1. Improving HPV Vaccination
[NOTE: State partners may replace the HPVIQ logo with their health department logo if they wish.]
[Introductions: Names and clinical roles]
Improving HPV Vaccination
with Adolescent AFIX

2. Disclosures
This quality improvement activity was developed with funds from the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention (CDC).
Developers
Dr. Noel Brewer has received grants from and/or served on paid advisory boards for Pfizer, Merck, GSK, FDA, CDC, and NIH. All other developers, Dr. Melissa Gilkey, Dr. Jennifer Leeman, and Jennifer MacKinnon, MPH, have no conflicts to disclose.
Activity Leaders
Activity leaders have no conflicts to disclose.
Before we begin, here’s our disclosure information. I have no conflicts to disclose.

3. Earn credit for MOC Part 4!
Objective
Design a quality improvement (QI) project to increase HPV vaccination
Agenda
Review evidence on HPV vaccination
Set a measurable QI goal
Select QI strategies
Develop an action plan
[STEP 1: Introduce the quality improvement approach]
Today I’d like to work with you to design a quality improvement project to increase HPV vaccination in your clinic. This visit is part of a national, CDC-sponsored program called “AFIX.”
Our meeting today will have 4 parts:
First, I’ll review some of the latest evidence on HPV and HPV vaccination.
Second, I’ll share data on your clinic’s adolescent vaccination coverage, and we’ll set a goal for improving coverage.
Third, we’ll select specific strategies to help your clinic achieve that goal.
Finally, we’ll make an action plan to put those strategies into practice.
In a few months, I’ll get back in touch with you with new coverage estimates so that you can see how well these strategies are working.
Since we’re using a data-driven approach, this project is a great opportunity to earn CME and MOC Part 4 credits. At the end of our meeting, I’ll tell you more about how to do that.
Do you have any questions for me before we get started?
Earn credit for MOC Part 4!
Adolescent AFIX

4. Review evidence
We’ve seen some exciting developments in research related to HPV and HPV vaccination in recent years.
I’d like to start by reviewing some key points that you may want to share with other providers and staff in your clinic.
I’ll leave a copy of this presentation with you so that you can pass it on.

5. HPV-related cancer incidence
[STEP 2: Encourage a commitment to HPV vaccination]
HPV is an extremely common infection; 79 million Americans are currently infected with at least one strain of the virus, and almost all of us will get HPV at some point in our lives.
These infections are a serious public health problem because they are associated with over 25,000 new cancers in the U.S. each year.
Both men (shown in the blue) and women (shown in the orange) are affected.
The incidence of HPV-related oropharyngeal cancer has tripled in recent years and is expected to overtake cervical cancer cases by 2020.
For this reason, protecting both boys and girls from HPV infection is critical.
President’s Cancer Panel Annual Report, 2014
Adolescent AFIX

6. HPV vaccination recommendations
On-time (ages 11-12)
2 doses for both males and females
6-12 month interval between doses
More effective in younger adolescents
Late (ages 13+)
3 doses needed for ages 15+
As you know, the CDC, AAP, and AAFP recommend giving all children two doses of HPV vaccine by age 12.
The second dose should be given 6 to 12 months after the first.
Giving HPV vaccine on time is important because younger adolescents have a better immune response and are less likely to have been exposed.
Research shows that giving the vaccine to younger adolescents makes it twice as effective at protecting against cervical pre-cancers.
Keep in mind that adolescents are late if they have not gotten HPV vaccine before age 13.
Furthermore, if they haven’t started the series by age 15, CDC recommends giving three doses instead of 2. This is another reason that timeliness matters.
Reviewing these guidelines with other providers and staff in your clinic is one good strategy for kicking off your quality improvement project.
Adolescent AFIX

7. HPV vaccination impact
Sharp decline in cervical pre-cancers in screened young women
Age 21-24
62%
Age
18-20
One thing that’s exciting is emerging evidence about how effective HPV vaccination is.
This graph shows rates of cervical precancers in women who have undergone regular screening. On the bottom you have years. On the left (y axis) you have the number of cases of CIN 2+ (cervical intraepithelial neoplasia, grade 2 or more severe or adenocarcinoma in situ).
The solid line represents cases found in young women ages
The dotted line represents cases in women ages
Together these lines average a 62% decline in cervical precancers attributable to the increase in HPV vaccination coverage.
These data show that HPV vaccination can protect against cervical cancer.
The vaccine can also protect against vulvar, vaginal, and anal cancers and probably oropharyngeal and penile cancers, too.
It’s a vaccine against cancer.
Gargano et al., 2017
Adolescent AFIX

8. HPV vaccine is safe Adolescent AFIX Stokley et al., 2014
In addition to being effective, HPV vaccine is also very safe.
Since 2006, healthcare providers have given over 270 million doses without any serious adverse events attributed to HPV vaccine other than fainting.
In 2017, scientists reviewed all available data on HPV vaccine safety. They found 109 studies of 2.5 million people from 6 countries. There was no unusual pattern or clustering of serious adverse events after HPV vaccination.
Studies have found no evidence for autoimmune, neurological, venous thromboembolic, or any other serious health problems due to HPV vaccination.
Stokley et al., 2014
Adolescent AFIX

9. Set a QI Goal
Our next step is talk about how your patients are doing with adolescent vaccination and to set a goal for getting even more of them vaccinated.

10. Your Immunization Report Card
Keep in mind: The national goal for adolescent vaccines is 80% coverage.
[STEP 3: Share the AFIX Report Card]
Your immunization report card shows the percentage of adolescents in your clinic who have gotten each of the adolescent vaccines.
We calculated coverage using records in the state’s immunization registry.
The first column shows the number of patient records for each age group. Columns 2-4 show the percentage of patients who have been vaccinated.
Pay special attention to coverage for patients, ages 13 through 17, because these adolescents should be up-to-date on all three vaccines.
The registry indicates that you have ### patients ages 13-17; X% have received the first dose of HPV vaccine, Y% have received meningococcal vaccine, and Z% have received Tdap.
Keep in mind that the national goal for all 3 adolescent vaccines is 80% coverage.
Adolescent AFIX

11. Your clinic
How well do these coverage estimates reflect what you know about your clinic?
What are your clinic’s strengths when it comes to adolescent immunization?
Your challenges?
What quality improvement resources are available to you?
Do you have any questions about these coverage estimates?
How well do these percentages reflect what you know about your clinic?
You are doing well with Tdap and meningitis vaccination, but your HPV vaccination coverage is low.
The good news is that many providers have been successful at raising their coverage by focusing on recommending the vaccine more frequently and more effectively.
How interested would you be in trying out a few new strategies to increase your HPV vaccination coverage?
Adolescent AFIX

12. Set HPV Vaccine QI goals
Your report card includes QI goals for delivering the first dose of HPV vaccine.
Goals represent the number of patients, ages and
Goals are for all providers in your clinic over the next 6 months.
We will provide progress reports for the number of patients vaccinated at 3 and 6 months.
[STEP 4: Set a measurable goal for improving HPV vaccination]
Before we select specific strategies for improving HPV vaccination, we should set a quality improvement goal.
As shown on your report card, we recommend aiming to deliver the first dose of HPV vaccine to [###] patients, ages 11-12, and [###] patients, ages 13-17, over the next 6 months.
This goal represents an increase of 15 percentage points in your clinic’s vaccination coverage.
As you can see, the total number of HPV vaccine doses in question is modest. Remember that this goal is for all of the providers in your clinic.
Do you think this is something your clinic could try?
We’re going to be using this immunization report card to track your progress. I’ll get back in touch with you in 3 months and then again in 6 months to let you know how many of your patients have received the first dose of HPV vaccine since this meeting.
Adolescent AFIX

13. Develop an Action Plan

14. Quality improvement strategies
Primary ☐ Recommend same-day HPV vaccination for all patients by age 11
[Step 5: Select QI strategies]
Now that we have a goal, the next step is to select strategies to use to meet that goal.
One strategy that we suggest to everyone we work with is to focus on provider recommendations.
The very best way to increase your clinic’s HPV vaccine coverage is for providers to recommend the vaccine more often and more effectively.
We want to make sure that all adolescents get a recommendation by age 11.
Plus, optimizing recommendations can actually save time in the clinical encounter. We see it as a win for everyone.
How open would you be to learning more about how to help providers deliver more effective and efficient HPV vaccine recommendations?
[Recommendations = CDC Site Visit Strategy #7]
Adolescent AFIX

15. Recommendations make a big impact
Received recommendation
Here you can see the difference that a provider recommendation makes in HPV vaccination coverage.
For both girls (on the left) and boys (on the right), many more adolescents are vaccinated with when they get an explicit recommendation.
This is just one of many studies that indicate that a provider’s recommendation is the most important factor in HPV vaccine delivery.
(Stokley et al., 2014)
Adolescent AFIX

16. Brief is more effective
CDC recommends saying:
“Now that your son is 11, he is due for vaccines to help protect him from meningitis, HPV cancers, and pertussis. We will give them today at the end of the visit.”
Recommendations for HPV vaccine are most effective when providers “expect a yes.” (Perkins et al., Pediatrics, 2014)
Brief statements have been shown to be more effective than longer, open-ended approaches. (Brewer et al., Pediatrics, 2017)
CDC recommends something like this: “Now that your son is 11, he is due for vaccines to help protect him from meningitis, HPV cancers, and pertussis, We will give them today at the end of the visit.”
This recommendation is timely, emphasizes cancer prevention, and bundles the adolescent vaccines so that parents know they are all important.
Research shows that providers who are trained to use this approach increase their HPV vaccination coverage by about 5 percentage points; plus, they report that this recommendation approach saves them time. (Brewer et al., Pediatrics, 2017)
If parents decline, continue to recommend HPV vaccine at later visits because over two-thirds will eventually accept. (Kornides et al., Acad Pediatr, 2018)
Do you think this recommendation approach is something that providers in your clinic could try?
Adolescent AFIX

17. Quality improvement strategies
Primary ☐ Recommend same-day HPV vaccination for all patients by age 11 Secondary ☐ Review CDC guidelines with all immunization staff ☐ Train front desk staff on scheduling ☐ Establish standing orders ☐ Other__________________________________________________
Now let’s talk about a secondary strategy.
In addition to HPV vaccine recommendations, many clinics select 1 or more other ways to increase HPV vaccination rates.
Which of these would work best as a secondary strategy for your clinic?
[Recommendations = CDC Site Visit Strategy #7]
[Review guidelines = #12]
[Train front desk staff = #13]
[Establish standing orders = #14]
Adolescent AFIX

18. Vaccination roles in your clinic
Schedule appointments
Review and flag charts
Prescribe vaccines
Administer vaccines
Plan for next dose
Support QI efforts
[STEP 6: Create an action plan]
Adolescent vaccination is a team effort, and you will need help in carrying out your QI project.
For each vaccination role, identify providers and staff in your clinic who can help support your QI efforts.
Don’t forget to name quality improvement leaders in your clinic or health system, even if they do not have a vaccine-specific role.
Now that we’ve identified the different people involved, let’s think about who will be most important to your QI team.
What tools, training, or information will each of these people need?

19. Your QI Action Plan
Select all that apply ☐ Share copies of the Immunization Report Card ☐ Create a team of two or more people to lead the QI project ☐ Present this QI project during a regular staff meeting ☐ Engage QI leaders and immunization champions ☐ Other___________________________________________________
Now, that we’ve put together a team, let’s think about next steps in our action plan.
Here are copies of your Immunization Report Card that I’d like you to distribute to all of the clinicians and staff who have a role in adolescent vaccination.
What are other opportunities to share information about the project? For example, making a short presentation at a regularly-scheduled staff meeting is a great way to get the word out.
Who in your clinic would be most likely to provide leadership support for you and your team?
What are other steps for kicking off your QI project? (who/what/when/where)
Adolescent AFIX

20. Next steps

21. What’s next? Progress reports on QI goal at 3- and 6-months
QI project leader will receive an request to complete a brief survey
You will receive a $10 gift card for completing two surveys over three months
Although you will lead your QI project, I hope to continue to support your team.
I will be providing progress reports with you clinic’s HPV vaccination coverage in 3 and 6 months.
Please note that the person designated to lead this group will receive two online surveys: one this week and one in 3 months. We appreciate your help evaluating our programs.
Adolescent AFIX

22. MOC Part 4 – Earn 25 credits! Using the attached templates, you will:
State your HPV vaccination QI goal.
Participate in planning and execution of the QI project, data review, and team meetings.
Use data from the Report Card to evaluate your progress.
Submit the application, with a $75 fee, to the agency of your choice.
This project is an excellent opportunity to earn 25 MOC Part 4 credits.
We will templates to help you complete a Small Group QI Project Application for up to 10 physicians in your clinic.
Using the materials we’ve talked about today, you will state your HPV vaccination QI goal.
You will also need to participate in planning and execution of the QI project, data review, and team meetings.
Using data from the report card, you can evaluate your progress at the three required timepoints.
Finally, you will submit the application fee to the agency of your choice, along with a $75 fee. Fees are per project, not per person.
Adolescent AFIX

23. CME Credit
You can also earn 1.0 hour of AMA Category 1 CME credit for participating in this visit. To claim credit, you will need to complete a brief survey that will be ed to you. If you do not receive the online survey link, please contact:
By participating in this visit, you are also eligible to claim CME credit.
To claim up to 1.0 hour of AMA Category 1 credit, following this link to the complete a brief survey.
The UNC evaluation team will you a link to a brief, online survey
Please complete the survey to receive your CME certificate of completion
If you have any questions or do not receive the survey link, you can the UNC team at
Adolescent AFIX

24. Questions? Contact us. <AFIX Reviewer Name>
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Adolescent AFIX

25. Additional resources

26. References Adolescent AFIX
Apter D, Wheeler CM, Paavonen J, et al. Efficacy of human papillomavirus 16 and 18 (HPV-16/18) AS04-adjuvanted vaccine against cervical infection and precancer in young women. 2015:22(4): doi: /CVI
Brewer NT, Hall ME, Malo TL, Gilkey MB, Quinn B, Lathren C. Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial. Pediatrics. 2017;139(1). pii: e doi: /peds
Hariri S, Markowitz LE, Dunne EF, Unger, ER. Population impact of HPV vaccines: summary of early evidence. Journal of Adolescent Health. 2013:53(6): doi: /j.jadohealth
Kornides et al. Parents who decline HPV vaccination: Who later accepts and why? Acad Pediatr Mar;18(2S):S37-S43.
Markowitz LE, Liu G, Hariri S, Steinau M, Dunne EF, Unger ER. Prevalence of HPV after introduction of the vaccination program in the United States. Pediatrics. 2016:137(3):e doi: /peds
Meites E, Kempe A, Markowitz LE. Use of a 2-Dose Schedule for Human Papillomavirus Vaccination - Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR, 2016;65(49):
Perkins RB, Clark JA, Apte G, Vercruysse JL, Sumner JJ, Wall-Haas CL, et al. Missed opportunities for HPV vaccination in adolescent girls: a qualitative study. Pediatrics. 2014;134(3):e doi: /peds
National Cancer Institute. President’s Cancer Panel Annual Report
Stokely S, Jeyarajah J, Yankey D, et al. Human papillomavirus vaccination coverage among adolescents, , and postlicensure vaccine safety monitoring, United States. MMWR Morb Mortal Wkly Rep, 2014;63(29):620-4
Adolescent AFIX

27. Online resources Continuing education
CDC’s You Are the Key
CDC’s You Call the Shots
AAP’s EQIPP Immunization Track 2
Websites
CDC’s HPV for Clinicians
HpvIQ Immunization Quality Improvement Tools
MN Provider Communication Videos video-for-health-care-providers/
Adolescent AFIX

28. FAQ: Immunization Registry Data
How accurate are data in our state’s immunization registry?
The quality of registry data is improving each year. For individual providers, quality can vary by a number of factors, including interoperability with EHR systems and how often providers clean data.
What can my clinic do to improve the quality of registry data?
Review your registry records periodically to inactivate patients you no longer see. If you suspect a larger problem with electronic data exchange, contact your VFC program for additional support.
How useful are registry data for evaluating QI efforts?
Even when registry data are incomplete, they can provide a good starting place for understanding which vaccines need most attention and showing changes in coverage over time.
Adolescent AFIX