Study Finds Greater Cincinnati Pediatricians Split On Legislative Mandates for HPV Vaccine

Monday, July 23, 2007

CINCINNATI -- A new study of pediatricians in the Cincinnati area and their attitudes about a vaccine for women to prevent human papillomavirus (HPV) infection shows wide-ranging opinions on whether the vaccine should be mandated for young girls.

The pediatricians are split evenly on the Centers for Disease Control (CDC) recommendation that all 11- to 12-year-old girls receive the vaccine -- prior to the onset of sexual activity. One-third believe the cancer-preventing vaccine should be mandated, one-third disagree with mandated vaccination, and one-third are unsure but believe that mandates are unlikely in the near future, according to the Cincinnati Children's Hospital Medical Center study.

HPV is the most common sexually transmitted disease and can cause cervical cancer. The Food and Drug Administration approved a vaccine in 2006, and an immunization advisory committee of the CDC recommended immunization of all 11- to 12-year-old girls.

"Pediatricians will play a critical role in HPV vaccine delivery," says Jessica Kahn, MD, MPH, a physician in the Division of Adolescent Medicine at Cincinnati Children's and the study's senior author. "The views of pediatricians, who have extensive experience administering vaccines to children and adolescents, will be valuable as HPV vaccine delivery strategies are designed."

Dr. Kahn's study, published in the August issue of the Journal of Adolescent Health – the official journal of the Society for Adolescent Medicine, involved interviews with 31 pediatricians in the tri-state area. In addition to being asked about legislative mandates for vaccination, the pediatricians were asked their opinions on cultural considerations related to HPV vaccination, whether vaccination should be universal or targeted to particular groups, and on clinical and public health strategies to increase vaccination.

Legislative mandates

Pediatricians who agreed with mandated HPV vaccination to enter school cited the public health benefits. "I would be all for requiring vaccines, because it's a public health issue. And I would certainly think that we could really impact significantly on a serious public health issue," said one of those interviewed. However, even those pediatricians who supported mandated vaccination noted that legislation should not be introduced until adequate safety, effectiveness and cost-effectiveness were available.

Pediatricians opposed to a mandated HPV vaccine cited two main reasons: the lack of long-term data on the safety and effectiveness of the vaccine, and that HPV is sexually transmitted while existing mandated vaccines generally target infections that are transmitted casually in schools. "The only mandates we currently have for vaccines in our country are for infectious diseases spread in a school setting. It would not be a school or public health issue but more of an individual issue," said a pediatrician opposed to legislative mandates.

Those pediatricians who were neither in favor of nor opposed to mandated vaccines believed that legislation was not likely in the near future. This was primarily due to "cultural conservatism" about adolescent sexuality, said one pediatrician.

Cultural considerations

Dr. Kahn and her colleagues at Cincinnati Children's found that virtually all pediatricians consider cultural considerations important when recommending vaccination and that vaccination should be recommended universally. "Provider awareness of families' cultural or religious beliefs, particularly those related to vaccines and adolescent sexuality, clearly will be important as they recommend HPV vaccines to girls and their parents," said Dr. Kahn.

Universal vs. Targeted Vaccination

The vast majority of participants in the study believed that HPV vaccination should not be targeted toward specific populations that might have higher rates of HPV but should be recommended universally. The primary reason cited was that all sexually active adolescents and adults are susceptible to HPV infection and its consequences, according to Dr. Kahn.

Clinical and public health strategies to increase vaccination

Pediatricians identified a number of strategies that they believe are critical for HPV vaccination to be successful. These include:

• Maximizing ease of vaccine administration, such as vaccine schedules involving a minimal number of injections, using less painful injection systems and combining HPV with other vaccines targeted towards early adolescence.
• Implementing office-based procedures and policies to optimize vaccine "uptake." This might include screening charts to check for eligibility, computerized recall or reminder systems, informational mailers and vaccination during sports physicals or urgent care visits.
• Ensuring access to vaccines through a broad spectrum of providers in non-traditional settings, such as school-based health centers and public health clinics.
• Ensuring endorsement of vaccination by influential organizations, such as the American Academy of Pediatrics and the Centers for Disease Control.
• Addressing the educational needs of providers, parents and patients.

Strategies to Meet Education Needs Related to HPV Vaccines

Pediatricians provided numerous suggestions for meeting their educational needs, generally preferring lectures and written materials from trusted sources. For patients and parents, pediatricians' recommendations included written materials available in the office, educational videos that could be shown during office visits, school-based sexuality education, reliable internet-based materials, other media (TV, radio and magazines) and peer education.

The study was funded in part by a grant from the National Institute for Allergy and Infectious Diseases, a branch of the National Institutes of Health (NIH).

Cincinnati Children's Hospital Medical Center, one of the leading pediatric research institutions in the nation, is dedicated to changing the outcome for children throughout the world. Cincinnati Children's ranks second among all pediatric institutions in the United States in grants from the National Institutes of Health. It has an established tradition of research excellence, with discoveries including the Sabin oral polio vaccine, the surfactant preparation that saves the lives of thousands of premature infants each year, and a rotavirus vaccine that saves the lives of hundreds of thousands of infants around the world each year. Current strategic directions include the translation of basic laboratory research into the development of novel therapeutics for the treatment of disease, and furthering the development of personalized and predictive medicine.