1. YOU ARE THE KEY: Get Into the Routine of Recommending Cancer Prevention
Jill B. Roark, MPH
Health Communication Science Office
National Center for Immunization and Respiratory Diseases
Centers for Disease Control and Prevention
Linda M. Niccolai, PhD
Department of Epidemiology of Microbial Diseases
Yale School of Public Health
#PreventHPVCancers

2. Learning objectives
Define the importance of HPV vaccination for cancer prevention and the rationale for vaccinating at age 11 or 12.
Describe the current status of uptake and impact in Connecticut, and barriers to higher coverage.
Understand the significance of the clinician recommendation for HPV vaccination.
Employ strategies for making effective recommendations to families of year olds.

4. Removing Barriers for Parents
Lack of knowledge, not needed
Concerns about safety and side effects
Proof of effectiveness
Permission for sexual activity
11 or 12 too young
Don’t receive a recommendation
Needed for cancer prevention
Extensive safety research
Impact information
Not linked with sexual activity
Explaining why 11 or 12
Receive a bundled recommendation

6. Cancers Caused by HPV per Year, U.S., 2009-2013
 Cancer site
Percentage probably caused by any HPV type
Number probably caused by any HPV type
Female
Male
Both Sexes
Cervix
91%
10,600
Vagina
75%
600
Vulva
69%
2,500
Penis
63%
700
Anus
3,200
1,600
4,800
Rectum
500
200
Oropharynx
70%
2,000
9,600
11,600
TOTAL
19,400
12,100
31,500
This slide shows the numbers that were displayed in the figure in the previous slide and focuses in on the number of cancers attributable to HPV per year in the United States from 2009 to An HPV-attributable cancer is a cancer probably caused by HPV. The column with “percentage probably caused by any HPV type” comes from the CDC genotyping study. HPV causes nearly all cervical cancers and many cancers of the vagina, vulva, penis, anus, and oropharynx. Since rectal cancer was not included in the CDC genotyping study, the HPV-attributable fraction for anal cancer was used because recent studies show that the HPV-associated types of anal and rectal cancer are similar.
CDC estimated that during 2009 to 2013, HPV caused about 31,500 cancers in the United States each year, with 19,400 cancers in women and 12,100 cancers in men. Most HPV-associated cancers in women were cervical cancers while, in men, most were oropharyngeal cancers.
Based on Viens et al. MMWR

7. HPV-Associated Cancers per Year, United States, 2009–2013
This slide shows the number of HPV-Associated Cancer cases that were diagnosed and reported each year in United States from 2009 to 2013 (the most recent 5-year period with available data).
Cancer registries do not routinely collect data on whether HPV is in the cancer tissue. So, to estimate the number of HPV-associated cancers, researchers look at cancer in parts of the body and cancer cell types that are likely to be caused by HPV. These parts of the body include the cervix, vagina, and vulva among women; the penis among men; and the anus, rectum, and oropharynx, which is the back of the throat, including the base of the tongue and the tonsils. The cellular types include carcinomas of the cervix and squamous cell carcinomas of the vagina, vulva, penis, anus, rectum, and oropharynx. Additionally, in this analysis, all cancers were microscopically confirmed.
A CDC study published in 2016 used population-based data to genotype HPV types from cancer tissue. These data are used to estimate the percentage of these cancers that are probably caused by HPV, what we call HPV-attributable cancers.
This graph shows the total number of HPV-associated cancers and uses the attributable fractions from the genotyping study to estimate the number probably caused by HPV types. HPV types were grouped as 16/18 (the dark blue bar), other high risk types 31/33/45/52/58 (the medium blue bar), and other HPV types (light blue bar). The white bar means that HPV DNA was not detected.
Based on Viens et al. MMWR

9. Rates of HPV-Associated Cancer and Median Age at Diagnosis Among Females, United States, 2004–2008
Rates of HPV-Associated Cancer and Median Age at Diagnosis Among Females in the United States, 2004–2008
*The vaginal cancer statistics for women between the ages of 20 and 39 is not shown because there were fewer than 16 cases.
Watson et al. Human papillomavirus-associated cancers—United States, MMWR 2012;61:

10. 25% of cervical cancers occur in women who are between the ages of 20 and 39

13. Cervical Precancer in U.S. Females
1.4M new cases of low grade cervical dysplasia
330K new cases of high grade cervical dysplasia
Getting a Pap smear by itself does not prevent cervical cancer.
When we use the Pap smear to look for pre-cancer of the cervix, we have to evaluate about 2 million women are year by biopsying their cervix in multiple locations, and when precancerous cells are found, we need to remove part of the cervix with a LEEP or cone procedure.
After removing 1 to 1.5 cm of a 5 cm cervix, women are at risk for pregnancy complications including preterm delivery preterm rupture of membranes and low birth weight.
Some studies indicate that the HPV infection itself can lead to some of these complications.
So my feeling is, why remove part of the cervix when you can get a shot in the arm instead?
----Notes-----
The illustration is of a cold knife cone biopsy. A LEEP procedure, which is done in the office, is much more common. The removal of cervical tissue is the same, but electrocautery is used instead of a scalpel.

15. Cancer Cases Most Likely Caused by HPV

16. Head and neck cancer survival:
Cost
12,989 new cases annually
Mean lifetime cost per new case is $43,200, with societal cost of $306 million
Importance of Early Detection
Head and neck cancer survival:
Early Stage  89%
Advanced Stage  27%
HPV-related OPSCC often present at a later stage
No good screening test
“No pap smear for the throat”
Majority of primary care residencies unfamiliar with disease
Little or no formal education

17. Impact of Eliminating Missed Opportunities by Age 13 Years in Girls Born in 2000
Had HPV vaccine been administered during health care visits when another vaccine was administered, vaccination coverage for at least one 1 dose could have reached 91.3% by age 13 years for adolescent girls born in 2000.
High HPV vaccination coverage with existing infrastructure and health-care utilization is possible in the United States. Taking advantage of every health-care encounter, including acute-care visits, to assess every adolescent’s vaccination status can help minimize missed opportunities. Potential strategies include using vaccination prompts available through electronic health records or checking local and state immunization information systems to assess vaccination needs at every encounter. Series completion also can be promoted through scheduling appointments for second and third doses before patients leave providers’ offices after receipt of their first HPV vaccine doses and with automated reminder-recall systems.
Missed opportunity: Healthcare encounter when some, but not all ACIP-recommended vaccines are given. HPV-1: Receipt of at least one dose of HPV. MMWR. 63(29);

18. how are we doing with HPV vaccination coverage in Connecticut?

19. The National Picture

20. Uptake in CT: Good news that could be better

21. CT and US over time: Fairly stagnant in CT (until 2015)

22. Boys: CT is doing relatively well

23. Up-to-date by age 13, US and CT
NIS-Teen, 2015, unweighted estimates

24. Completion

25. Reasons for not having child vaccinated for HPV reported by parents
Connecticut US
Not necessary
26%
22%
Not recommended
17%
Lack of knowledge
13%
14%
Not sexually active 9% 8%
Safety concerns
11%
NIS-Teen, 2015, unweighted estimates

26. What are some of the Challenges we face in Connecticut?
Results of a qualitative study with 32 clinicians in CT who provide immunizations to children and adolescents in 2015

27. Gaps in knowledge
“Efficacy and doing what it is we think it’s going to do has not been proven yet.”
“The energy of encouraging it is a little less for boys…I’m gonna have to be frank with the parents that we’re doing it merely to protect the girls.”

28. Important but not urgent
“The conversation typically is, ‘Well, your child is at the age now where they’re due for some booster vaccines. There’s also an additional vaccine that we feel gives excellent protection against certain types of cancer.’”
“If the kids truly have no risk…we often tell parents, ‘We’re gonna talk about this now, but you may have some time to decide whether you want to do this or not.’”

29. Anticipating parental hesitancy
“It’s a high priority but I dread it because it’s really – it’s a hot topic for these parents.”
“We aim for between 12 and 15 (years old). I don’t think parents are very receptive of it when they’re that young.”

30. Lack of a bundled recommendation
“Well, I say ‘These are required and this one’s recommended.’ I mean, they could still go to seventh grade or sixth grade…It’s not required. I tell them that.”
“HPV is the only one that is offered as a choice.”

31. Cognitive bias against HPV-associated diseases
“It (HPV) is not like meningitis. You could die in camp this summer from meningitis if you don’t get the shot.”
“Telling you that I’ll give you a vaccine to help you protect against a germ where you can die within two days if you don’t get this, that’s pretty compelling.”

32. Evidence of HPV vaccine impact in CT: Rates of precancerous cervical lesions are declining!
Percent declines:
Rate of precancerous cervical lesions per 100,000 women
74%
73%
62%
50%
34%
30%
Niccolai et al. Clinical Infectious Diseases 2017.

34. HPV Vaccination Is Safe, Effective, and Provides Lasting Protection
HPV Vaccine is SAFE
Benefits of HPV vaccination far outweigh any potential risks
Safety studies findings for HPV vaccination similar to safety reviews of MCV4 and Tdap vaccination
HPV Vaccine WORKS
Population impact against early and mid outcomes have been reported in multiple countries
HPV Vaccine LASTS
Studies suggest that vaccine protection is long-lasting
No evidence of waning protection
HPV vaccine is safe, effective and provides lasting protection against the types of HPV that most commonly cause cancer.

36. How Parents Feel

37. How Providers Think Parents Feel

38. The Difference
So, we think parents don’t value HPV vaccine, when they really do. I recommend that you use a practical communication strategy when a parent has a question.
Don’t panic. Interpret a question as a request for reassurance from YOU, the clinician they trust with their child’s health care.
Clarify and re-state their concerns to make sure you understand.
It sounds like you’re concerned that HPV vaccine isn’t necessary because Emily is a virgin. Am I understanding the question?
Address the parent's specific concerns.

39. Don’t anticipate opposition
It is important for providers to NOT anticipate opposition to HPV vaccination
Parents value HPV vaccine as much as they value other adolescent platform vaccines

41. Now that Sophia is 11, she is due for three vaccines
Now that Sophia is 11, she is due for three vaccines. These will help protect her from meningitis, HPV cancers, and pertussis. We’ll give those shots at the end of the visit.
So you could say something like “now that Sophia is 11, she is due for three vaccines. These will help protect her from meningitis, HPV cancers, and pertussis. We’ll give those shots at the end of the visit.”

42. Resistance Doesn’t Mean Refusal
Interpret questions as a request for reassurance and information
For HPV vaccine-hesitant parents, it is important to remain engaged with them and to ask questions before giving answers

43. Our practice is so dedicated to cancer prevention I know the doctor is going to want to talk with you more about this. Here is some additional information for you to read about it while you wait.

45. HPV Vaccine Recommendation
Girls & Boys can start HPV vaccination at age 9
Preteens should finish HPV vaccine series by 13th birthday
Just as a quick review, preteens should finish the HPV vaccine series before they turn 13. Delay is risky. It is hard to know for sure that the child will return for the next appointment, it makes it more difficult to ensure HPV vaccine series completion, and it gives the message that HPV vaccine is less important.
Plus girls years old who haven’t started or finished HPV vaccine series
Plus boys years old who haven’t started or finished HPV vaccine series

46. A few words on risk profiling: Don’t do it!
Too many doctors try to time vaccination to when they think their patients will be at risk for sexual activity, or delay vaccination and young preteen’s because they don’t think it is necessary yet where they find the conversation with parents to be uncomfortable.
In theory it seems like this will work, because as long as you complete the three shot series at least one month prior to HPV exposure, the patient should be protected.
But in practice this doesn’t work. You can be almost certain that at some point all of your patients will be exposed to HPV. What you can’t predict is who or when.
80% of people will be exposed to HPV
You can’t predict who or when

48. It sounds like you are generally in support of vaccines, but you have concerns about the safety of HPV. Is that right? So if you had information that convinced you the HPV vaccine was safe you might consider letting your daughter get it? I’d like to share with you what I know about the safety of HPV vaccine…
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49. When should the bike helmet go on?
Before they get on their bike
When they are riding their bike in the street
When they see the car heading directly at them
After the car hits them
Most people are familiar with, and endorse the use of bicycle helmets. You could also use seatbelts as an example. Ask parents, “When do you want your children to put on their bike helmets? Make the point that we can’t guess when the bike accident risk may occur so we always have our children put on their helmets before getting on their bikes.
Temte JL. Pediatrics 2014.

50. When do we put our seat belts on?
Before turning on car
When leaving driveway
After a near accident
You could also use seatbelts as an example. Ask parents, “When do we put our seat belts on?”
Temte JL. Pediatrics 2014.

51. All three vaccines are strongly and equally recommended by the CDC
All three vaccines are strongly and equally recommended by the CDC. All three are also recommended by Pediatric, Adolescent, and Family Medicine doctors and groups. School-entry requirements don’t always reflect the current recommendations for your child’s health.
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53. 1. Know your coverage rates
How to increase the number of target patients who come in & leave vaccinated
1. Know your coverage rates
Clinic-level rates are great, but rates for individual clinicians are even better!
Other than AFIX visits, rates can come from
Data from EHR
IIS inputs
The first is to know what your rates are. We only improve what we measure. There are a variety of ways to do this. If you are a VFC provider, ask for and attend the next AFIX site visit. If that is not available or won’t be happening soon, have data pulled from your EHR or IIS inputs for all of your 13 year old patients.

54. 2. Align office/clinic policy with mission
How to increase the number of target patients who come in & leave vaccinated
2. Align office/clinic policy with mission
Immunize at every opportunity
Implement and utilize standing orders
Prompt the person ordering the vaccine in multiple ways
Reminders & Recalls

55. 3. Align communication with mission
How to increase the number of target patients who come in & leave vaccinated
3. Align communication with mission
Give staff a cancer-prevention mission
All staff need to be saying the same thing
Share talking points
Use the Tip Sheet
Hold an in-service
Make sure that all clinic staff, including those answering the phone and making appointments, are communicating the same way about HPV vaccine. Put the focus on cancer prevention and provide talking points for the staff. One way to be sure that staff have the information that they need is to share with them the tip sheet “Addressing Parents’ Top Questions about HPV Vaccine.”

56. The Opener by the Nurse/MA
Encourage convenient same-day vaccination
“Today, Pat should have 3 vaccines. They’re designed to protect him from the infections that cause meningitis, HPV cancers, and pertussis. Do you have any questions for me?”
If a parents hesitates, the MA/nurse should say
“Our practice is so dedicated to cancer prevention that I’m sure the doctor will want to talk with you about your concerns.”
Here is example of how the staff on your team can communicate the importance of HPV vaccination to parents. The MA or nurse can let the parent know that ““Today, Pat should have 3 vaccines. They’re designed to protect him from the cancers caused by HPV and from meningitis, tetanus, diphtheria, & pertussis. Do you have any questions for me?”
If the parent expression hesitation or concern, the staff can respond by saying ““Our practice is so dedicated to cancer prevention that I’m sure the doctor will want to talk with you about your concerns.” This leaves the door open for additional conversation with the clinician.

57. CDC has a variety of resources available to assist clinicians in communicating about HPV vaccine and improving practice to increase immunization rates. Visit CDC.gov slash HPV and click on the section for clinicians.

58. Want to know when we have new resources and tools?
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