>> [Kera Beskin]: Welcome, my name is Kera Beskin. I'm a program manager of Immunization Practice Improvement here at the American Academy of Pediatrics, and I'm delighted to welcome you all to the webinar Spring 2019 HPV Vaccination Update Supporting Your Office Efforts, and I'm excited to introduce you to this amazing panel of HPV vaccination experts. But before I do that I want to remind the audience that there is continuing medical education, continuing nursing education and maintenance of certification part two credit available for viewing this webinar through Boston University. Please see the instructions to claim credit in the chat box which can be located in the middle of your screen towards the bottom a little speech bubble will bring the chat box up. If you have any questions, please chat in your questions anytime during the webinar. Now to introduce today's speakers. First we have Dr. Sharon Humiston, who is a Professor of Pediatrics at Children's Mercy Hospitals and Clinics in Kansas City, Missouri. She's a clinician and health services researcher. Dr. Humiston serves as co-Principal Investigator for the AAP, American Academy Pediatrics, Hub and Spoke Initiative focused on improving HPV vaccination rates. Dr. Humiston also serves as the Associate Director for Research for the Immunization Action Coalition and previously worked on the Centers for Disease Control and Prevention's National Immunization Program. Welcome Sharon. Next we have Dr. Kristin Oliver, who is an Associate Professor in both the Departments of Pediatrics and Environmental Medicine and Public Health at Mount Sinai in New York. Dr. Oliver is a clinician at school-based health centers who has conducted research projects with the CDC, the New York City Department of Health and UNICEF. Dr. Oliver's research focuses on vaccine preventable diseases, school-based health and tobacco cessation. She also has extensive policy experience and has served as a healthcare analyst for the Government Accountability Office in Washington DC. Lastly, we have Dr. Rebecca Perkins, who is an Associate Professor of Obstetrics and Gynecology at Boston University's School of Medicine and is a practicing gynecologist at Boston Medical Center. Her career is dedicated to reducing health disparities in cervical cancer. Her current research focuses on improving utilization of HPV vaccination and cervical cancer screening guidelines. Dr. Perkins is currently working on national projects related to HPV vaccination and cervical cancer prevention with the American Cancer Society, the American Academy of Pediatrics, and the Society for Lower Genital Tract Disorders. This presentation is made possible through a CDC funded cooperative agreement focused on improving HPV vaccination rates nationwide. The content of this presentation are solely the responsibility of the authors and do not necessarily reflect the official views of the CDC. Speaker bios are located on Slide 69 and everyone in this webinar is automatically muted to reduce distractions during this hour-long webinar. So we ask you to please use the chat box which can be located in the middle lower screen as a speech bubble. If we do not get to all questions, received questions and their answers will be emailed out along with the slides within 2 weeks after this webinar. I'm happy to report that CME, CNE, and MOC part two are available for this webinar. Please see instructions in the chat box or on Slides 70 and 71. Over 750 people have registered for this webinar and enduring CME, CNE, and MOC part two you are available if you were not able to join today. Also I like to state that none of our speakers, planners, or independent reviewers have any financial relationships to disclose. So without further ado I'd like to turn it over to our panelists.

>> [Sharon Humiston]: Thank you. My name is Sharon. So I'm going to pop through the objectives pretty quickly. We're going to describe the latest data on HPV cancers, HPV immunization rates, and HPV vaccine effectiveness and safety. Then we're going to identify effective HPV communication strategies and one of the important issues is that all your office staff need to use these to promote HPV vaccination. So it's not just the providers it's everybody in the office. Okay, we're going to describe some office-based strategies, I'll be talking about some other strategies once you've got your communication strategies down, and then Rebecca is going to explain the most current information about the HPV vaccination of mid adults. This is going to be something that parents are going to ask you so you need to be ready for that. All right. So, Rebecca, what is the news about HPV disease?

>> [Rebecca Perkins]: All right. Can you hear me okay?

>> [Sharon Humiston]: Yes, I can.

>> [Rebecca Perkins]: Fantastic. So HPV cancers are unfortunately becoming more common. Every time I update the slide I have to put a bigger number at the top. So the current number is that 43,000 people are diagnosed of a cancer caused by HPV every year. That's more than 1 case every 20 minutes. The majority of cancer cases in women are cervical cancer, but the majority of cancer cases overall are actually oropharyngeal cancers, specifically cancers of the tonsils and base of tongue. HPV actually causes six different human cancers. It causes, in addition to cervical and oropharyngeal cancers, it causes anal cancer, which is about twice as common in women as in men and that's just mostly due to what's called auto inoculation or essentially transmission of HPV from the vagina to the anus when showering, or wiping, or doing other daily activities. It also causes vulvar cancer, vaginal, and penile cancers. Oropharyngeal cancer is the newest story in HPV cancers and that is because it is unfortunately becoming an epidemic and it is also unfortunately an unscreenable cancer. When I used to present this slide about 2 years ago, I would say that oropharyngeal cancers are expected to outpace cervical cancers by 2020, but they arrived at that dubious honor 2 years early. In fact in the latest data, they were more common than cervical cancers.

>> [Sharon Humiston]: I don't think that most, I don't think almost anybody knows that, that oropharyngeal cancers are more common than cervical cancer from HPV.

>> [Rebecca Perkins]: Right. And it's also different from cervical cancer because we have another way to prevent cervical cancer. We have pap smears and HPV tests that can detect precancerous before they invade and women can get treated. And, in fact, we treat 330,000 women every year for a cervical pre-cancer, and if we didn't have screening, cervical cancer would definitely still be the most common cancer but with oropharyngeal cancers the HPV infect the tonsils or the base of tongue. That's an area that's very, very hard to see and these tumors often metastasize while they're still very small. So many people present with a persistent sore throat or a swollen lymph node in their neck that doesn't go down and that is often a stage 3 or 4 cancer. Oropharyngeal cancers used to be caused primarily by smoking and heavy drinking and so the typical patient would be, you know, a heavy smoker in his late 60s or 70s and HPV has completely changed who this disease affects. So if you talk to a head neck oncologist who has been in practice for 3 years they will say that the majority of patients walking into their office now are young men, 50 and younger, non-drinkers, non-smokers, whose cancers are HPV-related because more than three-quarters of new cases of oropharyngeal cancers are caused by HPV and almost all of those cancers are caused by HPV type 16, which is protected against in the vaccine. If you go to your dentist and your dentist is following guidelines, you'll notice that they pull out your tongue with a cotton swab and they feel your neck and they may not tell you what they're doing but they're actually checking for an HPV-related oropharyngeal cancer. So as we think about the diseases that are prevented by adolescent vaccinations, HPV actually causes about twice as much disease as other, as the other vaccines, of the other diseases that are preventable by vaccination. And the slide I'm on right now, I'm sorry, the slide I'm trying to be on right now looks at the epidemiology of HPV infection, which is a very important thing to understand. Most people are infected with HPV between the ages of high school and the end of college and most of those HPV infections will clear, but among those infections that don't clear if someone has an HPV infection that persists for more than about five years, almost all of them will go on to get a pre-cancer at least in the cervix where we have really good evidence of the epidemiology. So the most common age for women to be diagnosed with cervical pre-cancer is between 25 and 29. Luckily, we are able to diagnose and treat most women so they don't go on to get cancer. Cancer usually happens about a decade or so after the pre-cancer. So we actually see cervical cancer incidents begin to elevate around the age of 35 and it actually remains high through the ninth decade of life, through women in their 80s and beyond the age of 35 any cancers are really considered failures of screening, or in most cases actually failure to be screened, or inability to access screening. So what we want to see if this vaccination is working as it's supposed to we want to see the infections go away, and then the pre-cancers go away, and then the cancers go away. So what we have seen is that the HPV infection itself has started to decline. So they've done national studies where they actually swab women all over the country and they found in women between ages 14 and 24 the rate of HPV types that are prevented by the vaccine has dropped by about 70%. This includes a 90% reduction in girls who got the vaccine and a 30% reduction in those who didn't indicating herd immunity. So that's the first step. The second step is the reduction in pre-cancer. So we expect that if we see infection with oncogenic HPV types go down we will also see a reduction in pre-cancers and that is exactly what they have seen in this data from Australia. So in Australia, they introduced HPV vaccination in 2007. They rapidly got about 80% of their population vaccinated and almost immediately started to see pre-cancers disappear in women aged 18 to 20 and nearly disappear in the 21- to 24-year-olds and, in fact, the reductions were so profound that Australia has now started, doesn't need to start screening until 25 because there's no disease to detect before the age or 25, which is really exciting. And then we want to know what about cancer. So in some follow-up studies of women who participated in the original clinical trials, they actually were able to look at rates of cancer in women in particular in the trials and women of similar age who did not. And they found that in women who got the vaccine, there was zero cases of any HPV-related cancers and unfortunately even though these were young women, there were 10 cases of cancer in women who did not have the opportunity to get back vaccinated. So the vaccine is really working exactly and even better than we hoped it would and it really has the potential to vastly reduce or eliminate six different types of cancer.

>> [Sharon Humiston]: [Inaudible] slide that you're showing right now and the one before it showing the decrease in pre-cancers. When people say, oh, there's no evidence that the vaccine works. Oh, yes, you know, we are far enough down the road that there is evidence.

>> [Rebecca Perkins]: Oh, there's tremendous evidence and there's also evidence that it prevents HPV infections in the oropharynx. So even though we don't have evidence yet of preventing cancers of the oropharynx because we need decades to prove that, we know that it prevents infection, and that those infections cause cancer. So, therefore, it should, we have enough evidence I think to say that it's going to prevent cancer and also in Australia they have eliminated recurrent respiratory papillomatosis, which is where a baby gets infected with the HPV type that causes genital warts as they're passing through the birth canal and because the vaccination rates in Australia are so high that disease has virtually disappeared and the only cases that they see are in those rare women who didn't receive the vaccine. So we know that we have really good evidence that it's going to work and also keep working because again in Australia as the cohorts get older and older you just start to see reductions in pre-cancer in the older women. You don't see a tailing off of that effect indicating that the vaccine is likely to be lifelong as it was intended.

>> [Sharon Humiston]: Okay, it's exciting that we know that the vaccine is effective and we know that more and more people are getting vaccinated, but I also know we could be doing better. Next slide, please. What you see here is a slide of the United States. It shows the HPV vaccination coverage of adolescents 13 to 17 years of age. So this isn't 11 and 12 year olds, this is 13 to 17 years of age by state and this is the NIS teen data from 2017. This is all from teens vaccinated view. If you ever, the reference is real small at the bottom, but when you get the slide at the end of the program, you'll be able to go in and actually see your state's specific immunization rate. I know that different states are different. For example, Rhode Island is very, very high. My own state Missouri is not doing as well. So when we think about though why are different states different, it's not always apparent. Missouri is right below Iowa. Iowa is doing quite well. Just a shout out to Iowa and Nebraska as opposed to Missouri and Kansas. Why is that?

>> [Rebecca Perkins]: And, Sharon, while we're waiting for the slide to advance, I just want to point out that a lot of the states with really low vaccination rates also have very high cervical cancer rates. So unless you can do something about reversing those disparities and getting the girls in those states vaccinated, we're likely to have even more disparities geographically when looking at cervical cancer in the future as guidelines start to account for protection from vaccination.

>> [Sharon Humiston]: Here are the top reasons for not starting the HPV vaccine series. This was asked of parents of unvaccinated boys and girls, this was back in 2016. So it wasn't yesterday but pretty recent. And you see the answers of parents of daughters in pink and the answers of parents of sons in blue. So, for daughters the top reason is safety concerns and worry about side effects whereas for sons, next slide click it for me, whoops, too far, for sons the main concern is that it wasn't needed. Now, in both of those cases, it is clear that the problem is communication because there aren't, you know, we had this vaccine for around for a really long time and the vaccine is as safe as other vaccines meaning very, very safe. And how can we say that boys don't need it? We've just saw that Oropharyngeal cancer is a growing problem and 9 out of 10 men will be infected with HPV sometime in their life. So, of course, males need this. We move now to our objective to identify effective HPV communication strategies. If most people who aren't getting it aren't getting it because of a communication problem, well then it's clear we need better communication strategies. So, Kristin, what's a provider to do?

>> [Kristin Oliver]: Great question. We have the answers. So one of the things that you mentioned when you looked at that study about why parents were not getting the vaccine for their child initially the number 3 answer was not recommended, right? And the reality is a recommendation really, really matters. So we need to work on this. And what's nice is there's a lot of data now that shows us what is a good recommendation and why is it so important. So what we're looking at here is this is just for males, this group's parents who after they were asked whether or not their child has gotten the HPV vaccine asked them do you remember getting a recommendation from your provider? And you can see in red that a little over 65% of parents of males remembered getting a recommendation. The more interesting bars are the next two. So in yellow you're looking at of the parents that remembered getting a recommendation how many got their son vaccinated and that's over 68%, right? If you look at the blue bar, it's the parents who do not remember getting a recommendation, how many of those boys ended up getting vaccinated only 35%, which is a big difference. It really does matter if you are recommending that vaccine or not and this is, we've seen this sort of data before. Other data has shown if there's no recommendation maybe 20 to 30% of kids will get vaccinated, a low quality recommendation 50% will, but a high quality recommendation; we'll talk about the same way, same day recommendation will get you to 70 or 90% of kids getting vaccinated and that's what we want, right? So, it's possible that what happened to the parents who said they don't remember getting a recommendation maybe they really didn't get a high quality recommendation, right. And so we're going to go a little bit over what does that mean? What does it mean to get a high quality recommendation? So when you say optional, right, optional will be saying, so Alice is 11 today, have you thought about what shots you want to do? Right. As opposed to a high-quality recommendation that says Alice is 11 today. We're going to give her Tdap, her HPV and her meningococcal vaccine. These are the shots we are going to do today. And when I think about the low quality recommendation what's sort of in the middle some providers will say, oh, Tdap and menigicoccal are required for school HPV isn't required for school, right, you know. You should get all 3 but here's the difference between the 2. And so that's what I was, you know, saying the low quality recommendation. You're making HPV different pointing out that they don't need it for school. And so, I don't know, Rebecca, you're the mom of a teenage daughter. How would you respond to these sort of different approaches if your pediatrician recommended the vaccine this way?

>> [Rebecca Perkins]: So, if I were not myself, if my pediatrician says, oh, would you like HPV vaccine? I would say, of course, I would but frankly that's not how you're supposed to recommend it. In fact, when I brought my kids in, he was, I was so excited, he said "I'm so excited your son now has the opportunity to get the HPV vaccine!" and like he had a little note card. He's like, "Take this yellow card out to the desk and we're going to make sure to get the follow-up visit." I'm like, oh, yay, he remembered my lecture from last year, but if I were not myself and someone said, well, what vaccine would you like today? I would think I don't know. You're the doctor. If you don't know what vaccine they're supposed to get, how am I supposed to know? And I'd probably wind up not getting any because I would think, well, gosh, there must not be any important ones or they would tell me and if they're leaving it up to me, I better go and do some research.

>> [Kristin Oliver]: Right. And most, there's so many things in the visit we don't say, "Should we get the height and the weight today? What do you think?" You know are they going to get their height and their weight today and take their blood pressure, right. So it goes all along with that because these vaccines are standard of care. So I think we've said it before the same way same day recommendation, "your child needs 3 vaccines today, Tdap, HPV and meningococcal" and you can give a strong recommendation before 11. A lot of people are starting to offer the vaccine at 9 and 10 and anecdotally getting a lot of really great response from that. And so the way to phrase that in a non-optional way is to say today your child needs the HPV vaccine to protect them against cancers and other diseases that are caused by HPV. So you can still make that same [strong recommendation].

>> [Sharon Humiston]: Making it the default.

>> [Kristin Oliver]: Exactly. And then the other thing we know now is that the strong recommendation can't just come from the doctor or the nurse practitioner. It has to be the entire staff that's delivering this message consistently, right? And so we know that the nurse who gives the vaccine needs to be onboard in giving a strong recommendation, the MA, the person at the front desk, everyone needs to be giving the same quality recommendation. And so what we recommend is, you know, the nurse or the MA gives the opener, "Today Pat's going to have 3 vaccines. They're going to protect him from injections caused by HPV, meningitis, and pertussis, do you have any questions for me?" So she said this is what we're going to do today, what questions do you have. If at that point the parent says, well, I don't know about these vaccines. Then all that nurse or medical assistant has to say is, "Okay, I understand but I know that Dr. Oliver is going to want to talk to you about this so you can share your concerns. She's so big on cancer prevention." And that way for me at least the door is opened and let the parent know I'm going to continue this conversation and the responsibility also isn't on that MA or nurse to have to have the extensive conversation. Just for those of you or people in your practice who still need some practice with how to deliver this recommendation, there's a great app available now that was developed through the AAP and APA. It has basically a simulation, 15-minute role play. It's really nicely done. It helps you go through how to give this recommendation and how to sort of answer some common questions and improve HPV vaccine communication skills and there will be a link to that also at the resources at the end.

>> [Sharon Humiston]: That seems so valuable. What does that cost?

>> [Kristin Oliver]: It's free. Good news. And so now what we're going to do is just go through a little clinical scenario. So let's say that I'm about to see an 11-year old who up to this point has gotten all of her vaccines and what's great is that the nursing staff already said, "Emma's going to get 3 vaccines today, tdap, HPV ,and meningitis." Mom, said, "Oh, I don't think she's going to have that HPV one." Right? Okay, so then the nurse says, "No problem I understand but I know Dr. Oliver is going to want to talk to you more about it." So I come into the room, Sharon, I'm going to have you be the mom of Emma, is that okay?

>> [Sharon Humiston]: Okay.

>> [Kristin Oliver]: And we're going to go through. I'm going to say the same high quality recommendation, "So Emma is 11 now. We can give her Tdap, HPV, and meningitis vaccines today."

>> [Sharon Humiston]: Well, I've heard that it's a vaccine to prevent a disease that's transmitted by having sex and she is a long way from having sex.

>> [Kristin Oliver]: I understand you have some questions about this vaccine. I really want to make sure that I answer all your questions so let's talk about it. Do you mind sharing what your particular concerns are?

>> [Sharon Humiston]: Uhm, well, I mean she's too young for sex and I don't want to open that can of worms.

>> [Kristin Oliver]: I get it. So it sounds like really you think she really is too young for the HPV vaccine because HPV is transmitted through sexual activity. I get it. She's only 11. I've thought a lot about this. Is it okay if I go over with you how I've come to think about it over time?

>> [Sharon Humiston]: Of course, Dr. Oliver.

>> [Kristin Oliver]: Thanks. So when this vaccine first came out over 10 years ago, I also used to think about it as something that prevented a sexually transmitted infection, but I realized really it's for preventing cancer and the reason that we recommend it at this age is because kids that are young have a better immune response to the vaccine. If we give it to Emma now we only have to give her two doses instead of three. That being said it's a decision that only you and Emma can make and so I really recommend it for all my patients. I gave it to my daughter. But again, this is a decision for you and Emma. So I want to know what you think.

>> [Sharon Humiston]: Okay. Well, if you think it's that important.

>> [Kristin Oliver]: I really do. Otherwise I wouldn't recommend it.

>> [Sharon Humiston]: Okay.

>> [Kristin Oliver]: Great. Let's get it done. All right. Thank you. And Emma is by the way now thrilled that she's getting two doses instead of three eventually. I find that comment always perks up the ears of the child involved, but let's go ahead and unpack how that conversation went. So the first thing let's say after she initially said she wasn't going to do the HPV vaccine. The first thing I did was inside my head I took a big breath, right, and I reminded myself, okay, she's not refusing the vaccine. She just has some questions. I need to find out what those questions are, right? And the reason I need to find out what her specific questions are is I think what I used to do was just start talking and telling everyone what I assumed what their questions be it about safety, be it about sex, and I didn't always guess right what the concern was. And so you don't want to raise up concerns that that mom didn't have to begin with, right? So you want to make sure you're answering the right questions. And so that's why. And then the other thing is you want to make sure that you, you really do care about their questions because I think we all do as practitioners and so you want to make sure that they understand you don't see this as a personal affront. You want to ask your questions in a non-threatening way. And so that's when you say it seems like you have some questions, let's talk about it, right, very non-threatening and then you find out what the specific concern is that mom says. So in this case you said, you know, she's just too young. So the next thing that I did was to ask permission, right, for me to share my information. Not to dive right into all the information I had but to say, you know, is it okay if I share this with you? And the reality is I've never had a parent say no, right? I mean we all have pretty good relationships with our patients they're going to say yes, but it's important to sort of --

>> [Sharon Humiston]: -- but it feels different if you ask me permission to give me your insights rather than just cram the insight down my mouth.

>> [Kristin Oliver]: Yes, I mean that's the goal, right? And I think it really does as the patient and it doesn't take that much longer, right, it takes an extra five seconds. So it's definitely a step that's worth doing. The next thing that I did is try to change Sharon's perspective on this vaccine, right? So what I didn't try to was argue with her or contradict her. I'm just shifting the focus, right, and said I used to think about it as something like a sexually transmitted disease but then I realized it's about preventing cancer, right. You're shifting from whatever they're saying to cancer, cancer, cancer, because that's our message at the end of the day, right? And you're again not trying to argue. We're not trying to win a debate. That's a different sort of setting. At a clinical encounter, we're really just trying to develop a relationship and to sort of slowly move the parent to this yes and address their concerns. So I think that --

>> [Sharon Humiston]: -- someone said to me don't play fact tennis. Back and forth with the, you know, like oh but this, you know, no, you're not trying to win fact tennis.

>> [Kristin Oliver]: Exactly, absolutely. And that brings up the next point which is don't counter emotion with data or don't data dump. So what you do not want to tell this mom is, "Oh, well, you know, we know that a certain percentage of adolescents are going to have sex by middle school. If you're worried about sex, you know, you might want to get it earlier and we've also seen studies that the vaccine does not increase the likelihood of having sex." All of this true the only thing mom would hear during that is sex, sex, sex, sex, right? So she is not thinking about anything else. You haven't helped sort of shift her focus and you've just given her stats and she's even more emotional now. Right? And so that's sort of the opposite of what you want to do, but admittedly something that I think I probably used to do and I have really trained myself not to anymore, to hold on to some of that data that doesn't necessarily need to be shared. So the final step and one of the things that I said sort of giving a personalized recommendation, right? So I said, you know, I recommend this to all my patients and in my case to my daughter or to my niece or my nephew, right, this personal recommendation but then you also say giving the parent control again, right. At the end of the day this is a decision that you have to make. What would you like to do? What do you think? And you end with that open-ended question to let them have a chance to talk and tell you what their plan is. Now, this isn't always going to work, but I think those of us who have used motivational interviewing in other settings so it's maybe around diet and exercise, obesity, anyone who has done tobacco cessation, a lot of these techniques can be pretty similar, and it takes some practice admittedly because we're not used to doing it around vaccines and there's some other motivational interviewing techniques that can also work with these vaccine conversations. So, I'll give a couple of examples.

>> [Rebecca Perkins]: Kristin, I just want to pipe in and say that if you do the strong recommendation, that by itself will work about 70% of the time and then you're get an additional 10 to 15% of parents with this very simple motivational interviewing. So it's only going to be the real, the people who are really concerned who still say no and that's probably going to be less than 10% of your patients. So, 90% of the time this is going to work.

>>

>> [Kristin Oliver]: That's a really good point and I think those are the ones who say, no, you can't share your information with me and then you can stop then you know, right? But that's exactly right most of the time the strong recommendation works followed by these techniques. Another example that made use of motivational interviewing is this 1 to 10 scale. And so I'm going to try this with you. Rebecca, can you be the mom this time?

>> [Rebecca Perkins]: Sure.

>> [Kristin Oliver]: All right. So I'm going to say so, Mrs. Perkins, I want to understand your thoughts on the HPV vaccine. On a scale of 1 to 10 where 1 means no importance at all and 10 means very, very important, how important is it to you to have your daughter vaccinated against cancers caused by HPV?

>> [Rebecca Perkins]: Maybe like a three.

>> [Kristin Oliver]: Okay. Why is it a three and say not a one or a two?

>> [Rebecca Perkins]: Well, I do think that preventing cancer is important and it does seem like this vaccine might do that, but I feel like you can prevent the cancer in other ways. So I'm ranking it a three.

>> [Kristin Oliver]: Got it. And so cancer prevention is important to you, but you're very curious about other options. What would it take do you think for you to start thinking about it as a say a seven or an eight in importance?

>> [Rebecca Perkins]: Well, if you told me that HPV cancers couldn't be prevented by anything by vaccination, that would make it more important, but I just get my pap smear when I'm supposed to and that prevents cervical cancer.

>> [Kristin Oliver]: Okay. So what if I leave you with some literature to read up on on this? I have a couple of good handouts and the reality is that this vaccine is going to be much more effective than relying on cervical cancer screenings alone. Let me give you some information on that and we can continue this conversation next time you come in.

>> [Rebecca Perkins]: Or why don't you tell me about Oropharyngeal cancer now. [Laughter]

>> [Kristin Oliver]: [Laughter] Or I could say, well, we can't screen for Oropharyngeal cancers in which case this is another reason you want to get the vaccine. Very excellent point. Thank you. I didn't catch your lead in there.

>> [Rebecca Perkins]: I know. I was like there are six types of cancers caused by HPV and only one of them is preventable by screening and it's not the most common one.

>> [Kristin Oliver]: Excellent. So see how well that could work? This is one, usually the 1 to 10 scale is an example. The other thing you can do is again just ask these open-ended questions. So, you know, parents who are concerned about side effects, which we will talk about soon, you know, you mentioned side effects as a concern but what are some possible side effects of not getting the HPV vaccine, right, and have them talk about that a little bit more to shift the focus back to cancer. And then, again, reflecting their positive and negative but focusing on the positive. You see HPV as cancer as frightening but you're worried about the vaccine safety. Tell me more about your perspective on HPV cancers. Do you know anybody who has had an HPV cancer or pre-cancer or colposcopy? A lot of women and men know someone who has gone through something like this, right? And so talking about that experience for that friend or family member may really help focus them a little bit more on why this vaccine is so important. Now I think we touched a little bit on, you know, some people are going to at the end of the day decline the vaccine. When that happens, one, remember that this is not final that the reality is over 50% of people who initially decline end up getting their children vaccinated. So even of that small percentage who decline, those kids are probably going to get vaccinated. You want to revisit this conversation. And I say that to my patients all the time like, "Okay, I understand it's absolutely your decision but you know I'm going to talk about this again at the next visit?" And they say, "Yeah, Dr. Oliver we know", right? Because they know me and they just leave that door open. The other thing is, you know, offer additional reading material and we have some suggestions for that material at the end. And finally don't over remember this, right? This is the small, small percentage of parents who are really not going to accept the vaccine. Don't bring that with you into the next encounter because most are going to say yes. Don't let that prevent you from giving the same day, same way recommendation for your next patient for trying these motivational interview strategies with your next patient, right? And at the end of the day you really did your best you can for this child, relax. You're going to have another chance to get this child vaccinated and prevent those cancers.

>> [Sharon Humiston]: Kristin, we saw that a lot of parents who have unvaccinated kids are worried about safety issues, and I think that everybody on the phone today needs to feel very, very convinced that HPV vaccine is safe so that they can give a strong recommendation. Is it safe?

>> [Kristin Oliver]: Yes. That is the short and quick answer. It is absolutely safe. I would say, yes, it's as safe as the other vaccines otherwise I would not be recommending it. I am very concerned about vaccine safety too. I follow the stuff really closely and now I can share all of that very close knowledge with you. So, recently I read Charlie and the Chocolate Factory with my daughter and one of the characters there is Violet Beauregarde it's a little cartoonization of Violet Beauregarde, but she was 10 and if you remember she was one of the children who got the golden ticket so she could tour Willy Wonka's Chocolate Factory. I thought to myself, you know, what if the day before she went to go to see the Chocolate Factory, what if she had a well-child check and she was the one that went to one of these doctors who was starting to give the vaccine at 10 and her mom said, okay, she got the HPV vaccine at 10 and the next day she went on this tour and we know what happened to her. She's not a great role model. She ate some gum that she wasn't supposed to and she blew up into this big, purple sort of balloon and what if mom went home that night and said my daughter got the HPV vaccine and the next day look what happened to her? She turned into this big purple balloon, right? And so, you know, she posts this on Facebook. So what we have here is an example of a child who got a vaccine and then had an adverse event, right, from this mom's perspective, but the thing is, is this a coincidence or is this the cause? And all we have is this little box A over in the corner with that information from mom or from whoever else. To know that it's not just a coincidence, right, which most of us are probably pretty sure it was not the HPV vaccine but it was the gum, we need more information. We also need to know all of the kids who got the vaccine who did not have that adverse event. We need to know all the kids who did not get the vaccine but did have the adverse event and even all the kids who did not get the vaccine and did not get the adverse event. And then what you do, right, is to come the proportions of the kids who were exposed to the vaccine and the kids who weren't and the ones who got the adverse event versus those who didn't. And that's how we know something is actually causally linked and not just a coincidence.

>> [Rebecca Perkins]: Would it [the adverse event] have happened anyway? That's what we want to know.

>> [Kristin Oliver]: Yeah, exactly. We're incredibly lucky in the US because we have a very robust vaccine safety system that has all these different systems that are looking to see if what's being reported by a vaccination is caused by the vaccine and the most common one of these is VAERS, the Vaccine Adverse Event Reporting System. I think it's the one people are most familiar with. Some of us have probably sent in a report to VAERS, but VAERS is sort of the Facebook of the vaccine safety system, right? It's the early warning system. It casts a really wide net it lets anybody report anything that happened, mom can report it, your neighbor could report it, the aunt could report it, right, and it doesn't have to be a link but we cast a really wide net because we do not want to miss anything else, right, we want to make sure that the vaccines are safe so we want to catch all the really rare potentially impossible things so we can investigate them further and make sure there's not actually a causal link. All right so it's an early warning system if you pick up something you might be concerned about, then you have to do additional studies. This little box is not enough. So how do we get the other boxes? Those come from these other safety systems, Vaccine Safety Datalink, the Clinical Immunization Safety Assessment, the Post-Licensure Rapid Immunization Safety Monitoring Program. And those are the places that do really good case control studies and can come and tell us definitively whether an adverse event was actually related to a vaccine or not. And so now over 10 years after the HPV vaccine was introduced, we have very good data from all of these systems, right, that looked at all of these boxes and we can very definitively say there has not been an increase in any of these things.

>> [Rebecca Perkins]: It's going on 13 years now because it was 2006 when it was licensed. So the HPV vaccination data in VAERS is now old enough to be HPV vaccinated itself, right? [Laughter]

>> [Kristin Oliver]: Actually that's one way to think about it. I love it. These are all the things not related to the vaccine, right. I know people are very concerned about autoimmune disorders, fertility problems, right, all of that stuff definitively not linked to the HPV vaccine. I think recently, Rebecca, you showed something that was diabetes, Type 1 Diabetes not related to the vaccine, right? And the list goes on. So what can we say?

>> [Rebecca Perkins]: Keep trying to think of new things to study and all of them have thankfully shown absolutely nothing, which is great.

>> [Kristin Oliver]: And so we can say that we know that there are some side effects, pain, redness, swelling, right, sometimes fever or headaches. We know if you're allergic to anything in the vaccine, you shouldn't get it. And we know in this age group that sometimes kids can faint after any vaccine or any injection or blood draw, right? So it prevents injuries from that you have people sitting or lying down for 15 minutes afterwards, but 100% this is a safe vaccine. I'm very confident telling my patients that and my friends and family.

>> [Sharon Humiston]: All right. Rebecca, do you want to talk about how to increase office place strategies? What are the strategies to improve the vaccination rates in an office?

>> [Rebecca Perkins]: I would be happy to. Sorry, I'm so bad with this mouse. Okay, the first thing is to motivate yourself and your staff. So the staff need to understand the diseases that they're preventing. So, especially pediatric offices, you know, you guys don't see HPV diseases. I, as an adult woman provider, I see people suffering with HPV all the time, and I am not an oncologist but, you know, about once a year I wind up doing or referring a patient for a hysterectomy who is under the age of 40 for an aggressive pre-cancer caused by HPV. So, it's important that the staff understands that these diseases are real, they're in their communities and that they can be prevented by vaccinations. These are just some websites and stories that your staff, you and your staff can watch. And it's also important to actually figure out the office vaccination rates because oftentimes people think they're doing a great job because they get most of the kids who come in for their well child visit but don't realize that there are many kids who are never presented for well care and those kids may be missing, they may be falling through the cracks and missing their vaccinations. You can also use reminder and recall messages to bring adolescents in for well care if they are missing, if you know that they're missing vaccinations. Some EMRs can do that or you can use old-fashioned post cards, patient portals, sometimes you can do robo calls to try to get them in for appointments.

>> [Sharon Humiston]: The third step for people who do come in GRASPing your opportunity to vaccinate. So we have here a picture of a vaccine champion grasping a patient before he leaves the office. So grasp is an acronym. We are going to go through G-R-A-S-P. So G is grow a pro immunization culture. Every staff member in the office should be ready to explain the vaccine's importance. So basically the cancer story that we told you today, you know, in terms of this is preventable cancer use the same-day approach that Kristin talked about if the parent has concerns, leave the door open and have staff vaccinated themselves this is more of an issue with flu vaccine, for example, but you may have some young people who could be vaccinated working at your office. All right and then designating a vaccine champion and I think one of the main purposes of having the vaccine champion is as Rebecca just said assessing the immunization rate in the office because everybody thinks they're doing better than they actually are. Next slide, please. So the R is for having specific routines and roles. The tasks are less likely to be forgotten if it's clear what are the immunization-related tasks that need to be accomplished? When in the office workflow are they expected to happen like what's the routine? And who is taking responsibility for each task? If it's just different on everyday what, when, and who, then things are going to slip through the cracks. Next slide, please. The A is for have agreed upon office policies. This is one of the turning points in a lot of our quality improvement work when the whole office gets together and all the providers use the same vaccination schedule. Like everybody is going to start at age 11 or everybody is going to start at age 9 so the nurses don't have to remember, oh, you know, today it's Dr. Lewis so we're starting at 9. Having everybody do the same thing every time. Vaccinate at every visit type. So, whether it's an ankle sprain or a well-child check, the kid gets the vaccine. Give all indicated vaccines at a single visit. We find that if you just give two vaccines at one visit and one vaccine and hope that they come back for, you're going to have bad immunization rates in your office. Next slide, please. This is a big one. S is for standing orders. This is the number one most effective way to increase immunization rates and it takes very little effort from the provider. When I say standing orders, I mean when you enable the nursing staff to give the vaccine without a patient specific order. So, for example, coming into an emergency department you might have standing orders to give Tylenol for anybody over [inaudible]. In your office, it's great to have standing orders that all adolescents who meet certain criteria get the vaccine. It authorizes appropriately trained health care personnel as allowed by state law to assess immunization status and give the vaccine. If you want a template of standing orders, go to www.immunize.org/standing-orders. Next slide, please. And so then we come to P for provider prompt. Many offices have activated vaccine prompts in their EHR. What this does is having the provider know, oh, you know, today don't forget to give this kid these three vaccines. So it's a prompt for all the providers to easily make. The other thing though that we have found is that if it's not just the EHR because a lot of us click through all those EHR prompts. If the nursing staff also prompts the provider, that double prompt is much more effective than either one alone. The nursing staff may need some support in terms of knowing who should get it and who shouldn't, you know, like they may be afraid that they're going to miss a true contraindication. So, I show you here a link to a screening checklist that the nursing staff can use. Next slide, please. So we come now to the last objective explaining the most current information about the HPV vaccination of mid-adults. Rebecca, this is something I'm sure you're getting asked all the time.

>> [Rebecca Perkins]: So, there was recently FDA approval for Gardasil 9 from the ages of 27 to 45 and the question is will this actually prevent more cancer than vaccinating kids? And the short answer is not much. So people want to know is it safe, does it work, and will my insurance pay for it? HPV vaccination is extremely effective when given to early adolescents ages 9 to 13. It becomes less and less effective with every year of adolescence and over the age of 18 many studies show no effectiveness at all. In fact over age 20, two-thirds of studies show no effectiveness on a population level. So vaccinating through the age of 26 is estimated to prevent at least 25,000 HPV-related cancers every year, but vaccinating through the age of 45 is estimated to prevent only an additional 193 cancers. So, we really want to keep focusing our efforts on vaccinating the kids because that will give us so much benefit.

>> [Sharon Humiston]: It sounds if parents say, well, can't this just wait until, you know, until she's a grown up and makes this decision on her own, it looks like that's not really a viable approach?

>> [Rebecca Perkins]: That is not a good approach because you are likely to lose the child, she is likely, she or he is likely to not get the full benefit from the vaccine and the insurance coverage is much more difficult once kids age out of the vaccine for children. Even the 18 to 26 year olds now who have a full recommendation and when ACIP votes they're unlikely to give it a full recommendation they are more likely to give it a personal option recommendation, which may or may not be fully covered by insurance or covered at all. So, it's very important to get the kids vaccinated on time. They get fewer doses, they get full protection, and they will have the option of vaccination, which is covered by insurance. So people want to know is it safe? Does it work for adults? And will my insurance pay for it? Next slide, please. So HPV vaccination is safe for all ages. Its common side effects as Kristin went through are sore arm, maybe a little headache or fever for a day or two, very similar to other vaccines and no serious side effects have been reported for kids or adults. So, obviously since the vaccine has been given to over, I think, 80 million young girls and boys and young adults in over 180 countries around the world, there's a whole lot more data on kids than adults, but we know in kids it's very, very safe. Next slide, please. So parents want to know will it work for me and will it work for my child? Next slide. Well, we know that HPV vaccination works very well for children but less well after the age of 20. So, this is a study done at Kaiser Permanente in Northern California and they looked at young women who are participating in cervical cancer screening between the ages of 21 and 24 and it looks at these were all women who had some sort of a slightly abnormal pap smear and they looked at how likely they were to be diagnosed with a pre-cancer after having that slightly abnormal pap smear. So it found that in unvaccinated girls almost 5% were diagnosed with the pre-cancer. These are young, these are 21 to 24 years old, 1 in 20 was diagnosed with a pre-cancer. And less than 1% were diagnosed with a pre-cancer when the vaccine was given on time at age less than 18. So an 80% reduction in pre-cancer in girls who were vaccinated. Remember this was with the quadrivalent vaccine. You expect that reduction to be even better when you're looking at the 9-valent vaccine. Now if they didn't get the vaccine until they were 18 to 20, their risk is about 2.5%. So lower but still over twice as high as if they got the vaccine on time and when you're vaccinated at the ages of 21 to 24, probably getting vaccinated at that point after they were already coming in with their abnormal pap test which is caused by an HPV infection it didn't do any good at all. So, again, really underscoring the emphasis of vaccinating on time. Next slide, please. So, with that in mind, I want to review the data on cancer or pre-cancer prevention in the clinical trials in 27 to 45 year old women. So, when women were being recruited for this trial, they had to be between the ages of 27 and 45 and they recruited a very special population of women. They recruited women who had no more than four lifetime sexual partners and on average they had only one. So they were really trying to stack the odds of women not being previously exposed to HPV and, therefore, being able to benefit maximally from the vaccine. They then tested all women for any evidence of prior HPV infections and only in those women who had no evidence of any prior HPV infection where they considered for the per protocol group. So in the per protocol group, these were women who had no prior HPV infection and completed all three doses on time and not surprisingly in this group the vaccine worked. In the placebo arm, there were six pre-cancers and in the vaccine arm there was only one pre-cancer. However, when they looked at the intention to treat arm, which again is still women with on average only one lifetime special partner, but they either didn't get all three doses on time or more likely they had previously been exposed to HPV the reduction was not significant and you can see how much higher the rates are of pre-cancer in the intention to treat population which was supposed to mimic the general population, but in this case is very much weighted toward women who are very low risk. So, when you extrapolate that to our entire country, the likelihood of real benefit on a population level is unfortunately very small. Next slide, please. So who is most likely to benefit? Children and adults with HPV risks approximates those of 11 to 12 years and unfortunately due to copyright restrictions we can't have my slide of Steve Carell in the 40-Year Old Virgin movie on this slide, but that is my favorite way of remembering who is going to benefit, which adults are going to benefit from HPV vaccination. Next slide, please. So, should we vaccinate the whole family? Kids definitely should be vaccinated. Of that there is no question. There is clear evidence of benefit and the vaccine is safe. What about mom and dad? Well, mom and dad can be vaccinated. There's a possible benefit by preventing HPV types they don't have now but may be exposed to in the future and the vaccine is safe. Next slide, please. So 3 tips, oh, is that you, Sharon? Sorry.

>> [Sharon Humiston]: Yep. So, we're going to go ahead and wrap up because we are right at the top of the hour with the three tips for discussing HPV vaccines with parents. Remind parents that HPV vaccine helps prevent certain HPV-related cancers and pre-cancers later, you know, when you're beyond adolescence. Discuss vaccination with parents of your 11- and 12-year old patients when they're in your office today. This is urgent. This shouldn't wait. This is a vaccine series we want the whole series in before there's any risk of exposure at all. And recommend the same day and same way you recommend other adolescent vaccines. The underlying strategy for increasing immunization rates in your office is that default recommendation we used to say strong recommendation but that gives you the feeling that what we're talking about is saying, oh, this is really wonderful. No, just make it an effective recommendation by having it be the default. We're at the top of the hour. I don't know if we have, next slide, please, if we have time for questions or not if folks want to stick around and ask questions.

>> [Kera Beskin]: We would prefer to respect people's time, but I want to thank all of the panelists for this amazing presentation. Thank you all so much for your perspectives, and we did have some Q&A that came through the question box. So we will be putting our heads together and formulating answers for those. Thank you all so much for chatting in your questions. So if you have one, please feel free to chat in one before you leave and we'll formulate answers and we'll email out those answers and we'll email out the slides to everyone who registered. So feel free to share that with your colleagues that couldn't make it and there will be Enduring, CME, CNE and MOC part 2 from this recorded webinar. So thank you all so much for donating your time to this amazing presentation today.