Provider Focused Road Show to Improve HPV Rates You are the Key to HPV Cancer Prevention

Objectives 1. Define the importance of HPV vaccination for cancer prevention and the rationale for vaccinating at ages 11 or 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.

HPV INFECTION & DISEASE Understanding the Burden

HPV Infections ´ 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:

HPV Cancers

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; Available at

HPV vs. Other Diseases ´ HPV disease outpaces other diseases we routinely vaccinate against ´ Cervical cancer deaths alone compared to the deaths from other diseases ´ 4,000 HPV-related cervical cancer deaths in the U.S. today. ´ 1,904 polio deaths in the U.S. in 1950 (near the height of the epidemic).polio deaths ´ 450 measles deaths every year in the U.S. before the vaccinemeasles deaths ´ ~500 tetanus deaths each year before widespread use of the vaccine in the U.S.tetanus deaths ´ 100 chickenpox deaths every year in the U.S. before the vaccinechickenpox deaths ´ HPV-related cancers kill more people every year than polio, measles, tetanus, and chickenpox combined did before we had vaccines for those diseases

HPV VACCINE Immunization Recommendations

HPV Vaccine is Best at Ages 11 or 12 Years While there is very little risk of exposure to HPV before age 13, the risk of exposure increase thereafter.

ACIP Recommendation and AAP Guidelines for HPV Vaccine  Routine HPV vaccination recommended for both males and females ages years  Vaccine can be given starting at age 9 years of age for both males and females;  vaccine can be given up to age 26 years for males and females CDC. Quadrivalent Human Papillomavirus Vaccine: Recommendations of ACIP. MMWR 2007;56(RR02):1-24.

HPV Vaccine HPV2 (Cervarix) HPV4 (Gardasil) HPV9 (Gardasil) GlaxoSmithKlineMerck 16, 186, 11, 16, 186, 11, 16, 18, (31, 33, 45, 52,58) Females: Cervical precancer and cancer Males: Not approved for use in males Females: Anal, cervical, vaginal and vulvar precancer and cancer; Genital warts Males: Anal precancer and cancer; Genital warts Females: Anal, cervical, vaginal and vulvar precancer and cancer; Genital warts Males: Anal precancer and cancer; Genital warts Hypersensitivity to latex (latex only contained in pre-filled syringes, not single-dose vials) Hypersensitivity to yeast 3 dose series: 0, 1, 6 months 3 dose series: 0, 2, 6 months

HPV Vaccine Comparison These Genital warts ~66% of ~15% of HPV Types Cervical Cervical Cause: CancersCancers

HPV VACCINE COVERAGE United States

National Estimated Vaccination Coverage Levels among Adolescents Years, National Immunization Survey-Teen,

Vaccination Coverage Levels among Female Adolescents Years Data Source: Iowa's Immunization Registry Information System (IRIS) by county zip codes and with a status of Active in an organization

County Priority Areas 1. Stakeholder Engagement - Build and sustain a stakeholder group to provide input for HPV activities. 2. Marketing and Communication - Increase awareness of HPV vaccination among 75% of health care providers in the service area 3. Performance/Quality Improvement – 75% of clinics will update demographics and document administration of HPV vaccine in IRIS 4. Training and Education – 75% of providers in the service area will strongly recommend HPV vaccine with eligible patients at each visit 5. Vaccine Delivery – 50 % of health care providers in the service area will receive education on how to finance/bill insurance for HPV vaccine

Training and Education- 75% of providers in the service area will strongly recommend HPV vaccine with eligible patients at each visit  Identify champions  What Clinics and How many?  “Train” champions  Choose content (for talks & toolkit)  Develop Toolkit  Letter sent to clinics  Scheduling with Clinics  Champions on the ROAD!

Toolkit – on a thumb drive  Pre-Survey – 4 Questions  DCPHNS Postcard  IDPH “You can Prevent Cancer” posters in English and Spanish  IDPH “You can Prevent Cancer” brochure in English  Iowa Immunization Coalition “A Conversation about HPV”  Gardasil 9 Prescribing Info  Merck Pt Assistance application (those with no insurance that are not eligible for VFC/>18 years old)  Common Insurance/Assistance Program and HPV vaccine coverage  A modified 6 slide version of CDC’s “You are the Key” PowerPoint  CDC “Tips and Timesavers”  ACS “HPV and Cancer – Facts and Figures”  Merck “Your Child could be one less at risk for certain HPV-related Cancers and Diseases”  Merck Appointment reminder cards  IAC Standing Orders for HPV Vaccine for “Nurse Visits”  Videos – the MN video series, 20 sec of safety with Dr. Boonstra, Close the Door to Cancer, HPV Animation facts, Tips for talking about HPV with parents/teens  IRIS info on knowing rates and reminder/recall

FRAMING THE CONVERSATION Talking about HPV vaccine

Key Points  Parents are influenced by their provider  Recommend adolescent vaccines for all males and females at age  Bundle adolescent vaccines together  Highly recommend all adolescent vaccines  Guarantee Protection – with all 3 doses

Top 5 reasons for not vaccinating daughter, among parents with no intention to vaccinate in the next 12 months, NIS-Teen 2012 * Not mutually exclusive. ** Did not know much about HPV or HPV vaccine.

Communication Style Matters

Highly Recommend ´ 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.

A case of vaccine hesitancy?  Parents may be interested in vaccinating, yet still have questions  Many parents didn’t have questions or concerns about HPV vaccine  A question from a parents does not mean they are refusing or delaying  Taking the time to listen to parents’ questions helps you save time and give an effective response  CDC research shows these straightforward messages work with parents when discussing HPV vaccine—and are easy for you or your staff to deliver

“When discussing HPV vaccine with 11 and 12 year-olds and their parents, I will ask the simple question: When do you want your children to put on their bike helmets?  A. Before they get on their bike  B. When they are riding their bike in the street  C. When they see the car heading directly at them  D. After the car hits them I usually end up with a smile and a successfully launched series.” Temte JL, Pediatrics 2014, letter to the editor

SAMPLE MESSAGING

Clinicians can give a strong and effective HPV vaccine recommendation by stating:

If main concern is “Why does my child need this vaccine” try saying: HPV vaccine is very important because it prevents cancer. I know we’d like to protect Maureen from cancer and I’d feel better if she got her first dose of the HPV vaccine series today.

If main concern is “My daughter will wait for marriage/won’t be exposed”, try saying: HPV is so common that almost everyone will be infected at some time. When your daughter marries, she could catch HPV from her husband. He might have been infected before he ever met her.

If main concern is “why now, let’s wait until child is older,” try saying: HPV vaccine produces a more robust immune response in preteens than in older teens which is why I recommend starting the HPV vaccine series today.

If main concern is “HPV vaccine will be a green light for sex,” try saying: Studies have shown that getting the HPV vaccine doesn’t make kids more likely have sex, or to have sex at a younger age.

If main concern is “would you give it to your child,” try saying: Yes, I gave it to my child (or grandchild, etc) because I think preventing cancer is very important.

If main concern is “side effects,” try saying: Vaccines, like any medication, can cause side effects. With HPV vaccine most are mild, primarily pain or redness in the arm. This should go away quickly. HPV vaccine has not been linked with any serious or long-term side effects.

If the main concern is “not a required vaccination”, try saying I don’t vaccinate because it is required. I vaccinate because it is the best thing to do.

Before leaving the exam room, remind parents when to come back. Try saying: To work, Robert needs the full HPV vaccine series, so... Please make sure to make an appointment for the next shot on the way out, and put that appointment on your calendar before you leave the office today!

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