In the fall of 2014, the National Association of County & City Health Officials (NACCHO) launched a project to support a subset of local health departments to engage and collaborate with health care providers and other key stakeholders to increase human papillomavirus (HPV) vaccination rates in their communities. This project, supported by the Centers for Disease Control and Prevention, is one component of NACCHO's immunization program. NACCHO's immunization program is dedicated to strengthening local health departments' immunization infrastructure by working to increase their capacity to implement evidence-based public health programs, policies, and services to meet national standards for preventing and controlling vaccine-preventable diseases.
NACCHO is the voice of the 2800 local health departments in the United States that work every day to protect and promote health and well-being for all people in their communities. NACCHO provides resources to help local health departments develop public health policies and programs to ensure that communities have access to the vital services people need to keep them protected from disease and disaster.
Local health departments play a pivotal role in maintaining high levels of community immunization rates, acting as leaders in their communities and strengthening their networks through partnerships with state immunization programs, coalitions, and the immunization neighborhood. According to the 2013 National Profile of Local Health Departments, 90% of local health departments provide direct immunization services. In addition, local health department immunization programs deliver provider education, outreach campaigns, and vaccine-preventable disease outbreak response. In doing so, local health departments build and reinforce the community trust in vaccines.
Improving community trust is particularly important for HPV vaccination, as current vaccination rates are well below target levels. HPV infection causes the majority of cervical cancers and has increasingly been linked to cancers of the anus, penis, throat, vagina, and vulva.1,2 In 2006, the Advisory Committee on Immunization Practices recommended the HPV vaccine for routine vaccination of adolescent girls 11 to 12 years old and expanded the recommendation to include adolescent boys in 2010.3,4
Recently released national policy and guidance documents seek to improve public perception and increase awareness of the HPV vaccine as important cancer prevention. The Healthy People 2020 goal for HPV vaccination is to achieve 80% coverage for the 3-dose HPV vaccine series, yet national rates remain low at 39.7% and 21.6% for girls and boys, respectively.5,6 In addition, in the 2012-2013 President's Cancer Panel Annual Report, the panel expressed the need for urgency in addressing HPV vaccination and recommended 3 major goals to increase uptake, including reducing missed opportunities to administer the vaccine, increasing overall vaccine acceptance, and improving access to the vaccine.7
High vaccination rates for other adolescent vaccines make it clear that widespread HPV vaccination is possible. According to the National Immunization Survey—Teen 2014 data, 87.6% and 79.3% of 13 to 17 year olds received the tetanus-diphtheria-pertussis (TdaP) and meningococcal conjugate vaccines, respectively, demonstrating that adolescents are visiting medical providers but many are not being vaccinated against HPV.6 In fact, if providers had taken advantage of every opportunity to vaccinate, 93% of girls 13 to 17 years old would have received at least 1 dose of HPV vaccine by 2012.8
Overview of NACCHO's HPV Project
In response to the low HPV vaccine coverage and the nationwide focus on HPV infection, NACCHO awarded 10 local health departments in 2014 and 10 in 2015 in states with the lowest HPV vaccination rates with support to participate in an action planning process and receive technical assistance to increase HPV vaccination rates in their communities. The NACCHO-designed process engaged local health departments to conduct an environmental scan of their community resources and identify key community stakeholders. Following this process, these local health departments participated in a 1.5-day action planning meeting facilitated by NACCHO staff (Figure). At the meeting, local health departments worked with stakeholders, including state immunization programs, cancer and immunization coalitions, private medical providers, pharmacies, schools, and faith-based organizations, to develop strategic focus areas to guide the implementation of their initiative. These strategic areas became the basis of an action plan currently being implemented through June 2016 with additional funding from NACCHO.
Implementation of Action Plans
Local health department awardees identified performance measures to track their progress in accomplishing the action plan objectives. Funded local health departments also reported data about vaccine administration and ordering at 3 points during project implementation to assess the impact on HPV vaccination rates.
NACCHO provided additional support through the HPV Learning Community, a password-protected online forum for peer networking, and a series of technical assistance calls and webinars. To provide convenient access to existing HPV promotion materials, strategies, and communications, NACCHO also developed The Guide to HPV Resources for Local Health Departments, a collection of HPV resources and practice-based tools.9
Highlights from the local health department action plans
Local health department awardees developed action plans specific to their community's needs, which generally reflected 6 major themes: (1) reinforcing the message that the HPV vaccine is for cancer prevention; (2) working with schools to improve education about and access to the HPV vaccine; (3) engaging partners as immunization champions; (4) increasing access to the HPV vaccine; (5) identifying opportunities to improve data and evaluate progress; and (6) educating and supporting providers in the community.
Key highlights from early implementation of select action plans include the following:
Prince William Health District in Virginia used Immunization Information System data and mapping software to randomly select provider sites from 3 cross sections in their district. The District assessed adolescent vaccination rates over time by collecting administration data from the selected sites and combining it with health department clinic and pharmacy data. The District also advocated to include information about HPV-associated cancers in the school district's Family Life Education curriculum as an HPV and cancer prevention lesson.
Barren River District Health Department in Kentucky partnered with Western Kentucky University to develop a campus HPV education campaign to reach students 18 to 26 years old for catch-up vaccination. Activities included a screening of the film, Someone You Love: The HPV Epidemic, partnerships with Greek organizations to increase HPV awareness, and the addition of the HPV vaccine to the health and wellness student program that offers incentives for making healthy decisions.
Three health departments in Berkeley, Morgan, and Jefferson counties in West Virginia collaborated to develop an action plan that features coordination with community groups to increase HPV awareness. The health departments engaged nursing students at a local university to promote the HPV vaccine on campus, worked with Boys and Girls Clubs to include HPV education in a pregnancy prevention/sexually transmitted infection educational program, and presented to the Eastern Panhandle Dental Society to encourage members to provide HPV information to their patients.
Tarrant County Public Health, in Texas, worked closely with the Immunization Collaboration of Tarrant County to hold 23 separate back-to-school events during late summer and early fall 2015. The collaboration proudly reported that more than 1000 HPV vaccines were administered. Tarrant County Public Health also hosted a contest among its Vaccines for Children providers to increase HPV vaccination rates, which awarded prizes to the practices that showed the most improvement.
Recommendations for Increasing HPV Vaccination Rates
Effective strategies for increasing vaccination rates include provider, parent, and system-level interventions.10 In particular, a provider's recommendation is the strongest predictor of HPV vaccination; therefore, all community providers should strongly recommend the HPV vaccine at every adolescent visit.11,12
Local health departments can capitalize on these effective strategies by doing the following:
* Convening providers and other community members to fully understand the importance of HPV vaccination, community barriers to HPV vaccination, and strategize how to increase HPV vaccination rates;
* Serving as a resource to community members and providers to answer questions;
* Conducting patient vaccine reminder and/or recall for local health department clinic patients or jurisdiction-wide;
* Including HPV vaccine coverage rates in AFIX (Assessment Feedback Information Exchange) provider visits; and
* Educating providers to (1) strongly recommend the HPV vaccine; (2) establish system-based changes such as electronic medical record reminders or standing orders; (3) vaccinate adolescents at every opportunity; (4) use available immunization information systems to track patients' vaccination status; and (5) lead community HPV vaccine promotion efforts by hosting meetings, speaking to the media, or writing editorials.
HPV infection is a major public health problem that local health departments and their community partners can help address by increasing vaccinations among adolescents with the 3-dose HPV vaccine series. Although adolescents routinely visit medical providers, many are not vaccinated against HPV at the recommended ages, which leaves them vulnerable to HPV-related cancers and morbidities. NACCHO's HPV Project plays a critical role in engaging both local health departments and their communities to take action to increase HPV vaccination rates. NACCHO will analyze all data collected from the local health departments and evaluate both the process and effectiveness of the project. NACCHO will also document and share lessons learned with local health departments across the United States to assist others as they undertake similar efforts. For updates and more information about NACCHO's HPV Project, visit http://naccho.org/topics/HPDP/immunization/index.cfm.
1. International Agency for Research on Cancer. Monographs on the Evaluation of Carcinogenic Risks to Humans. Volume 90: Human Papillomaviruses. Lyon, France: International Agency for Research on Cancer, World Health Organization; 2007.
2. Gillison ML, Alemany L, Snijders PJ, et al. Human papillomavirus and diseases of the upper airway: head and neck cancer and respiratory papillomatosis. Vaccine. 2012;30(5)(suppl):F34–F54.
3. Centers for Disease Control and Prevention. Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2007;56(no. RR-2):1–24.
4. Centers for Disease Control and Prevention. FDA licensure of quadrivalent human papillomavirus vaccine (HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2010;59:630–632.
6. Reagan-Steiner A, Yankey D, Jeyarajah J, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years—United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64:784–792.
7. Accelerating HPV Vaccine Uptake: Urgency for Action to Prevent Cancer. A Report to the President of the United States From the President's Cancer Panel. Bethesda, MD: National Cancer Institute; 2014.
8. Centers for Disease Control and Prevention. Human papillomavirus vaccination coverage among adolescent girls, 2007–2012, and postlicensure vaccine safety monitoring, 2006-2013—United States. MMWR Morb Mortal Wkly Rep. 2013;62(29):591–595.
9. National Association of County & City Health Officials. The guide to HPV resources for local health departments. NACCHO Web site. http://bit.ly/NACCHOHPV
. Updated September 2015. Accessed October 22, 2015.
10. Community Preventive Services Task Force. Increasing appropriate vaccination. Guide to Community Preventive Services Web site. www.thecommunityguide.org/vaccines/index.html
. Updated July 14, 2015. Accessed October 22, 2015.
11. Gargano LM, Herbert NL, Painter JE, et al. Impact of a physician recommendation and parental immunization attitudes on receipt or intention to receive adolescent vaccines. Hum Vaccine Immunother. 2013;9(12):2627–2633.
12. Reiter PL, McRee AL, Pepper JK, Gilkey MB, Galbraith KV, Brewer NT. Longitudinal predictors of human papillomavirus vaccination among a national sample of adolescent males. Am J Public Health. 2013;103(8):1419–1427.