Call to Action ajog.

org

Preventing human papillomaviruserelated

cancers: we are all in this together
Sarah Dilley, MD, MPH; Isabel Scarinci, PhD, MPH; David Kimberlin, MD; J. Michael Straughn Jr, MD

Background
There was a drastic reduction in the rate THE PROBLEM: Human papillomavirus (HPV) vaccination rates are low, leading to missed
of cervical cancer after widespread opportunities for the prevention of HPV-related diseases.
adoption of the Pap test in the United
States. Now with a better understanding THE SOLUTION: Obstetrician-gynecologists (OBGYNs) and other women’s health care
of the natural history of cervical cancer providers have an important role to play in the prevention of HPV-related diseases and can
and its link to HPV, we have an oppor- incorporate multiple strategies to help increase vaccination rates.
tunity to further reduce cervical cancer
and other HPV-related diseases
(including cervical dysplasia and genital doses, and 41.9% finish the 3-doses se- vaccination are changing, with 87% of
warts) through primary prevention with ries. Despite the recommendation to pediatricians in 2013 reporting parental
the HPV vaccine. Over 12,000 women vaccinate boys in 2011, only 49.8% of vaccine refusals in their practices,
are diagnosed with and >4000 die of eligible boys complete the first dose, compared to 74% in 2006.7,8 Rather than
cervical cancer every year, and >90% of 39.0% complete 2 doses, and only 28.1% recognizing that the HPV vaccine is a
those cancers are attributable to HPV.1 finish the series.5 In contrast, uptake of cancer prevention vaccine, parents are
While the rate of cervical cancer is not the meningococcal and tetanus, diph- often worried that it is a license for un-
increasing, the rate of overall HPV- theria, and acellular pertussis vaccines, fettered sexual intercourse or believe that
related cancers (including cervical, the 2 other vaccines routinely given in their child does not need the vaccine
vulvar, vaginal, anal, and oropharyngeal adolescence, are much higher with prior to sexual debut.9-11 Others have
cancers) is on the rise in the United 86.4% of adolescents receiving the been swayed by the scientifically inac-
States, with >38,000 men and women tetanus, diphtheria, and acellular curate antivaccination attacks seen in
estimated to be diagnosed with HPV- pertussis vaccine and 81.3% receiving print and social media.12 The data clearly
related cancers every year.2 In 2006 the the first dose of the meningococcal reflect that this vaccine is safe, does not
HPV vaccine became available to prevent vaccine. lead to changes in sexual behavior, and is
these devastating conditions, yet despite While much of the burden of HPV most beneficial if given before exposure
its proven efficacy and safety 10 years vaccination falls on pediatricians and to HPV.13-15
after its introduction, vaccination rates primary care providers, OBGYNs and Public policy changes are potential
lag behind the Healthy People 2020 goal other women’s health providers must opportunities for increasing vaccine ac-
of 80% vaccination completion rate for share responsibility for vaccination of cess and uptake. The HPV vaccine is
girls and boys ages 13-15 years.3-6 As of eligible patients. In this call to action, we already available at no cost through the
2015 in the United States, only 62.8% of discuss the challenges that have impeded Vaccines for Children Program for pa-
eligible girls complete the first dose of widespread adoption of this vaccine, the tients age <19 years who do not have
the HPV vaccination, 52.2% complete 2 unique perspective OBGYNs have as health insurance or Medicaid.16 Publicly
providers who care for women affected funded school- and clinic-based vaccine
by HPV-related conditions, and the programs in other countries have been
From the Divisions of Gynecologic Oncology strategies that OBGYNs and other successful at increasing vaccination rates
(Drs Dilley and Straughn), Preventive Medicine
(Dr Scarinci), and Pediatric Infectious Diseases
women’s health care providers can use to and decreasing the incidence of cervical
(Dr Kimberlin), University of Alabama at maximize HPV vaccination in their pa- dysplasia.17-19 However, school entry
Birmingham, Birmingham, AL. tients and communities. HPV vaccination mandates in the United
Received Jan. 4, 2017; revised Feb. 12, 2017; States have not increased vaccination rates
accepted Feb. 14, 2017. Challenges to HPV vaccination thus far, in part due to lenient opt-out
The authors report no conflict of interest. Low HPV vaccine uptake is a multifac- policies.20 Finally, the multidose vaccina-
The content of this article is solely the torial problem that can be attributed in tion regimen has been cited as a barrier to
responsibility of the authors and does not part to pharmaceutical marketing, mul- full immunization coverage for many
necessarily represent the official views of the tidose vaccination schedules, safety patients. The new Centers for Disease
Association of American Medical Colleges.
concerns, and parental attitudes sur- Control and Prevention (CDC) Advisory
0002-9378/$36.00
rounding the vaccine’s association with Committee on Immunization Practices
ª 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2017.02.026 a sexually transmitted infection.7 recommendation to shorten the series to
Furthermore, parental attitudes toward 2 doses for adolescents age <15 years will

576 American Journal of Obstetrics & Gynecology JUNE 2017

ajog.org Call to Action

hopefully increase rates of vaccine course

completion; however, patients age 15 TABLE
years still require 3 doses.21 HPV vaccination promotion strategies for women’s health care providers
In the face of barriers to HPV vacci- In the office  Counsel patients who are mothers about vaccinating their children
nation, provider recommendation is  Provide vaccines to eligible patients between ages 9-26 y
- Incorporate new ACIP 2-dose schedule for adolescents ages
demonstrated to be the most important 9-14 y21
factor that can influence a patient’s or  Use opt-out approach when recommending vaccine
parent’s decision to vaccinate.11 Unfor-  Provide clear messaging about HPV vaccine as cancer prevention
tunately, some studies have shown vaccine
inconsistent messaging and a lack of  Vaccinate postpartum women age <26 y when they have
guaranteed access to health care
urgency from providers.22 While pedia-  Utilize ACOG HPV vaccination tool kit at immunizationforwomen.org/
tricians and primary care providers are at HPV27
the frontline of childhood vaccination,  Integrate vaccine into standing orders for nurse visits and provide
other providers must take responsibility script for nursing staff to utilize when providing vaccine
as well. As physicians who see the  Promote vaccination through educational activities for nurses and
medical assistants in clinic
tremendous disease burden from genital
warts, cervical dysplasia, and cancers of In the community  Speak with local pediatricians and primary care providers both
the lower genital tract, OBGYNs and formally and informally to promote vaccine
- Use “You are the key” presentation provided by CDC36
other women’s health care providers  Debunk myths and destigmatize HPV vaccine online and in person
have a responsibility to vaccinate their  Conduct and participate in research on promotion and provision of
patients from these diseases. Several HPV vaccine
professional organizations including ACIP, Advisory Committee on Immunization Practices; ACOG, American Congress of Obstetrics and Gynecology; CDC, Centers
the American Congress of Obstetrics for Disease Control and Prevention; HPV, human papillomavirus.

and Gynecology (ACOG),23 Society of Dilley. Preventing HPV-related cancers. Am J Obstet Gynecol 2017.

Gynecologic Oncology,24 and American

Society of Clinical Oncology25 released
position statements and calls to action to
increase HPV vaccination uptake. children, women’s health providers must lead educational sessions and incorporate
ACOG made HPV vaccination a priority, also maximize their efforts. the vaccine into standing orders for
publishing committee opinions on the eligible patients to give nurses autonomy
importance of vaccination, and an The role of the OBGYN over administering the vaccine. Nursing
online tool kit for promoting the vacci- There are many strategies that OBGYNs staff should be provided a clear-cut script
nation in clinical practice.23,26,27 and other women’s health care providers for introducing the vaccine to patients.
The primary goal is for patients to (including family medicine physicians, OBGYNs can look to the experiences of
receive the HPV vaccine in pediatric or certified nurse midwives, and other pediatricians and family medicine pro-
primary care offices in early adolescence, advanced practice providers) can use to viders for guidance when implementing
prior to exposure to HPV. However, due decrease the burden of HPV-related HPV vaccination in their clinics by using
to the large percentage of patients not disease in their clinics and commu- systems that are proven to work well such
vaccinated in this setting, women’s nities. Provider recommendation is as automated telephone calls or text
health care providers are essential for paramount, with the most successful message reminders18,31 and using re-
maximizing efforts to vaccinate patients recommendations coming in the form of sources provided by the American Acad-
who are eligible up to age 26 years. There clear, concise messages focused on can- emy of Pediatrics such as “Countering
are data to suggest there is room cer prevention and an opt-out approach vaccine hesitancy.”32
for improvement when it comes to to HPV vaccination.30 OBGYNs can use Studies looking at postpartum vacci-
OBGYNs’ provision of the vaccine. One this approach with adolescents and nation programs have shown high pa-
study showed that pediatricians were young women who present for annual tient and provider acceptance of this
significantly more likely to recommend exams or problem visits, and use that practice, and highlighted the opportu-
the HPV vaccine to eligible patients than opportunity to provide the vaccine at the nity to vaccinate women who may only
were OBGYNs or family medicine pro- same time. When caring for women who have access to preventive services while
viders.28 Another study demonstrated are the mothers or grandmothers of pregnant. Pregnancy is a time when most
that patients are much more likely to adolescent boys and girls, they can talk women are intimately engaged in the
receive the vaccine from pediatricians about how the HPV vaccine will benefit health care system, and many women
and family medicine providers than their children and grandchildren. who are uninsured have access to care
from OBGYNs.29 While the onus of Cervical cancer screening visits are under Medicaid during pregnancy.
providing the vaccine does and should opportune times for this counseling. To While the HPV vaccine is not approved
fall on providers who care primarily for improve buy-in from clinic staff, they can for use in pregnancy, it is safe for

JUNE 2017 American Journal of Obstetrics & Gynecology 577

Call to Action ajog.org

postpartum women. Despite being years in this messaging, these goals may 8. American Academy of Pediatrics. Periodic
eligible for the vaccine, very few post- now be more achievable for pediatri- survey 66: pediatricians’ attitudes and prac-
tices surrounding the delivery of immuniza-
partum women who are commercially cians and primary care providers. tions. Available at: https://www.aap.org/en-us/
insured are receiving it.33 Groups in OBGYNs and other women’s health care professional-resources/Research/Pages/PS66_
Texas and New York described successful providers are uniquely situated, as they Executive_Summary_PediatriciansAttitudesand
postpartum HPV vaccination programs, are involved in the prevention and PracticesSurroundingtheDeliveryofImmunizations
with a focus on minority (especially treatment of HPV-related diseases, and Part2.aspx. Accessed February 6, 2017.
9. Scarinci IC, Garces-Palacio IC, Partridge EE.
Hispanic/Latina) and publicly insured should feel empowered to support the An examination of acceptability of HPV vacci-
patient populations. Both groups re- efforts of increasing HPV vaccination nation among African American women and
ported high rates of vaccine acceptability rates. Women’s health care providers can Latina immigrants. J Womens Health (Larchmt)
by patients and providers, with signifi- provide the vaccine to all eligible patients 2007;16:1224-33.
cantly increased vaccine completion in their clinics, encourage their patients 10. Darden PM, Thompson DM, Roberts JR,
et al. Reasons for not vaccinating adolescents:
rates from baseline.34,35 With many to vaccinate their children and grand- national immunization survey of teens, 2008-
states foregoing Medicaid expansion and children, and provide education and 2010. Pediatrics 2013;131:645.
with the uncertain future of the Afford- leadership in their communities on the 11. Holman DM, Benard V, Roland KB,
able Care Act, the importance of primary prevention of HPV-related dis- Watson M, Liddon N, Stokley S. Barriers to
capturing patients while they have reli- eases. With a combined effort from all human papillomavirus vaccination among us
adolescents: a systematic review of the litera-
able coverage is of utmost importance. providers, we can save lives. -
ture. JAMA Pediatr 2014;168:76-82.
Women’s health care providers can 12. Betsch C, Renkewitz F, Betsch T,
also have an impact on their ACKNOWLEDGMENT Ulshöfer C. The influence of vaccine-critical
communitiesethrough research, advo- Thank you to Dr Charles A. Leath III of the Divi-
websites on perceiving vaccination risks.
cacy, and multidisciplinary communi- J Health Psychol 2010;15:446-55.
sion of Gynecologic Oncology, University of
13. Madhivanan P, Pierre-Victor D,
cation. As leaders in the medical Alabama, for his support and review of the
Mukherjee S, et al. Human papillomavirus
community, women’s health care pro- manuscript.
vaccination and sexual disinhibition in females.
viders have the opportunity to pass along Am J Prev Med 2016;51:373-83.
the message of urgency from experiences 14. Moreira ED, Block SL, Ferris D, et al. Safety
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Call to Action Supplemental Materials ajog.org

ABSTRACT
Preventing human papillomaviruserelated
cancers: we are all in this together
Human papillomaviruserelated cancers, which include cervical, vul- proportion of human papillomaviruserelated conditions, obstetrician-
vovaginal, anal, and oropharyngeal cancers, are on the rise in the gynecologists and other women’s health care providers must share
United States. Although the human papillomavirus vaccine has been on the responsibility for vaccination of eligible patients. Obstetrician-
the market for 10 years, human papillomavirus vaccination rates are gynecologists can support the efforts to eradicate human papilloma-
well below national goals. Research identified many barriers and fa- viruserelated disease in their patients and their families via multiple
cilitators to human papillomavirus vaccination, and provider recom- avenues, including providing the human papillomavirus vaccine and
mendation remains the most important factor in parental and patient being community leaders in support of vaccination.
decisions to vaccinate. While much of the burden of human papillo-
mavirus vaccine provision falls on pediatricians and primary care Key words: cancer prevention, cervical cancer, cervical dysplasia,
providers, they cannot do it alone. As clinicians who care for a large human papillomavirus, human papillomavirus vaccination

576.e1 American Journal of Obstetrics & Gynecology JUNE 2017