October 15, 2017
Noel Brewer, PhD
Professor of heath behavior
A cervical cancer survivor, Tamika Felder, once told me about her journey – from the stunning cancer diagnosis at age 25, through treatment that ended her ability to have children, to the present day, when she shares her experience to inspire others. Personal stories such as hers have motivated my research over the last decade on how to get the cancer-preventing HPV vaccine to more people.
More than 80 million people in the U.S. are infected with HPV – about a quarter of the population. With a good immune system, the body usually gets rid of the virus, but persistent infections can cause health problems.
HPV causes six cancers – of the cervix, vagina, vulva, anus, penis and mouth/throat – as well as genital warts. Globally, the virus causes more than 600,000 of the 14 million cancer cases diagnosed each year. In the U.S., HPV causes almost 40,000 cancers every year.
Screening can detect many cervical and anal cancers when they are still treatable, but it often fails. For example, cervical cancer has become less common in the U.S. since the advent of the Pap test. However, deaths from cervical cancer and other HPV cancers continue.
Many people don’t get screened for cancer, can’t get screened, or screening fails them. Large disparities exist in our state and the U.S., with black women being twice as likely to die from cervical cancer. No screening test exists for most HPV cancers. People with HIV are around 100 times more likely to get cervical and anal cancer, and if they do, they are, by definition, diagnosed with AIDS. In Africa, cervical cancer kills more women than any other cancer. HPV is a predatory virus that preys on the young and the vulnerable.
The HPV vaccine is extremely effective when given to young people. Children’s immune systems mount a more vigorous response than do adults’. Younger people also are less likely to have been exposed to HPV. The vaccine is so effective that experts now recommend fewer doses – two instead of three, if both are received by age 14. With more than 200 million doses delivered worldwide, HPV vaccine is one of the most studied and safest medicines. The vaccine easily can be co- administered with other recommended vaccinations for adolescents, including ones for tetanus, diphtheria and pertussis (TDaP) and for meningitis.
HPV vaccination is now the norm in our country, with 60 percent of children having received the first dose. Unfortunately, only 43 percent are given all recommended doses. Thus, the nation is far short of its goal of 80 percent of children fully vaccinated against HPV.
Q: How can we increase HPV vaccination?
A: The President’s Cancer Panel, chaired by our dean, Dr. Barbara K. Rimer, wrote an influential call to action in 2012, urging that more be done to ensure that boys and girls are given the HPV vaccine. (See the 2012–2013 panel report at tinyurl.com/PCP-HPV.) The Panel called for urgent action that would affect parents, providers and policies. The report has influenced my own work and that of many in the U.S.
Most parents want the HPV vaccine for their child, but they often have questions. There’s no single common reason for not vaccinating. It may be that the parents don’t have enough information, have questions about safety, or aren’t sure their children are the right age. All of these questions are ones that a provider can answer.
Providers should recommend the HPV vaccine routinely and confidently. The best recommendation may be no “recommendation” at all. It is more effective for a provider to say, “Your child is due for vaccines against meningitis, HPV cancers and whooping cough. The nurse will administer those at the end of the visit.”
The point is to set parents’ minds at ease by treating HPV vaccine the same as all other vaccines that keep children healthy.
In a 2016 feature story, National Public Radio described a successful trial we conducted with 30 pediatric and family medicine clinics in North Carolina, using this “presumptive announcement method.” (See tinyurl.com/NPR-HPV-vaccine-make-it-brief.) When doctors made brief statements that presumed parents intended to vaccinate their children, vaccine rates increased by 5 percent. There was no increase in vaccination rates following lengthy discussions. Now, the presumptive announcement method is used nationally to train a new generation of pediatricians and family physicians.
Providers should establish systems within their own practices to determine which children are due – or overdue – for the vaccination. Standing orders can be established, such that nurses and mid-level providers can initiate vaccination. Most importantly, the provider’s office should present a united message. From the receptionist to senior physicians, the staff should be “on the same page” in terms of the vaccination being required if children are to remain healthy.
Policy makers also impede a higher vaccination rate.
Political leaders have spoken about the vaccination without proper evidence, including a presidential candidate who publicly claimed to have “heard” that the HPV vaccine caused lasting side effects. Such pronouncements from public officials must be based on science, not hearsay. Data on the more than 200 million doses delivered globally show the vaccine is safe, as are the meningitis vaccine and other vaccines for teens.
My mother died of cervical cancer in 2012. While going through her belongings, I found a photograph of her, standing between her parents at the Empire State Building, beaming at the camera. She was perhaps nine years old. Were the HPV vaccine available then, my mom probably would be alive today.
It’s too late for her. She did not live to see her grandchild, and the best I can do is share her picture and my memories. It’s too late for Tamika, who can never have grandchildren. However, it’s not too late for today’s children, to help them stay healthy and become tomorrow’s parents and grandparents.
Carolina Public Health is a publication of the University of North Carolina at Chapel Hill Gillings School of Global Public Health. To view previous issues, please visit sph.unc.edu/cph.