Providing HPV Vaccine in a Community POD to Increase HPV Vaccination Rates

State: FL Type: Promising Practice Year: 2016

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Broward County is located in the southeastern portion of the State of Florida.  Broward County’s 2013 population estimate of 1,838,844, represents 9% of the State’s population, and is the second most populous county of the 67 counties in the State of Florida and eighteenth most populous county in the United States (US Census).  Its diverse population includes residents representing more than 200 different countries and speaking more than 130 different languages.  31.4% of the residents are foreign-born.   Broward County is a minority/majority county demonstrated by its 2013 population by race (Black 28.5%, Asian 3.6%, Hispanic 26.9%, other races 4.1%, more than one race .2%, for a total of 59.5% and White 40.8%).

The Florida Department of Health in Broward County (DOH-Broward) is the official Public Health Agency in Broward County since 1936. It is part of the Integrated Florida Department of Health (DOH) and operates in cooperation with the Broward County Commission under Florida Statute 154. DOH-Broward’s mission is “to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts”.  DOH-Broward is the lead agency providing core public health functions and essential services in the county as part of a complex public health system that includes hospitals, clinics, planning agencies, community-based organizations and others.  DOH-Broward provides population/community-based services to the county’s 1.8 million residents and over 10 million annual visitors, and is responsible for assessing, maintaining and improving health and safety within the county.

Public Health Issue: According to a CDC analysis (2006-2010), the State of Florida has high rates of HPV-associated cancers.  Florida ranks in the top third of States in HPV-associated cervical cancer (8.04-9.54 per 100,000), anal cancer in males (1.13-2.79 per 100,000) and in females (1.86-2.29 per 100,000), oropharyngeal cancer in males (7.11-8.52 per 100,000) and in females (1.60-1.93 per 100,000).  Florida ranks in the mid-third of States in HPV-associated penile cancer (0.71-0.85 per 100,000) and vaginal cancer (0.41-0.47 per 100,000).

According to 2013 CDC data, HPV vaccination rates of adolescent girls ages 13-17 in Florida was between 30-37.6%, placing Florida among the lower third in state ranking.  The Morbidity and Mortality Weekly Report (MMWR), August 30, 2013/62(34); 685-693, indicates that among females, Florida had the lowest coverage for ≥1 HPV vaccine dose (39.4%) compared to the rest of the States. Because Broward County represents 9% of the State’s population, and is the second most populous county in the State of Florida, it is reasonable to assume that Broward County contributes to Florida’s low HPV vaccination rates.

The goal is to increase HPV vaccination rates in Broward County and the objectives are:

1.       Increase awareness of HPV and the HPV vaccine by developing and distributing an HPV palm card and information to the community and providers.

2.       Increase HPV vaccination rates in Broward County by providing the HPV vaccine during DOH-Broward’s back to school immunization campaign as a part of routine immunizations.

In 1996, DOH-Broward led the creation of the Broward County Immunization Action Coalition. The mission is to develop, implement, and monitor immunization strategies that further the goals of providing complete protection against, and eventual elimination of, vaccine preventable diseases.  DOH-Broward and the Coalition held a community planning meeting on May 11 and 12, 2015 to develop an action plan to increase HPV vaccine rates in Broward County. DOH-Broward representatives presented HPV at the Broward County Pediatric Medical Society’s seminar on May 12, 2015. DOH-Broward conducts an annual back-to-school immunization point of dispensing (POD) that provides over 4,500 vaccines to over 3,000 children.  As part of the community action plan, it was agreed to offer HPV vaccine for the first time during back-to-school POD operations in addition to required school immunizations.  During the 8/10/15 – 8/25/15 POD, DOH-Broward offered HPV vaccine for the first time during this campaign.

During the POD, 903 HPV vaccines were provided as compared to zero in the prior year. In addition, over 1500 palm cards have been distributed to providers and community.

The success of this process was due to training immunization nurses on how to talk to parents about HPV and the willingness of the nurses to implement these new methods.  By making HPV vaccine a part of routine discussion, parents more readily accepted their child receiving this cancer prevention immunization series.

HPV causes 70% (http://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-fact-sheet) of cervical cancer in the United States. By offering HPV education and vaccine during the POD, 903 HPV vaccines were provided.

 

 

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Broward County Health Department
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Providing HPV Vaccine in a Community POD to Increase HPV Vaccination Rates
LHD Description: Broward County is located in the southeastern portion of the State of Florida.  Broward County’s 2013 population estimate of 1,838,844, represents 9% of the State’s population, and is the second most populous county of the 67 counties in the State of Florida and eighteenth most populous county in the United States (US Census).  Its diverse population includes residents representing more than 200 different countries and speaking more than 130 different languages.  31.4% of the residents are foreign-born.   Broward County is a minority/majority county demonstrated by its 2013 population by race (Black 28.5%, Asian 3.6%, Hispanic 26.9%, other races 4.1%, more than one race .2%, for a total of 59.5% and White 40.8%). The Florida Department of Health in Broward County (DOH-Broward) is the official Public Health Agency in Broward County since 1936. It is part of the Integrated Florida Department of Health (DOH) and operates in cooperation with the Broward County Commission under Florida Statute 154. DOH-Broward’s mission is “to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts”.  DOH-Broward is the lead agency providing core public health functions and essential services in the county as part of a complex public health system that includes hospitals, clinics, planning agencies, community-based organizations and others.  DOH-Broward provides population/community-based services to the county’s 1.8 million residents and over 10 million annual visitors, and is responsible for assessing, maintaining and improving health and safety within the county. Public Health Issue: According to a CDC analysis (2006-2010), the State of Florida has high rates of HPV-associated cancers.  Florida ranks in the top third of States in HPV-associated cervical cancer (8.04-9.54 per 100,000), anal cancer in males (1.13-2.79 per 100,000) and in females (1.86-2.29 per 100,000), oropharyngeal cancer in males (7.11-8.52 per 100,000) and in females (1.60-1.93 per 100,000).  Florida ranks in the mid-third of States in HPV-associated penile cancer (0.71-0.85 per 100,000) and vaginal cancer (0.41-0.47 per 100,000). According to 2013 CDC data, HPV vaccination rates of adolescent girls ages 13-17 in Florida was between 30-37.6%, placing Florida among the lower third in state ranking.  The Morbidity and Mortality Weekly Report (MMWR), August 30, 2013/62(34); 685-693, indicates that among females, Florida had the lowest coverage for ≥1 HPV vaccine dose (39.4%) compared to the rest of the States. Because Broward County represents 9% of the State’s population, and is the second most populous county in the State of Florida, it is reasonable to assume that Broward County contributes to Florida’s low HPV vaccination rates. Goals/Objectives: The goal is to increase HPV vaccination rates in Broward County and the objectives are: 1.       Increase awareness of HPV and the HPV vaccine by developing and distributing an HPV palm card and information to the community and providers. 2.       Increase HPV vaccination rates in Broward County by providing the HPV vaccine during DOH-Broward’s back to school immunization campaign as a part of routine immunizations. Practice Implemented:  In 1996, DOH-Broward led the creation of the Broward County Immunization Action Coalition. The mission is to develop, implement, and monitor immunization strategies that further the goals of providing complete protection against, and eventual elimination of, vaccine preventable diseases.  DOH-Broward and the Coalition held a community planning meeting on May 11 and 12, 2015 to develop an action plan to increase HPV vaccine rates in Broward County. DOH-Broward representatives presented HPV at the Broward County Pediatric Medical Society’s seminar on May 12, 2015. DOH-Broward conducts an annual back-to-school immunization point of dispensing (POD) that provides over 4,500 vaccines to over 3,000 children.  As part of the community action plan, it was agreed to offer HPV vaccine for the first time during back-to-school POD operations in addition to required school immunizations.  During the 8/10/15 – 8/25/15 POD, DOH-Broward offered HPV vaccine for the first time during this campaign. Results:  During the POD, 903 HPV vaccines were provided as compared to zero in the prior year. In addition, over 1500 palm cards have been distributed to providers and community. Success Factors:  The success of this process was due to training immunization nurses on how to talk to parents about HPV and the willingness of the nurses to implement these new methods.  By making HPV vaccine a part of routine discussion, parents more readily accepted their child receiving this cancer prevention immunization series. Public Health Impact:  HPV causes 70% (http://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-fact-sheet) of cervical cancer in the United States. By offering HPV education and vaccine during the POD, 903 HPV vaccines were provided. http://broward.floridahealth.gov/  
Public Health Issue:  According to population statistics available through the Executive Office of the Governor, Broward County’s population includes approximately 113,420 females and 119,753 males aged 15-24.    5.9% of Broward County’s population is under age 5, with 21.8% under age 18.  In addition, 51.4% of the County’s population is female with 48.6% male.  Broward County cervical cancer screening rates are below the Healthy People 2020 goal of 93%.    Data from the CDC Behavioral Risk Factor Surveillance System (BRFSS) indicate that Broward County women aged 18 and over who had received a pap test was 61.1% in 2010 and 76.6% in 2012.  Sexually active adolescents have higher HPV prevalence and incidence with more than 50-80% infectivity 2-3 years of beginning intercourse.  The CDC’s 2013 Youth Risk Behavior Survey (YRBS) indicate that 41.4% of high school youth had engaged in sexual intercourse with 30% indicating that they did not use a condom.   Broward County consistently ranks in the top 2-3 for newly diagnosed HIV cases in the entire US.  Broward County’s infections syphilis rates (14.9 in 2012) and number of congenital syphilis cases (15 in 2012) are among the highest in the state.  In addition, three year rolling rates for chlamydia and gonorrhea cases in females aged 15-19 in Broward County are also high, at 2,872.5 and 463.8 per 100,000 respectively.    An analysis of cancer statistics (2006-2010) conducted by the CDC, indicates that the State of Florida has high rates of HPV-associated cancers.  Florida ranks in the top third of States in HPV-associated cervical cancer (8.04-9.54 per 100,000), anal cancer in males (1.13-2.79 per 100,000) and in females (1.86-2.29 per 100,000), oropharyngeal cancer in males (7.11-8.52 per 100,000) and in females (1.60-1.93 per 100,000).  Florida ranks in the mid-third of States in HPV-associated penile cancer (0.71-0.85 per 100,000) and vaginal cancer (0.41-0.47 per 100,000). The State of Florida does not have legislative mandates in effect regarding HPV vaccination or education.  A bill to institute legislative mandates died in committee in May, 2013 (http://www.ncsl.org/research/health/hpv-vaccine-state-legislation-and-statutes.aspx#2013-2014 chart)  According to the CDC, 2014 national, state, and local area vaccination coverage among adolescents age 13-17 years (2013 data), HPV vaccination rates of adolescent girls ages 13-17 in Florida was between 30-37.6%, placing Florida among the lower third in state  ranking.  The Morbidity and Mortality Weekly Report (MMWR), August 30, 2013/62(34);685-693, indicates that among females, Florida had the lowest coverage for ≥1 HPV vaccine dose (39.4%) compared to the rest of the States with Rhode Island have the highest coverage (73.7%).  Additionally, the CDC also reported disparities in HPV completion rates, with lower rates of completion among Hispanics and Blacks, compared with Whites.  Because Broward County represents 9% of the State’s population, and is the second most populous county in the State of Florida, it is reasonable to assume that Broward County contributes to Florida’s low HPV vaccination rates.  Broward County Public Schools (BCPS) is the sixth largest public school system in the United States and the second largest in the state of Florida. BCPS has over 260,000 students and approximately 175,000 adult students in 238 schools, centers and technical colleges, and 102 charter schools. BCPS s student population reflects the diversity of the county.   What target population is affected by problem?:  The target population is boys and girls beginning at age 11 or 12.  Indirectly the campaign was able to target all Broward County residents.  From August 10-25, 2015, the Florida Department of Health in Broward County offered free immunizations to local residents to meet the state of Florida’s immunization requirements for students. The event took place at the Lauderhill Mall in central Broward County, a well-known mall that is accessible by public transit. During the 2015 back to school immunization POD campaign, DOH- Broward staff provided 6,283 vaccines to 2,160 children. HPV causes 70% (http://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-fact-sheet) of cervical cancer in the United States. By offering HPV education and vaccine during the back to school immunization POD, 903 HPV vaccines were provided to adolescents.  It is important to note that the high number of vaccines provided were due largely to the training provided to immunization nurses in making HPV discussion a part of the routine immunization discussion and in presenting the vaccine as a cancer preventative and not a response to a sexually transmitted disease transmission. What had been done in the past to address the problem? : In the past DOH Broward provided HPV vaccine at its immunization clinics only.  HPV was never addressed to the provider community nor was vaccine provided in the POD.  Why is current/proposed practice better?:  This practice utilized the community strategic planning session (May 11-12, 2015) to identify strategies to increase HPV rates.  By educating the community and sending the palm cards out prior to the POD, the acceptance rate of HPV vaccine increased.  As well, the HPV vaccine was only presented as cancer prevention to parents and parents accepted the vaccine as such.  Staff was trained on how to discuss any concerns with the parents.  Educating the community and parents, increasing awareness of HPV vaccine and providing the HPV vaccine in the POD as part of routine vaccines all helped to increase vaccination acceptance.  DOH-Broward administered 1,100 HPV vaccines (903 in the POD) to 1,100 clients from August 1-31, 2015.  During the same time period (August 1-31) in 2014, 150 HPV vaccines were administered to 150 clients.  In calendar year 2014, DOH Broward provided a total of 1698 HPV vaccines and through October 28, 2015. DOH Broward provided 2,245 vaccines, which is approximately 32% more than in the previous year to date. Is current practice innovative?:  The current practice is both innovative as it was completed in a community wide vaccination POD and given as part of routine vaccinations, and was adopted as a creative use of an existing tool by utilizing a  practice in The Guide to Community Preventive Services.  The Guide to Community Preventive Services suggests that to increase immunizations a community must increase community demand and increase access to vaccination services.  Sending out the HPV palm cards and educating the community on HPV helped to increase demand.  Providing HPV during routine vaccinations in the POD provided enhanced access to vaccination services.   
What are the goals and objectives of the practice?: The goal of the practice is to increase HPV vaccination rates in Broward County and the objectives are:   1.       Increase awareness of HPV and the HPV vaccine by developing and distributing an HPV palm card and information to the community and           providers. 2.       Increase HPV vaccination rates in Broward County by providing the HPV vaccine during DOH- Broward’s back to school immunization          campaign as a part of routine immunizations. What did you do to achieve the goals and objectives? Steps taken to implement the program were: Developed and distributed educational palm card on HPV.  Held community strategic planning meeting on HPV (May 11-12, 2015). Collaborated with the Broward County Pediatric Society on a meeting with physicians on how to improve HPV communication with Parents (May 12, 2015 in the evening). Provided HPV vaccines in the DOH Broward immunization Point of Dispensing, August 10-25, 2015, including night and weekend hours.  Any criteria for who was selected to receive the practice (if applicable)?: HPV palm card was distributed to DOH-Broward clinics, pediatricians and general and family practices, libraries and community partners. The strategic planning meeting (May 11-12, 2015), was held in partnership with the Immunization Action Coalition and had over 34 participants. The Broward County Pediatric Society held a meeting with pediatric providers (May 12, 2015 in the evening). DOH Broward provided the HPV vaccine to those who were 11 years of age and older in the immunization POD held August 10-25, 2015, including night and weekend hours. What was the timeframe for the practice?: March through August was the time frame for the practice.  Palm cards were distributed in May, the strategic planning session and pediatric society meeting were held in May and the immunization POD was held August 10 – August 25, 2015.  Were other stakeholders involved?What was their role in the planning and implementation process? What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s): The practice was first discussed during the strategic planning meeting held May, 2015 with 34 community providers.  During the planning session discussion occurred on providing HPV in the Back to School Immunization POD.  During the pediatric society meeting, information was obtained on the importance of providing and “selling” the vaccine as part of routine vaccinations and informing parents that HPV vaccine was “cancer prevention”.  DOH Broward informed the community of the Back to School immunization PODS through the public and private schools, libraries, community based organizations, print media and television.  This helped to increase the number of children who received their vaccinations in the POD.  DOH-Broward continually fosters collaboration with community stakeholders.  Staff participates on community-based committees including Broward County Comprehensive School Health Advisory Committee and Broward County Schools Educational Conferences.  DOH-Broward is in routine communication with the Broward County School Board, Broward County Superintendent of Schools, President of the Charter Schools Association, and Childcare Licensing Office.  DOH-Broward maintains relationships with the Broward County Administrator and local public health officials.  DOH-Broward leads an outreach workgroup that provides ongoing informational materials to community stakeholders. DOH-Broward hosts the monthly meetings of the Broward County Comprehensive School Health Advisory Committee (BCCSHAC).  DOH-Broward serves in leadership roles to the committee.  The committee membership includes the American Cancer Society, American Lung Association, Broward Health, Broward County Medical Association, Broward County Schools, Children’s Services Council, Florida Introduces Physical Activity and Nutrition to Youth (FLIPANY), Holy Cross Hospital, Leukemia & Lymphoma Society, DOH-Broward, and Medical Staffing Network. Sanofi-Pasteur presented on the meningococcal vaccine in March, 2014 and included information about HPV immunization rates to the group. Any start up or in-kind costs and funding services associated with this practice?  Please provide actual data, if possible.  Else, provide an estimate of start-up costs/ budget breakdown: The palm cards were produced at a cost of $150 for 2,500 cards plus $195 for the graphic design.  The strategic planning session was no cost to the program and the Broward County Pediatric Society meeting was provided as part of the Broward County Medical Association meeting.  The vaccines were provided for eligible children through the Vaccines For Children (VFC) program.       
Objectives: The practice was implemented by conducting a strategic planning meeting in partnership with key stakeholders to develop an action plan to create opportunities to conduct community-wide activities in an effort to increase HPV immunization rates.   All objectives were met.  The strategic planning meeting consisted of 34 community providers.   Over 30 physicians attended the HPV informational meeting.  The HPV palm cards were produced and distributed to the community and other Florida local health departments requested and received the template for the cards for distribution in their communities.  Finally, DOH-Broward administered 1,100 HPV vaccines (903 in the POD) to 1,100 clients from August 1-31, 2015.  During the same time period (August 1-31) in 2014, 150 HPV vaccines were administered to 150 clients.  In calendar year 2014, DOH Broward provided a total of 1698 HPV vaccines and through October 28, 2015. DOH Broward provided 2,245 vaccines, which is approximately 32% more than in the previous year to date.   
Lessons Learned:  When HPV become part of routine vaccination and is presented as cancer prevention, parents are more apt to agree to the vaccination for their child.  Stakeholder Commitment: As there was such success in the delivery and uptake of the vaccination, HPV will continue to be part of the routine vaccinations provided as part of the DOH-Broward Back to School Vaccination POD.  In addition, DOH-Broward will continue to educate the community on HPV as cancer prevention.  
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