Oregon Tribes and HPV Oregon HPV Roundtable Kerri Lopez Northwest Tribal Comprehensive Cancer Program May 2018 Supported by CDC Grant #U158/DP006283-01-00

Northwest Portland Area Indian Health Board NPAIHB Member Tribes Name and location of your coalition. If you are a 501c3, and the basic structure of your coalition: Northwest Tribal Comprehensive Cancer Coalition in the Northwest Tribal Epidemiology Center Office in Portland, Oregon We are a 501c3 and PL 638 Federal Contractor serving 43 Federally recognized tribes in Idaho, Oregon, and Washington Chair from member tribes and open coalition 11/12/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board Organizational Chart 11/12/2018 Northwest Portland Area Indian Health Board

About our Board: Board Delegates meet quarterly and in other State/Tribal meetings Provide program guidance to state, federal, and others Review HHS/IHS policy issues affecting Tribal health programs Currently looking at health care reform effects Discuss and Develop consensus positions on: Legislations/Budgetary issues Health Promotion/Disease Prevention Data & Research Issues impacting Indian Health Provide technical assistance to NW tribes

HPV Immunization Portland Area clinics (Idaho, Oregon, Washington) FY 2018 - 1st Qtr: October 1, 2017 - December 31, 2017 First Second Third AI/AN Female 13-17 84.6% 62.9% 26.4% AI/AN Male 79.9% 56.8% 23.1% ·         Girls 13 years old- there is a small increase in initiation and 14%  percentage point decrease in completion. ·         Boys 13 years old- there is again a small (4percentage point) increase in initiation and a 6.4% decrease in completion. ·         Girls 13-17- there is a small increase in initiation and a 7 percentage point decrease in completion. ·         Boys 13-17- there is no change in initiation and a drop of 5 percentage points in completion. National Immunization Reporting System - IHPES Program 11/12/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board HPV rates 13 years olds   2016 2017 2018 Girls 13  (n=443) (n=383) (n=318)        1 dose 82.4% 83.0% 84.6%        2 dose 63.2% 64.2% 62.9%        3 dose 39.1% 36.6% 26.4% Boys 13 (n=458) (n=390) (n=359) 75.5% 80.0% 79.9% 52.0% 53.6% 56.8% 29.5% 29.0% 23.1% ·         Girls 13 years old- there is a small increase in initiation and 14%  percentage point decrease in completion. ·         Boys 13 years old- there is again a small (4percentage point) increase in initiation and a 6.4% decrease in completion. ·         Girls 13-17- there is a small increase in initiation and a 7 percentage point decrease in completion. ·         Boys 13-17- there is no change in initiation and a drop of 5 percentage points in completion. National Immunization Reporting System - IHPES Program Indian health performance evaluation system 11/12/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board Immunization Rates   2016 2017 2018 Girls 13-17  (n=2404) (n=2071) (n=1886)        1 dose 85.4% 88.3% 87.1%        2 dose 75.1% 78.2% 76.4%        3 dose 60.5% 62.0% 53.0% Boys 13-17  (n=2258) (n=1967) (n=1813) 77.0% 84.6% 84.8% 59.6% 69.3% 70.0% 40.2% 51.4% 46.4% ·         Girls 13 years old- there is a small increase in initiation and 14%  percentage point decrease in completion. ·         Boys 13 years old- there is again a small (4percentage point) increase in initiation and a 6.4% decrease in completion. ·         Girls 13-17- there is a small increase in initiation and a 7 percentage point decrease in completion. ·         Boys 13-17- there is no change in initiation and a drop of 5 percentage points in completion. National Immunization Reporting System - IHPES Program 11/12/2018 Northwest Portland Area Indian Health Board

Oregon Cervical Cancer Screening 2017 Oregon Tribes GPRA 4 Tribes aggregate BRFSS 2011 Oregon BRFSS AI/AN 2011 Oregon BRFSS NHW Pap Test 61.2% (60% - 75%) Within past 2 years 75.7% Within past 3 years 82.2% 11/12/2018 Northwest Portland Area Indian Health Board

Oregon Cervical Cancer Incidence 2008-2012 Race Incidence (per 100,000) 95% Confidence Interval (Lower, Higher) AI/AN 8.1 (4.2, 15.6) NHW 6.7 (6.1, 7.3) 2.3% of AI/AN women’s cancers are diagnosed Cervical Cancer 11/12/2018 Northwest Portland Area Indian Health Board

Oregon Cervical Cancer Mortality 2008-2012 Race Mortality (per 100,000) 95% Confidence Interval (Lower, Higher) AI/AN 2.1 (0.4, 8.6) NHW 1.8 (1.5 2.1) From Masters thesis OHSU 2013 64.2% of AI/AN Cervical Cancer patients are diagnosed with regional or distant stage 11/12/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board National 5 year Cervical Cancer Survival 2006-2012 (2017 Report to Nation) Race 5 year Survival rate (%) 95% Confidence Interval (Lower, Higher) AI/AN 64.7 (55.9 to 72.2) NHW 70.0 (69.0 to 70.9) 11/12/2018 Northwest Portland Area Indian Health Board

2014 Federal Bureau of Prison’s expenditure: $6,400 NCAI proposed budget for 2018 2014 Federal Bureau of Prison’s expenditure: $6,400 Source: The Federal Bureau of Prisons’ Reimbursement Rates for Outside Medical Care, Evaluation and Inspections Division 16-04 June 2016

And this year - activities 2018 January HPV webinar (25 registered) Dr. Amanda Bruegl 2018 February HPV National Roundtable 2018 NTCCP HPV vaccination update Dr. Allison Empy Warm Springs HPV media update 2018 NTCCP tribal clinical update HPV Michelle Berlin Head and neck cancer presentation Cancer screening 11/12/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board NTCCP Activities 2017 Women’s Health NTCCP Coalition Meeting Presentation on Screening Screening Native Women If you don’t get screened AI/AN Presentation from BCCP outreach workers NARA/SPIPA 2017 April NTCCP Coalition Meeting HPV materials disseminated at tribal clinical directors cancer update Posters, provider education fact sheets, Presentation on women’s cancer 27 PCP from 14 tribal clinics Focus group from participants rating available HPV educational materials Preference for locally developed fact sheets and posters 11/12/2018 Northwest Portland Area Indian Health Board

Community Clinical Linkage Created environmental scan Piloted Community Clinical Linkage Four interviews Clinical presentation – Native Clinic Dr. Brugel Dr. Empy 11/12/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board Findings All doing immunizations Following IHS immunization protocol Focusing on strategies – back to school physicals HPV standing orders in place at the clinic Immunization package used – Electronic Health Record Utilize state program – vaccine supplies in especially in the Urban area 11/12/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board Findings Reminders for shots – cards and calls Utilizing community health nurse Emphasize cancer prevention Promoted as part of the immunization recommendations Information provided in the clinic - parents Sports camps – community events – back to school picnics Community health has a close relationship with clinic 11/12/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board Findings (continued) Women’s health and WIC programs and head start New medical director, very engaged in women’s health Provide Immunization clinics Parents and especially grandparents are skeptical of the shot All but one have immunization coordinator Utilize county coordinator Rates are low – but small population IHS and tribal clinic have relatively high rates for the first shot Fall off on the second and third 11/12/2018 Northwest Portland Area Indian Health Board

Cultural issues with the HPV Vaccination Don’t know enough Afraid of side effects Mistrust of medical system Mistrust of federal government Remember past of women being sterilized (From focus group at Northwest Tribal Comprehensive Cancer Coalition Meeting in 2015) 11/12/2018 Northwest Portland Area Indian Health Board

NTCCP Tribal Coalition Issues: Parents and especially grandparents are skeptical of the shot Need to emphasize cancer prevention Community incident with patient fainting Anxiety about pain or side effects of the injections Lack of education materials Apprehension of federal government Remember past of women being sterilized Patients’ distrust of the medical system 11/12/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board Lessons Learned NTCCP works in a three state area, one state is very inclusive The state task group already reaches out to multiple staff at my organization My target population is already showing good rates for immunizations We really need to be able to focus on issues in individual clinics that we work with We had good partners, the timing was challenging We had the Clinical application coordinator, who is a pharmacist, the IRB coordinator, the comprehensive cancer director and specialist, OHSU, ACS, and NTCCP director is a member of the National HPV roundtable In addition, it would be great to develop a media blitz, specific to our population and get that out There is an abundant amount of resources; it is just assuring that the information is getting to the clinics and health educators on a regular basis 11/12/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board Hope In Summary, several tribes will hopefully benefit from our efforts, as the NTCCP we will continue to work with our tribes to increase HPV vaccinations in our tribal clinics 11/12/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board NPAIHB Timeline 2006 October NTCC- HPV Vaccine - Thomas Becker, MD, PhD 2007 January NTCC- HPV Clinical Update - Thomas Becker, MD, PhD 2007 April NTCC - IHS, Tribal, and State HPV collaboration - Donnie Lee, MD, IHS 2007 October NTCC - HPV Clinical Update - Thomas Becker, MD, PhD 2008 April NTCC - Indian Health Service HPV Vaccine Update -Donnie Lee, MD, IHS 2008 – CDC funded HPV Parent Focus groups in 2 Urban and 3 Tribes 2009 – CDC AI/AN from 2008 focus groups 2010 February - HPV Clinical Update - Thomas Becker, MD, PhD 2011 May NTCC - Women’s Health Update - Michelle Berlin, MD, OHSU 11/12/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board Time line continued 2012 October NTCU - Head and Neck Malignancies – Screening, Prevention and Treatment - Eric J. Dierks, MD, DMD, FACS 2014 January NTCC – HPV Vaccination Update – Clarice Charging, Area Immunization Coordinator 2015 NTCCP Director Invited National HPV Roundtable 2016 Contract with ACS via partnership with the CPCRN (OHSU) – Pharmacists providing HPV shots 11/12/2018 Northwest Portland Area Indian Health Board

Northwest Portland Area Indian Health Board Time line continued 2017 Contract OHSU PRC HPV environmental scans in tribal communities Key informant interviews Community / clinical linkages (Pharmacist, MCH Nurse, MA, FNP, Case manager) Provider presentation – Dr’s Bruegl and Empy Presentation on new guidelines for HPV Efficacy Cancer prevention Role playing 11/12/2018 Northwest Portland Area Indian Health Board

Northwest Tribes Meet the Challenge Cooking classes/healthy eating Just Move It Tribal cancer coalition Women and Wellness Lifestyle Intervention Classes Breast Cancer Awareness Bingo Colorectal Cancer Poker Walk Pap-a-thon Pink Paddle Project Aerobics Video Pink Shawl Mother daughter tea/lunch Golf tournament Cancer awareness day Cancer 101 Great American Smoke out Men’s health day Relay on the Rez

Northwest Tribes Meet the Challenge Tribal health fair Community gardening project – fresh produce, elders luncheon, Men and women's wellness conference Pink and blue party – biggest loser Zumba fun and fitness night – cancer kab, smoothie station Youth camp – skin cancer, tobacco physical activity, healthy eating Youth prevention night “Traditional games” Traditional food gathering classes – salad class, and preserving strawberries Breathe free Memorial day cancer walk “Shining light”

Northwest Portland Area Indian Health Board Contact Information Northwest Tribal Comprehensive Cancer Project Kerri Lopez (Tolowa), Project Director Eric Vinson (Cherokee), Project Coordinator Antoinette Aguirre (Navajo), Cancer Prevention Coordinator Tom Becker, MD, PhD, Medical Epidemiologist Phone: 503-416-3301 Email: klopez@npaihb.org 11/12/2018 Northwest Portland Area Indian Health Board