Goal 1: Reduce Missed Clinical Opportunities to Recommend and Administer the HPV Vaccine

In its 2012-2013 report, the Panel recommended development of communication strategies and systems changes to ensure that all eligible adolescents and young adults were offered the HPV vaccine when they visited their healthcare providers. Since that time, the Centers for Disease Control and Prevention (CDC) launched a multipronged campaign aimed at improving clinicians’ practices, recognizing HPV vaccine champions, and supporting health systems (see Improving Providers’ Recommendations).1-3 The American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), and other health professional associations have urged their members to recommend vaccination strongly and developed resources to support increases in uptake (see Professional Organizations Urge Strong Recommendations).4-8 Several interventions targeting provider HPV vaccine knowledge and practices also have been developed.9,10

The commitment of these groups and the efforts of many healthcare providers undoubtedly have contributed to increases in HPV vaccination observed in recent years. Their roles in progress achieved to date should be commended. Yet, too many adolescents continue to leave their doctors’ offices without receiving the HPV vaccine, even when they have received other recommended vaccines.11-14 One study of girls who had not received the HPV vaccine by 13 years of age found that 80 percent had had healthcare encounters during which another vaccine was administered.12 If the HPV vaccine had been given at all of these visits, HPV vaccine initiation rates would have reached nearly 90 percent. The Panel Chair emphasizes strongly that provider- and systems-level changes hold the greatest potential for eliminating missed clinical opportunities, normalizing HPV vaccination, and ensuring that U.S. adolescents and future generations are optimally protected from HPV cancers.15

Strong Provider Recommendations Are Needed

Provider recommendation is one of the strongest predictors of adolescent HPV vaccine uptake, even stronger than often-studied factors such as race/ethnicity, insurance status, knowledge of HPV, and perceptions about HPV vaccine effectiveness and safety.16,17 Most physicians who provide care for adolescents say they recommend HPV vaccination,18,19 and surveys of parents suggest that providers are more likely to recommend the HPV vaccine now than in the past.20,21 However, too many parents of age-eligible adolescents do not recall receiving a recommendation from their children’s healthcare providers.17,20,21

How the vaccine is recommended is important. Studies have found that providers often deliver weak or unclear recommendations for the HPV vaccine (e.g., presenting the vaccine as being optional, less important, or less urgent than other adolescent vaccines).16,17,22,23 These recommendations may be sufficient for parents who already hold favorable views of HPV vaccination, but they are less likely to convince parents who have questions or uncertainties to vaccinate their adolescents.

CDC urges providers to deliver a clear, concise, and strong recommendation for same-day HPV vaccination.1 The vaccine’s efficacy in preventing cancer should be emphasized.17 Children of parents who received high-quality recommendations aligned with these guidelines are more likely to initiate and complete the HPV vaccine series than those of parents who received a low-quality or no recommendation.17 The Panel Chair urges healthcare providers to strongly recommend HPV vaccination for all eligible adolescents. Recommendations are most likely to be effective if providers:

• Use announcement language. Brief statements that assume parents are ready to vaccinate are associated with higher vaccine uptake than are open-ended, conversational approaches.24-27 Announcements may be particularly effective for parents who are ambivalent or uncertain about HPV vaccination because these types of statements present vaccination as the social norm and affirm the provider’s confidence in safety and effectiveness of the vaccine.15 Open-ended discussions should be reserved for instances in which parents raise specific questions or concerns.
• Bundle with other adolescent vaccines. The HPV vaccine should be recommended at the same time and in the same way as other recommended adolescent vaccines, with HPV cancer prevention in the middle of the list (your son/daughter is due for vaccinations to help protect him/her from meningitis, HPV cancers, and whooping cough).1,28
• Focus on vaccination of young adolescents. Although ACIP recommends routine HPV vaccination of 11- and 12-year-olds, providers are more likely to recommend the vaccine strongly to older adolescents.17 Providers should strongly recommend same-day HPV vaccination for all of their 11- and 12-year-old patients unless it is contraindicated. If parents suggest delaying vaccination, providers should emphasize that the vaccine is most effective when administered well before HPV exposure.29 Additionally, younger adolescents exhibit strong immune responses following vaccination,30 and those who initiate the series before 15 years of age require only two doses instead of three. Providers also should recommend the vaccine to older adolescents and young adults who have not completed the recommended series.
• Promote vaccination of boys and girls equally. Providers are less likely to consistently and strongly recommend HPV vaccination of boys than of girls,17-19 and parents of boys are more likely than those of girls to cite lack of provider recommendation as a reason for nonvaccination.20,21 Providers should deliver strong recommendations for both girls and boys to ensure that recent increases in vaccine coverage among boys continue. Males account for a growing proportion of HPV cancers in the United States due to the increasing incidence of HPV-associated oropharyngeal cancers.31-33
• Repeat recommendations as needed. Some parents respond to a provider’s recommendation with hesitance or refusal. Many of these parents will decide to vaccinate their children at the same visit if providers persist in identifying and addressing parents’ questions and concerns, reemphasize the importance of the vaccine, and restate the recommendation.34 Furthermore, a significant proportion of parents who initially decline HPV vaccination will accept it at a future visit. One study found that provider recommendations, particularly high-quality recommendations, played an important role in subsequent vaccine acceptance.35

CDC and health professional organizations (e.g., AAP, AAFP) should continue to promote strong, clear provider recommendations for HPV vaccination. CDC should continue to develop and provide resources to support providers. Studies have found that providers in rural areas are less likely to recommend the vaccine,36,37 and family physicians are somewhat less likely than pediatricians to consistently and strongly recommend the HPV vaccine.18,19,38 Increasing the quality of recommendations delivered in rural settings, which are commonly served by family practice physicians,39 may increase low vaccination rates observed in many rural areas. Continued monitoring also is needed to ensure that vaccine financing issues (e.g., provider concerns about upfront costs of the vaccine, inadequate reimbursement) do not interfere with access to the HPV vaccine or create disincentives for strong provider recommendations.

Systems-Level Efforts Facilitate Vaccination

Systems-level policies and practices have potential to drive substantial, enduring improvements in HPV vaccination rates by minimizing missed clinical opportunities, facilitating vaccine access, and promoting acceptance and normalization of the vaccine. Clinical practices, healthcare systems, and public health departments should identify and adopt strategies to increase their HPV vaccination rates. Programs that implement multiple strategies are more likely to be successful.9 Analyses of successful programs and experiences with other vaccines and cancer prevention and screening recommendations have identified several evidence-based approaches to promote HPV vaccination, including:9,10,15,38,40-50

• Conduct training. Providers should be trained to deliver strong recommendations and address common parent questions and concerns, including those about safety.
• Engage all office staff in vaccination efforts. All office staff who interface with patients should be trained to ensure consistent, positive messaging about the vaccine. A vaccine champion and quality improvement team can foster a provaccination culture and promote positive change.
• Use a tracking system. It is critical to reliably identify patients due or overdue for vaccination and monitor vaccination rates. Tracking systems can be embedded within or integrated with electronic health records (EHRs). Integration with state immunization information systems (IIS) would enhance tracking capacity.
• Prompt healthcare providers. Clinicians should be informed when a patient is due or overdue for HPV vaccination. Prompts can be automatically generated by EHR systems or manually noted based on review of patients’ charts prior to their appointments.
• Implement standing orders. Standing orders, which allow nurses or other medical personnel to administer vaccines using an established protocol without a direct order from a physician, increase vaccination rates in many settings.
• Send reminders. Parents should be informed when their children are due for a vaccine dose. One or more effective reminder methods can be used (e.g., phone, letter, email, text, EHR-based message), an approach that can be especially effective when handled in a centralized way.
• Facilitate access. Providing walk-in or immunization-only appointments can make it easier for patients to receive the vaccine, particularly second or third doses. The vaccine should be offered opportunistically at all types of appointments unless contraindicated (e.g., well child, sick child, sports physicals).
• Implement quality improvement initiatives. Provider-, clinic-, and systems-level vaccination rates should be monitored and shared to provide accountability and incentivize improvement. Education and quality improvement programs focused on HPV vaccination could be implemented to meet requirements for board certification (i.e., Maintenance of Certification; see Quality Improvement Initiative Improves HPV Vaccine Initiation and Completion).

The Panel Chair urges health system leaders to make HPV vaccination a high, measurable priority. Implementation of systems changes within large health systems could facilitate HPV vaccination of large numbers of adolescents and potentially increase overall vaccine coverage rates within geographic regions served. Some health systems already have established systems-level processes to support HPV vaccination, resulting in coverage rates well above the national average (see Rapid Adoption of the HPV Vaccine within a Health System).38,40 Clinics and health systems should use resources shown to be effective in increasing HPV vaccination. These include resources developed by organizations such as the CDC,2,51 AAP,8 the American Cancer Society,28 and the National HPV Vaccination Roundtable.52,53 Advocacy organizations, health professional organizations, state vaccine coalitions, National Cancer Institute-designated cancer centers, and state health officials should engage health systems within their regions to encourage prioritization of HPV vaccination and implementation of practices and policies to increase coverage rates.

Clinics and healthcare systems are motivated by quality metrics established by external bodies. Healthcare Effectiveness Data and Information Set (HEDIS) quality measures are used as the basis of health plan accreditation by the National Committee for Quality Assurance and are used by health plans themselves to drive improvements in quality of care and services.54 The updated measure for adolescent immunizations in HEDIS 2017 assesses the proportion of all adolescents who receive all recommended vaccines (meningococcal, Tdap, HPV) by their thirteenth birthdays.55 This should provide incentives for providers and healthcare systems to bundle their recommendations for all adolescent vaccines and may help raise HPV vaccine coverage to the level of the other vaccines.

The 2014 addition of a Healthy People 2020 goal focused on males may encourage gender-neutral vaccination.56 The Panel Chair agrees with the National Vaccine Advisory Committee that the Health Resources and Services Administration (HRSA) should include a measure for HPV vaccination of adolescents in the Uniform Data System, the required reporting system for HRSA grantees in community health centers, migrant health centers, health centers for homeless grantees, and public housing primary care organizations.57

Rapid Adoption of the HPV Vaccine within a Health System

Denver Health, an integrated urban safety net health system that serves more than 17,000 adolescents each year, has implemented several processes to facilitate vaccine uptake. The internally developed immunization registry (VaxTrax) creates a list of vaccines for which each patient is due. Vaccines are offered at every visit (even if they were previously declined), and providers are encouraged to bundle all adolescent vaccines together when recommending them. Standing orders allow adolescent vaccines, including the HPV vaccine, to be administered by a medical assistant. These processes contributed to rapid uptake of the HPV vaccine within Denver Health clinics. By 2014, nearly 90 percent of girls and boys (ages 13-17) had received at least one dose of the HPV vaccine. In contrast, national rates for 13- to 17-year-old girls and boys in 2014 were 60 percent and 42 percent, respectively.

Sources: Farmar AM, Love-Osborne K, Chichester K, et al. Achieving high adolescent HPV vaccination coverage. Pediatrics. 2016;138(5). Available from: https://www.ncbi.nlm.nih.gov/pubmed/27940751; Walker TY, Elam-Evans LD, Yankey D, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years—United States, 2017. MMWR Morb Mortal Wkly Rep. 2018;67(33):909-17. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30138305

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