There is substantial room for improvement in how primary care doctors communicate about and deliver the human papillomavirus (HPV) vaccine, according to a national survey of pediatricians and family practitioners. And a survey of US adults shows that few understand the link between HPV and cancer.

Published online today in Pediatrics, the snapshot of HPV vaccine practices and experiences of among 302 pediatricians and 228 family physicians (FPs) finds that many doctors likely hinder uptake by being less than ideally assertive when raising the issue of HPV vaccination with parents of adolescent patients.

What's lacking is a "presumptive" style, in which the doctor makes an announcement that assumes parents are ready to vaccinate their children, vs a conversational style that engages parents in an open-ended discussion. Although the former approach has been shown to increase vaccination in young adolescents, doctors may fear pushback from their parents.

"Although most physicians recommend the HPV vaccine for patients 11 to 12 years old, many are not using a presumptive style when introducing the HPV vaccine, standing orders, or electronic alerts for HPV delivery," write Allison Kempe, MD, MPH, of the Adult and Child Consortium for Health Outcomes Research and Delivery Science at the University of Colorado in Aurora, and colleagues.

According to the email survey, conducted from July to September 2018 as part of the Vaccine Policy Collaborative Initiative, pediatricians are more assertive than FPs in strongly recommending the vaccine: 65% of pediatricians vs 42% of FPs reported they "almost always" or "always" use a presumptive style. By contrast, 16% of pediatricians and 24% of family physicians said they almost always or always use a conversational style when bringing up the issue.

The American Academy of Pediatrics advises pediatricians to give a strong recommendation for vaccination worded in a presumptive style.

"I was not very surprised at the results because back when the vaccine was introduced, it was presented not as a 'cancer vaccine' but in the context of sexual activity, which I think was a big mistake," Kempe told Medscape Medical News. "But you want to give this vaccine well before sexual activity begins and when children are younger and have a better immune response."

The survey's results may help explain the 2018 National Immunization Survey–Teen findings that HPV vaccine initiation among US adolescents aged 13 to 17 years was 69.9% for girls and 66.3% for boys, while series completion was only 53.7% for girls and 48.7% for boys.

"Doctors probably overestimate parental pushback and don't make their vaccination recommendations strong enough," said Kempe. "They should not single out the HPV vaccine to parents but include it with the meningococcal and Tdap vaccines that are routinely given to 11- and 12-year-olds — in the same way and on the same day."

Recommending the Vaccine

The survey also showed that the proportion of physicians who reported they strongly recommend the HPV vaccine varies by patient age and sex. For example, 99% of pediatricians strongly recommend it for female patients age 15 years or older but only 83% do for male patients ages 11 to 12 years. For family physicians, the rates were lower, ranging from 90% for girls 15 years or older to 66% for boys 11 to 12 years (P < .0001 between specialties).

Yet the Advisory Committee on Immunization Practices has routinely recommended HPV vaccination for adolescents at 11 to 12 years since 2006 for girls and since 2011 for boys, the authors note. And a recent meta-analysis found compelling evidence that the vaccine reduces HPV infections, high-grade cervical lesions, and anogenital warts in young people of both sexes, although it is too early to gauge the impact on cervical cancers. Nevertheless, as of 2015 the majority of countries were vaccinating girls only.

Vaccine Refusal

Reported rates of refusal or deferral for 11- to 12- year-olds were high in the survey, though lower for older adolescents. FPs reported higher rates than pediatricians at all patient ages, and both specialties were significantly more likely to report refusal/deferral for boys than girls.

For example, the proportion of pediatricians reporting a >50% deferral/refusal rate for the 11-to-12 age group was 19% for girls vs 23% for boys. Among FPs, the rates were 27% and 36%, respectively.

The expectation of parental resistance affects physicians' behavior, Kempe and associates note, and those who have experienced or anticipate high rates of deferral/refusal may adjust the strength and style of their recommendations. "Such accommodations by physicians may perpetuate a lack of acceptance of the HPV vaccine among parents," the authors write.

In multivariable regression, refusal or deferral was associated with the following physician variables:

• not strongly recommending the HPV vaccine for the 11-to-12 age group

• not using a presumptive style

• perceiving less resistance when introducing the HPV vaccine to a 13-year-old patient vs a younger one

• anticipating an uncomfortable conversation when recommending the HPV vaccine for a patient 11 or 12 years old

"Greater physician awareness about the potential of overestimating the degree of parental resistance to HPV vaccination and about the effectiveness of a strong recommendation for the HPV vaccine, delivered in the same way as for other adolescent vaccines and on the same day as other adolescent vaccines, may be key to increasing acceptance among parents of 11- to 12-year-old patients," the authors write.

Vaccine Practices

According to the results, 40% of physicians report using standing orders for HPV vaccination, 66% use a computer-based system identifying adolescents who need to be vaccinated, and 42% have an electronic alert in medical records. No significant differences emerged by specialty.

In support of the now recommended two-dose schedule for younger adolescents, most doctors said it is translating to higher completion rates. But physicians, especially FPs, were often in error or unaware of the number of doses recommended in different scenarios or the proper timing for offering additional vaccination with 9 valent HPV.

Regarding dosing intervals, 74% of pediatricians reported routinely recommending the second HPV dose 6 months after the first, with 25% routinely recommending it at 12 months. Among FPs, corresponding percentages were 88% at 6 months and 12% at 12 months (P < .0001). National guidelines support either interval.

Opposition to Vaccination

When asked about major barriers to vaccination, misinformation from the Internet or social media was the most commonly cited (63% of pediatricians, 44% of FPs). Other frequently cited barriers included parental concerns about the vaccine's safety (45% and 24%, respectively), considering the vaccine unnecessary for sons (28% and 27%), moral or religious reasons (24% and 28%).

Few physicians (less than 14%) in either specialty cited parental concern that getting the HPV vaccine would encourage premature or risky sexual behavior.

Public Awareness Lacking

Meanwhile, Ryan Suk, MS, of the UTHealth School of Public Health in Houston, Texas, and colleagues report that fewer than 30% of US adults know HPV causes anal, penile, and oropharyngeal cancers.

Published online today in JAMA Pediatrics, Suk and colleagues analyzed responses from 2564 men and 3697 women who responded to the 2017 Health Information National Trend Survey. They report that men were considerably less knowledgeable than women about HPV across all age groups.

Among young adults aged 18 to 26 who have been eligible for the vaccine, 53.6% of men and 80.3% of women knew about the HPV virus; about half (52.7%) of the men and 79.0% of women knew about the HPV vaccine.

In the newly vaccine-approved 27-to-45 age group, fewer than half of men and women were aware the virus causes anal, penile, and oral cancers. Again, awareness was lower among men than women: 67.7% vs 86.4% for HPV awareness, and for vaccination 56.1% vs 81%.

Similar gaps in knowledge and differences between the sexes were observed in respondents 46 and older.

"In particular, the lack of HPV knowledge among adults aged 27 to 45 years and 46 years and older is concerning given that adults in these age groups are (or will likely be) the parents responsible for making HPV vaccination decisions for their children," the authors write.

In addition, the study found that only 19% of men and 31.5% of women who were of vaccine-eligible age (or had vaccine-eligible family members) had received a recommendation for HPV vaccination from their healthcare providers.

"Future work to eliminate current communication barriers and improve provider and patient and parent communication could help rapidly increase vaccination uptake," the study's corresponding author, Ashish A. Deshmuhk, PhD, MPH, of UTHealth School of Public Health, told Medscape Medical News.

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