Alabama falls below national average in adolescent vaccine which prevents cancers

Fewer than 60 percent of Alabama teenagers have begun vaccinating against the human papillomavirus, a virus which causes the majority of cervical cancers disproportionately affecting Alabama women. 

Alabama's HPV vaccination rate falls short of the national average, which is near 66 percent for 13- to 17-year-olds who have received at least one dose of the two- or three-dose vaccine.  

The HPV vaccine is widely recommended as protection against an array of cancers, but vaccination rates across the country continue to fall well-short of a national 2020 goal to reach 80 percent of adolescents. 

Two other recommended adolescent vaccines —Tetanus, diphtheria, and pertussis, and meningococcal disease— have already surpassed their 2020 goals, despite being similarly recommended by doctors.

Experts say the problem lies in the relative newness of the HPV vaccine, which is not a school-entry requirement in most states, coupled with general vaccine miseducation and discomfort related to HPV's status as a sexually transmitted illness. 

"Part of the reasons (the meningococcal disease vaccination) is not controversial is because the disease can be devastating, it’s horrific. But it’s also extraordinarily rare," said Gregory Zimet, a clinical psychology and co-director of the Indianapolis Center for HPV Research at Indiana University. "HPV-related diseases are not extraordinarily rare. Every year there are approximately 12,000 women diagnosed with cervical cancer. Approximately 4,000 women die of cervical cancer. And we’re not talking about anal cancers, vulvar and penile cancers. When you put them all together, it‘s a pretty substantial number of people effected."

The CDC estimates 79 million Americans are infected with some type of HPV, and 14 million more will become infected each year. But many may never realize it, or never be effected. But for those who are effected, decades can pass between HPV infection and diagnosis of cervical or penile cancer. 

"The difference is the devastating effects of HPV related diseases typically occur 15, 20, 25 years after infection," Zimet said. "There’s not the immediacy of the meningococcal disease. Pediatricians, for instance, don’t treat the cancers down the road the patients they have today can get."

In Alabama, the highest number of women in the country are dying from cervical cancer, of which HPV is the major cause of. 

Research from nonprofit Human Rights Watch released last month found that Alabama women are dying at an average rate of 3.9 deaths per 100,000 patients. Black Alabamians are nearly twice as likely as white women to die from the cancer, at a rate of 5.2 deaths per 100,000. HRW researchers say high mortality rates like Alabama's are particularly egregious because the cancer is so preventable. 

"(W)e should never, ever see cervical cancer," said Dr. William Stevens, a Selma OB/GYN. "Not in the United States."

In 2017, the Centers for Disease Control and Prevention estimates about 58 percent of Alabama adolescents between 13 and 17 received at least one HPV vaccination dose. Of those, about 40 percent are considered "up-to-date" on the vaccination, having received either two or three, depending on doctor recommendation. 

A CDC study in rural southeast Alabama found that improved education for providers such as doctors and nurses was majorly influential for the HPV vaccine. Strong recommendation from providers is key, research shows, so they can better inform parents on a vaccine that is not required for school registration, the major public health policy tool to boost vaccination rates, Zimet said. 

The initial roll-out of the HPV vaccine, which was first licensed to Gardasil in 2006, was flawed, Zimet said, with strong pushback from multiple groups. Some were hesitant to recommend a sexually transmitted virus vaccine for children as young as 11. 

'It’s allowed it to become, in many ways, a natural focus for the anti-vaccine groups," Zimet said. "It gave them kind of an in, or a handle, to focus their wrath and promotion of false attribution. Some of the anti-vaccine groups are really well organized, and they saw it as a vulnerable vaccine because HPV is sexually transmitted. All of these things undermined parental trust in the vaccination and raised anxiety. Because HPV is sexually transmitted and people know that, pediatricians may find it difficult to comfortably recommend the vaccination.

In a UAB survey of Alabama pediatricians, doctors felt parents were hesitant about the vaccine due to its link to sexual activity, as well as general vaccine safety.

"Doctors need to be able to communicate clearly to patients and parents why vaccination early on is important," HRW researcher Amanda Klasing said. "It's not just about sexual activity. It's about preparing and protecting children early for what can happen later in life.

The multi-dose requirement also presents a significant barrier, particularly in Alabama where rural access to health care has dwindled, as patients are less likely to return for subsequent shots. 

"People who live in rural areas tend to be vaccinated at a substantially lower rate than with other areas, Zimet said. "Having to return for a second dose, or a third, can be difficult."