Selling Parents on HPV Vaccination for Their Preteens: You Are The Key

Selling Parents on HPV Vaccination for Their Preteens: You Are The Key November 7, 2014 Jill B Roark, MPH Lead, Adolescent Immunization Communications Health Communication Science Office National Center for Immunization and Respiratory Diseases Centers for Disease Control and Prevention

Objectives 1. Define the importance of HPV vaccination for cancer prevention and the rationale for vaccinating at ages 11 or 12 years. 2. Discuss how healthcare professionals can provide useful and compelling information about HPV vaccine to parents to aid in making the decision to vaccinate. 3. Locate resources relevant to HPV vaccine communications.

Disclosure Jill B Roark, MPH has no financial disclosures or conflicts of interest However, Jill B Roark really hates the diseases caused by HPV and these intense feelings may come across during this presentation. 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.

HPV Facts TOP TEN List 10. HPV infection is common 9. HPV causes cancer 8. Preventing cancer is better than treating it 7. We have an anti-cancer vaccine 6. HPV vaccine will save lives 5. HPV vaccine is safe and effective 4. More young people need HPV vaccine to protect them from cancer 3. Healthcare professionals should give strong HPV vaccine recommendations 2. Healthcare professionals should use electronic office systems to support HPV vaccination 1. Resources are available to help you

FACTS ABOUT HPV HPV INFECTION IS COMMON

HPV Types Differ in their Disease Associations

HPV Infection Most females and males will be infected with at least one type of HPV at some point in their lives Estimated 79 million Americans currently infected 14 million new infections/year in the US Most people will never know that they have been infected Jemal A et al. J Natl Cancer Inst 2013;105:175-201

FACTS ABOUT HPV HPV CAUSES CANCER

Numbers of Cancers and Genital Warts Attributed to HPV Infections, U.S. CDC. Human papillomavirus (HPV)-associated cancers. Atlanta, GA: US Department of Health and Human Services, CDC; 2013. Available at http://www.cdc.gov/cancer/hpv/statistics/cases.htm

Average Number of New Cancers Probably Caused by HPV, by Sex, United States 2006-2010 Oropharynx n=1,800 10% Vagina n=600 3% Vulva n=2,200 13% Anus n=2,600 15% Penis n=700 8% Anus n=1,400 15% Cervix n=10,400 59% Oropharynx n=7,200 77% Women (n = 17,600) Men (n = 9,300) CDC, United States Cancer Statistics (USCS), 2006-2010

HPV-Associated Cervical Cancer Rates by Race and Ethnicity, United States, 2004 2008 Watson et al. Human papillomavirus-associated cancers United States, 2004-2008. MMWR 2012;61:258-261.

FACTS ABOUT HPV PREVENTING CANCER IS BETTER THAN TREATING IT

Without vaccination, annual burden of genital HPV-related disease in U.S. females: 4,000 cervical cancer deaths 10,846 new cases of cervical cancer 330,000 new cases of HSIL: CIN2/3 (high grade cervical dysplasia) 1 million new cases of genital warts 1.4 million new cases of LSIL: CIN1 (low grade cervical dysplasia) 3 million cases and $7 billion American Cancer Society. 2008; Schiffman Arch Pathol Lab Med. 2003; Koshiol Sex Transm Dis. 2004; Insinga, Pharmacoeconomics, 2005

FACTS ABOUT HPV WE HAVE AN ANTI-CANCER VACCINE

HPV Vaccine Quadrivalent/HPV4 (Gardasil) Name Bivalent/HPV2 (Cervarix) Merck Manufacturer GlaxoSmithKline 6, 11, 16, 18 Types 16, 18 Females: Anal, cervical, vaginal and vulvar precancer and cancer; Genital warts Males: Anal precancer and cancer; Genital warts Hypersensitivity to yeast Indications Contraindications Females: Cervical precancer and cancer Males: Not approved for use in males Hypersensitivity to latex (latex only contained in pre-filled syringes, not single-dose vials) 3 dose series: 0, 2, 6 months Schedule (IM) 3 dose series: 0, 1, 6 months

Routine HPV vaccination recommended for both boys and girls at ages 11 or 12 Also ages 13-21 years for teen boys and young men and 13-26 years for teen girls and young women Vaccine can be given starting at age 9 years of age for both boys and girls and vaccine can be given ages 22-26 years for young men CDC. Quadrivalent Human Papillomavirus Vaccine: Recommendations of ACIP. MMWR 2007;56(RR02):1-24.

FACTS ABOUT HPV VACCINE HPV VACCINE WILL SAVE LIVES

26 million: number of girls under 13 years of age in the United States 168,400: number who will develop cancer if none are vaccinated 54,100: number who will die from cervical cancer if none are vaccinated Adapted from Chesson HW et al, Vaccine 2011;29:8443-50

For each year we stay at 30% coverage instead of achieving 80%... 4,400: number of future cervical cases we will not prevent each year 1,400: number of cervical cancer deaths we will not prevent each year

FACTS ABOUT HPV VACCINE HPV VACCINE IS SAFE

allegations of harm from vaccination based on weak evidence can lead to real harm when, as a result, safe and effective vaccines cease to be used. WHO s Global Advisory Committee on Vaccine Safety March 12, 2014

Steady decrease in VAERS reports MMWR 2013;62:591-595 24

FACTS ABOUT HPV VACCINE HPV VACCINE IS EFFECTIVE

How do we know HPV vaccine works? 26

Prevalence (%) Early Outcome: Reduction in HPV Infections 30 25 20 2003-2006 2007-2010 15 10 56% decline 5 0 14-19 20-24 25-29 30-39 40-49 50-59 Age group (years) *weighted prevalence Markowitz, et al. Reduction in HPV prevalence among young women following HPV vaccine introduction in the United States, NHANES, 2003-2010. J Infect Dis 2013 27

Early Outcome: Reduction of Genital Warts Females Males Ali, et al., Genital warts in young Australians five years into national human papillomavirus vaccination programme: national surveillance data. British Med J 2013;346:f2032

FACTS ABOUT HPV VACCINATION MORE YOUNG PEOPLE NEED TO GET HPV VACCINE TO PROTECT THEM FROM CANCER

Kansas Arkansas Utah Montana New Jersey Missouri Kentucky Tennessee Florida West Virginia Maryland Virginia Alaska Hawaii Mississippi Illinois Georgia Nevada Indiana Wyoming Alabama Ohio Oklahoma Idaho DC Connecticut South Dakota Texas Iowa North Dakota Colorado Minnesota North Carolina Wisconsin Pennsylvania Louisiana Maine Vermont South Carolina Washington New York Massachusetts Arizona Nebraska Michigan Oregon New Mexico California New Hampshire Delaware Rhode Island Texas Percent 90 HPV Vaccine Series Initiation Girls 13-17 Years, by State, 2013 80 70 60 56.2 50 40 30 20 10 0 State

Percent vaccinated Impact of Eliminating Missed Opportunities in GIRLS in Texas 100 80 Among girls unvaccinated for HPV, 85% had a missed opportunity. 60 40 20 56 93 Actual Achievable 0 HPV-1 (girls) Vaccine Missed opportunity: Health care encounter on or after 11 th birthday, and on or after March 23, 2007 during which 1 vaccine was administered but not the 1 st dose of the HPV vaccine series HPV-1: Receipt of at least one dose of HPV

Percent vaccinated Impact of Eliminating Missed Opportunities in BOYS in Texas 100 80 Among boys unvaccinated for HPV, 36% had a missed opportunity. 60 40 20 34 58 Actual Achievable 0 HPV-1 (boys) Vaccine Missed opportunity: Health care encounter on or after 11 th birthday, and on or after December 23, 2011 during which 1 vaccine was administered but not the 1 st dose of the HPV vaccine series HPV-1: Receipt of at least one dose of HPV

Adolescent Vaccination Coverage United States, 2006-2013 100 90 80 86 77.8 70 Percent Vaccinated 60 50 40 57.3 37.6 Tdap MCV4 1 HPV girls 3 HPV girls 30 20 34.6 1HPV boys 3 HPV boys 10 13.9 0 2006 2007 2008 2009 2010 2011 2012 2013 Survey Year MMWR 2014; 63(29);625-633.

Stagnant HPV vaccination rates are leaving another generation vulnerable to devastating HPV cancers HPV vaccination rates are lagging behind the rates of the other vaccines for preteens and teens High HPV vaccination coverage is possible with the current healthcare structure

http://shar.es/tzfxv

FACTS ABOUT HPV VACCINATION HEALTHCARE PROFESSIONALS SHOULD GIVE A STRONG HPV VACCINE RECOMMENDATION

optional new vaccine not at risk she can wait

Why won t you daughter get HPV vaccine in the next year? Not sexually active Not recommended 13% Safety concern/side effects Not needed or necessary Lack of knowledge 0 5 10 15 20 Percent CDC. National and State Vaccination Coverage Among Adolescents Aged 13 17 Years United States, 2012 MMWR 2014; 63(29);625-633.

Strength of Clinician Recommendation Influences Intent to Vaccinate Got/will get Will not get Strongly rec d against it Rec d against it Talked about it but did not offer a rec Rec d it Strongly rec d it Did not discuss it 3.7% 1.1% 11.8% 36.4% 33.7% 13.4% 5.9% 5.1% 21.2% 15.3% 7.6% 44.9% Unsure 0.0% 1.5% 15.7% 20.9% 8.2% 53.7% Don t know 2.0% 0.7% 8.5% 19.6% 5.2% 64.1% 2012 SummerStyles (HealthStyles) Survey #WeCanStopHPV

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

Median Values Value Parents Place on Vaccines 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.

Median Values Provider s Estimates of the Value Parents Place on Vaccines 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.

Median Values Clinicians Underestimate the Value Parents Place on HPV Vaccine 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.

Reduce Missed Clinical Opportunities to Recommend and Administer HPV Vaccines Objective 1.2: Providers should strongly encourage HPV vaccination of age-eligible males and females whenever other vaccines are administered.

Take the HPV Vax Challenge! Start your vaccine discussion will ALL 11 and 12 year old patients and their parents with: Your child needs three shots today: meningococcal vaccine, HPV vaccine, and Tdap vaccine. or Your preteen needs three vaccines to protect against meningitis, HPV cancers, and pertussis.

HPV Vaccine is CANCER Prevention

Surely, this kid isn t going to be having sex anytime soon, right?

When should the bike helmet go on? A B C

FACTS ABOUT HPV VACCINATION HEALTHCARE PROFESSIONALS SHOULD USE ELECTRONIC OFFICE SYSTEMS TO SUPPORT HPV VACCINATION

Reduce Missed Clinical Opportunities to Recommend and Administer HPV Vaccines Objective 1.3: Healthcare organizations and practices should use electronic office systems, including EHRs and IIS, to avoid missed opportunities for HPV vaccination.

We improve what we measure! Assessment Incentives exchange Feedback

Reminder/Recall really does work! 60 50 40 49.5* 40.8 44.3* *p<0.05 30 29.5 26.5* Intervention 20 15.3 Control 10 0 Tdap MCV4 HPV-1 Vaccine Suh C et al. Pediatrics 2012;129:e1437-45

AFIX cdc.gov/vaccines/programs/afix/index.html

FACTS ABOUT HPV VACCINATION RESOURCES ARE AVAILABLE TO HELP YOU

Increase Parents', Caregivers', and Adolescents' Acceptance of HPV Vaccines Objective 2.1: CDC should develop, test, and collaborate with partner organizations to deploy integrated, comprehensive communication strategies directed at parents and other caregivers, and also at adolescents.

cdc.gov/vaccines/youarethekey

Your name here!

Tools for your Practice Continuing Education

Resources for Patients Factsheets cdc.gov/vaccines/who/teens/products/print-materials.html

Adolescent Immunization Schedule Resources for Patients cdc.gov/vaccines/schedules/easy-to-read/preteen-teen.html

Resources for Patients Spanish-language resources cdc.gov/spanish/inmunizacion/index.html

Resources for Patients Vaccines for Preteens and Teens Website cdc.gov/vaccines/teens

Resources for Patients Online Resources: Infographic www.cdc.gov/vaccines/who/teens/infographic/hpv-cancer-prevention.html

Resources for Patients Posters All posters are currently available in the following sizes: 8.5x11 / 11x17 / 18x24

Resources for Patients Posters All posters are currently available in the following sizes: 8.5x11 / 11x17 / 18x24

Video PSAs Close the Door to Cancer: AN Animated PSA that illustrates the numbers associated with HPV related infections and cancers. Why HPV Vaccine is Important: We have three separate PSA s one from a survivor, one from an English speaking pediatrician, and one from a Spanish speaking physician. Each of these PSAs talks about why HPV vaccine is so important. Each runs about 30 seconds.

HPV Vaccine is Cancer Prevention #WeCanStopHPV For more information, visit: cdc.gov/vaccines/youarethekey Email questions or comments to CDC Vaccines for Preteens and Teens: PreteenVaccines@cdc.gov Jill can be reached at: JRoark@cdc.gov 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.