HPV Vaccine, We Can do Better! - Paul M. Darden, MD - South Carolina Chapter of the ...
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HPV Vaccine,
We Can do Better!
Paul M. Darden, MD
Chief, General & Community Pediatrics
Email: paul-darden@ouhsc.edu
Office Phone: 405 271-4407
South Carolina Chapter of the
American Academy of Pediatrics
Annual Meeting, Ashville, NC
August 6, 2021
HPV Vaccine,
Delivery and Communication
University of Kansas School of Medicine-Wichita
Department of Pediatrics Grand Rounds
April 10, 2019 revised 9/17/2020
Paul M. Darden, MD
Chief, General and Community Pediatrics
Disclosure Statement
Paul Darden, MD
I have no relevant financial relationships or affiliations with commercial interests to
disclose.
Thanks to
◦ Peter Szilagyi
◦ Sharon Humiston
◦ CDC HPV speakers bureau
National Center for Immunization and Respiratory Diseases, Centers for Disease
Control and Prevention. Grant No. H23IP000950. National Immunization
Partnership with the APA (NIPA).
You are the Key to HPV Cancer Prevention
Pediatric Grand Rounds, July 16, 2014
Sponsored by the American Academy of Pediatrics
Professional Practice Gap
Healthy People 2020, IID-11.4 and 11D-11.5
◦ % of male and female adolescents 13-15 years who receive 2 or 3 doses of
HPV vaccine
◦ Goal 80% for both
2019 NIS Teen shows that 13-17 years HPV vaccine UTD
◦ US 54.2%
◦ Oklahoma 41.8%
Rhode Island 78.9% - Highest
Mississippi 30.5% - Lowest
Elam-Evans LD, Yankey D, Singleton JA, et al. National, Regional, State, and Selected
Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years - United
States, 2019. Mmwr. 2020;69(33):1109-1116. PMID 32817598
Learning objectives 1. Explain the importance of HPV vaccination and current vaccination rates. 2. Examine the current evidence for provider recommendation to increase HPV vaccination rates. 3. Evaluate and apply the current evidence to my HPV vaccination practices
October 5, 2018 Approval by the FDA versus Recommendations by the ACIP
ACIP shared decision making August 2019
https://www.cnn.com/2018/10/05/health/gardasil-hpv-vaccine-approved-older-ages-bn/index.html
Meites E, Szilagyi PG, Chesson HW, Unger ER, Romero JR, Markowitz LE. Human Papillomavirus Vaccination for Adults: Updated
Recommendations of the Advisory Committee on Immunization Practices. Mmwr. 2019;68(32):698-702.
ACIP recommended shared clinical decision-making regarding potential HPV vaccination for these persons. MMWR August 16, 2019
https://www.researchamerica.org/polls-and-publications/polls/public-opinion-polls
https://www.researchamerica.org/polls-and-publications/polls/public-opinion-polls
• Tribeca Film Festival scheduled and then withdrawn • Shown across the nation • Witchita 6/2016, Kansas City 8/2017 • Currently available on Amazon, Vudu, iTunes and Google Play • “Vaxxed Bus” in Oklahoma 10/2017,
Vaccine hesitancy …
A new problem?
“The Cow Pock – or – the Wonderful Effects of the New Inoculation!”
J. Gillray, 1802“The impact of vaccination on the
health of the world’s people would be
hard to exaggerate. With the
exception of safe water, no other
modality, not even antibiotics, has
had such a major effect on mortality
reduction and population growth.”
2013 Plotkin, Orenstein, Offit VaccinesAnd now a vaccine that prevents
CANCER!
Human Papillomavirus (HPV) VaccineHPV Infection
Most females and males will be infected with
at least one type of mucosal HPV at some
point in their lives
Estimated 79 million Americans currently infected
14 million new infections/year in the US
HPV infection is most common in people in their teens
and early 20s
Most people will never know that they have
been infected
Satterwhite et al. Sex Transm Dis. 2013Number of New HPV-Associated Cancer
Cases Each Year
Centers for Disease Control and Prevention. Cancers Associated with Human
Papillomavirus, United States—2013–2017. USCS Data Brief No 18. 2020.
https://www.cdc.gov/cancer/uscs/pdf/USCS-DataBrief-No18-September2020-h.pdf.
Published September 2020. Accessed September 17, 2020.Good News
HPV Vaccine Type Prevalence Among Females,
NHANES
Early vaccine era compared to pre-vaccine era
Markowitz et al. JID 2013;208:385-393HPV Vaccine Type Prevalence Among Females,
NHANES
Later vaccine era compared to pre-vaccine era
Oliver et al. JID. 2017:216(5);594-6032019 Immunization Schedule
www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf
Age at 1st dose of HPV vaccine
• Before 15th Bday: 2 doses
• On or after 15th Bday: 3
doses2020 Immunization Schedule
https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf
Age at 1st dose of HPV vaccine
• Before 15th Bday: 2 doses
• On or after 15th Bday: 3
dosesACIP June 2019: HPV Vaccine
Recommendations
Current Pending
Immunocompromising Approved not published
conditions – 3 doses Males recommendation
Females – 11-26 routine same as females
Males – 11-21 routine, to 11-26 routine
26 clinical decision-making Catch-up for all up to age
Can start as early as 9 years 26
Clinical decision – 27-45HPV vaccine other issues
9-14 years – 2 doses
15 and over – 3 doses
History of sexual abuse – 9 years, routine
Insurance
Vaccines for children covers eligible children
through age 18
Affordable Care Act mandates first dollar
coverage for vaccines
4 valent versus 9 valent vaccine (current)
Either “count”, no recommendation for
additional dosesHow are we doing?
Estimated vaccination coverage, 13-17 years,
NIS-Teen, 2006-2019
2019
90%
87%
72%
54%
Tdap, 3/2006
HPV vaccine
MenACWY, 5/2005
HPV female, 3/2007 HPV male, 5/2010
Elam-Evans LD, Yankey D, Singleton JA, et al. National, Regional,
State, and Selected Local Area Vaccination Coverage Among
2019 - 57% 2019 - 52% Adolescents Aged 13-17 Years - United States, 2019. Mmwr.
2020;69(33):1109-1116.Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration — United States, 2020. MMWR - Morbidity & Mortality Weekly Report. 2020.
Adolescent vaccination rates -
Oklahoma & US, 2019
*PRural urban adolescent vaccination differences
Non-MSA to MSA Central City: NIS Teen 2019
Non-MSA – MSA Central City**
-5.1* -0.5
100%
90% 89% 89% 91% 90% -9.6*
90% 84%
80%
71% 74% -9.8* *PHPV vaccine in Oklahoma 2020
1 dose of Tdap vaccine at 7th grade.
No requirement for MenACWY or HPV vaccine
Exemptions: Personal, religious and medical
Oklahoma State Immunization Information System (OSIIS)
- State-wide immunization registry (2018, 74.3% adolescent participation)
- No direct communication with EMRs
- New registry software Fall 2020
2019 HPV vaccine
≥ 1 Tdap ≥ 1 MenACWY ≥ 1 dose UTD
Oklahoma 88.0% 77.3% 65.6% 41.8%
US 90.2% 88.9% 71.5% 54.2%
Elam-Evans LD, Yankey D, Singleton JA, et al. National, Regional, State, and Selected Local Area Vaccination Coverage
Among Adolescents Aged 13-17 Years - United States, 2019. Mmwr. 2020;69(33):1109-1116.Increasing nationwide trend in kindergarten
NME rates from 2009 to 2017
The asterisk (*) indicates states demonstrating an upward trend
of kindergarteners with NMEs. NME, nonmedical exemption. Olive JK, Hotez PJ, Damania A, Nolan MS. The state of the antivaccine
movement in the United States: A focused examination of nonmedical
exemptions in states and counties. PLoS medicine. 2018;15(6):e1002578.Oklahoma: Kindergarten School Immunization Rates
2019-2020
https://osdh.maps.arcgis.com/apps/View/index.html?appid=01fc983c1890461d9866fb8a7a75bcfbShared decision-making for children
Definition: “both parties share
information…take steps to build
consensus about the preferred
treatment, and [reach an agreement]
on the treatment to implement”
Issues Examples
• Parent making decisions for a child • Breast-feeding
• Medically acceptable alternatives • Supine sleep position
• For vaccines, public health issues • Car seat use
Opel DJ. A Push for Progress With Shared Decision-making in Pediatrics. Pediatrics. 2017;139(2).http://www.immunize.org/letter/recommend_hpv_vaccination.pdf Accessed 12/14/2016
What is a strong recommendation?
◦ Many studies with consistent results across age groups and vaccines
◦ Provider recommendation, strongest or one of the strongest, associations with vaccination
◦ Almost all studies are cross-sectional, parent or patient report of
recommendation
◦ Brewer, et al, 2011 based on surveys 2007 and 2008
◦ Parents who reported a provider recommendation at baseline were more likely to have received
HPV vaccine at follow-up – 51% (46/94) versus 21% (103/473)
Darden PM, Jacobson RM. Impact of a physician recommendation.
Human vaccines & immunotherapeutics. 2014;10(9).Parent-reported provider
recommendation for adolescent vaccines
by year (female)
80
69
70 65
57 59 57
60 55 54
52 51 51
49
Percent
50 48
40 42
39 40
40 37
32
30
20
10
0
2008 2009 2010 2011 2012 2013
MenACWY Tdap HPV vaccine
NIS Teen 2008-2013UTD forUp-to-dates
those withRates
and among
withoutfemales by vaccine
provider recommendation by vaccine
with and without a recommendation
NIS-Teen 2008-2012State – OK and SC
Practices – 9
Parents Parents – 281
Discussion, Recommendation and Receipt
100% 92%
90% 85% 85%
77% 80%
80% 72%
68%
70% 62%
59%
60%
50%
40%
30%
20%
10%
0%
Discussion Recommendation Receipt
MenACWY Tdap HPV vaccineState – OK and SC
Practices – 9
Parents Parents – 281
Recommendation and receipt of vaccine
100% 92% 95%
90%
80%
69%
70%
60% 57%
50%
40%
30% 26%
21%
20%
10%
0%
MenACWY Tdap HPV vaccine
No Recommendation Recommendation
Recommendation versus No recommendation
PWhat is a strong recommendation?
◦ Cross-section of participants in large US managed care plan
◦ 19-26 year old women in 2008
◦ Case-Control design, HPV vaccine recipients (345) and non-recipients (185)
◦ Differential response rate (25% versus 13%)
Rosenthal SL, Weiss TW, Zimet GD, Ma L, Good MB, Vichnin MD. Predictors of HPV vaccine
uptake among women aged 19-26: importance of a physician's recommendation. Vaccine.
2011;29(5):890-895.Summary of Strong Provider
Recommendation
◦ Consistent evidence across multiple settings, age-groups and vaccines that
patient/parent-reported provider/clinician/doctor recommendation for
vaccines is effective in promoting receipt of that vaccine.
◦ There are a few studies that indicate that the patient-reported strength of
the doctor’s recommendation is important in promoting receipt of HPV
vaccine
Strong Provider Recommendation – What do I say?That’s why I’m recommending that your daughter/son receive
the first dose of HPV vaccine today.
Document undated, accessed 2014Your child is due for vaccinations today to help
protect against meningitis, HPV cancers, and pertussis.
We'll give those shots at the end of the visit.
April 2016Now that your son is 11, he is due for vaccinations today to
help protect him from meningitis, HPV cancers, and
pertussis.
December 2016 – Tips and Timesavers https://www.cdc.gov/hpv/hcp/for-hcp-tipsheet-hpv.pdfState – OK and SC
Practices – 11
Providers* Office staff – 71
Providers – 162
Parents – 281
How often do you use a strong recommendation … >90%
100% HPV vac vs Tdap, MenACWY
90% 89%
90% PWhich of these is the
strongest recommendation?
1. The AAP/CDC recommends HPV vaccine (passive)
2. I recommend that your child receive HPV vaccine (directive)
3. The nurse will be in to give you HPV Vaccine (expectant)
4. What do think about getting HPV vaccine? (collaborative)https://www.health.state.mn.us/people/immunize/hcp/hpvvideos.html https://www.youtube.com/watch?time_continue=8&v=vFHjK5L0t- Y&feature=emb_logo Accessed 9/18/2020 Two Silly Examples
MMR vaccine and diseases:
Randomized trial of
communication
Respondents: National random sample (Knowledge Networks) of
parents with a child < 18 surveyed in 2 waves, N=1,759.
1. Health and vaccine attitudes
2. Randomly assigned to intervention
Interventions, first 3 used text from CDC material
1. “Autism correction”, lack of a link of MMR and Autism
2. “Disease risks”, text about symptoms and adverse events of MMR
3. “Disease narrative”, narrative about an infant hospitalized with measles
4. “Disease images”, images of diseases prevented by MMR
5. “Control”, text about costs and benefits of bird feeding
Outcome: Vaccination knowledge (“vaccines cause autism”) and intent
questions (“MMR for next child”).MMR vaccine and diseases:
Randomized trial of
communication
Interventions, first 3 used text from CDC material
1. “Autism correction”, lack of a link of MMR and Autism
2. “Disease risks”, text about symptoms and adverse events of MMR
3. “Disease narrative”, narrative about an infant hospitalized with measles
4. “Disease images”, images of diseases prevented by MMR
5. “Control”, text about costs and benefits of bird feeding
Results
#1 correct knowledge but intent to vaccinate
#3 and 4 correct knowledgeSummary of communication trials
Currently recommended education/communication
➢ Can improve knowledge particularly among those with no concerns
about vaccination
➢ May decrease the intent to vaccinate among those with concerns
about vaccination even while improving knowledgeA randomized trial of communication training: The intervention Brewer NT, Hall ME, Malo TL, Gilkey MB, Quinn B, Lathren C. Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial. Pediatrics. 2016.
A randomized trial of communication training:
HPV vaccine outcomes in 11-12 y/o
3 months 6 months
Pre % Post % Difference Post % Difference
≥ 1 dose
Control 30.0 37.3 6.4 41.2 9.5
Announce 25.5* 38.0 11.5* 42.0 14.9*
Convers 21.3* 30.3 8.4 33.7 11.5
3 doses
Control 8.8 11.5 1.9 13.5 3.6
Announce 6.4* 9.2 2.6 10.7 3.9
Convers 5.6* 7.2 1.5 9.2 3.3
* PMCHB Adolescent Decision Making
Project
Study OverviewState – OK and SC
Practices – 9
Importance of vaccine Office staff – 71
Providers – 162
Parents – 281
… how important does THE OFFICE feel these vaccines are to
the health of preteens and teens? % Very Important
100% 94% 94%
90% 83% 83% 83% 86%
78% 78% 76%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Parents Office staff Providers*
MenACWY Tdap HPV vaccine
*Nurses and cliniciansState – OK and SC
Practices – 11
Office staff Office staff – 71
Providers – 162
Parents – 281
Do parents express concerns to you regarding any of the
following vaccines
70%
60%
58%
50%
40%
30% 27%
22%
20% 16%
10% 4% 6%
0%
Prior to the visit After the visit
MenACWY Tdap HPV vaccineWhat type of recommendation
works?
1-19 month old patients, oversampled vaccine hesitant
◼ “Well, we have to do some shots”
◼ Presumptive
◼ “What do you want to do about shots?”
◼ Participatory
Participatory v. presumptive aOR for resistance:
Opel DJ, Heritage J, Taylor JA, et al.
Pediatrics. Dec 2013;132(6):1037-1046.
17.5 (1.2–253.5)Summary
▪ Involve the whole office, including the front office and nursing
personnel
▪ Initiate the vaccine discussion with a recommendation for receipt
▪ Discuss all of the vaccines due together, do not separate out any
vaccine especially HPV vaccine
▪ Avoid using directive or passive language and use either expectant
or invitational
▪ Today you will receive meningococcal, HPV and tetanus vaccine …
▪ Today would you like to receive …YOUR OFFICE SYSTEMS CAN BOLSTER SERIES COMPLETION
Provider Prompts: QI 13 CORNET (Residency site) Practices Monthly learning collaborative calls with QI experts Monthly data collection (10 charts/month/practice) Focus on integrating resident QI, strong recommendations, consistency in practice change
Proportion of Eligible Teens
1 Receiving HPV Vaccinations
0.9
0.8 0.79
0.7
0.62
0.6
0.5 0.46
0.4 13 %
0.3 Point
0.2 increase!!
0.1 Start of Intervention
0
J F M A M J J A S O N D J F M A M J J AS
2013 2014Get your whole team involved 1. Be sure that everyone who has patient contact gets educated on HPV vaccination. 2. Be sure that each office staff group knows their role in HPV immunization and what they should say. 3. Have everyone encourage questions; interpret as natural caution, not refusal. 4. Systematically arrange for the next dose (schedule before patient leaves)
Standing Orders
Standing orders can be effective
We found impact in some (not all) practices as a
QI program
Not always easy to implement in practices
Require some sort of prompt (or nurse look-up)
Require buy-in by BOTH physicians and nursesThe benefits of being part of an Academic Pediatric
Association HPV QI Learning Collaborative…
• Increase your HPV vaccination rates and decrease your office
missed opportunity rates
• Learn from experts and peers
• Get MOC credit in a meaningful way!
Continuity Clinic sites contact Holly Tyrrell: hollyce@academicpeds.org
Community practices contact Jen Le: jennifer.a.le@med.uvm.edu
The next QI Learning Collaborative
is starting in Fall-Winter of 2018HPV VACCINATION RESOURCES
For More Information
• Shot by Shot
http://shotbyshot.org/story-gallery
• AAP
Info for parents (healthychildren.org)
Info for clinicians (http://www2.aap.org/
immunization/illnesses/hpv/hpv.html)
• Immunization Action Coalition
http://www.immunize.org/
• CHOP Vaccine Education Center
http://vec.chop.edu/
• EZ IZ
http://eziz.org/
• CDCHPV-9 Resource http://www.cdc.gov/vaccines/who/teens/downloads/9vHPV-guidance.pdf
HPV Vaccine Resources in Spanish Resources for Patients cdc.gov/vaccines/who/teens/for-hcp/hpv-resources.html
For more information,
including free resources for yourself
and your patients/clients, visit:
cdc.gov/vaccines/YouAreTheKey
Email questions or comments to
CDC Vaccines for Preteens and Teens:
PreteenVaccines@cdc.govSummary
1. HPV vaccination is important for cancer prevention
but current vaccination rates are low
2. Start vaccinating at ages 11-12; including males
3. Recommend HPV vaccine strongly, normalize it,
involve the whole office
4. Plan to increase your office HPV vaccination rates!
Reduce missed opportunities by using:
Nurse/EMR prompts, standing orders and QI
Try to use reminder-recall
5. Use some great HPV vaccination resourcesAcknowledgement
National Center for Immunization and Respiratory
Diseases, Centers for Disease Control and
Prevention (CDC-RFA-IP14-1405PPHF14). Grant No.
H23IP000950. National Immunization Partnership
with the APA (NIPA). Academic Pediatric Association
(recipient organization). PG Szilagyi (UCLA) and C
Rand (University of Rochester), Co-Principal
Investigators.
96“The Cow Pock – or – the Wonderful Effects of the New Inoculation!” J. Gillray, 1802
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