What's Keeping Girls from Getting the HPV Vaccine?
For parents around the country, back to school means more than new clothes and school supplies -- it means a trip to the doctor for federally mandated immunizations to protect their children against diseases like whooping cough. But there's another vaccine available to our young people that most parents won't hear about when they take their 7th graders in for a TDAP booster: the HPV vaccine, which protects against the sexually transmitted virus that causes both cervical cancer and genital warts.
According to the Centers for Disease Control and Prevention, the HPV vaccine is greatly underutilized in the United States, thanks to a perfect storm of barriers -- including the way the vaccine has been marketed, as well as its controversial coverage in the media -- that keep families from vaccinating their kids. In other countries, young people have received the vaccine at much higher rates. Denmark and Britain have vaccinated 80 percent of their teenage girls against HPV, while only one third of teenage girls in the U.S. have been vaccinated. And in Australia, the vaccine has already resulted in the sharp decline of genital warts among the 26-and-under population. The same age group in our country has not seen a decline in disease, despite having had the availability of the HPV vaccine for the same amount of time.
It is no coincidence that countries seeing success with the vaccine implemented it as part of a national policy. Or that information disseminated to the public about the vaccine looks much different abroad than it does here in the U.S. In Australia, for example, marketing of the HPV vaccine, as well as media coverage of the country's national vaccine program, has been overwhelmingly positive, unlike in the U.S. Here, the vaccine has consistently, though incorrectly, been referred to as the "promiscuity vaccine" in the media since the FDA first approved Merck's brand, Gardasil, in 2006.
The United States' lack of a collective government effort to first educate and then mandate the vaccine, in addition to the pharmaceutical company Merck's aggressive lobbying to create such a mandate, played into the public's growing distrust of vaccines in general. The news media had a field day exposing Merck's vested interest in funding politicians, including Rick Perry, to push legislation that would require the protective immunization for all girls.
This created fear that the already controversial pharmaceutical company would have a hugely profitable monopoly on a mandated vaccine -- a justifiable fear considering the potential ramifications of such a monopoly on industry accountability, drug safety, costs, and personal choice. The debate surrounding the vaccine from all angles in the media (the right side afraid that getting their daughters vaccinated meant giving them permission to have casual sex and the left side wary of Big Pharma's financial incentives) prevented most efforts to promote and implement the vaccine on a population level.
Another barrier that has contributed to the underutilization of the vaccine in the U.S. is its high cost. At retail, the three-dose vaccine is $390, plus the cost of copayments for the doctor's visits needed to administer the shots. While low-income and uninsured minors 18-and-under have been eligible to pay for the vaccine using the federal Vaccines for Children Program, the need to pay copays for the three required doctors visits has been a barrier. Uninsured young adults over 18 have had to pay for the vaccine out of pocket, and even young adults who are insured have often only had a portion of the vaccine's price covered by their insurance.
Without a sensitive and streamlined national policy supporting a program that provides better information about, access to, and payment for the HPV vaccine, the U.S. risks falling further down the list of health status rankings among developed countries. Rather than reinventing the wheel, however, we have the opportunity to learn from successful programs such as Australia's National HPV Vaccination Program.
The key to Australia's success in widely implementing the vaccine is its nationally funded, school-based vaccination program, which was marketed as a non-biased preventive health effort. The country's strategy of providing the vaccine within schools normalized the vaccine, putting it on par with any other childhood vaccination. Because the campaign was pushed by schools and paid for by the government's National Immunisation Program, there was little speculation that the vaccine was being given to exploit families for profits. School-based clinics ensured that kids whose parents could not bring them to their doctor because of finances or lack of transportation were not excluded from receiving the preventive vaccination. For an immunization like Gardasil that requires three doses over six months, streamlining all administration of the vaccine in schools removed the added burden from families' already hectic lives.
Additionally, the school-based vaccination program standardized treatment, making parents and the news media less likely to oppose it for political or religious reasons. Above all, Australia's program success is due to the country's collective value that all children should have equal access to preventive care, including protection from both cancer and genital warts, regardless of how the virus is transmitted.
Though a nationally implemented, school-based HPV vaccination program may seem unrealistic for the U.S., a country that is resistant to broad government regulations, the passage of the Affordable Care Act (ACA) is evidence that even in a hostile political climate, strong advocacy can make important public health policy, including preventive health care for children, a reality. The ACA also provides the needed funding mechanism for a national HPV vaccination program, as most private health insurance plans must cover the vaccine at no out-of-pocket cost.
Short of implementing a school-based program (which is not too far-fetched considering current federal legislation proposing to expand resources for school-based health centers), there are many opportunities for the U.S. to improve the utilization of the important vaccine, and these start with the marketing and media coverage surrounding it. While the news has exaggerated the HPV vaccine's minimal risks, journalists have the opportunity to shift that focus to the illness that can be prevented with the highly effective vaccine.
Additionally, journalists should explicitly address that the vaccine protects adolescents from both cervical cancer and genital warts. While marketers of the vaccine have shied away from publicizing the vaccine as a tool to protect one's sexual health, journalists can discuss that as an incentive for vaccination that is more likely to resonate with young people than the threat of cancer 20 to 30 years down the road. This is especially important with the recent passage of California's Assembly Bill 499, which allows minors 12 and older to consent for the vaccine and other preventive sexual health services.
Additionally, although Merck's overly aggressive marketing campaign of Gardasil circumvented public health campaigns that could have provided credible, risk-sensitive information about both the vaccine and the commonality of the virus, it is not too late to launch an unbiased public health campaign to raise awareness about the importance and effectiveness of the vaccine. This campaign should highlight successes in other countries where it is being used to protect the general health and wellbeing of the next generation.
Finally, the passage of the Affordable Care Act will result in more children receiving regular medical check ups, and this increased access to care provides both parents and doctors additional opportunities to discuss the issue and get their child vaccinated.
The Centers for Disease Control and Prevention is clear in its message that HPV vaccination rates are far too low among U.S. adolescents. One of the most important strategies our country has in improving its health status is minimizing our next generation's exposure to preventable diseases. If we value the health and wellbeing of our children, we can't continue to let effective preventive health measures, including the HPV vaccine, go to waste.