1. Partnering with FQHCs and CHCs to Increase HPV Vaccination Molly Black | Associate Director, HPV Vaccination | American Cancer Society Jane Harris | Health Systems Manager, Primary Care | American Cancer Society

2. Key Topics American Cancer Society’s HPV Vaccination Efforts The Impact of HPV Vaccination Strategies that Work

3. American Cancer Society’s HPV Vaccination Efforts: The National HPV Vaccination Roundtable is a national coalition of organizations working together to prevent HPV-associated cancers and pre- cancers by increasing and sustaining U.S. HPV vaccination. The HPV VACs program is aimed at increasing HPV vaccination rates for adolescents across the nation through improved provider awareness and education and improved system-wide processes—with a focus on adolescents ages 11 to 12.

5. The Impact of HPV Vaccination

6. For each year we stay at 30% coverage instead of achieving 80%... 4,400 4,400 : number of future cervical cases we will not prevent 1,400 1,400 : number of cervical cancer deaths we will not prevent Chesson HW. Sex Transm Dis. 2014 41(11):656-9

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

8. Extrapolating the prior pyramid with projections of vaccine efficacy based on Australian data Cervical cancer 46% reduction in CIN2/3 requiring LEEP 75% if vaccination by age 14 35% reduction in CIN1 92% reduction in genital warts

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

10. 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.

11. Higher effectiveness with vaccination at younger ages. SOURCE: Gertig DM, BMC Med 2013 % Reduction in cervical dysplasia 5 years after vaccination, by age at vaccination Age at vaccination Percent dysplasia reduction

12. Gardasil 9: Our newest tool SOURCE: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6349a11.htm based on years 2006-2010 and data from Saraiya JNCI 2015 (in press)

13. Strategies that Work Steps and Tools for Increasing HPV Vaccination in Practice

14. Resources Jane Harris | Health Systems Manager, Primary Care Great West Division | American Cancer Society Jane.Harris@cancer.org 720.524.5446

16. Step #1 Assemble a Team Form a Quality Improvement Team for HPV Vaccination. Identify External Organizations and Resources to Support Your Efforts. Identify an HPV Vaccination Champion.

17. Step #4 Get Your 11-12 Year Olds Vaccinated Make a Strong Recommendation. Prompt the Provider. Increase Access. Track Series Completion & Follow Up. Measure and Improve Performance.

18. Make a Strong Recommendation

19. Give a Strong Recommendation to Receive HPV Vaccine at Ages 11 or 12  A strong recommendation from a provider 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 MMWR 2014; 63(29);625-633; Unpublished CDC data, 2013.

21. Addressing all concerns in 45 seconds Provider: Meghan and Mark are due for their HPV vaccine. Parent: Why do they need an HPV vaccine? Provider: The HPV vaccine will help protect them from cancer caused by HPV infection. We know that HPV infection is dangerous– 27,000 people in the US get cancer from HPV every year. And we know that the HPV vaccine is safe– over 100 million doses have been given and there haven’t been any serious side effects. Parent: I don’t think they need that yet… Provider: Vaccines only work if they’re given before exposure– we never wait until a child is at risk to give any recommended vaccines. HPV vaccine is also given as early as possible because it produces a better immune response in younger adolescents. That’s why it is so important to start the shots now and finish all 3 of them in the next 6 months.

22. How does the Chair of ACIP do it? “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.” SOURCE: Temte JL, Pediatrics 2014, letter to the editor

23. Prompt the Provider

24. Ways to Prompt Patient Specific form EHR or Nurse – EHR automatic pop-ups – EHR visit “task lists” – Highlighted text in EHR chart – Sticky notes in chart – Checklists – Preprinted note in client’s chart – Highlighted CPT code on a visit summary

25. Increase Access

26. Increasing Access Standing Orders Different Types of Appointments – Walk-in – Immunization Only Assess and Administer at Every Opportunity – Well child – Sick – Sports Physicals – Nurse Only Visits Community – Clinical Linkages – Schools – Pharmacies

27. Delay more common than refusal Providers and parents may not understand that the vaccine is most effective when all three doses are finished by age 14. And delays intended to be temporary may become permanent Perkins et al, Pediatrics, 2014

28. Each adolescent visit may be the last chance to vaccinate! 30% of adolescents never present for preventive care 1 in 15 adolescent visits is for preventive care Preventive visits decline after age 13 Early adolescents (11-14 years old) had 3 times more preventive visits than late adolescents Rand et al. Arch Pediatr Adolesc Med

29. Track Series Completion & Follow Up

30. Increase the number of target patients who come in Timing – Reminder – to patients who will be due soon – Recall – to patients who are past due Content – Patient Specific – Dose Specific Notification – Educational message

31. Second Summit of Cervical Cancer-Free South Carolina January 7-8, 2016| Greenville, South Carolina

32. Step #2 Make a Plan Identify Opportunities to Increase HPV Vaccination. Determine Baseline Vaccination Coverage Levels for 11-12 year olds. Design Your Clinic’s HPV Vaccination Strategy.

33. Step #3 Engage & Prepare All Staff Engage All Clinical and Non- Clinical Staff in Your Efforts. Prepare the Clinic System. Prepare the Parent & Patient. Prepare the Clinicians.

34. CDC Materials

35. Print Materials www.cdc.gov/vaccines/who/teens/products/print-materials.html

38. Video and Audio Resources www.cdc.gov/vaccines/who/teens/products/video-audio.html

39. Video PSAs

40. Matte Articles www.cdc.gov/vaccines/who/teens/products/matte.html