Framing the HPV Conversation

By Isabel Stock, Colorado State University

Oregon Immunization Program Intern

Many parents who choose to vaccinate their children are faced with the worry, “Do I vaccinate my child for Human papillomavirus?” According to the 2012 National Teen Immunization Survey, one of the main reason parents that didn’t intend to vaccinate their children against HPV was a lack of healthcare provider recommendation. It’s time to frame the conversation between parents and providers on the importance of the HPV vaccination.

As a provider, it is important to recommend HPV vaccine as you would any other, especially on the same visit as other vaccinations. Here is a list of other important factors to highlight when discussing the HPV vaccine with parents:

  • It is one of the only vaccines available to prevent cancer.
  • HPV infection can be passed through any type of sexual activity, not just intercourse. Some types of HPV are spread by skin-to-skin contact.
  • Multiple research studies have shown that HPV vaccine does not make kids more likely to be sexually active.
  • HPV vaccine has a strong safety record. More than 62 million doses have been given in the United States, and there are no serious safety concerns.
  • Put HPV first when listing the vaccines that the child needs during the visit. For example, “Your child needs three shots today: HPV vaccine, meningococcal vaccine and Tdap vaccine.”
  • Vaccinate for HPV well before children might be exposed to it, just as you would for other diseases such as measles.
  • Emphasize your personal belief in the HPV vaccine, and let them know that you have given it to your son/daughter/family member/friend. This is a powerful tool to help parents feel more secure about their decision

All of these tips will help educate the parent to make a decision and avoid missed opportunities to increase HPV vaccination rates. There are many more resources available to frame the conversation between providers and parents on the CDC website. Below is a great resource for providers to start.

         HPV Tips FINAL

When talking with vaccine hesitant parents, it is helpful to use a communication approach that guides rather than directs and encourages the parent to ask questions. Engaging with good communication strategies allows parents to come to a decision on their own, using evidence based facts delivered by the provider. This technique has been shown to help families and providers address concerns in a way that allows the provider to convey respect and empathy while sharing medical information. For more information on effective communication strategies see, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3480952/.

To help parents understand just how safe, effective, and necessary this vaccine is for their children check out the National Cancer Institute’s recent Call to Action at, https://www.mdanderson.org/content/dam/mdanderson/documents/prevention-and-screening/NCI_HPV_Consensus_Statement_012716.pdf. Now, more than ever, it is important we give parents all the necessary facts about HPV vaccination to give their child the best possible chance to live a cancer free life.

References:

http://www.cdc.gov/hpv/hcp/index.html

http://www.cdc.gov/hpv/hcp/answering-questions.html

http://www.cdc.gov/hpv/hcp/speaking-colleagues.html

http://www.cdc.gov/vaccines/who/teens/vaccines/vaccine-safety.pdf

https://www.mdanderson.org/content/dam/mdanderson/documents/prevention-and-screening/NCI_HPV_Consensus_Statement_012716.pdf

http://bmcpediatr.biomedcentral.com/articles/10.1186/1471-2431-11-74

 

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We Can Prevent Cervical Cancer

By Katherine McGuiness, MPH, MSW

ScreenWise Engagement and Eligibility Coordinator, Oregon Health Authority

January is Cervical Health Awareness month, which is a great time to reflect on the fact that most cases of cervical cancer are preventable.  The two main ways we have of preventing cervical cancer are through the HPV (human papillomavirus) vaccine and cervical cancer screenings like pap smears and HPV co-testing and subsequent treatment.

 HPV

HPV Vaccine

The new Gardasil vaccine protects against the 9 of the most common HPV strains, many of which are found in a variety of cancers, including 90% of cervical cancers. The vaccine can be given between the ages of 9 and 26, with a preference of getting it earlier than later in age. Getting the HPV vaccine early is one of the best ways to prevent cervical cancer.

Cervical Cancer Screenings

Pap tests and HPV tests are screening tests that help prevent cervical cancer, or find it early. The HPV test looks for the virus that causes most cervical cancers. Currently, the HPV test is recommended for those over 30. The Pap test looks for precancers- like changes in cells on the cervix that can turn into cancer if they are not treated. National guidelines suggest that pap testing is recommended for people aged 21-65 with a cervix.

For people who have insurance, most insurance plans cover the cost of cervical cancer screenings. For those that do not have insurance, Oregon’s ScreenWise Program may be able to cover the cost. ScreenWise covers the cost of breast and cervical cancer screenings for people who live in Oregon, are uninsured, and meet certain income criteria. There are ScreenWise clinics all over the Oregon. To find out more about eligibility and clinic locations, call 1-877-255-7070.

Are you interested in having your clinic provide ScreenWise services?

Contact Katherine McGuiness at (971)673-0343 or Katherine.h.mcguiness@state.or.us

Sources:

http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hpv-gardasil-9.html

http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cervical-cancer-screening

http://www.nccc-online.org/images/pdfs/HPV_fact_sheet_2015.pdf

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2015-2016 Flu Season Update

Fall has arrived and along with the shorter days, colder weather and rain comes the season for influenza-like-illnesses (ILI) and pneumonia. This article includes updates from the Oregon Health Authority (OHA), Centers for Disease Control and Prevention (CDC), and flu-related highlights from the Advisory Committee on Immunization Practices’ (ACIP) final meeting of 2015.

OHA Flu Season Activity Findings

The OHA monitors flu activity in Oregon and reports weekly on the number of incidents and spread of ILI throughout the state from the first day of the 40th week of the year through the last day of 20th week of the following year. This year flu activity reporting began on September 28, 2015 and will end May 22, 2016.

The FluBites report for week 44, ending November 7, 2015, reported no positive influenza tests, a minimal level of ILI activity, and no reported outbreaks.

CDC Flu Season Activity Findings

The CDC monitors flu and pneumonia activity in the United States all year long but they report weekly on the incidents and spread of these illnesses throughout flu season.  There is a lot of good news this flu season. Here are a few of the highlights from the CDC weekly report as of week 44, ending November 7, 2015.

  • This year’s flu vaccine offers significantly more protection than last year’s vaccine because it includes two or three additional flu strains in the vaccine mix and those strains are similar to the circulating strains of flu this year.
  • The percentage of respiratory specimens testing positive for influenza in clinical laboratories is low. Of the 10,271 specimens tested in week 44, only 1.2% of the specimens were positive for influenza viruses.
  • None of the 2015 tested influenza viruses in circulation were found to be resistant to the three major anti-viral medications.

Flu graphic

http://www.cdc.gov/flu/weekly/index.htm#S1

 

ACIP Meeting Highlights Related to Flu

The October ACIP meeting included a presentation on the cost-effectiveness of high-dose influenza vaccine in adults aged 65 years and older.  The presenters concluded that high-dose flu vaccine is more cost effective than standard doses of flu vaccine based on the reduction in cardiovascular complications seen in patients 65 years and older who received the high-dose vaccine versus those who received the standard flu vaccine dose.1,2

A new influenza vaccine currently under FDA review was discussed.  The new vaccine, an adjuvanted trivalent vaccine, is expected to enhance immune response and have a safety profile similar to other licensed vaccines.

 

1 DiazGranados C A, et al: Efficacy of high–dose versus standard–dose influenza vaccine in older adults. New England Journal of Medicine: 2014;371:635–45. Available at:  http://www.nejm.org/doi/full/10.1056/NEJMoa1315727?query=featured_home&  Accessed 5 November 2015.

2CDC. Fluzone High-Dose Seasonal Influenza Vaccine. Questions and answers. Available at http://www.cdc.gov/flu/protect/vaccine/qa_fluzone.htm  Accessed 5 November 2015.

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Know Before You Immunize – Advice From A Breast Cancer Survivor

– By Lisa Stember, RN, BSN

It’s hard to avoid the color pink during the month of October when even football stadiums are decorated to raise awareness of breast cancer. As a two-time survivor of the disease, I don’t need pink ribbons to raise my awareness, but the pink ribbons do help me to stay focused on prevention of one of the more devastating side effects of cancer treatment: lymphedema.  This is especially important during flu season when I’m thinking about getting my annual flu vaccine.

Surgery to remove breast cancer frequently includes removal and examination of axillary lymph nodes for spread of disease.  The removal of or damage to lymph nodes can result in lymphedema, the abnormal buildup of fluid in soft tissue due to a blockage in the lymphatic system.  Lymphedema can develop immediately after surgery or radiation, but it may occur months or years after cancer treatment has ended. Swelling can cause pain, numbness and limit movement in the affected limb.  In severe cases, the skin becomes tight and the scarring causes hyperkeratosis.  Although treatment to reduce the swelling and relieve symptoms is available, once symptoms have occurred it’s usually a lifelong condition.

As a breast cancer survivor I have been instructed to avoid any blood draws, injections or blood pressure measurements on the affected side, as well as taking steps to avoid skin infections. This advice presents a dilemma when getting a vaccination because the Advisory Committee on Immunization Practices (ACIP) recommends the deltoid muscle area of the upper arm as the best route for adult vaccines. So what is the solution?

While ACIP discourages variations from the recommended route, site, volume, or number of doses of any vaccine1, when a patient has either lymph node removal or damage to the lymph system, using the thigh muscle as the vaccine injection site might become necessary.  If the vaccine needed is for hepatitis B or rabies, use of any site other than the deltoid muscle is considered an invalid dose.  For these vaccines, doses given in a nonstandard site can be verified by titer for efficacy.

After my first occurrence of breast cancer, I carefully protected my arm, avoided injuries, promptly treated cuts, and redirected health care personnel to my unaffected side for immunizations. When my breast cancer reoccurred on the opposite side resulting in the loss of more lymph nodes, I decided it was in my control to ask for help in preventing lymphedema and made a plan.   Although it isn’t always convenient, I now ask for immunizations in an alternate site.   Blood pressure can be done on a lower extremity.  Although not many women and men are bilateral breast cancer survivors, any person with loss of lymph nodes needs consideration.  If you are a breast cancer survivor or have loss of lymph nodes, check with your personal care provider for what adult vaccines you need, and where best to have them administered.

http://www.cancer.net/navigating-cancer-care/side-effects/lymphedema

http://www.breastcancer.org/treatment/lymphedema/reduce_risk/avoid

Lisa Stember is a registered nurse. She graduated with her nursing degree in 1986 from OHSU School of Nursing and also holds a Bachelor of Science degree in health education from Oregon State University. She is currently a public health nurse on the certification team for the Oregon School-Based Health Centers, Adolescent and School Health Program. Prior to that she worked for 17 years as a school nurse and spent 11 years in inpatient care in maternal and pediatrics at OHSU.

1 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm

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Immunizations and SBHCs

Thirty years ago, five School-Based Health Centers (SBHC) opened their doors in Oregon with the goal of providing patient centered health care services for all students, whether or not they have health insurance coverage.  Today Oregon has 75 certified SBHC’s that operate in urban, suburban and rural school districts.  Oregon SBHC Map

SBHCs are medical clinics that offer primary care services within or on the grounds of a school.  Each SBHC is staffed by a primary care provider, other medical, mental, and/or dental health professionals and support staff.

SBHCs focus on reducing barriers that can keep youth from accessing health care such as transportation, cost and concerns about confidentiality.  SBHCs bill Medicaid and many are credentialed with private insurance, but students may not be denied service for inability to pay for services.

Since inception, preventative health services such as immunizations have remained a core function for Oregon SBHCs.  Certified SBHCs participate in the Vaccines for Children (VFC) program and offer all ACIP routinely recommended vaccines at each site.   Bringing vaccines to the school results in fewer missed opportunities for all vaccines as well as preventing school exclusion due to incomplete immunization status. Parent involvement and consent is managed by frequent communication between the SBHC and home.

Ceci Robe, manager for Rogue Community Health SBHCs in Jackson County, describes the importance SBHCs place on vaccine education and outreach.  “We get the word out to students and staff in many ways, such as targeting 11th and 12th graders for meningococcal vaccine and HPV. We also outreach for Hepatitis A, and offer immunizations to siblings of students.  We provide flu clinics for all district students and staff. We have a close partnership with the school’s registrar and create a system of referral.  We get going in September and by February all students are compliant and no one is excluded from school.  This is a great benefit to the student and schools.”

Ceci feels all encounters are an opportunity to evaluate and discuss vaccination status.  “It only takes about 15 minutes, so we can update a student at school, during lunch. We are constantly monitoring the immunization status of all students that come into the health center for any reason.  We update ALERT in a timely manner, so when the student transfers schools they have an updated record in hand.”

 

 

 

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Back to School Immunization Guide

Exemption Rates

 

Summer is winding down and it’s time to gear up for a new school year. That means more kids coming in for vaccines. What do you need to know about immunizations for back to school this year?

  • Old religious exemptions to immunization signed prior to March 2014 are no longer valid. Senate bill 895 removed the provision that allowed old religious exemptions that were in place before the implementation of the new nonmedical exemption process. This is a great opportunity to discuss vaccines with parents who claimed an exemption for their child years ago. Parents will have two options:
    1. If the child has received the vaccines, the parent needs to fill in the vaccine dates on the Certificate of Immunization Status, sign the form and turn it into the school.
    2. If the parent wants a nonmedical exemption for their child, they need to get education about the benefits and risks of immunization from a health care practitioner or the online vaccine education module. If you are a health care practitioner and provide education to the parent, print off and complete the Vaccine Education Certificate available at healthoregon.org/vaccineexemption (go to the “For Providers Only” section at the bottom of the page). Mark “yes” next to each vaccine you provided education about for which the parent wants to claim an exemption. The online vaccine education module is also available at the same web address.
  • Remind parents to update immunization records with their child’s school or daycare every time their child receives a vaccine.
  • Make sure to screen for and give all recommended vaccines when you give school-required vaccines. When a student comes in for Tdap vaccine, give HPV and meningococcal vaccines as well. Adolescents can be a hard population to reach, and you might not see the patient again for several years. And don’t forget about flu vaccine!

Update from the 2014-2015 school year

For the first time in more than a decade, Oregon’s nonmedical exemption rate decreased: 5.8% of kindergartners had a nonmedical exemption to one or more vaccine in 2015 compared to 7.0% in 2014. Check out the graph above to see the nonmedical exemption rate over time. Thank you to clinics, schools and child care programs for helping to implement the new process for claiming a nonmedical exemption, and helping protect more kids against vaccine preventable diseases!

 

 

 

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Flu Season Update

The 2014-2015 flu season brought a new, drifted A strain of influenza that was not in the virus selection for the season’s vaccine. As a result, the effectiveness of the vaccine was lower than expected.  This has many people asking, “Why bother with a flu shot each season?”

Each year  the A strains that begin on the East Coast die out over the Mid-West allowing the B strains to take the lead somewhere over the Rockies en route to the West Coast. Every year the Centers for Disease Control and Prevention (CDC) begins tracking the influenza (flu) season in early October and select the vaccine strains that will be used to manufacture vaccine around February. If  a strain drifts into a new influenza virus after the vaccine manufacturing process begins, the new strain will not be included in the current season’s vaccine, but the  vaccine will still protect against the other most deadly strains identified during the winter season in the southern hemisphere.

The CDC reported that among the 2014-2015 seasonal influenza A viruses, 52,518 (50.1%) were subtyped; 52,299 (99.6%) were influenza A (H3N2) viruses, and 219 (0.2%) were A (H1N1) pdm09 viruses. In addition, three variant influenza A viruses (one H3N2v and two H1N1v) were identified.  In response to the CDC findings, this year the 2015-2016 flu vaccine mix has two or three new strains included.


 

Vaccine Strains included
FluMist® (live) nasal

flu vaccines

·A/Bolivia/559/2013 (H1N1)
(an A/California/7/2009 (H1N1)pdm09-like virus)·A/Switzerland/9715293/2013 (H3N2)-like virus

·B/Phuket/3073/2013-like (B/Yamagata lineage) virus

·B/Brisbane/60/2008 (B/Victoria/2/87 lineage)

Inactivated (injectable)

trivalent vaccines

·A/California/7/2009 (H1N1)pdm09- like virus

·A/Switzerland/9715293/2013 (H3N2)-like virus

·B/Phuket/3073/2013-like (B/Yamagata lineage) virus

Inactivated (injectable)

quadrivalent vaccines

·Same three strains as the injectable trivalent, plus:

·B/Brisbane/60/2008-like (B/Victoria lineage) virus


Here at the Oregon Immunization Program our flu season takes off with the delivery of the first available flu vaccines, sometime in late summer or early fall. The CDC recommends an annual flu vaccine for all individuals without contraindications ages 6 months and older.  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6421a5.ht
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