Are You the HPV Vaccine Champion? Advanced Strategies for Uptake and Cancer Prevention in Your Pediatric Practice

Introduction

Dr Sharon Humiston (Immunize.org): Hi. My name is Sharon, and I'm a pediatrician. I work for immunize.org, which is a not-for-profit organization that is an advocate for immunizations, as it sounds. And today, we're going to be talking about HPV.

We have a tiny group here in the room, but I want you to know that there are 800 people online watching us today. And so we – yes, quite a few online, and I don't know if they were timid about coming out through a tornado and a hurricane, but I want to congratulate the people who are in the room.

Okay, we are going to do some polling questions to start. Let's see if I can, back – no.

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Disclosures

Okay. So again, my name is Sharon Humiston. Also with us today is Rebekah Fenton, and we will be talking more about her introduction later. She'll be doing the second half of the talk.

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Learning Objectives

The learning objectives for today:

• We're going to describe the burden of HPV-related diseases and benefits of HPV vaccination in pediatric patients
• We'll do a selective, effective HPV vaccine messaging to overcome barriers to update – to uptake in parents and caregivers or older adolescents
• We'll develop – talk about developing strategies to overcome barriers to HPV vaccination in underserved patient populations

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Who’s the HPV Champion?

So we're going to have 3 teams. What you have in front of you, those iPads, you'll be answering questions into the iPads, and then your answers go to the back table where they'll figure out the scoring. If you don't put in an answer, you don't get any points. If you put in an incorrect answer, you get 5 points, so it's worth answering every question.

You can see on your table, you have a blue light or an orange light, so you're either on the blue team or the orange team. If you get a correct answer, you get 100 points for that. And after each round, we will check the scores, and hopefully your team will be ahead.

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Program Outline

So the outline – round 1, we're going to talk about the true burden of HPV infections. Round two, HPV vaccine messaging to optimize uptake. And round three, being their champion, reaching underserved populations. And then we'll have a lightning round at the end. So this is not just a regular lecture, but it's a competition.

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          Poll 2

So for those in the room, please select your team based on the color of the light on your table?

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Round 1

Okay, so round 1. I'm going to read you the question, and then you're going to answer.

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          Quiz Question 1

So the survey says, quiz question number 1, which HPV attributable cancer is most common in the United States? And your choices are:

1. Anal/rectal cancer
2. Cervical cancer
3. Oropharyngeal cancer
4. Penile cancer
5. Vaginal cancer
6. Vulvar cancer

Which of those is the most common in the United States?

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          Quiz Question 3

All right. Did I miss a question? Was there question 2?

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          Quiz Question 2

Yes, okay, there we go. I'm going to put that down. So question number 2, which HPV serotypes are most commonly associated with cervical cancer? And you see the answers there. I won't read them. These may be very easy for some people and hard for others. All right.

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          Quiz Question 3

Question number 3. Based on available evidence, HPV vaccination provides effective protection against which of these? You see, I have to read it.

1. Genital warts, but not cervical cancer or pre-cancers or cancers
2. Genital warts and cervical pre-cancers, but not cervical cancer
3. Cervical pre-cancer and cancer, but not genital warts
4. Genital warts, cervical pre-cancer and cervical cancer

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          Quiz Question 4

All right. Question number 4. Is a previously unvaccinated 24-year-old male indicated for HPV vaccination? You can see the answers there. Read all of the distractors so that you don't get tripped up.

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The True Burden of HPV Infections

All right. So we're going to start by talking about the true burden of HPV infections.

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          HPV Is Common in the US

There we go. Okay. You probably know that HPV is the most common sexually transmitted infection in the United States. It is – nearly all people who are sexually active, and I – this is – sexually active is a funny term because I think that sometimes when we say sexually active, people think that what we mean is promiscuous. You know, sexually active means having had sex.

So nearly anyone who has had sex will contract HPV at some point in their life. And that is such an important fact, because like we were talking about in Canada, the Catholic schools didn't want to give HPV vaccine because it's like associated in people's mind with promiscuity. But if your kid is going to get married, chances, you know, that one would hope that they would have sex.

A friend of mine used to say that – to the parent, do you want to have grandchildren someday? Because if you want to have grandchildren, the only way for that to happen is for your child to have sex someday. And so it's not just sex outside of marriage. There's nothing that happens that sterilizes you at the time of getting married. And so everybody should get this vaccine.

HPV infection is more prevalent in males than females. And I underline that because we all – you know, we've all sort of been inculcated with the thought that cervical cancer is just the only kind of cancer that's important. But you'll see that that is not true and that HPV infection is actually more common in males than females.

Most infections do resolve on their own, but those that persist can change the cells in a way that make it so that they – that there's cancers. And there's about 36,000 cancers in the United States each year caused by HPV, which to some people is still a surprise. My sister has 2 master's degrees, but not in medicine. And when I was talking about, you know, what are you doing today? And I explained that I'm talking about HPV and that it causes cancer. And she's like, there's a virus that causes cancer?

Like, I think that to lay people that still comes as a surprise that cancers can be caused by a virus. And you see here all the different kinds of cancer that are caused by HPV.

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          HPV Strains

There are more than 200 HPV types. And this is – again, when we first started talking about HPV, that some people would ask me, my kid gets warts, you know, just warts on the skin. Will the warts from the skin end up causing cancers? You know, like if she has a wart on her finger and touches her vagina, will she?

And those are 2 different kinds of HPVs. The mucosal invasive type are different. Most of the cervical cancer is caused by 16 and 18, which is one of the questions at the beginning. So underline that in your head as an answer. 16 and 18 are the cervical cancer types, about 70%, although those aren't the only types, which is why we have an HPV with nine types in it now.

And then the anogenital warts are caused by 6 and 11, which are also covered by the current vaccine in the United States. Interestingly, if you – how many – this isn't one of the questions, but how many kids do you need to treat with HPV vaccine in order to prevent anogenital warts? The answer is eight.

So if you can increase from where you are now just by 8 a week, you're preventing – and then like you go all the way to cervical cancer, it's like 300. If you can get 324 extra HPV vaccine doses in this year, you will have prevented a cervical cancer case.

The HPV9 vaccination could prevent up to 90% of cancers caused by HPV. Very exciting.

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          CDC: HPV-Attributable Cancer Cases

This slide is a little bit hard to see, maybe hard from the back of the room. Feel free to move up. We have plenty of space in the front. So these are HPV attributable cancers. So these are cancers that are caused by HPV. One of the surprising things is that oropharyngeal cancers are the most common overall. So look down on the table. The first row is – or the first column is the site. So you see like cervix.

The percent probably caused by any HPV type, 91%. And the number per year – again, this is just United States, like 10,800. So look down that row, down to oropharyngeal. You'll see that there are 14,800 oropharyngeal cancers each year from the United States – in the United States caused by any HPV type.

And so that is the most in any site. But it's – it’s kind of obvious because both men and women have an oropharynx, whereas only women have a cervix. All right. So oropharynx, the most common place to get an HPV attributable cancer, and overall – and in males.

Cervical cancer is the most common in females, but not the most common overall. HPV cancers are – there are more in females than males, even though males have more infections than females. More females get the cancer from it. So a little bit of a hair splitting there, but the main point is this is a vaccine that everybody needs. It's not just a vaccine for women that – you know, and I think that when we first started giving it to males, there was some like, my son doesn't need this, he doesn't have a cervix, but he does have an oropharynx.

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          HPV Transmission

So, all right, HPV transmission, it only takes 1 encounter or 1 partner to transmit the infection. And again, one of the misunderstandings is, well, if somebody doesn't have symptoms, that they won't transmit it. It's not like herpes, you know, where you – that you're looking for some sign that the person has HPV. In most people, you're not going to see a sign. It's spread through direct contact with an infected area, and it can happen from asymptomatic contact. You don't have to have penetrative intercourse. That is not the only route.

And that's important because a lot of people think, well, my kid will be a virgin when she marries a virgin, and so she doesn't need this vaccine. And I won't go in – you know, like I would never say to a parent, well, that's not going to happen. I would never say that, obviously.

But even – so this was a study among 88 male virgins, the prevalence of HPV in genital exfoliated cells was 25%. So you – the idea that somebody is a virgin doesn't necessarily mean that they haven't had exposure to HPV. And among those 88, the 18% had the high-risk HPV types. So basically, even if you're a virgin, you can still have HPV and have been exposed to HPV. So males and females, you know, everybody needs this.

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          HPV Vaccine Recommendations Have Expanded to Include More Groups and Situations

Another thing that we have to get out of the way is that this is a new vaccine. It is not a new vaccine. It was first recommended in the United States in 2006. So we're coming up on 20-year anniversary, not far off now. You see here that then the recommendation for males was in 2011. We dropped down from a 3-dose to a 2-dose schedule for people who were less than 15 who started the series before the 15th birthday in 2016.

And then the later vaccination started in 2019. My point with this slide is we're not talking about something that's new. This vaccine has been around for a long time, and that's in the United States.

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          HPV Vaccination Recommendations: When to Vaccinate

Another thing that I want to bring up is there's some – like a little bit of confusion about when to start. And I think the American Cancer Society has really emphasized starting as early as age nine. If you start at age nine or 10, you have more opportunities to complete the series by the time they turn 13.

The CDC recommendation says it's recommended for ages 11 or 12 and can start at age 9, whereas AAP is just slightly different. It's recommended for all adolescents starting between nine and 12 years of age, at an age that the provider deems optimal for the acceptance and completion of the vaccination series.

So they're just slightly different, but the take-home for me is that in your practice, if starting at nine works, that's approved by the FDA, fine with the CDC, and fine with the AAP. So that is part of the recommended.

I would love to see how many of you start at 9? About a half, okay. And I think that a lot of people are interested in starting at 9 or 10, partly because it makes it so – like kids, especially adolescents – well, adolescents sometimes, you know, are more vocal about pain and anxiety than younger kids. I mean, or maybe we pay attention more because they're verbal about it, but getting three vaccines at once, you know, so if you're getting mening, HPV, and Tdap at the same time, you know, you only have 2 arms.

And so – and then you add in flu and COVID, you get a lot of resistance then. So by spreading it out, I think that's one advantage of starting at nine. But then the other thing is that I think a lot of pediatricians – I've done a lot of work with quality improvement in various states, and a lot of pediatricians have said that by starting at 9 or 10, that what happens is that they kind of got rid of the whole sexuality issue. They could just focus on this as a cancer prevention, and not focus so much on transmission.

And really – okay, so I always think about this. When you gave somebody a polio vaccine, did you talk about fecal-oral spread? You know, did you say, there's a thin film of doo-doo everywhere? No, you did not. And it's the same with HPV. You don't have to talk about the route of transmission. This is a vaccine that prevents cancer.

Again, in our quality improvement work, we have found that parents are – you know, they get it when you talk about wanting to prevent cancer. When you start talking about preventing a sexually transmitted infection, that doesn't apply to my kid. Okay.

And obviously, this is another thing that – this isn't like a vaccine that you're going to give to treat an infection that's already there. Once the infection has been established, this vaccine isn't effective. And so, by giving it earlier, we – very few – you know, there's vanishingly few kids that are sexually active at 9 or 10. And so, by giving it early, we make sure that it's before they've been exposed because you could be exposed with the first encounter.

First encounter, no – I – with the first encounter, I always think the sexual debut. And that always makes me think of, like, the sexual debut sounds so elegant, like you're going to be wearing a tiara and gloves. No.

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          Rates of Vaccine-type HPV Infections in Sexually-Experienced Females

Okay. So now I move to the part where I want to show you the evidence that this vaccine is remarkably effective. And it's – we talked about all the different ways that it's been shown to be effective. And I talked about how you only need to treat eight people in order to prevent genital warts.

Well, now I'm going to show you – this is HPV infections, just infections, with the types that were in the original vaccine, 6, 11, 16, and 18. And it goes by year. So 2003, 2006, we weren't using the vaccine. So that's sort of that blue color on the far – is it blue, teal, whatever.

On the far left, that's the prevaccine era. And then the next is 2007 to ’10 in orange. Green is 2011 to ’14. And then in purple is 2015 to ’18. So the bars kind of march by year bracket.

And so, you see over on the far left for girls – this is females who have had any sexual contact. So on the far left is girls 14 to 19, females 20 to 24, females 25 to 29, and the far bunch is 30 to 34.

So on the far left are females who would have had an opportunity to be vaccinated against HPV, where on the far right, the 30- to 34-year-olds, they were born too late. They wouldn't have had an opportunity to be vaccinated.

So, you see that in terms of infection, the younger group, that there's been an 88% decrease in HPV infection from 2003, 2006 to 2015, ’18. And in that 20 to 24-year bracket, there's been an 81% decrease in infection. Very exciting. This is in a – you know, and I – you know, unfortunately, this is a country where not everybody's been vaccinated. And so, in other places where they – you know, they have more effective ways of getting adolescents vaccinated, like in schools, for example, that we might see even a better response. But this is an incredibly good response.

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          HPV-IMPACT: Cervical Precancer Incidence Rates 2008-2015

Now, let's move from infection to cervical precancers. When we first started talking about HPV vaccine, I didn't know why we cared about cervical precancers. Like, it's – like it's a precancer. So what? But the so what of precancers is partly because once you have a precancer, then you have to be followed up. And it's nerve-wracking to be examined every 6 months to find out if your precancer has turned into a cancer. So that's one thing.

And I always think about one of the things about vaccination is this is so much easier than so much of what we do as pediatricians, because it's not like changing their diet or changing their screen time. I mean, this is a one and done, one or two and done. You know, like you don't have to make, like with improving eating, you have 100 decisions. You know, that family is making 100 decisions a day about eating right.

Whereas with HPV, you know, preventing a cancer that can be done with 2 decisions. Yes, yes. And it's done. Okay. So precancers, the reason why this is so important is also because if you have a cervical precancer, one of the treatments currently has been that they scoop out the os of the cervix to take those cells out so that they don't go on to be cancerous.

Unfortunately, that is associated with having what is known in medicine as an incompetent cervix. I have to say incompetent cervix, like – isn't that like the most sexist thing? Like even my cervix is incompetent? For God's sake.

So I'm over time. Okay. So by having an incompetent cervix means that I might have a premature infant or that I may not be able to take a pregnancy all the way to term. So preterm delivery and miscarriage.

Unfortunately, one of my friends had this where she couldn't carry a pregnancy to term because she had had a cone biopsy. So this is – this slide is just to say you see the number of precancers by age group, the light orange at the bottom. This, you see that over time it has decreased. This is 21 to 24 decreased. The blue has increased. That probably has to do with that we have better ways of more sensitive screening for precancers.

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          Benefits of HPV Vaccination: Cervical Cancer Prevention

Okay. So that was infection to cervical precancers. So now we're up to cancer – cervical cancers. And this is a study with 1.6 million women from Sweden from 2006 to 2017. You see that the cumulative incidence of cervical cancer in unvaccinated in orange, up, up, up, vaccinated at age 17 through 30 up, but not as much as unvaccinated. And vaccinated before age 17, this green line at the bottom. So this is 2 things to me. One is yahoo, if we can get people vaccinated before they're 17, I have a real chance at preventing cervical cancer.

But the other thing it says to me is that even vaccinating people between 17 and 30, it's better than no vaccination at all. Like that's a real – you know, that's a real improvement too. And so ideally we get it done early, but if we don't get it done early, just get it done.

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          Benefits of HPV Vaccination: Cancer Prevention

Then one more piece of evidence that I want to show you that I – this is very new. This is from an article in 2024 and it shows the males – I won't go into a lot of detail here, but males nine to 39 years of age attending any medical encounter from 2010 to 2023. And you see that for males, any odds ratio less than one means that there was an improvement and here the vaccinated males had an odds ratio of head and neck cancers of 0.44. So far below one.

And, remember that if it doesn't cross over one, that means it's statistically significant. So it looks to me like clinically significant 0.44 and statistically significant both. So this vaccine is also preventing cancers in males.

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          Overall Benefits of HPV Vaccinations

So overall, the benefits include genital HPV, cervical precancers, all the – you know, cervical cancers and oropharyngeal cancers, real improvement.

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          Key Takeaways

And I think we've hit the takeaways over and over.

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          Leaderboard

All right. So the virtual team is ahead. Do –

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Round Two

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          Quiz Question 5

Okay. All right. Next round. According to 2023 CDC data compared to other adolescent vaccines, HPV vaccine uptake is? And you see the answers there.

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          Quiz Question 6

Okay. Question 6, according to a 2013 study by Doug Opel and his colleagues, compared to a participatory approach when a presumptive approach was used, parents were less likely, as likely or more likely to accept vaccine recommendations.

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          Quiz Question 7

All right. Question seven. For entry into seventh grade in the United States, HPV vaccination is:

1. Required in all
2. Required in some
3. Not required by any
4. Required by the federal government

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          US National Immunization Survey 2015-2023: Vaccination by Age 13 Using VFC Program Eligibility

All right. So this slide shows you the rates for vaccination. This is 2015 to 2023, so the most recent data. And you see there's – for each grouping, there's 2 lines. The gray line is – the – or the teal line is for kids who have – who are eligible for VFC and the gray line is non-VFC.

So higher CS[?]. And so this is for Tdap. This is – the dotted line is, for mening, just a little bit lower. And then you get down to at least 1 dose of HPV much – you know, much lower. And this is up to date. So having all the doses that you need for your age, for HPV so much lower.

So the – so answer to the question is significantly lower than both Tdap and mening.

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          Top 5 Reasons for Not Vaccinating Against HPV: National Immunization Survey 2017-2018

Top 5 reasons for not vaccinating. A lot of people – this is 2017, 2018. But a lot of people, parents who were answering this said it wasn't recommended. Now, sometimes I think that we might say that something is recommended, but that we say it in a way that they don't hear it as being that we're recommending the vaccine. So we'll talk more about that.

And I think that some of these other – that they think it's not needed or not necessary lack of knowledge. The lack of knowledge is certainly associated with the provider not having made it clear that it was recommended. And then safety concerns. Well, that's – that's the internet.

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          Improving Vaccine Uptake: 2 In-Office Strategies

There are lots of ways to improve. We were talking about quality improvement in office strategies. And improving communication is what we're going to focus on today, but there are other ways. In a study that we did, the American Academy Pediatric Research in Office Settings, the AAP PROS, we did a quality improvement through that network and found that the most effective thing that we did was better communication.

We also did prompts for providers from nurses and the EHR, which, you know, help some, sending parents reminders and giving HPV in acute and chronic visits. People found it very hard in offices to do that one.

So we're going to focus today because we don't have all day to talk about this, but we're going to focus just on the improving communication at first.

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          Reframing HPV Vaccine Expectations

There's lots of things reframing HPV expectations that until you see the one about it's not about sex, it's a cancer. They – one of the things that sometimes work is explaining – you know, parents that want to put this off, they might say to you, let's wait until they're older and then they can make the decision on their own when they're 18. But if you – if they start the series on or after their 15th birthday, they need 2 doses instead of 1 dose.

And so some people find that – especially when you explain that's because their immune system actually works better before they are a late teenager. When teenagers get older, a lot of times they don't say stop coming into our office that they're busy with this and that and sports and work and friends. And so they stop coming. And so let's get it done while they're here now.

And then the – the – just explaining that it's time for your 9-year-old visit, your 10-year-old visit, your shots.

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          Presumptive Approach: HCP Initiation

And I'll fly through this, just to say that, if you use what they call a presumptive approach, where instead of saying, how do you feel about getting the HPV vaccine today? If instead you do it like you would with polio vaccine, where you just say today you're due for HPV vaccine, that, that presumption that they're going to want what you're recommending is much more effective.

So here you see that if you use a presumptive – this is out of 84% of visits where the provider made a recommendation. If the provider made a presumptive recommendation, they only resisted 26% of the time where what they call a participatory – usually participatory sounds like a better approach, you know, saying, you know, like we want things to be more participatory, but if you use a participatory approach, like, what do you think about getting an HPV vaccine today? 26% use that approach. And out of those, 83% of the families resisted.

So the presumptive approach where you presume that people are going to want what you recommend is much more effective.

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          Presumptive Approach: General Principles

When we say, I – I worry about the word presumptive approach because it sounds like presumptuous, you know, and it's – like, it sounds like I'm saying, well, of course anybody with half a brain would want, and that's not what we're saying. It's just like what we do with – you know, when I say, I recommend amoxicillin for this ear infection, you know, like, this is what I recommend. It's my presumption that you're here because you want my opinion.

Using a declarative statement based on the best medical information, use the same approach as you would. Okay, so assume willingness to vaccinate. And then if you're wrong, and they don't want it, they will let you know. And that appeals to the majority of people.

Now, I know that there are some places, a friend of mine practices in LA, and he says, you know, a lot of people, it may not be the majority. It may be about 50-50. But if you start with the presumptive approach, you're going to vaccinate a lot of people. So one way of saying it, now that your son is nine, he is due for vaccination to help him protect with HPV cancers, we will give him that vaccine today.

Just something straightforward.

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          Presumptive Approach: Be Persistent

This just shows you – another thing that we found in our quality improvement, that a lot of offices were doing this thing where if somebody said no to the vaccine once, that they put in the chart, don't ask again. And so it like closes the door on future vaccination. And so again, one of the things that we did was to have them say, if they say no today, you know, and you know, you've done your spiel, say, I find cancer prevention so important that – and I know that you have an open mind. And so you may change your mind. So I'm going to ask you again. And just asking again, a huge percentage will turn that around.

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          Importance of Staff Training

Another thing is the importance of staff training, so that everybody in the office is on the same page with this, so that you don't have anybody in the office saying, you don't want it today, then we'll make sure we don't ask again. And this is also having everybody ready to understand the frequently asked questions. My son doesn't need this. My daughter doesn't need this. She won't have sex before marriage. You know, knowing the answers to those frequently asked questions, so that you don't have an MA in your office, giving misinformation, because that MA has a lot of power, because the MA may look more like the parent than you do.

And I want to point out, the bottom of this slide – you can download all of these slides, by the way, and give this talk as an in-service in your own office. So, you know, use these slides.

And this – this CDC.gov, this is a wonderful handout that has quick scripts for the frequently asked questions.

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          Motivational Interviewing Principles

Motivational interviewing. So when you get – there's going to be a group of parents that you say, you know, your child's due for the vaccine, and they just say, fine, whatever you say. Then there's going to be a group who say, well, I heard that it causes infertility, and you're going to give them a 1-sentence answer to, actually, HPV infection causes more infertility than HPV vaccine. One-sentence answer.

And then there's a group who are concerned and have a bigger concern. And so you are going to spend 3 minutes talking to them. And that's where the motivational coming. But I just want to say also, there's going to be some people who say, no, and that there has never been a study that I know of that shows a way for total refusers other than what we just talked about, leaving the door open for them to change their mind and asking at the next visit, at the next visit.

So let's go to that group that have a concern but aren't total refusers. This is where motivational interviewing comes in. It's a patient-centered approach. The basic idea, you're not going to go through 3 days of a workshop on learning motivational interviewing. Most of us aren't, at least. But you can do a couple of little things, like getting people to talk about why they might be interested in HPV vaccine.

Avoid addressing the wrong concern. So you don't start by assuming everybody's main concern is safety. You ask – you know, you start by asking so that you find out what their concern is. Nothing wastes time like addressing the wrong concern.

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          Avoid Fact Tennis

And then avoiding what they call tennis facts, where, you know, the parent says, you know, I'm worried about this. And you say, no, this. And then, you know, that kind of back and forth, it turns into a fight. And sometimes you can get people more entrenched in their anti-vaccine pose by playing tennis, you know, fact tennis. And so we don't recommend that.

[00:41:18]

          5-Step Approach to Addressing Vaccine Hesitancy

Instead, if you get down to the point where you've explored the reason for hesitancy, then the next step is to ask permission to address their concerns.

Now, I – I'm old enough that that doesn't come naturally to me. But I've found that when I say, do you mind if I talk about my perspective on this? Nobody has ever – I mean, nobody has ever said no. You know, like, again, they're there. You know, I have never had anybody who's not there because they want a medical opinion.

You know, they're all there because they want a medical opinion. So if I say that, just, you know, in a very simple, fast, do you mind if I give you my perspective on this? But most people do say yes. And then it may be that my perspective doesn't change them, but at least I've had a chance to say it without being that push me pull you.

And then if they go down to step 5 and they still are saying no, leaving that door open, I'll ask, you know, I think that cancer prevention is so important. I'll ask you again next time I see you.

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          Leave the Door Open

All right. I'm way behind, I'm sure. So I'm turning it over now to Rebekah.

Dr Rebekah Fenton (Alivio Medical Center): We make a great team because I talk fast. So I will make sure that everybody gets out. I know you all have – had a really long day and a really late night. So we'll make sure that we also cover all the material as well as answer all of your questions.

I think actually Sharon demonstrated this beautifully, so I won't go over too much. But again, just making sure that we are continuing that conversation and stating it as a statement and not a question.

[00:43:04]

          Start the Conversation Early (Age 9 or 10 Yr)

I think she also covered some of these things. And I'm glad that some people in the room are also already talking to nine-year-olds. I guess I will give the introduction that I'm adolescent medicine. So I only see people at 10. So thank you for starting this conversation before they're coming to me. I was in the thick of it like many of you all during school physical season where we're talking to those 11-year-olds and really trying to get them to get their full shots that we would recommend as opposed to the ones that just school requires, which often you hear.

And so I love this idea of disconnecting this from once we're at 11, especially when we're talking to kids by themselves, like parents are knowing like, you're the doctor, you're thinking about sexual activity. My kid is nowhere near that vs when you're having that conversation earlier. Like again, similarly, we're not talking about why newborns are exposed to Hep B other than, you know, so having those vaccines on board has huge benefit.

So we're decreasing that stigma where, as we already talked about the improved immune response and therefore getting less vaccines, as well as more time having them come in, at least within Chicago, where I practice, you get a required physical at 14. And then at 16, you have to have your shots to be able to graduate. And so we're not seeing those teenagers for those routine visits, as opposed to at this age, they're still very used to like, I have to have my annual checkup. And those are great opportunities to be able to vaccinate.

[00:44:15]

          Adolescent Consent to HPV Vaccination

Okay. So I wanted to talk about, especially from my world of adolescent medicine, like where in the country, because I think there's a lot of questions that teens can at least choose to get vaccinated. So there are eight states that allow adolescents to consent. I actually learned after making this slide that my own was one of them, but the language is so odd. It basically doesn't clearly say they can choose to.

It's more of adolescents can consent to practices related to their sexual health, including vaccines, which is all I need to now be like, okay, great. I can talk to you about your HPV during your heads assessment. Even if your parent is very clear, like, no, we don't want this, we don't need this. Ultimately, we do realize that, of course, teens trust their parents opinions. And that's why that education as a family is so important, but they do have that ability to consent in these eight states.

In other states, again, adolescents can get consented at 18. And so just remembering that, yes, we're having all these conversations earlier on, but the thing I really enjoy is when you're finally seeing them at that 18 to 21 years old, you're able to say, hey, actually now you are in charge of your health. Here's the reasons why this vaccine is still recommended. And we certainly saw the benefits that that has as far as their protection. So we're definitely still trying to get them vaccinated for that protection, even if it wasn't before their first exposure. And vaccination is available up to 45, but it is standardly recommended up to the age of 26.

[00:45:35]

          Secondary School Mandates for HPV Vaccination

All right. And so then as far as there are some very few places in the country that actually require this, and as you can imagine, their vaccine rates are also high as a result of that, because again, we're not having people parse out, I'll take the two required versus the one recommended, but we're really getting all three or even more depending on their seasonal vaccine availability.

And we have that those places are Hawaii, Virginia, DC, and Rhode Island, although some of those states do allow exceptions similar to other vaccinations.

[00:46:06]

          Key Takeaways

So our key takeaways from this section, as we talked about just kind of that presumptive approach that, hey, it's time for these shots that we're offering, again, separating the sex from cancer prevention. And I will also say with that, I find that kind of when you talk about some of the concerns, like there are certainly those parents who are saying like, but my child's too young for that. And that's when I do acknowledge the elephant in the room that like, yes, we do know that this comes from intimate contact, but ultimately again, going back to our points, we're not saying that they need this now. And I'll even say out loud, nobody in this room wants your child who is 11 years old to be having sex right now. But I knew though, it's beneficial to have that protection now and that it's stronger protection for their future.

And when I frame it that way, sometimes they're like, okay, we're, you know, it's just not some kind of permission. And I'll even share that we've seen studies that show that just because kids are getting these vaccines at these ages does not mean that they're increasing their sexual activity, doesn't mean that they have more partners. All of that is totally separate. Again, we're just focusing on that cancer prevention. And we talked about the benefits of going before 15, as well as again, the infrequency of visits. So keep things moving.

[00:47:09]

Leaderboard After Round 2       

All right. I think we want to look at our leaderboard. I also have to acknowledge the virtual team has a strong advantage of having so many members. So I'm going to focus more on the fact that within the room where the teams are more equally sized, the blue team is winning, but we – this is not our last check-in. So I'm still rooting for you, orange team. Thank you, virtual team for joining.

[00:47:31]

Round 3

All right. So now we will go on to our round 3 of questions.

[00:47:36]

          Quiz Question 8

I will slow down as well. Comparing 2016 to 2022 CDC data, HPV vaccination in males, and I should specify this is in male adolescents, have, and you can read the choices and select.

[00:48:02]

          Quiz Question 9

All right. And now we are on to question nine. In a 2016 to 2018 survey of men who have sex with men and transgender women, approximately what percentage of participants had completed their HPV vaccination series?

[00:48:31]

          Quiz Question 10

And for question 10, based on 2018 to 2022 TeenVax data, which racial and ethnic group had the lowest HPV vaccination rates?

[00:48:55]

Being Their Champion: Reaching Underserved Population      

All right. So now I just wanted to focus on some of the groups that we thought may get missed when we look at the data of who is reflected in getting the vaccine. And yet we know as we've already discussed how this is really truly beneficial for everybody, regardless of gender, area, sexual orientation, and just wanted to kind of show that within certain groups.

[00:49:15]

Young Adults Assigned Male at Birth

So first I want to talk about our young adults assigned male at birth.

[00:49:21]

          HPV Vaccination Among Males

So when we look at the HPV vaccination among males, we find that good news is between 20 and 16 and 22, we have made some progress. We went from 37.5% to 49.5%. But as you can see from those bigger blue bars that we're still getting the message that – I'm sorry, I apologize at 37.5 to 60.6. But as you can see, kind of comparison is that we still see even initially and continue today, although we're starting to close that gap that those who are birth assigned females are still vaccinating at higher rates.

[00:49:52]

          Factors Affecting HPV Vaccination in Males

And so then we think about some of the factors. We talked about this a little bit that, hey, first we really got the message out there. This vaccine is important. It's for cervical cancer. It's for girls. And then 2011, we're like, it's for boys too. And that there's still some catch up that we're doing from that message that also those recommendations have changed as far as initially thinking that it only was through the age of 21. And so there was a lot of missed people as opposed to now the strong recommendation for it being up to 26.

And then we think about some of the things that have hopefully helped us and continue to help us. And I think the biggest thing you're going to hear me repeat constantly is that healthcare provider recommendations. And I think I'm sure the fact that you all are here at whatever hour it is in the evening, listening to HPV vaccination, that you are those providers that are strongly recommending it, but also sharing that with your colleagues who maybe aren't necessarily so excited about being an HPV champion to know that even just recommending this as a part of their routine practice really does have a huge impact on helping patients get vaccinated as well as again, those frequent contact with their healthcare provider.

And actually the recommendation till 26. I don’t – do you have a better answer for that?

Dr Humiston: The statistical probability of not having already been infected goes down with time, as you would imagine. And so at 26, you know, the vaccine isn't free. And so the ACIP, one of the reasons that they make – or one of the criteria that they use in there is how cost effective is it. And so the ACIP looks at models of cost effectiveness as well as effectiveness. So that's – that’s one of the reasons.

Now, some people – that doesn't mean, you know, like we looked at that data from Sweden and it showed that people who were vaccinated between 17 and 30, there was still some effectiveness, just not as much. And so we're trying to squeeze the most cost effectiveness out of the vaccines.

Speaker: So that – I’m wondering why there’s such a discrepancy from male to female [inaudible 0:52:03].

Dr Humiston: No, they're the same. They're the same.

Dr Fenton: Basically for recommendation is nine to 26, regardless of gender, it can be given up to 45, excuse me, for either age.

Dr Humiston: It used to be separated, but not anymore. They made it all, you know, so that we didn't have to separate males and females anymore.

[00:52:27]

LGTBQ+ Populations

Dr Fenton: Okay. Now, when we think about our LGBTQ population, I realize, sorry, that acronym was not in the right order.

[00:52:34]

          HPV Infection and Vaccination Awareness Among Gay and Bisexual Men

Okay. So HPV vaccination and infection awareness among gay and bisexual men, basically they asked like, are you even just aware that HPV as a virus exist? And then a separate question, are you aware of the HPV vaccination? And I think what for me was really surprising is to see that the overall awareness is improving for both, but yet people are more aware of the HPV virus as opposed to the vaccine.

And so great to that the awareness of, hey, this is a sexually transmitted infection that could potentially cause problems. But if we're not as aware of the treatment as we are as the problem, then certainly there's a gap that we need to fill between those two.

[00:53:07]

          HPV Vaccine Coverage Among Men Who Have Sex With Men and Transgender Women

And then when we think about coverage among men who have sex with men and the transgender women, and this was one of the questions that we answered. So essentially there was a study that looked at the self-reported HPV vaccination status of about 1400 participants within that age group of 18 to 26 in various metropolitan areas.

And again, the study was done in 2016 to 2018. We found that actually barely more than one in five had actually completed that vaccination series. And that actually their first stage that they received it was at 19, which we've all acknowledged is way later than what we would recommend, especially since 73% of them had actually reported having their first sexual contact. And as we said, one encounters all that it may take to be able to have contact with a virus that many of them had contact long before they were ever vaccinated or received that protection.

But then again, on the other side of what helps them get that vaccine was again, those potentially missed opportunities of, yes, they unfortunately were missed in childhood, but somebody at that age of 19 was like, Hey, I think this is a vaccination that would really benefit your health. And that they agreed to that as well as there were kind of some other minor things that helped such as the communication we heard in other studies like mobile apps, web apps, as well as text-based reminders and education.

[00:54:22]

          HPV Vaccine Coverage in Women Who Have Sex With Women

Okay. And now moving on to women who have sex with women. So another survey is 2019, about 500 women who were – had sex with women in the ages of 18 to 45. And we see a huge discrepancy similar to some of the data we saw earlier on, as far as when these things are recommended. And therefore when people got appropriate coverage that within the 18 to 26 age group, we have 65% of them did get HPV vaccination versus 27 to 45, that's only one in three.

And again, huge driver for vaccination was that healthcare provider recommendation, as well as part of that, having disclosed their sexual orientation to their provider helped them realize, okay, this is something that, you know, regardless of who your partners are, again, with that intimate contact, they are at risk as well as greater perceived social support for vaccination.

So people in their lives think like, yeah, that's a really thing, good thing for you to get protected for, especially these are the age groups where they're often starting to think about that cervical cancer screening and pap smears. And so when you're putting those two things together, like, hey, this is what we're testing for. This is our opportunity to protect you from that concern, that that helps us be able to more effectively get that message across.

[00:55:27]

Adolescents Living in Rural Communities

All right. And then we think about our adolescents who are living in rural communities.

[00:55:33]

          People Living in Rural Communities

So the 2022 National Immunization Survey found that basically they kind of compared metropolitan areas to kind of outside of metropolitan areas to our non-metropolitan areas, which includes rural communities. And while the data was kind of complicated up to 11.7 – sorry, 11.5 lower percentages of vaccine coverage in those rural areas compared to the metropolitan areas.

So they also were less likely to have a well child, which we know was a missed opportunity for them to even receive that vaccine. And that was as a main driver for those differences.

We also see that healthcare providers in rural areas may be less likely to recommend HPV vaccination, as well as in rural areas and Southern states, adolescents and caregivers themselves are reporting greater barriers to receiving vaccines, such as lower confidence in them, especially with the routine vaccines, as well as in the post still COVID world. And a lot of the misinformation that's come from science and particularly vaccines, as well as continued expression of some of those concerns with safety and ingredients in the vaccines.

[00:56:39]

          Improving HPV Vaccination Rates in Rural Communities

So the same tools that help us be able to increase vaccinations and rural communities are often going to cover everything else that we talked about, encouraging attendance at those 11 and 12 year old visits, making sure that we're sharing effective vaccine recommendations, understanding some of those parent guardian concerns. We talked about that that's really just inviting the opportunity to even discuss them by asking that question, addressing those concerns.

And I love that we talked about the fact tennis. There actually are some studies just even realizing, I think often in the midst of COVID, we were like, these really cool posters are saying, here are the myths that people are hearing and here are the answers. And what I find fascinating is that when they actually shared these posters that we all as providers were like, yeah, that was really great. We really answered all of those.

In the end, after seeing them, the families and patients themselves left just reinforcing their own beliefs because they saw them printed on the paper.

So really avoiding answering back that we're repeating any of the statements that you've heard, but instead only responding, as we talked about that one sentence that she mentioned with the fact that response to that belief without repeating it back, and then ensuring that we're having consistent messaging on the importance of vaccination. And I loved how you expressed that being across the entire healthcare team, not just coming from the provider themselves, so that they're getting multiple reinforcements, even just in that one visit.

[00:57:52]

          Summary: HPV Vaccination Barriers and Facilitators

And so, then in summary, we are – HPV vaccination barriers are frequent, numerous, and can vary by patient population. But again, the biggest thing across all of these groups is when we are not recommending the vaccine, then we are losing that opportunity for patients to understand that this is something that we value just as much as the rest of their healthcare, as well as a lack of knowledge about the vaccine. And that's also our opportunity to be able to provide that education, perception that somebody is too old for the vaccine or that it's unnecessary, as well as safety concerns.

And yet understanding these barriers allows us to be able to have targeted approaches that often look very similar in nature, but may be different in design, such as those effective recommendations, providing patient education and addressing all of their questions, as well as improving attendance.

And so ultimately, HPV vaccine education and recommendations provided by us as healthcare providers are key for improving their uptake.

[00:58:47]

Coverage Inequities in Vaccinations     

And next, I just wanted to talk a little bit about some of the coverage and equities that we noticed.

[00:58:51]

          TeenVax: 2018-2022 Vaccination Coverage Among Adolescents Aged 13-17 Yr by Race and Ethnicity  

I will say that I practice in a federally qualified health center where the majority of my patients are Hispanic. And so I'm always kind of curious about like, where are we missing patients? And so I actually looked into this thinking like, it was for sure going to be black or brown kids, because we feel like that's often the answer, unfortunately, with all of these inequities. And so I actually was quite surprised when I looked into this TeenVax data to find that actually, at least within these most recent years of 2018 to 2022, that it was actually white youth who had the lowest rates.

But I would say statistically, very little difference. And so generally, we’re – there's a lot of work to do for all of our groups, seeing as the maximum that we're seeing is not even 61%.

[00:59:36]

          TeenVax: 2018-2022 Vaccination Coverage Among Adolescents Aged 13-17 Yr by Insurance Status

And then this one, I think, is the bigger effort that I'm hopefully, as far as thinking about inequities that we all take away from today. So they actually divided this data into 4 groups, but I figured we could focus just on our uninsured private insurance and any Medicaid. And there was a fourth group that was a catch-all for kids who were like, for example, military insurance or other forms of insurance.

So we certainly – you know, again, often the answer is like, Medicaid, they can't. But the reality is, thankfully, it's covering their appointments, it's covering their vaccines. And so they actually have the highest rate as opposed to private insurance. And yet for uninsured patients who have the same access to vaccines, they are significantly less vaccinated. And I think a big part of that has to do with, of course, their inability to access health care generally or the barriers that they have to experience as a result of that, or some of the additional costs that we often add to visits, even if the vaccines themselves are free.

[01:00:27]

          Vaccinating Uninsured Children

So I imagine all of us are very familiar with the Vaccines for Children program or VFC for short. And certainly that has given us the ability to be able to make up for some of the inequities that we just saw on that last slide. But that allows us to cover the cost of vaccines for all of those who are eligible. And that is anyone under 19 who is uninsured, underinsured, Medicaid eligible or enrolled, as well as our American Indian and Alaska Native patients.

And CDC purchases vaccines at a lower cost that can then be distributed to our clinics. And it was interesting to note that actually in the last 3 – well, 2020 to 2022, the rates of orders for HPV vaccines have declined. And I think I'm curious, but didn't really find some information as to like why, but certainly demonstrates that we're getting less of these out to patients, which is the exact opposite that we're hoping to achieve.

[01:01:14]

Leaderboard After Round 3       

Okay. So we're going to go back and look at our leaderboard. Okay. I think we're still kind of exactly where we are, but I appreciate orange team. Thank you so much for hanging in.

[01:01:26]

Lightning Round   

All right. So next we have some time for our lightning round of questions.

[01:01:33]

          Posttest2

And these will actually pause and get a chance to see our responses as a group, as well as discuss the answer. So for the first one, all of the following are educational messages that can be employed to increase HPV vaccination in adolescent males except:

[01:02:13]

          Posttest 2: Results

All right. So I love that we kind of already were having strong responses to begin with, but I think as a group we have made a consensus and I'd love to see that. So thank you so much for engaging. And I just want to move to our next slide, which will allow us to be able to review. Excuse me. All right. Response. Yeah. Sorry. Like I think we're both trying to push it.

[01:02:40]

          Posttest 2: Rationale

Okay. So you all are correct. B is our answer. HPV vaccination in males is only effective if administered before the age of 18 is our wrong answer. So as we said already, it is indicated for both males and females, 9 to 26. Some adults 27 to 45 might decide based off of discussion with the clinician. And again, the big kind of weighing that benefit and cost depending on their access, as well as previous exposures as to why that may be beneficial past that point.

[01:03:07]

          Posttest 3

Right. We now move on to our next posttest question. If using a presumptive approach towards HPV vaccination, what recommendation would you give to a parent of an 11-year-old patient?

[01:04:10]

          Posttest 3: Results

Wonderful. So we – I think I just quite can't see the bottom response, but it looks like just from the little gray bar I see at the bottom that we also are in agreement that option D or the fourth answer is the presumptive approach. So great job.

[01:04:27]

          Posttest 3: Rationale

So just an example phrasing, your child is due for vaccinations to help protect them from meningitis, HPV-related cancers, and whooping cough. We will give them these vaccines today. I will say that I think I might kind of open mind by saying like, hey, these are – I recommend – your child is 11 because that's when I'm seeing them. These are the three vaccines that I recommend for them today and express, you know, what they are for, as long as we're kind of introducing that as a statement and not a question, then that's when we're not doing that shared responsibility.

And actually, as Sharon was talking about, I was thinking as much as it sounds like participatory, what it's actually allowing is parents to bring any of the preconceived notions that they have about the vaccine in the room. When you're just asking, like, how do you feel about that? Then you're centering that as opposed to sharing, like, these are my – these are my recommendations. Then there's an opportunity for them to say, okay, here's this extra knowledge that I want to address. Like, you're actually starting the conversation in a leading position, as opposed to kind of starting at a defensive perspective, if that makes sense. So that just kind of clicked for me when you were describing that.

I'm like, yeah, I guess I wouldn't want any of mine to kind of be like, well, what have you heard online or other places where I scroll through TikTok. And I'm constantly seeing all the misinformation that's going viral, as opposed to really trying to center science in the patient visits.

So our rationales research has demonstrated that use of presumptive or announcement language increases parent acceptance of vaccines for their child more frequently than the participatory or conversational language. The presumptive approach uses language that assumes the parent will accept the recommendation. So great job.

[01:05:54]

          Posttest 4

All right, we'll move on to our next question. In a survey of women who have sex with women aged 18 to 45 who were not yet vaccinated with APV vaccine, the most common reason for not being vaccinated was:

[01:06:48]

          Posttest 4: Results

Great. I hope you heard me repeat that enough times to have gotten this answer right, and it looks like for 82% of us, you did. So thank you.

[01:06:59]

          Posttest 4: Rationale

And yes, that is the correct answer, that healthcare provider recommendation being the strongest. So we talked about – although it wasn't even just in this study, but really across any of these subgroups, your recommendation was the strongest thing. But then in that particular study, 32% of the patients reported a lack of their provider recommendation as the reason for not getting vaccinated or on the opposite, realizing that your recommendation was a strong facilitator for people ultimately accepting the vaccine.

[01:07:23]

          Final Takeaways

All right. So final takeaways, HPV vaccination is prevalent in both males and females. If the vaccine – sorry, HPV infection persists, it can lead to many types of oropharyngeal, as well as genitourinary cancers. Effective approaches to increasing HPV vaccine include strategic messaging, such as the presumptive approach, or really the focus on cancer prevention, as well as maintaining open lines of communication across visits.

And that we need to find ways to optimize our coverage for US adolescents, especially those who are underserved populations, referring to our males, LGBTQ, to make sure that anybody, regardless of gender and sexuality, is being covered, as well as meeting the needs of our underserved patients with insurance as well. And that barriers should be identified, and that we're mitigating those in a patient-centered approach and acknowledging that every environment is so unique.

So I just find, even within my clinic setting, I am constantly adapting my messaging based off of the feedback that I'm getting. And so really approaching all of this with an approach of culture, humility, and knowing that communities themselves will tell us their concerns, and we have to adapt to be able to address those, as opposed to bringing our preconceived notions.

[01:08:30]

          Posttest 1

All right. So we have a couple post questions that we would like for you to fill out, just so that we know that this was helpful. But then we also have a lot of questions that we were able to receive. I think right now we're seeing those from the online audience, but I'm not sure if we have the ability to type questions in the room. If not, feel free to raise your hand. I believe we have a mic, and somebody will come around, and we're happy to discuss those for the remaining time today. But I appreciate you all being here, and thank you for wanting to learn about HPV vaccination messaging with us.

So I guess I will read out our question – posttest question. I'm aware of strategies to overcome barriers to HPV vaccination in underserved population – patient subpopulations, excuse me. So if you can go ahead and take a couple seconds to answer that.

[01:09:49]

          Posttest: Results

All right. So great. We have mostly – actually, I think, are we missing some responses? Yeah. There we go. Okay, great. Yeah. The math was not mathing I was waiting for. Okay. Thank you. And then I think we have one more posttest question as well.

More – we – I can see more lightning. And then so while if you have – I guess we'll clarify for the room, are they – we're using a microphone for questions? So if you have any questions, feel free to type them into the iPad. Otherwise, we have just one last question for you also to answer.

[01:11:49]

          Leaderboard: Final Score

Congratulations, blue team. I also say, well, you're all winners because you all have learned more information about effective HPV vaccination messaging. So thank you all for being here.

Q&A

Dr Fenton: Okay. Now that we have cleared out our question portion, we'll do some question and answers. We have some that we are reviewing through here and I will read them out loud and kind of go back and forth between the two of us, depending on who I think would be the better answer, since I feel like I'm like the communication adolescents and you are the science and vaccines. So it's a perfect pairing.

All right. I think the first one I have is from Esther[?] online asking, we have tried vaccinating men who have sex with men who are HIV positive up to 45. Unfortunately, the insurance does not pay for it, even with 340B pricing. Any additional resources to consider?

Dr Humiston: Esther, I would say talk to your state immunization program because sometimes there's state money that can be used for adult vaccination, but that varies very much from state to state. So – but I – that would be my first inclination is to talk to your state program.

Dr Fenton: I agree. At least I know for Illinois, we have a program that does cover the vaccine for patients who are uninsured, and that's been hugely helpful for making sure that we're reaching any population that does not have access to their insurance.

All right. Next question. Can we use the vaccine for a child with recurrent cutaneous facial warts?

Dr Humiston: No. Cutaneous warts are – are a different – you know, we said that there's 200 different kinds of HPV types, and the cutaneous warts are different than the mucosal warts. So, no, the answer is no, there is no vaccine for that.

Dr Fenton: Okay. Next, Jerry asks, what is the downside of giving a 23-year-old male the vaccine, even if he has had sex in the past? There is no downside. I think it's just being realistic about the benefits being potentially different than prior to exposure. We, of course, as we said, there is greater than 200 subtypes. We're not doing routine testing in that person, so we don't know what subtypes they have been exposed to, but our goal is to protect them from any of the subtypes that they may be exposed to in the future, and that's the reason why we're still continuing to offer it, in addition to, of course, preventing cancer, as we saw, better to get it later than not at all.

Dr Humiston: So I just want to say that, unfortunately, in the United States, there is no vaccines for adult program, and so an adult who isn't covered by insurance may end up being asked to pay out-of-pocket, unless they can find an adult vaccine through their state immunization program.

Dr Fenton: And then I'm going to try to batch these. There's a couple questions they had about timing for the vaccine. One was asking the recommendation for women, is it 2 or 3 doses? And I think another one was asking something that we talked about in our prep about the recommendation for one versus two vaccines.

So, first, we'll talk about standard, like what is on the package recommendations within the US. Is that under 15, you're getting two doses at least 6 months apart, although often, because we're not seeing that patient until the next year, you're doing that at 12 months, versus after 15, we are doing 3 doses, one, the second one a month later, and then that third dose at 6 months plus.

Dr Humiston: I want to underline that if you can start the series before the 15th birthday, they only need two doses. So even if you can get one dose in, you don't even have to finish the series. But, you know – but if they start the series on or after the 15th birthday, it's a 3-dose series. Now, that may change in the United States, but it's currently being – they are reconstituting the HPV workgroup for the Advisory Committee on Immunization Practices to look to see if the United States is going to, again, reduce the number of doses in the series.

But that remains to be seen. Currently, the FDA approves it as a 2-dose series if you start the series before the 15th birthday.

Dr Fenton: I think we addressed this. If an adolescent is sexually active and potentially HPV positive, will the vaccine be effective? Yes. And do you test for HPV? So I will talk about, we are still, at least based off of current guidelines, starting screening for cervical cancer, which is not HPV specific at 21 years old. It's not until 30 that the recommendation is to do cotesting with both the cells as well, like cytology as well as HPV. There is no need for any kind of like cervical cancer screening prior to that age, regardless of sexual activity. But I think the vaccine recommendation for me feels even more important knowing that at least the American Cancer Society is actually considering moving that recommendation up to 25. And the big reason for that is because vaccinations has dropped cervical cancer cases so significantly.

But my worry is especially when you see, even just, I want to say earlier this year, there was a woman – a Black woman in her 30s, an influencer who died from cervical cancer that got misdiagnosed and could have been treatable or ultimately avoided with appropriate vaccination, that when there's concerns that we're now screening at later and later ages, this is – the vaccine really is going to be the best protection for making sure that all communities are going to be protected against that. So any opportunity to be able to do so even after exposure is important, but we're not doing that screening at least for now until 21. And again, well, it's to be continued if that may change.

All right. Our next, is there an increase in HPV vaccine hesitancy due to the polarization of COVID vaccines? I would say, yes, absolutely. There's so much – there's so much vaccine hesitancy in the United States. A group from Syracuse, including Joe Domachowske, looked at if you're in a red state vs a blue state by presidential – you know, presidential voting, that your likelihood of being vaccinated against HPV goes down if you are in a Republican state. And that’s – to me, that's worrisome.

Just like where you're born shouldn't influence how likely you are to be protected against cancer.

Dr Fenton: Absolutely. And I think also there's just this general questioning of what – you know, these things are made too quickly, what's in them. And so I think there's often been a lot of highlighting and spotlighting of any type of vaccine that does not have this long history. And so I think a lot of the concerns that came up initially are now often resurfacing and conversations are online and therefore in our exam rooms as well.

All right. Next question, what are major adverse reactions to the vaccine? Any differences for age groups? Again, I’m going to –

Dr Humiston: Well, the main one is pain. This is a vaccine. I mean just – I think most vaccines hurt. Adolescents complain about things that hurt. There's a movement actually – again, I do work for immunize.org. If you have never gone onto this website, immunize.org, I really hope that you do. We have a whole thing on addressing anxiety and pain because I think that a lot of – we could reduce the vaccine hesitancy if we just did little things like saying, you know, like in my pediatrician – kid's pediatrician's office, it said we couldn't use a cell phone inside the exam room.

Well, if they could have used the cell phone, it could have distracted them during the – you know, using distraction. Like we – with little kids, we use bubbles and pinwheels, but with adolescents, we could find distractions like using your cell phone, listening to music, lots of things that are cheap. They have the cell phone in their pocket anyway.

And so – so immunize.org has a series of handouts for healthcare providers about how to decrease anxiety and pain, but we also have them designed for parents so that – and for adult patients.

My husband is an asthmatic and he for many years avoided getting a flu shot despite what I do for a living. And so I finally said, why won't you get your flu shot? And he said, because it will hurt? You know, and so even adults need help managing injection pain.

I completely forget the question, but I hope I answered it.

Dr Fenton: I think you actually just answered the next one about any administration considerations to reduce pain related to the HPV vaccine. The only thing else I would add is that often somebody who sees adolescents all the time, really just trying to appeal to like, vaccines are going to hurt regardless. And so sometimes there's a like, the 2 vs 3, I'm like, you would rather have sore arms once than having to come back and do this again. And sometimes that can help. But also there's people who it's just a mental game and they're like, hey, I can only do this one, but I will come back and we make plans. All right, here's when you're coming back just to be able to get those other ones in that same short timeframe, as opposed to, all right, I'll try to catch you the next time.

If like we've gotten that, yes, we just have to figure out the logistics to make sure that that happens.

Dr Humiston: There's a genius pharmacist at SickKids who has done a lot of work on pain. And one of the things that she says is, you use the most painful vaccine last. So if you're going to give TD and HPV at the same visit, do the HPV second.

Dr Fenton: I'm going to jump down. So one was asking about how would you approach the conversation with parents if the child is open to receiving the HPV vaccine? I would personally not mention the fact that the child has expressed interest and instead try to make that be a family decision, just because I would worry about the situation where that child then feels like they can't speak up or later on the parents like, well, why did you say that we're doing this? And so I will just say, you know, like I actually recommend teenagers to start making decisions of their own.

And if this is a vaccine that they're interested in, then this is something that I think could be strongly recommended for them and exploring that conversation with them, as opposed to kind of being like, well, your kid said that they want this shot. Separately, I may tell the kid, like also, you know, depending on where I'm practicing, this is something you can have or, you know, preparing them for if the possibility that your parent decides this is something you cannot have, we can plan to do this when you are ready at 18, when you're able to make medical decisions of your own, but really trying to just frame it more of like autonomy generally, as opposed to kind of isolating that particular child. I'm proud of them for speaking up, but I also don't want to put them in a position where they still feel very vulnerable for the fact that they may be going against their parents' wishes.

And then –

Dr Humiston: I'm going to jump out of order and take the one about can HPV be transmitted at birth? And the answer is yes. I mean, I think a few of you are old enough to remember juvenile respiratory papillomatosis. You don't see it anymore. And part of it is the HPV vaccine has been associated with a real decrease in that too.

But that was when children, a baby going through an infected birth canal would be infected with HPV and so get HPV in their oral pharynx and deeper, and so they would grow papillomas in their airway that had to be lasered off recurrently.

And so it was – you know, it was a huge problem. And – you know, and sometimes ended up because that area would get sticky that the airway would heal closed. And so it was a big problem. And so we’re – this is, again, something that we don't talk about very often because how many people know about juvenile respiratory papillomatosis?

But old people do. I mean, we used to see that. I don't think that that's one of the things that's around much anymore.

Dr Fenton: Actually another one for you. Have you, they looked at titers and children who were vaccinated at a younger age versus older age.

Dr Humiston: Yes. And that's – so when we say younger and older, it's hard to imagine that there's immune senescence that early in life. But the difference between an 11-year-old and a 17-year-old, like your immune system is already going downhill. Bad news. It gets worse and worse. But that's why you get a higher antibody level if you vaccinate at 11, 12 than if you wait until you're 17, 18. It's because of immune senescence that early in life.

The other thing I just want to point out is that there have also been studies. We said this vaccine has been around for 18 years. So we know that the immunity is persistent.

Dr Fenton: And then I appreciate we have some thoughts from our colleagues in Canada. In Ontario, it's given in school with Menactra and Hep B at grade seven, but I like the idea of it being given at nine. However, it will not be covered if no private insurance, unfortunately.

Dr Humiston: So I was – probably by giving it at school, you're – you know, you're more likely to get the job done because everybody's going to school.

Dr Fenton: And I also just, I was trying to think of like trying to balance that with like the equitable perspective versus the missed opportunities. I would actually just say, if you're saying your recommendation is nine, then explaining like, we're talking about this vaccine at nine now because we know that this is available to you. And this is when I would recommend it. Unfortunately, insurance did not allow me to give it to 11. So I'll keep bringing this up with you. And in that way, it seems like you're starting that same conversation with everybody and just navigating through those barriers, as opposed to you feeling like you're providing care for some people, but not for others.

Like we all recognize, and we all live through the fact that there's what we would love to do versus what insurance and other barriers demonstrate for us. But as long as you're communicating that and kind of starting that conversation, that in my head seems to balance out.

All right. If a child gets the first vaccine less than 15, but doesn't get the second dose, now they are greater than 15. Do they get two more doses? I think you answered that one. So no, if you've started this series before 15, you only need one additional dose whenever you choose to get it. And why is it not mandated for school entry? Is there a movement for this to happen throughout the US instead of the three to four states that we talked about?

Dr Humiston: Actually, Texas was a great example where there was a movement to get it as a mandatory vaccine. And what happened was that there was so much pushback around it that like now a lot of states don't even want to open that can of worms because it's like inviting anti-vaccine people into legislative meetings because we're afraid that we're going to lose ground. And I think a lot of states are now losing ground in terms of what's required for school.

So in most states, they don't want to open that can of worms and introduce it as a mandatory vaccine.

Dr Fenton: Interesting. I think we have covered kind of the last couple of questions, which we said at what age can be offered 26. But I think people brought up good points about like it can be offered up to 45. But I think that should be a conversation and looking into both risk factors for the patient as well as benefits for them and also vaccine – coverage for that vaccine through insurance and that it's not treatment and therefore there actually is treatment. And so that's all the more reason to make sure that we are vaccinating and offering that.

Dr Humiston: I think that's one of the things that a lot of parents used to say, well, you know, if he gets it, we'll just get the treatment. You know, and like there's treatment in the sense of you can do a cone, but you don't want that treatment. And so there is no treatment for to get rid of the HPV from the body, unfortunately.

Dr Fenton: Is it normal to find warts in children who were delivered by C-section to mothers with warts? Should we still vaccinate these children?

Dr Humiston: It's not – it’s transplacental and coming through the C-section. So boy, I've never – I have never heard of a case through transplacental. So I would say no to that, but based not on that I have heard, the answer is no, but just on that I've never heard, the answer is yes. And I've seen a lot about transmission. I've never seen about transplacental. So I'd say no on that one.

Dr Fenton: Well, great. That was our last question.

Dr Humiston: I just want to say one more thing that it's unfortunate that it's called HPV because I think it sounds so much like HIV.

[01:28:47]

Go Online for More CCO Coverage of HPV!

And that I feel like – certainly back in the early 2000s when the first vaccine first came out, I think a lot of people thought we were talking about HIV. And so they – they were like, well, my kid doesn't need it because he's not going to get HIV. And so I think it's unfortunate that that name is so close.

Dr Fenton: Yeah. I actually love that at least when I'm working with Spanish interpreters, because I'm learning Spanish, but I don't have it. They actually say human papillomavirus. And so the families are immediately like, yes, I know what that is and I want that protection. And so it's so interesting when we talk about messaging that, yeah, like if we're hearing these kind of quick acronyms and you don't quite catch the middle word, you're like, yeah.

Dr Humiston: Yeah.

Dr Fenton: When we talk about stigma, even more so for that infection. Good point. Okay. So our final takeaways are your recommendation matters so, so, so much starting at nine up to 26 is recommended. Continue the conversation past that point, although we're not seeing the people of those age, but maybe people in your life who still need that protection and thinking of all our ways to be able to overcome some of the barriers.

[01:29:47]

          Thank You for Attending

Thank you all so much for being here. And I believe you'll see all of the information above as far as claiming your credit and getting certificates. And I hope you enjoy the rest of your time.

Dr Humiston: We really hope you will download the slides and use them because if, you know, it's great to be talking to 850 people, but it'd be really great if you took the slides and did your own in service on this so that we would be talking to –

Dr Fenton: Thousands.

Dr Humiston: 8000 people.

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