An Examination of HPV Vaccine Administration in Georgia Samantha Denson, Erika Holleran, Jasmine Gaffney, B.A., Candace Best, Ph.D.

Introduction Human papillomavirus (HPV) is the leading STI in the US and Georgia. HPV is linked to cervical, vaginal, penile, anal, and oropharyngeal cancer, and genital warts.   (CDC, 2016)

Introduction HPV Prevalence: 79 million HPV Incidence: 14 million A 3-dose quadrivalent HPV (HPV4) vaccine was approved by the FDA for ages 9-26 Females: 2006 Males: 2009 (CDC, 2016)

Introduction HPV4 vaccine dosing schedule: 1st Dose 2nd Dose: 1-2 months after initial dose 3rd Dose: 3-6 months after second dose (CDC, 2016)

Introduction 1st Dose 2nd Dose: 1-2 months after initial dose HPV4 vaccine dosing schedule: 1st Dose 2nd Dose: 1-2 months after initial dose 3rd Dose: 3-6 months after second dose (CDC, 2016)

Introduction 3rd Dose: 3-6 months after second dose HPV4 vaccine dosing schedule: 1st Dose 2nd Dose: 1-2 months after initial dose 3rd Dose: 3-6 months after second dose (CDC, 2016)

Introduction National initiation rates: Georgia’s initiation rates: Females: 62.8% Females: 54.4% Males: 49.8% Males: 51.0% National completion rates: Georgia’s completion rates: Females: 41.9% Females: 32.3% Males: 28.1% Males: 27.5% (CDC,2016)

Introduction The Georgia Department of Public Health (GDPH) requires providers to record administered childhood vaccinations. Our goal was to compare HPV4 and childhood vaccination rates.

Research Questions Research questions: R1: How do HPV4 vaccination trends compare to other childhood vaccines? R2: Are there gender differences in HPV4 vaccination trends?

Sample Children receiving vaccines in Georgia: Ages: 9-14 In 2009-2014 All childhood vaccines: Pertussis Measles, Mumps, and Rubella Meningococcal HPV4

Procedure The GDPH provided the de-identified childhood vaccine database, the Georgia Registry of Immunization Transactions and Services (GRITS). GRITS data included: Gender County Year and date of vaccine administration Identifier number

Analyses GRITS data variables were coded for: Vaccine type Gender Year of vaccine administration Descriptive statistics were conducted to examine the vaccine uptake frequency of our sample.

Demographics There were 2,457,005 vaccine entries between 2009- 2014 across all 159 Georgia counties Female entries = 1,275,643 Male entries = 1,129,224 No gender specified entries = 52,138 HPV4 specific entries included: Females = 455,622 Males = 387,366 There were 2,457,005 vaccine entries between 2009-2014 across all 159 Georgia counties. Male entries = 1,129,224 Female entries = 1,275,643 No gender specified entries = 52,138 HPV4 specific entries included: Males = 387,366 Females = 455,622

Results This graph displays the vaccination trends for all childhood vaccines from 2009 to 2014. Along the Y axis is our scale indicating vaccine uptake frequency. Along the X axis we have the corresponding study years in which the vaccine was administered. Each line on the chart corresponds with a vaccine: Blue indicates Pertussis, Red - Rubella, Green - Mumps, Purple – measles, aqua- meningococcal, and orange –HPV As you can see, Across the study years 2009-2014: -Vaccination rates increased for HPV, meningococcal, and pertussis, but remained relatively low for Measles, mumps and rubella- it is important to note here that the low rates of Measles, mumps and rubella may be due to them being reported seperately as apposed to the combined MMR -Pertussis was the most frequently administered vaccine until 2012 when it was surpassed by the HPV vaccine

Results This second graph displays HPV4 vaccination trends for males and females. Along the Y axis is our scale indicating vaccine uptake frequency. Along the X axis we have the corresponding study years in which the vaccine was administered. Females are represented with purple while males are represented in green As you can we can see Females had a higher rate of HPV vaccination across all study years However, Males demonstrated the most significant increase in HPV vaccination, rising consistently across the years

Discussion HPV4 vaccination rates: Low from 2009-2011 High from 2012-2014 Gender disparity in HPV4 vaccination HPV vaccination rates started off significantly lower than all other administered vaccines but that shifted in 2012 when it became the most frequently administered vaccine and continued to be the most frequent through 2014 We saw evidence of a gender disparity, Females received the HPV4 vaccine more frequency than males

Discussion We observed an upward trend. There was a significant increase in HPV4 vaccination rates for males following FDA approval. Results indicate an overall upward trend in HPV4 vaccine initiation for females and males throughout all study years Beginning in 2010 thru 2014, we observed a significant increase in male HPV4 vaccination initiation Poor HPV4 vaccine uptake for males in the years 2009-2010 may be partially due to delayed FDA approval for male vaccination

Limitations The sample may not be fully representative due to provider noncompliance. The data entries do not account for individual children receiving multiple vaccines. The data entries do not account for individual children receiving multiple vaccines. Accordingly, we are not able to specifically examine “missed opportunities” by which other vaccines were administered and the HPV4 vaccine was not administered.

Limitations Low uptake frequency for Mumps, Measles, and Rubella: Vaccines reported individually as opposed to a combined vaccine (MMR). We are not able to examine “missed opportunities” by which other vaccines were administered and the HPV4 vaccine was not administered.

Conclusion Interventions will: Improve HPV vaccine uptake Reduce HPV associated infections and diseases Moving into our conclusions, Interventions are needed to continue to improve HPV vaccination initiation and completion An increase in HPV vaccinated individuals would serve to reduce HPV associated infection and disease

Conclusion Provider recommendation implications Future research: Examining the role providers play in patient HPV vaccine uptake Provider recommendations have been identified as a key component in HPV vaccine initiation and completion Further inquest is needed to identify the behaviors and actions of providers and the role these behaviors play in HPV vaccine initiation and completion

Conclusion Childhood vaccination by county should be considered. Qualitative research examining differences between providers in highly vaccinated and poorly vaccinated areas may provide important information. Qualitative research examining the differences between providers in highly vaccinated areas and providers in poorly vaccinated areas could provide critical information Information that could aid in the construction of interventions for poorly vaccinated areas and where to best target resources to continue improving HPV vaccination

Implications Australia School-based vaccination program Herd immunity

Questions?

References Balakrishnan, V. S. (2015). Physicians' recommendation affects HPV vaccination uptake. The Lancet. Oncology, 16(16), e592. Centers for Disease Control and Prevention. (2016). National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years – united states, 2015. Morbidity and mortality weekly report, 65(33), 18. Retrieved from www.cdc.gov/mmwr/volumes/65/wr/pdfs/mm6533.pdf. Centers for Disease Control and Prevention. (2016). Immunization schedules. Retrieved from http://www.immunize.org/cdc/schedules/. Kulczycki, A., Qu, H., & Shewchuk, R. (2016). Primary care physicians' adherence to guidelines and their likelihood to prescribe the human papillomavirus vaccine for 11-and 12-year-old girls. Women's Health Issues, 26(1), 34-39. McCave, E. L. (2010). Influential factors in HPV vaccination uptake among providers in four states. Journal of community health, 35(6), 645-652. National Vaccine Advisory Committee. (2016). Overcoming barriers to low HPV vaccine uptake in the united states: Recommendations from the national vaccine advisory committee: Approved by the national vaccine advisory committee on June 9, 2015. Public Health Reports (Washington, DC: 1974), 131(1), 17. Shah, R. C. (2009). Prevention of cervical cancer—HPV vaccines. Pediatric Infectious Disease, 1(3), 134-146.