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“This isn’t a vaccine to prevent a sexually transmitted disease; it’s a vaccine to prevent cancer.”
— Dr. Roshan Bastani
THE DISCOVERY IN THE 1980s linking the human papillomavirus (HPV) to nearly all cases of cervical cancer led to the groundbreaking development of a cancer-prevention vaccine, approved for use in females in 2006 and for males in 2009. The U.S. Centers for Disease Control and Prevention (CDC) now recommends that the HPV vaccine — which can prevent cervical, anal, vulvar, vaginal, penile and certain throat cancers, as well as genital warts — be offered routinely to adolescents and young adults ages 11-26. The vaccines are administered in two (ages 11-14 years) or three (age 15 or older) doses over the course of about 6-12 months.
But 12 years after the HPV vaccine was introduced, usage rates among adolescents remain disappointingly low, says Dr. Roshan Bastani, Fielding School professor, director of the UCLA Kaiser Permanente Center for Health Equity and director for disparities and community engagement in the UCLA Jonsson Comprehensive Cancer Center. Nationally, in 2016, just 60 percent of 13-17 year olds had received the first dose of the vaccine, and only 43 percent had completed the series, according to CDC data.
Bastani attributes this in part to missteps in the way the vaccine was introduced. “The fact that it was initially promoted by the pharmaceutical industry and certain legislators raised suspicions among some people,” she says. “In addition, HPV is a sexually transmitted virus and there were early media reports of concern among parents that receipt of the vaccine would encourage their child to engage in sexual activity. Our own research and that of others around the country has shown that most parents do not hold such beliefs. We do know that many providers do not routinely recommend the vaccine to their patients, and that some providers are not comfortable having a discussion about a sexually transmitted virus with parents of young adolescents.”
To learn how health systems can effectively increase HPV vaccination rates, Bastani heads a $6.6 million, five-year study funded by the Patient-Centered Outcomes Research Institute (PCORI). The study is being done through a partnership with the Northeast Valley Health Corporation (NEVHC), a multisite federally qualified health center (FQHC) serving a low-income population in Los Angeles’ San Fernando and Santa Clarita valleys. Bastani’s team — including Drs. Beth Glenn, Alison Herrmann (PhD ’12) and Catherine Crespi from the Fielding School and Debra Rosen and Dr. Gina Johnson from NEVHC — will compare three strategies:
› A system-level strategy targeting physicians, staff and clinic-level policies, procedures and practices;
› Text-messaging or mailing reminders to parents of NEVHC adolescent patients who are due for a dose of the HPV vaccine; and
› A combination of the system-level and parent-reminder strategies.
More than 17,000 HPV vaccine eligible adolescents will receive services at participating NEVHC clinics during the five-year study period. The impact of each strategy will be assessed through a review of NEVHC’s electronic medical records.
The team has been laying the groundwork for the current study for nearly a decade, beginning shortly after the vaccine was introduced. In partnership with the Los Angeles County Department of Public Health, NEVHC and other community clinics, the FSPH researchers have conducted multiple studies to learn about parental knowledge and beliefs about the HPV vaccine and ways to improve vaccine uptake, and to pilot-test parent-reminder and system-level strategies.
“We didn’t find major opposition to the vaccine; it was more that many parents didn’t know much about it,” says Glenn, an FSPH associate professor of health policy and management and associate director of the UCLA Kaiser Permanente Center for Health Equity. “Knowing that, we began to focus on developing interventions within health systems to make sure that parents were consistently offered the vaccine and were reminded when their adolescent was due.”
NEVHC, the community partner in the study, provides care to a primarily uninsured or publicly insured population in which only about one-third of the teens have received the full HPV vaccine series. “This is a great opportunity to better understand what interventions will work with our safety-net population,” says Rosen, NEVHC’s director of quality and health education. “We are excited to collaborate with the Fielding School and to share what we learn with other organizations.”
Rosen notes that many adolescent patients fail to return to the health center after getting the first dose of the HPV vaccine; to that end, the text and mail reminders will serve both to let parents know that their child is due and to reinforce the importance of completing the series.
But for any organization with limited resources, it is important for strategies to be not just effective, but also efficient. “Convincing individual patients is very inefficient,” Bastani says. “We need to look at systematic changes that will serve patients today, tomorrow and into the future.” Among the system-level changes being emphasized at NEVHC is to view each visit by an adolescent patient, even if it’s for another purpose, as an opportunity to determine whether an HPV vaccine is due, and to offer it when it is. The NEVHC physicians are also being encouraged to make the HPV vaccine a more routine part of practice in the same way that vaccines are routinely ordered for younger-age children, and to de-emphasize that the virus is sexually transmitted. “This isn’t a vaccine to prevent a sexually transmitted disease; it’s a vaccine to prevent cancer,” Bastani says.
The UCLA-NEVHC study is funded through PCORI’s Pragmatic Clinical Studies initiative, which aims to produce results that are broadly applicable to a diverse range of patients and health care settings and can be more quickly adopted in routine clinical practice. “Making an impact on 17,000 patients in this one system is huge,” Bastani says. “But what we learn from this study will also have the potential to improve the prevention of HPV-related cancers in other low-resource clinical settings across the country. This is an extremely safe vaccine that prevents a horrible disease from ever developing. It is important that we learn how to ensure that it’s reaching the population.”