The vaccine with the poorest track record in the U.S. has its worst uptake in Mississippi. Nearly 20 years after the first FDA-approved HPV vaccine was introduced to the public, Mississippi has one of the highest rates of cervical cancer deaths in the country.

The Human Papillomavirus, or HPV, vaccine protects against the nine most common and high-risk strains of the virus that cause cancers and genital warts in both males and females. Despite its efficacy, it has one of the lowest immunization records of recommended vaccines in the country, with a national average of only 63% of teens up to date on their two-dose vaccine. 

In Mississippi, only 39% of teens are up to date on immunization. Practitioners say the biggest barriers to immunization against the virus are the stigma around how the virus is thought to be transmitted and misunderstanding about who the vaccine is for.

Dr. Anita Henderson, pediatrician at Hattiesburg Clinic and the former president of the Mississippi chapter of the American Academy of Pediatrics, said that it has taken time for the public to understand that the vaccine is not simply preventing a sexually transmitted disease. 

“That is not what the HPV vaccine was developed for – it was developed to prevent cancers,” Henderson said. “And unfortunately, I think the misinformation around this vaccine has played a significant role in its poor uptake.”

In fact, despite the longstanding definition of HPV as a “sexually transmitted disease,” research is now bringing to light instances of non-sexual contact transmission. Some pediatricians are seeing HPV transmission from mother to baby during birth.

“We have had several babies with HPV in their airways causing stridor and difficulty breathing,” Henderson said. “The pediatric ENT made the diagnosis of HPV warts in the airway with diagnosis and treatment via upper airway endoscopy.”

For parents who associate the virus with sexual behavior, it can be confusing why practitioners recommend the vaccine at such a young age. But the impact of age on efficacy of the vaccine is also misunderstood. 

“The vaccine is about 90% effective against cervical cancer when given at the age of 12 or 13, it is about 60% effective if given at the age of 14 to 16, and it is about 30 or 35% effective if given at the age of 16 to 18,” Henderson explained.

According to Henderson, that has to do not only with the fact that earlier immunization increases one’s chances of vaccinating prior to exposure, but also with the fact that “when you’re younger, your immune system does a better job of developing the appropriate antibodies to the vaccine.”

The HPV vaccine has been an outlier in childhood vaccines in Mississippi. The state has been at the forefront of childhood immunization for years, often ranking first for vaccination in young children – a title that only now could be challenged as Mississippi joined other states in allowing religious exemption for childhood vaccination last month. 

The widespread association of the HPV vaccine with sexual activity is part of what makes HPV vaccine hesitancy so unique and pervasive in the state, explained the Mississippi HPV Roundtable Coordinator Amy Ellis.

The Mississippi HPV Roundtable works to increase HPV vaccination rates by offering online resources for parents and coordinating health initiatives across the state. Member organizations come from a diversity of sectors including academia and state and local agencies. 

“If it was a vaccine to prevent any other type of cancer that wasn’t sexually transmitted, I don’t think it would be this controversial,” Ellis said. 

And while some parents might fear that the vaccine encourages sexual behavior, studies show there is no evidence to support that claim. 

“A misconception that some parents have is that if their kids get the HPV vaccine, that that is going to give them permission to have sex, and that has just not proven to be the case,” Ellis continued. “Kids don’t even know what vaccine they’re getting.”

While the state has the worst HPV vaccine rates, there are a number of Mississippi initiatives to change that statistic that Ellis is excited to see play out. One of the most successful so far, she said, is the college campus initiative, that aims to inform college students who never received the vaccine, for whatever reason, about the HPV virus and vaccine. 

“Ole Miss is taking the lead on that and doing an amazing job,” Ellis said, “educating students about the vaccine, and then if they want to get it, they can go get it at a clinic on site.”

The Mississippi Board of Dental Examiners also ruled in April 2021 to allow licensed dentists in the state to administer the vaccine, according to the board minutes. Currently, there are no dentists who have completed the process to store and administer the vaccine on site, but the policy is in place for that to happen in the future. 

“We are ahead of the game there,” Ellis said. “There are not many states that have dentists that are able to give the vaccine, so that is exciting for Mississippi.”

Cervical cancer is a more known example of HPV-related cancer because there are so many studies and an abundance of data and marketing highlighting the connection to the HPV virus. But Tara Smith, an epidemiologist and professor at Kent State University College of Public Health whose research is rooted in science denial and vaccine hesitancy, noted there are also several debilitating cancers for males.

HPV can cause penile, anal and oral cancers in men, the last of which has been on the rise in recent years. 

“I don’t think some people have gotten past the idea that the only reason to get it for boys is to protect their female partners,” Smith said. “I think that that education campaign has been kind of lacking.”

Smith also said that one of the biggest causes of this miseducation is the reluctance to talk about these topics – both on the part of parents and practitioners. 

“I think there is a lot of misunderstanding that if teens behave in a manner that the parents would like them to, as far as abstaining, that that will protect them, which unfortunately, it really doesn’t,” she explained. 

Even teens who abstain from intercourse might end up engaging in other forms of sexual activity, all of which can transmit the virus. For those who do abstain entirely, Smith said, “you still don’t know who they’re going to marry.”

What makes these conversations even more trying for parents, Smith explained, is that they “can sometimes bring up more uncomfortable topics about things like rape and sexual assault, where your child may not be protected, and it may not be their choice to engage in sexual activity.”

But for Smith, there is nothing more important than setting up the dialogue between parents and practitioners as early as age 9, which is the youngest age the HPV vaccine can be administered.

“We need to be talking about it, and talking about it earlier,” she said. “When you get to the time when kids are recommended for the vaccine, which is generally around 12 or so, parents are starting to think about things like their child growing up, and bringing in that conversation about sex is sometimes difficult. So I really think it’s about the dialogue, and starting early, and not being afraid to talk about these things.”