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

Despite current recommendations for human papillomavirus (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). There are many reasons for this, some of which are more easily remedied than others.

Doctor giving teen HPV shot — KidStock / Getty Images

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

This may help reduce cancer incidence in the United States overall, as the virus is believed to be 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 those, 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 instances, an infection can persist and lead to the development of cancer.

As of yet, there is no way to predict who with HPV will get cancer in later life.

In 2018, there were about 43 million HPV infections in the United States.

While it is possible to reduce your risk of HPV with condom use, 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.

HPV Vaccination

There is only one HPV vaccine available in the United States—Gardasil-9. It is given in a two- or three-shot series.

The Advisory Committee on Immunization Policy (ACIP), an independent group of experts within the CDC, recommends its use in children 11 to 12 and anyone up to the age of 45 who has not been adequately vaccinated.

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 in the United States by the manufacturer in 2016.)

Vaccination aims to provoke a disease-specific immune response in the form of HPV antibodies—proteins that make the body more readily able to neutralize the virus if an exposure occurs. This needs to be done before a person 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% of cases 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.

A 2016 review of studies in Clinical Infectious Diseases 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 People Don't Get the HPV Vaccine

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 is 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 insight:

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 disapproval: HPV is stigmatized in many communities because it is sexually transmitted, and there are some who believe that vaccination may encourage teen sex. Research among college-age people has shown that this is not true and that HPV vaccination does not influence the likelihood of having sex, the age at which a person first has sex, or the number of sex partners a person has compared to a matched set of unvaccinated people.
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 significantly influence HPV vaccine uptake. Even though the vaccine is covered as an Essential Health Benefit (EHB) under the Affordable Care Act (ACA) and offered free to low-income families through manufacturer assistance programs, the cost of having a practitioner actually give 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 that warns 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 rely heavily on the internet and mass media sources that promote non-adherence to recommended vaccination schedules 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. Some experts have even endorsed reducing the recommended series to one shot to decrease cost and inconvenience to parents.

ACIP Recommendations

The ACIP currently recommends 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 through 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 six to 12 months later.

People vaccinated between ages 15 and 26 should receive three doses. The second and third doses should be given one to two months and then six months after the first dose, respectively.

A Word From Verywell

If in doubt about HPV vaccination, resist the temptation to ask friends or social media 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 them. This is especially true with regard to HPV and cancer.

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