Vaccination coverage rates among adolescent patients for the three-dose human papilloma virus (HPV) vaccine series remain low, placing many young patients at risk for HPV-associated diseases such as cervical and anogenital cancers. To enhance coverage rates, the establishment and optimization of an “immunization neighborhood” are essential. This term, coined by APhA, involves communication, coordination, and collaboration among multiple immunization stakeholders with the goal of meeting the immunization needs of patients and protecting the community from vaccine-preventable diseases.
Approximately 80 million people are currently infected with HPV, with 14 million new infections occurring annually. It is the most common sexually transmitted infection and is most prevalent in patients in their early twenties. More than 100 different serotypes of HPV exist, with some classified as low risk (e.g., 6, 11) and others classified as high risk (e.g., 16, 18, 31, 33, 45, 52, 58). Low-risk types may result in low-grade cervical abnormalities or genital warts, and high-risk types may result in high-grade cervical abnormalities, cervical cancer, or other anogenital cancers in both females and males.
To help prevent HPV-associated diseases, FDA approved three HPV vaccine products in the past decade, with recommendations for female and male adolescent patients. Data for these vaccines show they are highly effective and safe, with documented vaccine efficacy rates of 96% or more and pain at the injection site being the most commonly reported adverse event. Despite these data, HPV vaccination coverage rates among adolescents remain low, with the most recent data from the National Immunization Survey–Teen reporting coverage rates for one or more doses of the vaccine of 57.3% among females and 34.6% among males.1
Multiple factors may be contributing to the low HPV vaccination coverage rates, such as parent attitudes and concerns, financial considerations, knowledge gaps, and less frequent contact with the health care system among adolescents.
This is where the establishment and optimization of an HPV immunization neighborhood can help. The supporting elements of an immunization neighborhood are to increase immunization access points, provide enhanced and more consistent patient education and communication, document outcomes in patient medical records and immunization information systems (IIS), track quality measures, improve collaboration, and simplify and broaden payment models. It is built on a foundation that involves all immunization stakeholders—including the patient, the physician, the pharmacist, other health care providers, the payer, and the health department—and focuses on three Cs: communication, coordination, and collaboration.
Recently, the National Vaccine Program Office (NVPO) sponsored a continuing education program hosted by APhA, “Optimization of the Pharmacist’s Role within the Immunization Neighborhood with Emphasis on HPV.” Jean-Venable “Kelly” Goode, PharmD, professor in the School of Pharmacy at Virginia Commonwealth University, discussed the three Cs and how pharmacists can play an active role in the immunization neighborhood to increase HPV vaccination coverage rates.
Goode emphasized that communication is essential to the immunization neighborhood. Pharmacists need to communicate their education, training, and applicable state laws related to the HPV vaccine to other providers, parents, and patients to ensure they know about pharmacists’ ability to administer the vaccine. She also encouraged pharmacists to highlight their successes with other vaccines so that other stakeholders are aware that these successes can be potentially replicated with the HPV vaccine series. In addition, communicating extended hours and increased access to the pharmacy is needed, as adherence to subsequent doses of the HPV vaccine after the initial dose may be a challenge for busy adolescents.
Knowledge gaps by parents and teens about HPV-preventable diseases and parental concerns and attitudes have been identified as some of the key barriers contributing to low coverage rates. One of parents’ key concerns is the false belief that giving their child the HPV vaccine series will increase the child’s likelihood to engage in sexual activity at an earlier age. Goode noted that you do not need to talk about sex with parents; instead, shift the conversation to the cancer-preventing benefits of the vaccine.
CDC has released discussion pearls to help providers communicate with parents about HPV and the three-dose series. The document, Tips and Time-savers for Talking with Parents About HPV Vaccine, can be accessed at www.cdc.gov/vaccines/who/teens/for-hcp-tipsheet-hpv.html. In addition, NVPO, in collaboration with other organizations, created a parent toolkit on HPV and other adolescent vaccines that is available via WebMD.
Parental concerns about the safety of vaccines, including the HPV vaccine, also contribute to their willingness to have their adolescent vaccinated. These concerns, captured by the terms “vaccine hesitancy” and “vaccine confidence,” may also attribute to suboptimal vaccination rates. Media headlines and other social influences questioning the safety of vaccines may be to blame for this lack of confidence. Providers within the immunization neighborhood should be equipped to discuss the overt benefits of vaccinations with parents and patients who may be questioning them.
Websites such as Vaccines.gov and CDC.gov may be good resources for talking points on vaccine safety and reasons to get vaccinated. In addition, parents may be referred to WebMD, a good resource for information. Understanding their rationale for vaccine hesitation or declination may help to improve, and further justify, the short- and long-term benefits of HPV vaccination.
Provider recommendation is one of the strongest predictors of vaccination. Goode noted that pharmacists should recommend the HPV vaccine for their adolescent patients with the same strength and conviction as they do with other vaccines, such as the influenza, tetanus–diphtheria–acellular pertussis (Tdap), and meningococcal conjugate (MCV4) vaccines. In addition, she encouraged all colleagues and staff of the pharmacy (e.g., technicians) to deliver the same message to all patients. She emphasized that vaccination benefits need to be communicated to parents, adolescents, and adults at every opportunity.
Goode also highlighted various communication opportunities, including one-on-one conversations with parents and patients, in-store communication aids (e.g., shelf-talkers, other signage), receipt messaging, and handouts and/or videos in the pharmacy discussing the HPV vaccine. Parents may also be referred to the various websites mentioned previously.
Goode noted that back-to-school campaigns are an excellent time to highlight the need for HPV vaccination. She also pointed out that adolescent patients are well connected to social media, so newer communication venues such as Twitter, Facebook, and Instagram may appeal to this patient population. She commented on potential Twitter hashtags that can be used, such as #preventcancer or #HPV. Texting patients as a recall reminder for additional doses of the vaccine may also be an effective means of communicating with this patient population.
Within the communication realm comes good documentation and communication back to the patients’ provider. Any vaccine information must be documented in available electronic databases, including the electronic health record and IIS, and communicated back to other immunization stakeholders via fax, mail, e-mail, or technology interfacing platforms.
Goode discussed the importance of treating HPV immunization services as a priority, as the influenza vaccine is currently, with coordination occurring both within and outside the pharmacy. Within the pharmacy, Goode said, protocols and standing orders need to be in place with local providers to ensure the vaccine can be easily administered.
Goode highlighted the need to establish a referral process between various stakeholders such as primary care providers and pediatricians and to establish education and reminder pieces for patients regarding well visits with their primary care provider. In addition, she noted that pharmacists should go where parents are to discuss the HPV vaccine, including schools (e.g., Parent–Teacher Association [PTA] meetings), malls, and community events. As part of coordination, Goode also provided an example of a yearly HPV immunization plan that can serve as a promotional model for pharmacy providers (see Table 1).
The main goal of collaboration is to facilitate initiation and completion of the series, regardless of the provider giving the vaccine. Collaboration should encompass numerous stakeholders, including the pharmacist, medical home, public health, immunization coalitions, and community outreach organizations.
Goode reviewed various models for completing the three-dose HPV vaccine series through a coordinated effort among stakeholders in the immunization neighborhood. She noted that either the pharmacy or medical home may be the initial members of the neighborhood to identify an adolescent HPV vaccine gap and may either refer the patient out for vaccination or administer the first dose. She also presented various scenarios on how the second and third doses can be given by either of these providers and how all administered doses should be entered into an IIS and communicated to providers to ensure accurate documentation.
Pharmacists can play a central role in establishing an HPV immunization neighborhood by assessing vaccination needs of all their adolescent patients, administering needed vaccines as allowed by state laws, and appropriately documenting and following up with other providers to ensure continuity of care.