De-Sexualizing the HPV Vaccine How to Counsel Your Families

Transcription

1 De-Sexualizing the HPV Vaccine How to Counsel Your Families Laura J. Benjamins, MD, MPH Assistant Professor, Adolescent Medicine The University of Texas Medical School, Houston

2 Objectives Understand current trends in vaccination rates Review barriers to improving rates Review common myths and concerns that parents have about the HPV vaccine Review the the facts behind these myths Discuss ways to counsel families on the HPV vaccine and recommendations for advocacy

3 HPV Vaccine History 2006: The Quadrivalent Human Papillomavirus (Types 6, 11, 16, 18) recombinant vaccine (HPV4) was licensed for use in females by the Food and Drug Administration 2009: A bivalent vaccine (Types 16 & 18) (HPV2) was approved for use in females 2009: HPV4 was also licensed for the prevention of warts in males 2010: HPV4 was licensed for the prevention of anal cancers in both males and females

4 How are we doing? 2007: Females who had received at least one dose of the HPV vaccine was 25% 2008: Females aged 13 to 15, 17% percent had received at least 3 doses of the HPV vaccine Healthy People 2020 Goal: Increase to 80% 2011: Females who had received at least one dose of the HPV vaccine was 53%; All 3 doses 34%; Males at least one dose 8% 2012: Females who had received at least one dose of the HPV vaccine was 54%; All 3 doses 33%; Males at least one dose 21% CDC National Immunization Survey Teen (NIS-Teen)

5 Comparison Tdap (2005) 2008: 46.7 percent of adolescents aged 13 to 15 years had received at least 1 dose : 85% MCV (2005) 2008: 43.9 percent of adolescents aged 13 to 15 years had received at least 1 dose : 74%

6 Human Papillomavirus Vaccination Coverage among Adolescent Girls and Post-Licensure Vaccine Safety Monitoring United States,

7 One other comparison HPV related diseases (CDC & ACS) 6 to 14 million new infections each year In 2012 there were 12,170 new cases of cervical cancer and 4220 deaths In 2012 there were 40,250 new cases of oropharyngeal cancer and 7850 deaths Other vaccine preventable diseases (CDC) There were 845 cases of meningococcal disease reported in the U.S. in 2011 There were 3374 cases of acute hepatitis B in the U.S. in 2010 and 1792 deaths (80-90% vaccine coverage of all three doses)

8 Why aren t we doing better?

9 Reasons I Have Heard My daughter is not sexually active yet. I don t want my child to think that sex is o.k. My doctor did not recommend it. It is not required by school, so I didn t think he needed it. I have had an abnormal PAP smear and was told that I can t get it. I don t think it is safe. I think it is a government conspiracy. I just don t want my child to get it.

10 Reasons for Poor Uptake Healthcare Providers (HCP) Healthcare providers report acceptance, but often feel uncomfortable giving to younger patients (three studies nurse practitioners, OB/GYN and Family Medicine) 1,2, National survey published in PEDIATRICS found that only half of the pediatricians surveyed anticipated giving the HPV vaccine to their patients ages 10 to survey physicians who always recommend the HPV vaccine to 11 and 12 year old patients: 47% pediatricians; 34% family physicians; 36% OB/GYNs 5 HCP recommendation plays a crucial role in patients decisions to receive the HPV vaccine, and lack of recommendation is a major reason for non-vaccination 6 1. Mays RM, Zimet GD. Recommending STI vaccination to parents of adolescents: the attitudes of nurse practitioners. Sex Transm Dis. 2004;31: Raley JC, Followwill KA, Zimet GD, Ault KA. Gynecologists attitudes regarding HPV vaccination. Infect Dis Obstet Gynecol 2004;12: Riedesel JM, Rosenthal SL, Zimet GD, et al. Attitudes about HPVvaccine among family physicians. J Pediatr Adolesc Gynecol 2005; 18(6): Daley MF, Liddon N, Crane LA, et al. A national survey of pediatrician knowledge and attitudes regarding HPV vaccination. Pediatrics 2006; 118: Vadaparampil ST, Kahn JA, Salmon D, et al. Missed Clinical Opportunities: provider recommendations for HPV vaccination. Vaccine 2011; 29: Zime GD, Roseberger Z, Fisher WA, et al. Beliefs, behaviors and HPV vaccine. Preventive Medicine 2013; in press.

11 Reasons for Poor Uptake Parents (CDC NIS-Teen) Belief that vaccine is not needed Vaccine is not recommended Lack of knowledge about the vaccine or the disease Safety concerns Teen is not sexually active, too young Patients Apprehension of pain Limited communication from the clinic Lack of information about cervical cancer, HPV and the vaccine

12 HPV Epidemiology Lifetime prevalence is close to 80% 20 million Americans are positive for anogenital HPV at any given time = 15% of the population (excluding children) About 9.2 million are between the ages of 15 & 24 HPV 16 & 18 cause approximately 70% of cervical cancer HPV has also been found to be a causative agent in cancers of the oropharynx, anus, vagina, vulva and penis

13 HPV Transmission We know the vaccine works best when all three doses are given prior to sexual debut Other things to consider Studies have found that 6-15% of virgins test positive for HPV HPV has been found under fingernails, in saliva and breast milk Some evidence for vertical and horizontal transmission (significance is unknown) High risk of acquisition, even after just one partner

14 Cumulative incidence of any genital HPV infection associated with a first sex partner. Winer R L et al. J Infect Dis. 2008;197: by the Infectious Diseases Society of America

15 Vaccine Safety Vaccine Adverse Event Reporting System (VAERS) 2009, a CDC-FDA report analyzed adverse events reported to VAERS following Gardasil vaccination from June 2006 through December 2008 The findings were similar to what is seen in the safety reviews of other vaccines recommended for a similar age group, 9 to 26 years old. The most common adverse events reported were: Syncope - common after receiving shots, especially in pre-teens and teens Local reactions at the site of immunization (pain and redness Dizziness Nausea Headache

16 Vaccine Safety Post-licensure safety monitoring from June 2006 through March 2012 continues to show no new HPV vaccine safety concerns. Vaccine Safety Datalink (VSD) In 2011, VSD active surveillance (called Rapid Cycle Analysis) looked at specific adverse events following more than 600,000 doses of Gardasil Looked at: GBS, stroke, VTE, appendicitis, seizures, syncope, allergic reactions, and anaphylaxis No statistically significant increased risk for any of these adverse events was detected after vaccination

17 Number of Serious and Nonserious adverse events after administration of quadrivalent HPV vaccine in females, by year Vaccine Adverse Reporting System, United States, June ; CDC

18 HPV Vaccine & Initiation of Sex Since 2006 the number of teens reporting that they have ever had sex has NOT increased 1 National probability sample of 1243 women ages 15 24; those who were given the HPV vaccine were NOT more likely to be sexually active or have more sex partners 2 A study of over 1300 girls found that girls who received the vaccine at ages 11 to 12 were NOT more likely to have sexual activity-related medical conditions 3 1. CDC - YRBS Liddon NC, Leichliter JS, Markowitz LE: HPV vaccine and sexual behavior among adolescent and young women. Am J Prev Med 2012: 42:44 3. Bednarczyk RA, Davis R, Ault K, et al: Sexual activity-related outcomes after HPV vaccination of 11 to 12-year-olds. Pediatrics 2012; 130:798

19 What can we do?

20 Educating HCP Importance of endorsement by professional organizations (AAP, ACOG, AANP, AAFP, ASCCP, etc.) Web-based resources Be familiar with credible websites Continuing education Peer and provider feedback to influence behavior Quality Improvement

21 Educating Parents Advocate for more accurate vaccine information and evidence-based media coverage Compare to other childhood vaccines (e.g. HBV) Provide fact-based information Efficacy Safety HPV Prevalence Reasoning behind recommended schedule

22 Educating Patients School-based efforts Social media Educational videos Acknowledge apprehension Consider methods for reducing pain (e.g. topical anesthetics, distraction, etc.) Empower adolescents and young adults to be active in health decisions

23 What can we do?

24 Strong Messages The HPV vaccine prevents cancer Just like other vaccines, we are vaccinating your child today BEFORE they are exposed HPV is so common, nearly everyone will be infected at some point I strongly believe in the importance of this cancerpreventing vaccine This vaccine has been shown to be extremely effective for both boys and girls This vaccine is just as safe as other vaccines we routinely give

25 Patient reminders Phone calls by staff Auto-dialers Reminder cards by mail Text messages Patient portals Office Tips Provider prompts or standing orders Include all recommended vaccines at every visit

26 Discussions with Parents - Identify and Discuss Concerns Identify parental concerns What are your concerns about the vaccine? Motivational interviewing Tell me what you know about the HPV vaccine? What are the bad things about giving the vaccine? What are the good things? Acknowledge parental concerns I understand your concerns Provide information to directly address concerns What information would you like?

27 More Research is Needed Effective strategies for Increasing HCP administration and advocacy Increasing parental knowledge and acceptance Increasing patient s understanding of the disease and why immunization is important

28 Resources

29 Questions?