Improving HPV Vaccination Coverage

I live in Los Angeles, so this page is somewhat Los Angeles-centric, but many of the ideas are universal.

National Efforts

See Accelerating HPV Vaccine Uptake: Urgency for Action to Prevent Cancer (President's Cancer Panel - 2012/2013 report)

How well is Los Angeles vaccinated against HPV?

The County of Los Angeles Public Health department's Immunization Program estimates that, in 2009, 63.5% of 13-17 year old females in Los Angeles had received one shot, and 30.9% had received all three shots.

By comparison, they report that 58.3% of kids aged 13-17 had gotten the Tdap shot required for 7th grade starting in 2010. (The more recent 7th Grade Asseessment for 2012-2013 from the state says Los Angeles schools reached 97.85% on Tdap, so evidently mandating a vaccination is quite effective.)

Nationally, "Human Papillomavirus Vaccination Coverage Among Adolescent Girls, 2007-2012" reported

"The 2012 NIS-Teen shows that 84% of unvaccinated girls had a health-care encounter where another vaccine was administered. Had the 3-dose HPV series been initiated at these visits, coverage for ≥1 dose could be as high as 92.6%. ... In 2012, only 53.8% of girls had received ≥1 dose of HPV vaccine, and only 33.4% had received all 3 doses of the series."

What are the barriers to good vaccine uptake?

"Understanding suboptimal human papillomavirus vaccine uptake among ethnic minority girls" surveyed Los Angeles mothers. A few of its findings:
- 65% of mothers thought their daughter was at lower risk than other girls the same age
- "Mothers on average reported 13.9 years old was the youngest age acceptable for HPV vaccination"
- "The strongest independent predictor of vaccine initiation was having heard of HPV (OR 12.8, 95% CI: 6.01, 27.2)"
"Missed clinical opportunities: provider recommendations for HPV vaccination for 11-12 year old girls are limited" found "34.6% of physicians reported they 'always' recommend the HPV vaccine to early adolescents, 52.7% to middle adolescents..."

Who provides immunizations in Los Angeles?

People with health insurance or who can pay for the vaccine themselves can get it from their doctor, or at pharmacies like CVS, Ralphs, Rite Aid, Vons, and Walgreens.
The California Vaccines for Children program provides both Cervarix and Gardasil to enrolled doctors at no cost for children 9 to 18 years of age who are medicaid-eligible or uninsured. See also the state's HPV page.
Los Angeles County Health Department's Immunization Program administers vaccines to uninsured children up to 18 years old at 11 public health centers around the county. Their 2011 report says they administer roughly half of all immunizations for kids 7-18 years in the county, and about 10% of the immunizations they administer in that age range are for HPV.
The LA County Immunization Program also lists about 140 other clinics that provide free vaccination to eligible children.
The LAUSD said in 2006 it would offer HPV vaccination at in-school clinics, but the home page for LAUSD District Nursing Services doesn't currently mention it.

What is being done to increase vaccination coverage?

California Immunization Coalition puts on the California Immunization Summit conference every year on improving immunization coverage. Presentations are online and good reading.
One of the presentations from the 2011 California Vaccination Summit was about how Pharmacies are willing to work with schools to provide vaccinations, and the VFC coordinator is looking for pharmacies to partner with
Preteen Vaccination Week is an annual week in January or February during which the county health department, school districts, and many health care providers jointly try to reach many adolescents. For instance, on January 28-29 2009, free HPV shots were offered at John Muir Middle School.
UCLA is studying whether delivering vaccination information and referrals to users of the existing Office of Women's Health can increase vaccine uptake.
The CDC, UCLA, and the county have studied vaccine uptake in Los Angeles; see "Parent attitudes about school requirements for human papillomavirus vaccine in high-risk communities of Los Angeles, California", "Human papillomavirus vaccine initiation among adolescent girls in high-risk communities", and "Proximity to safety-net clinics and HPV vaccine uptake among low-income, ethnic minority girls".

Possible opportunities

The LAUSD hosts free Tdap immunization clinics before 7th grade; could HPV vaccine be offered at the same visit?
Reminding parents about overdue vaccinations can increase vaccination rates, and the California Immunization Registry can "Generate reminder and recall notices to let patients know which immunizations are due or overdue". But the Los Angeles County Immunization Program Reminder and Recall Guidelines recommends this only for children under 3 years of age. It does "encourage" it for older patients "as resources allow". Can we provide those resources, and get the health department to more strongly recommend this practice?
(Note: The California Vaccine Registry has explicit instructions about how to do reminders and recall notices.)
Combining the two above ideas, could schools identify kids who do not yet have non-mandatory vaccinations, and invite them for vaccination at in-school clinics?
Could HPV vaccination be made mandatory? California law, Health and Safety code section 120325-120380, says
[schools] shall not unconditionally admit any person as a pupil ... unless prior to his or her first admission to that institution, he or she has been fully immunized. The following are the diseases for which immunizations shall be documented: ... (11) Any other disease deemed appropriate by the department, taking into consideration the recommendations of the Advisory Committee on Immunization Practices of the United States Department of Health and Human Services, the American Academy of Pediatrics, and the American Academy of Family Physicians.
In other words, the state health department is free theoretically to require HPV vaccination, although it does not currently do so.

"Community-Based Interventions to Improve HPV Vaccination Coverage among 13- to 15-Year-Old Females: Measures Implemented by Local Governments in Japan"
"Dissemination and Implementation Research: Connecting Interventions to Practice"
"A Quality Improvement Initiative to Increase HPV Vaccine Rates Using an Educational and Reminder Strategy With Parents of Preteen Girls"
"Encouraging HPV Vaccine for Preteen Boys: Response to a Social Marketing Campaign"
"Immunization in Adolescents: Past, Present and Future"
"Scaling up human papillomavirus vaccination: a conceptual framework of vaccine adherence"
"Global challenges of implementing human papillomavirus vaccines"
"Challenges to immunization: the experiences of homeless youth" - homeless youth suggested that convenient access to free immunizations, advertised with positive messages in public spaces like busses and grocery stores, would help.

Corrections and suggestions welcome, please send them to dank at kegel com.