Human Papillomavirus Immunization Rates br

Human Papillomavirus Immunization Rates
THE JOURNAL OF PEDIATRICS • www.jpeds.com Volume 205
and their parents as a 2-phase effort improved HPV vaccine series initiation and completion rates by as much as 20%. Straightforward, low-cost provider education combined with the distribution of cancer prevention awareness booklets to pa-tients and Atezolizumab addresses 2 factors well known to improve vaccine uptake: a strong provider recommendation and the un-derstanding that HPV vaccine plays a role in cancer preven-tion. Our intervention was the use of a general cancer prevention education booklet that bundles all 5 cancer pre-vention topics in 1 resource. Presenting HPV vaccine as a high impact strategy to prevent cancer alongside of the very well-known strategies of smoking cessation and use of sunscreen allow the adolescent and the parent to better understand its importance.
In our anonymous survey, we found that 85% of partici-pating pediatric providers and nurses strongly agreed that cancer prevention was in their scope of practice. Yet, the US Preven-tive Services Task force clearly recommends comprehensive counseling of adolescents directed at preventing threats to the health of their patients.21 Similarly, despite available AAP policy statements for counseling adolescent patients regarding tobacco use, physical activity, healthy nutrition, HPV infection, and ul-traviolet radiation through sun exposure or indoor tanning, all known risk factors for the development of cancer in adult-hood, we found that only one-half of providers self-reported routinely providing verbal counseling regarding these life-style choices and even fewer provider written materials.22-27 Our finding is consistent with other studies documenting that US adolescents are underserved in their health counseling needs.21,28,29 For example, 1 study showed that diet and exer-cise guidance was provided at only 26% and 22% of well visits, respectively.28 We have shown that education-driven changes in the way providers and their staffs convey vaccine informa-tion that also incorporates written material with simple, con-sistent messages, has the potential to raise HPV vaccination rates with minimal cost and effort.
Our study was performed more than 5 years after the Ad-visory Committee on Immunization Practices expanded its HPV vaccination recommendation to include male adoles-cents, yet age-specific HPV vaccine completion rates for boys and girls remained highly discordant across all 6 of our par-ticipating practices, a finding consistent with published re-gional and national epidemiologic data.30-33 There are several possible reasons for this observation. Routine vaccination for female adolescents was recommended almost 2 years earlier than for male adolescents. There may be a general lack of un-derstanding on the part of providers and parents regarding the potential for HPV-associated anal, penile, and oropharyn-geal cancers, and many providers still do not provide a strong, consistent recommendation for their male patients.34-37 Inter-ventions are needed to improve provider, parent, and adoles-cent male awareness regarding the risks that male patients who are infected with oncogenic HPV-types are at risk for devel-oping malignancy, and that the most common types associ-ated with cancer are vaccine preventable.
We recognize that our study has several limitations. Only 6 pediatric practices were included. The majority of the prac- 
tices care for a large suburban population in upstate New York, which may limit the ability to generalize the data. Similarly, the recruited practices had baseline immunization rates at or above the state and county rates, thus, the data may not be gen-eralizable to those practices with immunization rates lower than the state and county. It is possible that provider education and use of cancer prevention education booklets in practices with low baseline rates could show greater changes in HPV vaccine uptake. Another important limitation is that there was no stan-dardization to the approach and delivery of the verbal and written information to the adolescents and their parents, with regards to the timing, duration, method of delivery, and amount of information provided by practice providers and staff. Instead, it was left to the staff to determine the logistics that suited their work flow best. Variations in the decided approach may explain, in part, why 3 of the outpatient practices demonstrated some decline in vaccine completion over time. Further study is nec-essary to determine the impact, if any, on when and how the flow of education is provided during an individual’s outpa-tient visit. The study team, also, had little control over the uti-lization methods of the provider messaging and booklet distribution, which may be relevant to the practice-specific dif-ferences in the measured outcomes. Also, it is unclear whether the results observed in this study are long-lasting or if peri-odic intervention and provider feedback will be required to ensure sustainability of results. Lastly, the surveys we per-formed assessed self-reported delivery of verbal counseling and written material regarding cancer prevention guidance. It has been well-described that self-reporting by providers over es-timate their behavior, however, this would result in overesti-mation of provider’s delivery of cancer prevention guidance. This emphasizes the need for tools to facilitate delivery of in-formation to adolescent patients and their families.