NUR 7074 Module 2 HPV Vaccination Paper: Recommending the Vaccine Presumptively and Catching Up Young Adults Example

"Today He's Due for Three Vaccines": Announcing HPV Vaccination in Primary Care

Student Name

M.S. in Nursing, Family Nurse Practitioner, Thomas Edison State University

NUR-7074: Adolescent and Early Adult Primary Care

Mentor Name

Month Day, Year

"Today He's Due for Three Vaccines": Announcing HPV Vaccination in Primary Care

Two Patients, One Vaccine

Ethan Cruz, an invented 11-year-old, came with his father for a well visit. He was due for the Tdap booster, the meningococcal conjugate vaccine and the first dose of HPV vaccine. His father asked whether the HPV vaccine was "really needed for a boy." The same week, Ethan's cousin Marisol, an invented 24-year-old graduate student, came in for a new-patient visit. Her records showed one dose of HPV vaccine at age 16 and nothing since.

What ACIP Recommends

Meites et al. (2019) summarize the Advisory Committee on Immunization Practices recommendations. HPV vaccination is routinely recommended at age 11 or 12 and can begin at age 9. Anyone through age 26 who missed doses should be caught up. For adults aged 27 through 45, ACIP advises a shared clinical decision instead of routine catch-up, since by then most adults have met some HPV types already and gain less. Two doses, 6 to 12 months apart, are enough when the series starts before the 15th birthday; three doses are needed when it starts at 15 or older or in people with certain immunocompromising conditions.

Why It Matters

Lei et al. (2020) followed roughly 1.7 million Swedish residents, girls and women between 10 and 30, over more than a decade, linking vaccination records to the national cancer registry. Women vaccinated before age 17 developed invasive cervical cancer about 88 percent less often than women never vaccinated, with age and other factors taken into account. Women vaccinated between 17 and 30 also had lower rates, though the reduction was smaller. The study was the first large population study to show that HPV vaccination prevents invasive cancer, not only the precancerous lesions measured in earlier trials, and it showed the advantage of vaccinating early, before exposure.

Recommending the Vaccine

Brewer et al. (2017) randomly assigned 30 primary care practices, pediatric and family medicine, across North Carolina to one of three groups: training in announcements, training in conversations or no training. Announcement training taught clinicians to state that the child was due for vaccines, naming HPV among them, in a way that assumed parents would proceed. Conversation training taught clinicians to open a discussion. Six months later, the share of 11- and 12-year-olds starting the series climbed about 5 percentage points higher in the announcement clinics than in untrained clinics, while conversation training had no measurable effect.

Ethan's Visit

I began with an announcement: "Ethan is due for three vaccines today, for meningitis, HPV and tetanus-diphtheria-pertussis." His father asked about the HPV vaccine for boys. I explained that HPV causes cancers of the throat, anus and penis in men as well as cervical cancer in women, and that vaccinating boys also protects their future partners. He asked whether giving it so young encouraged sexual activity; I said studies have not found that, and that the vaccine works best years before any exposure. He agreed, and Ethan received all three vaccines. Because he started before 15, he needs only one more HPV dose in 6 to 12 months, which was scheduled before they left.

Marisol's Catch-Up

Marisol started her series at 16, so she follows the three-dose schedule. A series does not need to be restarted after a long gap; dose two was given at this visit and dose three booked at least five months later. She was also reminded that cervical cancer screening continues on schedule whether or not she is vaccinated, since a few high-risk HPV types fall outside the vaccine's protection.

Recommending to Young Adults

Presumptive language works with adults too. With Marisol I said, "Your record shows one HPV dose, so you're due for the next one today." She mentioned that her partner is 30 and asked whether he should be vaccinated. I explained that for adults aged 27 to 45, ACIP recommends a shared decision rather than routine vaccination, because benefit is lower for people likely to have been exposed already, and that he could discuss it with his own clinician. Keeping the two age groups distinct prevents both missed doses and overpromising.

Changing the Clinic

Our clinic's HPV initiation rate for 11- and 12-year-olds was 54 percent, well below its rates for the other preteen vaccines. With my preceptor and the nurse manager, I led a one-hour session in which clinicians and medical assistants practiced announcement statements, short answers to the five most common parental questions and the habit of scheduling the next dose before the family leaves. Medical assistants also began flagging HPV doses due on the visit summary.

Measuring the Change

We will compare the clinic's initiation and completion rates for patients aged 11 and 12 at six and twelve months, using the state immunization registry, and share the results at staff meetings.

Equity

Missed opportunities fall unevenly. Families without regular well visits, including many uninsured teens and young adults, are less likely to complete the series. Offering HPV vaccine at sick visits and sports physicals, through the Vaccines for Children program for eligible children, reduces those gaps.

Documentation

Each dose was recorded in the state immunization registry so that other clinics and schools can see it.

Limits

The Swedish study was observational, though it adjusted for many factors. Brewer and colleagues measured initiation, not completion. The patients and clinic are invented.

Conclusion

Meites and colleagues set out who should receive HPV vaccine and how many doses, Lei and colleagues showed that vaccination prevents invasive cervical cancer, especially when given early, and Brewer and colleagues showed that announcing the vaccine works better than opening a debate. Two doses for Ethan, catch-up for Marisol and a clinic that now recommends the vaccine with confidence turn evidence into protection.

References

Brewer, N. T., Hall, M. E., Malo, T. L., Gilkey, M. B., Quinn, B., & Lathren, C. (2017). Announcements versus conversations to improve HPV vaccination coverage: A randomized trial. Pediatrics, 139(1), Article e20161764. https://doi.org/10.1542/peds.2016-1764

Lei, J., Ploner, A., Elfström, K. M., Wang, J., Roth, A., Fang, F., Sundström, K., Dillner, J., & Sparén, P. (2020). HPV vaccination and the risk of invasive cervical cancer. New England Journal of Medicine, 383(14), 1340-1348. https://doi.org/10.1056/NEJMoa1917338

Meites, E., Szilagyi, P. G., Chesson, H. W., Unger, E. R., Romero, J. R., & Markowitz, L. E. (2019). Human papillomavirus vaccination for adults: Updated recommendations of the Advisory Committee on Immunization Practices. MMWR. Morbidity and Mortality Weekly Report, 68(32), 698-702. https://doi.org/10.15585/mmwr.mm6832a3