Tennessee has one of the lowest human papillomavirus (HPV) vaccination rates in the nation, and investigators at Vanderbilt University Medical Center (VUMC) are hoping to change this by improving the way medical providers present these vaccines to patients and by improving patient and patient family education.
“HPV is the most commonly sexually transmitted infection in the United States, with an estimated four out of five adults infected with the virus during their lifetime,” said Pamela Hull, Ph.D., a medical sociologist with the Vanderbilt Epidemiology Center. “Many infections are asymptomatic and resolve without long-term consequences; however, infection with some types of HPV can cause cancer, including cancers of the cervix, vagina, vulva, penis, anus, rectum and of the head and neck.”
An HPV vaccine was first licensed in the United States for females in 2006 and for males beginning in 2009.
The vaccines are recommended for those ages 11 or 12 years, and through age 26 for those who have not been previously vaccinated. Initially, the HPV vaccine was given in a three-dose series, but in 2016, the Centers for Disease Control and Prevention (CDC) recommended a revised two-dose schedule for those under age 15.
According to the CDC’s 2014 National Immunization Survey-Teen, Tennessee ranked poorly in HPV vaccination rates for both males and females, ages 13–17. Tennessee’s rate for males beginning the vaccine series was approximately 30.5 percent, and only 14 percent for series completion.
For females, vaccine initiation was approximately 47.8 percent, and the rate for series completion was just more than 20 percent, ranking last in the nation.
Hull, whose research focuses on behavioral interventions to promote cancer prevention behavior in youth, has received a five-year, $2.7 million grant from the National Cancer Institute with the goal of increasing HPV vaccinations at community-based pediatric practices. She is working in partnership with the Cumberland Pediatric Foundation (CPF), a non-profit organization that supports scientific, charitable and educational efforts to improve children’s health care services.
Improving the HPV vaccination rate has been a focus of the CPF for several years, said CPF Executive Director Lora Harnack, MSN, R.N., and the organization has teamed with VUMC and other organizations in efforts to do so, including community-based educational events and quality improvement initiatives with CPF member practices. CPF currently has 77 community-based pediatric practice locations in its membership.
“Pediatricians want to take the best possible care of their patients,” said Harnack. “In having conversations with them, we learned that a lot of physicians perceived that they were doing a lot better than they were, in terms of getting these vaccinations completed. When parents hear a strong recommendation from a clinician for their child needing the vaccination, they respect that advice.”
The study involves implementing a quality improvement project starting this summer at 22 CPF-affiliated pediatric practices in Tennessee, in which two methods of coaching will be tested for their efficacy in increasing vaccination rates.
One method will use an in-person coach — a nurse educator — who will travel to 11 of the pediatric offices to conduct a needs assessment and train staff on how the HPV vaccine should be presented to patients and their families. The second method will provide a web-based version of this service to the remaining 11 participating clinics. The clinics’ HPV vaccination rates will be measured at the study’s completion.
The clinics will also be provided patient education materials (www.get3shots.org) that were developed in a previous study under the Meharry Medical College, Vanderbilt-Ingram Cancer Center (VICC) and Tennessee State University (TSU) Cancer Partnership led by Hull; Maureen Sanderson, MPH, Ph.D. (Meharry); and Elizabeth Williams, Ph.D. (TSU); in collaboration with a Community Advisory Board.
While HPV is a sexually transmitted disease, the vaccinations should be viewed and presented by clinicians as a cancer prevention vaccine, and the best time for patients to receive the vaccinations is while individuals are pre-teens and adolescents, Hull said.
“The challenge is how to get doctors and primary care clinics to consistently make strong recommendations for HPV vaccinations and that those recommendations occur at the appropriate ages,” Hull said. “The recommended ages for the vaccine are ages 11 and 12 because that’s when the body has the best immune response and creates the best protection against the virus.”
A pilot study to test ways to improve HPV vaccination rates was done during the summer of 2015 at University Pediatrics at One Hundred Oaks.
The study included patient information materials provided before and during appointments, as well as education of the clinic’s entire staff about the HPV vaccination and how to provide a consistent message to parents, said Rachel Lenox Mace, M.D., a pediatrician at University Pediatrics.
“The study was eye opening,” she said. “We went from a vaccination rate of around 17 percent up to 67 percent in three months’ time. It was clear from our experience that families are receptive. Just by making a simple change in how we recommended this vaccine, we’ve made an important improvement that will have a long-term, positive impact on our patients’ lives.”
Debra Friedman, M.D., a co-investigator on the study and director of the Division of Pediatric Hematology and Oncology, said the importance of ongoing efforts to increase HPV vaccination rates can’t be overstated.
“There are so many types of cancer for which preventive strategies remain inadequate,” she said. “However, the HPV vaccine presents an unprecedented opportunity to significantly decrease the burden of several forms of cancer, with simply two vaccinations. We are excited to partner with our community pediatrician partners in the Cumberland Pediatric Foundation to help develop methods to increase uptake and completion of the HPV vaccine series. This will be a small step that can positively impact their patients for decades to come.”
