WELCOME TO THE NILE WEBINAR FOR JUNE 2021!
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WELCOME TO THE NILE WEBINAR FOR
JUNE 2021!
Immunize Nevada is a nonprofit 501c3 coalition that is widely recognized as
Nevada’s trusted resource for immunization information and community health
outreach for all ages. We accomplish this by fostering education and statewide
collaboration with a variety of health partners and collaborators.
You may view upcoming web trainings at ImmunizeNevada.org/NILE-webinars
Thank you for joining us today!
HOUSEKEEPING ITEMS
Connectivity Please log back in and we’ll continue
Issues where we left off.
Locate the Q & A box and type them
Have a
there. We will address questions
Question?
throughout the presentation.
Nursing/Pharmacy/CHW CEUs: Complete
CEU the post-event survey. Certificates will be
Claiming emailed within one week of the live
presentation.
Recording The recorded webinar and slides will be posted
& Slides to ImmunizeNevada.org/NILE-webinars.
DISCLAIMER
Immunize Nevada’s NILE webinars are made possible by the generosity of
speakers who donate their time and expertise to benefit the coalition. The
expectation and goal is for community partners to gain knowledge on
immunization/infectious disease-related topics through a non-branded, unbiased
presentation.
The opinions expressed are those of today’s presenter(s) and do not necessarily
reflect those shared by Immunize Nevada or its partners.
Working with the Successes of
HPV Vaccine in a Time of Rising
Anti-Vaccine Sentiment
Immunize Nevada
June 16, 2021
Richard Moriarty, MD, FAAP
MA Chapter AAP Immunization Initiative Professor of Clinical
Pediatrics, UMass Medical School
I HAVE NO FINANCIAL DISCLOSURES.
OBJECTIVES
● Understand the CDC/ACIP HPV Vaccine recommendations for pre-teens and
adolescents
● Describe the current status of HPV-related disease and vaccination efforts
● Learn how to create a culture of immunization in your practice
● Describe steps MA took to increase vaccine use
● Understand the resources and materials available to help your practices
H UMAN PAPILLOMA VIRUS • >170 different types • Most types are benign • Transmitted through breaks in any epidermis • 16& 18have viral oncogenes and cause most cancers • Can cause local self-limited infection, or chronic infection, or a dysplastic response • HPV is the most common STD • 5.5million new infections yearly • Virus can be passed by someonewho has no symptoms
HPV-CANCER H ISTORY 1950-60s: Cervical cancer more common in women having more partners and earlier sex 1980s: Zur Hansen HPV 16 & 18 found in cervical cancers; received Nobel Prize in 2008 1989: HPV16 DNA in tonsillar SCCs 1990s: Frazier & Zhou developed vaccine 2006: HPV-4 licensed in US & Australia for girls 2009: HPV-4 vaccine licensed for boys in US 2014: HPV-9 approved for boys & girls in US
NFID webinar 3/21/2018 6
HPV-ASSOCIATED CANCERS *J Natl CancerInst.2015Jun;107(6):djv086. doi:10.1093/jnci/djv086 # https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21590
HPV DISEASE CAN AFFECT PREGNANCY
• Consistent and significant association between HPV and
preterm birth and premature rupture of membranes
• May also be associated with intrauterine growth
restriction, low birth weight, and fetal death
TheJournalofInfectiousDiseases,jiaa054,https://doi.org/10.1093/infdis/jiaa054 February2020CERVICAL CANCER: JUST THE TIP OF THE HPV ICEBERG https://www.cdc.gov/hpv/hcp/protecting-patients.htm
HPV-RELATED OROPHARYNGEAL CANCER
Rate of cervical cancer is 3X greater in Alabama, Mississippi, and Arkansas than in Massachusetts.
HOW DOES HPV GET TRANSMITTED?
• Sexual contact
• Sexual intercourse
• Genital-genital
• Manual-genital https://vimeo.com/230653242
from Kids Plus Pediatrics, Pittsburgh, PA
• Oral-genital
• Genital HPV infections can occur from non-penetrative sexual contact
• Condom use may reduce but not eliminate risk
• Non-sexual routes
• vertical: mother-to-infant; juvenile respiratory papillomatosis
Most infected individuals are unaware that they are infected and may
unknowingly spread the virusH UMAN PAPILLOMA VIRUS VACCINE
Vaccine prevents
progression
from infection
to cancerlog scale
log scale
ADVANTAGES OF STARTING EARLY • Thinks of HPV vaccine like car seats or bike helmets: start early to protect children before “the event” • Middle school appointments • Better immune response • More chances to complete the series • Lack of exposure • Prevents at least twice as much cancer • Up to 40X the antibody level of natural infection • Only 2 shots instead of 3 shots • May help remove “sex” from the discussion • This is a cancer vaccine.
HPV VACCINE IS EFFECTIVE! • 82% (M) to 93% (F) reduction in genital warts • Evidence of herd immunity • Decline in cervical pre-cancers • HPV vaccine prevents cervical cancer • HPV vaccine prevents oropharyngeal infection • Some cross-protection from HPV4 against the 5additional strains in HPV-9
HPV VACCINE DECREASES CERVICAL CANCER R ISK
• 1.67million Swedishwomenages 10-30during the period 2006-2017
• Risk of cervicalcancer88% lowerin those whobegan HPV vaccinebeforeage 17
than in those not been vaccinated
• Risk of cervicalcancerrose as age of receipt of vaccinerose
• Recommendation:begin HPV vaccineseries
BEFORE HPV exposure
N Engl J Med 2020;383:1340-8.
DOI:10.1056/NEJMoa1917338> 270 million doses
worldwide
> 120 million doses in US
https://doi.org/10.7326/M20-2726 20 year study of vaccine safetyHPV VACCINE DOES N OT CAUSE OVARIAN FAILURE
• 199,078 females Kaiser Permanente Northwest 2006-14
• Part of the Vaccine Safety Datalink
• 58,871doses of HPV vaccine during study period; ages 11-34y
• No evidence of increased incidence of POF after HPV immunization
• POF rate:
• 1in 1,000 ages of 15and 29
• 1in 100 ages of 30 and 39
• No biologic plausibility to believe that vaccine was the cause; HPV disease does not
cause ovarian failure
PEDIATRICS Volume 142,number 3,September 2018:e20180943
DOI: https://doi. org/10. 1542/peds. 2018- 0943SYNCOPE AFTER VACCINATION • 62% happens between ages 11-18: VAERS • Most common when Tdap, MCV, and HPV given together • HPV vaccine hurts: 60-80% report some pain • Falls after fainting can cause head injury • Sit or lie down post-vaccines • Wait 15 minutes • Other vaccines hurt too (flu, Tdap, Shingles) Vaccine 2009 Nov 16;27(49): 6840–6844V doi: 10.1016/j.vaccine.2009.09.016
VAERS IS A SENTINEL SYSTEM
Dosing errors Balloon
Admin errors Bird
Side effects Drone
Allergic reaction Small plane
Adverse reactions Commercial plane
Rareevents Hostile enemy
● Anyone can report anything to VAERS
● A VAERS report does not prove causality
● Reports are examined; more information may be obtained to examine
possible causality
● Recent “hold” on AZ vaccine shows system can work to identify rare
reactionsSAFETY OF HPV VACCINE
REPORTS OF DEATH H AVE BEEN GREATLY EXAGGERATED
• VAERS reports over 3years 2014-2017
• 7reports of death after HPV vaccine
• 5heresay reports no data available to confirm death
• 2 had complete data and autopsy reports
– 14yo F - HPV/flu vaccines; dissecting aortic aneurysm
– 16yo M- HPV/HepA vaccines; cerebellar aneurysm
• No causal effect of vaccine found
• 28 million doses of HPV9 distributed during this period
DOI: https://doi.org/10.1542/peds.2019-1791 Pediatrics vol 114;December 2019HPV VACCINE IS LONG LASTING
• >10 years of durable protection from high-risk strains
• New study shows durable protection against HPV 16/18for at least 14years
(Denmark, Iceland, Norway, Sweden)
• Some cross-protection from HPV4 against the 5additional strains in HPV-9
• HPV9 can prevent up to 92% of HPV-attributable cancers or about 44,000 cancer
cases per year
Pediatrics 2019Feb;143(2):e20181902.doi:10.1542/peds.2018-1902
https://www.cancer.gov/news-events/cancer-currents-blog/2020/hpv-vaccine-single-dose-long-
term-protectionWHY H AVEN ’T MORE CHILDREN GOTTEN HPV VACCINE?
• Recommendation initially for girls, not boys
• Diseases pediatricians don’t see
• Little information about scope of diseases
• Little information about messaging to parents
• Concerns about safety
• Politics and sex
• Anti-vaccine movement
• Another vaccine at a time of “vaccine overload”
BUT now, 15years since approval, we know more
about thediseases and the vaccine.
HPV vaccine is safe, effective and long lasting!WHAT DO PARENTS WANT TO KNOW?
• What is HPV disease?
• Age to start the vaccine?
• Vaccinate both boys and girls?
• Vaccine safety and side effects?
• Why vaccinate those not sexuallyactive?
• National recommendations?
• School requirements?
• Standard of care?
PEDIATRICS DOI:https://doi.org/10,1542/peds.2018-1872PARENTAL I NTENT:HPV VACCINE FOR CHILDREN
• Parents of adolescents 13-17 in 2017-2018 NIS-Teen
• >82,000 parents completed survey
• 37% unvaccinated for HPV; 58% no intent to vaccinate
• ID, KS, MI, MT, NE, OK, ND, UT
• Reason: safety, not needed, not recommended
• 11% had had 1dose; 23% had no intent to complete series
• AK, FL, GA, HI, ID, UT, WV
• Reason: not recommended
www.thelancet.com/public-healthVol 5September 2020
DOI:https://doi.org/10.1016/S2468-2667(20)30139-0I MPROVING VACCINE UPTAKE: MA
• 2002: Christine Baze
• Team Maureen: 2007; HPV symposium
• 2013: MA DPH awarded CDC grant for
• AFIX quality improvement program
• 2013: An Act Establishing the Massachusetts Childhood Vaccine Program
• www.mass.gov/dph/hpvvax to provide information for parents & providers
• #2shots2stopcancer on twitter
• Seminars provide updates, survivor stories
• Oral Task Force; toolkits for dental practices
• MCAAP webinars, CME immunization updatesCOLLABORATE WITH OTHERS
HTTPS://WWW.MAHPVCOALITION.ORG/
Otolaryngology CDC
OB-GYN MCAAP
Dental
Social MA DPH
Media
Associations
School Health & CollegeHealth
CME- CEU Seminars
with Cancer Survivors
Community Health Centers
Pediatric Practices
ASTHOHPV VACCINE:WHERE DO WE STAND
Combined data for boys and girls ages 13-17
State HPV>1 HPV UTD
#1 RI* 91.9% 78.9%
#2 ND 88.8% 76.9%
#3 MA 87.9% 74.3%
US 71.5% 54.2%
NV 68.9% 52.9%
MS 49.5% 30.5%
Healthy People 2020 Goal was 80% UTD
NIS-Teen is a random-digit-dial telephone survey
https://www.health.nd.gov/immunize/coverage-rates
https://www.cdc.gov/mmwr/volumes/69/wr/mm6933a1.htm?s_cid=mm6933a1_w
https://stacks.cdc.gov/view/cdc/91797Strong Provider Recommendation a Key toNorth
Dakota’s High Immunization RateCOVID VACCINE STRATEGIES – USEFUL FOR HPV & OTHER
R OUTINE VACCINES?By 2066, less than
one woman per year
in Australia
could be diagnosed
with
cervical cancer.
Lancet Public Health 10/2/2018
NY Times 10/2/18January 2019
VACCINE HESITANCY: TOP 10 THREATH OW DID WE GET TO THIS POINT? • Distrust of government • Distrust of big pharma • Disappearance of VPDs • Magnification of AV beliefs on social media • Viral spread of doubt • Feeling of loss of control • Loss of liberty • COVID-19 contagion risk linked to “anti-other” • “Operation Warp Speed,” “race,”“finalists”
H OW CAN WE FIX THIS?
IT TAKES A VILLAGE
• Local Health Departments
• Local School Committee
• Schools:admin, nurses, PTOs
• Local - Regional Hospitals, ERs
• Primary Care Physicians:OB, Peds, FP
• Health Centers
• Libraries
• Press
• Parents
• LegislatorsBuild A Relationship On Trust
Demonstrate Confidence in Our Vaccines
Motivational Interviewing - Immunize Colorado
www.immunizecolorado.org ›uploads ›Motivational-I...TRUST • Physicians, nurses, office staff • Community leaders • Religious leaders • Neighbors • Relatives • Stories • Bewilling to listen
VACCINE CONFIDENCE IN Y OUR OFFICES • “We immunize” • Website, practice letter, handouts, prenatal visits, officeposters • Makeclinical resources availablefor staff • All staff must be on board with the same message!!! • Give strong presumptive recommendation • Provide VIS for every vaccine at every visit • Know what is in the package inserts
VACCINE CONFIDENCE IN Y OUR OFFICES
• “Whichvaccines would you like today?”
vs
• “Today she is due for these vaccines.”
• “These are the recommended vaccines to prevent………. I highly recommend
them.”
• “These vaccines will prevent…”
• “These vaccines are standard of care.”
• “Sameway, same day” Tdap, HPV, MCV4BUT I’VE HEARD BAD THINGS ABOUT THE HPV VACCINE
• Welcome questions and know the answers
• Listen to or ask about concerns
• “I can see why you might be worried.”
• “Would you share what you have read?”
• “May I share some information with you?”
• “What information would be helpful for you now?”
Amanda Dempsey video and slide set on motivational interviewing
https://www.youtube.com/watch?v=WstEm3zjIJQandCombination of Fact Sheet and Motivational
Interviewing ...Vaccine Confidence in Your Offices
• “I immunize my children.”
• Tell your personal stories about VPDs
• Messages with urgency less well received
• Audit your immunization rates (EMR or IIS)
• Examine strategies that can help improve immunization rates
• If at first you don’t succeed, try again - up to 35% will change
• Customized fact sheets
https://www.cdc.gov/vaccines/programs/iqip/at-a-glance.htmlCHAMPION • Lead the effort • Help develop consensus • Believein the vaccine • Know the package insert • Answer questions about vaccine • Knows the immunization rates • Provides handouts & references • Can talk with parents & patients • Periodically run coverage reports • Decrease missed opportunities
“CHOICE,”“FREEDOM,”“LIBERTY”
• Long-standing anti-vaccine mantras (autism, safety, religion)
• Choice: disease vs disease protection
• “Freedom” and “personal responsibility”
• Seat belts, car seats, bike helmets save lives, save $$, and protect
others
• Jacobson v MA 1905
• “No one is safe until we are all safe”
https://supreme.justia.com/cases/federal/us/197/11/WHO PAYS WHEN VPDS OCCUR?
• MN: 79 cases measles, $2 million
• NY: 949 cases measles, $8.4 million
• WA: 72 cases, $3.4 million
• OR: one tetanus case >$800,000
VPD outbreaks are expensive, lead to time missed from work
and school, and may lead to serious sequellae.
We all pay!
https://www.cdc.gov/mmwr/volumes/68/wr/mm6809a3.htm?s_cid=mm6809a3_e
Pediatrics April 2021, 147(4) e2020027037; DOI: https://doi.org/10.1542/peds.2020-027037COMMON QUESTIONS ABOUT HPV VACCINE
• HPV vaccine for adults ages 27-45 years?
• Vaccine less effective and less cost-effective
• Does insurance cover it?
• “Shared clinical decision-making”
• HPV-9 for those who completed series with HPV-4?
• HPV-9 covers 15% more cancers than HPV-4
• Series started with HPV-4 can be completed with HPV-9
• No recommendation to re-do HPV-4 series with HPV-9
• HPV-9 series after completing HPV-4 series may lead to lower antibody response for
the 5 additional HPV types
CDC: Supplemental information and guidancefor vaccination providersregarding use of 9-valent HPVcdc.gov/hpv
https://www.nytimes.com/2019/12/11/opin
ion/anti-vaccine-
HPV.html?searchResultPosition=1
https://www.youtube.com/watch?v=R -S1h_pQOFUR EFERENCES “Communicatewith Confidence: Talking with Patients about Vaccinesresource list from MA Department of Public Health and MA ChapterAAP Vaccine Confidence Project https://hpvroundtable.org/ resources,staff education, suggestionto help https://mcaap.org/immunization-initiative/immunization-hpv/ link to MA program to increase HPV uptake;news, material, training, handouts, resources www.immunize.org very comprehensive site with up to date Vaccine Information Statements, pictures and videos of vaccine-preventablediseases, handouts for discussing religious concerns, thimerosal, vaccine ingredients, alternative schedules, vaccine safety,and much more www.cdc.gov/vaccines/parents/index.html vaccine schedules, safety information, vaccine ingredients, and a verygood video called “TheJourney of Your Child’s Vaccine.” The information in this video is also available in a large office-size chart that you can request from CDC; many printable handouts http://www.boostoregon.org/peers programto help train community members as vaccine educators; also a very goodvideo about communicating about vaccines https://lillianlabs.com/2021/05/26/watch-the-webinar-breaking-through-covid-19-vaccine- hesitancy
R EFERENCES www.aap.org/en-us/advocacy-and-policy/aap-health- initiatives/immunizations/Pages/Immunizations-home.aspx Teaching toolsfor staff; “HPV:Same way same day”free downloadableappat GooglePlay Store& AppleiTunes Store https://zdoggmd.com/ Dr. Zubin Damania https://zdoggmd.com/zpupp-hpv-shot/ AmandaDempseyvideo and slide seton motivationalinterviewing https://www.youtube.com/watch?v=WstEm3zjIJQandCombinationof Fact Sheetand MotivationalInterviewing… Voicesfor Vaccinesparent-run site;manytools and references;sign up for weekly newsletter: “Thisweekin vaccinehesitancy.” AAP: sign up for Immunization Newsletter at IZCommunity@listserv.aap.org https://www.skepticalraptor.com/skepticalraptorblog.php/one-stop-shop-science-myth- debunking-gardasil/ This columnexplodesall themyths aboutsupposedharms of HPV vaccine.
LAST MINUTE QUESTIONS &
HOUSEKEEPING ITEMS REVIEW
Locate the Q & A box and type them
Have a
there. We will address as many questions
Question?
as we can today.
Nursing/Pharmacy/CHW CEUs: Complete
CEU the post-event survey. Certificates will be
Claiming emailed within one week of the live
presentation.
Recording The recorded webinar and slides will be
& Slides posted to ImmunizeNevada.org/nile-webinars.You can also read
