HPV Vaccination Barriers

December 9, 2014
Sherrie Flynt Wallington, PhD
Assistant Professor of Oncology
Program Director, Health Disparities Initiative
Lombardi Comprehensive Cancer Center
Georgetown University Medical Center

Objectives
Educate parents and adolescents to improve knowledge and reduce barriers
to HPV vaccination initiation and completion
Work with health providers to give a Provide strong referrals for HPV
vaccination

Identify missed opportunities for HPV vaccination within health provider

clinical practice
Support implementation of HPV reminder recall notifications

Provide appropriate care and counsel for patients and their families.

Summary

HPV Clinical Features

Most HPV infections are asymptomatic
and result in no clinical disease
Clinical manifestations of HPV infection
include the types shown below
Anogenital
Warts

Recurrent
Respiratory
Papillomatosis

Cervical
Cancer
Precursors

Cancer
(cervical, anal,
vaginal, vulvar,
penile, head,
and neck)

Age-adjusted rate per 100,000 females

HPV-Associated Cervical Cancer Rates

by Race and Ethnicity, U.S., 19982003
16

14.2
14

12.6

12
10

8.4

8.3

8.4

API

Non-Hispanic

8
6

4
2
0
White

Black

RACE

Hispanic

ETHNICITY

This graph was adapted from Watson M, Saraiya M, Benard V, Coughlin SS, Flowers LC, Cokkinides V, Schwenn M, Huang Y, Giuliano AR.
Burden of cervical cancer in the United States, 19982003.
Cancer 2008;113(S10):28552864.

HPV Vaccine Safety

57 million doses of HPV vaccine distributed in
US from 2006 2013 (many more abroad)
The most common adverse events reported
were considered mild (e.g., sore arm)
For serious adverse events reported, no unusual
pattern or clustering that would suggest that the
events were caused by the HPV vaccine
These findings are similar to the safety reviews
of MCV4 and Tdap vaccines

DC HPV Vaccine Uptake

Estimated vaccination coverage with selected vaccines and doses* among
adolescents aged 1317 years, by HHS Regions/state/area -- National
Immunization SurveyTeen

Females (N=8,264)

US National
Dist. of
Columbia

Males (N= 9,554)

1 HPV

2 HPV

3 HPV***

1 HPV

2 HPV

3 HPV***

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

57.3(1.9) 47.7(2.0) 37.6(1.9) 34.6(1.9) 23.5(1.7) 13.9(1.4)

55.6(14.6)

43.0(14.4)

30.2(12.3) 67.7(13.9) 40.2(14.5) 24.5(13.0)

Source: National Immunization SurveyTeen (NIS-Teen), United States, 2013

HPV
Road
Blocks

Family/Parent Barriers

Lack of knowledge
Health literacy issues
Efficacy
Concern about
appropriateness
Cost
$360 for the series

HPV Mandates
Sexual promiscuity
Age appropriateness
Dempsey AF et al. Pediatrics. 2006; 117:1486-1493

State Proposals to Educate, Mandate, or

Reimburse for HPV Vaccine

National Conference of State Legislators: www.ncsl.org

 7-1651.04.

Human Papillomavirus
Vaccination Program
By the beginning of the 2009 school year, and of every school year
thereafter, the parent or legal guardian of a female child enrolling in
grade 6 for the first time at a school in the District of Columbia shall
be required to submit certification:
That the child has received the HPV vaccine; or
That the child has not received the HPV vaccine because:
It violates his or her religious beliefs;
The vaccination is medically inadvisable; or
The parent or legal guardian has signed an opt-out form.

This current HPV legislation is expressly applicable to female

students with the authority to extend the program, through
rulemaking, to males. A rule to include males is pending.

10

Media Frenzy

SUNDAY, JUN 2, 2013 03:38 PM EDT

Michael Douglas: HPV caused my throat cancer

"Without wanting to get too specific, this particular cancer
is caused by HPV," Douglas said in a recent interview
BY KATIE MCDONOUGH

NO HPV
Shots
For Me

Separating Myth from Fact

Why does my son

need the HPV
vaccine?
He does not
have a cervix.

SUNDAY, JUN 2, 2013 03:38 PM EDT

Michael Douglas:
HPV caused my throat cancer
"Without wanting to get too specific, this particular cancer is caused by
HPV," Douglas said in a recent interview
BY KATIE MCDONOUGH

By RYAN JASLOW /
CBS NEWS/ June 3, 2013, 12:42 PM

Oral sex and throat cancer:

Michael Douglas HPV report
spotlights epidemic

By RYAN JASLOW /
CBS NEWS/ June 3, 2013, 12:42 PM

Katie Couric:
Admits disproportionate reporting
on HPV Vaccine

Methodological Tools
Community
Assessments
Focus Groups
Key Informant
Interviews
Randomized
Controlled Trials
Asset Mapping

Social Network
Analyses
Photo Voice
Logic Models
Mixed-Methods

Providers

Target Key Stakeholders

Pediatricians
Adolescent Health Physicians
Family Medicine Physicians
Nurse Practitioners
OB-Gyns
School Nurses
Parents
Adolescents

Physicians play a key role by

providing information on benefits
of vaccination
Physician recommendation
is reported by parents as one
of the top reasons for receipt
of recommended vaccines

Gargano et al, 2013

Williams et al. 2013

Pilot Program Curriculum

Facilitator: Sherrie Flynt Wallington, PhD
Modules

Brief Description

Core Competence

Module 1:

Goals are to improve knowledge of

factors (i.e. health provider,
parental, and adolescent) that may
be barriers to HPV vaccination
initiation and completion.

Improved Knowledge

Goals are to define what a strong

HPV provider referral is and identify
missed opportunities for HPV
vaccination in health provider
clinical practices

Improved Knowledge
Performance

Goals are to improve and refine

knowledge about the importance
and practice of HPV Reminder
Recall Notifications

Improved Knowledge
Performance

HPV and HPV

Vaccine Barriers and
Opting Out
Module 2:
The Art of the Strong
Referral & Missed
Opportunities
Module 3:
HPV Reminder Recall
and HPV Vaccine
Reminder Recall &
Notification

DOH HPV Provider Trainings & Tool Kit Distribution

Date

Provider Types

Site/Location

# Tool Kits
Distributed

July 8, 2014

Physicians, NP,
Medical Assistants

School-based Health Centers and

Adolescent Health, Unity Health
Care Inc.

15

July 16, 2014

Physicians, NP,
Medical Assistants

Marys Center
3912 Georgia Avenue, NW
Washington, DC 20011

60

July 30, 2014

Physicians, NP,
Medical Assistants

Childrens National Medical Center

111 Michigan Avenue, NW
Washington, DC 20010

55

August 28, 2014

Physicians, NP,
Medical Assistants,
Medical Students

Gallaudet University
800 Florida Ave NE, Washington,
D.C. 20002

125

Subtotal
November 19, 2014

DC School Nurses

Peoples Congressional United

Church of Christ

Continuing Education Units -1 credit hour

255
40 anticipated

Partnerships
DC Chapter of the American Association
of Pediatricians
DOH staff participated in planning and presented in
the May AAP HPV Meeting

DC Managed Care Organizations

HPV Presentations at local meetings
Presenter: Sherrie Flynt Wallington, PhD

DC Public School Nurses

HPV training presentation
Presenter: Sherrie Flynt Wallington, PhD

Stakeholder
Tool Kits
Tool Kit Components
HPV Facts
HPV clinical educational materials

Barriers to HPV vaccination

initiation and completion
Frequently asked questions about
HPV vaccine safety
DCs HPV vaccination Legislation

Tips and time-savers for talking with

parents about the HPV Vaccine
The art of making a HPV Vaccine
strong referral
Immunization resources and HPV
vaccination reminder/recall
notification strategies

Provider HPV
Communication Strategies
In your communication with parents and
adolescents:
Frame your communication and discussion
around cancer prevention rather than the
sexually transmitted aspect of the virus
Discuss the HPV vaccine as you would
any ACIP-recommended vaccinations
Use gender-neutral messages
Give a strong HPV vaccine referral
Be cognizant of the cultural, religious,
and linguistic barriers

Adolescents
& Parents

Parents Have Little

Knowledge About HPV

Why is this vaccine needed?

What is HPV?
Is HPV common?
How is HPV spread?

Preliminary Findings:
Black & Hispanic Mothers
Misconceptions Regarding
HPV and HPV Vaccine

Obstacles to
HPV Vaccination of Daughters

Understood HPV was related to breast

cancer, not cervical cancer
Not aware of opt-out option:
vaccinated daughters out of fear they would
not be allowed to enroll in school
Lack of understanding regarding
reproductive anatomy
(i.e., not knowing where their cervix was)

No awareness of DC mandate to
vaccinate daughters
No understanding of HPV or HPV vaccine
Pediatricians or other doctors
were reluctant to vaccinate

Did not know HPV is transmitted sexually

Cultural value is not to question doctors

Believed HPV is the same thing

as AIDS/HPV

Daughters refused to complete vaccine

series due to fear or pain of injection
Demanding schedules of parents limited
ability to initiate or complete vaccine series
Cultural constraints, such as reluctance
to talk about reproductive subjects
with family or health provider

Believed you can get HPV from the vaccine

Men can not get HPV

Preliminary Findings:
Black & Hispanic Daughters
Misconceptions Regarding
HPV and HPV Vaccine
Did not know HPV is transmitted sexually
Lack of understanding regarding
reproductive anatomy
(i.e., not knowing what or where
their cervix was)
Mothers never discussed HPV with
daughters, so they believed it did not apply
to them

No understanding of HPV or HPV vaccine

Boys can not get it

Some daughters described the shots as

painful so they did not complete the series

Believed HPV could be transmitted only

female-to-male, not male-to-female
Fatalistic attitude to getting or
dying from cancer

Obstacles to Taking
HPV Vaccination
No awareness of DC mandate

Mothers that did vaccinate daughters

sometimes did it without the daughters
knowledge or understanding

Heard media stories of girls dying

from the vaccinations
Their schedules or parents schedules
prevented initiating or completing
vaccine series

Communication Campaign

Sample DC Media
Advertisements
Web (Hyperlink)

Emblem

Transit Ad

Newspaper Ad
Web Ad (Radio & CBOs)

HPV Research
Testing the Feasibility of an HPV Educational Intervention with a
Cellular Phone and Text Messaging Component--American Cancer
Society: Grant # ACS #IRG-97-152-17

Assessing HPV Mandates through a Public Health Law Lens: A

Study of the District of Columbias HPV Mandate-- Robert Woods
Johnson: Grant #68428
An HPV Health Communication Randomized Controlled
Trial Intervention
National Cancer Institute Mentored Career Development Award to
Promote Diversity (K01): Grant #1K01CA155417-01A1
HPV Knowledge Awareness and Vaccine Acceptability among Inner
City Black Males(R03): Grant #1R03CA165147-01A1

Acknowledgements
DC Chapter of the American Academy of Pediatrics
DC Department of Health
Lucile L. Adams-Campbell,
Lombardi Comprehensive Cancer Center,
Georgetown University Medical Center
Richard C. Schlegel,

Sherrie Flynt Wallington, PhD

Professor of Oncology and Program Coordinator
Program Director, Health Disparities Initiative
Lombardi Comprehensive Cancer Center,
Georgetown University Medical Center

202-687-1314
slw49@georgetown.edu