Position Paper on HPV Immunization

APHON Position Paper on Human Papillomavirus Immunization


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


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


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


o The pediatric hematology/oncology nurse should work in collaboration with

primary care providers to ensure patients initiate and complete the HPV vaccine


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


 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.


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.


American Academy of Pediatrics. (2012). HPV vaccine recommendations. Pediatrics, 129 (3), 602 – 605. doi:10.1542/peds.2011-3865

American Nurses Association. (2015a). Code of ethics for nurses with interpretive statements : Silver Spring, Maryland: ANA, American Nurses Association.

American Nurses Association. (2015b). Position statement on immunizations. Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/official-position- statements/id/immunizations/

Arbyn, M., Xu, L., Simoens, C., & Martin-Hirsch, P. P. (2018). Prophylactic vaccination against human papillomaviruses to prevent cervical cancer and its precursors. Cochrane Database Syst Rev, 5 , Cd009069. doi:10.1002/14651858.CD009069.pub3

Bailey, H. H., Chuang, L. T., duPont, N. C., Eng, C., Foxhall, L. E., Merrill, J. K., . . . Blanke, C. D. (2016). American Society of Clinical Oncology Statement: Human Papillomavirus Vaccination for Cancer Prevention. Journal of Clinical Oncology, 34 (15), 1803-1812. doi:10.1200/JCO.2016.67.2014 Brisson, M., Laprise, J. F., Drolet, M., Van de Velde, N., Franco, E. L., Kliewer, E. V., . . . Boily, M. C. (2013). Comparative cost-effectiveness of the quadrivalent and bivalent human papillomavirus vaccines: a transmission-dynamic modeling study. Vaccine, 31 (37), 3863-3871. doi:10.1016/j.vaccine.2013.06.064

Castle, P. E., & Maza, M. (2015). Prophylactic HPV vaccination: past, present, and future. Epidemiology and Infection , 1-20. doi:10.1017/S0950268815002198

Centers for Disease Control and Prevention. (2016). Vaccines for Children Program. Retrieved from https://www.cdc.gov/vaccines/programs/vfc/index.html

Chesson, H. W., Ekwueme, D. U., Saraiya, M., Watson, M., Lowy, D. R., & Markowitz, L. E. (2012). Estimates of the annual direct medical costs of the prevention and treatment of disease associated with human papillomavirus in the United States. Vaccine, 30 (42), 6016-6019. doi:10.1016/j.vaccine.2012.07.056 Chesson, H. W., Markowitz, L. E., Hariri, S., Ekwueme, D. U., & Saraiya, M. (2016). The impact and cost-effectiveness of nonavalent HPV vaccination in the United States: Estimates from a simplified transmission model. Human Vaccines & Immunotherapeutics, 12 (6), 1363-1372. doi:10.1080/21645515.2016.1140288

Children's Oncology Group. (2013). Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers, version 4.0 . Monrovia, CA: Children's Oncology Group, available: www.survivorshipguidelines.org.

Crow, J. M. (2012). HPV: The global burden. Nature, 488 (7413), S2-3. doi:10.1038/488S2a

de Martel, C., Plummer, M., Vignat, J., & Franceschi, S. (2017). Worldwide burden of cancer attributable to HPV by site, country and HPV type. International Journal of Cancer, 141 (4), 664-670. doi:10.1002/ijc.30716

Drolet, M., Benard, E., Boily, M. C., Ali, H., Baandrup, L., Bauer, H., . . . Brisson, M. (2015). Population-level impact and herd effects following human papillomavirus vaccination programmes: a systematic review and meta-analysis. The Lancet Infectious Diseases, 15 (5), 565-580. doi:10.1016/s1473-3099(14)71073-4

Forman, D., de Martel, C., Lacey, C. J., Soerjomataram, I., Lortet-Tieulent, J., Bruni, L., . . . Franceschi, S. (2012). Global burden of human papillomavirus and related diseases. Vaccine, 30 Suppl 5 , F12-23. doi:10.1016/j.vaccine.2012.07.055

Gilkey, M. B., Calo, W. A., Moss, J. L., Shah, P. D., Marciniak, M. W., & Brewer, N. T. (2016). Provider communication and HPV vaccination: The impact of recommendation quality. Vaccine, 34 (9), 1187-1192. doi:10.1016/j.vaccine.2016.01.023

Hofstetter, A. M., Lappetito, L., Stockwell, M. S., & Rosenthal, S. L. (2017). Human Papillomavirus Vaccination of Adolescents with Chronic Medical Conditions: A National Survey of Pediatric Subspecialists. Journal of Pediatric and Adolescent Gynecology, 30 (1), 88-95. doi:10.1016/j.jpag.2016.08.005

Inskip, P. D., & Curtis, R. E. (2007). New malignancies following childhood cancer in the United States, 1973-2002. International Journal of Cancer, 121 (10), 2233-2240. doi:10.1002/ijc.22827

Klosky, J. L., Hudson, M. M., Chen, Y., Connelly, J. A., Wasilewski-Masker, K., Sun, C. L., . . . Landier, W. (2017). Human Papillomavirus Vaccination Rates in Young Cancer Survivors. Journal of Clinical Oncology, 35 (31), 3582-3590. doi:10.1200/JCO.2017.74.1843 Nasioudis, D., Ramer, I., Sisti, G., & Fambrini, M. (2015). Risk of Second Primary Tumors After Childhood and Adolescent Ovarian Malignancies: A SEER Analysis (1973-2011). Journal of Pediatric and Adolescent Gynecology, 28 (6), 522-525. doi:10.1016/j.jpag.2015.03.009

Ojha, R., Tota, J., Offutt-Powell, T., Klosky, J., Minniear, T., Jackson, B., & Gurney, J. (2013). Human papillomavirus-associated subsequent malignancies among long-term survivors of pediatric and young adult cancers. PloS One, 8 (8), e70349. doi:10.1371/journal.pone.0070349 Reagan-Steiner, S., Yankey, D., Jeyarajah, J., Elam-Evans, L. D., Curtis, C. R., MacNeil, J., . . . Singleton, J. A. (2016). National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years - United States, 2015. Morbidity and Mortality Weekly Report (MMWR), 65 (33), 850-858. doi:10.15585/mmwr.mm6533a4 Reulen, R. C., Frobisher, C., Winter, D. L., Kelly, J., Lancashire, E. R., Stiller, C. A., . . . British Childhood Cancer Survivor Study Steering, G. (2011). Long-term risks of subsequent primary neoplasms among survivors of childhood cancer. JAMA: The Journal of the American Medical Association, 305 (22), 2311-2319. doi:10.1001/jama.2011.747 Saslow, D., Andrews, K. S., Manassaram-Baptiste, D., Loomer, L., Lam, K. E., Fisher-Borne, M., . . . Fontham, E. T. (2016). Human papillomavirus vaccination guideline update: American Cancer Society guideline endorsement. CA: A Cancer Journal for Clinicians, 66 (5), 375-385. doi:10.3322/caac.21355 Simms, K. T., Laprise, J. F., Smith, M. A., Lew, J. B., Caruana, M., Brisson, M., & Canfell, K. (2016). Cost-effectiveness of the next generation nonavalent human papillomavirus vaccine in the context of primary human papillomavirus screening in Australia: a comparative modelling analysis. The Lancet Public Health, 1 (2), e66-e75. doi:10.1016/s2468-2667(16)30019-6 SOGC, SCC, GOC, & CFPC. (2015). JOINT POSITION STATEMENT: Safety of Gardasil HPV vaccine [Press release]. Retrieved from http://www.cfpc.ca/uploadedFiles/Publications/News_Releases/News_Items/HPVvaccine PositionStatement_Final[1].pdf

Temming, P., Viehmann, A., Arendt, M., Eisele, L., Spix, C., Bornfeld, N., . . . Lohmann, D. R. (2015). Pediatric second primary malignancies after retinoblastoma treatment. Pediatric Blood and Cancer, 62 (10), 1799-1804. doi:10.1002/pbc.25576

Torre, L. A., Bray, F., Siegel, R. L., Ferlay, J., Lortet-Tieulent, J., & Jemal, A. (2015). Global cancer statistics, 2012. CA: A Cancer Journal for Clinicians, 65 (2), 87-108. doi:10.3322/caac.21262

World Health Organization. (2017). Human papillomavirus vaccines: WHO position paper, May 2017-Recommendations. Vaccine, 35 (43), 5753-5755. doi:10.1016/j.vaccine.2017.05.069

Zhai, L., & Tumban, E. (2016). Gardasil-9: A global survey of projected efficacy. Antiviral Research, 130 , 101-109. doi:10.1016/j.antiviral.2016.03.016


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.

Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12


Powered by