APHON Position Paper on Human Papillomavirus Immunization
Authors
Debra Eshelman-Kent, DNP MSN APRN RN
Brooke Cherven, MPH RN CPON ®
Wendy Landier, PhD CPNP FAAN CPON ®
APHON’s core purpose of supporting nurses and their practice with the goal of optimizing
outcomes for children, adolescents, and young adults with cancer and blood disorders mandates
substantial attention to human papillomavirus (HPV) immunization. Pediatric
hematology/oncology nurses dedicate their practice to maximizing health throughout the cancer
trajectory (ie, from initial cancer diagnosis through survivorship) for patients with oncologic
diseases and the continuum of care for patients with blood disorders. Pediatric
hematology/oncology patients may be at increased risk for not receiving crucial adolescent
vaccines compared with the healthy population because their care often is delivered in
subspecialty clinics, where the focus is on disease management, rather than in primary care,
where the focus is on health promotion (Hofstetter, Lappetito, Stockwell, & Rosenthal, 2017).
Cancer prevention strategies are an essential component of education provided by pediatric
hematology/oncology nurses, and immunization against HPV is a necessary preventative
measure.
HPV is an attributable cause of a significant number of cancers, including cervical,
vaginal, vulvar, anal, penile, and oropharyngeal cancers and high-grade dysplasia (Forman et al.,
2012; Torre et al., 2015). Globally, more than 600,000 cases of cancer are attributable to HPV
each year (de Martel, Plummer, Vignat, & Franceschi, 2017). Infection with HPV leads to
significant morbidity, mortality, and healthcare costs (Chesson et al., 2012; Crow, 2012; Reagan-
Steiner et al., 2016). HPV vaccines have been developed to target the most common types of
dysplasia and cancers attributable to HPV, have been proven safe and effective, and are
recommended through vaccination policy for males and females during pre- and early
adolescence — prior to sexual contact — to maximize effectiveness (Arbyn, Xu, Simoens, &
Martin-Hirsch, 2018; Castle & Maza, 2015; Drolet et al., 2015; Zhai & Tumban, 2016).
Despite established efficacy and safety, uptake of the HPV vaccine lags behind that of
other recommended adolescent vaccines (Reagan-Steiner et al., 2016), and vaccination rates are
significantly less in cancer survivors than in the general population (Klosky et al., 2017).
Underimmunization is a problem that has particular relevance for the pediatric, adolescent, and
young adult (PAYA) oncology patient population because this population has the potential to be
at increased risk for secondary cancers, including those associated with HPV (Inskip & Curtis,
2007; Nasioudis, Ramer, Sisti, & Fambrini, 2015; Ojha et al., 2013; Reulen et al., 2011;
Temming et al., 2015). In many cases, the cause of second cancers may be apparent (eg,
radiation), but for others, the etiology of a second cancer may not be specifically linked with
prior cancer therapy or known genetic causes. Therefore, for cancer prevention, all potential risk
factors, including HPV, should be considered, highlighting the need for preventative
immunization against HPV.
Nursing Practice
As suggested by the American Nurses Association (ANA) Code of Ethics, Provision 4,
“the nurse takes actions consistent with the obligation to promote health and to provide
optimal care” (American Nurses Association, 2015a). A PHON endorses the ANA’s
position of immunizing individuals against vaccine-preventable diseases, since
immunization aligns with “the nurse’ s obligation to use interventions to optimize health
and well- being” (American Nurses Association, 2015a, 2015b).
The pediatric hematology/oncology nurse is responsible for assessing the patient ’s and
family ’s knowledge of the importance of HPV immunization to ensure they receive
comprehensive education and recommendations for immunization.
The pediatric hematology/oncology nurse is responsible for supporting and fostering the
autonomy of the young adult hematology/oncology patient to make decisions about HPV
immunization, when appropriate.
The pediatric hematology/oncology nurse should educate the patient and family that
receiving the HPV immunization series does not negate the need for cancer screening
practices.
Nursing Interventions
APHON recognizes the need to decrease missed opportunities for administration of the
HPV vaccine to age-eligible cancer survivors and patients with hematologic disorders.
o The pediatric hematology/oncology nurse should assess the HPV vaccine status of
age-eligible patients during healthcare encounters. For patients who have not
initiated or completed the HPV vaccine series, the pediatric hematology/oncology
nurse should provide a strong recommendation for the vaccine and facilitate
vaccination at the soonest available opportunity (including at the current
healthcare encounter, whenever possible). Pediatric hematology/oncology nurses
should be aware that receiving a recommendation for the HPV vaccine from a
healthcare provider is the strongest predictor for initiation of the HPV vaccine in
both the general population (Gilkey et al., 2016) and among cancer survivors
(Klosky et al., 2017).
o The pediatric hematology/oncology nurse should use available technology, such
as electronic medical record alert systems, to prompt time-sensitive reminders to
help decrease the number of missed opportunities for vaccination.
o The pediatric hematology/oncology nurse should use existing recall and reminder
strategies (or develop new strategies, if none exist) to facilitate completion of the
vaccine series.
APHON recognizes the importance of collaborating with primary care providers to
optimize the health care of hematology/oncology patients.
o The pediatric hematology/oncology nurse should recognize that provision of the
HPV vaccine may occur in the oncology or primary care setting, depending on
institutional and practice characteristics as well as patient circumstances and
preferences.
o The pediatric hematology/oncology nurse should work in collaboration with
primary care providers to ensure patients initiate and complete the HPV vaccine
series.
Nursing Advocacy
The HPV vaccine is promoted as a cancer-prevention intervention by national
organizations in the United States (American Academy of Pediatrics, 2012; Saslow et al., 2016)
and Canada (SOGC, SCC, GOC, & CFPC, 2015) and internationally by the World Health
Organization (World Health Organization, 2017). The Children’s Oncology Group (Children's
Oncology Group, 2013) and the American Society of Clinical Oncology (Bailey et al., 2016)
specifically state that the HPV vaccine should be recommended to all eligible cancer survivors
and other immunocompromised patients. Therefore, APHON stands with other national and
international organizations in recommending the HPV vaccine for age-eligible cancer survivors
and patients with hematologic disorders.
Despite these recommendations, less than 25% of AYA cancer survivors report initiating the
HPV vaccine (Klosky et al., 2017). Cancer survivors are less likely than peers to report a
healthcare provider recommendation for the HPV vaccine, yet provider recommendation is the
strongest predictor for HPV vaccine initiation among cancer survivors (Klosky et al., 2017).
Pediatric hematology/oncology nurses should address this gap by incorporating HPV vaccine
recommendation into hematology/oncology nursing practice. Adolescent and young adult cancer
survivors and patients with hematologic disorders have the right to receive education about
cancer prevention, including the HPV vaccine, and pediatric hematology/oncology nurses have
the responsibility to promote vaccination among cancer survivors and patients with hematologic
disorders.
APHON supports equity of access to HPV immunization.
Economic Considerations
HPV vaccination has been evaluated for cost effectiveness within the United States and
internationally among the general population. The currently recommended nonavalent vaccine is
considered cost effective, particularly when administered during early adolescence (Brisson et
al., 2013; Chesson, Markowitz, Hariri, Ekwueme, & Saraiya, 2016; Simms et al., 2016; World
Health Organization, 2017). In countries with universal health care or school-based
immunization programs, there usually is no cost to the patient. In the United States, the cost of
the HPV vaccine may be covered by private insurance policies, governmental programs, or
pharmaceutical company patient assistance programs (Centers for Disease Control and
Prevention, 2016).
The pediatric hematology/oncology nurse should have an understanding of how children,
adolescents, and young adults with hematologic and oncologic diseases can access the
HPV vaccine.
Support of Future Research
APHON recognizes the need for continued research regarding the HPV vaccine to: 1)
determine the immunogenicity of the vaccine in cancer survivors to ensure the vaccine affords
these survivors adequate protection against HPV and 2) increase the low uptake of HPV
vaccination in the population of children, adolescents, and young adults with hematologic and
oncologic diseases.
Summary
PAYA with hematologic and oncologic disorders are missing opportunities to receive the
HPV vaccine, and vaccination uptake in this population is low. Pediatric hematology/oncology
nurses have the opportunity to promote HPV vaccination among PAYA hematology/oncology
patients and have the responsibility to discuss cancer prevention strategies, including the HPV
vaccine, with their patients. APHON supports the promotion of the HPV vaccine as a crucial part
of clinical practice for pediatric hematology/oncology nurses.
References
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Disclaimer
The Association of Pediatric Hematology/Oncology Nurses (APHON) publishes its position
statements as a service to promote the awareness of certain issues to its members. The
information contained in the position statement is neither exhaustive nor exclusive to all
circumstances or individuals. Variables such as institutional human resource guidelines, state or
federal statutes, rules, or regulations, as well as regional environmental conditions, may impact
the relevance and implementation of these recommendations. APHON advises its members and
others to carefully and independently consider each of the recommendations (including the
applicability of same to any particular circumstance or individual). The position statement should
not be relied upon as an independent basis for care, but rather as a resource available to APHON
members or others. Moreover, no opinion is expressed herein regarding the quality of care that
adheres to or differs from APHON position statements. APHON reserves the right to rescind or
modify its position statements at any time.
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