Higher Risk Young Women May Be Less Likely to be Offered, Accept HPV Vaccine

MedicalResearch.com Interview with:
Dr Rachel J Sacks
Jefferiss Wing,  St Mary’s Hospital
Imperial College Healthcare NHS Trust,
London UK

MedicalResearch.com: What is the background of this study?

Dr. Sacks: 2247 anonymous questionnaires were completed by young women, aged 13-19 years old, attending sexual health services across England, looking at their HPV vaccination outcomes and prevalence of risk factors associated with HPV acquisition and cervical cancer development, and comparing the survey results with national data where available. Known HPV acquisition and cervical cancer development risk factors include cigarette smoking, early age at first intercourse, increasing number of lifetime partners, co-infection with other sexually transmitted infections.

MedicalResearch.com: What are the main findings of the study

Dr. Sacks:

  •          Young women, aged 13  to 19 years old attending sexual health services across England had higher prevalence of known risk factors associated with HPV acquisition and cervical cancer development, compared with national data.
  •          Survey respondents had lower HPV vaccination offer and lower HPV vaccination completion rates than nationally.
  •          Subgroups within the survey respondents were identified as having a significantly lower offer and significantly lower completion rate of the HPV vaccination. These subgroups included respondents from London, those of non-white ethnicities, 17 to 19 year olds, smokers and those not in education, employment or training (NEETs).
  •          The highest risk individuals, in terms of HPV related risk factors, were the least likely to be offered and additional the least likely to complete the HPV vaccination course.
  •          Currently sexual health services in England are not involved in the delivery of the HPV vaccination programme and this is felt to be a huge missed opportunity for the primary prevention of HPV acquisition and its potential sequelae. Sexual health services should be included as a supplementary HPV vaccination delivery site in order to target these particularly vulnerable young women and to increase the success of the HPV vaccination programme in England.

MedicalResearch.com: Were any of the findings unexpected?

Dr. Sacks: We were expecting to demonstrate that young women attending sexual health services were vulnerable in terms of risk factors associated with HPV acquisition and cervical cancer development based on previous research. However, we were surprised by the extent of the prevalence of these risk factors in our survey respondents compared with the comparative UK national data, particularly in terms of smoking rates (48% vs. 14% of 15 year olds), rates of coitarche under 16 (52% vs. 38%), inconsistent/no condom use (88% vs. 76% in 16 to 19 year olds) and previous sexually transmitted infections (25% vs. 4%).

We were also surprised by the high proportion of survey respondents who were not in education, employment or training (NEETs). We believe this sub group of young people are particularly vulnerable: not only do they have even higher rates of risk factors making them more vulnerable to acquiring HPV and developing cervical cancer but they were the subgroup with the lowest HPV vaccination completion rates. Respondents living in London, those of non white ethnicity, those aged 17 to 19 and smokers were also found to have lower HPV vaccination offer and lower completion rates than the survey respondents overall, but to a lesser extent than seen in NEETs.

Although no HPV vaccine uptake target has been set in the UK, previous research has demonstrated that an 80% uptake of the 3-dose course should have a significant impact on cervical cancer rates. National UK data demonstrated a 66% completion rate of HPV vaccination in eligible women in the first 3 years of the UK programme, which was introduced in 2008. We were surprised to find that the overall completion rates of the HPV vaccination in our survey respondents was even lower at just 47%. Not only were the respondents less likely to complete the vaccination but also less likely to be offered the vaccination in the first place. There is evidence from previous research that some schools in England are opting out of the HPV vaccination delivery programme which may result in even lower offer rates in the future.

Overall we are concerned that young women attending sexual health services are particularly vulnerable to acquiring HPV and cervical cancer but are less likely to be offered and less likely to complete the HPV vaccination course that might have reduced their risk of acquiring oncogenic HPV. The subgroups discussed above (namely NEETs, London respondents, those of non-white ethnicities, 17 to 19 year olds and smokers) are at additional risk and the concern is that the reasons they didn’t receive the HPV vaccination (i.e. lack of awareness of risk and poor engagement with healthcare services) may follow them into adulthood, which ultimately may result in them not attending for cervical cytological screening, further increasing their vulnerability to the effect of HPV.

In addition, we were surprised that those who were offered the vaccination, but declined it, reported that they might have accepted the offer had they, their parents and their friends received better information re indications efficacy safety of the vaccination and those who did not complete the course the most common reason was not being adequately followed up.

Currently sexual health services in the UK are not participating in the vaccination delivery programme and we believe that this is a huge missed opportunity. We feel that sexual health services are ideally placed to access these at risk women, to counsel them so that they can make an informed decision and encourage and support them in completing the course.

MedicalResearch.com: What should clinicians and patients take away from your report?

Dr. Sacks: All eligible should be counselled thoroughly by Healthcare professionals about HPV infection (it’s transmission, asymptomatic and symptomatic presentations, and potential sequelae) about the HPV vaccination (it’s indication, efficacy and safety) and about the cervical cytological screening programme.

Healthcare professionals may be able to identify young women who have not had the HPV vaccination through routine delivery programmes and in addition identify those at higher risk of developing cervical cancer in order to target these women.

Healthcare professionals can play an important role in raising awareness of these issues and supporting young women to access the HPV vaccination programme and complete the course, as well as to offer advice on how to reduce their risks of acquiring HPV and developing cervical cancer. This advice could include promoting safe sex and condom use, encouraging regular attendance for sexual health screening, offering smoking quitting programmes and continuing to provide regular cervical screening to eligible women.

This research will hopefully raise patients’ awareness of HPV infection, it’s potential sequelae and the HPV related modifiable risk factors. These modifiable risk factors include smoking, early age at first sexual intercourse, increasing numbers of lifetime sexual partners, co-infections with other sexually transmitted infections and attending for cervical cytological screening. We hope that this research will highlight the importance of completing the HPV vaccination course.

MedicalResearch.com:  What recommendations do you have for future research as a result of this study?

Dr. Sacks:  We would like to extend this research to look at young men, who are not currently part of the UK HPV vaccination delivery programme, attending sexual health services to ascertain whether by including them in the programme in future could improve overall herd immunity. In addition we would like to look at HIV positive young people and their risk factors of acquiring HPV and its sequelae. We know that immunocompromised people are particularly susceptible to oncogenic HPV effects and believe that HIV positive individuals should be offered the HPV vaccination.

 Citation:

Uptake of the HPV vaccination programme in England: a cross-sectional survey of young women attending sexual health services

Rachel J Sacks, Andrew J Copas, Dawn M Wilkinson,  Angela J Robinson

Sex Transm Infect sextrans-2013-051179Published Online First: 17 March 2014 doi:10.1136/sextrans-2013-051179