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MiCMRC Educational Webinar HPV Cancer Prevention September 20, 2017

MiCMRC Care Management Educational Webinar: You are the Key to HPV Cancer Prevention Expert Presenter: Abby Moler Sr. Manager, Primary Care American Cancer Society

You are the Key to HPV Cancer Prevention Abby Moler Sr. Manager, Primary Care American Cancer Society

Objectives 1. Define the importance of HPV vaccination for cancer prevention and the rationale for vaccinating at ages 11 or 12. 2. List the recommendations for HPV vaccine for girls and for boys. 3. Provide useful and compelling information about HPV vaccine to parents to aid in making the decision to vaccinate. 4. Locate resources relevant to current immunization practice.

Understanding the Burden HPV INFECTION & DISEASE

HPV 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 Jemal A et al. J Natl Cancer Inst 2013;105:175-201

New Cancers Caused by HPV per Year Vagina n=600 3% Oropharynx n=2,000 10% Vulva n=2,400 13% United States 2008-2012 Rectum n=500 3% Anus n=3,000 16% Cervix n=10,700 56% Penis n=700 6% Rectum n=200 2% Anus n=1,600 14% Oropharynx n=9,100 78% Women (n = 19,200) Men (n = 11,600) CDC, United States Cancer Statistics (USCS), 2008-2012

Cervical pre-cancer in U.S. females 1.4 million new cases of low grade cervical dysplasia 330,000 new cases of high grade cervical dysplasia American Cancer Society. 2008; Schiffman Arch Pathol Lab Med. 2003; Koshiol Sex Transm Dis. 2004; Insinga, Pharmacoeconomics, 2005

Evidence-Based HPV Disease Prevention HPV VACCINE

HPV Vaccine Recommendation Girls & Boys can start HPV vaccination at age 9 Preteens should finish HPV vaccine series by 13 th birthday Plus girls 13-26 years old who haven t started or finished HPV vaccine series Plus boys 13-21 years old who haven t started or finished HPV vaccine series

ACIP Recommendations Age Routine vaccination at age 11 or 12 years* Vaccination recommended through age 26 for females and through age 21 for males not previously vaccinated Vaccination recommended for men through age 26 who have sex with men (MSM) or are immunocompromised (including persons HIV-infected) Formulation by gender (assuming availability) 9vHPV 4vHPV 2vHPV Females Males *vaccination series can be started at 9 years of age MMWR 2015;64:300-4 13

Updated ACIP Recommendations: 2-Dose Series CDC routinely recommends two doses of HPV vaccine for 11 and 12 year olds to prevent HPV cancers. The first dose is routinely recommended at 11-12 years old. The second dose of the vaccine should be administered 6 to 12 months after the first dose. Vaccination can be started at age 9. 14

Updated ACIP Recommendations: 3-Dose Series Teens and young adults who start the series at ages 15 through 26 years will continue to need three doses of HPV vaccine to protect against cancercausing HPV infections. Adolescents aged 9 through 14 years who have already received two doses of HPV vaccine less than 5 months apart, will require a third dose. Three doses are recommended for people with weakened immune systems aged 9-26 years. 15

ACIP Recommendations: Timing of the 3-dose Series 2vHPV, 4vHPV and 9vHPV should be given in a 3-dose schedule for ages 15-26 years Interval between doses 1 2: Interval between doses 1 3: 1-2 months 6 months The minimum interval between doses 1 and 2 is 4 weeks The minimum interval between doses 2 and 3 is 12 weeks If the vaccine schedule is interrupted, the series does not need to be restarted MMWR 2015;64:300-4 16

HPV VACCINE SAFETY

VAERS: HPV Vaccine Safety Monitoring Ongoing safety monitoring has shown most reports are non-serious Among the 7.6% of reports coded as serious, most frequently cited possible side effects are headache, nausea, vomiting, and fever Syncope (fainting) continues to be reported following vaccination among adolescents Adherence to a 15-minute observation period after vaccination is encouraged MMWR. 2014;63(RR05);1-30. 1

Monitoring Impact of HPV Vaccine Programs on HPV-Associated Outcomes HPV VACCINE IMPACT

HPV vaccine impact monitoring Post licensure evaluations are important to evaluate real world effectiveness of vaccines Population impact against early and mid outcomes have been reported: HPV prevalence Australia, Norway, Denmark, Sweden, UK, US Genital warts Australia, New Zealand, Denmark, Sweden, Germany, Quebec, US Cervical lesions Australia, British Columbia, Denmark, Sweden, US 20

Challenges in Monitoring HPV Vaccine Impact on Cervical Lesions Detected through cervical cancer screening Changing screening recommendations Lack of cervical cancer screening registries in some countries Incomplete linkages with vaccination registries 21

HPV Vaccine Duration of Immunity Studies suggest that vaccine protection is long-lasting; no evidence of waning immunity Available evidence indicates protection for at least 10 years Multiple cohort studies are in progress to monitor the duration of immunity

HPV Vaccination Is Safe, Effective, and Provides Lasting Protection HPV Vaccine is SAFE Benefits of HPV vaccination far outweigh any potential risks Safety studies findings for HPV vaccination similar to safety reviews of MCV4 and Tdap vaccination HPV Vaccine WORKS Population impact against early and mid outcomes have been reported in multiple countries HPV Vaccine LASTS Studies suggest that vaccine protection is long-lasting No evidence of waning protection

Talking about HPV vaccine FRAMING THE CONVERSATION

Adolescent Vaccination Coverage United States, 2006-2015 100 Revised APD* definition Percent Vaccinated 90 80 70 60 50 40 30 20 1 Tdap 1 MenACWY 1 HPV (F) 1 HPV (M) 3 HPV (F) 2 MenACWY 3 HPV (M) 10 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Survey Year Reagan-Steiner, et al. MMWR; August 26, 2016 / 65(33);850 858 * APD = Adequate provider data 2 doses MenACWY among adolescents aged 17 years

Reasons parents won t initiate HPV vaccination for children Not sexually active Not recommended Safety concern/side effects Not needed or necessary Lack of knowledge 0 5 10 15 20 Percent MMWR 2014; 63(29);625-633;

Value Parents Place on the Vaccines Median Values 10 9 8 7 6 5 4 3 2 1 0 Parent 9.4 9.5 9.5 9.3 9.3 9.2 Meningitis Hepatitis Pertussis Influenza HPV Adolescent vaccines Adapted from Healy et al. Vaccine. 2014;32:579-584.

Provider estimations Median Values 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 Adapted from Healy et al. Vaccine. 2014;32:579-584.

Clinicians underestimate the value parents place on HPV vaccine Median Values 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 7.0 5.2 Meningitis Hepatitis Pertussis Influenza HPV Adolescent vaccines 7.8 Adapted from Healy et al. Vaccine. 2014;32:579-584.

Median Values Clinicians Underestimate the Value Parents Place on HPV Vaccine real concerns of parents 10 9.4 9.2 9.5 9.2 9.5 9.3 9.3 9.3 9.2 9 7.8 7.0 8 7 6 5 4 3 2 1 0 The perceived and Parent Provider's estimate influence how the 5.2 provider recommends and administers HPV vaccine. Meningitis Hepatitis Pertussis Influenza HPV Adolescent vaccines Adapted from Healy et al. Vaccine. 2014;32:579-584.

Give an Effective Recommendation to Receive HPV Vaccine at Ages 11 or 12 An effective recommendation from you is the main reason parents decide to vaccinate Many moms in focus groups stated that they trust their child s doctor and would get the vaccine for their child as long as they received a recommendation from the doctor Unpublished CDC data, 2013.

What is an EFFECTIVE recommendation for HPV vaccination?

Same Way Same Day

Make an Effective Recommendation Same way: Effective recommendations group all of the adolescent vaccines 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. Unpublished CDC data, 2013.

Your preteen needs three vaccines today to protect against meningitis, HPV cancers, and pertussis.

Tdap MenACWY HPV

Now that Sophia is 11, she is due for three vaccines. These will help protect her from meningitis, HPV cancers, and pertussis. We ll give those shots at the end of the visit.

Some Parents Need Reassurance Many parents simply accept of this bundled recommendation Some parents may be interested in vaccinating, yet still have questions. Interpret a question as they need additional reassurance from YOU, the clinician they trust with their child s health care Ask parents about their main concern (be sure you are addressing their real concern) Unpublished CDC data, 2013.

Why does my child need HPV vaccine?

HPV vaccination is important because it prevents cancer. That s why I m recommending that your child start the HPV vaccine series today.

Is my child really at risk for HPV?

HPV is a very common and widespread virus that infects both females and males. We can help protect your child from the cancers and diseases caused by the virus by starting HPV vaccination today.

Why at 11 or 12 years old?

When should the bike helmet go on? A B C

Most clinicians wait too long to make strong recommendations for HPV vaccine Allison et al. https://cdc.confex.com/cdc/nic2011/webprogram/paper25181.html

As with all vaccine-preventable diseases, we want to protect your child early. If we start now, it s one less thing for you to worry about. Also, your child will only need two shots of HPV vaccine at this age. If you wait until 15, your child will need three shots. We ll give the first shot today and then you ll need to bring your child back in 6 to 12 months from now for the second shot.

How long can we wait and still give just two doses?

The two-dose schedule is recommended if the series is started before the 15th birthday. However, I don t recommend waiting to give this cancer-preventing vaccine. As children get older and have busier schedules, it becomes more difficult to get them back in. I d feel best if we started the series today to get your child protected as soon as possible.

I have some concerns about the safety of the vaccine I keep reading things online that says HPV vaccination isn t safe. Do you really know if it s safe?

It sounds like you are generally in support of vaccines, but you have concerns about the safety of HPV. Is that right? So if you had information that convinced you the HPV vaccine was safe you might consider letting your daughter get it? I d like to share with you what I know about the safety of HPV vaccine

I know there are stories in the media and online about vaccines, and I can see how that could concern you. However, I want you to know that HPV vaccine has been carefully studied for many years by medical and scientific experts. Based on all of the data, I believe HPV vaccine is very safe.

Vaccines, like any medication, can cause side effects. With HPV vaccination this could include pain, swelling, and/or redness where the shot is given, or possibly headache. Sometimes kids faint when they get shots and they could be injured if they fall from fainting. We ll protect your child by having them stay seated after the shot.

I m just worried that my child will perceive this as a green light to have S-E-X.

Numerous research studies have shown that getting the HPV vaccine does not make kids more likely to be sexually active or start having sex at a younger age. Starting the HPV vaccine series today will give your child the best protection possible for the future.

How do you know if the vaccine works?

Ongoing studies are showing that HPV vaccination works very well and has decreased HPV infection, genital warts, and cervical precancers in young people, in the years since it has been available. Starting the vaccine series today will help ensure your child gets the best protection possible.

Why do boys need HPV vaccine?

HPV infection can cause cancers of the penis, anus, and throat in men and it can also cause genital warts. Getting HPV vaccine today for your son can help prevent the infection that can lead to these diseases.

Would you get HPV vaccine for your kids?

Yes, I have given HPV vaccine to my child because I believe in the importance of this cancer-preventing vaccine. The American Academy of Pediatrics, the American Academy of Family Physicians, NIH cancer centers, and the CDC, also agree that getting the HPV vaccine is very important for your child.

If a parent doesn t say yes Ask Acknowledge Advise Clarify & restate their concerns to make sure you understand. Emphasize it is the parents decision. Acknowledge risks & conflicting info sources. Applaud them for wanting what is best for their child. Be clear that you are concerned for the health of their child, not just public health safety. Clarify their concerns: make sure you understand & are answering the question they actually care about. Allow time to discuss the pros & cons of vaccines. Be willing to discuss parents ideas. Offer written resources for parents. Tailor your advice using this presentation.

If a parent declines Declination is not final. The conversation can be revisited. End the conversation with at least 1 action you both agree on. Because waiting to vaccinate is the risky choice, many pediatricians ask the parent to sign a Declination Form

Increase the number of target patients who come in & leave vaccinated 1. Know your coverage rates 2. Align office policy with mission 3. Align communication with mission

1. Know your coverage rates AFIX visits for VFC providers Data from EHR Ordering data

2. Align office policy with mission Immunize at every opportunity Standing orders Prompt the person who is supposed to order the vaccine Reminders Recalls

3. Align communication with mission EVERYONE in the office needs to be saying the same thing Share talking points

The Opener by the Nurse/MA Encourage convenient same-day vaccination Today, Pat should have 3 vaccines. They re designed to protect him from the cancers caused by HPV and from meningitis, tetanus, diphtheria, & pertussis. Do you have any questions for me? If a parents hesitates, the MA/nurse should say Our practice is so dedicated to cancer prevention that I m sure the doctor will want to talk with you about your concerns.

ACS Tools

HPV VACCINE IS CANCER PREVENTION And YOU are the key! #WeCanStopHPV