesitance or refusal. Many of these parents will 

decide to vaccinate their children at the same visit 

if providers persist in identifying and addressing 

parents’ questions and concerns, reemphasize 

the importance of the vaccine, and restate the 

recommendation.93 Furthermore, a significant 

proportion of parents who initially decline HPV 

vaccination will accept it at a future visit. One study 

found that provider recommendations, particularly 

high-quality recommendations, played an 

important role in subsequent vaccine acceptance.94 

CDC and health professional organizations (e.g., AAP, 

AAFP) should continue to promote strong, clear provider 

recommendations for HPV vaccination. CDC should 

continue to develop and provide resources to support 

providers. Studies have found that providers in rural areas 

are less likely to recommend the vaccine,95,96 and family 

physicians are somewhat less likely than pediatricians 

to consistently and strongly recommend the HPV 

vaccine.78,79,97 Increasing the quality of recommendations 

delivered in rural settings, which are commonly 

served by family practice physicians,98 may increase 

low vaccination rates observed in many rural areas. 

Continued monitoring also is needed to ensure that 

vaccine financing issues (e.g., provider concerns about 

upfront costs of the vaccine, inadequate reimbursement) 

do not interfere with access to the HPV vaccine or create 

disincentives for strong provider recommendations. 

Systems-Level Efforts Facilitate Vaccination

Systems-level policies and practices have potential 

to drive substantial, enduring improvements in 

HPV vaccination rates by minimizing missed clinical 

opportunities, facilitating vaccine access, and 

promoting acceptance and normalization of the 

vaccine. Clinical practices, healthcare systems, and 

public health departments should identify and adopt 

strategies to increase their HPV vaccination rates. 

Programs that implement multiple strategies are 

more likely to be successful.70 Analyses of successful 

programs and experiences with other vaccines and 

cancer prevention and screening recommendations 

have identified several evidence-based approaches to 

promote HPV vaccination, including:70,71,75,97,99-109

 Conduct training. Providers should be trained to 

deliver strong recommendations and address 

common parent questions and concerns, including 

those about safety. 

Engage all office staff in vaccination efforts. All 

office staff who interface with patients should be 

trained to ensure consistent, positive messaging 

about the vaccine. A vaccine champion and quality 

improvement team can foster a provaccination 

culture and promote positive change. 

Use a tracking system. It is critical to reliably 

identify patients due or overdue for vaccination 

and monitor vaccination rates. Tracking systems 

can be embedded within or integrated with 

electronic health records (EHRs). Integration with 

state immunization information systems (IIS) would 

enhance tracking capacity. 

Prompt healthcare providers. Clinicians should 

be informed when a patient is due or overdue for 

HPV vaccination. Prompts can be automatically 

generated by EHR systems or manually noted 

based on review of patients’ charts prior to their 

appointments.

Implement standing orders. Standing orders, 

which allow nurses or other medical personnel to 

administer vaccines using an established protocol 

without a direct order from a physician, increase 

vaccination rates in many settings. 

Send reminders. Parents should be informed when 

their children are due for a vaccine dose. One or 

more effective reminder methods can be used (e.g., 

phone, letter, email, text, EHR-based message), an 

approach that can be especially effective when 

handled in a centralized way. 

Facilitate access. Providing walk-in or immunizationonly appointments can make it easier for patients 

PRESIDENT’S CANCER PANEL

Goals and Opportunities to Increase HPV Vaccine Uptake 13


Quality Improvement Initiative Improves HPV Vaccine 

Initiation and Completion

The American Cancer Society’s HPV Vaccinate Adolescents Against Cancers (VACs) program 

partners with primary care practices, health plans, hospital systems, and state entities to 

strengthen regional HPV vaccination efforts. Quality improvement (QI) partnerships are a core 

focus of the program. In 2017, VACs staff engaged Federally Qualified Health Centers (FQHCs) 

in evidence-based QI interventions, including an intensive learning collaborative that awarded 

Maintenance of Certification and Continuing Medical Education credits. About 40 participating 

FQHCs, comprising 119 clinic sites, increased their HPV vaccine series initiation rates by an average 

of 16 percentage points. Series completion rates rose by 18 percentage points, on average. 

Source: American Cancer Society. HPV Vaccinate Adolescents Against Cancers: activity and impact 

report, 2017-2018. Atlanta (GA): ACS; 2018. Available from: https://www.mysocietysource.org/sites/HPV/

ResourcesandEducation/CDC%20Annual%20Report%20%20Test/2018/VACs%202017-2018%20Activity%20

and%20Impact%20Report.pdf

PRESIDENT’S CANCER PANEL

14 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action

t o receive the vaccine, particularly second or 

third doses. The vaccine should be offered 

opportunistically at all types of appointments 

unless contraindicated (e.g., well child, sick child, 

sports physicals).

Implement quality improvement initiatives. 

Provider-, clinic-, and systems-level vaccination 

rates should be monitored and shared to provide 

accountability and incentivize improvement. 

Education and quality improvement programs 

focused on HPV vaccination could be implemented 

to meet requirements for board certification 

(i.e., Maintenance of Certification; see Quality 

Improvement Initiative Improves HPV Vaccine 

Initiation and Completion above).

The Panel Chair urges health system leaders to 

make HPV vaccination a high, measurable priority. 

Implementation of systems changes within large 

health systems could facilitate HPV vaccination of large 

numbers of adolescents and potentially increase overall 

vaccine coverage rates within geographic regions 

served. Some health systems already have established 

systems-level processes to support HPV vaccination, 

resulting in coverage rates well above the national 

average (see Rapid Adoption of the HPV Vaccine within 

a Health System on page 15).97,99 Clinics and health 

systems should use resources shown to be effective in 

increasing HPV vaccination. These include resources 

developed by organizations such as the CDC,63,110

AAP,69 the American Cancer Society,88 and the 

National HPV Vaccination Roundtable.111,112 Advocacy 

organizations, health professional organizations, state 

vaccine coalitions, National Cancer Institute-designated 

cancer centers, and state health officials should engage 

health systems within their regions to encourage 

prioritization of HPV vaccination and implementation 

of practices and policies to increase coverage rates. 

The updated HEDIS measure for adolescent 

vaccines promotes bundling of HPV with 

other recommended vaccines.

Clinics and healthcare systems are motivated by quality 

metrics established by external bodies. Healthcare 

Effectiveness Data and Information Set (HEDIS) 

quality measures are used as the basis of health plan 

accreditation by the National Committee for Quality 

Assurance and are used by health plans themselves to 

drive improvements in quality of care and services.113 

The updated measure for adolescent immunizations in 

HEDIS 2017 assesses the proportion of all adolescents 
The Healthy People 2020 goal for HPV 

vaccines now includes both girls and boys. 

who receive all recommended vaccines (meningococcal, 

Tdap, HPV) by their thirteenth birthdays.114 This should 

provide incentives for providers and healthcare systems 

to bundle their recommendations for all adolescent 

vaccines and may help raise HPV vaccine coverage to 

the level of the other vaccines. The 2014 addition of a 

Healthy People 2020 goal focused on males 

may encourage gender-neutral vaccination.50 The 

Panel Chair agrees with the National Vaccine Advisory 

Committee that the Health Resources and Services 

Administration (HRSA) should include a measure for 

HPV vaccination of adolescents in the Uniform Data 

System, the required reporting system for HRSA 

grantees in community health centers, migrant health 

centers, health centers for homeless grantees, and 

public housing primary care organizations.4

Rapid Adoption of the HPV Vaccine within a Health System

Denver Health, an integrated urban safety net health system that serves more than 17,000 adolescents 

each year, has implemented several processes to facilitate vaccine uptake. The internally developed 

immunization registry (VaxTrax) creates a list of vaccines for which each patient is due. Vaccines are offered 

at every visit (even if they were previously declined), and providers are encouraged to bundle all adolescent 

vaccines together when recommending them. Standing orders allow adolescent vaccines, including the 

HPV vaccine, to be administered by a medical assistant. These processes contributed to rapid uptake of 

the HPV vaccine within Denver Health clinics. By 2014, nearly 90 percent of girls and boys (ages 13-17) had 

received at least one dose of the HPV vaccine. In contrast, national rates for 13- to 17-year-old girls and 

boys in 2014 were 60 percent and 42 percent, respectively. 

ACIP Recommendation

Percentage Who Received ≥1 Dose HPV Vaccine

10

20

30

40

50

60

70

80

90

100

2006 2007 2008 2009 2010 2011 2012 2013 2014

Females Males

Females – Denver Health

Females – U.S.

Males – Denver Health

Males – U.S.

PRESIDENT’S CANCER PANEL

Goals and Opportunities to Increase HPV Vaccine Uptake 15

Sources: Farmar AM, Love-Osborne K, Chichester K, et al. Achieving high adolescent HPV vaccination coverage. Pediatrics. 

2016;138(5); Walker TY, Elam-Evans LD, Yankey D, et al. National, regional, state, and selected local area vaccination 

coverage among adolescents aged 13-17 years—United States, 2017. MMWR Morb Mortal Wkly Rep. 2018;67(33):909-17.
Goal 2

Increase Parents’ Acceptance of 

HPV Vaccination.

Parents and legal guardians are the primary decision 

makers about adolescent vaccination, particularly at 

the recommended ages for routine vaccination (11 

to 12 years old).115 HPV vaccination increasingly is a 

standard part of care for U.S. adolescents. The majority 

of parents have their children vaccinated against HPV. 

In 2017, more than 65 percent of 13- to 17-year-old 

adolescents had received at least one dose of the HPV 

vaccine.7 Surveys of parents of unvaccinated teens 

indicate that a growing proportion are accepting of 

their children receiving the vaccine,81 and many parents 

who initially decline the vaccine eventually accept it.94

This progress is likely due, in part, to communication 

campaigns—such as those carried out by the CDC,116

ACS,117 and Merck & Co.118—and promotion of the 

vaccine by a growing number of healthcare providers. 

However, more must be done to increase acceptance of 

the HPV vaccine. A 2015 survey found that about half of 

parents of unvaccinated teens did not intend to have 

their children vaccinated against HPV.81 No single 

reason predominated, but common reasons cited by 

parents included:80,81

 Vaccination not needed 

Vaccination not recommended by healthcare 

provider 

Lack of knowledge about the vaccine or diseases 

caused by HPV 

Concerns about safety and side effects 

Son or daughter not sexually active

The Panel Chair encourages CDC, ACS, and other 

trusted organizations to continue to develop and 

deploy evidence-based communication campaigns 

to increase parents’ acceptance of HPV vaccination. 

It is important that parents have access to clear, 

accurate information about HPV vaccination, particularly 

if they have questions or concerns. Key messages 

may include: 









The HPV vaccine prevents cancers and other 

diseases in both girls and boys.

The HPV vaccine prevents six cancers and

other diseases.

The HPV vaccine is safe.

The HPV vaccine is most effective when 

administered to young adolescents, well before 

they are exposed to HPV.

Campaigns should build on current knowledge and 

use existing materials whenever possible. Use of 

multiple tools and modes of communication will reach 

as many parents as possible. Strategies are needed 

to directly reach older adolescents and young adults 

who may make their own decisions about vaccination. 

Targeted campaigns may be needed in some cases 

to counteract widely circulated misinformation (see 

Addressing Misinformation on page 17). 

While communication campaigns play an important 

role in multipronged approaches to increase HPV 

vaccine uptake, evidence suggests that interventions 

designed to influence parents’ knowledge, thoughts, 

and feelings are likely to only modestly affect 

vaccination rates and may be most effective when 

a vaccine is new.75,103 Ensuring that providers make 

strong recommendations and address parents’ 

questions and concerns likely will be the most 

effective way to increase parents’ acceptance of HPV 

vaccination and boost vaccine uptake (see Goal 1). 

Systems- and community-level interventions also may 

facilitate access to the vaccine so that parents with 

positive or neutral views of HPV vaccination have their 

children initiate and complete the series (see Goal 1 

and Goal 3).

PRESIDENT’S CANCER PANEL

16 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action
Addressing Misinformation

Misinformation about the HPV vaccine can be spread widely and quickly through social media and 

traditional media outlets, often with dire effects. Widespread dissemination of misinformation about 

safety has resulted in dramatic decreases in HPV vaccination in several countries, including Japan, Ireland, 

Colombia, Denmark, Romania, and India, leaving thousands of young people vulnerable to HPV cancers. 

In some cases, vaccination programs have even been terminated. Effective communication campaigns 

before and during vaccine rollout may make the general public less susceptible to misinformation. Effective 

crisis communication and leadership by policymakers are essential to prevent misinformation from having 

dramatic negative effects on coverage.

Once misinformation about vaccines takes hold, it can be exceedingly difficult to debunk. Contrasting 

myths with facts is often ineffective, and, in some cases, even reinforces false beliefs. There have been 

some success stories. Multipronged campaigns in both Ireland and Denmark have begun to reverse 

dramatic drops in HPV vaccine coverage precipitated by spread of misinformation about safety through 

the media. In both countries, coverage fell from around 90 percent to 50 percent or less. Both campaigns 

have involved multiple stakeholders, including policymakers, and have disseminated accurate information 

through multiple outlets. More research is needed to better understand how and why misinformation 

spreads, examine the role of media and policymakers in fostering or halting HPV vaccine coverage collapse, 

and develop better ways to effectively combat it. 

Strategies that have been recommended to help overcome misinformation include: 

 Keep key messages simple. 

Emphasize core facts, not the myth.

Give explicit warnings before mentioning a myth. 

Provide an alternative explanation to fill gaps left by debunking the myth.

Emphasize scientific consensus about the benefits of HPV vaccination. 

Use visuals to convey core facts whenever possible. 

Stakeholders, including national and local governments, advocacy groups, and others, should monitor 

the emergence of messages with potential to undermine confidence in the vaccine and quickly mobilize 

tailored responses. It is rarely possible to change the minds of people who strongly oppose vaccination; 

rather, the goal should be to provide the general public with accurate information from credible sources to 

make them more resilient to unsubstantiated anti-vaccine statements and stories.

PRESIDENT’S CANCER PANEL

Goals and Opportunities to Increase HPV Vaccine Uptake 17
Sources: Corcoran B, Clarke A, Barrett T. Rapid response to HPV vaccination crisis in Ireland. Lancet. 2018;391(10135):2103; 

Cordoba V, Tovar-Aguirre OL, Franco S, et al. Barriers and facilitators of human papillomavirus (HPV) vaccination during the 

implementation of the school-based HPV vaccine program in Manizales, Colombia [poster]. Presented at: ASCO Annual 

Meeting; 2018; Chicago, IL: Journal of Global Oncology. Available from: http://ascopubs.org/doi/abs/10.1200/jgo.18.11000; 

World Health Organization. Denmark campaign rebuilds confidence in HPV vaccination [Internet]. Geneva (CH): WHO; 2018 

Feb [cited 2018 Aug 28]. Available from: http://www.who.int/features/2018/hpv-vaccination-denmark/en/; Penta MA, Baban 

A. Mass media coverage of HPV vaccination in Romania: a content analysis. Health Educ Res. 2014;29(6):977-92; Sabeena 

S, Bhat PV, Kamath V, Arunkumar G. Global human papilloma virus vaccine implementation: an update. J Obstet Gynaecol 

Res. 2018;44(6):989-97; Pluviano S, Watt C, Della Sala S. Misinformation lingers in memory: failure of three pro-vaccination 

strategies. PLoS One. 2017;12(7):e0181640; World Health Organization Regional Office for Europe. Best practice guidance: 

how to respond to vocal vaccine deniers in public. Copenhagen (DK): WHO Regional Office for Europe; 2017. Available 

from: http://www.euro.who.int/__data/assets/pdf_file/0005/315761/Best-practice-guidance-respond-vocal-vaccine-denierspublic.pdf; Cook J, Lewandowsky S. The debunking handbook (version 2). St. Lucia (AT): University of Queensland; 2012 

Jan. Available from: https://www.skepticalscience.com/docs/Debunking_Handbook.pdf

PRESIDENT’S CANCER PANEL

18 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action

Research Priority: Harnessing Social Media

Social media use has grown dramatically over the past decade. Research is needed to 

identify ways to effectively use social media to spread research-tested messages about HPV 

and HPV vaccination. 

Goal 3

Maximize Access to 

HPV Vaccination Services.

Ensuring that HPV vaccination is affordable and 

convenient for all U.S. adolescents will support 

optimal vaccine uptake. Access barriers likely play 

a role in low and uneven HPV vaccine uptake in the 

United States. These barriers—and approaches for 

addressing them—may differ across geographic 

regions, populations, and clinical settings. National, 

regional, and local efforts are needed to understand 

and address existing and potential barriers to access.

Coverage for HPV Vaccination Costs 

Must Be Maintained

The HPV vaccine is among the most expensive 

vaccines in the United States,119 but multiple sources 

of private and public financing ensure that the cost 

of the vaccine is covered for nearly all age-eligible 

adolescents.120 The Affordable Care Act requires 

private insurance plans and marketplace plans to 

cover all ACIP-recommended immunizations, including 

the HPV vaccine, with no consumer cost sharing.121

The vaccine also is available through the Vaccines 

for Children (VFC) Program for children under age 19 

who are Medicaid-eligible, uninsured, underinsured, 

or American Indian/Alaska Native. HPV vaccine costs 

also are covered by Medicaid, state Children’s Health 

Insurance Programs, and Merck-sponsored patient 

assistance programs.120 The Panel Chair asserts that 

insurance coverage for preventive services must be 

maintained to ensure that cost does not limit U.S. 

adolescents’ access to HPV vaccination. 

Alternative Settings May Expand Access 

to HPV Vaccination in Some Situations

Ideally, all adolescents would receive regular 

care—including immunizations—from a provider with 
whom they have an ongoing relationship. However, 

many adolescents do not receive regular preventive 

care through medical homes.122 In its 2012-2013 report, 

the Panel recommended that, for those adolescents, 

HPV vaccination be promoted and facilitated in 

venues outside the medical home, citing pharmacies 

and schools as potential sites within the “medical 

neighborhood” that could increase access to HPV 

vaccination. Since that time, these venues have been 

explored by various groups in different settings, and 

a clearer picture of the associated challenges and 

opportunities has emerged. 

Both pharmacies and schools have potential to 

provide convenient access to HPV vaccination. Nearly 

90 percent of U.S. residents live within five miles of a 

community pharmacy;123 pharmacies often have longer 

operating hours and shorter wait times than doctors’ 

offices and many provide walk-in vaccinations. Schools 

also provide the opportunity to reach the vast majority 

of adolescents, and school-based HPV vaccination 

programs have been highly successful in many 

countries around the world.34 In the United States, 

pharmacies and schools have not played major roles 

in HPV vaccination to date due to several challenges 

(see Challenges Associated with HPV Vaccination in 

Pharmacies and Schools on page 20). 

Given these challenges, it is unlikely that HPV 

vaccination in pharmacies or schools will contribute 

to substantial increases in national HPV vaccination 

rates in the near future. However, alternative settings 

may expand access in some situations. Offering and 

promoting HPV vaccination in schools, pharmacies, 

and other sites within the medical neighborhood may 

be particularly useful in rural areas, which have fewer 

primary care physicians per capita than urban areas 

and greater obstacles to access.124 School-located 

programs have helped increase coverage rates in 

some areas (see School Program Increases HPV 

Vaccination in Rural North Dakota on page 21).125,126 

The small but growing number of school-based health 

centers—which provide comprehensive healthcare 

services, have dedicated staff, and often serve large 

numbers of VFC-eligible students—may be able to 

more easily overcome the most common barriers to 

school-located vaccination.126,127 

State and local laws, local cultural factors, potential 

partner organizations, and available resources should 

be considered when exploring options to increase 

access to HPV vaccination. Providers and programs 

in alternative settings should communicate and 

coordinate with primary care providers to the extent 

possible, including reporting all administered vaccine 

doses to the state’s immunization information system 

(IIS). The Panel Chair supports the call by the National 

Vaccine Advisory Committee4 for greater investment 

and commitment to promote interoperability of 

electronic health record systems and IIS. Once 

interoperability is achieved, states should consider 

requiring providers to report vaccinations to IIS to 

ensure that all vaccine providers have access to 

complete, timely information. 

PRESIDENT’S CANCER PANEL

Goals and Opportunities to Increase HPV Vaccine Uptake 19
Challenges Associated with HPV Vaccination in 

U.S. Pharmacies and Schools

Pharmacies

 Restricted authority in some states—Pharmacists in 48 states and the District of Columbia 

have authority to administer the HPV vaccine, but 11 of these states do not allow HPV 

vaccination of 11- and 12-year-old children and several other states require a physician 

prescription or protocol.





Inadequate insurance coverage—Many private insurance plans do not cover or provide 

inadequate coverage for vaccine administration within pharmacies. Relatively few 

pharmacists are VFC providers. Some states do not enroll pharmacies in VFC, while 

pharmacies in other states may elect not to participate in the program due to the 

cumbersome requirements.

Low demand—Pharmacists who stock the HPV vaccine report providing very few doses, 

and parents consider doctors’ offices to be a better environment than pharmacies for 

adolescent vaccination. 

Schools

 Complicated billing—Students within a school or school district may be covered by a range of 

private insurance plans and public programs, which makes billing cumbersome and costly. 

Competing priorities—Schools have limited resources and must focus these resources on 

education and other priorities (e.g., transporting students, meals). 

Low demand—Surveys of parents suggest support for school-located vaccination, but most 

say they prefer their adolescents to be vaccinated in providers’ offices. Participation in schoollocated HPV vaccination programs to date has generally been low in the United States. 

Sources: Islam JY, Gruber JF, Lockhart A, et al. Opportunities and challenges of adolescent and 

adult vaccination administration within pharmacies in the United States. Biomed Inform Insights. 

2017;9:1178222617692538; Barden S. National HPV Vaccination Roundtable Pharmacy-located HPV 

Vaccination Pilot Project: final report. Lansing (MI): Michigan Pharmacists Association; 2018. Available from: 

http://hpvroundtable.org/wp-content/uploads/2018/02/Pharmacy-located-HPV-Vaccination-Pilot-FinalReport_MI.pdf; Curry S, Vanderpool R, Lopez K, et al. National HPV Vaccination Roundtable Pharmacy-Located 

HPV Vaccination Pilot Project: final report. Carrboro (NC): Cancer Prevention and Control Research Network; 

n.d. Available from: http://hpvroundtable.org/wp-content/uploads/2018/02/CPCRN_Pharmacy-locatedHPV-Vaccination_Pilot-Project-Findings-from-IA_KY_OR.pdf; Hastings TJ, Hohmann LA, McFarland SJ, et al. 

Pharmacists’ attitudes and perceived barriers to human papillomavirus (HPV) vaccination services. Pharmacy 

(Basel). 2017;5(3); Shah PD, Marciniak MW, Golden SD, et al. Pharmacies versus doctors’ offices for adolescent 

vaccination. Vaccine. 2018;36(24):3453-9; American Pharmacists Association. Pharmacist authority to immunize 

by type of immunization [Internet]. Washington (DC): APhA; [updated 2018 Jan 18; cited 2018 Jun 28]. Available 

from: https://www.pharmacist.com/immunization-center; Daley MF, Kempe A, Pyrzanowski J, et al. Schoollocated vaccination of adolescents with insurance billing: cost, reimbursement, and vaccination outcomes. J 

Adolesc Health. 2014;54(3):282-8; Kempe A, Allison MA, Daley MF. Can school-located vaccination have a major 

impact on human papillomavirus vaccination rates in the United States? Acad Pediatr. 2018;18(2S):S101-S5. 

PRESIDENT’S CANCER PANEL

20 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action
School Program Increases HPV Vaccination in Rural North Dakota

Access to healthcare is limited in many rural counties in North Dakota. In 2012, some of 

these counties had rates of HPV vaccine series completion as low as 10 percent. To address 

this, the North Dakota cancer control and state immunization programs partnered with 

local public health units, schools, and communities to implement an in-school vaccination 

program. Vaccinations were provided during school hours in 20 middle and high schools 

in 4 counties. Parents provided information on insurance coverage and Vaccines for 

Children Program eligibility. Public health units billed insurance companies, Medicaid, or 

parents, as appropriate, to cover vaccine costs and administration fees. In one participating 

county, coverage rates increased by 18 percent within two years, and the program became 

self-sustaining in three years. The success of this program was attributed to the strong 

collaborative efforts of the North Dakota state immunization and comprehensive cancer 

control programs to inform parents of the need for the vaccine and increase access to it.

Sources: Pastir J. School HPV immunization clinics increase vaccination rates in North Dakota. Atlanta 

(GA): Centers for Disease Control and Prevention; 2017 Nov 30. Available from: https://nccd.cdc.

gov/nccdsuccessstories/showdoc.aspx?s=14291&dt=0; Personal communication with Janna Pastir 

(Comprehensive Cancer Prevention and Control Program, North Dakota Department of Health, Bismarck, 

ND) and Molly Howell (Division of Disease Control, North Dakota Department of Health, Bismarck, ND). 

2018 Aug.

Goal 4

Promote Global HPV Vaccine Uptake.

HPV was responsible for nearly 630,000 cases of cancer 

worldwide in 2012, the most recent year for which 

data are available (Figure 5). Although HPV causes 

multiple cancers, the vast majority of HPV cancers 

worldwide—530,000—are cervical cancers. Most HPV 

cancers could be prevented by currently available HPV 

vaccines.19 The potential impact of HPV vaccination is 

greatest in less developed countries.

HPV Vaccination Is Low in Countries with 

Most Cervical Cancer Cases and Deaths

The vast majority of cervical cancer cases and deaths 

occur in countries with lower levels of socioeconomic 

development.128 The number of cervical cancer deaths in 

less developed regions is predicted to increase by about 

50 percent by 2030.129 Vaccination rates in less developed 

regions are disproportionately low. In 2014, it was 

estimated that fewer than 3 percent of 10- to 20-year-old 

girls in less developed regions had completed the HPV 

vaccine series, compared with 34 percent of girls in 

more developed regions.130 Despite the World Health 

Organization (WHO) recommendation that all countries 

vaccinate 9- to 14-year-old girls,24 as of May 2018, only 9 

low- and lower-middle-income countries (LLMICs) had 

included the HPV vaccine in their national vaccination 

programs, compared with 70 high- and upper-middleincome countries.131

PRESIDENT’S CANCER PANEL

Goals and Opportunities to Increase HPV Vaccine Uptake 21

In 2014, it was estimated that fewer than 

3 percent of 10- to 20-year-old girls in less 

developed regions had completed the HPV 

vaccine series.

The disproportionate numbers of cervical cancer cases 

and deaths in less developed regions are due to the 

challenges of implementing cervical cancer screening 

programs, which have substantially reduced cervical 

cancer in many high-income countries, including the 

United States.132,133 While increasing HPV vaccination 

of adolescents will prevent future cancers in less 
Anus

8,500

12,000

13,000

29,000

35,000

Cervix 530,000

Vulva

Vagina

Penis

Oropharynx

PRESIDENT’S CANCER PANEL

22 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action

developed regions, development and deployment 

of cost-effective screening programs are needed to 

alleviate the burden of cervical cancers among the 

current generation of women.134-136

Figure 5. Cancers Caused by HPV Worldwide

Source: de Martel C, Plummer M, Vignat J, Franceschi S. Worldwide burden of cancer attributable to HPV 

by site, country and HPV type. Int J Cancer. 2017;141(4):664-70; Note: de Martel et al. include cancers of the 

oral cavity and larynx in their estimate of HPV-attributable cancers. The U.S. Centers for Disease Control and 

Prevention has concluded that HPV causes some cancers of the oropharynx, but that the evidence that HPV 

causes cancers of the oral cavity and larynx is insufficient. Thus, numbers in this figure include estimates for 

oropharyngeal but not oral cavity and laryngeal cancers. 

HPV Vaccination Is Feasible in 

Low-Resource Settings

HPV vaccination in low- and middle-income countries 

has been supported by many organizations, including 

pharmaceutical companies; charitable organizations; 

PATH; the Pan American Health Organization 

(PAHO) Revolving Fund; and Gavi, the Vaccine 

Alliance.137 These organizations have supported 

small-scale demonstration projects, as well as national 

introductions of the HPV vaccine. Since 2013, most 

financial support for HPV vaccination programs 

in LLMICs has come from Gavi, an international 

public-private partnership focused on increasing 

access to immunization in lower-income countries.

Although the pace of vaccine introduction has been 

slower than hoped in low-resource settings, there 

are reasons to be encouraged. At least 45 low- and 

middle-income countries have gained experience with 

HPV vaccination through demonstration projects or 

national programs. These experiences have yielded 

important lessons and identified several factors that 

contribute to program success (see HPV Vaccination in 

Low- and Middle-Income Countries: Lessons Learned

on page 23). 

National programs and demonstration projects in 

LLMICs have been highly effective. Among 34 LLMICs 

with coverage data, nearly half delivered at least one 
dose to more than 90 percent of the target population 

of girls, and all of these programs achieved at least 60 

percent coverage with at least one dose.138 In addition 

to being effective, these programs illustrate that many 

countries have the political will and recognition of the 

need to introduce the vaccine.

U.S. Support Is Needed to Promote 

Global HPV Vaccination

Many organizations—including WHO, PAHO, Gavi, 

and others—have increased access to HPV vaccines in 

many low-resource areas over the past ten years, and 

the United States has contributed to these efforts. The 

Panel Chair urges the United States to continue 

to support implementation and sustainability 

of HPV vaccination programs around the world, 

particularly in low- and middle-income countries. 

Gavi remains the best mechanism for promotion of 

HPV vaccination in LLMICs. The United States—which 

contributed $275 million to Gavi in 2017139— should 

continue its financial support of this partnership. 

HPV Vaccination in Low- and Middle-Income Countries: Lessons Learned

Coordination and Planning

 Planning processes should include representatives from the ministries of health, education, and 

finance and other key experts.

National immunization program involvement is critical for effective vaccine delivery.

Proactive development of crisis communication plans will help address safety scares.

Communication and Education

 Social mobilization in communities should be initiated well in advance of vaccination campaigns. 

Messaging should focus on cervical cancer prevention; safety and efficacy, including lack of fertility 

impact and long-term adverse events; government endorsement; and vaccination logistics.

Delivery

 School-located delivery should be pursued if school attendance is high and resources allow. If school 

enrollment is low, a mixture of strategies may help attain good coverage. Out-of-school girls should 

have the opportunity to receive the vaccine.

Integration 

 Once the first round of vaccination is complete, HPV vaccination should be gradually integrated into 

existing structures and processes for delivery of other vaccines.

Sources: Gallagher KE, Howard N, Kabakama S, et al. Lessons learnt from human papillomavirus (HPV) vaccination 

in 45 low- and middle-income countries. PLoS One. 2017;12(6):e0177773; World Health Organization. HPV vaccine 

communication: special considerations for a unique vaccine: 2016 update. Geneva (CH): WHO; 2016. Available from: 

http://apps.who.int/iris/bitstream/handle/10665/250279/WHO-IVB-16.02-eng.pdf

PRESIDENT’S CANCER PANEL

Goals and Opportunities to Increase HPV Vaccine Uptake 23
U.S. agencies, including CDC and NCI, should 

continue working with other global health partners 

to promote HPV vaccination. Examples of valuable 

support include providing input on HPV vaccinerelated policies and guidelines; offering technical and 

field support; and contributing to implementation 

research, such as research on the costs of national 

HPV vaccination programs.140,141 CDC and NCI also 

should continue to support cancer control planning 

and tumor registry activities in less developed 

regions. This will help countries gather the resources 

and data needed to make decisions about and 

measure effectiveness of HPV vaccination programs. 

The U.S. President’s Emergency Plan for AIDS Relief 

(PEPFAR) should promote HPV vaccination as part 

of its efforts to address the cervical cancer burden 

in HIV-infected women, including through the 

Partnership to End AIDS and Cervical Cancer.142

The United States also can promote HPV vaccine 

uptake in less developed regions by funding research 

on ways to make vaccine distribution, storage, and 

administration easier and less expensive. In particular, 

additional evidence is needed on the efficacy and 

duration of protection provided by a single dose of 

the HPV vaccine. The shift to a two-dose schedule 

decreased the logistical challenges and costs of HPV 

vaccination. Delivery of one dose would be even easier 

and less costly, facilitating introduction and sustainability 

of HPV vaccination programs around the world.143,144 

NCI and the Bill & Melinda Gates Foundation recently 

launched a clinical trial that will determine whether a 

single dose of the HPV vaccine works as well as two 

doses in young women.145 Results should be available 

in 2024. These types of trials should be supported to 

ensure that the benefits of HPV vaccination are 

provided with optimal cost-effectiveness.

Research Priority: Test Effectiveness of One Dose

Additional evidence is needed on the efficacy and duration of protection of a single HPV 

vaccine dose. If one dose were sufficient, vaccination program costs could be considerably 

lower, which may lead to more widespread uptake worldwide. 

PRESIDENT’S CANCER PANEL

24 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action
PRESIDENT’S CANCER PANEL

CONCLUSIONS

Conclusions 25

HPV causes nearly 630,000 cancers worldwide each 

year, including nearly 34,000 in the United States. 

The majority of these cancers could be prevented 

by HPV vaccination. In its 2012-2013 report, the 

President’s Cancer Panel found that underuse of 

HPV vaccines was a serious but correctable threat to 

progress against cancer and identified several goals 

to increase uptake. 

There has been very encouraging progress in HPV 

vaccine uptake in the United States and globally over 

the last five years. However, HPV vaccination rates 

are still too low to achieve the full potential for cancer 

prevention. As of 2017, less than half of U.S. adolescents 

were fully vaccinated. In addition, HPV vaccines are not 

included in the national vaccine programs of many lowand middle-income countries, where the vast majority 

of cervical cancer cases and deaths occur. In this 

report, the Panel Chair identifies strategies for building 

on recent progress and overcoming persistent barriers 

to vaccine uptake. While local cultural factors and 

available resources should inform efforts to increase 

HPV vaccination, knowledge and experience suggest 

that the following priorities likely will have the greatest 

population-level impact. 

Provider- and systems-level changes hold 

the greatest potential to increase U.S. HPV 

vaccination rates. Provider recommendation is 

one of the strongest predictors of adolescent HPV 

vaccine uptake, but some providers give weak or 

unclear recommendations. Providers should clearly 

and strongly recommend same-day vaccination of 

all eligible adolescents. Systems-level changes that 

prioritize HPV vaccination and provide easy access 

to the vaccine also would reduce missed clinical 

opportunities to recommend and administer the HPV 

vaccine. Such interventions would contribute strongly 

to increasing HPV vaccine coverage to the same 

levels as for other adolescent vaccines.

Partnerships and collaborations are essential. 

Diverse groups of stakeholders—including cancer 

control and immunization experts and organizations, 

health professional organizations, government 

agencies, advocacy organizations, and others—have 

partnered to overcome barriers to HPV vaccination. 

These partnerships have been key to many of 

the successes achieved over the past few years. 

Stakeholders should continue to engage in and 

support collaborations to accelerate progress in HPV 

vaccine uptake. 

Progress and momentum built over the past half 

decade have created a compelling opportunity to 

increase HPV vaccine uptake further and 

dramatically reduce—and perhaps eventually largely 

eliminate—the preventable burden of HPV cancers. 

The elements of success are at hand: evidence of 

the benefits of HPV vaccination is strong and 

growing, numerous stakeholders are committed to 

the cause, and the knowledge and tools to increase 

vaccination coverage are available. Now is the time 

to apply what is known to ensure that today’s young 

people and future generations are protected 

against HPV cancers. Cancer and immunization 

stakeholders worldwide must renew their collective 

commitment to achieving HPV vaccination targets. 

All should rally without hesitation around the 

ultimate goal of cancer prevention.

PRESIDENT’S CANCER PANEL

REFERENCES

References 27

1. de Martel C, Plummer M, Vignat J, Franceschi S. Worldwide burden of cancer attributable to HPV by site, 

country and HPV type. Int J Cancer. 2017;141(4):664-70.

2. Accelerating HPV vaccine uptake: urgency for action to prevent cancer: a report to the President of the United 

States from the President’s Cancer Panel. Bethesda (MD): National Cancer Institute; 2014. Available from: 

https://deainfo.nci.nih.gov/advisory/pcp/annualReports/HPV/index.htm

3. National Vaccine Advisory Committee. Overcoming barriers to low HPV vaccine uptake in the United States: 

recommendations from the National Vaccine Advisory Committee. Washington (DC): NVAC; 2015 Jun 9. 

Available from: https://www.hhs.gov/sites/default/files/nvpo/nvac/reports/nvac-hpv.pdf

4. National Vaccine Advisory Committee. Strengthening the effectiveness of national, state, and local efforts to 

improve HPV vaccination coverage in the United States: recommendations of the National Vaccine Advisory 

Committee. Washington (DC): NVAC; 2018 Jun 25. Available from: https://www.hhs.gov/sites/default/

files/2018_nvac_hpv-report_final_remediated.pdf

5. Cancer Moonshot Blue Ribbon Panel. Cancer Moonshot Blue Ribbon Panel Report 2016. Bethesda (MD): 

National Cancer Institute; 2016 Oct 17. Available from: https://www.cancer.gov/research/key-initiatives/

moonshot-cancer-initiative/blue-ribbon-panel

6. Cancer Moonshot Task Force. Report of the Cancer Moonshot Task Force. Washington (DC): the White House; 

2016 Oct 17. Available from: https://obamawhitehouse.archives.gov/sites/default/files/docs/final_cancer_

moonshot_task_force_report_1.pdf

7. Walker TY, Elam-Evans LD, Yankey D, et al. National, regional, state, and selected local area vaccination 

coverage among adolescents aged 13-17 years—United States, 2017. MMWR Morb Mortal Wkly Rep. 

2018;67(33):909-17.

8. Centers for Disease Control and Prevention. Genital HPV infection–fact sheet [Internet]. Atlanta (GA): CDC; 

[updated 2017 Nov 16; cited 2018 Apr 16]. Available from: http://www.cdc.gov/std/HPV/STDFact-HPV.htm

9. Centers for Disease Control and Prevention. How many cancers are linked with HPV each year? [Internet]. 

Atlanta (GA): CDC; [updated 2018 Aug 22; cited 2018 Aug 26]. Available from: https://www.cdc.gov/cancer/hpv/

statistics/cases.htm

10. Centers for Disease Control and Prevention. 5 things you might not know about human papillomavirus [Internet]. 

Atlanta (GA): CDC; 2016 Jan 20 [updated 2017 Nov 8; cited 2018 Jul 6]. Available from: https://blogs.cdc.gov/

publichealthmatters/2016/01/5-things-you-might-not-know-about-human-papillomavirus

11. Habbema D, Weinmann S, Arbyn M, et al. Harms of cervical cancer screening in the United States and the 

Netherlands. Int J Cancer. 2017;140(5):1215-22.

12. Chaturvedi AK, Anderson WF, Lortet-Tieulent J, et al. Worldwide trends in incidence rates for oral cavity and 

oropharyngeal cancers. J Clin Oncol. 2013;31(36):4550-9.

13. Chaturvedi AK, Engels EA, Pfeiffer RM, et al. Human papillomavirus and rising oropharyngeal cancer incidence 

in the United States. J Clin Oncol. 2011;29(32):4294-301.

14. Javadi P, Sharma A, Zahnd WE, Jenkins WD. Evolving disparities in the epidemiology of oral cavity and 

oropharyngeal cancers. Cancer Causes Control. 2017;28(6):635-45.

15. Mourad M, Jetmore T, Jategaonkar AA, et al. Epidemiological trends of head and neck cancer in the United 

States: a SEER population study. J Oral Maxillofac Surg. 2017;75(12):2562-72.
16. Van Dyne EA, Henley SJ, Saraiya M, et al. Trends in human papillomavirus-associated cancers—United States, 

1999-2015. MMWR Morb Mortal Wkly Rep. 2018;67(33):918-24.

17. Kavanagh K, Pollock KG, Cuschieri K, et al. Changes in the prevalence of human papillomavirus following a 

national bivalent human papillomavirus vaccination programme in Scotland: a 7-year cross-sectional study. 

Lancet Infect Dis. 2017;17(12):1293-302.

18. U.S. Food and Drug Administration. Gardasil 9 [Internet]. Silver Spring (MD): FDA; [updated 2018 Feb 26; cited 

2018 Mar 23]. Available from: https://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/

ucm426445.htm

19. Zhai L, Tumban E. Gardasil-9: A global survey of projected efficacy. Antiviral Res. 2016;130:101-9.

20. 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):1405-8.

21. Centers for Disease Control and Prevention. Quadrivalent human papillomavirus vaccine: recommendations of 

the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56(RR-2):1-24.

22. Centers for Disease Control and Prevention. FDA licensure of bivalent human papillomavirus vaccine (HPV2, 

Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory Committee on 

Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2010;59(20):626-9.

23. Centers for Disease Control and Prevention. Recommendations on the use of quadrivalent human 

papillomavirus vaccine in males—Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb 

Mortal Wkly Rep. 2011;60(50):1705-8.

24. World Health Organization. Human papillomavirus vaccines: WHO position paper, May 2017- recommendations. 

Vaccine. 2017;35(43):5753-5.

25. Centers for Disease Control and Prevention. Grading of Recommendations Assessment, Development and 

Evaluation (GRADE) of a 2-dose schedule for human papillomavirus (HPV) vaccination [Internet]. Atlanta (GA): 

CDC; [updated 2016 Dec 15; cited 2018 Mar 23]. Available from: https://www.cdc.gov/vaccines/acip/recs/grade/

hpv-2-dose.html

26. World Health Organization. Meeting of the Global Advisory Committee on Vaccine Safety, 7-8 June 2017. Wkly 

Epidemiol Rec. 2017;92:393-404.

27. Phillips A, Patel C, Pillsbury A, et al. Safety of human papillomavirus vaccines: an updated review. Drug Saf. 

2018;41(4):329-46.

28. Centers for Disease Control and Prevention. Frequently asked questions about HPV vaccine safety 

[Internet]. Atlanta (GA): CDC; [updated 2018 Apr 11; cited 2018 Apr 19]. Available from: https://www.cdc.gov/

vaccinesafety/vaccines/hpv/hpv-safety-faqs.html

29. Muñoz N, Kjaer SK, Sigurdsson K, et al. Impact of human papillomavirus (HPV)-6/11/16/18 vaccine on all HPVassociated genital diseases in young women. J Natl Cancer Inst. 2010;102(5):325-39.

30. Lehtinen M, Paavonen J, Wheeler CM, et al. Overall efficacy of HPV-16/18 AS04-adjuvanted vaccine against 

grade 3 or greater cervical intraepithelial neoplasia: 4-year end-of-study analysis of the randomised, doubleblind PATRICIA trial. Lancet Oncol. 2012;13(1):89-99.

31. Joura EA, Giuliano AR, Iversen OE, et al. A 9-valent HPV vaccine against infection and intraepithelial neoplasia in 

women. N Engl J Med. 2015;372(8):711-23.

32. Huh WK, Joura EA, Giuliano AR, et al. Final efficacy, immunogenicity, and safety analyses of a nine-valent 

human papillomavirus vaccine in women aged 16-26 years: a randomised, double-blind trial. Lancet. 

2017;390(10108):2143-59.

PRESIDENT’S CANCER PANEL

28 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action
33. Herrero R, Quint W, Hildesheim A, et al. Reduced prevalence of oral human papillomavirus (HPV) 4 years after 

bivalent HPV vaccination in a randomized clinical trial in Costa Rica. PLoS One. 2013;8(7):e68329.

34. Brotherton JML, Bloem PN. Population-based HPV vaccination programmes are safe and effective: 2017 update 

and the impetus for achieving better global coverage. Best Pract Res Clin Obstet Gynaecol. 2018;47:42-58.

35. Mesher D, Panwar K, Thomas SL, et al. The impact of the National HPV Vaccination Program in England 

using the bivalent HPV vaccine: surveillance of type-specific HPV in young females, 2010-2016. J Infect Dis. 

2018;218(6):911-21.

36. Oliver SE, Unger ER, Lewis R, et al. Prevalence of human papillomavirus among females after vaccine 

introduction—National Health and Nutrition Examination Survey, United States, 2003-2014. J Infect Dis. 

2017;216(5):594-603.

37. Machalek DA, Garland SM, Brotherton JML, et al. Very low prevalence of vaccine human papillomavirus (HPV) 

types among 18 to 35 year old Australian women, nine years following implementation of vaccination. J Infect 

Dis. 2018;217(10):1590-600.

38. Benard VB, Castle PE, Jenison SA, et al. Population-based incidence rates of cervical intraepithelial neoplasia in 

the human papillomavirus vaccine era. JAMA Oncol. 2017;3(6):833-7.

39. Flagg EW, Torrone EA, Weinstock H. Ecological association of human papillomavirus vaccination with cervical 

dysplasia prevalence in the United States, 2007-2014. Am J Public Health. 2016;106(12):2211-8.

40. Niccolai LM, Meek JI, Brackney M, et al. Declines in human papillomavirus (HPV)-associated high-grade 

cervical lesions after introduction of HPV vaccines in Connecticut, United States, 2008-2015. Clin Infect Dis. 

2017;65(6):884-9.

41. Brotherton JM, Gertig DM, May C, et al. HPV vaccine impact in Australian women: ready for an HPV-based 

screening program. Med J Aust. 2016;204(5):184-e1.

42. Oakley F, Desouki MM, Pemmaraju M, et al. Trends in high-grade cervical cancer precursors in the human 

papillomavirus vaccine era. Am J Prev Med. 2018;55(1):19-25.

43. Gargano JW, Park IU, Griffin MR, et al. Trends in high-grade cervical lesions and cervical cancer screening in five 

states, 2008-2015. Clin Infect Dis. [Epub 2018 Aug 23].

44. Guo F, Cofie LE, Berenson AB. Cervical cancer incidence in young U.S. females after human papillomavirus 

vaccine introduction. Am J Prev Med. 2018;55(2):197-204.

45. Luostarinen T, Apter D, Dillner J, et al. Vaccination protects against invasive HPV-associated cancers. Int J 

Cancer. 2018;142(10):2186-7.

46. Chaturvedi AK, Graubard BI, Broutian T, et al. Effect of prophylactic human papillomavirus (HPV) vaccination on 

oral HPV infections among young adults in the United States. J Clin Oncol. 2018;36(3):262-7.

47. Korostil IA, Ali H, Guy RJ, et al. Near elimination of genital warts in Australia predicted with extension of human 

papillomavirus vaccination to males. Sex Transm Dis. 2013;40(11):833-5.

48. Centers for Disease Control and Prevention. National and state vaccination coverage among adolescents aged 

13-17 years—United States, 2012. MMWR Morb Mortal Wkly Rep. 2013;62(34):685-93.

49. Patel EU, Grabowski MK, Eisenberg AL, et al. Increases in human papillomavirus vaccination among adolescent 

and young adult males in the United States, 2011-2016. J Infect Dis. 2018;218(1):109-13.

50.

PRESIDENT’S CANCER PANEL

References 29

U.S. Department of Health and Human Services. 2020 topics and objectives: immunization and infectious 

diseases objectives [Internet]. Washington (DC): DHHS; [updated 2018 Mar 22; cited 2018 Mar 26]. Available 

from: https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/

objectives
51. National HPV Vaccination Program Register. HPV vaccination coverage 2016 [Internet]. Victoria (AU): Australian 

Government Department of Health; [cited 2018 Apr 23]. Available from: http://www.hpvregister.org.au/

research/coverage-data/HPV-Vaccination-Coverage-2016

52. National HPV Vaccination Program Register. HPV vaccination coverage 2016—male [Internet]. Victoria (AU): 

Australian Government Department of Health; [cited 2018 Apr 23]. Available from: http://www.hpvregister.org.

au/research/coverage-data/HPV-Vaccination-Coverage-2016---Male

53. Public Health England. Annual HPV vaccine coverage 2016 to 2017: by local authority, local team and area team. 

London (UK): Public Health England; 2017 Dec 15. Available from: https://www.gov.uk/government/statistics/

annual-hpv-vaccine-coverage-2016-to-2017-by-local-authority-local-team-and-area-team

54. NCI-designated cancer centers endorse goal of eliminating HPV-related cancers. Available from: https://moffitt.

org/media/8151/hpvconsensusstatement-2018.pdf

55. American Cancer Society. American Cancer Society launches campaign to eliminate cervical cancer [Press 

Release]. Atlanta (GA): ACS. Available from: http://pressroom.cancer.org/HPVcancerfreelaunch

56. Aranda S, Berkley S, Cowal S, et al. Ending cervical cancer: A call to action. Int J Gynaecol Obstet. 2017;138(1 

Suppl):4-6.

57. Garland SM, Giuliano A, Brotherton JML, et al. IPVS statement moving towards elimination of cervical cancer as 

a public health problem. Papillomavirus Res. 2018;5:87-8.

58. World Health Organization. WHO Director-General calls for all countries to take action to end the suffering 

caused by cervical cancer [Internet]. Geneva (CH): WHO; 2018 May 19 [cited 2018 Jul 6]. Available from: http://

www.who.int/reproductivehealth/call-to-action-elimination-cervical-cancer/en

59. Reiter PL, Gerend MA, Gilkey MB, et al. Advancing human papillomavirus vaccine delivery: 12 priority research 

gaps. Acad Pediatr. 2018;18(2S):S14-6.

60. Kalorama Information. Retail clinics 2017: the game-changer in healthcare. New York (NY): Kalorama 

Information; 2017 Apr 17. Available from: https://www.kaloramainformation.com/Retail-ClinicsGame-10780773

61. Fulton BD. Health care market concentration trends in the United States: evidence and policy responses. 

Health Aff (Millwood). 2017;36(9):1530-8.

62. Centers for Disease Control and Prevention. Talking to parents about HPV vaccine [Internet]. Atlanta (GA): 

CDC; [updated 2018 Apr 30; cited 2018 May 31]. Available from: https://www.cdc.gov/hpv/hcp/for-hcptipsheet-hpv.html

63. Centers for Disease Control and Prevention. Tools and materials for your office [Internet]. Atlanta (GA): CDC; 

[updated 2017 Mar 10; cited 2018 Jun 1]. Available from: https://www.cdc.gov/hpv/hcp/tools-materials.html

64. Centers for Disease Control and Prevention. HPV Vaccine Is Cancer Prevention Champion [Internet]. Atlanta 

(GA): CDC; [updated 2017 Oct 25; cited 2018 Jun 1]. Available from: https://www.cdc.gov/hpv/champions/index.

html

65. American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians 

and Gynecologists, et al. Letter to: Colleagues 2014. Available from: http://www.immunize.org/letter/

recommend_hpv_vaccination.pdf

66. Hswen Y, Gilkey MB, Rimer BK, Brewer NT. Improving physician recommendations for human papillomavirus 

vaccination: the role of professional organizations. Sex Transm Dis. 2017;44(1):42-7.

67.

PRESIDENT’S CANCER PANEL

30 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action

American Academy of Pediatrics. Immunizations [Internet]. Itasca (IL): AAP; [cited 2018 Jul 20]. Available from: 

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/immunizations/Pages/HPV.aspx
68. American Academy of Family Physicians. Human papillomavirus vaccine (HPV) [Internet]. Leawood (KS): 

AAFP; [cited 2018 Jul 20]. Available from: https://www.aafp.org/patient-care/public-health/immunizations/

disease-population/hpv.html

69. American Academy of Pediatrics. HPV vaccine is cancer prevention [Internet]. Itasca (IL): AAP; [cited 2018 Jul 20]. 

Available from: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/immunizations/HPVChampion-Toolkit/Pages/Making-a-Change-in-Your-Office.aspx

70. Smulian EA, Mitchell KR, Stokley S. Interventions to increase HPV vaccination coverage: a systematic review. Hum 

Vaccin Immunother. 2016;12(6):1566-88.

71. Walling EB, Benzoni N, Dornfeld J, et al. Interventions to improve HPV vaccine uptake: a systematic review. 

Pediatrics. 2016;138(1).

72. Kepka D, Spigarelli MG, Warner EL, et al. Statewide analysis of missed opportunities for human papillomavirus 

vaccination using vaccine registry data. Papillomavirus Res. 2016;2:128-32.

73. Jeyarajah J, Elam-Evans LD, Stokley S, et al. Human papillomavirus vaccination coverage among girls before 

13 years: a birth year cohort analysis of the National Immunization Survey-Teen, 2008-2013. Clin Pediatr (Phila). 

2016;55(10):904-14.

74. Espinosa CM, Marshall GS, Woods CR, et al. Missed opportunities for human papillomavirus vaccine initiation in 

an insured adolescent female population. J Pediatric Infect Dis Soc. 2017;6(4):360-5.

75. Brewer NT, Chapman GB, Rothman AJ, et al. Increasing vaccination: putting psychological science into action. 

Psychol Sci Public Interest. 2017;18(3):149-207.

76. Dempsey AF, O’Leary ST. Human papillomavirus vaccination: narrative review of studies on how providers’ 

vaccine communication affects attitudes and uptake. Acad Pediatr. 2018;18(2S):S23-7.

77. Gilkey MB, Calo WA, Moss JL, et al. Provider communication and HPV vaccination: the impact of 

recommendation quality. Vaccine. 2016;34(9):1187-92.

78. Finney Rutten LJ, St Sauver JL, Beebe TJ, et al. Association of both consistency and strength of self-reported 

clinician recommendation for HPV vaccination and HPV vaccine uptake among 11- to 12-year-old children. 

Vaccine. 2017;35(45):6122-8.

79. Allison MA, Hurley LP, Markowitz L, et al. Primary care physicians’ perspectives about HPV vaccine. Pediatrics. 

2016;137(2):e20152488.

80. Thompson EL, Rosen BL, Vamos CA, et al. Human papillomavirus vaccination: what are the reasons for 

nonvaccination among U.S. adolescents? 

J Adolesc Health. 2017;61(3):288-93.

81. Hanson KE, Koch B, Bonner K, et al. National trends in parental HPV vaccination intentions and reasons for 

hesitancy, 2010-2015. Clin Infect Dis. [Epub 2018 Mar 27].

Gilkey MB, Malo TL, Shah PD, et al. Quality of physician communication about human papillomavirus vaccine: 

findings from a national survey. Cancer Epidemiol Biomarkers Prev. 2015;24(11):1673-9.

Gilkey MB, McRee AL. Provider communication about HPV vaccination: a systematic review. Hum Vaccin 

Immunother. 2016;12(6):1454-68.

Opel DJ, Heritage J, Taylor JA, et al. The architecture of provider-parent vaccine discussions at health 

supervision visits. Pediatrics. 2013;132(6):1037-46.

Opel DJ, Mangione-Smith R, Robinson JD, et al. The influence of provider communication behaviors on parental 

vaccine acceptance and visit experience. Am J Public Health. 2015;105(10): 1998-2004.

82.

83.

84.

85.

PRESIDENT’S CANCER PANEL

References 31
86. Brewer NT, Hall ME, Malo TL, et al. Announcements versus conversations to improve HPV vaccination coverage: 

a randomized trial. Pediatrics. 2017;139(1).

87. Malo TL, Hall ME, Brewer NT, et al. Why is announcement training more effective than conversation training for 

introducing HPV vaccination? A theory-based investigation. Implement Sci. 2018;13(1):57.

88. American Cancer Society. Steps for increasing HPV vaccination in practice: an action guide to implement 

evidence-based strategies for clinicians. Atlanta (GA): ACS; 2016. Available from: http://hpvroundtable.org/

wp-content/uploads/2017/11/Steps-for-Increasing-HPV-Vaccination-in-Practice.pdf

89. Markowitz LE, Dunne EF, Saraiya M, et al. Human papillomavirus vaccination: recommendations of the Advisory 

Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2014;63(RR-05):1-30.

90. Dobson SR, McNeil S, Dionne M, et al. Immunogenicity of 2 doses of HPV vaccine in younger adolescents vs 3 

doses in young women: a randomized clinical trial. JAMA. 2013;309(17):1793-802.

91. Gillison ML, Chaturvedi AK, Anderson WF, Fakhry C. Epidemiology of human papillomavirus-positive head and 

neck squamous cell carcinoma. J Clin Oncol. 2015;33(29):3235-42.

92. D’Souza G, Wentz A, Kluz N, et al. Sex differences in risk factors and natural history of oral human papillomavirus 

infection. J Infect Dis. 2016;213(12):1893-6.

93. Shay LA, Baldwin AS, Betts AC, et al. Parent-provider communication of HPV vaccine hesitancy. Pediatrics. 

2018;141(6):e20172312.

94. Kornides ML, McRee AL, Gilkey MB. Parents who decline HPV vaccination: who later accepts and why? Acad 

Pediatr. 2018;18(2S):S37-S43.

95. Henry KA, Swiecki-Sikora AL, Stroup AM, et al. Area-based socioeconomic factors and human papillomavirus 

(HPV) vaccination among teen boys in the United States. BMC Public Health. 2017;18(1):19.

96. Warner EL, Ding Q, Pappas L, et al. Health care providers’ knowledge of HPV vaccination, barriers, and strategies in a 

state with low HPV vaccine receipt: mixed-methods study. JMIR Cancer. 2017;3(2):e12.

97. Irving SA, Groom HC, Stokley S, et al. Human papillomavirus vaccine coverage and prevalence of missed 

opportunities for vaccination in an integrated healthcare system. Acad Pediatr. 2018;18(2S):S85-S92.

98. Rosenblatt RA, Hart LG. Physicians and rural America. West J Med. 2000;173(5):348-51.

99. Farmar AM, Love-Osborne K, Chichester K, et al. Achieving high adolescent HPV vaccination coverage. 

Pediatrics. 2016;138(5).

100. Lollier A, Rodriguez EM, Saad-Harfouche FG, et al. HPV vaccination: pilot study assessing characteristics of high 

and low performing primary care offices. Prev Med Rep. 2018;10:157-61.

101. Oliver K, Frawley A, Garland E. HPV vaccination: population approaches for improving rates. Hum Vaccin 

Immunother. 2016;12(6):1589-93.

102. Zimet G, Dixon BE, Xiao S, et al. Simple and elaborated clinician reminder prompts for human papillomavirus 

vaccination: a randomized clinical trial. Acad Pediatr. 2018;18(2S):S66-S71.

103. Community Preventive Services Task Force. What works: increasing appropriate vaccination: evidencebased interventions for your community. Atlanta (GA): CPSTF; 2017 Nov. Available from: https://www.

thecommunityguide.org/sites/default/files/assets/What-Works-Factsheet-Vaccination.pdf

104. Community Preventive Services Task Force. Increasing appropriate vaccination: standing orders. Atlanta 

(GA): CPSTF; 2016 Jan 20. Available from: https://www.thecommunityguide.org/sites/default/files/assets/

Vaccination-Standing-Orders.pdf

PRESIDENT’S CANCER PANEL

32 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action
105. Kempe A, O’Leary ST, Shoup JA, et al. Parental choice of recall method for HPV vaccination: a pragmatic trial. 

Pediatrics. 2016;137(3):e20152857.

106. Perkins RB, Zisblatt L, Legler A, et al. Effectiveness of a provider-focused intervention to improve HPV 

vaccination rates in boys and girls. Vaccine. 2015;33(9):1223-9.

107. Fiks AG, Luan X, Mayne SL. Improving HPV vaccination rates using Maintenance-of-Certification requirements. 

Pediatrics. 2016;137(3):e20150675.

108. Rand CM, Schaffer SJ, Dhepyasuwan N, et al. Provider communication, prompts, and feedback to improve HPV 

vaccination rates in resident clinics. Pediatrics. 2018;141(4).

109. Kempe A, Saville AW, Dickinson LM, et al. Collaborative centralized reminder/recall notification to increase 

immunization rates among young children: a comparative effectiveness trial. JAMA Pediatr. 2015;169(4):365-73.

110. Centers for Disease Control and Prevention. AFIX (Assessment, Feedback, Incentives, and eXchange) [Internet]. 

Atlanta (GA): CDC; [cited 2018 May 31]. Available from: https://www.cdc.gov/vaccines/programs/afix/index.html

111. National HPV Vaccination Roundtable. Resource library [Internet]. Atlanta (GA): the Roundtable; [cited 2018 May 

31]. Available from: http://hpvroundtable.org/resource-library

112. National HPV Vaccination Roundtable. Clinician and health systems action guides [Internet]. Atlanta (GA): 

the Roundtable; [cited 2018 Jun 1]. Available from: http://hpvroundtable.org/action-guides

113. National Committee for Quality Assurance. HEDIS and performance measurement [Internet]. Washington (DC): 

NCQA; [cited 2018 Jun 1]. Available from: http://www.ncqa.org/HEDISQualityMeasurement.aspx

114. National Committee for Quality Assurance. NCQA updates quality measures for HEDIS 

2017 [Internet]. Washington (DC): NCQA; 2016 Jul 5 [cited 2018 Sep 14]. Available from: https://www.ncqa.

org/news/ncqa-updates-quality-measures-for-hedis-2017

115. McRee AL, Reiter PL, Brewer NT. Vaccinating adolescent girls against human papillomavirus—who decides? 

Prev Med. 2010;50(4):213-4.

116. Centers for Disease Control and Prevention. Human papillomavirus (HPV): for parents and public [Internet]. 

Atlanta (GA): CDC; [updated 2015 Sep 30; cited 2018 Jun 1]. Available from: https://www.cdc.gov/hpv/parents/

index.html

117. American Cancer Society. Prevent cancer with the HPV vaccine [Internet]. Atlanta (GA): ACS; [cited 2018 Jun 11]. 

Available from: https://www.cancer.org/healthy/hpv-vaccine.html

118. Merck. Know HPV [Internet]. Kenilworth (NJ): Merck Sharp & Dohme Corp.; [cited 2018 Sep 14]. Available from: 

https://www.hpv.com/

119. Centers for Disease Control and Prevention. CDC vaccine price list [Internet]. Atlanta (GA): CDC; [cited 2018 

Jun 1]. Available from: https://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-management/price-list/

index.html

120. The Henry J. Kaiser Family Foundation. The HPV vaccine: access and use in the U.S. [Fact Sheet]. San Francisco 

(CA): KFF; 2017 Oct. Available from: http://files.kff.org/attachment/fact-sheet-the-hpv-vaccine-access-and-usein-the-u-s

121. U.S. Department of Health and Human Services. Where and how to get vaccines [Internet]. Washington (DC): 

DHHS; [cited 2018 Apr 16]. Available from: https://www.hhs.gov/ash/oah/adolescent-development/physicalhealth-and-nutrition/vaccines/where-and-how-to-get-vaccines/index.html

122. Rand CM, Goldstein NPN. Patterns of primary care physician visits for U.S. adolescents in 2014: implications for 

vaccination. Acad Pediatr. 2018;18(2S):S72-S8.

PRESIDENT’S CANCER PANEL

References 33
123. National Association of Chain Drug Stores. Home page [Internet]. Arlington (VA): NACDS; [cited 2018 Jun 28]. 

Available from: https://www.nacds.org

124. Petterson SM, Phillips RL, Bazemore AW, Koinis GT. Unequal distribution of the U.S. primary care workforce. 

Washington (DC): Robert Graham Center; 2013 Jun 1. Available from: https://www.graham-center.org/rgc/

publications-reports/publications/one-pagers/unequal-distribution-2013.html

125. Pastir J. School HPV immunization clinics increase vaccination rates in North Dakota. Atlanta (GA): Centers 

for Disease Control and Prevention; 2017 Nov 30. Available from: https://nccd.cdc.gov/nccdsuccessstories/

showdoc.aspx?s=14291&dt=0

Kempe A, Allison MA, Daley MF. Can school-located vaccination have a major impact on human papillomavirus 

vaccination rates in the United States? Acad Pediatr. 2018;18(2S):S101-S5.

127. School-Based Health Alliance. 2013-2014 digital census report [Internet]. Washington (DC): the Alliance; 

[cited 2018 Jun 29]. Available from: http://censusreport.sbh4all.org

126.

128. International Agency for Research on Cancer. Fact sheet: cervix uteri. Lyon (FR): IARC; 2018 Sep. Available 

from: http://gco.iarc.fr/today/data/factsheets/cancers/23-Cervix-Uteri-fact-sheet.pdf

129. World Health Organization. Projections of mortality and causes of death, 2015 and 2030 [Internet]. Geneva 

(CH): WHO; [cited 2018 Aug 31]. Available from: http://www.who.int/healthinfo/global_burden_disease/

projections/en

130. Bruni L, Diaz M, Barrionuevo-Rosas L, et al. Global estimates of human papillomavirus vaccination coverage 

by region and income level: a pooled analysis. Lancet Glob Health. 2016;4(7):e453-63.

131. World Health Organization. Vaccine in national immunization programme update. Geneva (CH): WHO; 2018 

May. Available from: http://www.who.int/immunization/monitoring_surveillance/data/en

132. Basu P, Meheus F, Chami Y, et al. Management algorithms for cervical cancer screening and precancer 

treatment for resource-limited settings. Int J Gynaecol Obstet. 2017;138(1 Suppl):26-32.

133. Holme F, Kapambwe S, Nessa A, et al. Scaling up proven innovative cervical cancer screening strategies: 

challenges and opportunities in implementation at the population level in low- and lower-middle-income 

countries. Int J Gynaecol Obstet. 2017;138(1 Suppl):63-8.

134. Campos NG, Castle PE, Wright TC Jr, Kim JJ. Cervical cancer screening in low-resource settings: a costeffectiveness framework for valuing tradeoffs between test performance and program coverage. Int J 

Cancer. 2015;137(9):2208-19.

135. Mezei AK, Armstrong HL, Pedersen HN, et al. Cost-effectiveness of cervical cancer screening methods in lowand middle-income countries: a systematic review. Int J Cancer. 2017;141(3):437-46.

136. Campos NG, Sharma M, Clark A, et al. The health and economic impact of scaling cervical cancer 

prevention in 50 low- and lower-middle-income countries. Int J Gynaecol Obstet. 2017;138(1 Suppl):47-56.

137. Gallagher KE, Howard N, Kabakama S, et al. Lessons learnt from human papillomavirus (HPV) vaccination in 

45 low- and middle-income countries. PLoS One. 2017;12(6):e0177773.

138. Gallagher KE, LaMontagne DS, Watson-Jones D. Status of HPV vaccine introduction and barriers to country 

uptake. Vaccine. 2018;36(32 Pt A):4761-7.

139. Gavi, the Vaccine Alliance. Funding and finance: donor profiles: United States of America—proceeds to 

Gavi from donor contributions & pledges (2016-2020) as of 31 December 2017 [Internet]. Geneva (CH): Gavi; 

[cited 2018 May 17]. Available from: http://www.gavialliance.org/funding/donor-profiles/united-states

140. Senkomago V, Duran D, Loharikar A, et al. CDC activities for improving implementation of human 

papillomavirus vaccination, cervical cancer screening, and surveillance worldwide. Emerg Infect Dis. 

2017;23(13).

PRESIDENT’S CANCER PANEL

34 HPV Vaccination for Cancer Prevention: Progress, Opportunities, and a Renewed Call to Action
141. Botwright S, Holroyd T, Nanda S, et al. Experiences of operational costs of HPV vaccine delivery strategies 

in Gavi-supported demonstration projects. PLoS One. 2017;12(10):e0182663.

142. The United States President’s Emergency Plan for AIDS Relief. Renewed partnership to help end AIDS and 

cervical cancer in Africa [Press Release]. Washington (DC): PEPFAR; 2018 May 11. Available from: https://www.

pepfar.gov/press/releases/281984.htm

143. LaMontagne DS, Bloem PJN, Brotherton JML, et al. Progress in HPV vaccination in low- and lower-middleincome countries. Int J Gynaecol Obstet. 2017;138(1 Suppl):7-14.

144. Burger E, Campos N, Sy S, et al. Health and economic benefits of single-dose HPV vaccination in a Gavi-eligible 

country. Vaccine. 2018;36(32 Pt A):4823-9.

145. National Cancer Institute. Scientific evaluation of one or two doses of the bivalent or nonavalent prophylactic 

HPV vaccines—the ESCUDDO Study [Internet]. Bethesda (MD): NCI; [cited 2018 Jul 11]. Available from: https://

dceg.cancer.gov/research/cancer-types/cervix/escuddo

PRESIDENT’S CANCER PANEL

References 35
PRESIDENT’S CANCER PANEL
PRESIDENT’S CANCER PANEL

APPENDIX: ACRONYMS

Appendix: Acronyms 37

ACRONYM DEFINITION

AAFP American Academy of Family Physicians

AAP American Academy of Pediatrics

ACIP Advisory Committee on Immunization Practices

ACS American Cancer Society

AIDS Acquired immunodeficiency syndrome

CDC Centers for Disease Control and Prevention

EHR Electronic health record

FDA Food and Drug Administration

HEDIS Healthcare Effectiveness Data and Information Set

HIV Human immunodeficiency virus

HPV Human papillomavirus

HRSA Health Resources and Services Administration

NCI National Cancer Institute

NHANES National Health and Nutrition Examination Survey

PAHO Pan American Health Organization

PEPFAR U.S. President’s Emergency Plan for AIDS Relief

QI Quality improvement

VFC Vaccines for Children

WHO World Health Organization
Printed November 2018