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A Push for HPV Vaccinations

4/01/13 (Mon)

The government recommended years ago that all adolescent girls get a vaccine to protect against cervical cancer. But nearly seven years after it first came to market, an overwhelming majority of girls have yet to be inoculated.
 
Just 35 percent of girls 13 to 17 have received a full course of the vaccine, which inoculates against the strains of human papillomavirus that can cause cervical cancer, according to 2011 data from the Centers for Disease Control and Prevention. And a study in Pediatrics this month, also based on C.D.C. data, says the intent to vaccinate is declining: 44 percent of parents in 2010 said they did not intend to vaccinate, up from 40 percent in 2008.
 
Alarmed by the stubbornly low rates, doctors and federal health officials are brainstorming about how to get more children vaccinated.

Behind these numbers are people who will develop cervical cancer that could have been prevented, said Dr. Bruce Gellin, director of the National Vaccine Program Office at the Department of Health and Human Services. At a meeting in Washington last month, federal and local officials, doctors and other health workers explored ways to make the shots more accessible. Some suggested giving the first of the three doses required to complete the vaccine at a doctors office and the other two at schools or pharmacies.
 
Others argued for a greater emphasis on cancer prevention, playing down the fact that the vaccine prevents a sexually transmitted disease. The STD link has put off many parents who are loath to talk about sex with their children.
 
Outside the policy world, local health departments and researchers are applying their own ideas. At Indiana University School of Medicine in Indianapolis, researchers have designed postcard reminders for children who got the first of the three shots required over six months, but did not finish the course. One card features a child in the rain with a broken umbrella.
 
In Kentucky, advocates have used Facebook to conduct a public education campaign that has increased inoculations by 10 percent in areas that participated.
 
Researchers at Boston University have raised inoculation rates for patients in two clinics in Massachusetts by teaching pediatricians to present the HPV vaccine as being equal in importance to other childhood vaccines, even though it is rarely required for school. The virus is usually diagnosed in adults, so pediatricians are less experienced with it and may give the vaccine short shrift.
 
HPV is the most common sexually transmitted infection in the United States. Nearly half of woman ages 14 to 59 were infected with at least one strain, with the highest rate, 54 percent, among women ages 20 to 24, according to a recent analysis by the C.D.C. A vaccine to prevent certain strains of HPV, first licensed in 2006, was seen as a major breakthrough by doctors and researchers.
 
Experts attribute the low rates to an array of factors: The three-dose requirement is unwieldy. The vaccine is for adolescents, who are less likely than younger children to have regular checkups.
 
In addition, it comes with a stigma. HPV is a sexually transmitted infection, and some parents fear their daughters will see talking about the vaccine as condoning sex or giving the green light to start having it. Health professionals say it should be administered at age 11, though it is approved for children as young as 9.
 
Finally, there is the lingering fear many people have for vaccinations in general. The Pediatrics study found that in 2010, fear of side effects had risen to the second-most cited reason parents did not vaccinate, said Dr. Paul M. Darden, one of the studys authors and a pediatrics professor at the University of Oklahoma.
 
HPV vaccination rates vary dramatically by state. According to the C.D.C. data for 2011, Rhode Island had the highest, with 57 percent of adolescent girls fully inoculated, followed by Vermont and South Dakota, both 50 percent. Arkansas had the lowest, 15 percent, less than half the national rate. Other states with low rates were Mississippi and Utah, at 20 percent, and Kansas, at 22 percent.
 
The pattern of vaccination among ethnic groups was surprising: while Hispanic girls were less likely to come from families with health insurance or to get regular medical care, they were more likely to have been vaccinated than white girls.
 
Just 48 percent of white teenage girls had received the first dose of the vaccine, compared with 56 percent of blacks and 65 percent of Hispanics, according to the C.D.C. But the rate fell steeply by the third dose. In all, 42 percent of Hispanic teenage girls had been fully vaccinated. About a third of whites had received all three doses, similar to the share of black girls.
 
That breakdown turns the typical pattern of whites having better health outcomes on its head. I can'tremember a vaccine where I saw a pattern like this, said Dr. Walter A. Orenstein, director of Emory Universitys Program for Vaccine Policy and Development, who ran the C.D.C. immunization program for 16 years.
 
One reason is money. A federal inoculation program that covers vaccines for the poor and underserved gave the HPV vaccine to clinics for free. Private insurance coverage was less reliable, and many patients had high co-pays or had to pay the full price, generally up to $500 for a complete cycle of the vaccine.
 
The new health care act requires insurers to cover the vaccine, a change that has the potential to even out the disparity and increase the vaccination rate.
 
There are other sociological factors at work. Dr. Amanda F. Dempsey, an associate professor of pediatrics at the University of Colorado in Denver, said that in her previous practice, in Michigan, the most-educated parents were the most reluctant to get their daughters vaccinated. For some, the hesitation stemmed from a suspicion of vaccines. For others, it was more about having to broach the topic of sex.
 
Cultural differences also play a role. Many foreign-born Hispanics are from countries where babies still die of vaccine-preventable diseases like measles. They consider vaccines essential for survival. Parents born in the United States, on the other hand, are more skeptical of vaccines, as many have no living memory of the lethal diseases they prevent.

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