2. Mandatory Adolescent Vaccinations (HPV) Molina Allen Josha Harvey

3. Objectives Understand the purpose of the Human Papilloma Virus (HPV) vaccine and its issue involving nursing care Have an understanding of the research, policies, financial, political and ethical concerns regarding the HPV vaccine Recognize implications and consequences related to concerns regarding the vaccine Identify pertinent recommendations related to the HPV vaccine and nursing care

4. Introduction HPV is the most common sexually transmitted infection in U.S. (Markowitz, et. Al, 2014) Can cause cancer in women and genital warts in men and women Debate whether or not to mandate immunizations

5. Assessment Research ▫ HPV in U.S.  Most common sexually transmitted disease  26.8% of girls/women infected  44.8% between 20-24 years old  Cause of genital warts and certain cancers in both men and women (Gostin, 2011) Policies ▫ FDA  Approved prophylactic HPV vaccine for females ages 9- 26  Gardasil & Cervarix ▫ Advisory Committee of Immunization Practices (ACIP)  Advises vaccination of females/males age 11-12 ▫ Mandates  Texas (currently revoked), Virginia, District of Columbia

6. Assessment Financial ▫ Cost: 3 doses total $400-$1000+  Insurance coverage?  State Health Departments burdened  Physician reimbursement post-vaccination (Gostin, 2011) Political ▫ Merck Lobbyist Campaign (Maker of Gardasil)  Governor Rick Perry – Received $28,500  Republican Governors Association – Received $377,500 (Gostin, 2011)  HPV Debate HPV Debate Ethical ▫ Mandating females only  Vaccination is safe and effective for males  Parent’s right to refuse  Morality

7. Assessment Nursing Practice ▫ Patient Education  Sexual Education - Preventative  Protection that HPV vaccination does/does not offer  Cervical cancer screening ▫ Payment Assistance  Vaccines for Children program  VFC Website VFC Website Quality/Safety ▫ CDC, 2014  Over 57 Million doses administered  No serious safety concerns  May be given concurrently with: TDAP, meningococcal, and influenza vaccines

8. Assessment Root Cause Analysis (5 Ways Method) Problem Statement: According to the CDC (2014), HPV vaccination rates continue to remain low with 57.3% receiving first dose compared to goal of 91.3%. 1. Why does there continue to be lack of knowledge despite aggressive marketing from Merck and the CDC? 2. Why do there continue to be misconceptions about the safety of the vaccine? 3. Why have 1/3 of eligible adolescent girls not received the first dose during their well-child visit? 4. Why do parents/patients feel the vaccination is not needed? 5. Why are some physicians not recommending vaccination?

9. Implications & Consequences Why does there continue to be lack of knowledge despite aggressive marketing from Merck and the CDC? ▫ Sexual topics still may be taboo ▫ Some parents feel vaccination would encourage sexual activity ▫ Believe it is not needed or necessary ▫ Difficulty explaining to child reason for shots ▫ Resistance from child (Gostin, 2011) Outcome: Continued efforts to educate and dispel misconceptions will increase public knowledge that the vaccination may prevent up to 2/3 rd of cervical cancer. (CDC, 2014).

10. Implications & Consequences Why do there continue to be misconceptions about the safety of the vaccine? ▫ Parents wary of “new” vaccine ▫ 2009-2014: 719,000 doses, 25,176 adverse side effects  Syncope, Dizziness, Nausea, Headache  Injection Site Reactions (CDC, 2014) ▫ Rare Complications  Guillain-Barre Syndrome  Deep Vein Thrombosis  Auto-Immune Response Outcome: To combat public skepticism, research based facts and figures must be presented to the public in a meaningful way.

11. Implications & Consequences Why are eligible adolescent girls not receiving the first dose during their well-child visit? ▫ Not sexually active  Vaccination should be received prior to becoming sexually active  Adolescent girls potentially exposed once sexually activity begins  May encourage initiation of sexual health communication  Parents Perceptions are Preventing HPV Vaccination Success Parents Perceptions are Preventing HPV Vaccination Success Outcome: Increase communication between parents, physician, and child on sexual health issues during well-child visits and increase child’s involvement in health care management.

12. Implications & Consequences Why are some physicians not recommending vaccination? ▫ Only 34.6% of physicians “always” recommend HPV vaccination ▫ Pediatricians more likely than Family Practitioners or OBGYNs ▫ Research Findings  Hispanic doctors have highest recommendation rates  Cervical cancer rates are increased in Hispanic women  Physicians’ 40-49 years old more likely to recommend (Vadaparampil et al., 2011) Outcome: Encourage primary care provider participation through reimbursement incentives and providing pamphlets to give to patients.

13. Recommendations ▫ Mandating the HPV vaccination has been met with distrust and resistance ▫ Alternatives:  Improve communication opportunities between provider and patients/parents  Provide physicians with educational packets and patients pamphlets containing clear and easily understood information  Continue campaigns that convey the message that the HPV vaccination can prevent cervical cancer and other types of cancer and is beneficial for both males AND females

14. Recommendations Education ▫ Patients/Parents  What it is for  Why it is recommended for patients  Possible consequences for not getting vaccinated  Safe sex/STI/Abstinence education  Most effective between ages 11-12 Get involved if you want your state to mandate the vaccine

15. Conclusion HPV is a very common sexually transmitted infection in the United States, which, has been linked to cancer and genital warts. There have been two vaccines approved for adolescents. The vaccine has been mandated infrequently; however, different states have developed policies regarding the vaccine. There are still many things that have to be taken into consideration such as ethical, financial, quality and safety concerns, as well as cultural morals. It is uncertain whether or not mandating the vaccine will continue to be pushed for in the future; however, increasing public awareness, education, and provider’s willingness to discuss vaccination may increase rates of first dose administration to the CDC’s goal of 91.3%.

16. References American Cancer Society. (2014). HPV vaccines. In Learn about cancer. Retrieved from http://www.cancer.org/cancer/cancercauses/othercarcinogens /infectiousagents/hpv/humanpapillomavirusandhpvvaccinesfaq/hpv-faq-vaccine-cost Center for Disease Control and Prevention [CDC]. (2014). HPV also known as Human Papillomavirus. In Diseases and the vaccines that prevent them. Retrieved from www.cdc.gov/hpv CDC. (2014). Teen vaccination coverage. In Preteen and teen vaccines. Retrieved from http://www.cdc.gov/vaccines/who/teens/vaccination-coverage.html Gostin, L. (2011). Mandatory HPV vaccination and political debate. Journal of American Medical Association, 305(15), 1699-1700. doi: 10.1001/jama.2011.1525 Katterfelto, A. (2011). Heated debate about mandatory vaccinations in Texas. Retrieved from https://www.youtube.com/watch?v=VQnrmyq8Qaw Markowitz, L. E., et. Al. (2014). Human Papillomavirus Vaccination: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6305a1.htm Mayo Clinic. (2013). Parental perceptions are preventing HPV vaccination success. Retrieved from https://www.youtube.com/watch?v=ApbzIYdzE6k McRee, A. & Reiter, P. (2010). Vaccinating adolescent girls against human papillomavirus–who decides? Preventative Medicine, 50, 213-214. doi: 10.1016/j.ypmed.2010.02.001 National Conference of State Legislatures [NCLS]. (2015). HPV vaccine policies. Retrieved from http://www.ncsl.org/research/health/hpv-vaccine-state-legislation-and-statutes.aspx Vadaparampil, S., Kahn, J., Salmon, D., Lee, J., Quinn, G., Roetzheim, R.,... Halsey, N. (2011). Missed clinical opportunities: Provider recmmendations for HPV vaccination for 11-12 year old girls are limited. Vaccine, 29 (2011), 8634- 8641. doi: 10.1016/j.vaccine.2011.09.006 Zimet, G., Rosberger, Z., Fisher, W., Perez, S., & Stupiansky, N. (2013). Beliefs, behaviors and HPV vaccine: Correcting the myths and the misinformation. Preventative Medicine, 57, 414-418. doi:10.1016/j.upmed.2013.05.-13