Why Don't More American Teens Get the HPV Vaccine?

The benefits of vaccination from human papillomavirus (HPV) are potentially enormous. By getting vaccinated during your preteen years, you can greatly reduce your risk of HPV-associated cancers, including cervical and anal cancer as well as penile, vaginal, vulvar, and head and neck cancers.

Despite current recommendations for HPV vaccination in all girls and boys ages 11 to 12, only 49% have completed the recommended vaccine series, according to the Centers for Disease Control and Prevention (CDC).

Doctor giving teen HPV shot — KidStock / Getty Images

There are many reasons for this, some of which are more easily remedied than others. Overcoming these barriers may help reduce the cancer incidence in the United States, of which HPV infection is believed linked to 5% of all cases.

What Is HPV?

HPV is a group of viruses that belong to the Papillomaviridae family. Of the roughly 200 types of HPV in circulation, around 40 are sexually transmitted.

Some of these can cause genital warts (particularly HPV types 6 and 11), while a small group of high-risk types are linked to cancer (specifically types 16, 18, 31, 33, 45, 52, and 58). Of the risk-risk types, types 16 and 18 account for 70% of all HPV-associated cancers.

In most cases, an HPV infection will clear on its own without any long-term consequence. However, in some cases, an infection can persist and lead to the development of cancer. As of yet, there is no way to predict who will get cancer in later life.

HPV infection is extremely common. Updated surveillance from the CDC suggests that roughly nine in 10 people in the United States will get HPV at least once in their lifetime.

While it is possible to reduce your risk of HPV with condoms—as well as a reduction in the number of sex partners—the virus can be spread by skin-to-skin contact which condoms cannot protect you from.

HPV vaccination is therefore considered the primary form of protection in children before they are exposed to the virus in later life.

About HPV Vaccination

In the United States, there is only one HPV vaccine called Gardasil-9 that is recommended for use by the Advisory Committee on Immunization Policy (ACIP), an independent group of experts within the CDC.

Gardasil-9 protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 and replaces the original Gardasil vaccine which only protected against four. (Another vaccine called Cervarix, which protects against types 16 and 18, was voluntarily discontinued by the manufacturer in 2016.)

The aim of vaccination is to provoke a disease-specific immune response—in the form of HPV antibodies—so that the virus can be neutralized if an exposure occurs. This needs to be done before a child becomes sexually active, which is why the ACIP recommendations are aimed at preteens.

Benefits of Vaccination

Since the introduction of Gardasil in 2006, the incidence of HPV-associated cancers has plummeted. This is especially true with cervical and anal cancers of which 90% are linked to HPV.

In countries like Australia where 80% of females and 76% of males are fully vaccinated, the decrease in the rate of HPV-linked cancer has been even more impressive.

According to a 2016 review of studies in Clinical Infectious Diseases, which examined the real-world impact of HPV vaccinations around the world from 2007 to 2016, the use of Gardasil has translated to:

90% fewer HPV infections overall
90% fewer cases of genital warts
45% fewer cases of low-grade cervical changes caused by chronic HPV infection
85% fewer cases of high-grade cervical changes linked to cancer

A 2020 study in the New England Journal of Medicine further concluded that HPV vaccination by the age of 17 decreases the risk of invasive cervical cancer (ICC) by no less than 88%.

Reasons for Poor Uptake

The poor uptake of HPV vaccination in the United States appears to be unique. The same has not been seen in other resource-rich countries like Denmark, Hungary, Ireland, Norway, Portugal, Sweden, and the United Kingdom, where HPV vaccination coverage in the range of 80% to 90%.

There is much speculation as to why this is a distinctly American phenomenon, but research has provided some insights. Some of the causes include:

Lack of awareness: A 2019 study in JAMA Pediatrics revealed that many American adults are unaware of the link between HPV and cancer and how vaccination can help. Men tend to be less aware than women not only about what HPV is (54% vs. 80%) but about the availability of a vaccine (53% vs. 80%).
Social disproval: HPV is stigmatized in many communities because it is sexually transmitted, and there are parents and others who believe that vaccination may encourage teen sex. Research has shown that is not true and that HPV vaccination neither increases the likelihood of sex, the age that a person first has sex, or the number of sex partners a teen or young adult has.
Absence of a mandate: To date, only Hawaii, Rhode Island, Virginia, Washington, D.C., and Puerto Rico have made HPV vaccination mandatory. This is in contrast to other ACIP-recommended vaccines like MMR (measles, mumps, rubella) and DTaP (diphtheria, tetanus, pertussis) which are mandatory in all states.
Cost: Cost and insurance coverage has been found to significantly influence HPV vaccine uptake. Even though the vaccine is covered as an Essential Health Benefit (EHB) under the Affordable Care Act and offered free to low-income families through manufacturer assistance programs, the cost of delivering the shots may sway some parents from getting their children vaccinated.

Anti-vaccine messaging: Anti-vaccination campaigners, who contend that vaccines are harmful, have contributed to an overall decline of the childhood vaccination rate in the United States. This includes attack messaging warning parents about the "dangers" of the HPV vaccine. It has been found that people influenced by such messaging tend to have large social networks and relied heavily on the internet and mass media for health information.

To counter some of the effects, public health messages promoting HPV vaccination have increased on TV, print, and social media. Efforts to positively influence state and school-based vaccination policies have also intensified, while some experts have even endorsed reducing the recommended two-dose series one to decrease costs and inconvenience to parents.

ACIP Recommendations

Gardasil-9 is given in either two or three doses to provide optimal protection against HPV infection. The ACIP along with the American Pediatric Association (APA) recommend HPV vaccination in the following groups:

Girls and boys ages 11 to 12 as part of their childhood vaccination schedule
Children as young as 9 who may be at risk of getting HPV
Anyone up to age 26 who has not been adequately vaccinated

Although the ACIP does not recommend vaccination for anyone over 26 (since they will most likely have gotten HPV already), they allow for vaccination up to the age of 45 based on individual circumstances after consultation with a doctor.

Children who receive their first vaccine dose before 15 should get a second dose 6 to 12 months later. People vaccinated between ages 15 and 26 should receive three doses—starting with a first dose, a second dose 1 to 2 months later, and a third dose 6 months later.

A Word From Verywell

If in doubt about HPV vaccination, resist the temptation to ask friends or Facebook contacts for advice. Speak with a doctor or other qualified health professionals.

Despite unfounded claims that vaccines can cause everything from autism to ovarian failure, the greatest harm comes not from vaccines but from the avoidance of vaccines. This is especially true with regards to HPV and cancer.

In the end, two simple injections may be all it takes to prevent the development of cervical cancer, anal cancer, and other cancers later in life.