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Frances Hsieh

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  • 1. A comprehensive intervention to promote HPV vaccination of adolescent girls in the United States to prevent cervical cancer Capstone Project by Frances Hsieh Candidate for Master of Public Health Johns Hopkins University Bloomberg School of Public Health May 11, 2010
  • 2. 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
  • 3. 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
  • 4. Comparing the two vaccines Quadrivalent (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
  • 5. 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)
  • 6. 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
  • 7. Current levels of HPV vaccine coverage are low and vary across the country
  • 8. There is also a problem with girls returning for follow-up doses
  • 9. 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
  • 10. 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
  • 11. Health Belief Model Enabling factors  Insurance coverage for vaccine  VCF program  Time and means of getting to appointments Reinforcing factors • Physician recommendation • Subjective norm: peer’s expectations of vaccination 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 vaccine effectiveness and safety, vaccination recommendations, counseling talking points • Offer CME for training 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 Ecological Model Models used in the intervention
  • 12. Enabling factors  Insurance coverage for vaccine  VCF program  Time and means of getting to appointments Reinforcing factors • Physician recommendation • Subjective norm: peer’s expectations of vaccination 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 vaccine effectiveness and safety, vaccination recommendations, counseling talking points • Offer CME for training 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 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
  • 13. 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
  • 14. 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.
  • 15. 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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