Racial, ethnic and poverty disparities in human papillomavirus vaccination completion

Barriers that hinder young African-American, Hispanic and poor women from completing a series of three vaccinations to prevent human papillomavirus infection (HPV) also leave them at higher risk for cervical cancer and death

That is the conclusion of new study from the Yale School of Public Health that extends previous findings of the disparity in a nationally representative group. The study appears online and in the October issue of the American Journal of Preventive Medicine.

"The degree to which these vaccines reduce disparities in cervical cancer is going to depend on adequate uptake by women who need them most," said lead study author, Linda Niccolai, Ph.D., an associate professor of epidemiology.

The new study uses data collected from the federal government's 2008-2009 National Immunization Survey on teen girls who received at least one dose of HPV vaccine. During that period, 55 percent of the adolescents received all three doses, 21 percent received one dose and 24 percent received two. While not ideal, the authors cited an "encouraging" annual completion rate increase from the first study year to the second.

According to the Centers for Disease Control and Prevention, HPV is the most common sexually transmitted infection and at least 50 percent of sexually active men and women get it at some point in their lives. Persistent HPV infections are the primary cause of cervical cancer. In the United States, clinicians diagnose approximately 12,000 new cervical cancer cases each year, resulting in about 4,000 deaths, according to the CDC.

The U.S. Food and Drug Administration (FDA) approved two vaccines to protect against HPV-16 and HPV-18, the virus types that cause about 70 percent of cervical cancers. The Advisory Committee on Immunization Practices recommends routine use of either vaccine in a three-dose series for girls ages 11 or 12. The committee recommends the second dose two months after the initial dose, and the third three to six months after the first dose.

Previous reports have shown that African-American, Hispanic and poor adolescent women were as likely, if not more likely than white adolescents and adolescents who are not in poverty, to complete the first dose. Help is readily available, since the federal vaccine program for low-income families, Vaccines for Children, covers the cost — more than $100 each — of all three doses, Niccolai said. Women might be more likely to receive a vaccination during their annual recommended, preventive visit, when they connect with health care services, she said.

"However, to complete the series requires knowledge, motivation and the belief that it's important, even though the cost is covered," Niccolai said. Deterrents to vaccination completion at additional visits might include office visit co-payments, transportation issues or parents' inability to take time off work. "Something keeps them from returning two more times."

"It doesn't surprise me that this has been a recurring issue for years," said Lovell Jones, Ph.D., director of the Dorothy I. Height Center for Health Equity and Evaluation Research at the University of Houston/University of Texas M.D. Anderson Cancer Center. "In terms of addressing health issues in minority and underserved populations, ...[T]his is a multidisciplinary, multi-factorial problem."

Jones said he feels "health disparities" have become, in his words, "the flavor of the month."

"I hear people say that 'If these women truly cared about themselves, they'd find a way to do it [the vaccinations]. Clearly, these women have not," Jones said. "Why not approach this in a more holistic fashion, looking at the non-health issues, the reasons that prevent completion of a second and third vaccination, and develop solutions to those?"

"The overall economic cost of vaccinations pales when compared to the cost of treating Stage 3 or 4 cervical cancers," Jones said.