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HPV Vaccination: Barriers to Routine Implementation
Katherine E. M. Hoops, BS
Leo B. Twiggs, MD, ACOG, ACS

By her eighteenth birthday, a girl in the United States may have received up to 44 vaccine injections, all of which are recommended for children and adolescents. The three doses for the HPV vaccine would bring the total to 47 injections ¹. Several vaccinations, such as the Hepatitis B, Pertussis booster, and meningococcus vaccines, are required or recommended for children entering the seventh grade. The HPV vaccine is seen as either conjunction or competition with other vaccines given at the same age. Health agencies appreciate the convenience of administering the vaccine at the first well-adolescent visit. Two-thirds of parents living in the United States believe, however, that no more than two immunizations should be given at a single office visit, and many children are under- immunized due likely to the complexity of the vaccination schedule ².

Similar arguments to those against the HPV vaccine were made when the Hepatitis B vaccine was mandated because Hepatitis B is also spread primarily through sexual contact. Targeted vaccination programs were proposed, but such programs were found to be less effective in preventing spread of the disease than a universal vaccination program. Vaccination against meningococcus is also strongly recommended for children and students, especially college freshmen living in dormitories. However, according to the Centers for Disease Control and Prevention, of the 1,400 to 2,800 cases of meningococcal disease that occur each year in the United States, only 3 percent are associated with outbreaks while 97 percent are sporadic.

The critical question is why state governments are reluctant to pass legislation related to the HPV vaccines. Religion and sexuality have dominated the discussion, and political agendas are inherent to the process. However, ethical and epidemiological analyses are also essential to the decision to mandate the HPV vaccine. Studies show that schools with exemption rates as low as 2% to 4% are at an increased risk for disease outbreaks of vaccine-preventable diseases ^{3, 4}. Women and girls have a right to be protected against those vaccine-preventable diseases. HPV may not be transmitted “casually,” but this must not be the sole reason to deny protection to adolescent girls. A woman is not guaranteed protection from forcible means of transmission—including rape, other sexual assault—or even from acquiring the disease during marriage.

A recent study by Blake and colleagues suggests that the vast majority of adolescents (97%) receiving cervical cancer screening and a majority of their mothers (60%) could not adequately define the terms Pap smear or HPV ⁵. Education is a critical link. The vaccine could prevent up to 70% of cervical cancers, but Pap testing is necessary to diagnosis of the remaining 30% early. Moreover, since cervical cancer is extremely rare before age 25 years in the United States and does not reach peak incidence until 35 to 40 years of age, it will take almost 20 years before the vaccination programs aimed at 10 to 12 year olds will have an initial impact on cervical cancer rates. And because of the age distribution of cervical cancer, the full impact of vaccination on cervical cancer incidence would not occur for almost 50 years ⁶. Therefore, local, regional, and national organizations will need to develop programs which facilitate both initial vaccination and continued screening in accordance with current guidelines as well as making use of newly available techniques.

Prevention of cervical cancer is a goal that is attainable. Public and private groups need to develop strategies that produce socially acceptable funding mechanisms to implement these critical programs. It is imperative that public health organizations continue to emphasize cervical cancer screening in all women as well as continued education on HPV itself.