HPV vaccination may pose delivery concerns

Pediatricians can expect problems meeting vaccination schedules for human papillomavirus (HPV) vaccine. Based on data from the 1996 to 2002 Medical Expenditure Panel Survey, only 11% of adolescents have primary care visits on a schedule appropriate to HPV vaccination.

"Getting all three vaccinations to adolescents will challenge primary care delivery," said Cynthia Rand, MD, MPH, Strong Children's Research Center University of Rochester, NY. "Ideally, we should see every adolescent every year, but that doesn't happen in the real world. We are going to have to work on educating patients and their parents."

The first HPV vaccine is expected to be approved for use in the United States later this year. Once the initial dose has been given, follow-up doses must be administered at two months and six months. MEPS reports show that, while 38% adolescents have three physician visits in a two-year period, fewer than one third of those visits come at intervals appropriate for HPV vaccination.

Patients who are older, non-white, Hispanic, uninsured, and poor are the least likely to have multiple visits within the vaccination period, Dr. Rand told an audience at the PAS Annual Meeting.

The problem, she explained, is that few adolescents get regular medical care. Older adolescents, as well as those who are non-white, uninsured, or poor get even less medical attention than the rest of the community. Most primary provider visits are for acute care, which makes it particularly important to educate patients about HPV vaccination at every visit, regardless of the reason for that visit.

"These data suggest that, if you begin vaccination at an acute visit, you actually have a better chance at getting all three vaccinations in the right time frame," Dr. Rand said. She recommended pamphlets and other educational materials in waiting rooms and provider reminders to discuss HPV vaccination at every visit.

A parallel report suggests that pediatricians also need education about the HPV vaccine. A random survey of American Academy of Pediatrics members nationwide found that, although as many as 89% said they would likely give the vaccine, 73% also believe that inadequate reimbursement will be a barrier.

Matthew Daley, MD, University of Colorado at Denver and Health Sciences Center, found that physicians are divided over use of the vaccine. Trials have found that vaccination is 100% effective in preventing HPV infection in females 11 years and older, but only 46% of responding pediatricians said they would vaccinate patients 10 to 12 years old. The likely vaccination rate jumps to 77% for girls 13 to 15 years old and 89% for patients 16 to 18 years old. Physicians cited potential parental objections as well as their own fears that vaccination could encourage risky sexual activity.

"We heard some extreme right-wing objections when the vaccine was announced," Dr. Rand said, "but it was more noise than reality. Most parents want to do what is best for their children. If their pediatrician says vaccination is the right thing to do, most will move in that direction. It is a matter of educating providers as well as patients and their parents.