Improving HPV Vaccine Coverage Why We Must and How We Can Do Better

National Center for Immunization & Respiratory Diseases Improving HPV Vaccine Coverage Why We Must and How We Can Do Better Melinda Wharton, MD, MPH Director, Immunization Services Division Illinois State HPV Roundtable Chicago, Illinois November 15, 2018

number of cases per year Estimated annual numbers of HPV-associated cancers attributable to HPV 16/18 and 5 additional types in 9-valent vaccine, Illinois, 2010-2014 450 400 350 300 250 200 150 100 50 0 females males HPV 16/18 5 additional types Proportions of attributable cancers from Viens et al, http://www.cdc.gov/mmwr/volumes/65/wr/mm6526a1.htm 2010-2014 data from https://www.cdc.gov/cancer/hpv/pdf/uscs-databrief-no2-march2018-508.pdf

Percent Vaccinated Estimated Vaccination Coverage among Adolescents Aged 13-17 Years, NIS-Teen, United States, 2006-2016 100 New APD definition * 90 80 70 60 50 1 Tdap 1 MenACWY 2 MenACWY 40 1 HPV vaccine (females) 30 3 HPV vaccine (females) 20 1 HPV vaccine (males) 10 3 HPV vaccine (males) 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 * APD = Adequate provider data 2 doses MenACWY among adolescents aged 17 years Survey Year

Trends in Vaccination Coverage among Adolescents Aged 13-17 Years, NIS-Teen, United States, 2006-2017

Estimated vaccination coverage among adolescents 13-17 years of age National Immunization Survey-Teen, United States and Illinois, 2017 United States Illinois Females 1 HPV 68.6% (66.9-70.2%) 62.3% (55.4-68.8%) HPV UTD 53.1% (51.2-55.0%) 48.9% (42.2-55.6%) Males 1 HPV 62.6% (60.9-64.2%) 69.6% (63.6-75.0%) HPV UTD 44.3% (42.6-46.0%) 51.8% (45.6-58.1%) All adolescents 1 HPV 65.5% (64.3-66.7%) 66.1% (61.5-70.4%) HPV UTD 48.6% (47.3-49.9%) 50.4% (45.8-55.0%) 1 Tdap 88.7% (87.8-89.6%) 92.4% (89.4-94.6%) 1 MenACWY 85.1% (84.2-86.1%) 89.2% (85.9-91.8%) UTD: up to date. HPV UTD includes those with 3 doses, and those with 2 doses when the first HPV vaccine dose was initiated before age 15 years and time between the first and second dose was at least 5 months minus 4 days.

Why Is HPV Vaccine Coverage So Low? Parents Parents are not offered vaccination Parents perceive vaccine as optional or unnecessary at that time Parents perceive that their providers discouraged vaccination Parents want information about vaccine safety Parents do not understand the reason to vaccinate at 11 to 12 years of age Providers Providers are reluctant to give multiple shots at one visit Providers introduce HPV vaccination at age 11 years but do not recommend it strongly Providers recommend vaccination based on their estimation of sexual activity Providers have limited experience with HPV and underestimate risk Providers perceive HPV as more emotionally charged than other vaccines Delaying vaccination leads to nonvaccination Both providers and parents know they are often unaware of the timing of sexual debut. Perkins RB et al. Pediatrics 2014;134:e666-e674

Reasons for Not Vaccinating Adolescents with HPV Vaccine, Unvaccinated Adolescents* Aged 13-17 Years, NIS-Teen, United States, 2017 Parents of Girls Safety concerns/ side effects 24.5 (21.6-27.8) Parents of Boys % (95% CI) % (95% CI) Safety concerns/ side effects 16.8 (14.5-19.4) Not needed/necessary Not recommended Lack of knowledge Not sexually active 14.5 (11.8-17.8) 7.6 (5.9-9.7) 7.5 (5.7-9.6) 7.3 (5.7-9.4) Not recommended 15.2 (12.6-18.2) Not needed/necessary 14.2 (12.0-16.7) Lack of knowledge 9.2 (7.3-11.5) Not sexually active 7.7 (5.7-10.2)

Physicians Perceptions of Adolescent Vaccine Endorsement for Patients Ages 11-12, 2014 100 Proportion endorsing highly (physicians) and physicians estimate of parents 90 80 70 60 50 40 30 20 10 0 Tdap Meningococcal HPV Physicians themselves Parents Gilkey MB et al, Preventive Medicine 2015;77:181-185

Median Values Parent opinions on the importance of vaccines and provider estimates of parental responses 10 9 8 7 6 5 4 3 2 1 0 Parent Provider's estimate 9.4 9.2 9.5 9.2 9.5 9.3 9.3 9.3 9.2 Meningitis Hepatitis Pertussis Influenza HPV Adolescent vaccines 7.0 5.2 7.8 Adapted from Healy et al. Vaccine. 2014;32:579-584.

Why don t adolescents finish the HPV vaccine series? Reasons given by parents for incomplete vaccination (%) Conscious decision 11% Provider expectations for vaccine completion (%) Opportunistic 7% Inconvenience 24% Expect clinic reminder 65% Schedule second dose at time of 1st dose 41% Expect parent to schedule appointment 52% Perkins RB et al. Human Vaccines and Immunotherapeutics, 2016

What can we do about it?

What can healthcare providers do? Make an effective recommendation for HPV vaccination as cancer prevention for every 11- or 12-year-old patient Assess HPV vaccine coverage for each provider in your practice and develop an office-wide strategy to improve it Engage the entire practice not just the healthcare providers in committing to improve HPV vaccine coverage Implement systems strategies to improve HPV vaccine coverage

Now that Sophia is 11, she is due for vaccinations today to help protect her from meningitis, HPV cancers, and pertussis.

What can healthcare providers do? Make an effective recommendation for HPV vaccination as cancer prevention for every 11- or 12-year-old patient Assess HPV vaccine coverage for each provider in your practice and develop an office-wide strategy to improve it Engage the entire practice not just the healthcare providers in committing to improve HPV vaccine coverage Implement systems strategies to improve HPV vaccine coverage

What can healthcare providers do? Make an effective recommendation for HPV vaccination as cancer prevention for every 11- or 12-year-old patient Assess HPV vaccine coverage for each provider in your practice and develop an office-wide strategy to improve it Engage the entire practice not just the healthcare providers in committing to improve HPV vaccine coverage Implement systems strategies to improve HPV vaccine coverage

Systems Strategies to Improve HPV Vaccine Coverage Establish standing orders for HPV vaccination beginning at age 11-12 years in your practice Conduct reminder/recall beginning at 11-12 years of age Assess HPV vaccine coverage at every visit and prompt clinical staff to give HPV vaccine at that visit Schedule return visit for next dose before the patient leaves the office Document each dose in the child s medical record and the state s immunization information system

Tactics for Successful HPV Vaccine Delivery, Denver Health Routine use of a robust immunization registry for multiple functions, including recording vaccine history and recommended needed vaccines at every visit Medical assistants check vaccine registry for recommended vaccines at every visit Standing order for routine immunizations Vaccines are given early in the visit when possible Education for providers to present Tdap, MCV, and HPV as a standard bundle of adolescent immunizations Provider-level report cards with adolescent vaccination coverage rates Vaccination drives at school-based health centers Farmer et al, Pediatrics 2016

Immunization Rates for Adolescents Denver Health, 2004-2014 Farmer et al, Pediatrics 2016

HPV VACCINATION FOR CANCER PREVENTION: Progress, Opportunities, and a Renewed Call to Action A Report to the President of the United States from the Chair of the President s Cancer Panel November 2018 Stakeholder resources: key report findings and graphics

Partnerships and Collaborations are Essential The coalescence of a critical mass of dedicated stakeholders has created momentum and opportunity to achieve the goals outlines in this report. Stakeholder collaborations and partnerships should continue in implementing proven strategies to increase vaccination rates among all populations to target levels.

Thank you For more information, contact CDC 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 www.cdc.gov www.cdc.gov/vaccines www.cdc.gov/hpv www.cdc.gov/vaccinesafety The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Timeline of ACIP s Recommendations for HPV Vaccination June 2006: ACIP recommended HPV4 as a 3 dose series for females at age 11-12 years, with catch up for those 13-26 years who were not previously vaccinated. HPV4 can be given as young as age 9 years. October 2009: ACIP updated recommendations to include HPV2 for use in females and provided guidance that HPV4 could be used in males October 2011: ACIP recommended HPV4 as a 3 dose series for males at age 11-12 years, with catch up for those 13-21 years who were not previously vaccinated. HPV4 can be given to males 9-26 years of age. February 2015: ACIP updated recommendations to include HPV9 as a 3 dose series for use in both males and females. October 2016: ACIP recommended 2 doses of HPV vaccine, at least 6 months apart, for adolescents beginning the vaccine series before their 15 th birthday and are immunocompetent, and 3-doses of HPV vaccine for persons 15-26 years of age or persons who are immunocompromised

HPV-Associated Cervical Carcinoma Rates by State, United States, 2008 2012 Rate are per 100,000 persons and age-adjusted to the 2000 US standard population. Data are from population-based registries participating in CDC s National Program of Cancer Registries or NCI s Surveillance, Epidemiology, and End Results Program, meeting USCS publication criteria for all years 2008 2012, and cover about 99% of the US population. Rates were suppressed if the data did not meet USCS publication criteria or if there were fewer than 16 cases. HPV-associated cancers were defined as cancers at specific anatomic sites with specific cellular types in which HPV DNA frequently is found. All cancers were confirmed histologically. Cervical cancers (ICD-O-3 site codes C53.0 C53.9) were limited to carcinomas (ICD-O-3 histology codes 8010 8671, 8940 8941). Adapted from: Viens et al. Human Papillomavirus- Associated Cancers United States, 2008 2012. MMWR 2016;65(26):661-666.

HPV Vaccination: What Works Parents Parents want to prevent cancer Parents trust their provider s recommendation Parents think benefits outweigh risks Parents want a strong recommendation Providers Providers emphasize cancer prevention Providers normalize the HPV vaccine and coadminister with other vaccines Providers give a strong recommendation Perkins RB et al. Pediatrics 2014;134:e666-e674

National, State, and Denver Health Immunization Rates, 2013 Farmer et al, Pediatrics 2016

HEDIS Measures for HPV Vaccination Coverage CDC partnered with the National Committee for Quality Assurance (NCQA) to develop a HEDIS measure for HPV vaccination coverage of girls Proportion of girls who have received three doses of HPV vaccine by their 13 th birthday The measure was first publicly reported in HEDIS 2014 (MMWR 2015) The NCQA/HEDIS measure was included in the Core Set of Children s Health Care Quality Measures for Medicaid and CHIP in FY2014 CDC partnered with NCQA to update the measure HEDIS 2017: receipt of three doses of HPV vaccine by age 13 included in the Adolescent Immunization measure for both boys and girls HEDIS 2018: two dose schedule allowed, aligned with current ACIP recommendation

HPV Vaccine Recommendations, United States, 2006-present 2006: HPV vaccine recommended as three dose series for girls at 11-12 years of age, with catch up through 26 years of age 2011: HPV vaccine recommended as three dose series for boys at 11-12 years of age, with catch up through 21 years of age. 2015: 9-valent HPV vaccine replaced 4-valent HPV vaccine 2016: For boys and girls who start series before 15 th birthday, only two doses of HPV vaccine needed

What will result in change?

https://www.bcbs.com/the-health-of-america/ reports/adolescent-vaccination-rates-in-america