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Four years ago, many in public health predicted that a vaccine for a sexually transmitted disease would be a hard sell for the parents of teenage girls -- even one that prevents cervical cancer later in life.
They were right. In Minnesota, only about 16 percent of teenage girls have gotten all three of the shots needed to protect against HPV, or human papillomavirus, according to data from the Minnesota Department of Health. About one-third have received at least one, about the same as nationally.
"Now, even the public health and vaccine people are saying this is slower than we should be tolerating," said Dr. Levi Downs, a cancer expert at the University of Minnesota who researched the vaccine and who has received funding from the manufacturer.
The vaccine has faced an uphill battle. It's expensive, about $300 -- a problem for those with limited or no health insurance -- and requires three shots over six months. Unlike virtually all other childhood immunizations, it's not required for school.
But the biggest problem, say doctors on the front lines, is convincing parents that their kids are at risk for a sexually transmitted infection.
"How much do you want to impress parents that this is a disease that can affect their child?" said Dr. Peter Dehnel, a pediatrician at the All About Children clinic in Eden Prairie. "It can be a long discussion that you may not have time for."
The vaccine, Gardisil, was approved in 2006 and a second one, Cervarix, was approved last year to protect against the most common sexually transmitted infection in the world. In the United States, at least half of both men and women carry HPV at some point in their lives. Most clear the virus easily, but in some it causes genital warts and a variety of cancers in men and women.
Prevention of cancer, warts
The vaccines are aimed at women because they protect against the two types of the virus that cause 70 percent of all cervical cancers and 90 percent of genital warts. They are viewed as a significant advance in women's health because they could prevent most of the 11,000 new cases of cervical cancer diagnosed each year.
"What if we got them all vaccinated, this big chunk of kids?" said Pam Glenn, a clinical director at Planned Parenthood in Minneapolis, a major provider of the vaccines. "What a huge public health impact that would have on cervical cancer and genital warts."
The Centers for Disease Control and Prevention says that girls should get the shots when they are 11 so they are covered no matter when they start having sex, and because it's more effective when administered at a younger age.
For Liz Montgomery, of Chanhassen, the choice was clear. "Eventually she will be sexually active -- you can't deny that," she said of her 14-year-old daughter, who just got the second of the three-shot series. "This is something that could protect her in her later years."
But for many others, the choice is complicated by what the vaccine implies about sexuality or abstinence and giving their kids the wrong idea.
"Yeah, it would definitely send a mixed message," said Teri Stark of Minnetonka, who has a 13-year-old daughter and a 12-year-old son. "We don't want you to have sex, but just in case you do, here you go?"
Stark said her daughter's pediatrician said it's fine to wait until she's older, partly to ensure that no unexpected problems turn up with the vaccine.
"I do intend to protect my daughter," she said. "But I have no fears that she is sexually active now."
Kris Ehresmann, director of immunization for the Minnesota Department of Health, said the acceptance rate is frustratingly low.
According to immunization data on nearly 300,000 teenage girls in Minnesota, only 16 percent of those ages 11 to 18 have completed the three-shot series. The rates rise with age -- one-fifth of those ages 13 to 18 have received all three and 38 percent have received at least the first shot.
Education campaign helping
There is an unexpected bright spot. The rates are higher among black and Hispanic girls than whites. Poor and minority groups tend to have higher rates of sexually transmitted infections and significantly higher rates of cervical cancer.
That success may be because the eight health plans that administer coverage for families in Medicaid and MinnesotaCare, state programs for the poor, have launched a broad-based education project to increase vaccination rates.
"We sent letters to parents," said Bethany Krafthefer, of PrimeWest, a health plan in Alexandria, Minn., that participates in the project. "We developed brochures for health fairs, posters for school nurse organizations. We gave posters and brochures to public health agencies, sent providers letters."
As a result, in one year the number of 11-year-olds in the health plans who got the first shot increased from 24 percent to 34 percent, she said.
Some say Minnesota needs that kind of statewide action to increase vaccination rates. Planned Parenthood this week issued a public report on HPV that calls for a statewide public information campaign.
It would be "a critical first step in raising awareness about the vaccine and making its promise a reality for future generations," said Sarah Stoesz, chief executive officer.
But it's not clear who would fund or lead such a campaign. Ehresmann said the health department would not lead a vaccine campaign for HPV alone.
Dehnel, the pediatrician, said his job would be easier if parents could stop seeing the vaccine as a treatment only for kids who engage in risky sexual behavior, and instead consider it just a routine vaccination that their kids need to prevent disease -- and go to school.
"If you had to get HPV vaccine to participate in sports ...the success rate would go up dramatically," he said.
Josephine Marcotty • 612-673-7394