Across the country, immunization rates against the human papillomavirus lag well behind other vaccines recommended for adolescents, but Philadelphia has had some success "selling" the controversial vaccine to the moms and dads of preteens.


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The city has the highest HPV immunization rate among big cities in the United States.

Several years ago, Naja Fousheé worked as a recruiter for a University of Pennsylvania study designed to educate families about HPV and the newly approved-vaccine.

Fousheé says the parents of some 11- and 12-year-olds were uncomfortable talking about protecting their child against a sexually transmitted disease. And, she says, some doctors were hesitant too.

"It's not just the regular chicken pox, mumps, measles or rubella vaccine, it brings up the sex issue, which is still a little still taboo," Fousheé said. "I guess they don't want to cross that line of maybe this parent has not started this conversation with their child, and if I brought this up, that would open that box."

HPV can spread through sexual contact, not just intercourse. Vaccine supporters say the shots are recommended for middle-school kids to increase the chances that a child is protected before they become sexually active.

The vaccine roll-out became entangled in politics; still, public health people hate it when you call it "controversial."

"I believe this is a completely safe vaccine -- and effective," said Dr. Caroline Johnson, director of the Division of Disease Control at the Philadelphia Department of Health.

Stories about rare side effects fuel resistance

Originally, the vaccine was only for girls. About a year ago, the Centers for Disease Control and Prevention added boys to the vaccine recommendation.

Anecdotal stories about side effects began to surface soon after the first vaccine, Gardasil, was approved six years ago.

"You know when you Google anything you always get the bad news," Johnson said. "And you never get the good news about all the cancers that will be prevented and the kids that won't have genital warts."

HPV usually clears without treatment, but chronic infection can lead to cervical cancer in women and other cancers in men.

Nationwide, only about 35 percent of adolescent girls have gotten the shots. But in Philadelphia, the completion rate for the three-dose series is now 49 percent, for girls age 13 to 17.

"The things that we've done aren't regulations, are not laws," Johnson said. "We haven't mandated this for entrance to school, we haven't mandated it for anybody to take."

Education and outreach pay off

"Our providers are very progressive in adopting new vaccines, they want to educate families, and I think that's contributed to our great success locally," she said. She said the trust between health providers and patients has helped ease some initial reservations.

For girls, Philadelphia's initial one-dose vaccine rate is higher than some locations where the vaccine is required for school entry, such as New York state, Washington, D.C., and Virginia (See chart).

The health department promotes and offers the vaccine in non-traditional settings, such as outside schools and at basketball tournaments. Officials market the vaccine directly to children through Facebook, and teenagers don't need a parent's permission to get the shots. The city also holds walk-in clinics.

Many teens know about HPV, but are wary about what they've heard about the vaccine, says Dr. Lenore Asbel, medical director of Philadelphia's STD clinic.

"Their friend's arm hurt or somebody passed out," she says. "We do a lot of vaccine in clinic and we are able to explain that those side effects are rare."

Keeping vaccine readily available

The HPV vaccine can cost more than $300 for the three-dose series; still, Johnson says, many Philadelphia doctors make sure the vaccine is in the fridge and ready to go.

"We actually give them the vaccine, and then bill the insurance companies on the back end," Johnson said.

The federal Vaccine for Children program finances those upfront costs for doctors who serve lots of children enrolled in Medicaid. For cities with a smaller percentage of low-income kids, Johnson says, it can be harder to persuade doctors to pay for and keep the vaccine in stock.

Financing may also explain a blip in HPV coverage rates in the Philadelphia. Lower-income kids are more likely to get the initial vaccine dose, compared with children who live in households above the poverty line.

Johnson calls it a "reverse disparity" but said she does not sense that low-income kids have been targeted for the vaccine. She called the difference an "accidental byproduct of the way that the vaccine is made available and how it's financed."

"I think in some communities, not so much in Philadelphia, the anti-vaccine movement, anti-vaccine sentiment, is more of a problem, in educated white populations," Johnson said. "That's really an issue on the West Coast, not an issue here."