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

Infection from human papillomavirus, or HPV, is incredibly common. Scientists think that more than half of sexually active adults are infected with HPV at any given time. Not all of those infections are the same, as there are more than 100 types of HPV - many of which are spread sexually. Some types of HPV are considered to be high-risk. These strains are associated with an increased risk of a variety of cancers in both men and women. Other types are considered to be low-risk, including strains are associated with genital warts.

Because HPV is spread from skin-to-skin, condoms aren't completely protective against infection. That's why it was so exciting for many people when the first HPV vaccine was developed. That vaccine, Gardasil, protected against the two most common high-risk and the two most common low-risk varieties of HPV. A few years later, another vaccine, Cervarix, was released - and this vaccine focused on the high-risk strain. These days, there are three HPV vaccines. The third vaccine is a new version of Gardasil called Gardasil-9 that protects against 9 strains of HPV. It's important to note that Gardasil-9 is currently the only vaccine available in the US.

The vaccines aren't perfect. However, countries that have had good vaccine uptake have seen their cervical cancer numbers drop. So why don't more American teens get an HPV vaccine?

The Benefits of the HPV Vaccine by the Numbers

In countries, such as Australia, where many young women are given the 4-strain HPV vaccine (Gardasil) before they can be exposed to the virus, the effects have been extraordinary. A 2016 study review of the literature found that there were:

• 90% fewer infections with HPV 6, 11, 16, and 18. These are the four strains protected against by Gardasil.
• 90% fewer cases of genital warts.
• 45% fewer diagnoses of low-grade cervical changes.
• 85% fewer diagnoses of high-grade cervical changes. These are the types of changes associated with the development of cancer.

However, for these benefits to be seen, young people have to get the HPV vaccine. More importantly, the vaccine is most effective if administered before they start having sex.

Some countries are doing incredibly well at getting people vaccinated. In 2014, almost three quarters of all Australian girls had been vaccinated. Denmark, Hungary, Ireland, Norway, Portugal, Sweden, and the United Kingdom all have vaccination coverage in the range of 80-90 percent. In contrast, by 2014, only 40% of American girls and 22% of American boys had been vaccinated.

Why Is America Behind in HPV Vaccination Rates?

The HPV vaccine came to the United States very early. However, in its early years, there were a lot of debates about whether it should be part of regular vaccination recommendations. People were initially concerned about safety. It has since been shown to be a very safe vaccine. They were also concerned that the HPV vaccine might encourage young people to have more sex, which has also proven to be an unfounded concern.

Today, the American Academy of Pediatrics (AAP), the US Centers for Disease Control and Prevention (CDC) and the American Cancer Society (ACS) all recommend routine HPV vaccination for adolescents. CDC and AAP guidelines recommend routine vaccination for females and males ages 11 and 12 , while ACS guidelines recommend routine vaccination begin at age 9, which is the youngest age for which Gardasil 9 is indicated for. ACS argues that the earlier recommendation can help support earlier and on-time vaccination rates overall. 

The HPV vaccination can be given at an older age, but it's not as useful. Most people older than 26 have already come into contact with HPV, and the vaccines are not effective if you've already been exposed.

So why do vaccine rates still fall behind those of many other developed nations, even now that the HPV vaccine is so widely recommended? There are a number of reasons. In no particular order:

• Doctors don't do a good job of consistently recommending the vaccine to adolescent patients and their parents.
• Parents aren't aware that the vaccine is needed for young men and women. Therefore, they don't know to ask for it or about it.
• When parents are aware of it, many don't believe HPV vaccination is as important as other childhood and adolescent vaccinations. This is particularly concerning alongside the overall decline in childhood vaccination that is being seen all over the United States. Decreasing use of vaccines is largely attributable to parents' fears about vaccination. These fears are not based in science. They also fail to recognize that vaccines are many orders of magnitude safer than the diseases they are designed to prevent.
• Parents are concerned about the cost of the vaccine. They're also worried about the cost of the visits required to get the vaccine. There is some evidence that Medicaid recipients get the vaccine more often than those on private insurance. This could be for several reasons. One of those reasons is the lower cost of seeking care when you don't need to pay visit co-pays.
• HPV vaccines aren't always available in all areas of the United States. Availability varies a lot depending on where people get care.

There are ways to fix these problems. Educational programs can help teach doctors about the importance of routine vaccination. That way, doctors could learn more about both the vaccine and how to talk about it in culturally appropriate ways. HPV vaccines can be made part of standard prevention programs. This could make discussing them easier for parents and physicians alike. Electronic medical records can be improved and access to the vaccine can be expanded. That would help doctors identify people who need the vaccine. It could also mean that parents and teens would have more options for where to get their shots.

Finally, parents and teens need to have access to better information about the HPV vaccine. If more people understood the benefits to both boys and girls, they'd probably be more interested in getting it. Most importantly, they need to learn that getting the HPV vaccine isn't about having sex. It's about protecting health.