1. Thomas Weiser, MD, MPH Medical Epidemiologist Portland Area Indian Health Service Northwest Portland Area Indian Health Board

2. Before vaccines, parents in the United States could expect that every year:  Polio would paralyze 10,000 children.  Rubella (German measles) would cause birth defects and mental retardation in as many as 20,000 newborns.  Measles would infect about 4 million children, killing 3,000.  Diphtheria would be one of the most common causes of death in school-aged children.  A bacterium called Haemophilus influenzae type b (Hib) would cause meningitis in 15,000 children, leaving many with permanent brain damage.  Pertussis (whooping cough) would kill thousands of infants.

3. Today…  Polio has been eradicated in the western hemisphere and remains endemic in only 4 countries (India, Pakistan, Afghanistan and Nigeria)  Only 30 cases of rubella were reported in the past 5 years, and only 5 case of congenital rubella syndrome  On average, only 118 cases of measles were reported annually over the past 5 years. There were 8 deaths from measles from 2000-2010. The majority of these cases occurred in individuals from other countries or unvaccinated US travelers to endemic countries.  No more than 5 cases of diphtheria have been reported in the US in any given year since 1980 and only one in the past 5 years  Haemophilus influenzae type b (Hib) infection has been reduced 99% since first vaccine introduced in 1985 averaging just 24 cases annually over the past 5 years  Pertussis cases were reduced to less than 2000/year in 1980s but have increased in recent years, averaging 23,408/year over the past 5 years. From 2006-2010, there were 79 deaths from pertussis

4. Immunization Schedules  More complex  More shots  More protection  More controversy

5. 2014 Immunization Schedule

7. Recent/New Immunizations  Pneumococcal- 2000  Meningococcal- 2005  Hepatitis A- 2006  Tdap- 2006 (for adolescents)  Human Papilloma Virus- 2007  Rotavirus- 2008 (Rotarix)  Influenza- 2008 (for children 6 mos-18 yrs)  H1N1 Pandemic Influenza (A) - 2009

8. Concerns About Safety  Autism- most recent studies have concluded that there is no link between MMR or thimerosol and autism  Landmark study recently retracted by Lancet  http://www.chop.edu/video/vaccine-separating- fact-from-fear/home.html?item=6 http://www.chop.edu/video/vaccine-separating- fact-from-fear/home.html?item=6  Chronic Illness- studies have found no link between immunizations and multiple sclerosis, ADHD, diabetes, inflammatory bowel disease or SIDS

9. Human Papilloma Virus (HPV)

10. Human Papilloma Virus  Genital human papillomavirus (also called HPV) is the most common sexually transmitted infection (STI)  There are about 40 types of HPV that can infect the genitals and reproductive organs of men and women. Some types of HPV cause cervical and other cancers (types 16,18), other types of HPV cause genital warts (6, 11, 16, 18). HPV is not the same as herpes or HIV (the virus that cause AIDS). All three viruses can be passed on during sex, but they have different symptoms and cause different health problems.

11. Human Papilloma Virus  HPV is so common that most adults get it at some point in their lives. Most never know they have it.  HPV is most common in young people in their late teens and early 20’s.  The incidence of cervical cancer among American Indian and Alaska Native women compared to non-Hispanic white women is relatively high.

13. HPV Vaccine  ACIP has recommended HPV vaccine for 11-to-12-year old girls and boys and given in a series of three shots over six months. It is important to get all three doses to get the best protection.  HPV vaccines have been studied in the U.S. and around the world, and serious side effects are rare.  When all three doses are received, HPV vaccine is very effective against the types of HPV that are included in the vaccine, the ones most likely to cause cancer.  Two HPV vaccines are available to protect against HPV types that cause most cervical cancer-Cervarix and Gardasil.

14. Facilitators and Barriers to HPV Vaccination  AI/AN youth younger than 19 years of age can get vaccines free through the Vaccines for Children (VFC) Program.  IHS, tribal and urban Indian Health Clinics participate in the VFC program.  Perceived barriers to HPV vaccinations for adolescents include parental concerns, safety, and moral/religious concerns.  Funding was the main barrier for 19-26 year olds.  Provider education should stress pregnancy testing is not needed before vaccination.  Importance of communicating the need for continued cervical cancer screening.

15. HPV Vaccination Reporting  National Immunization Reporting System (NIRS)  Indian Health Service web-based reporting system for collecting quarterly immunization data, including HPV  The Immunization Coordinator from each tribal clinic enters data from their RPMS report into the NIRS data entry screens.  Reports are automatically aggregated for the Portland Area and Nationally for monotoring of immunization coverage.

16. FY 2014 2nd Quarter Report

17. Take Home Message  HPV vaccine is safe  HPV vaccine is effective  Initiation of the HPV series is high for girls (84%) but completion is low (59%)  HPV vaccination initiation and completion are much lower for boys (63% receive 1 dose, 21% receive all 3) but this is improving  Need to make sure that girls and boys receive all 3 doses before becoming sexually active

18. A qualitative study of immunization providers and community members Understanding Low Childhood Immunization Rates

20.  Is low reported immunization coverage simply a data question?  Are NW AI/AN communities hesitant or resistant to immunizations like many non- AI/AN communities in the NW?  Do elders play a supportive role in immunizations through their experience with vaccine-preventable diseases? Hypothesis-generating Questions

21.  Email survey of healthcare workers in ID and OR clinics  Interviews with healthcare workers in ID, OR and WA clinics (n=33)  Focus groups with community members from AI/AN communities in OR and WA  Focus groups 3 focus groups 1 (OR), 2 (WA) with approximately 36 total participants Methods

22.  Major themes included:  Mistrust/Fear  Inadequate information  Parental logistical concerns  Poor clinic reputation  Community and personal aversion to immunizations  Belief in natural immunity/natural lifestyle Focus Group Barriers

23.  Information  Making information understandable  Advertising, newsletters, handouts  Personal Experience  Having had the disease or a child with the disease  Community Support and Trust  Clinic Support  Providers with time/ability to educate in plain language  Having pediatricians was perceived as increasing confidence and acceptance of immunizations Focus Group Facilitators

24.  Develop patient education tools endorsed by Tribes and Tribal organizations trusted by community members  Develop healthcare provider education tools to help providers talk to patients more effectively  Share “Best Practice” recommendations for improving immunizations services Next Steps

26. Contact: Thomas Weiser, MD, MPH Portland Area IHS/NPAIHB Immunization Program 503-416-3298tweiser@NPAIHB.org Clarice Charging 503-416-3256ccharging@NPAIHB.org