Talking About the HPV Vaccine

CMS adopts policies to encourage full compliance
By Elizabeth Sidney

The Chicago Medical Society’s public health mission remains as steady as ever, evolving to meet local needs. That commitment was on full display last Sept. 30, when the CMS Governing Council took multi-pronged action aimed at boosting HPV vaccination rates, particularly among boys. Under a new measure, CMS will push for making the full HPV vaccine series a routine part of health care for all adolescents and young adults. Physician education is a big part of that effort.

The initiative comes after talks between CMS President Kathy Tynus, MD, and City Health Commissioner Julie Morita, MD, on how our organizations can collaborate on projects. Support for HPV immunization and screening is the latest example of CMS acting to reinforce the work of public health agencies. Prior to passing the measure, the Society’s Public Health Committee met to lay the policy groundwork. As a first step, the committee heard testimony from Dr. Morita, on HPV vaccine progress in the City of Chicago.

Immunization campaigns typically concentrate on girls in order to prevent cervical cancer. Yet by 2020, HPV-oropharyngeal cancer will likely become the most common form of HPV-related cancer, with boys at higher risk due to their lagging immunization rates, Dr. Morita notes. Consensus continues to build that immunization can protect boys over a lifetime from oropharyngeal cancer.

Physician Education

HPV-related continuing medical education forms a key plank in the Medical Society’s new platform. Along with providing clinical information, the CME will give practical advice on aggressive follow-up with patients, discussing the vaccine with parents, and arranging appointments to ensure full vaccine compliance. Physicians need to discuss HPV and potential cancer risks with patients and their parents, framing the vaccine as a preventive health measure against cancer. Getting teenagers to cooperate may call for using graphic case examples.

The measure seeks the full integration of HPV vaccination into all health care settings, as part of the office visit for adolescents and young adults. It also supports the development and funding of programs targeted at HPV.

When Less is More

Dr. Morita encourages adolescent health care providers to “strongly recommend HPV vaccination with the same minimal dialogue and attention given to other pediatric and adolescent vaccines.” She calls this the “less is more” approach to discussing the issue with parents.

Dr. Morita offers the following script:

“Today Miraya is due for three routine vaccines, which include the meningitis vaccine, Tdap, which is tetanus, diphtheria and whooping cough; and HPV, which is Human Papillomavirus vaccine. The nurse will be right in to administer those vaccines, and I look forward to seeing you next year.”

Reporting in the American Journal of Public Health, Dr. Morita and colleagues gave highlights of the approach’s effectiveness, by comparing HPV vaccination rates before and after the educational intervention. The comparison looked at 42 Chicago clinics that provide care to at least 200 patients ages 13-17. Results to date show that coverage for both single and three vaccine doses shot up from the pre-intervention period in Chicago clinics. Over a one-year period ending January 2015, both single and three vaccine doses rose from 50.2% to 57.4%, and 15.4% to 21.2%, respectively. Among females, coverage for one and three doses rose from 52.6% to 59.1%, and 19.4% to 24.6%, respectively.

Citywide public education was highlighted in the CDC’s annual National Immunization Survey-Teen. This campaign to improve vaccine acceptance and awareness among patients and parents led to significant increases. In July, the City announced that 78.1% of females in Chicago had their first HPV vaccine dose in 2014, up from 57.6%, in 2013. Within this group, 52.6% received all three vaccine doses, up from 36.5% a year earlier. Coverage levels among Chicago males increased also, with 64.9% receiving their first dose in 2014; within that group, 26.1% had all three doses. In 2013, 45.8% of Chicago males had received the first dose of HPV vaccine; only 18.5% got all three doses.

High-risk HPVs cause cervical, anal, oropharyngeal cancer and rare forms such as vaginal, vulvar and penile cancer, according to the National Cancer Institute. High-risk HPV types cause about 3% of all cancers in women and 2% of all cancer cases among men in the United States.

The updated American Academy of Pediatrics HPV vaccine recommendations include all children ages 11-12, as part of the adolescent immunization platform. Females should receive three doses of 9vHPV, 4vHPV or 2vHPV, while males should receive three doses of 9vHPV or 4vHPV. The second dose is given one to two months after the first dose, and the third dose at least six months after the first dose, according to the AAP.

Physician offices should schedule follow-up appointments after the first dose is given and utilize reminder systems to help get all three doses to each child, Dr. Morita stresses.

The CDPH has set a goal of 80% coverage by the year 2020.