Examining HPV Vaccine Uptake for Adolescents During the Pandemic

The majority of cervical cancers are associated with human papillomavirus (HPV), a sexually transmitted infection. Therefore, widespread immunization with the HPV vaccine greatly reduces the impact of cervical cancer and other cancers caused by HPV worldwide.

The Centers for Disease Control and Prevention (CDC) recommends that the HPV vaccine be given to adolescents between the ages of 11 and 12 years, although in recent years, there’s been more effort to get children aged as young as 9 years vaccinated.

Historically, HPV vaccination has lagged behind other adolescent vaccinations, and the numbers fell even more during the COVID-19 pandemic, when less people went to the doctor.

A new study¹ conducted by a trio at the University of Texas Health Science Center School of Public Health in Dallas, examined the declining numbers and looked for ways to improve them.

“The study really started out as a scholarly project from a resident who approached me during her adolescent medicine rotation and said she was interested in the HPV vaccine because she wanted to go into oncology,” said Jenny Francis, MD, MPH, director of the adolescent medicine fellowship program at UT Southwestern Medical Center Children’s Health in Dallas. “She wanted to see if there were ways to improve the process of vaccinating teenagers as they come through the clinic.”

It snowballed into a systematic approach of collecting data and monitoring vaccinations at the site.

Their cross-sectional study assessed encounters of adolescents for the period between January 2019 to December 2021 for those aged 9 to 22 years who came into the Children’s Health Medical Group for well visits or follow-up visits. Additionally, there was no change in HPV vaccine supply or availability during the study period.

“We characterized HPV vaccination by age and season from 2019 to 2021 and compared vaccination by encounter before and during the COVID-19 pandemic to identify catch-up priority groups,” Francis said.

Structured queries of electronic health records were examined to identify patients due for an HPV dose and whether it was received at an encounter. Demographic characteristics and encounter features associated with HPV vaccination were assessed using Mann-Whitney tests adjusted for non-independence of observations.

To understand pandemic effects and seasonal variation, difference-in-difference testing compared total vaccines administered each season in each year, Francis noted.

Of the 4548 patients with 10,469, the percentage receiving HPV vaccination was higher in 2021 and 2020 compared with 2019, despite a 19.3% decrease in the number of encounters in 2021.

“We found a steady increase in the HPV vaccine per encounter across each year from 2019- 2021,” Francis said. “What was interesting is that it went up even though during COVID-19, there was a substantial decrease in the total number of encounters. We can’t say why because the study wasn’t designed to detect that, but we can say that there was a decrease though the percent of those vaccinated went up. This shows that pediatricians, especially since COVID-19, have been more focused on vaccinating youth.”

Not surprisingly, those aged 9 and 10 years were the grouping with the lowest number of being vaccinated. In fact, there were only 10 vaccinations of 3522 encounters (0.3%).

“It’s an important age group but also a very young age group,” Francis said. “The guidance from the American Academy of Pediatrics have said that those 9 and 10 years old who are inoculated early have as much protection against HPV virus later in life than it does if you wait, so it makes a lot of sense to vaccinate early before any exposure.”

The challenge, she noted, is that pediatricians have been waiting until later years based on now-outdated recommendations, and it’s hard to change when they’re so used to recommendations that were initially to delay until later in adolescence.

“It takes time for providers to change their practice to improve vaccination numbers,” Francis said. “Subconsciously, the COVID-19 pandemic has shifted the importance of vaccinating children in adolescents I believe. I was surprised to see there was an improvement in numbers because of the fewer encounters. It was a positive finding that we are doing a good job in promoting the HPV vaccine, but we still need to do more for those 9 and 10 years.”

Another surprising takeaway was that vaccination levels in the summer of 2020 and 2021 did not catch up to pre-pandemic vaccination levels in 2019 despite summer typically having more well visits and sports-related examinations for adolescents.

“Pediatricians could do a better job around the summertime when kids are coming in for wellness checks for school,” Francis stated, adding that the University of Texas Health Science Center School of Public Health is going to launch an education video that targets families to help them understand what HPV can cause and the importance of getting vaccinated.

References

1. Francis JKR, Weerakoon SM, Lucas SL, et al. Human Papillomavirus Vaccination Before and During the COVID-19 Pandemic. JAMA Netw Open. 2022;5(9):e2234000. doi:10.1001/jamanetworkopen.2022.34000