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The Advisory Committee on Immunization Practices (ACIP) has recommended human papillomavirus (HPV) vaccination for adolescents in the United States since 2006. Though recommended at a similar time to the routine recommendations for adolescent tetanus, diphtheria, and acellular pertussis vaccination (Tdap) and quadrivalent meningococcal vaccination (MCV4), HPV vaccine uptake has consistently lagged behind these other adolescent vaccines. The ACIP recommends HPV vaccination at 11-12 y, with vaccination starting at 9 y of age included as an option that is routinely encouraged by the American Academy of Pediatrics and American Cancer Society. To support efforts to increase HPV vaccination at the first opportunity, this commentary summarizes the current HPV vaccination recommendations and available evidence regarding HPV vaccination starting at 9 y - including recent studies and trials documenting the effectiveness of HPV vaccination at 9 in supporting vaccine series completion, while providing future directions for research and implementation to improve HPV vaccination.

The US Advisory Committee on Immunization Practice recommends routine human papillomavirus (HPV) vaccination at 11-12 years of age, but states that vaccination may be initiated as early as 9 years. Our primary goal was to assess whether initiating HPV vaccination at 9-10 years of age, compared to 11-12, was associated with a higher rate of series completion by 13 years of age, and to identify factors associated with series completion by age 13. The study used vaccine claims and other data from the IBM MarketScan Commercial Claims and Encounters (privately insured) and IBM MarketScan Multi-State Medicaid (publicly insured) databases. Participants were 9-12 years of age and initiated HPV vaccination between January 2006 and December 2018 (publicly insured) or February 2019 (privately insured). Among 100,117 privately insured individuals, those initiating the HPV vaccination series at 9-10 years of age had a significantly higher series completion rate by 13 years of age than did those initiating at 11-12 years of age (76.2% versus 48.1%; p  < .001). The same pattern was observed for 115,863 publicly insured individuals (70.4% versus 40.0%; p  < .001). Provider and health care plan type, female sex, race/ethnicity, and wellness checks or non-HPV vaccinations during the baseline period were significantly associated with series completion by 13 years of age. Proactive initiation of HPV vaccination at 9-10 years of age was associated with higher rates of series completion by 13 years of age. These findings can inform provider education and other interventions to encourage timely HPV vaccination series completion.

Proactive HPV vaccination at age 9 better prevents infection and improves vaccine series completion. Because national organizations recommend starting the vaccine at different ages, we sought to understand the impact of these recommendation frames. In 2022, we surveyed 2,527 US clinical staff (45% physicians) who provide HPV vaccine for children. We randomized respondents to one of three frames based on HPV vaccine recommendations of national organizations or a no-recommendation control, and assessed willingness to recommend HPV vaccine for children ages 9-10. Respondents also reported perceived benefits of HPV vaccination at ages 9 or 12. Recommending HPV vaccination "at ages 11-12" led to lower willingness to vaccinate at ages 9-10 than control (37% vs. 54%, p  < .05). Recommending vaccination "at ages 9-12" led to similar willingness as control. However, "starting at age 9" led to higher willingness than control (63% vs. 54%, p  < .05). Results were similar across respondents' training, specialty, or years in practice, or their clinic's rurality or healthcare system membership. More common benefits of recommending at age 9 than 12 were avoiding the topic of sex (24% vs. 10%, OR = 2.78, 95%CI: 2.23, 3.48) and completing the vaccine series before age 13 (56% vs. 47%, OR = 1.44, 95%CI: 1.23, 1.68). Less common benefits for age 9 were having parents ready to talk about HPV vaccine and agreeing to vaccination (both p  < .05). An effective way to encourage proactive HPV vaccination is to say that it starts at age 9. Aligning national recommendations to start at age 9 can promote timely vaccination.

This article provides best and promising practices for recommending HPV vaccination at age 9 as a way to ensure high uptake. An effective method for recommending HPV vaccination is the Announcement Approach, which consists of 3 evidence-based steps. The first step, Announce , involves noting that the child is 9 years old, saying they are due for a vaccine that prevents 6 HPV cancers, and saying you'll vaccinate today. This adapted version of the Announce step simplifies the bundled approach used at ages 11-12 that emphasizes the prevention of meningitis and whooping cough in addition to HPV cancers. For hesitant parents, the second step, Connect and Counsel , involves finding common ground with the parent and communicating the value of starting HPV vaccination at the first opportunity. Finally, for parents who decline, the third step is to Try Again at a later visit. Using the Announcement Approach at age 9 stands to increase HPV vaccine uptake, save time, and lead to high family and provider satisfaction.

The US's 64 CDC-funded immunization programs are at the forefront of efforts to improve the quality of adolescent vaccination services. We sought to understand immunization program managers' perspectives on partnering with healthcare systems to improve HPV vaccine uptake. Managers of 44 state and local immunization programs completed our online survey in 2019. Immunization managers strongly endorsed the importance of partnering with systems to improve HPV vaccine uptake (mean = 3.8/4.0), and most wanted to do so in the next year (mean = 3.5). Immunization managers reported that common barriers included difficulty contacting systems' leadership (57%), differing organizational cultures (52%), and time (52%). Many perceived systems as not prioritizing HPV vaccination (77%). Immunization managers expressed strong interest in participating in a training on partnering with systems (mean = 3.5). Overall, immunization managers are highly interested in partnering with systems to improve HPV vaccine uptake. Training and other support are needed to expand programs' capacity for such partnerships.

HPV vaccination is recommended for U.S. adolescents at ages 11-12 and requires two versus three doses if the series is started before age 15. We evaluated how talking about recommended age or fewer doses motivates on-time HPV vaccination. Our national, online experiment randomized 1,263 parents of adolescents to view one of three messages about HPV vaccination recommendations or no message. Messages framed guidelines as recommending: vaccination at age 11-12; fewer doses for those who start vaccination at age 11-12; or, fewer doses for those who start vaccination before age 15. We then assessed parents' preferred age for HPV vaccination, categorizing preferences of ≤12 years as on-time. Parents who viewed "at age 11-12" versus no message more often preferred on-time HPV vaccination (63% vs. 43%, p < .05) and did not differ from those viewing "fewer doses at age 11-12" (63% vs. 64%, p > .05). Parents who viewed "fewer doses before age 15" less often preferred on-time HPV vaccination (39%, p < .05). Recommending HPV vaccination at age 11-12 encouraged on-time vaccination, while offering fewer doses had little impact. Providers should avoid framing HPV vaccination guidelines in reference to age 15 because doing so may discourage on-time vaccination by introducing confusion about the recommended age.

HPV vaccine uptake remains below national goals in the US, driven in part by parental uncertainty about the vaccine fueled by negative stories on social media and other information platforms. To identify opportunities for mobilizing parents to increase HPV vaccination uptake, the National HPV Vaccination Roundtable and Vaccinate Adolescents Against Cancers program convened two national meetings in 2016 at the American Cancer Society. Stakeholders recommended a focus on positive message to parents; cultivating parent champions to use the power of personal storytelling and to distribute these messages; and defining the role of national organizations in supporting parent champions. Stakeholders supported three message themes: HPV vaccination is the norm, HPV vaccination is cancer prevention, and HPV vaccination supports families across generations. Parents' negative stories about vaccination are especially difficult to counteract with scientific evidence, making the cultivation of pro-vaccine parent champions an especially promising intervention on social media and other information platforms.

Pharmacies are promising alternative settings for human papillomavirus (HPV) vaccination because of their population reach, convenience, and existing infrastructure for vaccine delivery. However, pharmacies in the US are rarely used for adolescent HPV vaccination. We sought to document challenges and opportunities of implementing pharmacy-located HPV vaccination services in five US states by mapping process evaluation results onto key implementation science constructs: service penetration, acceptability, appropriateness, feasibility, fidelity, adoption, and sustainability. Pilot projects were planned in North Carolina (k = 2 pharmacies), Michigan (k = 10), Iowa (k = 2), Kentucky (k = 1), and Oregon (no pharmacy recruited) with varying procedures and recruitment strategies. Sites had open enrollment for a combined 12 months. Despite substantial efforts in these states, only 13 HPV vaccine doses were administered to adolescents and three doses to age-eligible young adults. We identified two major reasons for these underperforming results. First, poor outcomes on service penetration and appropriateness pointed to engagement barriers: low parent demand and engagement among pharmacy staff. Second, poor outcomes on feasibility, adoption, and sustainability appeared to result from administrative hurdles: lacking third party reimbursement (i.e., billing commercial payers, participation in Vaccines for Children program) and limited integration into primary care systems. In summary, pilot projects in five states all struggled to administer HPV vaccines. Opportunities for making pharmacies a successful setting for adolescent HPV vaccination include expanding third party reimbursement to cover all vaccines administered by pharmacists, increasing public awareness of pharmacists' immunization training, and improving care coordination with primary care providers.

HPV vaccination coverage in the United States (US) falls short of the Healthy People 2020 goal of 80% coverage among 13-15 year-old adolescents. Pharmacies are a promising alternative vaccine delivery site that may increase access to HPV vaccination. Our objective was to assess pharmacists' insights into HPV vaccination provision to adolescents. We recruited 40 licensed pharmacists in eight states with different pharmacy vaccination laws: Alabama, California, Indiana, Kentucky, Maine, Tennessee, Texas, and Washington. Eligible pharmacists either previously provided or were currently providing HPV, tetanus-diphtheria-pertussis, or meningococcal vaccines to adolescents aged 9-17 years. Pharmacists were administered a semi-structured survey to explore insights into HPV vaccination provision. Forty-five percent of surveyed pharmacies offered HPV vaccination to adolescents. Pharmacists' reported challenges to providing HPV vaccination were parental consent (28%), tracking and patient recall (17%), perceived stigma of vaccination (17%), and education about or promotion of vaccination (17%). Pharmacists offering HPV vaccination sent patient reminders for vaccines with multiple doses (89%) and utilized telephone reminders (72%). Pharmacists informed patients' primary care providers of HPV vaccination doses most commonly through fax (72%) and updating electronic medical records (22%). One-third of pharmacists reported vaccination provision using the state immunization information system (IIS). Seventy-five percent reported vaccination rates could be increased at their respective pharmacy. Pharmacies are underutilized, although highly accessible, for HPV vaccination in the US. National efforts should expand educational programs to improve public awareness of in-pharmacy HPV vaccination, and improve the utilization of state IIS for reporting immunization coverage of adolescents by pharmacists.

Background: We sought to estimate the national prevalence of HPV vaccine refusal and delay in a nationally-representative sample of parents of adolescents. We also compared parents who refused versus delayed HPV vaccine in terms of their vaccination beliefs and clinical communication preferences., Methods: In 2014 to 2015, we conducted an online survey of 1,484 US parents who reported on an 11- to 17-year-old child in their household. We used weighted multinomial logistic regression to assess correlates of HPV vaccine refusal and delay., Results: Overall, 28% of parents reported that they had ever "refused or decided not to get" HPV vaccine for their child, and an additional 8% of parents reported that they had "delayed or put off getting" HPV vaccine. Compared to no refusal/delay, refusal was associated with lower confidence in adolescent vaccination (relative risk ratio [RRR] = 0.66, 95% confidence interval [CI], 0.48-0.91), lower perceived HPV vaccine effectiveness (RRR = 0.68, 95% CI, 0.50-0.91), and higher perceived harms (RRR = 3.49, 95% CI, 2.65-4.60). In contrast, delay was associated with needing more information (RRR = 1.76, 95% CI, 1.08-2.85). Most parents rated physicians and information sheets as helpful for making decisions about HPV vaccination, although parents who reported refusal endorsed these resources less often., Conclusions: Our findings suggest that HPV vaccine refusal is common among parents of adolescents and may have increased relative to previous estimates. Because the vaccination beliefs and communication preferences of parents who refuse appear to differ from those who delay, targeted communication strategies may be needed to effectively address HPV vaccine hesitancy.

Background: Healthcare providers may vary their communications with different patients, which could give rise to differences in vaccination coverage. We examined demographic disparities in parental report of collaborative provider communication and implications for human papillomavirus (HPV) vaccination., Methods: Participants were 4,124 parents who completed the National Immunization Survey-Teen about daughters ages 13-17. We analyzed disparities in collaborative communication (mutual information exchange, deliberation, and decision) and whether they mediated the relationship between demographic characteristics and HPV vaccine initiation., Results: Half of parents (53%) in the survey reported collaborative communication. Poor, less educated, Spanish-speaking, Southern, and rural parents, and parents of non-privately insured and Hispanic adolescents, were least likely to report collaborative communication (all p<.05). These disparities in communication accounted for geographic variation in HPV vaccination, specifically, the higher rates of uptake in the Northeast versus the South (mediation z=2.31, p<.01) and in urban/suburban vs. rural areas (mediation z=2.87, p<.01). These disparities were also associated with vaccination among subgroups with relatively high coverage, minimizing what could have been even higher uptake among Hispanic compared to non-Hispanic white adolescents (mediation z=-3.04, p<.01) and non-privately versus privately insured adolescents (mediation z=-3.67, p<.001). Controlling for provider recommendation attenuated some of these associations (but all p<.10)., Conclusions: Collaborative communication showed widespread disparities, being least common among underserved groups. Collaborative communication helped account for differences-and lack of differences-in HPV vaccination among some subgroups of adolescent girls. Leveraging patient-provider communication, especially for underserved demographic groups, could improve HPV vaccination coverage.

School-entry requirements in the US have led to high coverage for several vaccines, but few states and jurisdictions have adopted these policies for human papillomavirus (HPV) vaccination. Because physicians play a key role in advocating for vaccination policies, we assessed physician support of requiring HPV vaccine for school entry and correlates of this support. Participants were a national sample of 775 physicians who provide primary care, including vaccines, to adolescents. Physicians completed an online survey in 2014 that assessed their support for school-entry requirements for HPV vaccination of 11 and 12 y olds. We used multivariable logistic regression to assess correlates of support for these requirements. The majority of physicians (74%) supported some form of school-entry requirements, with or without opt-out provisions. When opt-out provisions were not specified, 47% agreed that laws requiring HPV vaccination for school attendance were a "good idea." Physicians more often agreed with requirements, without opt-out provisions, if they: had more years in practice (OR=1.49; 95% CI: 1.09-2.04), gave higher quality HPV vaccine recommendations (OR=2.06; 95% CI: 1.45-2.93), believed that having requirements for Tdap, but not HPV, vaccination undermined its importance (OR=3.33; 95% CI: 2.26-4.9), and believed HPV vaccination was as or more important than other adolescent vaccinations (OR=2.30; 95% CI: 1.65-3.18). In conclusion, we found that many physicians supported school-entry requirements for HPV vaccination. More research is needed to investigate the extent to which opt-out provisions might weaken or strengthen physician support of HPV vaccination school-entry requirements.

During and after the 2011 Republican presidential debate, a candidate questioned the safety of HPV vaccine. The authors aimed to determine the effect of these comments on parents. A national sample of 327 parents with adolescent sons ages 11-17 years completed online surveys in fall 2010 (baseline, about 1 year before the debate) and 2011 (follow-up, about 1 month after the debate). The authors used regression models to examine the association of parents' awareness of the candidate's comments with HPV vaccine initiation among their sons, their willingness to get sons free HPV vaccine, and their beliefs about potential harms of HPV vaccine. Overall, 17% of parents reported hearing about the Republican presidential candidate's comments about HPV vaccine. Parents aware of the comments had a larger increase between baseline and follow-up in the belief that HPV vaccine might cause short-term health problems compared with parents who were not aware. Although the candidate's comments may have increased some parents' beliefs about the short-term harms of HPV vaccine, the comments had no effect on other beliefs, willingness to vaccinate, or behavior. Having accurate information about HPV vaccine that is readily available to the public during such controversies may diminish their effect.

Vaccination in alternative settings, defined here as being outside of traditional primary care, can help address the pressing public health problem of low human papillomavirus vaccine coverage among adolescents in the United States. Pharmacies are promising because they are highly accessible and have well established immunization practices. However, pharmacies currently face policy and reimbursement challenges. School-located mass vaccination programs are also promising because of their high reach and demonstrated success in providing other vaccines, but control by local policymakers and challenges in establishing community partnerships complicate widespread implementation. Health centers in schools are currently too few to greatly increase access to human papillomavirus vaccine. Specialty clinics have experience with vaccination, but the older age of their patient populations limits their reach. Future steps to making alternative settings a success include expanding their use of statewide vaccine registries and improving their coordination with primary care providers.

Low uptake of human papillomavirus (HPV) vaccine calls for innovative approaches. Offering the vaccine in settings outside the traditional medical home, such as schools and pharmacies, could increase use. We sought to characterize the acceptability of HPV vaccine delivery in these alternative settings using a national (US) sample of parents of adolescent males ages 11-17 y (n = 506) and their sons (n = 391) who completed our online surveys in Fall 2010. We used multivariable regression to identify correlates of parents' and sons' comfort with (i.e., acceptability of) alternative settings. Half of parents (50%) and over one-third of sons (37%) reported that they were comfortable with schools or pharmacies as locations for the sons to receive HPV vaccine. Parents and sons were more comfortable with HPV vaccination in alternative settings if the sons had not recently visited their health care providers or had previously received vaccines at school, or if parents and sons were comfortable talking with each other about new vaccines. Parents who perceived greater barriers to HPV vaccination were more comfortable with alternative settings, as were sons who perceived that their peers were more accepting of HPV vaccine (all p < 0.05). Offering HPV vaccine in alternative settings may increase vaccination, especially among hard-to-reach adolescents. For example, our results suggest that offering the vaccine in alternative settings to boys who had not had recent health care visits could increase uptake by more than 10%. Study findings also highlight factors that should be addressed to maximize the potential success of HPV vaccination programs.