	Betsy Guimond is an Assistant Clinical Professor of Nursing and the Doctor of Nursing Practice Coordinator at Duquesne University School of Nursing, Pittsburgh, Pennsylvania.

Persistent infection with specific subtypes of human papillomavirus (HPV) has been definitively linked to progression to cervical cancer. The identification of the link between HPV and cancer has led to the development of a vaccine to prevent infection from the most prevalent cancer-causing subtypes (16 and 18) in the United States. Although vaccination against HPV is recommended for males and females because of the protection afforded against nongender— specific HPV-related cancer and disease, uptake and completion has been underwhelming—about 36% for teenage girls and 13% for boys.

The decision to refuse or delay vaccination has been linked to concerns about the safety profile for the HPV vaccine.

 Some researchers have pointed to the Vaccine Adverse Events Reporting System (VAERS) data as evidence of substantial risk associated with vaccination,

 but evidence does not exist that the deaths listed in the VAERS data are attributable to the vaccine. Arguments against vaccination also do not consider its benefits in reducing significant morbidity related to cervical biopsies, nor does it consider reduction in other HPV-related diseases.

Anaphylaxis is always an issue with vaccine, which is best dealt with by careful observation after vaccination. Syncope too, is a very real risk in vaccination, particularly for adolescents, but the risk is no greater for HPV vaccination than for other vaccines.

 Because nuanced questions around clinical trials fit easily into the anti-vaccine narrative and are often used out of context as arguments against dissemination of vaccine, healthcare providers must be able to address these concerns when they are posed by concerned parents or patients.

Reduction in vaccine-preventable HPV strains has been demonstrated in several large studies. When compared with prevaccine era data in the United States,

 a 56% decrease was reported in the prevalence of vaccine-preventable HPV among 14- to 19-year-olds. Data from countries where school-based programs are in effect show similar trends. In Australia, substantially lower rates of cervical abnormalities have been attributed to the quadrivalent HPV vaccine.

		Applying the 4-Cs Framework in a Discussion of HPV Vaccine

			Commit to staying up-to-date with the vaccine news by subscribing to CDC email or Twitter feeds to receive the latest information regarding HPV vaccination safety.

			Convey understanding that the potential for risk exists for one lot of the vaccine.

			Communicate the evidence that the risk is limited to a single lot and review the lot number of the vaccine that you are giving with the individual to allay their concern. Or, if vaccination has occurred, reassure patients and parents that the reaction is limited to redness and swelling at the site of vaccination.

			Collaborate about risks and concerns. Acknowledge that there are risks for all vaccines and address each concern in a respectful way. Provide anticipatory guidance that allows the parent or young adult to schedule an appointment for vaccination after you have presented the safety profile and long-term benefits of vaccination.

It can be difficult for many healthcare providers and parents to address the advantages of a vaccine that prevents sexually transmitted disease, and this challenge in communication may contribute to some of the confusion regarding how to recommend HPV vaccination in preteen children. An insidious belief persists that vaccination is tacit approval for sexual behavior, despite the lack of evidence that sexual behaviors are influenced by vaccination status.

 Further, the effectiveness of the vaccine is greater among children who are following the regular immunization schedule rather than the catch-up schedule for adolescents or young adults.

I developed the 4 Cs framework to facilitate difficult discussions when confronting misinformation about health-related topics. This framework may prove helpful when discussing the safety and efficacy of HPV vaccination.

 To communicate evidence-based practice, nurses should: commit to staying up-to-date with evidence; convey understanding about concerns; communicate the evidence/ answer questions; and collaborate with parents and young adults to acknowledge risks and concerns surrounding vaccination. For example, in December 2013, the CDC reported that one lot of Gardasil vaccine was being voluntarily recalled because of the potential for approximately 10 vials to contain glass particles.

 Although the risk of injury was very low, the potential for misrepresentation was high, making it an ideal opportunity to demonstrate the 4 Cs framework (Box).

The framework encourages the nurse to be knowledgeable about the evolving science supporting the safely of HPV vaccination and to seek common ground related to risk reduction for individuals who are at risk for HPV-related cancers.

		Stokely S. Update on HPV vaccination coverage in the US: Advisory Committee on Immunization Practices. http://www.cdc.gov/vaccines/ acip/meetings/downloads/slides-oct-2013/02-HPV-Stokley.pdf. Accessed April 15, 2014.

		Dorell C, Yankey D, Jeyarajah J, et al. Delay and refusal of human papillomavirus vaccine for girls, national immunization survey-teen, 2010. 

		Tomljenovic L, Shaw CA. Who profits from uncritical acceptance of biased estimates of vaccine efficacy and safety? 

		Briones R, Nan X, Madden K, Waks L. When vaccines go viral: an analysis of HPV vaccine coverage on YouTube.

		Markowitz LE, Hariri S, Lin C, et al. Reduction in human papillomavirus (HPV) prevalence among young women following HPV vaccine introduction in the United States, National Health and Nutrition Examination Surveys, 2003-2010. 

		Gertig DM, Brotherton JM, Budd AC, et al. Impact of a population-based HPV vaccination program on cervical abnormalities: a data linkage study. 

		Macartney KK, Chiu C, Georgousakis M, Brotherton JM. Safety of human papillomavirus vaccines: a review. 

		Guimond ME. Confronting confirmation bias about breast cancer screening with the four Cs. 

		Centers for Disease Control and Prevention. Voluntary recall of one Lot of Gardasil HPV Vaccine. December 20, 2013. http://www.cdc.gov/ media/releases/2013/s1220-gardasil-vaccine.html. Accessed April 15, 2014.

Articles

Persistent infection with specific subtypes of human papillomavirus (HPV) has been definitively linked to progression to cervical cancer.

Mary Elizabeth Guimond, PhD, WHNP-BC

Articles

Addressing Concerns About HPV Vaccination