Why the “No-Brainer” HPV Vaccine Is Being Ignored
Authors: Rita Rubin
Journal: JAMA (2015)

Rodney Willoughby, MD, a pediatric infectious disease specialist at the Medical College of Wisconsin, can’t help thinking about the future—a future in which thousands of men and women developprecancerousorcancerous lesionsthat could have been prevented had they been vaccinated against the human papillomavirus (HPV) as 11or 12-year-olds. “The family practitioners and pediatricians do a really bad job in promoting HPV vaccination for a variety of reasons,” said Willoughby, amemberof theAdvisoryCommittee on Immunization Practices’ (ACIP) working group on the HPV vaccine and the American Academy of Pediatrics’ Committee on Infectious Diseases. “We recognize that we are falling down on the job. This is actually a real emergency.” Research has shown thatmost parents would immunize their children if their pediatrician or family practitioner recommendedtheHPVvaccineaspartof thestandard package of vaccines for adolescents (Holman DM et al. JAMA Pediatr. 2014; 168[1]:76-82, and Rickert VI et al. Vaccine. 2015;33[5]:642-647). But studies alsohave found that parents, like physicians, sometimes delay immunization because they think their child is years away from becoming sexually active and contracting HPV. In addition, theHPVvaccine requires3 trips to the physician’s office, which might prove daunting to busy families. The urgency for vaccination is underscoredby the fact thatHPV is themost common sexually transmitted infection, and most sexually active men and women become infected at least once during their life (http://1.usa.gov/1NZJvwU).Moreover, persistent infectionwith certain strains causes virtually all cervical cancers aswell as about two-thirds of vulvar and penile cancers, three-fourths of vaginal and oropharyngeal cancers, and about 9 in 10 anal cancers (http://1.usa.gov/1CjY7nN). Human papillomavirus vaccines can’t prevent infectionafter the fact,which iswhy theACIPrecommends immunizationforpreteens before they become sexually active. The ACIP has recommended routine vaccinationofgirls aged 11or 12years since2006, when Gardasil, the first approved HPV vaccine, became available (http://1.usa.gov /1DoEGKj). The committee issued the same recommendation for boys in 2011 (http://1 .usa.gov/1G97qVc). Gardasil, Merck’s quadrivalent vaccine approved for males and females, protects against 2 HPV types (16 and 18) that cause 70% of cervical cancers as well as 2 other HPV types (6 and 11) responsible for 90% of genital warts cases. Cervarix, GlaxoSmithKl ine’s bivalent vaccine approved only for girls, protects against the same 2 cancer-causing types of HPV (http: //bit.ly/1wPTsYd). In December, the Food and Drug Administration approved the 9-valent HPV vaccine (9vHPV), Gardasil 9, which protects against HPV types in the original quadrivalent vaccine and an additional 5 HPV types that cause cervical cancers (http://1.usa.gov/1LiJp4E). ACIP recently updated its HPV vaccine recommendations to include 9vHPV as one of the three recommended vaccines that can be used for routine immunization (Petrosky E et al. MMWR Morb Mortal Wkly Rep. 2015; 64[11]:300-304). Humanpapillomavirus types 16 and 18, associatedwith cervical cancer, are also associatedwithpenileandoropharyngeal cancer. Although the HPV vaccines are presumed toprotect against those2 cancers as well as cervical cancer, clinical trialshavenot yet been conducted to demonstrate efficacy against these cancers (http://1.usa.gov /18tjZiY). Such studies would be prohibitively long and expensive, Willoughby said, because researchers have nothing comparable to thePap smear to detect precancerous penile or oropharyngeal lesions. Despite the preventive benefits and documented efficacy in protecting against cervical cancer, HPV vaccination rates remain far below 2 other recommended preteen vaccines—the one for Tdap (against tetanus, diphtheria, and pertussis) and the meningococcal conjugate vaccine (ElamEvansLDetal.MMWRMorbMortalWklyRep. 2014;63[29]:625-633). In 2013, 86%ofUS teens aged 13 to 17 years had received Tdap and77.8%had received themeningococcal vaccine. But only 57.3% of girls and 34.6% of boys had received at least 1 of the 3 recommendeddoses ofHPVvaccine, and only 37.6%of girls had receivedall 3 doses (http: //kff.org/womens-health-policy/fact-sheet /the-hpv-vaccine-access-and-use-in/). These vaccination rates fall far short of the Healthy People 2020 initiative’s target goal to have 80% of 13to 15-year-old girls and boys fully immunized with all 3 HPV doses (http://1.usa.gov/1MFXTH7). Medical News&Perspectives .....p1502