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CASE STUDY: IMPLEMENTATION OF HUMAN PAPILLOMAVIRUS VACCINE: MISSED OPPORTUNITIES

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Approximately 80% of individuals will become infected with human papillomavirus (HPV) during their lifetimes. Infection occurs at various sites in both sexes and may result in anogenital and oropharyngeal condyloma, precancers, or cancers. HPV causes more than 750,000 cases of cancer and 275,128 deaths worldwide per year. Comprehensive cancer screening, diagnosis, and treatment programs have reduced the incidence of HPV-related cancers where implemented, but these secondary cancer prevention efforts are associated with tremendous expense ($8 billion/year in the United States), complicated logistics, and significant morbidity. HPV vaccine offers an amazing opportunity to prevent the adverse outcomes associated with HPV infection. HPV vaccine is a safe, evidence-based intervention to prevent certain cancers and reduce health care costs.

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Despite its great potential, HPV vaccination is not widely accepted by health care providers and the public. HPV vaccination rates are much lower in the United States (33% for all three doses in 2012) than in many other countries (Figure 17-1). A robust body of literature indicates that vaccine uptake is influenced by both parental and provider knowledge and attitudes about the vaccine. Parents have unfounded worries about vaccine safety and the stigma associated with a vaccine to prevent a sexually transmitted infection. Some primary health care providers (PHCPs) are reluctant to strongly recommend HPV vaccines for their patients despite provider recommendation being the best predictor of vaccine initiation. Providers may be unfamiliar with the burden of disease and deterred in their recommendation of the vaccine in anticipation of difficult parental discussions about sexual issues. These perceived and actual barriers to the uptake of HPV vaccination can be addressed using evidence-based dissemination and implementation (D & I) strategies.

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Figure 17-1.

National immunization survey of teens, United States, 2006 to 2013. ACIP, Advisory Committee on Immunization Practices; HPV, human papillomavirus; MenACYW, meningococcal conjugate; Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis. (Reproduced from Centers for Disease Control and Prevention (CDC). National and state vaccination coverage among adolescents aged 13-17 years—United States, 2012. MMWR Morb Mortal Wkly Rep. 2013;62(34):685-706.)

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Systematic reviews and dissemination research show that active, multifaceted dissemination strategies are more effective than passive strategies for changing provider behavior. Educational outreach, academic detailing, and the use of local opinion leaders are the most consistently effective interventions reported. Implementation strategies likely to work best in primary care and among PHCP include academic detailing and quality improvement approaches. Table 17-1 describes evidence-based goals and strategies for both D & I approaches to address deficits in HPV vaccination rates.

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Table 17-1.

Dissemination and implementation goals and strategies for increasing human papillomavirus vaccination rates.

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