The phrase “starting at age 9” in recommendations about HPV vaccination provided clinicians with a simple, clear directive to use in discussions with parents.

“Three vaccines are given to children at ages 11 and 12: HPV, Tdap, and meningitis,” Noel Brewer, PhD, explains. “Most states require meningitis and Tdap vaccines, and we showed in previous research that 28% of clinicians will give no more than two vaccines at a single visit. When parents come in and say, ‘I want the vaccines required for this age,’ the doctor focuses on Tdap and meningitis first and says, ‘We’ll get to this other one—HPV—later.’”

This illustrates the influence of clinician recommendations on vaccination uptake. “The single largest influence on HPV vaccination uptake is a provider’s recommendation. There is nothing as powerful as this; there is no intervention that comes even close,” he says. “As a result, the way healthcare professionals frame the HPV recommendation means that uptake is relatively low.”

Another factor is the phrasing from national organizations around HPV vaccination, including the CDC, ACIP, and the American Academy of Pediatrics (AAP). “As more HPV vaccines came onto the market, the recommendations from these organizations took on slightly different wording,” Dr. Brewer says.

For a study published in Human Vaccines and Immunotherapeutics, the researchers examined the influence of HPV vaccination frameworks on willingness to recommend the vaccine series at different ages among 2,527 healthcare clinicians in the United States (45% physicians). They also assessed how the potential benefits of the vaccine varied based on the recommended starting age for the vaccine series.

Benefits of the Phrase “Starting at Age 9”

The recommendations examined by the researchers are described below. They attributed all the recommendations to the same organization—the AAP—to exclude a potential confounder in the assessment, according to the study results.

• “The AAP recommends starting HPV vaccination at age 11 or 12, which supports series completion before HPV exposure risk increases” (aligned with current CDC recommendations).
• “The AAP recommends starting HPV vaccination between age 9 and 12, which supports series completion before HPV exposure risk increases” (aligned with current AAP recommendations).
• “The AAP recommends starting HPV vaccination at age 9, which supports series completion before HPV exposure risk increases” (aligned with current National HPV Vaccination Round Table recommendations).
• No recommendation (control).

“The clear choice was to say ‘starting at age 9,’” Dr. Brewer notes. “The the worst thing to do was to talk about ages 11 and 12; that was actually harmful to motivate providers to recommend at age 9. Talking about the age range of 9 to 12 was okay, and sometimes as good as doing nothing, or sometimes only slightly better, but the thing that most motivated providers was to say starting at age 9.”

Specifically, the phrase “starting at age 9” resulted in a higher willingness by clinicians to recommend the HPV vaccine series versus the control (63% vs 54%; P<0.05). Results were comparable across different levels of training, specialty, or years in practice, as well as the clinic’s rurality or healthcare system membership.

Dr. Brewer and colleagues noted two factors seen as beneficial in recommending the vaccine at age 9 rather than 12 (Table). Respondents stated that, in recommending the vaccine series start at age 9, “sex does not come up in discussions with parents” (24% vs 10%) and that “children complete the vaccine series before age 13” (56% vs 47%).

Using the Presumptive Announcement Approach

Currently, “there is a lot of different language” in existing HPV recommendations, Dr. Brewer notes. “Some recommendations use hedged wording; some of them include caveats. All of that is harder for clinicians to make sense of. They need something simple and definitive. That’s the language that is most effective.”

He recommends using a “presumptive announcement” when discussing the HPV vaccine series. “Note the child’s age, say they’re due to start a vaccine series that prevents six cancers, and you’ll take care of it that day. The second piece of the recommendation is to address any concerns parents have.”

The third step, according to Dr. Brewer, is trying again with parents who decline the vaccine. “Evidence shows that nearly three-quarters of people who have said no to HPV vaccination for their children will vaccinate those children within the next year. Ask parents what their biggest concern is. Restate the concern, make sure the parents feel heard, and address the concern using the best available evidence.”