Last week, the CDC reported a statistic about the most common sexually transmitted infection that should alarm all physicians (but especially pediatricians, obstetrician/gynecologists, urologists, and ENT surgeons) and parents of teenagers:

In 2013, only 57.3% of girls and 34.6% of boys had initiated the HPV vaccine series.

 

Human papillomavirus (HPV) causes genital warts and cancer. Genital warts are common, embarrassing, and difficult and often painful to treat.  But the vaccine was not created and recommended (beginning in 2006) to prevent genital warts. Rather, the vaccine prevents cancer.

In women, HPV causes more than 20,000 cases of cervical cancer in the United States each year.  Worldwide, cervical cancer is one of the leading causes of cancer deaths in women.  Vulvar and vaginal malignant tumors also are caused by human papillomavirus.

In American men, 12,000 HPV-related cancers occur annually — mostly oropharyngeal (mouth and throat) malignancies, but also penile cancer as well.

HPV causes most cases of oral cancer (ahead of tobacco and alcohol) and most cases of anal cancer, in both men and women.

With all that we know about human papillomavirus — and all that we know about the effectiveness and safety of the HPV vaccine series — why are so few tweens and teens getting immunized against it?  While it might be a knee-jerk reaction to blame parents’ refusal to vaccinate for these low numbers, it seems that the real problem lies with the physicians who keep missing opportunities to initiate and finish the series.  Steven Reinberg says that some doctors just aren’t promoting it:

Parental concerns are one obstacle, the researchers found. When asked why they hadn’t had their son or daughter vaccinated, parents said their doctor didn’t recommend the vaccine, that they had concerns about the vaccine’s safety or that their children were not sexually active.

 

Every pediatrician at Pediatric Alliance strongly recommends the HPV vaccine beginning at 11 years old for both girls and boys.  (At the 11 year-old visit, children are due for the Tdap booster and meningococcal meningitis vaccine.  It may also be the time to catch-up on their hepatitis A series.  It is certainly time to begin the HPV series.)  The idea is to prevent cancer before they become sexually active teens and adults.

Perhaps most parents think predictable teen behavior won’t apply to their kids, but children have been known to be sexually active (sometimes not consensually) before their teen years. Furthermore, as tweens turn into teens, and teenagers turn into young adults, parents have less control over what their kids think and do, not to mention control over where their children put their fingers, mouths, and private parts.

The vast majority of parents I talk to about the HPV vaccine understand all this, and most of them elect to vaccinate their girls and boys beginning at 11 years old.  Some parents agree with the importance of the vaccine but want to wait until their teenagers are older (and, presumably closer to being sexually active).  I don’t agree with this thinking, but I do understand it and accept it. There’s a big difference about what an 11-12 year-old knows and says about sex, and what a 13-14 year-old knows and says.  It could be argued that enhancing a teenager’s understanding about sex (and its infectious, procreative, and emotional consequences) by discussing the HPV vaccine with them at 13-14 years old instead of directing the conversation solely towards the parents of the 11-12 year-old makes more sense.  And it does, except you would miss those unfortunate younger children who do in reality get infected. I’ve spoken with some parents who want to let their own kids make the decision to vaccinate or not when they turn 18.  I understand that, too, but by that milestone birthday, the horse may already be out of the barn: many of these kids have already had some intimate or sexual exposure that goes beyond “Spin The Bottle” (experiences that they certainly won’t share with their parents).

Mostly, I think parents just get caught off-guard at the 11 year-old checkup.  It’s really the first time we begin to talk about teen issues like tobacco use and the prevention of sexually-transmitted cancer.  It’s hard for most parents to envision their innocent and possibly prepubescent pre-teenager as a potentially sexually-active teenager, especially if it’s their first child.  Putting off the inevitable — “maybe we’ll do this next year, after I have a chance to speak with my husband” — is an understandable (though not advisable) dodge in this case.

Of course there are parents (really, there aren’t many) who refuse any and all vaccines, so discussing HPV vaccine to these fact-resistant parents is probably a waste of time (though we try anyway).

Still, it’s up to physicians (and not just pediatricians: a large number of American children see family practitioners, “Docs-in-Boxes” or no doctors at all) to educate parents about the horribleness of HPV and cancer and to strongly recommend the vaccine series.  It’s up to parents to consider the facts and to vaccinate their children — before they are at risk.

More PediaBlog on HPV here.

Additional fact-based information from the CDC about HPV here, here, here, and here.