How to Pump up the Volume on Gardasil Coverage

August 21, 2017

Fingers point in all directions when the topic of low US HPV vaccination rates comes up. How to skip the drama? Just do it.

Editor's note: this is an updated version of the original article which appeared in January 2016.

If you combined the number of annual deaths in America caused by meningococcus, measles, mumps, rubella, polio, diphtheria, and tetanus before the introduction of the specific vaccines, the number is approximately 6,000. Compare this to the estimated number of deaths caused by HPV-induced cancers each year-about 11,000. The CDC estimates that 75-80% of Americans have been infected with genital strains of HPV by age 50 years.1 HPV disease is both common and deadly.

Physicians blame parents

So why is our completed vaccination rate for HPV among eligible recipients (about 40%) lower than that achieved in many third world countries? If you ask health care providers the question, many would answer that parents refuse it.

  • Some refuse based on fear of lasting side effects listed on anti-vaxxer web sites.
  • Some refuse because they know their child will marry a virgin and not have sex until marriage.
  • Some refuse it for the middle-school-aged child for whom it is recommended, but plan to get it when the child is older.

Unfortunately, most adolescents have their first sexual encounter way before the parents think they will. The result is teens with a vaccine-preventable infection that would have been prevented had the vaccine only been given earlier.

CDC blames physicians

If you ask the CDC why our completed vaccination rate for HPV is below all the other recommended vaccines in the pediatric age group, they will point a finger at us, the health care providers (aka the pro-vaxxers).

In astudy by Gilkey et al2 on the quality of physician communication about HPV vaccine, 27% of surveyed pediatricians and family practice physicians didnot “strongly recommend” HPV vaccination at the CDC recommended time. Is there any advantage to delaying the vaccine? No, immunity does not seem to wane. We vaccinate babies against hepatitis B, also a sexually transmitted disease. Should we wait until they are older and more likely to engage in risky behaviors? We already tried that and it didn't work when the hepatitis B vaccine was just given to those “at risk.” 

I tell parents that age11 years is the perfect time to give Gardasil since it is nearly always ahead of possible exposure and that 11-year-olds produce higher antibody levels than 16-year-olds. (Not that that really matters; the protection from this vaccine is extremely good no matter when it is administered.)

Next: Poor communication: Defense is the worst offense


Defense is the worst offense

There are experts who think, too, that even those providers who do feel strongly that HPV vaccine should be given may be using an ineffective communication approach. We like to think that if we provide the parents with the correct information, they will make the correct choice. Health care professionals are aware of the controversy around the HPV vaccine that circulates through social media and lives on the Internet and often feel obliged to provide more information about this vaccine than they do about dTap and meningococcus-the other two vaccines given at the 11-year-old visit.

Clark and Kuter3 audiotaped pediatric well visits and found that in 72% of the total visits, more time was spent discussing HPV vaccine versus the other two. In 17% of the visits the HPV vaccine was mentioned without a recommendation and in 11% of the visits the parents were basically told, “Your child is due for 3 vaccines today, HPV, dTap, and meningococcus.”  

See if you can match up the same-day immunization rate with the 3 different communication approaches; which approach had the highest success rate?

Communication approachSame-day vaccination rate
1.a. 27%
2.b. 94%
3.c. 38%


For the next installment in the Patient Care Pediatric Vaccines Special Report, click below:
"Gardasil vs Meningococcal Vaccine: A Lesson for Anxious Parents"


1. Roush SW, Murphy TV, and the Vaccine-Preventable Disease Table Working Group. Historical comparisons of morbidity and mortality for vaccine preventable diseases in the United States.JAMA. 2007;298:2155-2163. doi:10.1001/jama.298.18.2155.

2. Gilkey MB, Malo TL, Shah PD, Hall ME, Brewer NT. Quality of physician communication about human papillomavirus vaccine: findings from a national survey. Cancer Epidemiol Biomarkers Prev. 2015 Nov;24(11):1673-9. doi: 10.1158/1055-9965.EPI-15-0326. Epub 2015 Oct 22.

3. Clark L, Kuter B. An investigation of the recommendation styles and same day vaccination rates for pediatricians discussing HPV vaccine with adolescent patients and their caregivers. Open Forum Infect Dis. 2014;(suppl 1): S36. doi: 10.1093/ofid/ofu051.97