Wednesday, August 11, 2010

Physicians Avoid Recommending HPV Vaccine in Girls Aged 11 to 12 Years

From Medscape Medical News
Fran Lowry

August 4, 2010 — The majority of pediatricians and family physicians in the United States are offering the human papillomavirus (HPV) vaccine to their older adolescent patients, but fewer are recommending the vaccine to their younger patients (those aged 11 to 12 years) — the age group that is particularly targeted for vaccination by national guidelines — according to a survey reported online August 2 and in the September print issue of Pediatrics.

"A HPV vaccine was licensed in 2006," write Matthew F. Daley, MD, from the University of Colorado School of Medicine and the Kaiser Permanente Institute for Health Research, Denver, and colleagues. "In surveys before vaccine licensure, physicians generally viewed HPV vaccines positively, but some expressed reservations about vaccinating young adolescents. Little is known about current HPV vaccination practices of US physicians."

The aims of this study were to assess HPV-related attitudes and vaccination practices, perceived barriers to vaccination, and factors associated with whether physicians strongly recommended HPV vaccine to 11- to 12-year-old female patients in a sample of US pediatricians and family physicians.

From January to March 2008, the researchers administered a survey through the Internet or by mail to a national network of 429 pediatricians and 419 family physicians recruited from the American Academy of Pediatrics and the American Academy of Family Physicians. Eighty-one percent of pediatricians and 79% of family physicians responded to the survey.

Virtually all pediatricians (98%) and 88% of family physicians reported administering HPV vaccine to female patients in their offices (P < .001). Female family physicians were more likely to give the vaccine than male family physicians (95% vs 83%; P = .001).

The survey also showed regional variation in vaccine administration among family physicians. In the South, 79% reported administering HPV vaccine in their offices, compared with 89% in the Northeast, 95% in the Midwest, and 92% in the West (P = .005). Comparisons of HPV vaccine administration rates by sex and region were not done for pediatricians because only 6 pediatricians reported they did not offer the vaccine.

Fewer respondents strongly recommended HPV vaccination for 11-to 12-year old girls than for older female patients. Among pediatricians, 57% said they recommended the vaccine for that age group, but 90% recommended the vaccine for their 13- to 15-year old patients (P < .001).

Among family physicians, 50% said they recommended the vaccine for 11- to 12-year-old girls, and 86% recommended the vaccine for their 13- 15-year-old patients (P < .001).

The survey also found that vaccine costs and insurance coverage were the main financial barriers to strongly recommending HPV vaccination. Another barrier was reluctance to discuss sexuality with 11- to 12-year-olds (risk ratio [RR], 1.27; 95% confidence interval, 1.07 - 1.51).

Parental concern about HPV vaccination was also a barrier, with 39% of pediatricians and 43% of family physicians reporting that parents of their adolescent patients worried that vaccination against a sexually transmitted infection may encourage earlier or riskier sexual behavior. The survey also found that 22% of pediatricians and 23% of family physicians reported that parents of their 11- to 12-year-old patients were upset that they were offering the vaccine to that age group. Eighteen percent of pediatricians and 29% of family physicians reported that at least one fourth of parents of 11- to 12-year-old patients refused HPV vaccine (P < .01). Common reasons for parent refusals were that the vaccine was too new, the child was too young, and lack of health insurance for HPV vaccination.

"These survey data indicate that there may be substantial challenges to timely initiation and completion of the 3-dose HPV vaccine series," the study authors write.

The possibility that attitudes of network physicians in the survey might differ from those of physicians outside of the network is one limitation of the study. Another is that only family physicians and pediatricians were surveyed. Finally, the study assessed physician-reported behavior but did not observe actual vaccination practices. "It is not known how physicians convey a 'strong vaccination recommendation' to patients and parents, and this may differ among physicians and between pediatricians and family physicians," the authors note.

Because physicians are more likely to recommend the HPV vaccine strongly at older ages, and because parents are more likely to refuse or defer vaccination at younger ages, vaccination may not occur at the age recommended by national guidelines. "It is also likely that proactive, innovative strategies will be needed to achieve high levels of 3-dose HPV vaccination coverage in the United States," the authors write in their conclusion.

"HPV vaccination is our best chance at preventing cervical cancer, so it's reassuring [that] doctors are using it. However, vaccination should ideally begin at 11 years of age, so that young women complete the 3-dose series and are protected," Dr. Daley added in a statement.

Pediatrics. Published online August 2, 2010.

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