AAP Initiative to Improve HPV Vaccine Uptake Results from NHMS & NHPS Survey December 9-10, 2013

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1 AAP Initiative to Improve HPV Vaccine Uptake Results from NHMS & NHPS Survey December 9-10, 2013 David C Fredenburg MD AAP Liaison for the NHPS on Immunizations

2 Estimated vaccination coverage with selected vaccines and doses among adolescents aged years, by survey year National Immunization Survey Teen, United States, ov/mmwr/previe w/mmwrhtml/m m6234a1.htm

3 HPV Vaccine in NH Teens (13-17) Courtesy of Everett Lamm, MD > 2 doses HPV > 1 HPV > 3 doses HPV series complete males 2012 * Series complete: Percent of females and males who received 3 doses among those who had at least 1 HPV dose and at least 24 weeks between the first dose and the interview date. National Immunization Survey 2013, (Teen, years) United States, NH results.

4 HPV Vaccine in NH Teens (13-17) Courtesy of Everett Lamm, MD > 1 HPV > 2 doses HPV > 3 doses HPV series complete 2010 Female 2011 Female 2012 Female * Series complete: Percent of females and males who received 3 doses among those who had at least 1 HPV dose and at least 24 weeks between the first dose and the interview date Male National Immunization Survey 2013, (Teen, years) United States, NH results.

5 NHPS & NHMS HPV Grant Survey December 9-10, 2013 Please indicate which of the following best describes your practice: Pediatric Fam Pract OB/GYN Other 136

6 Approximately how many prescribing clinicians see patients at your site? >10 Urban Suburban Rural Which of the following best describes your practice location?

7 Do the clinicians or other staff at your site routinely recommend the HPV vaccine for female or male adolescents at years of age? % (202) 86.0% (185) % (15) 14.0% (30) Yes No 0 Female Male

8 Do the clinicians or other staff at your site routinely recommend the HPV vaccine for female adolescents at years of age? If no, why not? do not see patient of that age group We don't see this age group The prison is for men, though we do have a few "They feel that it is a parents personal choice female inmates within the walls. and that the parents should hae the option of we do it at 14, 9th grade having these kinds of discussions with their Our adolescent population usually enters our child first. program at age 14 and over. On the parents side they seem very reluctant parents sometimes decline at the earlier ages stating"" we don't need to deal with that yet"" presumingly meaning that I did when still seeing out patients they don't need to consider it as the child is not sure, time factor not sexually active yet" I do not know about my partners Active population is age 14 and older Not our age group patients. physicians decided as a group what age group Not seeing patients in this age group here they wanted to start Not sure The providers feel that the age is too young. Parents more receptive when girls are older We begin at age 13 around 14 or 15 when they may become Sometimes at but more commonly sexually active and we are OK with this offered around 13 because our population is not active at such a I believe most offer at this time but young age. Also they are getting recommendations are stronger in teen years ~ menactra/menveo around this age plus flu vaccine or hep A and the kids themselves want Not at 11 as we are giving 2-3 other vaccines to space the imms out. then. We do start at 12 yrs usually. Most of the patients that we see have PCP office and receive that vaccine from them.

9 Do the clinicians and office staff at your site routinely recommend the HPV vaccine for male adolescents at years of age? If no, why not? NA I do, but my partner does not. I do, but do not know if my partners do. slow uptake of evidence They are not seen here prior to age 18 usually do it later age 14 The adolescents enter our program at age 14 and older. same This may have changed by now Not yet but we should not all feel it is that easy to convince the parents. Same as for females starting to difficult subject on STD prevention in this age group. for girls, its more about cancer prevention and easier I believe this is simply because it has not entered people's consciousness in the same way as for females usually, there may be some incosistency when it comes to boys Females only. slow to adopt new recommendations same We do recommend and show them the information when a child comes in for a PE at that age (Physical Exam) and let them decide. There are patients that do not want the vaccine and they are quite clear about the reasons. just not consistenly not sure, actually It is increasing but not something that is as remembered as the females. same answer as for girls Do not see male patients. Followed by outside PCP We don't see this age group. forget to Do not see patients of this age the physicians decided as a group what age group they wanted to start again they feel the age is too young Most do, but some to not promote it as much as I think they should None of them want it that early... better accepted later at see last comment

10 Are parents and adolescents knowledgeable about diseases associated with HPV and vaccination before the year physical exam? Yes No I do not know Other If you know, please explain. How have they learned this information? Sources cited media, internet, commercials, older siblings, general knowledge 18 out of 41 (43.9%) of responses mentioned medical office as source of HPV info

11 With which of the following HPV-related diseases are they (parents/patients) familiar? 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% Total Peds FP OB Other 10.0% 0.0% Cervical CA Rectal CA ENT CA RRP Genital Warts

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13 HPV Cervical Dysplasias & Cancer HPV types 16 and 18 - high-risk types of HPV; most high-grade intraepithelial lesions that may progress to carcinomas HPV infection & implicated cofactors o Tobacco use o Ultraviolet radiation o Pregnancy o Folate deficiency o Immune suppression PAP smear (recommendations) o Initial Pap test 21 years; then every 2 years thereafter if initially normal o Interval becomes every 3 years > 30 years at low risk and 3 consecutive Pap tests normal o Pap smears should contain cells from the ectocervix, the transformation zone, and the endocervical canal o Liquid-based Pap smears improve the diagnostic sensitivity of cervical cytology screening & enable easy testing for human papillomavirus Cervical metaplasia is prevalent among sexually active adolescents with increased risk for HPV infection, immune system clearance within 1-2 years is common

14 HPV Disease Burden Anogenital HPV is the most common sexually transmitted infection in the US ~ 20 million currently infected 6.2 million new infections/year Common in adolescents and young adults HPV types 6 and 11 (and others) Estimated 80% of sexually active women will have been infected by age 50 Infection also common in men

15 Oropharyngeal Squamous Cell Carcinoma SCC - 95% of laryngeal cancer ~11,000 new cases diagnosed in US annually Risk Factors Chronic HPV RR~230 Tobacco & alcohol RR>100 Tobacco abuse RR~14-35 Excess ETOH use RR~16 Infrequent F/V RR~2.7 du/content.aspx?bookid=685&sectionid=

16 Recurrent Respiratory Papillomatosis RRP is the most common benign neoplasm of the larynx among children HPV 6, 11 & 16 implicated Incidence 4.3 per 100,000 children 1.8 per 100,000 adults Triad of risk factors for juvenile onset Firstborn child Teenage mother Vaginal delivery risk of contracting RRP after delivery from infected mother is %, C-section does not uniformly prevent RRP

17 Lack of knowledge of HPV-associated diseases Lack of parental acceptance Lack of patient acceptance Refusal of vaccination altogether Pain of vaccination Series of 3 shots Fear of side effects Limited exposure to disease Sexual activity issues associated with HPV exposure Perceived sexual activity changes with HPV vaccination Cost concerns regarding vaccination Prefer to defer until older What issues are the most difficult in parental or adolescent acceptance of vaccination (at any age)? 70.0% 62.6% 60.0% 50.0% 47.9% 54.0% 40.0% 30.0% 33.6% 31.8% 34.1% 20.0% 10.0% 0.0% 7.6% 19.4% 11.8% 12.3% 13.3% 1.9%

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20 HPV Vaccine & that Sexual Activity Thing? HPV vaccination in the recommended ages was not associated with increased sexual activity related outcome rates. R.A. Bednarczyk et al. Sexual activity related outcomes after human papillomavirus vaccination of 11- to 12-year-olds. Pediatrics, 130 (2012): These data suggest that sexual behaviors were not altered because of the vaccine. T. Cummings et al. Reduction of HPV infections through vaccination among atrisk urban adolescents. Vaccine, 30 (2012): No association was found between HPV vaccination and risky sexual behavior. N.C. Liddon et al. Human papillomavirus vaccine and sexual behavior among adolescent and young women.am. J. Prev. Med., 42 (2012): 44 52

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23 A few questions on HPV to consider: Does just say No work for sex (including outercourse ) as it does for drugs regardless of age? Do you routinely recommend delaying vaccination for rotovirus, DTaP, HIB, Pneumococcal and/or MMR until the child is actively & undeniably at risk for exposure? How many vaccines in your office are you not sure what recommendation your office mates are making? Are the preadolescents/adolescents/parents truly informed about HPV related disease? Are they getting their information from the best possible source to decide (i.e. informed consent) on HPV vaccine? Honestly, could a vaccine be marketed as an aphrodisiac?

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