Roark: Hello, everyone,
and welcome to our second installment
of the Preteen Vaccine Adolescent Immunization
webinar series. Today's webinar is "HPV Vaccine
Is Cancer Prevention: CDC's Clinician
Engagement Initiative." All right. So…
for everyone on the line, thank you
for joining us today. We want you to know
that all of your lines are currently on mute,
so you don't need to worry about muting your phone line
or your computer. We are recording this webinar,
and you will hear when the recording, um… that we are recording
the webinar, and we'll know
when the presentation slides become available online. We will send you an e-mail
through the same e-mail address that you received
the invitation for this webinar. There's going to be
a question-and-answer session towards the end
of the webinar. If you have a question, please type it into
the "question" section on your webinar panel
at the bottom. We will be reading
selected questions out loud for each of the presenters
to answer.
I am Jill Roark,
and I am the team lead for the adolescent immunization
communications team here at CDC, where we are focusing a lot
on HPV vaccination, which is going to be the focus
of this webinar today. And thank you all
for joining us. I know that some of you have been in our
presentations before, and I'm going to just talk
about a couple of things we've talked about
in the past and then cover a few
new things as well. So, as many of you have seen
this slide that's currently up– this is from the President's
Cancer Panel report on accelerating
HPV vaccine uptake, and in terms of how we,
as a nation, will be accelerating
HPV vaccine uptake, we can look
at 3 main areas.
So in terms of what
our providers can do, they can provide
a strong recommendation for HPV vaccination to
adolescents and their parents, and then also use
electronic office systems to support HPV vaccination
in their practices or clinic. And then also, um…
CDC especially is working with both
providers and parents with communication strategies
to help increase knowledge regarding cancer prevention
benefits, efficacy, and safety
of the HPV vaccines.
So this is our main
strategy going forward. So in terms of
communications, when you look very specifically
how we can impact the HPV vaccine
decision process, and that's why we're
all here today, is to talk a little bit
about, um, how it is that we're communicating
about HPV vaccine. And so there's
3 leverage points essentially. Um, we can change the way
that doctors, um, think about HPV vaccine and the way that
they recommend it. We can have parents
ready to accept an HPV vaccine
recommendation when they hear it
from the clinician. And then during
that clinician encounter, when the preteen
and their parent is there with the clinician, we can help facilitate
a better conversation.
So we have some
behavioral objectives and desired outcomes
for each one of those 3 leverage points,
or our 3 audiences. Um, the first…
parent of a preteen, uh… we want parents,
as I said before, of preteens who accept
that recommendation to start the HPV vaccine series,
and we want them to do that so their preteen is able
to finish the series before they turn
13 years old.
And so, through
the work that we're doing, what we're hoping to see
is by 2020, which is, um, related
to the healthy people 2020 goal. The preteens will have started
the HPV vaccine series and completed it
by age 13. So, during the visit,
we want to improve that conversation
that's occurring about all of adolescent
immunization, including HPV vaccination, and really normalizing
HPV vaccine. And so the outcome
of that will be that every 11- and 12-year-old
is initiating the HPV vaccine series
on that same day that they receive their Tdap
and meningococcal vaccines. So we mentioned before
that we would be talking a little bit about
the three pillars, um… of cancer prevention
through HPV vaccination. And essentially
what we're trying to do is help clinicians become
HPV vaccine champions, and it doesn't have to
necessarily be the clinician that's putting
the shot in the arm. There is a place
for everyone here. So we're asking folks
to commit to the cause by making HPV vaccination
a priority in their practice.
Know the facts. So learn more about HPV vaccine
as the primary prevention tool for many cancers. And also lead
the conversation about the importance
of HPV vaccination with your patients,
your staff, your colleagues, particularly those colleague
peers who are in pediatrics or family practitioners
that are serving adolescents. OK. So now I am
going to introduce our conversation leaders, those folks that will be leading
the conversation with you today. Um, first is
Dr. Benard Dreyer, who we are very grateful
to have with us to lend his support
and encouragement to our initiative. Dr. Dreyer is president-elect of
American Academy of Pediatrics. He'll begin his one-year term
as AAP president on January 1, 2016. Dr. Dreyer is a general and development
behavioral pediatrician who has spent
his professional lifetime serving poor children
and families. He's been a professor
of pediatrics at NYU, where he leads
the division of developmental
behavioral pediatrics, and is the director of
pediatrics at Bellevue Hospital, where he also works
as a hospitalist. Next we'll have
Dr.
Rebecca Perkins speaking about HPV vaccine from the gynecological
perspective. Dr. Perkins attended
Stanford University, Harvard Medical School, and completed her obstetrics
and gynecology residency at Brigham and Women's and Massachusetts
General Hospitals. Since 2005, Dr. Perkins
has been on faculty at Boston University
School of Medicine. Dr. Perkins' goal
as a practicing gynecologist and physician scientist
is to decrease overall rates
of cervical cancer and also to reduce
race and income disparities in the disease. Dr. Perkins became involved
in cervical cancer prevention after seeing firsthand
the devastating consequences of cervical cancer as a medical
volunteer in Honduras in 2003 and has been very active in cervical cancer
prevention since then.
Dr. Perkins' current research
focuses on improving utilization of HPV vaccination, and she's working
on several projects with the American
Cancer Society, the American Academy
of Pediatrics, the American College of
Obstetricians and Gynecologists, as well as CDC to improve HPV
vaccination rates nationwide. And third we'll have
Dr. Sharon Humiston, who is going to summarize
tips for success on focusing on how pediatricians
and pediatric clinicians as well as family practitioners
can increase acceptance and uptake of HPV vaccine. Dr. Humiston is a professor
of pediatrics for Children's Mercy Hospital. She earned
her medical degree from Medical College
of Ohio and Toledo and is a Master
of Public Health from the University
of Rochester School of Medicine and Dentistry. Dr. Humiston completed
a pediatric internship and residency
at the University of Iowa Carver College of Medicine
in Iowa City as well as a fellowship
at the University of Rochester School of Medicine
and Dentistry.
Dr. Humiston's area
of interest is immunization-related
health services research. Dr. Humiston has worked in the CDC's national
immunization program as an educator
for healthcare providers and is a member of the National
Vaccine Advisory Committee. Dr. Humiston presents lectures
on the state and national level on various
immunization-related topics, including individual routinely
recommended vaccines, vaccine updates,
communication, meningococcal disease,
pertussis, and influenza. Now I will take
this opportunity to turn the webinar over to
our first conversation leader, Dr. Dreyer. Dr. Dreyer: Thank you. And thank you all
for joining us today and for your dedication
to improving HPV vaccination rates. The American Academy
of Pediatrics recommends giving
the HPV vaccine at 11 to 12 years of age,
but we hear from our members, who are leaders
in vaccination, that they are struggling
with parental hesitation and requests to delay. While some parents will
ultimately refuse the vaccine, most trust the recommendations
of their pediatrician, family practitioner,
or nurse practitioner. Our recommendations matter, and how we say it
matters more. Today's presenters
have proven strategies to improve HPV vaccination rates at the 11-
or 12-year-old visit. One simple strategy
is to lead the conversation, the vaccine conversation,
with parents and children by saying, "Today your child
is due for 3 vaccines: HPV, Tdap,
and meningococcal." With a little modification
of our approach, we can address
the concerns of parents and protect more children
against HPV.
And as we get
additional data, we will be able
to further refine the most effective messages
that clinicians should be giving
to parents and children. The AAP stands ready to support
its members and the CDC in doing better. We have all the tools needed
to make a change in the office. We need to keep
the end goal in sight. We can prevent
HPV-related cancers, and now is the time
to protect our patients. Dr. Perkins:
Good morning, everyone. My name is Rebecca Perkins, and I'm an obstetrician-
gynecologist at the Boston University
School of Medicine and Boston Medical Center. As Jill Roark mentioned
in my bio, I'm extremely happy this year
to be following my passion by working with
not only the CDC, but also the American Academy
of Pediatrics, American Cancer Society, and the American College
of Obstetricians-Gynecologists on this topic. The, um, slides that
I'm going to present today were developed
in conjunction with the American Academy
of Pediatrics and the wonderful
Dr. Humiston, and they will be coming soon
to a website near you.
The website will appear
multiple times at the bottom. It's http://www.aap.org/hpvtoolkit, which is, um…
going to be a website having all the information
you could ever want about how to improve
HPV vaccination rates in your practice. I have no financial
relationships to disclose. So in the next 20 minutes,
I want to convince you that HPV vaccination is worth
your passionate advocacy. HPV vaccine is worth giving
long before infection.
And your recommendation
can make all the difference to a family's acceptance. So I'm going to
start with HPV 101. What is this virus? So HPV is a virus that infects
human skin and mucosal surfaces. And it is incredibly easy
to transmit HPV. It is a skin virus,
and it transmits about 1,000 times
more readily than herpes. Because of this,
at least 80% of people are exposed
during their lifetime. HPV has been shown to be
a causal agent in 6 different types
of human cancers and is classified
as a human carcinogen. So how much disease
down HPV really cause? Most people are not aware
of the disease burden of HPV because we are learning more
about this virus every week. We know that about
3 million Americans seek medical care
related to a disease caused by HPV every year. 27,000 of these visits
are related to an HPV-related cancer. About 8,000 Americans
die every year from an HPV-related cancer, and this is as many deaths
every year as measles caused in the pre-vaccine era.
So we are vaccinating to prevent
HPV-associated cancer. And in the remainder
of the talk, I'll show you why current
screening is not enough. We do have tools to screen
for cervical cancer, but that's the only one. Cervical cancer
is the most common HPV-related cancer
in women, and we see about 10,000
to 12,000 cases of cervical cancer
every year, but oropharyngeal cancers, specifically cancers of the base
of tongue and tonsils, are giving cervical cancer
a run for its money. oropharyngeal cancers
are more common in men, though women get them as well. And the other cancers
caused by HPV are anal cancers, which are twice as common
in women as men, again speaking
to the ease with which this disease
is, um, transmitted. It's most likely
autoinoculation while bathing that gives women anal HPV, and vaginal, vulvar,
and penile cancers. There are great disparities
in rates of cervical cancer based on a woman's access
to screening and treatment. And despite our best efforts,
we still have 4,000 deaths caused by cervical cancer
in the United States every year.
But most HPV-related morbidity
is not from cancer, it's from the treatment in women
of precancerous lesions. So I'm a gynecologist
that practices in the community, and in a clinic day,
I'll see about 25 patients, and a good 20% of them
will be coming to me for a problem related to HPV. This can be genital warts,
it can be an abnormal PAP test, or it can be cervical dysplasia
or precancer, which requires a treatment, and these treatments are called
LEEP or cone procedures, and they are
a wonderful improvement, because before we had those,
every woman had to undergo a hysterectomy
in order to prevent cancer. And these are great
because we can just remove the diseased part of the cervix
and preserve fertility.
So what we do is we take
a cone-shaped biopsy, which removes about one
to one and a half centimeters of the dysplasia
in your cervix, and you have
330,000 women undergoing these procedures
every year. Unfortunately,
it's not a free ride. Multiple studies have shown
that either the LEEP procedure or possibly the presence
of dysplasia or HPV infection itself has been associated
with obstetric morbidity, including about double the risk
of preterm delivery, preterm rupture of membranes,
and low birth weight. And as everyone
on this call knows, when infants are born
prematurely, they could have long term
developmental consequences as well as very high
neonatal intensive care costs. So my feeling
as a gynecologist is why do I need to remove
part of the cervix when my patient
could have gotten a shot in the arm instead? But what about boys? The story about HPV-related
cancers in boys is much less well known. Most people,
especially most physicians, are well aware that HPV
causes cervical cancer. But the oropharyngeal
cancer story is one that is becoming more common
and needs to be told, especially because there's
no screening test for oropharyngeal cancers.
Now, if you're really
paying attention and you've been
to the dentist recently and your dentist
has been following guidelines, you may have noticed
that your dentist pulled out your tongue
with a cotton swab and had you move
your tongue all around and looked down your throat and
felt the glands in your neck. They were looking for
oropharyngeal cancers, 75% of which
are caused by HPV. However, that would not
prevent the cancer. It would simply allow you
to get treatment earlier. The number of HPV-related
tongue and tonsil cancers have more than doubled
in the past 20 years. We see about
11,000 cases annually. 7,000 of these
are in men. And it's estimated
that oropharyngeal cancers caused by HPV
will be more common than cervical cancers
within the next 5 years. And some head and neck cancer
surgeons believe that they're already
more common.
The typical patient presenting
with oropharyngeal cancer is a college-educated white male
in his forties. Why is this? Why does HPV
cause so much disease? Well, because it's
so easily transmitted that almost everyone,
over 80% of people, will be exposed,
and while we used to think HPV was the common cold of
sexually transmitted infections and would go away,
we're now learning that infections may,
in fact, be lifelong. The most common route
of acquiring HPV is sexual intercourse,
by which I mean penetrative vaginal-penile
or vaginal-anal intercourse. However, because HPV
is a skin virus, it can be transmitted
by genital-genital touching that does not involve
penetration, anal-genital, oral-genital,
and manual-genital contact. And studies indicate that at least half
of high school students have already engaged
in vaginal-penile intercourse. This is about 1/3
of 9th graders and 2/3 of 12th graders. So it's the unusual
high school senior who makes it
all the way through prom without having
their first sexual experience. And nearly a quarter
of high school seniors have had multiple partners. But, again, you don't actually
have to have sex to get HPV.
This very interesting study
looked at the frequency with which HPV could be detected
shedding in the vagina prior to the first
vaginal-penile intercourse. And they found that
nearly half of women had vaginally detectable HPV prior to their first
vaginal sex. And most of these women reported
non-coital behaviors, such as experimentation,
oral-genital contact, and other forms
of touching that could explain
genital transmission. And these are two
of my favorite studies paired together
in a single slide. These are studies of very,
very special college students.
The green line
is college women, and the yellow line
is college men. And I say that these
are very special students because these are among
the 1/3 of high-school seniors who had never had sex
before they got to college. And then they're in… I don't know what percentile
of responsibleness, but they actually went
to university health services to obtain information
about contraception and safe sex before their first
sexual experience. And then they were willing
to sign up for a study where their genitalia
were swabbed every 4 months for 2 to 4 years to look for
the detection of HPV. So these are incredibly
rule-following, responsible college students. And look how fast they were
infected with HPV. Within the first year,
30% of college men and women had acquired HPV,
and by the second year, over 60% of the men
had acquired HPV, and by the end
of college, about half of the women
had acquired it. And we used to think,
based on studies that looked for the presence
of vaginally shedding HPV in young women, that HPV
infections would go away, because, in fact, most women
will stop shedding HPV within a couple of years after
the infection is first detected.
However, new data indicates
that the infection may not actually go away
but, in fact, remain dormant for decades and then reactivate
later in life as the immune system declines. And this data makes a lot
of sense to me in my practice because I have many women
with newly positive HPV tests who are in their forties
or fifties, have been married
for decades, and my record of the length
of abstinence prior to a newly detected
HPV infection in one patient who had not had sex
in 26 years. So this data comes from
over 700 women aged 35 to 60, and they found
that only 13% of newly detectable
HPV infections could be attributed
to a new partner, while 85% of these infections
occurred during periods of abstinence or monogamy. But early vaccination
can prevent these initial infections.
There's been concern
raised in the media about vaccine safety,
but in fact, HPV vaccine safety
is well proven. The HPV vaccine is
a little bit different than some other vaccines because it doesn't actually
contain any virus. It's simply the viral envelope. So there's absolutely no risk
of it causing the cancers or diseases
it is intended to prevent. Unlike other vaccines,
it also causes a much more robust
and effective immune response than wild type infection. HPV vaccination is recommended
for all boys and girls ages 11 to 12,
and then catch-up for older young men and women who have not been
previously vaccinated. In terms of HPV
vaccine safety, we've now given over
170 million doses worldwide. And the most common
adverse events are mild. For any serious adverseness
that was reported, there was no unusual pattern
or clustering that indicated they might be due
to the vaccine itself. And our findings are similar
to the safety reviews of other adolescent
and childhood vaccines. Specifically, studies have
looked at large groups, at this point, over 4 million
girls who have either– girls and young women
who have either received or not received
HPV vaccination, and they found no increase
in any category of illness, including emergency-room visits,
hospitalizations, autoimmune disease,
thromboembolic disease, neurologic disease,
and of course death.
So the vaccine is safe. HPV disease is terrible. But does the vaccine work
to prevent HPV disease? And the answer is yes. In the United States– we are having this webinar
because our rates are not where we would
like them to be. Only 33% of our girls
are fully vaccinated, and we would like that number
to be 80% by the year 2020. Yet despite this,
in our 14- to 19-year-olds, after the vaccination
was introduced, we saw a 56% decline
in vaccine type HPV. But what we really want to
look like in the United States is Australia. They had an incredibly
successful introduction of HPV vaccination
into their population in 2007 and have already started to see
dramatic benefits in terms of disease reduction
in their young men and women. Between 2007,
when the vaccine was introduced, and 2011, Australia
has noted a 93% reduction in genital warts in girls
younger than age 21 and an 82% reduction
in boys, even though the boys
were not receiving a vaccine. So strong evidence
of herd immunity.
And warts are terrible, and I've had people
cry over warts, and their relationships
end because of warts. However, we are really
vaccinating to prevent cancer. And the Australian data
is very encouraging about the ability
of the HPV vaccine to prevent cancer
in the real world. And it also speaks
to the vast importance of vaccinating early. When you vaccinate
at the ages of 11 and 12, you have essentially
no exposure to HPV, and you get much higher
antibody responses compared to vaccinating older. And what that translates into
in the Australian data is that girls who have received
all 3 doses of HPV vaccine by the age of 14
had a 75% reduction in high-grade
cervical precancer, those precancers that require LEEP or cone procedures
to treat within 5 years
of being vaccinated.
When they had reached the age
of 15, 16, or 17 by the time they got
their vaccine, that effectiveness
dropped to 35%, so half of what it was
when they received their vaccines
by the age of 14. And that's why it's
so important to vaccinate early. This pyramid describes
the current burden of genital HPV disease
in the United States. So we see about
1.4 million cases of low-grade
abnormal PAP smears, about 350,000 new cases
of genital warts, about 330,000 new cases of that high-grade
cervical dysplasia, or CIN2/3, requiring LEEP or cone
procedures to treat, and 10,000 to 12,000 new cases
of cervical cancer with about 4,000 deaths
every year. Now, if we reached
80% vaccination rates, if we reach those
healthy people 2020 goals and look like Australia, we could shrink
our pyramid to this– a 35% reduction in CIN1, a 92% reduction
in genital warts, a 46% reduction
in our high-grade dysplasias requiring LEEP
and cone procedures, which would be
a 75% reduction if we get everybody vaccinated
when they're supposed to be…
With corresponding reductions
in cervical and other HPV related cancers. Now, I mentioned that we have
no screening test to prevent
oropharyngeal cancers, and that makes it impossible
to do a clinical trial where you look for the end point
of oral cancer precursors to look for
the vaccine effect. So what they had to do instead
was look for decreases in rates of oral
HPV infection, and in fact,
in the clinical trials, they found an estimated
vaccine efficacy of 93% for oral infection
with HPV 16 and 18. And that's really important, because 95% of oropharyngeal
cancers are HPV 16. So in summary,
HPV exposure is ubiquitous. HPV causes many cancers. HPV vaccine is safe. HPV vaccine is effective. So why isn't everyone
vaccinated yet? I will now turn it over
to Dr.
Humiston to answer that question. Dr. Humiston: Ha ha ha. Thank you, Rebecca. Dr. Perkins:
You're welcome. Dr. Humiston: Is my…
can everyone hear me ok? Um…So I'll be talking about
making a strong recommendation about HPV vaccine
to parents in primary care. I want to say that, um… my comments are…
are largely based on slides created
by Jill Roark, um, for the CDC,
the HPV Speakers Bureau, as well as research
that was presented as recently
as this past week at the April 2015 Academic
Pediatric Association meeting in San Diego. So you are hearing it
right off of the presses. I'm going to be making
just 3 points. Number one–you need to recruit
your whole office team to take a role in HPV
vaccination communication. I'm not sure
who's on the phone today, and I don't know how many
of the office nurses and MA's that we have, but we need them
as well as the, um, advanced practice nurses and…
and primary care doctors to hear this message,
because the whole team has to do this
as a concerted effort.
The second thing I'll talk about
is recommending HPV vaccine the same way
and the same day as other routine
adolescent immunizations. My third point will be– and I'll go into
quite a lot of detail using a practical
communication strategy when a parent
does have a question. Not every parent
is going to have a question, but when they do,
how do you address it? So point number one–
recruit your whole office team to take a role in HPV
vaccination communication. I say this partly based
on the new research, um, that Mandy Dempsey talked about
last week at the APA meeting, but also on the basis
of old research that I did. We were looking at childhood
vaccines at that time, and what we found was that
parents talked about instances where the front
office people scared them away
from a vaccine. For example, the registration
people said, "Oh, you're due
for the MMR vaccine. I would never get
my child that vaccine." And that, even though
the registration person had no background
in medical, uh…information, the parent took it
as part of the team saying, "Don't get the vaccine," and they took that person's
recommendation.
So your whole office team
needs to hear Rebecca's talk about how important
this vaccine is. One of our problems, I think,
is that parents don't know about the consequences
of HPV. I mean, a lot of scientists
are just learning about this. So having the parents
understand it and having the whole office
be in on letting them know this. OK. Um…So be sure that
everyone who has patient contact gets educated on HPV. You didn't know you were at
a train-the-trainer session, but that's exactly
what you're at right now. The point of today
is not only to, um… talk to the hundreds of people
that are on the phone, but to have you become
the trainer and turn around, take these slides
as well as, as Rebecca said, the AAP slides
that will be in the toolkit and CDC's slides, which are
already on their website.
So all of us taking
this information and going forth with it,
and I will also say, in addition to talking
to your office staff, talking to your
legislature about it. All right. The second point
is, um…everyone in the office needs to know their role
in immunization communication. So, for example,
the registration people hand out the vaccine
information statement. You know what I mean,
those CDC one-pagers that are required by law
to go out before vaccinations. Well, the registration people
need to know that HPV is one of the routinely
recommended vaccines that will be given
at that visit so that she's giving that out
as part of the package. Then, for example,
say, um…the nursing staff brings the patient
back to the room. As they're talking about
what to expect during the visit, they include in that bundle
the normal process, which includes
HPV vaccination. And they know not to put it
as a…as a…
"And then there's this
optional additional vaccine." And then let's say, um…
the nurse has handled the routine questions
about, "Well, will it hurt? How can I deal
with the pain?" Then the primary care provider
only has to answer the last hard questions. So by…by having it
so that everybody knows their role in
the communication process, there's no repetition, and the whole job
gets done efficiently. Key staff roles– We talk about the presumptive
or normative plans, so that everybody knows
this is part of the routine. Giving and explaining the
vaccine information statements, obviously vaccinating, And arranging
for the next dose. I forgot to talk
about that part. Um, after this dose is in,
the parent needs to understand that this is a…a series,
not just a one-time vaccine, and that that series…we want
to get it in pretty efficiently. OK. My second point–
Recommend HPV vaccine the same way
and the same day as the other routine
adolescent immunizations. By same way,
what I'm talking about is grouping all
the adolescent vaccines and recommending them
all in the same way.
Again, HPV is not
some additional add-on. And I think that
that got started because, um…the Tdap
is required for school. In some places, meningococcal
vaccine is required for college entry. In New York State, it's
at least a conversation about meningococcal vaccine
as even required to go to camp. So those sort of stuck
in people's minds as "the required ones," and HPV got this bad reputation
as an add-on, but it's not. It's just as routinely
recommended as the others. So when you're
recommending it, you're recommending it as part
of the package of protection. And then same day.
What I mean by that is recommending HPV vaccine
today because… if you let this young person
out of your office, we know that adolescents don't
come to the office every day. It's…I mean, we try not to
let, um, babies and toddlers out of the office without all
of their vaccines either.
But at least
with babies and toddlers, we have the expectation
that they'll be coming back every…couple of months. With adolescents, once you let
them out of the office, you don't know
when they're coming back. And so we want to give
HPV vaccine the same day that you give the Tdap
and the meningococcal vaccines. Now, some people say,
"Well, they only have two arms. It's gonna hurt." Hmm…Which would I prefer–
an owie or cancer? Making a presumptive
statement like this– "Today, Michelle should have
3 shots that will protect her "from the cancers
caused by HPV, "and infections causing
meningitis, whooping cough, tetanus, and diphtheria." In that one sentence,
you have given them the reason
for the vaccinations, so you can bill,
and you've…
You've taught them the purpose
of the package of protection that you're offering. And I think it's also…
one of the things about it is that it's
a very positive statement. It's about, "Today we can
protect her from…" One of the things
you'll notice about this is… that it uses
the presumptive, um… "We will, You should," rather than
the participatory style. Don't start with an invitation
like, "Oh, now let's discuss how you feel about the
vaccinations for adolescents." That's been show to not be
as effective, um, and it also makes it
so you're opening a can of worms when you didn't need to, and so you're
using up your time that you could use to describe
the importance of doses 2 and 3. OK. My third point– You've gotten the…the routine
recommendation across. Now, once in a while,
you're going to have a parent who has a question. One of the things–
I love being a pediatrician, because I think
that we are, um…
Not a group
that likes to argue. We're a warm and fuzzy
group of people. But one of the problems
with that is that when a parent
even has a question, we interpret it
as resistance and controversy, and we don't want
to go there. So one of the things
I'm gonna say is, when a parent has a question,
don't panic. Interpret it as a question… the question as a request
for reassurance from you, the clinician they trust
with their child's health. It's…it's not opposition.
It's a request for reassurance. And then go from there
to clarifying. Re-state their concerns to make
sure that you understand, because nothing wastes time
like answering a question that the person didn't have
in the first place. So say something like,
"It sounds like you're concerned "that the HPV vaccine
isn't necessary "because Emily is a virgin. Am I understanding
the question?" One of the other things
Mandy Dempsey from Colorado talked about last week
was that, um…
Using that motivational,
interviewing style where you…you bring
the conversation back to yes, is an important way to get
the conversation back on track. So by saying, "I think
I'm hearing you. Am I understanding
the question?" Well, if the answer
is a yes, then the conversation flows
forward in a different way. And then address the parent's
specific concerns. And this can be done, um… the CDC has
this wonderful sheet. All you have to do is Google
"tips and timesavers," and this will come up. I love this sheet
because it has, um…beauti– This is designed
for providers, not for… for providers
and the whole office staff. This is not
to give out to parents. This gives you scripts
on how to say things in a quick way so that you get
across the accurate information without spending
a lot of time on it.
We're not gonna go into
all of the answers. And…and Rebecca
has already given you the medical information that…
that supports these answers. So I just want to say
that after today, when you're giving your talk, handing out these
tips and timesavers I think is a great way
to have everybody prepared for answering
the parent's question. What if you do get
to the point where a parent actually
declines vaccination? One of the things
that I think is important, just like we were talking
about interpreting a question as wanting reassurance,
when a parent declines, interpreting it
as delaying, not shutting the door
for all time. I think that's
really important, because you will have
more opportunities. Because delaying
is the risky choice, consider asking parents
to sign a declination form, and AAP has their
declination form online, and you see
the website there.
My point in this
is that I think that by having the parent
sign a declination, what you're saying is, "You're
choosing the risky thing, "and so I want to make sure
that you understand that you're taking
the risk burden upon yourself." I mean, who knows…
Heaven forbid that, you know, 10 years from now,
15 years from now, this kid ends up
having cancer. You also want to document
that you did the standard of care thing, which was to give
a strong recommendation.
That is the standard of care
in the United States. So you want to document it, but I believe that
even more important, you want to get across
the point to the parent that you see the vaccination
as the less risky thing. Now I want to show you
some videos that I love. This is, um…
from "Just Another Shot: Reframing the HPV Vaccine." Again, if you want to find it
without memorizing this website that you see across the bottom,
you can just go onto YouTube and Google Minnesota
Department of Health HPV, and you'll see this. Basically what's happening
is the doctor saying, "Well, your baby looks great.
I want to give today the… "Tdap and IPV and, um…
Hib vaccine, "and, oh, by the way,
there's this other vaccine.
It's called
pneumococcal vaccine." Doctor: Kayla looks fantastic.
Before you go, there are a few vaccines
we give at the two-month visit– rotavirus, hib, polio,
the second dose of hepatitis B, and the Tdap vaccine
against diphtheria, tetanus, and pertussis. Also, there is one other
vaccine you could consider. Mother: What's that? Doctor:
The pneumococcal vaccine. If you're interested,
we could add it to the list, but it's up to you. Dr. Humiston: And you saw
the mother's sour look, like "Why would we give
an extra vaccine?" Would we ever present
a routinely recommended vaccine as an "And, oh, by the way,
do you want this extra vaccine?" Of course not!
That was just for emphasis.
Um…How we recommend
childhood vaccines is as a package
of protection, and that's what
I'm asking you to do with the adolescent
vaccines as well. And when we recommend
childhood vaccines, we do so with a full
understanding of and a conviction in
each vaccine's importance. That's one of the reasons
why I think that Rebecca's talk
is so incredibly important, is because I,
as a pediatrician, don't see cervical cancer
or oropharyngeal cancer. As Rebecca said,
oropharyngeal cancer is going to be
in middle-aged men. So I'm not seeing it, but I need to educate myself
and my office about it so that I'm saying these things
with the same level of understanding and conviction
that I do about hib disease and pneumococcal,
which unfortunately, I am all too familiar with. Mother: I told you, this hockey
is just not a good idea. [Sighs] Well… Doctor: Oh, so that's gonna
be sore for a few days, but it should get better
by the end of the week. Let us know if it doesn't, ok?
All right? Now, I see that you turned 12,
so since you're here, this would be a great time
for those vaccines which are recommended
at this age, with are HPV, Tdap,
meningococcal.
Are there any questions
about that? Mother: Yeah. The HPV,
that seems like something that could wait until
she's a little older. Don't you think? Doctor: I think
I get your drift, and I know it seems
kind of soon, but the thing is,
the vaccine are recommended at the youngest age for which they've been proven
safe and effective. No matter what the disease,
you want to make sure that immunity is in place
before the exposure happens. A bonus is that
at Isabella's age, kids respond much more
vigorously to the vaccine than older kids
and adults, and that might make
even better protection. It's also convenient
because, well, there are two other vaccines
due at the same age, and, well, those two
and the first dose of HPV can all be given
at the same appointment. Mother: OK.
But I just wonder what we might be
opening the door to. Doctor: OK. Some people
have had that worry.
There's research been done
that has studied that question, and they found
no more sexual activity among girls that have
had that vaccine compared to those
that hadn't. So that may have
eased some minds, especially considering
what you get in exchange. I think it's pretty amazing
that there's a safe and effective way
of preventing cancer. I'd feel a lot better
if we got her protected today. Mother: OK. Dr. Humiston:
He does a great job. First of all,
he seizes the moment. He is dealing with
her sprained ankle, but he looks
at her immunization record because he knows
the likelihood is that this healthy
young athlete may not be in his office
again any time soon. Secondly, he doesn't "profile," meaning he recommends
the vaccine even though this girl doesn't
look like she's interested in having sex
any time soon. Number 3–He bundles
the recommendation. He offers all the vaccines
all at once. He asked for
the mom's questions.
He answered mom's questions
accurately and calmly, not as if he's going
into an argument. Um…His answer
was a bit longwinded but got to the point
and wrapped it up in just a couple
of sentences. When mom asked
her second question, um, about, um…"I'm worried about
what this will open up," the innuendo was that
what it opens up– the can of worms that it
opens up is sexuality. And he says, "Some people
ask me about this." So it validates
the mother's concern but he–
and makes it normative, but he doesn't stop there.
He stays positive and answers. And finally, he ends up with,
"I'd feel better if…" And I love that, because
I think it comes across in a way that is
so genuinely caring.
So, I mean, obviously you're not
gonna say those exact words, but staying
in the mode of not "I'm doing this
because I want. "I'm, you know…We're doing
a quality improvement project, "and we're trying to increase
our immunization rates, but because I care about
this kid who's in front of me." That's the end
of my comments. Thank you so much
for listening.
Jill: Great.
Well, I want to thank all three of our presenters, um,
for doing a great job, and I believe that we've had
some questions coming in, and, um…our moderator,
if you'd like to go ahead and start with our first
question, that would be great. Moderator: OK. We have
a question, um… from a Ms. Torres. If a teen receives the previous
HPV number one and number two, and the vaccine–
I'm sorry. And the number 3 vaccine
will be the new HPV vaccine, do they have to start over
with the new vaccine, or are they ok? Dr. Humiston: At…I could…
At this time, um… Can you hear me? Man: Yes. Dr. Humiston: OK. At this time,
um…CDC has not given detailed, um…recommendations
about, um…about the series, other than to say that just
the substitution of HPV 9 for the other formulations
is acceptable. So if you've already had,
for example, two doses of HPV4,
the quadrivalent, you can switch over
to the 9.
Um…In June of this year,
ACIP will…will reconsider, you know, a more complex,
um, catch-up schedule. But at this time,
it's simply a substitution for, you know…
for whatever dose needs done. Dr. Dreyer:
This is Dr. Dreyer. Just to add to that, but clearly, I mean,
that's the recommendation. And clearly you won't be
protecting adequately for the additional, um…types
that are in the new vaccine but will be adequately, uh.. protecting for
the previous types. Now, that's what
substitution means– you're basically giving
the equivalent. With one dose, you're perhaps
having some protection, but not completely adequate. Moderator: We have a question
from Percy Lupold. Has vaccination been proven
to decrease mortality from cervical cancer compared to routine
cervical cancer screening? Dr.
Perkins: Um, this is
Rebecca Perkins. I can answer that one.
So, we… Because usually the lag time
between infection and cancer and death from cancer
is more than a decade and often more
than two decades, the vaccine has not
been around long enough to decrease mortality
from cervical cancer. What we expect to see
more quickly than decreases in mortality
from cervical cancer are decreases in the number
of women who have to undergo invasive LEEP
and cone procedures to prevent cervical cancer, and we have seen decreases
in these cervical precancers.
Dr. Humiston:
I want to emphasize that, um…you know, we…
we talk a lot about the cancer, and Rebecca did a lovely job
of reminding us about the precancerous lesions and the importance that has
in a woman's life. Um…Parents sometimes ask
about the, um…problem, you know, like that they're
afraid that HPV vaccine is going to harm their child's
fertility in some way. And what we actually know
is that, um.. having a LEEP procedure
can lead to obstetric problems over the long run. So it's…it's… To avoid the vaccine
for fear of fertility problems is exactly opposite
of what you should do. Moderator: Um…We have
a question from Sandra Talley. Um, how long
does immunity last? Dr. Humiston: We know that
it's at least 10 years. Again, um…the vaccine
manufacturer and CDC are working together to monitor
the duration of immunity.
And one of the things
about HPV is it's especially important,
um, to get… to get people
vaccinated young because of the changes
in the cervical environment. You know, the cervix
of a…an adolescent is different than the cervix
of an older person, and you want to protect
people early because of those differences. Moderator: OK. We have another
question from Beth Bellin. We have parents who turn
to their preteen or teen and ask them if they
want the vaccine. How would you handle this? Dr. Humiston: I personally
worry about that a lot, just as much
as you would, um… You wouldn't… You wouldn't turn
to your two-year-old and say, "So how do you feel
about hepatitis A today?" Um…I think that
I would address the dyad and say, "I want to make sure
that you understand the risk that you're
assuming by waiting," and talk about the very reason,
you know, that– Rebecca, again, went over why we
vaccinate at a younger age. And so, um…And emphasizing
that avoiding an owie today in trade for
protection from cancer is not a great tradeoff.
Dr. Perkins: And people have
also described success when addressing, um…
the children, talking about a lot of kids
who have had experience with plantar warts or warts
on their hands and feet, and saying, you know,
this vaccine prevents against… "You know, you had
that wart on your hand "that took 6 months
to go away. "This vaccine is going to
prevent against a wart on your penis
or your vagina," and they look horrified
and tend to accept the vaccine. Dr. Dreyer: Yeah.
And this is Dr. Dreyer. I agree with that
last statement as well. I've used that information to be
helpful with the adolescent. And also what I find
is if I include the adolescent in the initial discussion
when I talk to them, then the…the parent
is less likely to turn to them after the fact. If you just talk to the parent,
then sort of appropriately, the parent is involving
the adolescent after the fact.
So just remember, I think,
to involve the… both of them together
and have some eye contact with the adolescent about it
as well as the parent in your initial discussion. Dr. Humiston: It's analogous to,
um…getting kids not to smoke by telling them that they… they will look worse
if they smoke. Um… Moderator: OK. We actually
received a few questions asking whether or not
the slides and webinar will be available online. Jill, would you–do you want to
answer that question? Roark: Sorry.
I was on mute. Yes, we will have
the slides available. What we're going to be doing
is actually posting the recordings
of these presentations, and so to be compliant
with the Federal Government and disability standards,
it takes us a little while to make those, um…
captioned and get them online. They get posted on the CDC
streaming health YouTube page with a link to our website. So once we have those up, we'll
start sending out announcements. In the meantime,
we will go ahead and send out the slides
to everyone so that you do have the slides.
Moderator: And I know it's
a little bit after 12:00 now. Um…So, Jill,
if you're ok with this, we were gonna move
into the polling questions. Roark: Yeah, let's do the
polling questions real quick, and then we'll tie this up. Moderator: We are asking
a couple of questions just to get your feedback
on today's webinar. And we'll launch it, and you should see
the questions on your screen. OK. We're gonna close this one. And then we will launch
the second question. OK. We're gonna close it. Roark: All right. Well, thank you, everyone, for
joining us today on the webinar. And, again, we will be
sending out information on how to get
to the recordings, and then also we'll
send out the slides. Thank you very much.
If you have any questions ever, please send us an e-mail
to preteenvaccines– that's plural–@cdc.gov. Thanks, and have
a great day..
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