frances hsieh

A comprehensive intervention to promote HPV

vaccination of adolescent girls in the United States to prevent

cervical cancer

Capstone Project by

Frances HsiehCandidate for Master of Public Health

Johns Hopkins University Bloomberg School of Public Health

May 11, 2010

Background: cervical cancer and human papillomavirus (HPV) Cervical cancer affects about 10,800 new

women a year, about a third of whom will not survive

Cervical cancer is caused by persistent infection with HPV, a common sexually transmitted virus

High-risk HPV are oncogenic HPV-16 and HPV-18 are the most prevalent, accounting

for ~70% of cervical cancer Low-risk HPV are not oncogenic but may cause

benign problems such as genital warts HPV-6 and HPV-11 account for ~90% of cases of genital

warts

There are ways to help prevent cervical cancer Papanicolaou test (Pap smears)

Examine cervical cells for precancerous changes

The introduction of Pap smears in 1949 allowed for 75% drop in incidence of cervical cancer and 74% drop in mortality rate

Treatment of abnormal findings can prevent progression to cancer

Also two new HPV vaccines: Gardasil and Cervarix

Comparing the two vaccinesQuadrivalent (Merck) Bivalent (GSK)

Licensed in US 2006 2009

HPV types covered HPV 6/11/16/18 HPV 16/18

Protection against HPV 16/18 related

precancerous lesions>98% >93%

Protection against HPV 6/11 related genital

lesions>98% --

Schedule 0, 2, 6 months 0, 1, 6 months

Approvals

Males and females 9 to 26 years old

Protection against cervical, vaginal and

vulvar cancer and precancerous lesions

Protection against genital warts

Females 10 to 25 years

Protection against cervical cancer and

precancerous lesions

CDC’s Advisory Committee on Immunization Practices (ACIP) recommends:

Routine vaccination of females ages 11-12 May be started as young as 9 years old Vaccine also recommended for females 13

to 26 years old, the “catch-up” group

Recommendations are supported by American College of Obstetrics and Gynecology

(ACOG) American Academy of Pediatrics (AAP) American College of Physicians (ACP) American Academy of Family Physicians (AAFP)

Recommendations are targeted at adolescents because: Highest prevalence rates found in girls

following sexual debut Important to have been vaccinated prior to

exposure to HPV Antibody development triggered by the

vaccine is higher when given to girls 12-16 than at older ages

Both bigger health impact and more cost-effective to target girls up to 18 years old for rather than up to 26 years old

Current levels of HPV vaccine coverage are low and vary across the country

There is also a problem with girls returning for follow-up doses

Barriers to HPV vaccination Knowledge and awareness of HPV, the link to

cervical cancer, and the vaccine Parents and adolescents may not fully understand risk

and severity or the efficacy of the vaccine Providers may be reluctant to bring up vaccination if

unfamiliar with HPV Attitude toward HPV as STI

Parents may be reluctant to vaccinate daughters due to concern it may condone sexual activity

Logistical barriers for adolescents No regular schedule for physician visits Busy with school and extracurricular activities Remembering two other follow-up appointments Cost of vaccine

Enabling factors

Insurance coverage for vaccine

VCF program Time and means of

getting to appointments

Reinforcing factors

• Subjective norm based on:

• Physician recommendation

• Perceived expectation of peers

Quality of Life

Healthy adolescent girls and young women

Health

• Lower rates of HPV infection

• Lower rates of cervical cancer

Behavior

HPV vaccination:• Making and

keeping appointments

Environment

Access to and availability of:

• HPV vaccine• Health care team

to administer vaccine

Genetics

Health Program

Phase I: Social Assessment

Phase II: Epidemiological, Behavioral, & Environmental

Assessments

Phase III: Education & Ecological Assessments

Phase IV: Administration & Policy Assessments

Educational Strategies

• Educational campaign /social marketing targeted to parents about HPV infection risk and severity

• Train physicians in related specialties (pediatrics, family and internal medicine) on HPV and the vaccine, recommendations, and counseling points

• Offer CME for training

PRECEDE Framework Including the Health

Intervention Program

Policy, Regulation and Organization

• Include HPV vaccination in school curriculum on STI prevention

• Allow adolescent consent for vaccination

• Vaccine administration through family planning clinics, community health centers, school clinics

• Reminders about further doses through e-mail or text messages

Predisposing factors

Awareness and knowledge of HPV

Perceived risk and severity of HPV infection

Perceived effectiveness and safety of vaccine

Perceived barriers

Health Belief Model

Enabling factors




Reinforcing factors


• Subjective norm: peer’s expectations of vaccination



• Train physicians in related specialties (pediatrics, family and internal medicine) on HPV vaccine effectiveness and safety, vaccination recommendations, counseling talking points











Perceived barriers

Ecological Model

Models used in the intervention

Enabling factors




Reinforcing factors


• Subjective norm: peer’s expectations of vaccination



• Train physicians in related specialties (pediatrics, family and internal medicine) on HPV vaccine effectiveness and safety, vaccination recommendations, counseling talking points











Perceived barriers

Integrative Behavior Model

Behavior

HPV vaccination:• Making and

keeping appointments

Environment

Access to and availability of:

• HPV vaccine• Health care team

to administer vaccine

Norms

Attitude

Personal Agency

Summary Human papillomavirus is a sexually transmitted virus that

can cause cervical cancer if infection persists Recently developed vaccines have been shown to be

effective in preventing persistent HPV infection and precancerous lesions

It is best to vaccinate at an early age, before sexual debut. For this reason, adolescent girls are targeted for coverage

However, current vaccination rates are low and vary widely from state to state

Low awareness and knowledge of HPV and its natural history, attitudes towards STIs, and logistical barriers are obstacles to overcome to increase vaccination

A comprehensive, theory-based, intervention of education, policy changes, and programmatic changes may help increase rates of vaccination

Implementation and ways to tailor the intervention to specific groups should also be addressed

references Adams, M., Jasani, B., Fiander, A. Human papilloma virus (HPV) prophylactic screening: Challenges

for public health and implications for screening. Vaccine, 2007, 25: 3007-3013. Brabin, L., Greenberg, D.P., Hessel, L., Hyer, R., Ivanoff, B., Van Damme, P. Current issues in

adolescent immunization. Vaccine, 2008, 26: 4120-4134. Brewer, N.T. and Fazekas, K.I. Predictors of HPV vaccine acceptability: A theory-informed,

systematic review. Preventive Medicine, 2007, 45: 107-114. CDC. Vaccination coverage among adolescents aged 13-17 years – United States, 2008. MMWR

2009;58(36);997-1001. Conroy, K. Rosenthal, S.L., Zimet, G.D., Jin, Y., Bernstein, D.I., Glynn, S., Kahn, J.A. Human

Papillomavirus Vaccine Uptake, Predictors of Vaccination, and Self-Reported Barriers to Vaccination. Journal of Women’s Health, 2009, 18(10):1679-1686.

Herzog, T.J., Huh, W.K., Downs, L.S., Smith, J.S., Monk, B.J. Initial lessons learned in HPV vaccination. Gynecologic Oncology, 2008, 109: S4-S11.

Human Papillomavirus Vaccination. ACOG Committee Opinion No. 344. American College of Obstetrics and Gynecology. Obstet Gynecol 2006;108:699-705.

Prevention of Human Papillomavirus Infection: Provisional Recommendations for Immunization of Girls and Women With Quadrivalent Human Papillomavirus Vaccine. American Academy of Pediatrics. Pediatrics, 2007;120(3):666-668.

Saslow, D., Castle, P.E., Cox, J.T., Davey, D.D., Einstein, M.H., Ferris, D.G., Goldie, S.J., Harper, D.M., Kinney, W., Moscicki, A-B., Noller, K.L., Wheller, C.M., Ades, T., Andrews, K.S., Doroshenk, M.K., Kahn, K.G., Schmidt, C., Shafey, O., Smith, R.A., Partridge, E.E., (for The Gynecologic Cancer Advisory Group) and Garcia, F. American Cancer Society Guideline for Human Papillomavirus (HPV) Vaccine Use to Prevent Cervical Cancer and Its Precursors. CA Cancer J Clin, 2007, 57;7-28.

Guttmacher Institute, State Policies in Brief. An Overview of Minors’ Consent Law. April 1, 2010. Guttmacher Institute, State Policies in Brief. Minors’ Access to STI Services. April 1, 2010.

references Zimet, G.D., Improving adolescent health: Focus on HPV vaccine acceptance. Journal of Adolescent

Health, 2005, 37:S17-S23. Zimet, G.D. Understanding and overcoming barriers to human papillomavirus vaccine acceptance.

Curr Opin Obstet Gynecol, 2006, 18(suppl 1): S23-S28. American Academy of Pediatrics, Committee on Infectious Diseases, Policy Statement. Prevention of

Human Papillomavirus Infection: Provisional Recommendations for Immunization of Girls and Women With Quadrivalent Human Papillomavirus. Pediatrics, 2007, 120(3):666-668.

American College of Obstetrics and Gynecology. ACOG Committee Opinion No. 344. Human papillomavirus vaccination. Obstet Gynecol, 2006;108:699-705.

Kollar, L.M. and Kahn, J.A. Education about human papillomavirus and human papillomavirus vaccines in adolescents. Current Opinion in Obstetrics and Gynecology, 2008, 20:479–483.

Centers for Disease Control and Prevention. HPV-Associated Cervical Cancer Rates by Race and Ethnicity. http://www.cdc.gov/cancer/hpv/statistics/cervical.htm Accessed March 15, 2010.

National Cancer Institute. Cervical Cancer Screening (PDQ). http://www.cancer.gov/cancertopics/pdq/screening/cervical/HealthProfessional/page3 Accessed March 10, 2010.

Gold, R.B., Challenges and Opportunities for U.S. Family Planning Clinics in Providing the HPV Vaccine. Guttmacher Policy Review, 2007;10(3):8-14.

CDC Advisory Committee on Immunization Practices. Recommended Adult Immunization Schedule 2010. http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/2010/adult-schedule.pdf. Accessed March 2, 2010.

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