1. Mandatory immunizations For children and adolescents (HPV)
Alisha Gross and Jessica Olcheske

2. Objectives
Define what is Human Papillomavirus (HPV) and who is at risk
Explain symptoms and complications if infected with HPV
Explain importance and barriers to mandatory vaccination.
Describe legal considerations for mandatory HPV vaccine.
Identify recommendations to increase rate of HPV vaccination and decrease rate of HPV.
Explain ways nurses can help to educate parents and adolescents of HPV.

3. Introduction
HPV is the most common sexually transmitted infection and is so common that almost all sexually active women and men get it at some point in life.
There are many different strands of HPV and some can cause genital warts and cancers.
HPV can be spread through vaginal, anal, or oral sex.
An infected person may not have any signs or symptoms.
HPV can cause cancer of the cervical, vulva, vagina, penis, anus and back of throat.
The cancer may take years to develop after infection (CDC, 2017)
HPV is a commonly transmitted STI that can cause genital warts and cancers of the cervical, vulva, vagina, penis, anus and the back of the throat. HPV can affect women as well as men. The infected person may not have any signs or symptoms and therefore will not know that they are infected with HPV. Cancers caused by HPV can take years to develop.

4. HPV vaccines are available through VFC program in all 50 states.
The CDC recommends that all girls and boys ages receive the vaccine.
Catch up vaccines are recommended for males up to age 21, and females up to age 26, if not vaccinated when younger (CDC, 2017).
HPV vaccines are available through VFC program in all 50 states.
Debate in states has centered in part around school vaccine requirements, which is determined at the state level.
(NCSL, 2017).
The CDC recommends that all girls and boys ages 11 to 12 years receive two doses of the HPV vaccine to protect against cancers caused by HPV. For those that did not receive the vaccine when younger they recommend catch up vaccines for males through age 21, and females through age 26 (CDC, 2017). HPV vaccines are available through the Vaccines for Children (VFC) program in all 50 states. The VFC program provides vaccines to Medicaid, Alaskan-Native children, Native American children, some underinsured or underserved ages 9-18 years. Many debates in states have centered around school vaccine requirements, which are determined by each individual state (NCSL. 2017).

5. Barriers to mandatory vaccine
Distrust in pharmacy companies, and government providing vaccine
Concerns with side effects and safety
Recommended age of receiving vaccine
General anti vaccination beliefs
Encourage adolescent sexual behavior
Parent discomfort in discussing sexual behavior with child
Financial costs of vaccines
Insufficient or misleading information in past or in own research regarding vaccine
(Ferrer, 2014)
There are many barriers that prevent vaccinations from occurring. Parents may have distrust toward pharmaceuticals and government entities providing the vaccines to children and adolescents. Parents may also be concerned with side effects, and safety of children ages 11 and 12 receiving a vaccine that protects against an STI. There are also many parents that are against any type of vaccination for their children or adolescents. Some also believe that vaccinating for HPV at an early age will encourage their child to partake in sexual behaviors at an earlier age. Parents may also feel uncomfortable discussing any type of sexual behavior or preventative measure with their child. Financial costs of the vaccine also plays a role. Low income, uninsured or those with high deductibles may be not be able to afford the vaccine series and may need help finding ways to cover it.

6. Root cause analysis
Cindy is a 12 year old girl, whose mother was presented with the opportunity to give her the HPV vaccination, as her school did not mandate it. Cindy’s mother declined the vaccination because she believed that Cindy was too young for sexual intercourse and did not want to encourage under age sex. At 16 she engaged in unprotected sexual intercourse with her boyfriend and was infected with HPV. She was unaware because she did not have any symptoms. At age 20 Cindy had an abnormal Pap smear that tested positive for cervical cancer. Cindy is now undergoing treatment for cervical cancer.

7. Receiving the HPV vaccine is the best way to prevent against an infection with HPV. Engaging in unprotected intercorse increases the chance of becoming infected with HPV. HPV typically does not have any signs and symptoms, therefore an individual may not know they are infected and does not seek medical attention and may also spread the disease to other partners. HPV can cause certain cancers and may take years to develop.

8. Why important 79 million Americans are infected with HPV.
More than 11,000 women in US get cervical cancer each year.
Approx. 17,600 women and 9,300 men are affected by cancer caused by HPV.
HPV vaccine can protect girls and boys against disease and cancers caused by HPV when given as recommended.
HPV does not always show signs or symptoms, so it may not discovered until abnormal Pap smear or develop more serious problems like cancer
(CDC, 2017).
About 79 million Americans are infected with HPV and more than 11,000 women in the U.S. will develop cervical cancer each year. Approximately 17,000 women and 9,300 men are affected by cancer that was caused by HPV each year. The HPV vaccine can prevent girls and boys from developing cancers caused by HPV when given as recommended. The HPV vaccine is a safe and effective way of preventing many of the long term health effects caused by HPV. HPV does not always show signs or symptoms until an abnormal PAP smear is complete or more serious signs/symptoms of cancer develop.

9. Legal Considerations
School vaccination requirements are decided mostly by state legislation. They can delegate this power to the health department.
Michigan first state to introduce bill that required HPV vaccine for girls entering 6th grade, but was not enacted.
A least 25 states, including Michigan, have enacted legislation to require the vaccine, fund or educate school children and the public on the HPV vaccine.
Many states support availability of HPV vaccine, but do not support a school mandate due to drug cost, safety and parent’s right/choice to refuse.
Federal funding is available through VFC program in all 50 states but does not require mandatory vaccine programs, that is up to each state (NCSL, 2017)
Mandatory school vaccinations are decided by state legislation and can delegate this power to the health department. In 2006 Michigan's introduced bill to require HPV vaccine for girls entering 6th but the bill was not enacted. Many states offer the HPV vaccine but do not mandatory school children to be vaccinated due to drug cost, safety and parents refusal.

10. recommendations Identify barriers to receiving the vaccine.
Educate parents and adolescents about the HPV vaccine.
Provide access to accurate materials/information that is easy to understand.
Advise parents, adolescents and young adults on where and how they can receive vaccine for an affordable amount.
Identifying the barrier that is preventing vaccinations and educating them on that barrier may help increase vaccinating against preventable diseases and infections. It’s important to educate parents and adolescents on the reasoning for vaccines and the effects that may result from not vaccinating. Providing materials that have accurate information that they can understand and review later may help with understanding HPV infection and the vaccine. Parents, adolescents and young adults should be educated on ways to access the vaccine, and if covered by insurance or if qualify for a program that covers vaccine.

11. conclusion HPV is a commonly transmitted STI.
Can be prevented by vaccines.
Provide education regarding HPV and vaccine programs.
Identify barriers
Offer school based programs to increase education level and help increase vaccine rates.
HPV is a commonly transmitted STI that can be spread without knowledge and cause serious health concerns later. It can be prevented by vaccines that were approved by the FDA to prevent cancer and major health issues. Education and vaccine programs can prevent the spread of HPV. Identify those barriers and instilling school based programs can increase education level and increase vaccine rates.

12. References
Center for disease control. (2017). Genital HPV Infection-Fact Sheet. Retrieved from
Ferrer, H., Trotter, C., Hickman, M.< Audrey, S. (2014) Barriers and Facilitators to HPV Vaccinations of Young Women in High Income Countries: A Qualitative Systematic Review and Evidence Synthesis. BMC Public Health. doi: /
Gostin, O., L. (2011). Mandatory HPV Vaccination and Political Debate. Retrieved from:
National Conference of State Legislatures. (2017). HPV Vaccine: State Legislation and Statutes. Retrieved from
Stubbs, B., Panozzo, C., Moss, J., Reiter, P., Whitesell, D., Brewer, N. (2014). Evaluation of an Intervention of Providing HPV Vaccine in Schools. Am J Health Behav. doi: /AJHB Retrieved from