Sherri Zorn, MD, FAAP
WCAAP Vaccine Committee
Timely HPV (human papillomavirus) vaccination of preteens can prevent an estimated 90% of HPV-related cancers (oropharyngeal, cervical, anal, penile, vaginal, vulvar). However, despite being available in the United States for 15 years, the rate of HPV vaccination has lagged behind the other adolescent vaccines. The pre-pandemic 2020 rate for completed HPV series in 13-17 year olds is 58% nationally and 59% for Washington State, in comparison to 90% for Tdap and 89% for MenACWY.1
Unfortunately, during the COVID-19 pandemic, administration of adolescent vaccines fell between 20-24% in 2020 and modeling predicts 2 to 10 years for recovery. 2 Medical providers continue to report ongoing challenges related to the pandemic including staffing challenges and the redirection of limited resources. Simple and effective strategies are critical to raising vaccination rates.
Recommending the HPV vaccine starting at age 9 has emerged as a promising best practice endorsed by American Academy of Pediatrics, WA Department of Health, American Cancer Society, Washington State HPV Task Force and the National HPV Vaccination Roundtable, which includes leading thought experts from clinical, public health, and academic research institutions. Under the guidance of “HPV Free WA”, several local clinics are testing adoption of the “HPV vaccine at 9” strategy, and they are observing notable success.
There are many benefits to recommending HPV vaccination starting at age 9. Immunologically, 9-10 year olds attain the highest antibody titers after HPV vaccination when compared to older age groups.3 From a practical standpoint, early recommendation allows more opportunities to complete both doses before age 13. The second dose (due 6-12 months after the first dose) can be paired with the subsequent annual wellness visit, avoiding an extra “vaccine only” visit. For hesitant parents, recommending HPV at 9 starts the conversation earlier and allows them more time to learn about the vaccine; a recent study reported that most parents who initially declined HPV will eventually accept or plan to accept the vaccine at subsequent visits.4
Additionally, starting the HPV vaccine at 9 helps space out the adolescent vaccinations which many providers and patients prefer instead of bundling them at the 11-12 year visit.
Once a clinic embraces the “HPV vaccine at 9” strategy, there are several supportive measures to increase success. First, the entire medical team, including front office, medical assistants, nurses and providers need to understand that the HPV vaccine is safe and provides highly effective, long-lasting protection against HPV-related cancers. Team members should be trained to give a simple strong recommendation focused on cancer prevention. Placing the emphasis on cancer prevention results in an easier and more effective recommendation. 5 Finally, all staff should recognize the dosing schedule and appreciate the goal to complete both doses before age 13.
Great visuals in the lobby and exam rooms can enhance success. Colorful posters introducing the HPV vaccine as powerful cancer prevention beginning at age 9 and featuring preteens with a diverse representation of genders, races, and cultures may help the message resonate with patients, parents and guardians. Prominently posting your clinic’s standard immunization schedule in the exam room (including HPV vaccination starting at 9) will add authority and reinforce your strong recommendation. Parents frequently refer to the posted immunization schedule to make sure they are staying up to date with all recommended vaccines.
Finally, reminder recall approaches are essential but may be resource intensive. Approaches that may minimize recall burden for staff include utilizing an automated outreach to increase annual well child visits and using WAIIS (the state vaccine registry) or the Electronic Medical Record (EMR) to send reminder messages, letters, or texts to guardians of patients between 12-17 years who are overdue for their 2nd HPV vaccine.
We encourage our WCAAP partners to begin HPV vaccination at age 9 for powerful cancer prevention.
HPV Free WA is a collaboration between WA DOH, American Cancer Society, and UW Health Promotion Research Center, and is sponsored by Amerigroup and Livesmyle.
- Pingali C, Yankey D, Elam-Evans LD, Markowitz LE, Williams CL, Fredua B, McNamara LA, Stokley S, Singleton JA. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years – United States, 2020. MMWR Morb Mortal Wkly Rep. 2021 Sep 3;70(35):1183-1190. doi: 10.15585/mmwr.mm7035a1. PMID: 34473682; PMCID: PMC8422873.
- Kunal Saxena, Jessica Marden, Cristina Carias, Alexandra Bhatti, Oscar Patterson-Lomba, Andres Gomez-Lievano, Lixia Yao & Ya-Ting Chen(2021)Impact of the COVID-19 pandemic on adolescent vaccinations: projected time to reverse deficits in routine adolescent vaccination in the United States,Current Medical Research and Opinion,DOI: 1080/03007995.2021.1981842
- Iversen OE, Miranda MJ, Ulied A, Soerdal T, Lazarus E, Chokephaibulkit K, Block SL, Skrivanek A, Nur Azurah AG, Fong SM, Dvorak V, Kim KH, Cestero RM, Berkovitch M, Ceyhan M, Ellison MC, Ritter MA, Yuan SS, DiNubile MJ, Saah AJ, Luxembourg A. Immunogenicity of the 9-Valent HPV Vaccine Using 2-Dose Regimens in Girls and Boys vs a 3-Dose Regimen in Women. JAMA. 2016 Dec 13;316(22):2411-2421. doi: 10.1001/jama.2016.17615. PMID: 27893068.
- Kornides ML, McRee AL, Gilkey MB. Parents Who Decline HPV Vaccination: Who Later Accepts and Why? Acad Pediatr. 2018 Mar;18(2S):S37-S43. doi: 10.1016/j.acap.2017.06.008. PMID: 29502636; PMCID: PMC5859546.
- How to Recommend HPV Vaccine: https://www.hpviq.org/wp-content/uploads/2021/01/HPVIQ-flyer-FINAL.pdf