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Why We Care About HPV

By Isabel Stock, Colorado State University

Oregon Immunization Program Intern

The idea immunizing your child to prevent a sexually transmitted infection may seem foreign to many parents. People across the world have different views regarding vaccination, but all can agree on cancer prevention. It is our duty as public health advocators, medical professionals and community stakeholders to promote the importance of the HPV vaccination. Here are some astounding numbers to show the impact Human Papilloma Virus has compared to other diseases that we commonly vaccinate children for:

  • 1,904 polio deaths in the U.S. in 1950 (near the height of the epidemic)
  • 450 measles deaths every year in the U.S. before the vaccine
  • 500 tetanus deaths every year before widespread use of the vaccine in the U.S.
  • 100 chickenpox deaths every year in the U.S. before introduction of the vaccine
  • 4,000 HPV-related cervical cancer deaths in the U.S. every year

With 12,000 women being diagnosed every year with cervical cancer, it’s noteworthy that 1 in 3 of them do not survive for five years, especially when the HPV vaccination and screening can prevent up to 93% of these cancers. Other than the cervix, HPV is associated with cancer of the anus, vulva, vagina, oropharynx and cervix in women and HPV related cancers in men are found in the anus, oropharynx and penis.

With 79 million people in the U.S. currently infected with HPV, 14 million new infections every year, the National Cancer Institute has released a Call to Action. In the U.S. 40% of females and 21% of males are receiving all three doses of the HPV vaccine. In Oregon, 36.4% of females and 20.6% of males are receiving all three doses of the HPV vaccine. It is clear that the U.S. will fail to meet the Healthy People 2020 goal of 80% HPV vaccination rate for all three doses. We are faced with a significant public health threat if we don’t take immediate action to improving our vaccination rates.

Here are the best ways to begin improving HPV rates in your clinic today:

  • Know how to frame your conversation regarding HPV with parents and provide them with educational resources
  • Start the vaccine on time; schedule wellness visits at age 11 and 12
  • Schedule follow-up visits before they leave the office
  • Practice reminder/recall for 2nd and 3rd doses
  • Provide walk-in or immunization only visits
  • Immunize at sports physicals

For more information on how to implement these actions, go to: https://public.health.oregon.gov/PreventionWellness/VaccinesImmunization/ImmunizationProviderResources/vfc/Documents/AFIXQIActionSteps.pdf
HPV kids

References:

https://karenvaxblog.wordpress.com/2016/01/14/im-pro-vaccine-but-that-hpv-vaccine/

http://www.cdc.gov/hpv/parents/vaccine.html

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

www.cdc.gov/vaccines/teens

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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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Alison and Kelly: two of a kind

Two members of our extended immunization family are changing roles, which often happens in the public health field. But the funny thing is, these two have a relationship that goes way back. Alison Alexander worked for four years as a Vaccines for Children (VFC) health educator for the Oregon Immunization Program. She is now the Oregon Adult Immunization Coalition coordinator. Kelly Martin, who has been with Marion County for 10 years (eight in the immunization program), is now changing jobs within the health department to work on such projects as Healthy Communities.

These two met about a decade ago when Alison was a student at North Salem High School and Kelly was the school’s teen pregnancy prevention program coordinator.  They worked together on a school program, STARS, and have been friends ever since. “I’ve been lucky to work with Alison throughout her time with the VFC program,” says Kelly. “Her calmness and get-things-done attitude has been a blessing to work with in a program that is always changing.”

Alison enjoyed working with Kelly too. “She’s a fun, flexible and understanding person,” she says. “Kelly is a go-getter, willing to take on any challenge and do her absolute best. She’s not afraid to make changes and get things done.”

According to Alison, Kelly “has great questions that stump me and keep me on my toes.” Kelly says, “Alison has always been approachable and never makes you feel like you’re asking too many questions.”

Though the two will no longer work side-by-side in the immunization field, they will still remain good friends and dedicated to public health. Best wishes to Alison and Kelly in their new roles.

 

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The Cost of Doing Business

By Karen Vian, RN, Communicable Disease and Immunization Program Manager, Douglas County Health and Social Services

Douglas County Public Health purchased lab-grade refrigerators and freezers in 2008.  In addition, our main site and three satellite clinics are on a 24/7 NIST-certified temperature monitoring, which is broadcast to a secure website; alarms trigger both telephone and email notifications. We are very experienced with responding to false alarms that are triggered by frost/defrost cycling of units, vaccine doors left open too long during inventory and internet connectivity issues.

On the morning of Monday, January 30, 2012, multiple staff received telephone and email notifications that the temperature of one of our main refrigerator units was high and out of the 2-8 degree Celsius acceptable range. In responding to the alarm, we immediately noted that the temperature on the unit’s screen was high and out of range, a significant concern as the internet monitoring is measured by a separate monitoring system. An even bigger concern was that this refrigerator was stocked with 2170 doses of vaccine in readiness for the annual school law exclusion process and our annual Shots for Tots clinic.

Quick action on the part of clinic staff, management and IT employees helped to avert a costly loss of vaccine. Vaccine from the questionable unit was immediately moved into a different refrigerator unit, logged and counted, and designated ‘not to be used’ until the situation was fully understood. Because Douglas County Public Health administers approximately 9,000 doses of vaccine each year, our refrigeration and freezer units are physically separate units and we have more than one refrigeration unit in the clinic. This helps to spread the vaccine liability out as much as possible in the event of unit failure. Staff contacted the state immunization program immediately; they notified us that all vaccine remained viable. With internet monitoring, Douglas County was able to document the time at which the refrigeration unit failed and how long the temperature was out of range. We were also able to provide a graph of that day’s temperature to others to accurately describe and assess the situation. We called the refrigerator company’s tech support line and worked with public health staff to troubleshoot the problem.  The tech support walked through the following questions:

  1. Is the probe bottle full of solution? If not, fill this up to the bottle shoulder.
  2. Is the evaporator fan inside the refrigerator spinning?
  3. Is the compressor fan on top of the refrigerator spinning? Is the compressor itself running?
  4. Is the condenser grill on the back of the refrigerator dusty?
  5. Is there any ice accumulation inside the refrigerator? If so, is it on the evaporator, the back wall, or both?
  6. Have the program parameters of the refrigerator been changed?

Because our refrigerator unit required troubleshooting past the above points, tech support recommended further troubleshooting be performed by a Bio Med or HVAC specialist. They informed us that a Bio Med or HVAC specialist will possess tools (e.g., volt-meters, pressure gauges) to further investigate the cause of the problem and to assess for other potential problems. We contacted an HVAC specialist, who arrived the following morning and worked by telephone with the unit’s tech support line to diagnosis the specific issue.

In summary, the refrigerator compressor motor failed. We learned that the motor was still under the 7 year warranty for parts (not labor). Prior false alarms were good training to avert what could have been a very real and very costly catastrophe and a very real recall for sub potent doses. The HVAC specialist returned 7 days later with a new compressor motor and fixed the refrigerator. The HVAC specialist also discovered that the air conditioning unit in the vaccine room was not working adequately. We monitor the room temperature in the vaccine room, and learned that it was 75 degrees at the time of the incident. Upon review of the online temperatures, it was noted that on or around January 19 the room temperature increased from baseline without explanation. A week later the refrigerator compressor failed. The HVAC specialists explained that if the room temperature gets too warm, the oil in the refrigerator’s compressor motor piping gets sludgy and can block the piping. They had recorded high pressure readings in the piping that verified this. In closer review of temperatures, the room temperature reached a maximum of 82 degrees during the time in question. Moving forward, we have installed a new air conditioner and have lowered parameters of the room temperature alarms. After monitoring the temperature in the repaired refrigerator unit for 7 days, the vaccine was placed back into the unit.

One additional lesson learned during our response to this issue is to develop and include a procedure to monitor the temperature probe solution regularly for possible evaporation and/or replacement. We found the temperature probe solution to be discolored and unsanitary in appearance in several of our refrigerator units. 

So what is the cost of doing business in the vaccine management world?

Cost of Vaccines in the one Failed Unit: $62,288.97

Cost of Vaccine Management Equipment: $7,437.37

Lab-Grade Refrigerator with shipping:  $4847.00

Glycerol for Probe Bottle Solution (32 ounce bottle):  $25.00

TCP/IP Based Monitoring Device (up to 4 probes): ~$300/ea (one per room)

Heavy Duty sealed Probe: ~$40 to ~$75 (depends on length)

Monitoring Software: ~$500.00 + yearly support (to monitor all sites)

Voice Dialer: ~$250.00

Web Relay (allows the software to trigger the voice dialer): ~$130.00

HVAC Repair Services:  $789.00

Replacement Air Conditioner:  $517.02

Refrigerator Alarm Battery Replacement (6 size D):  $4.35

 Cost to Ensure Public Health:                                                                                  PRICELESS

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Vaccine Emergency Plans: Details to Consider

When it comes to storing vaccine, expect the unexpected. The Oregon Immunization Program requires that your clinic create an emergency plan:  a document that describes, in detail, the process for relocating vaccine in case of an emergency such as a natural disaster, equipment malfunction or other event.

The emergency plan should be written for your clinic specifically. If your clinic belongs to an umbrella organization, it is not acceptable to rely on one plan for the entire organization. An  emergency plan is most  useful when it takes into account a clinic’s location, equipment, etc. It’s also important that an emergency plan be written clearly and in great detail so a person who is not trained in vaccine management can successfully follow its instructions. This is critical since, in the case of an emergency like a snow storm, the first staff person able to reach the clinic may not be familiar with handling vaccine. The plan should be easily accessible to all staff and all staff members should be aware of its location. Your emergency plan needs to be reviewed by all relevant staff members and dated annually.

A complete emergency plan should have:

  • instructions on how to check the temperature of the vaccine
  • the correct temperature range for the vaccine
  • instructions on packing the vaccine
  • the location of vaccine packing material in your clinic
  • the phone numbers of the primary and secondary contact people for the emergency vaccine storage location
  • directions to the emergency vaccine storage location
  • phone numbers of your clinic’s vaccine coordinator and back-up
  • phone numbers for your clinic’s utility company, etc.
  • the phone number of the Oregon Immunization Program*

 *We will help you determine the viability of the vaccine if the temperatures have gone out of range. We also must be informed when the vaccine is being, or has been, moved to the emergency location.

 

 

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EOC Staff Transition

Enhanced Ordering Cycle (EOC) is a process that balances clinic vaccine order sizes, order frequencies, and storage and handling costs to improve work flow and reduce costs.  The Oregon EOC Team has appreciated the ongoing efforts made by clinics that have implemented the process over the past year and a half. A total of 178 clinics were targeted and trained in EOC.  This training phase of EOC will be ending in June 2011. 

 As the Oregon EOC Team transitions to other duties within the Immunization Program, there will be some changes to the EOC process that clinics should take note of.

  •  Starting in June, all questions related to your assigned ordering cycle should be directed to your clinic’s VFC Health Educator. 
  •  All VFC orders will continue to be tracked and assessed by state VFC staff to ensure that clinics are adhering to their assigned cycle and ordering windows.

 The EOC Team is pleased to report that participation in EOC has contributed to a 30% reduction in orders placed by the targeted clinics. Of all the orders placed by targeted clinics, 78% have been within the recommended ordering frequency and nearly 70% have been within assigned ordering windows. Because of these positive trends, the Oregon EOC Team is confident that clinics will continue to place on-cycle orders by following their ordering calendars and staying on top of their vaccine inventory quantities. 

 By the end of this year, all remaining clinics that were not included in the targeted group of 178 will also be assigned a new ordering cycle. Notification and guidance regarding new ordering cycles will be sent to all remaining clinics by mail. Clinics with questions regarding order assignments can contact their VFC Health Educator.

 

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