HPV vaccines work – so why do so few states require them?

Nine years after the HPV vaccine was first approved in the U.S., only Virginia, and Washington, D.C., currently require the vaccine for school entry, according to new research.

They both require the vaccine for girls entering the sixth grade, and Rhode Island will implement a similar requirement this August for all children entering seventh grade.

The Centers for Disease Control and Prevention recommends that all girls and boys receive the three-dose series of the HPV vaccine between ages 11 and 12 to protect against HPV-linked cancers, which include those of the cervix and other cancers of the anus and genitals, as well as some head and neck cancers. The vaccines are close to 100 percent effective against the strains of HPV they include.

But there’s widespread resistance to the HPV vaccine in this country, said Dr. Jason Schwartz, an ethics researcher at Princeton University who led a study published Tuesday in the Journal of the American Medical Association examining the state requirements. As of 2013, only 38 percent of U.S. girls and 14 percent of boys aged 13 to 17 had received the recommended three doses of the vaccine, according to a CDC survey. 

Healthy People 2020, a 10-year set of health goals run by the U.S. Department of Health and Human Services, recommends 80 percent of adolescents receive the HPV vaccine by 2020. Clearly, we’re falling well short of that goal, Schwartz said.

Dr. Denise Galloway, a virologist at Fred Hutchinson Cancer Research Center who made critical discoveries that definitively linked the virus to cervical and other cancers, believes that resistance is because of how the virus is transmitted.

“It has to do with it being considered a vaccine to protect against a sexually transmitted infection, that’s likely the case,” said Galloway, who was not involved in the state-requirements study. “Even though hepatitis B should fall in that same category, it’s been portrayed more as protecting against a liver disease.”

Even with its low uptake, the vaccine is having an effect in this country — HPV prevalence among young women dropped from nearly 12 percent before the vaccine was available to just over 5 percent in the four years following its introduction.

Can state requirements help?

Both Virginia and Washington, D.C., have HPV vaccination rates lower than the national average for adolescent girls, according to the 2013 CDC survey, despite their school entry requirements.

And that’s because they have broader exemptions allowed for the HPV vaccine than for other vaccines, Schwartz said, making their requirements “really toothless in many respects.”

Similar legislation was proposed but failed in several other states shortly after the vaccine became available in the U.S., and Texas was the first state to pass a school admission requirement for the HPV vaccine in 2007, but the law was overturned that same year.

Still, Schwartz remains hopeful that school entry requirements could help boost HPV vaccination rates in this country, and that’s partly because of the law that will go into practice in Rhode Island this coming school year. Unlike those in Virginia and Washington, D.C., the Rhode Island legislature doesn’t allow for any additional exemptions specific to the HPV vaccine.

The Rhode Island requirement also includes boys, which the other two states don’t. (The vaccine wasn’t approved for boys when those bills passed.)

“This is the first real movement we’ve seen on this front since the first year or two [after the vaccine was approved],” Schwartz said. “I’m optimistic that it will lead to some significant benefits.”

Washington state’s Sen. David Frockt sponsored a resolution in March to recognize and promote HPV awareness. The resolution passed, but there are no current bills in the works in Washington to add HPV to the state’s school requirements, Frockt said. Instead, many in the state government have been focusing on tightening the exemption rules for existing school-required vaccines, he said, although that proposed bill did not get far this year.

“As awareness of the issue is raised and the fact that [the vaccine] is really preventive toward cervical cancer, we ought to take a look at something like that, but I can’t say that it’s really on the agenda right now,” Frockt said. “It’s something that we ought to look at and be open to.”

Strategies that work

There are other strategies we could be using now to get more children vaccinated, Schwartz said.

“We have clear evidence that there are missed opportunities when young women and young men are going in to receive their pre-adolescent vaccines — the Tdap booster, the first dose of the meningococcal conjugate vaccine — those rates are quite good. And HPV vaccine can and should be, in the opinion of the public health community, administered at the same time,” he said. “But it’s not.”

The three doses currently required for the vaccine can also be a stumbling block since it requires so many trips to the doctor, Schwartz said. A two-dose HPV vaccine has been approved in several other countries (but not the U.S.). More children in the U.S. have received the first dose of the three than have received the full series, although at 57 percent of girls and 35 percent of boys 13 to 17 years old, that rate is still not at the target 80 percent.

School-based programs, in which vaccines are administered for free at school, have shown great success in raising HPV vaccination rates in countries like Australia and Great Britain, Galloway said. But the success of such programs relies on those countries’ single-payer health care systems.

“Even though a lot of the development work for the vaccine has been done in the U.S., we’re lagging behind,” she said.

More than 17,000 U.S. women and some 9,500 men are afflicted by HPV-associated cancers every year, according to the CDC. Additionally, the virus costs the U.S. an estimated $8 billion every year in screening, prevention and treatment costs.

“So [the vaccine] is important both from a preventing cancer and from a public health standpoint,” Galloway said.