So, a little bit about me.
My name is Deanna Kepka, I'm a health services researcher
and an assistant professor here at the University of Utah.
I've been here at the University of Utah for about six years.
I work at Huntsman Cancer Institute
and I'm on faculty in the College of Nursing.
I've been working in HPV vaccination
research and education for about ten years.
I started working in this field right around the time
when the vaccine was approved for girls,
that was in 2006.
And HPV vaccination is my prevention,
I have spent many many years and countless hours
working to integrate this vaccine into our primary care
system here in the United States.
And I'm hoping to share my passion with you today.
I'm also the director of the
Intermountain West HPV vaccination coalition
so most of my work has been done in the mountain west states.
So i'm excited to be here today
and I look forward to sharing with you some work
of my research team and of the Mountain West coalition, with you.
So can I move to the slides?
[inaudible]
I think we'll move to that after
we have Mandy's presentation.
[inaudible]
So, the title of my of my webinar today is a
HPV Vaccination Challenges in Rural and Suburban Settings,
I'm going to focus on one of
the most important determinants of
who is getting recommended the HPV vaccine.
And who is receiving the HPV vaccine
and their in the United States
and what factors are related to that recommendation
and getting that support for cancer prevention.
But before I move into my research and
my,
my areas of future research
and our discussion on factors related to this disparity.
I'd like to introduce to you one of my friends
and one of our partners in HPV cancer prevention
Mandy, so I'd like to share a little bit with
you about Mandy,
she's a writer, a speaker,
she's a public relations consultant
she's a cancer thriver,
and she is known on social media
for her hashtag cloud surfer and champagne lover.
One thing I love about her is her posts
of champagne glasses toasting
all around the world.
She's an accredited international travel,
lifestyle, health and wellness writer
and future's published articles in Thrive Global,
Bella Grace,
24-karat MC Living X magazine,
The Huffington Post, Yucatan Times,
Live and at Best overseas, travel west,
and so much more.
Her captivating storytelling adds magic to
her words and her passion for writing is contagious
as her passion for life and cloud surfing, flying.
She is an active blogger
and she's just an amazing HPV
advocate and she's here to share her story
on why this vaccine is so impor-
so important and can truly change the lives of so many people.
Thanks Mandy for joining us.
Thank You Deanna,
hi everyone obviously my name is Mandy
and I am joining you from from Nashville Tennessee today
I'm actually traveling so I'm doing this from a
from a hotel and I apologize if there's
background noise I'll mute myself
when I'm done so you won't hear any of that
but just want to apologize for that up front
because I do travel a lot as Deanna said
so as a travel and lifestyle writer I'm kind of
all over the world sometimes
but I am a huge advocate for HPV
and I'm just going to start with
with my story
and I want to start from August 2003
so this is before it's pre-HPV vaccine
and I'm sitting in a doctor's office at the
University of Utah and they tell me that
you know there's a chance that you have sexually
transmitted disease and I
kind of was in shocked in awe like how could
this be I'm not sexually active what's
what's what's wrong and reality of it is
is that's August 2003 by December 2003
I had to make a very big decision in life
and that was to have my uterus and cervix removed.
Now at the time I did not
know that it was HPV
wasn't an STD it was actually yeah
you know like a
typical what they were trying to tell me
it might be it was actually HPV that
caused me to have cervical cancer
no family history, obviously no vaccine, so
I'm sitting you know at the age of 22
coming out of surgery saying I'm never
going to be able to have children and
I have cancer.
It fast-forwards from there to
then i develop ovarian cancer,
two different times and because of my age
it was will take one the other one looks fine and
then the year after that,
the other one developed cancer
and so it was this
repetitive cycle which I didn't understand
and my health problems started at 16
I had endometriosis and so
I knew and I'd already been having
surgeries every six months
to combat my endometriosis but
I never knew what,
why I got cancer and now I do know and it, it is,
it was from the from HPV.
When I was a young girl
I was sexually abused and went through
a few series of years and traumas that actually
was where I contr-
contracted the HPV I just did not know
and as slow growing as it is
by the time I figured it out I had already had cancer
and so, I think that what's so important is that,
the vaccine is so important but in the
in rural areas and where people aren't discussing HPV,
we don't, we don't know
what we don't know and if we don't have the
conversation we're not helping anybody move forward
and if I could have had the vaccine
my life could have turned out very different.
Now obviously I was
before the vaccine and
how I met Deanna was the fact that my HPV test
became positive again so it's that
it's that worry that fear that
by the way you have abnormal pap results
by the way you have HPV
come back in six months that's
six months
for every single woman that has to go through
that you have abnormal results
I don't care if there's sixteen or fifty-two
that's six months of waiting is some of the most
frightening and scary moments of someone's life
waiting because it's not it's not a blood test
that can come back in 10 days
it's a
you have to wait six months and then maybe
we have to wait another six months
and you don't know the entire time if
you're going to have cancer and how
how much it will affect or not affect your life
and that's why I
appreciate all of the work that Deanna
that Deanna does with the HPV coalition and
the message that they have
because HPV is,
it can be, we can prevent cancer
we can literally change the lives of men and women and
it's, it's the most important conversation
that we should be having
because this is one cancer that
we can completely wipe out and
I don't know if we'll speak to this today Deanna but
the information that you shared in your TEDx talk with
with Australia I mean combating
the mindset that that
we have surrounding around HPV it is a
discussion it's a topic because
we shouldn't be afraid of a vaccine
that can wipe out a disease
and for one bad post on social media
there's probably millions of lives saved
and so when we breed positive
I believe that we can all
surround and come at HPV from a very positive place
and it takes people
like Deanna, takes people like me to share their stories
and their work to create change in
such a place with stigma and
especially I think in rural areas and
where people don't have access to
to the vaccine or to the conversation
you just have to start talking and we have to raise our hands
and say let's save lives
this is about saving lives it's not about
it's not this isn't a this isn't a
vaccine or the stigma around vaccination
or no vaccination it's really about saving lives.
So that's a little bit of my story, Deanna I don't know if you have,
if you have specific questions or if we want to open it up to questions?
um let's
am i unmuted, okay so,
could you tell me a little bit about
what your relationship was like with your family?
Yeah absolutely that, I think that's
that's probably a very important piece.
And I think in a rural, a lot of rural
communities there is a lot of challenges with
families and talking about this vaccine.
Yeah absolutely um
so I was I was raised and in the
Mormon religion and this,
this stigma of what happened to me
not even related to HPV was
was more of like let's sweep it under the rug
let's not talk about it
let's, let's just hide it from everyone else
and then never speak about it again
so not only does that
hinder conversation forward in any realm
but it also it's, it's emotional on so many levels.
When I figured out that it was HPV that caused
that caused the cancer
that's so emotional for me and and still
no one wants to talk about it and they've been very
trying to control this
conversation of
don't say anything let's not talk about it
we can't let people know we can't let
because what happened to me was
done by a family member
which you know, completely changed my life
completely changed my life
and I think that
when we're talking about small communities
and even larger communities
when we're trying not to have the conversation
we're trying to protect something
because of we're trying to protect a
secret it's
it's not helping
we have to be able to have the conversation because,
now I'm de- I'm dedicated to
to speaking out about it
because it's going to help so many other people
these unfortunately
circumstances like mine continue to happen
and we don't know where we will contract HPV.
As you know, it's you know, over 80% of us,
is that the number?
80 percent of us have it,
now does that always go to cancer? No.
and it's unfortunate we can't
say who's going to get cancer and who's not going to get cancer
but with my family they've still been in that place of like
please don't speak out, please don't,
please don't tell anybody they also
don't understand and if we can help one person
be able to step forward and receive the vaccine
so if there's an unfortunate circumstance
that they contract HPV and develop cancer
we can save their lives and so
it's hard it's not, it's not,
I don't think I have an answer on
how do we have the conversation of
being able to help someone talk
but having
different people speak about their situation
hopefully inspires
a smaller community or rural area to
to talk about it and
and step up and and I guess
do something about it.
Thank you so much for your strength
I think your message is
invaluable and so important in the work that we do.
Does anyone have any questions?
Please type your questions in
and Troy can read them out or if
please feel free to share some
supportive words.
Troy are you able to get those?
Well thank you so much Mandy
really appreciate you taking the time
especially on your long journey
from North Carolina
with this, with your,
I want to see car when you get here.
Alright yes I'm driving my, my
convertible from Asheville North Carolina to Salt Lake City so
that sounds really fun
especially just in time to get here for better weather, hopefully
we'll go for a ride when I get there
but Thank You Deanna for all the
work that you've done and thank you
everyone for your being on the
on the call and
it takes all of us right it
takes a village to make changes.
So, what I'm seeing is many people saying
thank you for sharing your message,
thank you for sharing your story,
you're an inspiration,
thanks so much for your strength
it shows great strength thanks for sharing your story.
Thank you for deepening this message
by sharing your story you're an inspiration,
thank you.
So many positive words.
Well thank you all
thank you so much.
Okay, do you want to share the results from what the
survey Troy?
Who do we have on the call today?
And there were some issues,
I guess we reached our cap of response
respondents.
But yeah, it looks like quiet a few in Nevada,
some in North Dakota, California.
Interesting mix of people. Super interesting.
California, Nevada, North Dakota.
So a lot of undergraduate students that's
good we're getting people before they're
out as professionals and this is when we
need to reach people
need to reach people before they become practicing
professionals either in social service agencies
or health departments or as
doctors or nurses
or as parents let's get you before your parents
or let's get you while you're eligible for the vaccine.
Graduate students, healthcare providers a few of you,
health department other,
great sounds like we have a nice mix of people
that's wonderful.
Do you see this question here?
What are some new and novel ideas
that folks are using to promote higher vaccination rates?
I work in a suburban pediatric clinic in Plano Texas that
mostly serves the medically indigent,
what, we would love to hear other scripts.
So, I think sharing um survivor stories
is is really important for healthcare
providers to motivate providers to
recommend the vaccine
but I think as we
get through our presentation today
we're gonna share a lot of the evidence-based
meth- methods like what is
the most effective strategies for improving
vaccination and really a lot of it rests
on that strong healthcare provider
recommendation and the provider
strong health care provider team supporting
this vaccine but we'll get into that
a little bit more as we move on in the
talk I look forward to discussing that further
does that sound okay?
Alright, so can you still see my slides?
Alright, how about now?
Okay the goals for today's talk is
we're going to present an over- overview of HPV
HPV cancers and vaccinations
and then we'll move into what we know about the social
cultural and instrumental barriers
surrounding HPV vaccinations that are
relative to rural and suburban settings
and what we mean by social and cultural
barriers they're barriers that affect attitudes not knowledge
interpersonal relationships, perception,
recommendation, willingness to accept the vaccine
and then when we talk about
instrumental barriers we're talking about access,
is the vaccine available at the clinic?
Can clinics afford to stock the vaccine?
Are parents able to get the vaccine, due to maybe transportation barriers
if they're in a rural setting.
Instrumental barriers are more tangible barriers.
So, we're talking about attitudes and relationships
and then actual tangible barriers.
So barriers that relate to costs or direct access
or feasibility
and then we're going to discuss evidence-based strategies
to improve HPV vaccination.
That could work in rural and suburban settings or what
we know works across the United States
and then we're going to talk about where
we really need future research.
Where do we need future research to really close
this disparity, to really start equaling out
the playing field where location no
longer is a determining factor on
whether or not you get the HPV vaccine.
I hope that sounds alright for everyone.
So, how many cancers are caused by vaccine
preventable HPV each year in the United States?
30,000.
How many people is this?
So, I'm in Utah,
this is as if each person
who filled up our football stadium had
an HPV related cancer
cancer that was vaccine preventable.
30,000 cancers.
An entire college football stadium
of cancers could be preventable if we just
increase uptake of this HPV vaccine.
That's amazing and it's more than just
cervical it's more than just female cancers.
What else could be prevented?
400,000 cases of genital warts.
400,000 cases. That's two times the population of
Salt Lake City.
Two times an entire city of people
could be prevented from having
genital warts.
True, genital warts are not going to kill you
but if you ask any teenager if they
could prevent themselves from having
genital warts for the rest of their lives
they will say yes.
If you could ask any mother if she could prevent the
transmission of HPV type 6 and 11
which are not cancer-causing they are not oncogenic,
oncogenic means cancer-causing,
HPV type 6 and 11 are not
oncogenic so she could prevent the transmission
of those two types from
herself to her child during delivery
which would then cause her child it
could lead to this
recurrent respiratory papillomatosis
in her child's throat
which would be recurrent warts in her child's throat
which would be need to be
removed by recurrent surgical procedures
she would say yes.
The HPV vaccine
prevents transmission of those HPV types.
It prevents the transmission of 7
oncogenic types and then 2 types
that cause 90% of genital warts.
Not only that
it prevents pre-cancers.
Now Mandy talked about
the anxiety of having that HPV
test every six months.
The HPV vaccine prevents that anxiety
it prevents 90% of
the infections that cause pre cancers and cancers
those oncogenic HPV types.
One in ten women will have an abnormal pap test.
This represents cervical
dysplasia that is caused by infection with HPV.
What does this mean?
This is 1.4
million new cases of low-grade
plus 330 thousand cases of high-grade cervical
dysplasia.
Why is this stressful? Why is this a negative occurrence?
Well I think
Mandy gave us some clues to this.
It causes anxiety, it causes stress about
one's sexual health,
it causes stress about one's fertility,
it causes stress about one's
interpersonal relationships, one's sexual
relationship with one's partner.
It can lead to surgical procedures medical
procedures that can impact your ability
to carry a child to term, it can result
in hysterectomy
for more advanced stages of cervical dysplasia.
It can lead to
a lot of lost wages the time you had to take off
of work to get these tests to
get the follow up procedures.
We can prevent this with HPV vaccination.
So now we need to talk about the HPV vaccine
not as a vaccine for girls but as a
vaccine for all 11 and 12 year olds.
And in the last few years this is more
important than ever.
HPV oral pharyngeal cancer if you look
at the bottom row is more common in men
than cervical cancer in women.
HPV cancers are no longer just female cancers
we have HPV oropharyngeal more
common in men than cervical in women
if you look at HPV 1618 I like to call them
our tzunami HPV types.
They are, cause the most amount of HPV related cancers
and then we have 31, 33, 45, 52, and 58
they're our hurricane types they are the
second most damaging HPV types
second was damaging oncogenic HPV types and
then our lighter blue tropical storm.
So, the vaccine protects against the tsunami
and hurricane types,
90% of the types that cause cervical cancer
and the vast
majority of the types that cause oralpharyngeal
along with these other
cancer types in the anogenital region.
This vaccine protects
against cancers in men and women.
30,000 cancers each year in the U.S.
So who has HPV?
We need to remove the stigma around HPV
and I think Mandy was talking about
how stigmatized she has felt and she is
not alone because you know what?
I have HPV, you have HPV, we have HPV,
Nearly all of us have had HPV
or will have HPV at some point in our lives.
It is so common that 80% of us
will have it at some point in our lifetime.
Most infections go away on their own
and most, and those that don't
go away on their own can
cause precancerous and cancers.
One in four of
us on this call today have active HPV infection.
The other trick of it is if we
don't know if we have it
and it has no signs or symptoms.
So any one of us can
pass it from one person to another
without knowing that we have it.
It's when it persists and a person doesn't
clear it within six months to two years
that's when it can lead to pre cancer and cancer.
The other trick of it is in
women we have PAP testing and HPV testing
so we're able to detect it in
women and treat it early
but in men in oral pharyngeal cancers
we do not have
an fda-approved HPV test
we are not able to detect it as a pre cancer.
We are not able to detect it effectively as an HPV
positive oral infection effectively we
do not have an FDA test for that.
That's why now more than ever it's
important to vaccinate boys
just as frequently as girls integrated into our
primary, primary care system.
We should be recommending HPV
same day same way as
all other vaccines and at every visit
when a child comes into the healthcare
system and this vaccine is so effective
we have dropped it down from three doses
to two for under age 15.
The data showed this vaccine works
and giving it at it
at a younger age works.
The immune system is stronger at a younger age
and as a result
kids can get just two doses under age 15
within a 12 month time frame spaced six
months apart.
And like Mandy mentioned
Australia has a phenomenal vaccination
rate eighty percent of girls
seventy-three percent of boys
successfully integrated it into their school
immunization program for kids up
to age fifteen is on the path to become
the first country to completely
eliminate cervical cancer.
Let me say that again,
the first country to
completely eliminate a cancer
due to successful integration of HPV into their
immunization program for kids.
Where are we with this?
We are not quite on that path yet,
we can turn these numbers around
but right now, we are not quite on that path.
We have less than half of our kids
43 percent these are the most recent
NIS-Teen data 2016
showing that our kids are up to date with the vaccine
by ages
17, so this is even older than Australia data.
Australia's data was up through
15 we're at 17 we have 43 percent
about half of our girls 38 percent of our boys
so we see a disparity between girls and boys
so we've got a ways to go to get to
the same numbers as Australia.
And this blows my mind because this is a safe and
effective cancer prevention vaccine.
It prevents 9 HPV types and I think I laid
out why preventing these HPV types are so important
it is not a new vaccine it's
been around for more than 10 years
and it has been proven to be just as safe as
any other immunizations that we give to
our 11 and 12 year olds and yet we see
this huge disparity not only have it do
we have low vaccination rates in our
country compared to other nations like Australia
but we see big differences
across the U.S. by where you live.
If you live in California or in Maine
you're more likely to have been recommended
and to receive the vaccine
or Massachusetts than if you live in Utah or Texas
and you can look at this
map and you see the different shades of blue.
So, the darkest blue regions have
vaccination rates of 70% or higher for
first dose of the vaccine where the
lightest regions have less than half of
the kids.
So this, this is a disparity
this is where we see big disparities by
where you live
likelihood of having received a vaccine
then so those in certain locations are
have a much higher likelihood of having
received a vaccine than those in other locations,
it's a geographic related disparity.
And then when we look at other disparities
around HPV related cancers
we see a little bit of a flip so
in the south we
see lower rates of HPV vaccination rates
we don't see a lot of dark blue in the
southern region of the U.S.
We do you know a lot of those southern states are rural
like South Carolina and New Orleans
they have very light blue HPV vaccination
coverage but then when we look at
issue related cancers in the south we see a
lot of this darker orange to red
which means that they have higher incidence of
HPV realated cancers in the south.
So, they're not receiving the protection
because their vaccination rates are lower
and their HPV cancer incidence is higher,
it doesn't mean the whole country
shouldn't be trying to strive to rom- to
meet that HPV healthy people 2020 goal
of 80% vaccination coverage two or three
dose completion
but I'm still showing an additional disparity that we're gonna
see over time by these regions of the country
with higher HPV cancer incidents
and lower HPV vaccination.
So, health officials are seeing this disparity and
there's been news around this, we're seeing
this rural-urban gap widening
and unlike in the past where
we've seen urban regions
lower-income urban regions having
larger challenges with access to preventive
services we're seeing the flip with the HPV vaccine.
And that's why health
officials are puzzled
I'm going to walk you through this.
So these are those
NIS teen data again
they're the most recently available data.
So if you, let's
look at the first column first dose
this means kids that by the age of 17 who've
received the first dose of the H I-
the HPV vaccine
so the average for first
dose receipt of the vaccine is 65 percent
that means 65 percent of the
kids by age 17 in the u.s. among
boys and girls have received one dose if we
look at urban kids
it's almost 71% have received one dose
but then we look at suburban
it drops down by eight percentage points,
63 percent and then rural 56 percent
oh wait so and then that's for females and
then we look at males it's 56 for the, um,
the u.s. average and then for girl for
males for first dose for urban is 61
for suburban is 54 and rural is 44 so we're
seeing this huge disparity each and
every single measure you're seeing a
reduction.
So let's do this one more time
females urban 70% suburban 63% world 56
percent males urban 61% for first dose
suburban 54 rural 45%.
Now let's look at third dose
for females we're seeing urban 48%
suburban 42% so it's the same pattern,
rural 34%, so there's a huge gap between
urban and rural from 48 percent to 34 percent
but that suburban is right in
the middle - there's a gap for suburban
and then we look at males again it's the
same pattern,
35 percent for urban
for three doses, 30% so this is
when three doses were recommended 30%
for suburban and then only 23% for rural.
Wow, that is such a huge disparity
and it's a trend that is happening across
the whole country.
So, I'm going to talk about
some rural barriers to that
vaccination.
So these are some general barriers
that we know to HPV vaccinations
that are happening across the whole United States.
Major barrier, a lot of
people are just not associating even though
those vaccines been around for ten years
HPV is related to 30,000 cancers each
year in the US people are just not
making that association, they're not
making the association or
the relationship between HPV and male and
female cancers.
Across the whole u.s.
people are waiting to vaccinate until
older pages they're thinking it's not
an appropriate vaccine for a younger ages
they're thinking oh it's STI
we can wait till my kids older, we're not thinking
it's for 11 and 12 year olds.
There's been a trend, there's been an over -ly
feminin- feminized attitude about
this vaccine for, that it's for girls and
not boys because mainly in part because
it was recommended in 2006 for girls in
2011 for boys,
maybe in part because it was really promoted
as a cervical cancer
vaccine, within there's this delay
of uptake for boys.
A lot of times adolescents at these ages
11, 12, 13, 14,
they're healthier so they're not going
the primary care providers as often,
don't have as much opportunity to get the vaccine.
It hasn't been framed as a cancer prevention vaccine.
All the stig-
stigma around sexually transmitted infections
and talking about it at this
age where kids are going through puberty
has just caused so many problems that
this vaccine has not been successfully
integrated into your primary care for
this age.
Now, let's look at rural challenges.
Strong provider recommendation,
we know this is the number one reason
and why a kid gets this vaccine
and we know in rural regions it's even less
likely that a provider is going to make this
strong recommendation. There's just
data that shows when providers are
even more hesitant to make this
recommendation in rural regions.
We know that there's health care system
challenges for why the HPV vaccine is
not being strongly recommended or
systems aren't being developed to
integrate reminder systems is even more
challenging in rural environments because
healthcare systems have fewer
financial resources, they may have fewer
providers, they may have electronic
health record systems that are not as
fancy or sophisticated, so in a rural
region it's even more difficult
those same challenges that are present across
the whole US are even more problematic
and have a greater impact and less
likelihood of kids getting the HPV vaccine.
What else is going on? There's
multiple doses for this vaccine,
so this can be a problem for kids all over the
place because kids are busy
11 and 12, 13, 14 year-old kids are busy parents are
busy but now if you factor the
multiple doses in a rural environment some
parents are driving hour and a half
two hours to get their kids to the doctor.
If they have to go back for two and three doses,
that's gonna be an extra hindrance
it's going to be another barrier
that's going to prevent vaccine completion.
Costs.
This vaccine needs to be stored in a
refrigeration, it needs to be refrigerated.
This couldn't be expensive
for a rural practice if it's a small
practice and if there's a low demand for this vaccine,
if patients are not
accepting this vaccine
if it's not being integrated
into vaccine delivery it can
be expensive to stock this vaccine
if the vaccine is expiring and it's not
being used.
So there's higher costs for cold storage
if the vaccine is not being used for rural practices
and when you have new
patient populations so in some rural clinics
they may only have 50 age
eligible kids in a whole year
for the vaccine so this could be really
difficult or they may only have a hundred
kids compared to an urban
practice that has thousands of kids.
These are huge challenges.
And then the
availability of a vaccine I've talked to
a number of small practices in
Wyoming and Montana where
really small practices like maybe only one primary
care provider or two primary care providers
at the practice and they
cannot afford to stock the HPV vaccine
they can't afford to stock any
adolescent immunizations.
So what they do
is they recommend the child to go to the
health department to receive their immunizations
and well this is an extra
step so this means the parent needs to
go to the primary care provider for the
well child visit
and then needs to go to
the health department to get their immunizations.
So it's an extra step as
the parent is more likely not to do it
one more step is another trip that they
have to make and then the next challenge
is tracking,
it's making sure that the data
are reported back to the primary
care provider.
So, this is where I see
the additional challenges that rural
practices have on top of the standard
challenges, the standard barriers, to HPV
vaccinations.
And I'm getting this information
from conversations with
world doctors from
literature reviews that I've done and from
some of my own
research.
So, I'd like to stop and just for a few
moments and see if anyone has
any questions or any comments.
I'm just going to take a little drink of my
coffee about some of these points
before I move on to my next topics,
okay,
trying to see them, okay yeah.
"This is great information we have to do more to
change the conversation"
and Christy Brown shared, "providers need to recommend
recommend this this is very important there needs to be a
concerted effort made in rural
communities regarding getting HPV
vaccinations to the kids"
Yeah that's thank you definitely
definitely especially, yeah we need this
protection and a lot of times we see
disparities and cervical cancer in
rural communities because of access to PAP
testing that's why we need the protection
even more.
Okay, anything else?
Okay, I'm gonna move on.
So now I'm gonna talk a little bit about my research in
Utah, so the thing about Utah is
we have some large much of metropolitan regions
so we call the Wasatch Front,
the Salt Lake City Provo area and then we also
have st. George which is border of Nevada
an hour from Las Vegas so
those in Nevada are familiar probably with Saint George
but then we have many
rural towns and we have regions
which are considered frontier and so that
means very even smaller than rurals so,
few people, just a few people per square mile,
so that allows us to measure differences
between urban and rural and so what my
team is able to do is we looked at
missed opportunities for HPV vaccination
using registry data. So we got ahold of
our immunization information system so
most states have vaccine registry data
but the challenge with it is for
researchers to work with health department's
to get access to these data
it's really difficult
but we were really successful we have a
phenomenal health
department and we've built a really great partnership,
so we got access to
data on 55,000 girls over a
five-year time period and these data
allowed us to see real-time visits
when girls went in and got immunizations from
80% of the visits that happened in Utah
over this time period so we're able to
see what happened when kids came in for immunization
visits did they get the HPV
vaccine or not when they got another adolescent visit,
and this paper was published a few years ago
and papillomavirus research you see
the citation below if you want to look it up
and learn more about it. So what we
saw is so this data is more
sophisticated than the NIS chain data
which I was just reporting to you
because that data is survey based and
then they pull medical records
but they're just looking at overall
vaccination rates while we're looking at
individual visits to a provider office
and what happens in those individual
visits so these are more exact data
because we're looking at every single
interaction when a vaccine is delivered
and we saw it when we looked at all of
those 55,000 interactions for those
women and those girls 44% of the time
a girl got another vaccine and not the HPV
vaccine over a five-year time frame.
So that means there's 44% of the time we
could have improved access to cancer prevention
and then there was another
40% of the visits we saw a missed opportunity
where there was an
opportunity to get dose two and three
and the patient didn't get that vaccine.
So, there's a lot of missed opportunities
happening in Utah over that five year
time frame.
And then we dug a little deeper and
tried to tease apart what was
going on a little bit closer
and we saw that two out of three preteens that
means 11 and 12 year olds had a missed opportunity
so our younger kids are definitely most
likely to go in and get one of those
other immunizations which is Tdap
meningococcal or menara or flu and that
HPV and this is the age when you really
should be getting the vaccine you'll get
the most protection at this younger age
and so two out of three of our younger
teens are getting a missed opportunity
compared to one out of three of our
older teens.
And then we found in Utah
whites are more likely to have on this
opportunity compared to Hispanics and
that's where we're seeing so many
differences with this vaccine compared to
other health issues we're seeing this
disparity it's just flips
like a reverse disparity where
urban kids are more likely to get the vaccine
in Utah Latinos are more likely
to get the vaccine.
And then now for the hot topic of today,
we see urban kids are
less likely to get the vaccine so
rural kids had a higher level of missed
opportunity which means they are more likely
to see their doctor and get Tdap
meningococcal or flu
42% of the time they went in to see their
doctor and got
one of those other vaccines and not HPV
over five years.
Some limitations in this
study is we weren't able to look at visits
when they went in and didn't get
a vaccine I would have liked to looked at
look at like when they got a physical
or when they went in for
another visit like strep throat or ear infection
this really the vaccine you should be offered
at every single visit
and sometimes there's mistakes in data entry
in these type of data so we had to do a
lot of cleaning
but the strengths are- these are data
for the whole state they're very complete
but huge participation and are
very long time interval.
So here's where I think we need more research we
need to look at more provider and healthcare system
level factors
especially in suburban barriers this is
where it's really tricky because it's
like middle ground it's easier to tease out
the urban and rural because they're
they have
it's clear with looking at different
zip codes, looking at more
distinctive factors based on population
and the way health care systems are set
up what's going on in these suburban settings?
What's going on with vaccine hesitancy?
What is going on with attitudes? Is it
really a stronger rates of just
concern around vaccination overall that's
impacting it or is it problems with HPV vaccinations
specifically? Is it at the
provider level or the parent level?
Is it factors around bundling practices
or is it um perceptions by the doctors that
these kids aren't risk for HPV
related cancers so
we don't need to recommend
this vaccine in suburban practices.
So, I think there's so many issues that
needs to be teased apart in that
lower level of HPV vaccination that's
taking place in suburban settings across
the u.s.
So I'm going to move into talking a little
bit about some
evidence-based strategies that we know improve
HPV vaccination.
So we need to be
educated and this is some of the work
that our coalition's been doing we need
to learn about making this a public
health priority we need to become
Australia, we need to be right up there with
one of the countries that's on the
path eliminating this cancer.
We need to make sure that our providers are on
board with this, this is not an optional vaccine
this is- you don't have an option
just to talk against this vaccine
this is part of our public health platform in
the United States supported by the CDC
the ACS, the National Cancer Institute, we
need to share the benefits with parents
and patients it needs to be bundled when
your child comes in for a visit your
physician or primary care provider and
nurse should be saying your child
needs three vaccines today: Tdap, HPV, and
meningococcal.
Today your child should have three vaccines that
are designed to
protect him and her from meningitis
cancers caused by, caused by HPV, tetanus,
diphtheria and pertussis.
BAM, that is it.
Should be routine procedures to reduce
miss opportunities.
Here are some evidence-based interventions that work:
standing orders, what is standing orders mean?
they mean all medical staff who are
eligible to deliver vaccines should
be able to deliver vaccines to age eligible
parents, you don't need to wait for the doctor
to approve it, they should just be
able to do it once a child is in there
and is willing to do it you have the
parents approval BAM you do it.
Provider prompts: providers should be reminded
that a child is eligible to do it
through EHR systems electronic health
record systems and they should be giving that
strong and bundled recommendation
that I just demonstrated for you.
Providers need to assume parents are
getting it don't ask a parent, just tell
them tell them they're getting it be
confident don't present it as optional.
Use prevent parent patient reminder and
recall systems: this could be really important
in rural settings especially
if you have to commute pretty far way to
get to your provider those postcard
reminders, text, emails, phone calls,
could be really helpful for reminding parents
to get into their provider office
or maybe to make that appointment when
they're making another trip into
town for another reason and to really
encourage plan-do-study-act cycles, so
what these cycles are are quality
improvement processes where,
if you want health care teams improve they need
to know how they're doing so they need
to be interfacing with data but not on a
big scale it's not going to help them
to know what their vaccination rate is for
an entire year it's going to help them to know
what it is for today and
tomorrow and this week so they could set
tiny goals to try and improve and they
can make small changes and see how that impact
impacts their vaccination rate
it's almost like each day is a tiny
experiment if they change their language
a little bit if they do things a little
bit different that they work together as
a team and in slightly different way
slightly different way, how does
that impact their rates and that helps
motivate them looking at data looking at
ways where numbers go up or down
could help them make slight adjustments to
then improve or adjust from a decline
to make a change and try again,
all of these processes work.
We are working with
American Academy of Pediatrics here in
Utah right now we're doing a quality improvement
project with small practices
in Utah Wyoming and Alaska.
We use HPV cancer survivors stories
Mandy is one of our advocates to
share stories with pediatricians who working
in small practices all over this region
with low HPV vaccination rates to help
motivate them to make that smart strong recommendation.
So pediatricians and
their health care teams often never seen
a HPV cancer. HPV cancers affect people
in their 20s 30s 40s 50s sometimes 60s
so we want them
to make this cancer real we want them to
feel how painful it can be on someone's
life if they feel that they will be
inspired and motivated to know that
they're doing good when that child gets that
vaccine.
We also include webinar
based provider coaching strategies on
those plan-do-study-act cycles and we
use webinar based strategies on a monthly
basis so people can participate
from anywhere in the world they can
participate from rural Alaska, rural
Montana, rural North Dakota.
So, and it helps have interaction and get feedback
on their vaccination strategies that are working
help them look at their data, map
their data out,
and in the past we did
the same study the same quality
improvement project with Montana, Nevada,
Utah, and Wyoming and we had
improvements in vaccination rates,
not huge but small ones but every every
vaccinated child makes a difference
that's one child is going to not be
facing HPV related disease.
Some future areas of research that I think are
needed is we need to look at the effectiveness
of targeted provider and
healthcare teen training activities
for rural and suburban settings, what do we
need to do differently in these settings.
What are the characteristics of these
rural and suburban regions that are
really relating to lower rates of
vaccination and how does that relate to
where we should be targeting our
interventions and how we should be designing
our interventions.
Aside from
that strong provider recommendation,
do we need other messages for parents in
the rural and suburban settings?
Do we need to look at this,
come at it from a
slightly different angle to be more
impactful and to address parent concerns
How can we get rural and suburban
practices to own and prioritize HPV
vaccination?
I think our HPV advocate
program is one way of doing that
I think stories like Mandy's really help.
How can we make this more normative, how
can we get them to buy into how
important it is to prevent experiences
like Mandy's had.
How can we improve access to
HPV vaccine in rural clinics?
How can we subsidize the cost
for storing the vaccine in rural clinics?
You know, is it fair that a rural clinic
needs to pay the same as a wealthier
more urban clinic just to store and
stock that vaccine?
I don't know because
that's limiting the access of that
vaccine to rural kids and how we best
monitor and celebrate improvements for
HPV vaccination rates and small
practices?
So, rural practices may not have these
fancy electronic health record
systems, they may not even have EHR systems,
so what are some ways that we
can give them feedback on their data
and help them celebrate their achievements?
So, what questions do you have about
location and HPV vaccination? let's see
we have a couple of minutes.
Feel free
J Anderson says,
"I'm in Elko Nevada and were hosting a teen health fair
May 22nd, we were having a
vaccination clinic at the health groups to include
HPV, I can't thank you enough
for this presentation it will help us as we move forward
with promoting the event."
Great, thank you!
Question here, is it reasonable for men older than 26 to get the vaccine?
so that's so for that it should be between
a discussion between yourself
and your provider that is completely up to
you and your provider the only issue
with that it could be reasonable definitely
is, it- it is not likely that
insurance will cover it unless you're of
a very high-risk population.
Are family practitioners slash general practitioners
included in the outreach and improvement efforts?
Rural areas may not have pediatricians.
definitely
so um yes
in for AAP they focus on
pediatricians but for my work
I focus on primary care providers so I'm working on
a couple big intervention grants
and if they get funded all of my partners are
family practitioners and general practitioners.
I've been reading a lot of articles and blogs on the
internet stating the HPV vaccine
will cause horrible side effects
although I'm not sure how true these
statements are, do you have any studies or
evidence comparing the data between
vaccinated people who have had issues
directly correlated to the vaccinations
versus issues caused by HPV
and unvaccinated people that could be
prevented if they received the full vaccination?
So the CDC has done a phenomenal
job of reporting VAERS which
is the vaccine adverse side effects
V-A-E-R-S and there is no reason to believe
that HPV causes has any more
associated adverse side effects and any other
vaccine that is given at this age
so the associations we don't see but it doesn't
mean it's impossible but there are no at this
point, there are no known serious
side effect associations noted
other than pain at injection sites and the
risk of fainting following vaccination
so because of the risk of fainting it's
recommended that kids and young adults
sit down or lay down after they're
vaccinated but the CDC has done an
excellent job tracking vaccination risk
and they track association with serious
side effects and at this point there is
a higher risk with known serious side effects.
Is there any benefits of getting the vaccine
after you already been diagnosed?
I think that's another conversation
between yourself and your provider
I think if you're within the age
recommendations for the vaccine
which is up through 26 it protects against 9
types so the idea around the age 26
is unlikely that you've been exposed to all
9 types so you may still benefit from protection
in the vaccine against one of
those types or most of those types
there's still benefit up through age 26
based on epidemiological estimates.
Any tips for dealing with anti-vaxxers?
I think it's anti-vaxxers I
I'm still learning I don't know other than I think
if people have a difficult story
of someone who they believe has been harmed
by a vaccine I think just show
compassion because when a child has ever
been harmed we need to show compassion
for any child's pain or illness or
disease and I think what I like to do
is just cite the data that we do know this
the resources that CDC knows
and I say associations but when we look at causes
we, we don't, we can never say that
something does not cause something we
could just say the data show that it's unlikely
that's what I try and do that's
the best I can do.
Kind of like hypothesis testing right
I just want to make sure we address these few last questions,
if you have to sign off feel free,
thank you so much for joining us today.
please share my slides with everyone
because I have a link to my TED talk I
have a link to our coalition if anyone wants
to join our coalition which we
have monthly webinars we're also hosting a
meeting in June here at Huntsman
Cancer Institute and anyone's welcome to come
it's a national HPV vaccination
meeting that's gonna be co-hosted with
NCI and the CDC and all the cancer
centers who are working in HPV vaccinations
please share my slides!
Can you provide
some talking points parents say my child
is with me all the time they aren't
having sex or I've heard the vaccine
can affect fertility?
So, I think
for the not having sex I say this is a
prevention vaccine and it's given at 11
and 12 because your immune system is
best able to respond and give protection
against the HPV types and the vaccine is
supposed to be given before sexual
activity has begun so I
I stress that it's not supposed to be
given when sex begins it's not supposed to be given
after sex has been initiated
it's supposed to be given early on
many years before sexual initiation and
that's when the body best responds
to HPV types in the vaccine and
that's why evidence has shown us that
it's so effective that we only need two
doses under age 15
and then the fertility I would say data have not
shown that it is not associated with
lower rates of fertility in fact
abnormal pap tests are related to
problems with fertility we the data show
the opposite that abnormal pap tests
are related to risks of infertility and an
extreme extreme are higher rates of
cervical dysplasia in extreme cases can
be even related to hysterectomy
so in fact the opposite is true that's what I
would say.
Have you heard of any programs where HPV vaccination
is administered by a nurse in a school based programs?
Seems like that would reduce barriers
vaccine expiration and travel.
Yeah I know a program in Utah in small
in our small towns here they kind of
receive a blanket permission from parents
to administer it but I do know
it's a little slippery slope and they do need
to receive permission from their
parents to do it so what they do is they say,
we're gonna give your kids XYZ
vaccines and they just have HPV as one of them
and they've been successful in
doing it but when I interviewed this
nurse and I really wanted to like do a
press story on and I want to just you know
commend her as a hero she didn't
want to do it when I wanted to show her off
in the media so I think it's a
slippery slope it was a local hero but
she wanted to stay quiet about yeah I
think it's possible but you kind of have to not you know in our in my culture
here it's a quiet unsung heroes so it'll do it.
So what's the current thinking about the possibility that
vaccinating against high incidence HPV types will in
the long run result in other types
becoming dominant as the cause of cancer?
There's no reason to believe in that
if you look at data in Australia if you
look at the fact that
the top epidemiologists in the world who study
HPV types this is their job
do not support that as a feasible hypothesis.
When we're looking at the incidence
of cervical dysplasia related to
vaccination and a declining there's no reason
to believe that but who knows
what could happen in 50 years I think
it's unlikely good question.
Texas was one of the states that had the lowest
vaccination rate but it still was low for HPV, why is that?
Good question.
It was low for HPV related cancers, I think if you look
it well for one thing you can't see the
relationship there because the vaccine
was just improved in 2006 for girls
and it takes you know 20 to 30 years to
develop cervical cancer.
so we're not gonna see a relationship to cervical
cancer yet.
So when I presented those two slides
my argument was we know we're
looking at 50 years from now
my what I said good question and I don't know why
Texas is low for HPV related cancers
I would think certain subpopulations do
have higher HPV related cancers but
we don't-- we're not seeing a
relationship right now between incidence
of HPV related cancers in states and
their vaccination rates we won't see that
for another 20 years what we're
seeing now is just relationship between
issued vaccination and declines in HPV
infection at the population level
so we're able to see that now.
How do they join the coalition?
Oh yeah so you could email me,
Deanna.Kepka@utah.edu
and I'm in the slides at the end
and just email me and you can join
our coalition you'll be on our list
and you'll get all our monthly updates
in our newsletter and you can join our monthly
meetings they're all webinar
based and we have amazing speakers from all
over the country and we have we
tried in by next month we're going to have
an oral-pharyngal cancer survivor
from Florida, a male, a guy,
so you try and get speakers who have different
experiences to share their stories to.
on your slide you wrote vaccine should be completed by
age 13, is there a reason for that?
I know you can start at age 11 but is there a
reason that its best to be completed by age 13?
So, the recommended ages I mean that's the
ideal recommendation guidelines that are
those are the CDC recommended practices
it doesn't mean-- better late than never,
so better late than never like if you
get one dose at age 11
you can complete the series and get your second dose at
age 18 you won't even need a third dose,
better late than never but the
younger the better.
The guidelines are two doses
under age 15 within twelve
months starting at 11 and 12 are ideal
because it's really supposed to be
integrated with the Tdap and menactra
vaccines. Some practices are starting in
early as 9 and 10 because they think parents
are more willing to accept it
that age, so they give one dose at nine
or ten and then they give the second
dose at 11 when the kid comes back
for Tdap or mena-- menactra and bam they're done.
So there's a lot of different ways to do it
but the younger the better so
that's why it's best by thirteen.
Alright, I think that was the last question.
thank you so much, Deanna.
Thank You Mandy for sharing her story this was just fantastic, thank you.
Thank you have a happy weekend!
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