1. Observations from the Well: ALERT IIS Data and HPV
Steve Robison
Immunization Epidemiologist
Oregon Immunization Program

2. So What is the ALERT IIS?
ALERT data In the past
Alert IIS is Oregon’s all-age immunization information system.
ALERT IIS is one of the most complete childhood IIS in the U.S. according to the CDC.
Most shots are reported in real- time to ALERT IIS through bi- directional exchanges with EHRs.
ALERT today

3. HPV and Teen Shots in Oregon
ALERT IIS is used for adolescent rates every May (synched to school year).
233,000 teens age 13 to 17 with a tdap in Oregon, and 178,000 with at least one HPV.
Almost 1,600 sources reported HPV for teens- around 500 private practices with more than 20 teen clients included.
So are there 233,000 stories for teens, why or why not HPV?
Are there 1,600 stories for providers?
Goal of analysis using ALERT IIS- looking for commonalities across all individual stories.

4. Oregon HPV Immunization Rates
Patterns:
Rates of HPV initiation and completion are slowly increasing in Oregon.
Increases are happening across all categories of race/ethnicity.
Starting HPV on-time and completing HPV series are closely linked.
Rural-Urban and northern-southern region disparities exist in Oregon for HPV.

6. Oregon 2019 Adolescent Age 13-17HPV UTD Rates

7. Oregon HPV Vaccination by Race/Ethnicity, Age 13-17
HPV Initiation HPV Completion(UTD)
White 62.9% % 43.1% %
Black 69.2% % 47.1% %
AIAN 72.7% % 51.3% %
Asian 68.2% % 48.0% %
NHPI 68.9% % 45.5% %
Latino 72.1% % 48.0% %
note: categories are not mutually exclusive

8. Starting vs Completing
The problem of HPV completion is a problem of timely HPV initiation
Teens who start on time are 1.4 times as likely to complete the HPV series as those who start late.

10. Teen HPV Immunization Failures
What we see can be characterized by one of:
Putting off immunizations
Getting only school-required immunizations
Preferring to get/give only one teen shot at a time
Prioritizing other immunizations as Meningococcal over HPV.
Limited teen vaccinations per visit and HPV non-prioritization explain 76% of teens without complete HPV series.

11. Oregon Counties by Rates of Teens Age 13-17 Who Never
Receive More Than One Shot per Visit(Age 9+)
Clatsop
Columbia
Multnomah
Hood
River
Washington
Tillamook
Yamhill
Lincoln
Polk
Clackamas
Marion
Benton
Linn
Lane
Douglas
Coos
Curry
Josephine
Jackson
Klamath
Lake
Harney
Crook
Jefferson
Deschutes
Wasco
Sherman
Gilliam
Grant
Wheeler
Malheur
Baker
Umatilla
Wallowa
Union
Morrow

12. Provider or Parent?
Shot-limited and school-only teen immunization patterns reflect a true missed opportunity.
Teens age that don’t have co-administered vaccines almost never become complete for HPV.
Does this reflect on parent reluctance, provider lack of enthusiasm, or the interaction of parent and provider?
Does lack of HPV initiation relate to prior immunization patterns too?

13. 33% of teens
18% of providers
10% of teens
29% of providers

15. Urban-Rural Differences and Shot Limited Teens
Nationally a gap has been found between urban and rural teens for HPV.
In Oregon, urban teens are 1.2 times as likely to become HPV UTD as teens in rural settings.
When controlling for shot-limited and school-only immunizations, there is no longer a visible urban-rural difference.

16. Prior Immunization History
Does a teen’s prior and early history of immunization predict whether they will get HPV immunization?
Hard to assess as many children move in and out of state.
One way is to only look at teens who
Were born in Oregon, &
Have evidence of still being here such as having school-required tdap.
About 93% of Oregon teens get a tdap by the 7th grade.

18. 24% of OR-born w/tdap

20. Prior History Vs HPV Initiation
There is a very black and white relation between getting pretty much everything on the ACIP schedule (other than flu) and starting HPV.
Getting everything doesn’t mean getting it on time.
Missing a few shots versus missing a lot has the same effect on HPV initiation.
This suggests a stronger role for providers than parents.

21. Crystal Ball Time
Based on prior immunization history, how much can we expect HPV initiation rates to increase in the future?
2019 HPV initiation rate: 70.5%
In ten years (2029), given current childhood patterns: 76%
If we want to do better than this, then we need to:
Improve provider catch-up and reduce missed opportunities at all ages
Increase provider recommendations of HPV
Reduce the rate of school-only or shot limiting among teens.

22. Caveat for Projecting Immunizations to Disease
Immunization profiles for Oregon teens may not translate to HPV risk for Oregon adults.
Roughly half of teens will move out of Oregon as adults-
and about half of current young adults have moved into Oregon.

23. Questions?
Contact information: