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HPV Vaccination

Are you doing enough to make sure your patients are protected?

An "in remembrance" photograph hangs on the wall of a primary care provider's office in suburban Philadelphia. It shows a medical assistant who was the provider's friend and coworker, and who died in 2011 from a recurrence of cervical cancer. A woman in the fullness of life, with a family to care for and a career to build, she had already done battle with treatment - along with losses of hair, weight, well-being, productivity and self-identity. But in the end, cervical cancer won the war.

Is it possible the misery of this disease might have been prevented had HPV vaccines been available when she was younger and all the promises of life stretched ahead?

Such an outcome will become less common, thanks to the availability of the highly effective and available HPV vaccines in bivalent, quadrivalent and the new nine-valent varieties.

The only rut in the road: Too many adolescents are not getting vaccinated. That's sad news "because we now have an opportunity to change the face of cancer," said Laura Hagedorn, ARNP, MSN, who practices at Orlando Health Physician Associates in central Florida. "We now have the potential to assist in the prevention of 90% of cervical cancers caused by HPV and significantly reduce HPV-related cancers and diseases in both men and women."

The Disconnect
Statistics show a disconnect that begins, inadvertently, with providers. "We know that about 57% of girls and 35% of boys ages 13 to 17 have started the three-vaccination series for HPV," said Shannon Stokely, MPH, associate director for science in the Immunization Services Division at the Centers for Disease Control and Prevention. "We need to see an increase in those rates. Yet the No. 1 reason we hear from parents about why they did not vaccinate their child is, 'My healthcare provider didn't recommend it. I didn't know it was so important.'"

Stokely added, "We know that parents view their clinicians as their most trusted source of information. Unfortunately, providers think they are recommending the vaccine, but their message isn't strong enough for the parents to really 'get it.' Parents get the sense it is an optional vaccine and not critical. This is something we have to change."

Part of the breakdown in communication and education came early on, when the vaccination was first licensed for use in 2006. It was associated with sexual activity. "I've heard of parents asking, 'Oh my God, if we give our child this vaccine will it be seen as permission to have sex?'" said Robert Smithing, NP, FAANP, clinical director of FamilyCare of Kent in Kent, Wash. "But ... there has not been any increase in sexual activity in those using the HPV vaccine compared to those who have not."

Indeed, an open door to early onset sexual activity generally isn't part of the mindset of the child (preteen age is recommended) receiving the HPV shots. "Our goal must be to get a child vaccinated early - before a first exposure to, and possible infection from - an HPV virus, because that is when the immune response is most robust," Smithing said.

A Matter of Immunogenicity
Parent confusion and lack of enthusiasm have resulted from misinformation about vaccine safety that is based on conjecture, not scientific fact, as well as an emphasis on HPV vaccination as a means to prevent transmission of infection rather than an emphasis on its role in cancer prevention, explained Tami L. Thomas, PhD, RN, CPNP, FAANP, FAAN. Thomas, associate dean of academic affairs and an associate professor at Florida International University in Miami, developed a catch phrase for the situation: "I say, 'HPV vaccination by age 11 is a matter of immunogenicity, not promiscuity.'"

She recommends three strategies to improve acceptance of the HPV vaccine. "First, build a relationship based on trust and respect with parents and caregivers; this happens over time and requires listening. Second, educate around optimal times for a child to receive vaccines by focusing on immunogenicity. I give this vaccine at ages 10, 11 and 12 because the growing body will have the best response to vaccines at these times. Third, 'norm the vaccine.' By that I mean when children go from 5th to 6th grade, they need a group of vaccines: meningococcal, Tdap and HPV. It should be regarded as just one more normal vaccine focused on providing children with a healthy future."

SEE ALSO: Who Should Be Vaccinated Against HPV?

Proactivity in Action
CDC statistics show that the HPV vaccination uptake rate has been lowest in the southeastern states. In August 2013, published vaccine rates in Florida were lower than the national average, prompting Orlando Health Physician Associates to take a proactive stance. "We developed a multi-pronged quality improvement project aimed at increasing our vaccination rates," Hagedorn said. "This involved total transparency within the pediatric division. We had numerous education sessions for NPs, doctors and all staff, and utilized multiple patient engagement methods. We immediately saw results."

Hagedorn said that over a 16-month period, the practice's vaccination series completion rates increased by 55% in girls and 321% in boys, versus annual increases in the National Inpatient Sample teen rates of 12.6% and 104%, respectively.

Hagedorn said it is a goal of the practice to be sure parents are comfortable talking about the vaccinations with everyone on a healthcare team, from clinicians to the scheduling staff. "Now when patients come into the office, the staff member checking them in will initiate the vaccine conversation based on our pre-visit provider planning." In short, emphasis is something that cannot be overlooked. "This is our responsibility," Hagedorn said. "Parents trust us to care for their children. As long as we are knowledgeable about HPV vaccination, can educate on it and recommend it, they will vaccinate."

Tough Talk
Lois McGuire, RN, MSN, WHNP, specializes in women's health at the Mayo Clinic in Rochester, Minn. "This is the first vaccine we have ever had that can prevent a common cancer; it's a really big deal," she said.

She noted that while emphasis should not be placed on the stigmatizing STI aspect, neither can clinicians overlook reality.

"While smoking-related cancers of the throat and tongue have decreased, throat and tongue cancers caused by HPV 16 and 18 have increased astronomically. In middle school and high schools, some students think oral sex isn't really 'sex,'" she explained.

To drive the point home, she noted that HPV as a cause of oral and throat cancers has increased from less than 20% in 1988 to more than 70% today. The existence of youthful sexual experimentation simply serves as another imperative to have young patients vaccinated.

Yet with all the statistics in play, McGuire conceded that providers often stop short at delivering the harshest reality of failing to vaccinate a child. "Considering 3 out of 4 people acquire HPV in their lifetime, perhaps we should say, 'How would it feel to watch your child die from an HPV-related cancer and know you could have done something to prevent it?'"

It may require tough talk like that to help the vaccination rates approach the now distant Healthy People 2020 objectives of 80% coverage. The CDC is looking to the medical community to push those rates up, and it recently launched a clinician-targeted campaign to propel providers' efforts.

"We are really trying to improve those discussions in providers' offices and give tools to clinicians to help them be more effective in driving home the point that children should be vaccinated by 11 or 12," Stokely said.

She suggested that NPs take advantage of the "You Are the Key" resource area on the CDC website (, designed specifically for clinicians trying to improve their discussions about HPV vaccines. "One tool included is a 'Tips and Timesavers' help sheet that provides specific language for discussion as well as a dozen of the most frequently asked questions providers are likely to encounter," Stokely said.

The website also provides a video clip of Daron Ferris, MD, a professor of obstetrics and gynecology at Georgia Regents University Cancer Center. Here is part of his stark statement:

"To tell a patient they have cancer - particularly a cancer that could have been entirely prevented - is terribly depressing. . Why it's not given to so many young individuals to prevent these horrible things from happening, I have no idea ."

Valerie Neff Newitt is a staff writer. Contact:

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