increasing the uptake of human papillomavirus (hpv ... the uptake of human papillomavirus (hpv )...
TRANSCRIPT
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Increasing the Uptake of Human Papillomavirus (HPV ) Vaccine
Among IndigenousYouth
Amy GroomGabrielle McCallumRuth Richardson
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Faculty/Presenter Disclosure
• Amy Groom has no relevant financial relationships with the manufacturer(s) of commercial services discussed in this CME activity
• Gabrielle McCallum has no relevant financial relationships with the manufacturer(s) of commercial services discussed in this CME activity
• The authors do not intend to discuss any unapproved/investigational uses of commercial products in this presentation
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Overview• Review HPV vaccine delivery strategies for indigenous populations in the U.S., Australia, and Canada
• Share HPV vaccine coverage information for indigenous youth in the U.S., Australia and Canada
• Discuss barriers to and best practices for HPV vaccine delivery in indigenous communities
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U.S. HPV Vaccine Recommendations
• Routine vaccination for 11‐12 year olds– Females: 2006– Males: 2011
• Catch up vaccination for females and males – Females 19‐26 years– Males 19‐21 years
• 3 dose series over 6 months• 2 dose series approved Oct. 2016
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HPV Vaccine Delivery in the US• Routine childhood and adolescent vaccines are delivered through the clinical system– Limited school‐based vaccination
• No cost for vaccines for American Indian/ Alaska Native (AI/AN) children– Federally‐funded Vaccines for Children program
• Indian Health Service– Federally‐funded system of healthcare for 2.2 million AI/AN people in 35 states
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0%
20%
40%
60%
80%
100%
Tdap MenACWYHPV 1st dose, femalesHPV 1st dose, males
U.S. vs. IHS Vaccination Coverage2015, Ages 13‐17 years
U.S.
IHS
CDC. National Immunization Survey‐Teen. Available at: http://www.cdc.gov/vaccines/imz‐managers/coverage/nis/teen/index.htmlIHS Quarterly Immunization Reports. FY 2016 Quarter 1. Available at: http://www.ihs.gov/epi/index.cfm?module=epi_vaccine_reports
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IHS HPV Vaccine Initiative*
• Using IHS vaccine coverage data, identified Best Practice and Intervention Sites
• Conducted provider interviews – Identified facilitators and barriers to HPV vaccine initiation and series completion
• Provided support for implementation of best practices over 2 year period (2013‐2015)
* Jacobs‐Wingo J, Jim C and Groom A. Human Papillomavirus Vaccine Uptake: Increase for American Indian Adolescents, 2013–2015. Am J Prev Med. Available On line 28 February 2017.
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Best Practices• Provider reminders • Simultaneous administration of all adolescent vaccines during the same visit
• Standing orders – Nurse‐only immunization visits
• Reminder/recall strategies• Provision of HPV vaccine information/education outside the clinic
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Barriers• Patient Awareness
– Lack of patient awareness about HPV vaccine benefits
– Parental misconceptions of vaccine safety and link to sexual activity
– Lack of awareness among patients and their parents of the need for 3 doses of HPV vaccine
• Access issues• Missing/incomplete data
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Interventions Implemented • Education
– Reminder/recall strategies– Information at health fairs, schools, newsletters, and other
community events– Provider education
• You Are the Key ‐ “HPV is Cancer Prevention” training
• Access to Vaccine Services– Established standing orders and/or nurse‐only immunization
clinics– Immunization outside the clinic
• Systems‐based interventions– Missed opportunities and missing data analysis– Access to state Immunization Information Systems (IIS)
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Mean Increase in HPV coverage*
12%
24%
9%
0%5%
10%15%20%25%30%35%40%45%50%
Mean coverage increase
HPV 1st dose
*Source: Jacobs‐Wingo J, Jim C and Groom A. Human Papillomavirus Vaccine Uptake: Increase for American Indian Adolescents, 2013–2015. Am J Prev Med. Available On line 28 February 2017.
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Conclusion
• Improving HPV vaccine uptake requires multi‐faceted interventions– Community
• Education for parents, reminder/recall
– Health Care System• Increasing vaccine access• Provider education
– Data• Missed opportunities• Partnerships with state IIS
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HPV VACCINE IN AUSTRALIASlides courtesy of: Assoc Prof Julia BrothertonMedical Director, Public Health PhysicianNational HPV Vaccination Program RegisterEpidemiologistVictorian Cervical Cytology RegistryVCS
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HPV vaccination in Australia• Disease burden
– For Indigenous Australian women, cervical cancer incidence 2x and mortality 4x other Australian women*
– Participation in cervical screening lower
– In baseline pre‐vaccination study of clinic attenders, high HPV prevalence in young women=non‐Indigenous women**
* Source: Cervical screening in Australia 2012‐2013, AIHW 2015** Garland/Brotherton et al, BMC Medicine 2011
19.5
8.7
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National HPV Vaccination Program
• 4vHPV vaccine 3 dose course prevents infection and disease (CIN, cervical, anogenital cancers and genital warts) due to HPV types 16/18/6/11
• 2007‐2009: catch up females aged 12‐26• 2009‐present: routine school based vax
girls (1st yr high school – usual age 12‐13)• 2013‐2014: catch up program males at
school age 12‐15 (+ some GP delivery)• 2015: routine school based vax boys and
girls (1st yr high school – usual age 12‐13)
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National notified coverage female catch up
As held at Sept 2011. Excludes consumers who have opted off.
* Brotherton JML, et al. Vaccine 2014;32: 592– 597 http://dx.doi.org/10.1016/j.vaccine.2013.11.075.
Under notified by 10‐20%*
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Coverage for Indigenous women ‐ HPV catch up
Source: Brotherton et al, Med J Aust 2013
8680
737671
64
0
10
20
30
40
50
60
70
80
90
100
dose 1 dose 2 dose 3
Northern Territory, HPV coverage for 12‐17 year old females, 2007‐2009 catch up program
Non‐Indigenous Indigenous
8479
70
80
69
54
0
10
20
30
40
50
60
70
80
90
100
dose 1 dose 2 dose 3
Queensland, HPV coverage for 12‐17 year old females, 2007‐2009 catch up program
Non‐Indigenous Indigenous
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Impact in females• 90% reduction 12‐17 year olds, from mid 2007• 73% reduction 18‐26 year olds, from mid‐2008• Reductions similar in Indigenous (87%) and non‐Indigenous (76%) females aged 15‐24 years (Pheterogeneity=0.08)
Impact on genital warts – national hospital data*
* Source: Smith M et al. Fall in Genital Warts Diagnoses in the General and Indigenous Australian Population Following Implementation of a National Human Papillomavirus Vaccination Program: Analysis of Routinely Collected National Hospital Data. J Infect Dis (2015) 211 (1): 91‐99
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HPV Vaccinations on Reserve in Alberta, Canada
Slides courtesy of: Ruth Richardson, First Nations and Inuit Health Branch, Alberta Region
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Provincial and Territorial HPV Vaccine Programs in Canada
# of doses School Grade
Population Vaccine used
British Columbia 2 6 Girls HPV-9
Alberta 3 5 Girls, boys HPV-9
Saskatchewan 2 6 Girls HPV-4
Manitoba 2 6 Girls, boys HPV-4
Ontario 2 7 Girls, boys HPV-4
Quebec 2 4 Girls, boys HPV-9
New Brunswick 2 7 Girls HPV-4
Nova Scotia 2 7 Girls, boys HPV-4
Prince Edward Island
3 6 Girls, boys HPV-4
Newfoundland 2 6 Girls HPV-4
Yukon 2 6 Girls HPV-4
NorthwestTerritories
32
4 – 6,9 to 14 years old
Girls HPV-4
Nunavut 3 6 Girls HPV-4
Table does not include “catch-up” programs, nor targeted programs that may be in place temporally.
Adapted from Gina Ogilvie’s “HPV Vaccines and Their Impact” presentation at Canadian Immunization Conference, Dec 6, 2016.
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Alberta First Nations:• 3 Treaty Areas• 7 Cultural Groups• 46 First Nations• ~125,000 First Nations
people in Alberta; ~65,000 of which live on reserve
Immunization on Reserve in Alberta:• Schedule established at
provincial level, administered by Community Health Nurses
• Vaccines outside the provincial schedule may be available for sale through pharmacies, physicians, or public health
• First Nations people can access immunization on or off reserve.
• No national immunization registry; provincial database is not currently linked with the on-reserve system.
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A Timeline of HPV Vaccine in Canada
Source: Gilla Shapiro’s “ Obstacles and opportunities for including males in Canadian human papillomavirus vaccination programs” presentation at Canadian Immunization Conference, December 6, 2016.
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Introducing HPV Vaccine• Key activities within First Nations and Inuit Health Branch (FNIHB) Alberta:
– Training for Community Health Nurses (CHN)– Education resources for CHNs to use
• PowerPoint for use in presentations• Information handout
• Anecdotes from community staff:– Evening gatherings inviting mom’s and daughters – part of coming of age
discussion, healthy bodies– Education sessions in classrooms and with teachers– One on one discussions with families and/or students
• Vaccine available at school, or at the Health Centre
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Factors impacting Immunization Uptake• Staffing: reduced or no nursing staff in some communities, especially in
northern Alberta Communities.• Schools: 35/46 communities have schools on-reserve.
– Students can attend school either on or off reserve• Immunization systems are not linked.
• Coverage rates for vaccines with multiple doses are always lower than for vaccines with fewer doses.
• Community characteristics: multiple factors can impact completion of preventive actions like immunization, many of them socio-economic in nature.– Uptake for HPV vaccine is comparable to uptake for other vaccines in the same
community
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How are we doing?
0
20
40
60
80
100
2010-11 (n=652)
2011-12 (n=645)
2012-13 (n=607)
2013-14 (n=679)
2014-15 (n=640)
2010-11 (n=313)
2011-12 (n=312)
2012-13 (n=295)
2013-14 (n=334)
2014-15* (n=640)
HBV HPV
PRO
POR
TIO
N IM
MU
NIZ
ED (%
)
VACCINE AND SCHOOL YEARCoverage Uptake Target
*2014-15 data for HPV includes data for both males and females therefore the denominator for 2014-15 will be larger than previous years. HPV data for school years between 2010-11 and 2013-14 only included data for females.Vaccine abbreviations: HBV=hepatitis B virus; HPV= human papillomavirus.
Coverage: 3 doses completed; Uptake: 1 dose or 2 doses only
Immunization coverage and uptake for HBV and HPV, Grade 5 students, First Nations in Alberta, 2010-11 to 2014-15.
Source: Regional Communicable Disease Control Report, 2016; FNIHB, Alberta Region
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How are we doing?
55.7
62.6
59 58.3
60.1
58 62.7
65.3
63.1
53.9
6.6 21
.4
6.5
31.7
7.6
24.7 6.
7 26.6
6.4
25.8
0
20
40
60
80
100
AB FN* AB FN* AB FN* AB FN* AB FN*
2011 2012 2013 2014 2015
PRO
POR
TIO
N IM
MU
NIZ
ED (%
)
POPULATION AND YEAR
Coverage Uptake
Source: Alberta Health interactive Health Data interaction, accessed 2016-12-23 http://www.ahw.gov.ab.ca/IHDA_Retrieval/selectSubCategoryParameters.do#
HPV Coverage rates: Grade 5 students on reserve / 12-year-olds in Alberta
AB Rates calculated on calendar year: denominator is AB 12 year old population calculated annually. FN Rates calculated on school year: denominator is those in grade 5 on reserve as of June for the school year.
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First Nations and Inuit Health Branch – Alberta Region
Ruth RichardsonRegional CDC Nurse Manager
First Nations and Inuit Health Branch, Alberta [email protected]
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Overall ConclusionsUS, Australia, Canada
• Good uptake of HPV vaccine in indigenous communities– Coverage for indigenous populations is similar to or higher than coverage for the general population in some countries
• Provision of vaccine in non‐clinical settings (e.g. communities, schools) can facilitate access
• Data quality/Completeness issues may impact vaccine uptake and coverage estimates
• Identifying culturally‐appropriate community education opportunities is important