12/4/18 HPV VACCINATION IN MASSACHUSETTS AND BEYOND VANUCCI DISCLOSURE OBJECTIVES VACCINE BENEFITS VACCINE COMMUNICATION WORLD

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1 HPV VACCINATION IN MASSACHUSETTS AND BEYOND Rebecca Vanucci, MA 6 th Annual HPV-Related Cancer Summit November 30, VANUCCI DISCLOSURE OBJECTIVES I, Rebecca Vanucci, have been asked to disclose any significant relationships with commercial entities that are either providing financial support for this program or whose products or services are mentioned during our presentations. I have no relationships to disclose. I may discuss the use of vaccines in a manner not approved by the U.S. Food and Drug Administration. But in full accordance with ACIP recommendations. Review the Vaccine Communication World and impact on HPV vaccine Discuss HPV vaccination and cancer statistics Highlight initiatives that are going on in Massachusetts as well as the US Encourage incorporation of effective communication strategies to increase HPV vaccination rates 3 4 VACCINE BENEFITS VACCINE COMMUNICATION WORLD 5 6 1

2 VACCINE CONFIDENCE But: The majority of people follow the recommended immunization schedule! Percentage of US toddlers with no vaccines has almost tripled since 2003 There s a lot more time spent on vaccine conversations with healthcare providers Generally the two most frequently questioned vaccines HPV and Flu 7 8 IMMUNIZATION A COMPLEX COMMUNICATION ENVIRONMENT Low disease awareness = increased focus on vaccine risks Time is often limited Low tolerance for vaccine risks Many places to find and get information Full and complicated immunization schedule WE NEED MORE HOW There has been a lot of research on parents knowledge, attitudes, beliefs Little research on what communication techniques actually change parents behavior We ve been focused more on the what more than the how 1 Brunson EK. The impact of social networks on parents' vaccination decisions. Pediatrics. 2013;131(5):e Smith PJ, Kennedy AM, Wooten K, Gust DA, Pickering LK. Association between health care providers' influence on parents who have concerns about vaccine safety and vaccination coverage. Pediatrics. 2006;118(5):e OUR COMMUNICATION ASSUMPTIONS MAY BE WRONG Improved knowledge Better decisions Known as the Information Deficit Model If only she just understood the facts, she d realize she s making the wrong choice. Humans are rationale? HPV STATISTICS Vaccination decisions are often based on emotion, not logic, reason, or facts

3 Females: routine EVOLUTION OF RECOMMENDATIONS FOR HPV VACCINATION IN THE UNITED STATES Bivalent Females: routine Males: may be given Males: routine Bivalent 9-valent Females 9-valent Males 2-dose schedule June October October February October CANCERS ATTRIBUTABLE HPV PER YEAR, U.S., Cancer site Percentage of HPV cancers attributable to HPV Number of HPV cancers attributable to HPV Female Male Both Sexes Cervix 91% 10, ,751 Vagina 75% Vulva 69% 2, ,707 Penis 63% Anus* 91% 4,008 1,949 5,957 Oropharynx 70% 2,160 10,725 12,885 TOTAL 20,260 13,477 33,737 *Includes anal and rectal squamous cell carcinomas CDC, National Program of Cancer Registries and the NCI Surveillance, Epidemiology and End Results Program, and Saraiya M et al. J Natl Cancer Inst. 2015;107:djv086 Note on terminology: An HPV-associated cancer is a specific cellular type of cancer that is diagnosed in a part of the body where HPV is often found. An HPVattributable cancer is a cancer that is probably caused by HPV. 14 HPV CANCER INCIDENCE MASSACHUSETTS AND US Change of HPV-Associated Cancer Incidence Rate, Annual Percent, Massachusetts, ADOLESCENT VACCINATION COVERAGE WITH TDAP, MENACWY, AND HPV, MASSACHUSETTS, NIS, YEARS, % Vaccination Coverage 100% 90% 80% 70% 60% 50% 40% 30% 96% (-1) 94% (+4) 85% (+7) 79% (+13) 67% (+5) 64% (+13) Tdap MenACWY 1 HPV - Females HPV UTD - Females* 1 HPV - Males 20% HPV UTD - Males* 15 Numbers in parentheses indicate a change from the previous year Year *HPV Up to date (UTD): 2 doses if the first dose given before the 15 th birthday and doses were separated by at least 5 months, otherwise, 3 doses NIS, CDC 16 ADOLESCENT VACCINATION COVERAGE WITH HPV, NIS, YEARS OF AGE, MA VS US, 2016 VS 2017 SO WHAT S WORKING? MA US Females Males Females Males HPV 78% 85% 66% 79% 65% 69% 56% 63% HPV UTD* 62% 67% 51% 64% 50% 53% 38% 44% HPV-UTD 2 doses if the first dose was given before the 15th birthday and doses were separated by five months, otherwise, 3 doses 2 DOSE SCHEDULE UPDATED HEDIS MEASURES ROBUST COLLABORATION Statistically significant improvement from the previous year NIS Data, CDC

4 HPV INITIATIVES IN MASSACHUSETTS AND US HEALTHCARE PROVIDER EDUCATION IN MASSACHUSETTS MASSACHUSETTS HPV DENTAL PROJECT Primary Care Providers School Nurses Local Public Health MCAAP Immunization Initiative AFIX program DPH conferences School Nurse Trainings American Cancer Society campaign MAPHN Public Health HPV Clinic HPV CANCER RATES RISING ~33,700 A YEAR OROPHARYNGEAL CANCER NOW SURPASSED CERVICAL CANCER AS MOST COMMON NO SCREENING FOR OROPHARYNGEAL CANCER DENTAL PROVIDERS AS ADVOCATES HPV VACCINATION CAN PREVENT ~31,000 OF THOSE CANCERS Advocacy Organizations MA Chapter of AAP Connect Dental world Cancer partners Dept. of Public Health Comp. Cancer Dental Professionals Meet Conference calls In-person Dept. of Public Health Immunization Program Oral HPV Prevention Taskforce Widow/ Advocate Collaborate Presentations Projects

5 NATIONAL INITIATIVES C O M M U N I C AT I O N S T R AT E G I E S immunizationforwomen.org/ 25 toolkit/hpv 26 TOP 5 REASONS FOR NOT VACCINATING ADOLESCENTS WITH HPV VACCINE (NATIONAL IMMUNIZATION SURVEY-TEEN, US, 2013) CDC GRAPHIC MAKE AN EFFECTIVE RECOMMENDATION WHEN SHOULD THE BIKE HELMET GO ON? Same way: Recommend HPV vaccination the same way you recommend Tdap & meningococcal vaccines. Same day: Recommend HPV vaccine today Recommend HPV vaccination the same day you recommend Tdap & meningococcal vaccines. A B Your child needs 3 vaccines today- Tdap, HPV and meningococcal C Unpublished CDC data,

6 IMPACT OF RECOMMENDATION QUALITY Vaccine initiation rates: 20%-30% if no recommendation given or presented as optional 50% if low-quality recommendation 70-90% if a high-quality recommendation given Recommend same way, same day 31 OPTIONAL VERSUS HIGH QUALITY RECOMMENDATION Optional: Have you thought about what shots you d like to get today? May unintentionally imply shot is not important or few people do it 20-30% vaccination rate in studies of both childhood and adolescent vaccines High quality: We have some shots to do today Implies shot is important and most people get it 70-90% vaccination rate in studies of both childhood and adolescent vaccines If a parent hesitates, say Our team is so dedicated to cancer prevention -- I m sure the nurse (or doctor) will want to respond to your concerns. Opel Pediatrics 2013, Brewer Pediatrics 2016, Gilkey, et al., HOW TO HANDLE RESISTANCE: STEP 1 ASK PARENTS TO SHARE THEIR CONCERNS Example: So you seem to have concerns about the HPV vaccine. Well, that s perfectly understandable I ve had a number of questions about this one. Would you mind please sharing what your particular concerns are? (Note: non-threatening) Well, I ve heard that it s a vaccine to prevent a disease that s transmitted by having sex, and she is a loooong way from having sex. HOW TO HANDLE RESISTANCE: STEP 2 REFLECT, SUMMARIZE, ASK, ADVISE Reflect back what the parent is saying to be sure you understand (showing empathy) Then summarize what has been heard before proceeding, again with permission, to make a recommendation For Example: So I hear that you re concerned that she s too young for the HPV vaccine because HPV is transmitted by sexual activity. Well, I completely get that she is only 11 after all. I ve thought a lot about this. Is it okay if I go over how I ve come to think about this vaccine? HOW TO HANDLE RESISTANCE: STEP 3 THE CRUCIAL STEP Example: What NOT to say: Well, data shows that many adolescents will be having sex by middle school, and if you re worried about her having sex, studies have shown that it won t increase the likelihood of her having sex. Avoid using statistics like a battering ram in an emotional discussion Example: HOW TO HANDLE RESISTANCE: STEP 3 THE CRUCIAL STEP What to say: I used to think of this vaccine as something to prevent a sexually transmitted disease, but realized it s really about preventing cancer. Almost everyone gets this virus, so I think it s important for every adolescent to receive before they re exposed to it. Instead of arguing, move the conversation back to what s really important: cancer prevention

7 Example: HOW TO HANDLE RESISTANCE: STEP 4 MAKE A PERSONALIZED RECOMMENDATION If she were my daughter I would not hesitate to recommend this vaccine for her and most of my patients are getting the vaccine. Having said that, this is a decision that only you and your daughter can make. What do you think? MOTIVATIONAL INTERVIEWING A way of being with the client, not just a set of counseling techniques* helps to resolve ambivalence Provider becomes a helper in the change process Works to strengthen a person s intrinsic motivation for a behavior More about the words you use than the underlying goal 37 *Miller and Rollnick, MOTIVATIONAL INTERVIEWING (MI) MI TECHNIQUES RULER MI Techniques Your next patient is a 12 year old boy who you haven t seen in a few years, in for a well visit and to get some forms signed You finish the visit and offer a presumptive recommendation for the HPV vaccine Not so fast His mother seems a little uncomfortable. Um, well, I d rather not do that HPV vaccine. I ve heard some bad things about it. You are a little surprised, since you ve known this family for many years, and this child has received all of his recommended vaccines to now. To find out more you say, Example I see. So on a scale of 1 to 10, with 1 never getting the vaccine and 10 definitely getting it today, where are you at? (ruler) About a 3 OK can you tell me more about why you are a 3 instead of a 1? TECHNIQUE OPEN ENDED QUESTIONS Well, I definitely don t want my son to ever have cancer, so I m open to the idea of the vaccine, but I m just scared it s not safe Example: Would you mind telling me what safety issues you are worried about? (openended question) Well, I ve heard that this is really just a vaccine for girls and that some children that get the shot can die from it. I know it s probably not true, but it just makes me worry. 41 TECHNIQUES AFFIRMATION AND PERMISSION You reflect back the concern to be sure you understand and summarize what has been heard before proceeding, again with permission, to make a recommendation. Example: Well, I can see why that information would scare you that would scare me too! (affirmation) This question of dying from the vaccine has come up for me before from other patients, and I ve looked into where it came from. Would you mind if I went over what I found out, and why I think this is such an important vaccine? (permission) 42 7

8 TECHNIQUES After getting permission, proceed with your response. Examples: To address you specific concern, it turns out people started rumors about this vaccine on the Internet, and those rumors spread. There is no truth to them. In fact, this is one of the safest vaccines we have, and it s been very well studied. This vaccine prevents several types of cancer in both men and women, including oropharyngeal cancer which is now the most common HPV-related cancer and affects men more than women. The vaccine works really well to protect against 6 different types of cancer. I ve given it to my own children, and I think it s a really important vaccine. That said, this is a decision only you can make. (autonomy) 43 1 Treat HPV vaccine like every other vaccine recommendation COMMUNICATION SUMMARY 2 Bring the conversation to cancer prevention 3 Remember that both boys and girls need the vaccine 4 Give a strong, personalized recommendation 44 HPV VACCINE MAIN MESSAGES HPV cancers are rising HPV vaccine is safe, effective, and longlasting We need to increase HPV rates to decrease HPVassociated cancer Oropharyngeal cancer now surpassed cervical cancer as most common 6 different types of HPV-associated cancers Over 100 million doses distributed in US Infections with HPV types that cause most HPV cancers and genital warts have dropped 71% in teenage girls The 9vHPV vaccine has the potential to prevent 92% of HPV-attributable cancers, which equals 31,000 cancer cases! 45 WE CAN INCREASE HPV VACCINATION RATES TO DECREASE HPV CANCERS! 46 REBECCA VANUCCI RLVANUCCI@GMAIL.COM 47 8