Strengthening the Effectiveness of National,State,and Local Efforts to Improve HPV Vaccination Coverage in the United States: Recommendations From the National Vaccine Advisory Committee

Abstract

In February 2018, recognizing the suboptimal rates of human papillomavirus (HPV) vaccination in the United States, the assistant secretary for health of the US Department of Health and Human Services charged the National Vaccine Advisory Committee (NVAC) with providing recommendations on how to strengthen the effectiveness of national, state, and local efforts to improve HPV vaccination coverage rates. In the same month, the NVAC established the HPV Vaccination Implementation Working Group and assigned it to develop these recommendations. The working group sought advice from federal and nonfederal partners. This NVAC report recommends ways to improve HPV vaccination coverage rates by focusing on 4 areas of activity: (1) identifying additional national partners, (2) guiding coalition building for states, (3) engaging integrated health care delivery networks, and (4) addressing provider needs in rural areas.

Keywords

National Vaccine Advisory Committee human papillomavirus immunization coalition health systems rural health

Introduction

In June 2015, the National Vaccine Advisory Committee (NVAC) issued the report, “Overcoming Barriers to Low HPV Vaccine Uptake in the United States: Recommendations From the National Vaccine Advisory Committee.”¹ The report provided recommendations to the assistant secretary for health (ASH) on strategies to increase human papillomavirus (HPV) vaccine uptake among adolescents by reviewing the current state of HPV immunization, exploring the root causes for low vaccine uptake in both initiation and series completion, and identifying some of the best practices currently in use to attain high immunization coverage. The NVAC endorsed, among other recommendations, the recommendations of a report issued by the President’s Cancer Panel, a federal advisory committee of the National Institutes of Health’s National Cancer Institute, Accelerating HPV Vaccine Uptake: Urgency for Action to Prevent Cancer.²

Since the 2015 report, a range of policy and program changes and advances in research have resulted in progress on HPV vaccination.¹ In 2016, the Advisory Committee on Immunization Practices updated its HPV vaccination guidance to routinely recommend a 2-dose schedule for males and females aged 9-14, while maintaining a 3-dose schedule for those aged ≥15.³ Shortly thereafter, 2 existing Healthcare Effectiveness Data and Information Set measures that assessed the receipt of adolescent vaccines were modified and combined. Specifically, in 2017, the Human Papillomavirus for Female Adolescents measure and the Immunizations for Adolescents measure were combined to report receipt of all recommended vaccines (meningococcal, tetanus–diphtheria–acellular pertussis, and HPV) for both male and female adolescents.^2,4,5 The 2-dose schedule and updated Healthcare Effectiveness Data and Information Set measure may increase vaccine uptake among adolescents.

Primary care providers deliver most vaccinations in practice-based settings in the United States, but there is a considerable amount of state-to-state and within-state variability.⁶ Since the 2015 NVAC report, successful ways of improving HPV vaccination coverage have included more effective provider communication and education, systems-level operational changes in clinical practice settings, and the use of multidisciplinary approaches.^7,8 A recent publication, “Raising Human Papillomavirus Vaccination Rates,”⁹ offers ways to improve HPV vaccination coverage by addressing well-established gaps and implementing proven interventions at scale to optimize HPV vaccination.

National Vaccine Advisory Committee

Chair

Kimberly M. Thompson, ScD, Kid Risk, Inc, Columbus, OH

Designated Federal Official

Angela K. Shen, ScD, MPH, National Vaccine Program Office, Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington, DC

Public Members

Steven Black, MD, Cincinnati Children’s Hospital, Cincinnati, OH

Jay C. Butler, MD, Alaska Department of Health and Social Services, Division of Public Health, Juneau and Anchorage, AK

Melody Anne Butler, BScN, RN, Good Samaritan Hospital Medical Center, Lindenhurst, NY

John Dunn, MD, MPH, Kaiser Permanente Washington Health Research Institute and University of Washington School of Medicine, Seattle, WA

David Fleming, MD, PATH, Washington, DC

Ann Ginsberg, MD, PhD, Aeras, Rockville, MD

Robert H. Hopkins, Jr, MD, University of Arkansas for Medical Sciences, Little Rock, AR

Mary Anne Jackson, MD, Children’s Mercy and University of Missouri–Kansas City, Kansas City, MO

Melissa Martinez, MD, University of New Mexico Medical Group and University of New Mexico, Albuquerque, NM

H. Cody Meissner, MD, Tufts University School of Medicine, Boston, MA

Saad Omer, PhD, MBBS, MPH, Emory University, Atlanta, GA

Larry Pickering, MD, Emory University School of Medicine, Atlanta, GA

Nathaniel Smith, MD, MPH, Arkansas Department of Health, Little Rock, AR

Geeta Swamy, Duke University Department of Obstetrics and Gynecology, Durham, NC

Representative Members

Timothy Cooke, PhD, NovaDigm Therapeutics, Brookline, MA

Leonard Friedland, MD, GSK Vaccines, Philadelphia, PA

Ex Officio Members

Rick Bright, PhD, Biomedical Advanced Research and Development Authority, Assistant Secretary for Preparedness and Response, US Department of Health and Human Services, Washington, DC

John Borrazzo, PhD, Bureau for Global Health, US Agency for International Development, Washington, DC

Marion Gruber, PhD, Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD

Lori Hoffman Hōgg, MS, RN, National Center for Health Promotion and Disease Prevention, US Department of Veterans Affairs, Washington, DC

Jeffrey A. Kelman, MD, MMSc, Center for Beneficiary Choices, Centers for Medicare & Medicaid Services, Washington, DC

Donna L. Malloy, DVM, MPH, Center for Veterinary Biologics, US Department of Agriculture, Washington, DC

Jeffrey McCollum, DVM, MPH, Office of Public Health Support, Indian Health Service, Rockville, MD

Nancy Messonnier, MD, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA

Justin A. Mills, MD, MPH, US Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, MD

Barbara L. Mulach, PhD, Office of Scientific Coordination and Program Operations, Division of Microbiology and Infectious Diseases, National Institutes of Health, Bethesda, MD

Narayan Nair, MD, Division of Injury Compensation Program, Health Resources and Services Administration, Rockville, MD

Tonya Rans, MD, Col, US Air Force, Immunization Healthcare Branch, Public Health Division, Defense Health Agency, US Department of Defense, Falls Church, VA

Judith Steinberg, MD, MPH, Bureau of Primary Health Care, Health Resources and Services Administration, Rockville, MD

Liaison Members

Nancy Bennett, MD, MS, Advisory Committee on Immunization Practices, Rochester, NY

James Blumenstock, MS, Association of State and Territorial Health Officials, Arlington, VA

Gina Charos, Public Health Agency of Canada, Ottawa, Ontario, Canada

Rebecca Coyle, MSEd, American Immunization Registry Association, Washington, DC

Kathryn M. Edwards, MD, Vaccines and Related Biological Products Advisory Committee, Nashville, TN

Kristen Ehresmann, RN, MPH, Association of Immunization Managers, Rockville, MD

Nathalie El Omeiri, MS, MPH, Pan American Health Association, Washington, DC

Jean-Venable “Kelly” Goode, PharmD, American Pharmacists Association, Washington, DC

James David Nordin, MD, MPH, America’s Health Insurance Plans, Washington, DC

Alexandra Stewart, JD, Advisory Commission on Childhood Vaccines, Washington, DC

Tiffany Tate, MHS, National Association of County and City Health Officials, Washington, DC

HPV vaccine uptake was relatively slow during the first 10 years of the US HPV vaccination program. Despite the availability of safe and effective HPV vaccines,¹⁰ an updated Healthcare Effectiveness Data and Information Set measure used by more than 90% of America’s health plans,¹¹ and a public health commitment to support the Advisory Committee on Immunization Practices recommendation, coverage for HPV vaccination remains lower than coverage for other vaccines recommended for the same age group. The 2016 HPV vaccination coverage rate for males (32%) and females (43%) did not reach the Healthy People 2020 target¹² of 80% for adolescents aged 13-15 and lags behind coverage rates for tetanus–diphtheria–acellular pertussis and meningococcal conjugate vaccines by 22% and 28%, respectively.¹³ Although HPV vaccination initiation rates (ie, receipt of the first dose of the HPV vaccine series) among teenagers increased from 56.1% in 2014-2015 to 60.4% in 2015-2016, overall only 43.4% (49.5% of females; 37.5% of males) completed the vaccination series in 2015-2016.¹⁴ The low completion rate warrants increased attention. According to the 2016 National Immunization Survey,¹³ several sex, racial/ethnic, and socioeconomic disparities exist:

Lower HPV vaccination coverage among males (58.6%) aged 17 years compared with females (72.7%);

Lower coverage among non-Hispanic white adolescents (54.7%) compared with Hispanic (69.8%) and non-Hispanic black (65.9%) adolescents;

Lower coverage among adolescents living at or above the federal poverty level (57.3%) compared with those living below the federal poverty level (70.2%); and

Lower coverage among those living in rural (50.4%) compared with urban (65.9%) settings.

The cause of low HPV vaccination rates is multifactorial. Because HPV is a vaccine that prevents infections that cause cancer, the uptake of other cancer preventive services offers helpful context. People have differing perspectives on risks and benefits. Data from the 2015 National Health Interview Survey showed that only 83% of women reported being up to date with cervical cancer screening, well below the Healthy People 2020 target of 93%.¹⁵

Low HPV vaccination coverage is often attributed to 4 other main causes. First, many adolescents do not regularly visit their primary care provider for preventive care and, thus, present no opportunity for vaccination. During 2014, nearly half of adolescents did not attend a primary care appointment and only one-third had a preventive visit.¹⁶ Second, many parents refuse HPV vaccination for their children.^17,18 Third, some research suggests that providers are not giving strong recommendations for HPV vaccine compared with other adolescent vaccines.¹⁹ Fourth, a lack of HPV vaccination mandates may contribute to low HPV vaccine uptake; only 3 states require HPV immunization for school entry.

Charge to the NVAC

In February 2018, the ASH charged the NVAC with establishing a working group to produce a brief report by June 2018 on recommendations to “strengthen the effectiveness of national, state, and local efforts to improve HPV vaccination coverage rates.” The ASH specifically requested the NVAC to consider the following:

Many national organizations are currently supporting HPV vaccination efforts. Are there additional national organizations that might contribute to increasing HPV vaccination coverage?

At the state level, many states have formed coalitions to support HPV vaccination efforts. Is there general guidance for states that do not yet have coalitions?

Integrated health care delivery networks can successfully integrate comprehensive quality improvement approaches to increase vaccination coverage rates. How can state immunization programs and coalitions engage with health systems to work together on improving HPV vaccination coverage?

Please specify recommendations on how to meet the needs of providers in rural areas.

The NVAC established the HPV Vaccination Implementation Working Group in February 2018 and asked the group to engage with a wide range of federal and nonfederal partners from government, industry, health systems, associations, academia, and nonprofit organizations to inform the development of these recommendations. The working group began with a review of the 2015 NVAC HPV report¹ and focused on recommendations 3 and 4 (Box), which were particularly relevant to the current charge, and noted that recommendations 1, 2, and 5 had been partially or fully addressed.

NVAC Recommendations

Focus Area 1: Many National Organizations Are Currently Supporting HPV Vaccination Efforts. Are There Additional National Organizations That Might Contribute to Increasing HPV Vaccination Coverage?

The American Cancer Society and the Centers for Disease Control and Prevention (CDC) established the National HPV Vaccination Roundtable (Roundtable) in 2014. The Roundtable is a national coalition of public, private, and volunteer organizations and individuals dedicated to reducing HPV cancers in the United States through coordinated leadership and strategic planning. The Roundtable seeks to improve how often and how strongly clinicians recommend HPV vaccination to their patients, decrease missed opportunities for HPV vaccine administration, and increase state and national HPV vaccination rates. To achieve these goals, the Roundtable works with traditional and nontraditional stakeholders and develops best practices for dissemination and use.

The Roundtable provides clinical guidance on HPV vaccination that will engage physicians, physician assistants, and nurse practitioners and evidence-based interventions that will engage entire health care teams.²⁰ Because most oropharyngeal cancers are linked to HPV, and these HPV-attributable oropharyngeal cancers are increasing, the dental community (eg, representatives of the American Dental Association and the American Association of Public Health Dentistry) has recently joined the Roundtable as a key partner in HPV prevention efforts, seeking to educate and refer their patients for HPV vaccination.²¹ Long-standing partners in the HPV Roundtable include advocacy groups; professional organizations (eg, primary care providers, nursing, pharmacy); corporate associations; health care organizations; state-level coalitions and roundtables; policy and research organizations; and local, state, and federal agencies that deliver and pay for services (eg, Indian Health Service, Centers for Medicare & Medicaid Services, state Medicaid agencies). The wide range and depth of partners come from both the immunization and cancer communities. In addition to participating in the HPV Roundtable at the national level, many of these organizations work with their respective state and local chapters and partners to implement HPV initiatives and promote increased usage of HPV vaccine.

The Roundtable has been successful at engaging a broad range of stakeholders to promote HPV vaccination through implementation of clinical guidance and evidence-based interventions. However, the 2015 NVAC HPV report,¹ through recommendation 3 (Box), recognized the continued need to develop evidence-based, effective, coordinated communication strategies to increase how consistently and how strongly clinicians recommend HPV vaccination to their patients. The NVAC recognizes the need for additional efforts and offers the following recommendations:

Recommendations for focus area 1

1.1. To promote inclusion of new health care partners, the ASH should encourage further development, dissemination, and implementation of evidence-based practitioner resources and support collaborative relationships.

1.2. The ASH should encourage enhanced engagement with payers, employers, and quality improvement organizations to increase communication to beneficiaries about HPV vaccine coverage and the importance of receiving the full HPV vaccination series.

1.3. The ASH should encourage employers and payers to link value-based payment to provider benchmarks for HPV vaccination.

1.4. The ASH should encourage the Health Resources and Services Administration to include an HPV vaccination adolescent measure in the Uniform Data System, which serves as a reporting requirement for Health Resources and Services Administration grantees in community health centers, migrant health centers, health centers for homeless grantees, and public housing primary care organizations. The data should be used to improve health center performance and operation and to identify trends over time.

Focus Area 2: At the State Level, Many States Have Formed Coalitions to Support HPV Vaccination Efforts. Is There General Guidance for States That Do Not Yet Have Coalitions?

States decide how to best allocate resources for their specific immunization priorities. Coalitions, which bring together private and public partners, can help catalyze action around immunization priorities. The HPV Roundtable has developed the “State Coalitions and Roundtable Guide”²² to help states establish these coalitions. The guide provides information for states seeking to improve (1) their coalitions’ engagement and management, (2) HPV vaccination coverage and HPV-related cancer data collection and use, (3) evidence-based interventions, (4) policies related to HPV vaccination, (5) partner networks and other stakeholder engagement tools, (6) education tools for providers, parents, and state and local health departments, and (7) messaging for targeted audiences. The NVAC supports the use of these resources as general guidance to states, while recognizing that not all states may be able to or wish to establish a coalition.

The NVAC recognizes that the strength and effectiveness of coalitions will vary. In some jurisdictions, immunization advocates may take the lead on promoting HPV immunization. In other jurisdictions, the cancer prevention community may be the natural lead. Information and data exchange between these 2 communities should remain a central activity within coalitions to ensure coherent messaging and share resources. The NVAC offers the following recommendations for additional efforts:

Box.

Overcoming barriers to low human papillomavirus (HPV) vaccine uptake in the United States: recommendations from the National Vaccine Advisory Committee (NVAC)¹

Recommendation 1	The ASH [assistant secretary for health] should endorse the PCP [President’s Cancer Panel] report, Accelerating HPV Vaccine Uptake: Urgency for Action to Prevent Cancer,² and adopt the recommendations outlined therein.
Recommendation 2	As the PCP recommended, the NVAC should monitor “the status of uptake and implementation of the recommendations.” This should be done by hearing an annual progress report from HPV vaccination stakeholders identified in the PCP report.
Recommendation 3	The ASH should work with relevant agencies and stakeholders to develop evidence-based, effective, coordinated communication strategies to increase the strength and consistency of clinician recommendations for HPV vaccination to adolescents (both males and females) in the recommended age groups and to improve acceptance among parents/guardians, adolescents, and young adults.
Recommendation 3.1	Develop practical tools to increase clinicians’ skills and confidence in promoting HPV vaccination as a routine adolescent vaccine and part of routine adolescent care. These communication tools should equip clinicians to emphasize HPV vaccine as a cancer prevention strategy, to increase clinicians’ ability to respond to questions from parents/guardians and adolescents about HPV as a sexually transmitted infection, and to enable clinicians to effectively address parental hesitancy.
Recommendation 3.2	Develop evidence-based, culturally competent communication strategies for parents/guardians, adolescents, and young adults that address key beliefs driving decisions to vaccinate and address barriers to vaccination.
Recommendation 3.3	Promote collaboration among all stakeholders to coordinate communications and messaging that increase message consistency across professional organizations and their constituencies.
Recommendation 3.4	Utilize multiple methods for communication, including one-on-one counseling, public health messaging, social media, and decision support systems.
Recommendation 3.5	Promote science-based media coverage about HPV vaccination and appropriate response to media coverage that does not adequately reflect the science of HPV vaccines and HPV vaccination recommendations.
Recommendation 4	The NVAC recommends the ASH should work with the relevant agencies and stakeholders to strengthen the immunization system in order to maximize access to and support of adolescent vaccinations, including HPV vaccines.
Recommendation 4.1	Addressing barriers to vaccination in venues outside the traditional primary care provider office, including pharmacies, schools, and public health departments. This may include immunization status assessment and administration of the appropriate doses toward completion of the HPV vaccination series.
Recommendation 4.1.1	Develop strategies to overcome barriers regarding reimbursement for vaccination administration and compensation of vaccine administrators and their staff.
Recommendation 4.1.2	Strengthen immunization information systems (IISs) to allow pharmacies, school-located programs, and public health clinics to view and query patient immunization records and submit records of immunizations administered to their state IIS, which ensures proper communication and record of immunization histories are available to the patient’s primary care provider, vaccination administrator, and the state public health system.
Recommendation 4.1.3	Encourage collaboration and sharing of best practices for successful vaccination programs at pharmacies, schools, and public health clinics.
Recommendation 4.2	Work with relevant agencies and stakeholders to increase the widespread use of quality improvement strategies, such as Assessment, Feedback, Incentives, and eXchange visits, to support and evaluate HPV immunization practices within all vaccination venues.
Recommendation 4.3	Encourage widespread adoption of state-centralized reminder recall for adolescent vaccines and reporting of vaccinations into existing IISs and electronic health records.
Recommendation 5	The ASH should encourage the review or development of available data that could lead to a simplified HPV vaccination schedule. In addition to a review that could impact existing vaccines, manufacturers of HPV vaccines in development should also consider opportunities to support the simplest HPV immunization schedule while maintaining vaccine effectiveness, safety, and long-term protection.

Recommendations for focus area 2

2.1. The ASH should engage with and encourage state health officials to use existing publicly available resources for coalition building and partner coordination, including the National HPV Vaccination Roundtable’s “State Coalitions and Roundtable Guide.”

2.2. The ASH should encourage continued collaboration and active engagement between immunization and cancer advocacy groups to increase the availability of resources for HPV immunization.

Focus Area 3: Integrated Health Care Delivery Networks Can Successfully Integrate Comprehensive Quality Improvement Approaches to Increase Vaccination Coverage Rates. How Can State Immunization Programs and Coalitions Engage With Health Systems to Work Together on Improving HPV Vaccination Coverage?

Health systems and integrated delivery networks play a unique role in their ability to track patients, invest in health information technology, and incorporate population health approaches and preventive strategies. Increased attention to population health and wellness can help manage the quality and the cost of care delivered to patients. Health systems and integrated delivery networks should support Advisory Committee on Immunization Practices recommendations, including those for HPV vaccination, and should include accountability measures for HPV vaccination and other Advisory Committee on Immunization Practices–recommended vaccines in strategic and operational plans, such as reporting requirements to the Healthcare Effectiveness Data and Information Set and other quality reporting programs.

Improved utilization of immunization information systems (IISs) by health systems and health delivery networks offers a substantial, but underutilized, opportunity to improve HPV vaccination uptake. CDC’s 2016 Immunization Information Systems Annual Report, which assesses the 64 CDC-funded immunization program grantees across the United States,²³ found that 28.3% of females and 21.8% of males aged 13-17 received at least 3 doses of HPV vaccine in 2016. In comparison, the National Immunization Survey¹³ reported that 43% of females and 32% of males received 3 doses of HPV vaccine. These disparities suggest underreporting of HPV vaccination to state IISs.

The 2015 NVAC HPV report,¹ through recommendations 4.1 and 4.1.2 (Box), emphasized the importance of addressing barriers to vaccination in nontraditional venues by strengthening the ability of IISs to view, query, and submit immunization records from a range of venues. Although all IISs accept HPV immunization information, some federal agencies, including the US Department of Defense and the US Department of Veterans Affairs, are not required to participate in meaningful use of certified electronic health record (EHR) technology and, therefore, are not incentivized to share immunization data with state IISs.²⁴ The NVAC makes the following recommendations:

Recommendations for focus area 3

3.1. The ASH should work with state health officials and local health departments as key immunization leaders to engage with regional and local health systems and integrated delivery network executives to prioritize HPV vaccination as an effective means for cancer prevention and to develop accountability mechanisms to track and incentivize performance.

3.2. The ASH should engage the Office of the National Coordinator for Health Information Technology, state health officials, and partners to support interoperability by encouraging bidirectional electronic data exchange and broad use of immunization data across EHRs and IISs and with all federal partners, particularly as it relates to HPV immunization. Activities may include:

3.2.1. Supporting the onboarding process of new users (ie, getting a provider organization ready to send, submit, and query patient data from an EHR to the IIS), including adult providers.

3.2.2. Developing a memorandum of understanding or data use agreement among the US Department of Defense, US Department of Veterans Affairs, and IISs to support immunization data exchange.

3.2.3. Supporting the acceleration of current EHR, pharmacy information system, and IIS standardization efforts, including promoting functionality that supports query and response for clinical decision support.

3.3. The ASH should work with state health officials, local health departments, and their partners to encourage the use of IISs and EHRs to:

3.3.1. Generate coverage assessments for a provider’s population for use in targeting reminder efforts for adolescents who are due and past due for HPV vaccination.

3.3.2. Assess opportunities to vaccinate individuals in a provider’s practice to reduce missed opportunities to vaccinate and increase protection for populations (eg, through the use of clinical decision support and quality improvement processes such as Assessment, Feedback, Incentives, and eXchange).

Focus Area 4: Please Specify Recommendations on How to Meet the Needs of Providers in Rural Areas

Rural health care providers and communities face many of the same challenges as other communities, including increasing health care costs, overextended health care infrastructure, and lower HPV vaccination coverage rates relative to other adolescent vaccines. However, the percentage of adolescents living outside of urban areas who have received the first dose of the HPV vaccine series remains 16% lower than for adolescents who live in urban areas.¹³ Critical shortages of primary care providers may partially account for the lower HPV vaccination rate in rural communities.^13,25,26 Rural communities may face special challenges in raising HPV vaccination rates, such as (1) less access to vaccine supply, particularly HPV vaccine; (2) limited resources for communication to patients and the community; (3) less access to cancer experts, vaccination sites, and pharmacies; and (4) less community-based vaccine and immunization education for providers. To investigate and improve HPV vaccine uptake, some rural communities may be able to leverage the expertise and resources of pediatric clinical trial networks and telemedicine services.^27,28 Local problems often can be solved with local solutions by using available resources, and rural communities can share best practices with other rural communities. The NVAC recommends the following:

Recommendations for focus area 4

4.1. The ASH should request further research be conducted to better understand the needs of rural providers in supporting the administration of or referral to vaccination services in rural environments and to identify and determine barriers to accessing vaccination services for patients in rural settings.

4.2. The ASH should encourage the increased use of technology-based telemedicine systems, such as teleconsulting and telementoring partnerships, to reach rural and underserved communities to strengthen provider education on HPV vaccination and cancer prevention.

4.3. The ASH should support a stronger social media presence across the US Department of Health and Human Services to improve the reach of communication strategies and directly engage parents and adolescents to build trust and recognition about the importance of HPV vaccination and how to best engage patients in rural communities.

Implications for Future Consideration

Improving complete HPV vaccine coverage will require effective partnerships and consistent messaging to patients, parents, providers, and the community. The Roundtable’s activities demonstrate that a focus on HPV vaccination as cancer prevention provides an effective message for garnering public support. Consistent messages from national organizations and a stronger social media presence can improve communication strategies and directly engage parents and adolescents. Future HPV vaccination messaging should address the concerns of parents, who serve as the primary decision makers on adolescent vaccination.

Although substantial progress has been made to improve HPV vaccination coverage rates since the 2015 NVAC HPV report,¹ several recommendations still emerge as priorities. Much work remains to optimize health systems to improve vaccination coverage, particularly in underserved populations, and to develop more effective communication strategies for distinct populations and communities. Further progress requires additional investment to address remaining gaps and disparities in HPV vaccination coverage.

Footnotes

Authors’ Note

The views represented in this report are those of the National Vaccine Advisory Committee. The positions expressed and recommendations made in this report do not necessarily represent those of the US Department of Health and Human Services, the US government, or the individuals who served as authors of, or otherwise contributed to, this report.

Acknowledgments

The members of the National Vaccine Advisory Committee (NVAC) thank the members of the HPV Vaccination Implementation Working Group (Co-Chairs Nathaniel Smith and Geeta Swamy, NVAC members Mary Ann Jackson and Robert Hopkins, and NVAC liaison members Achal Bhatt, Kristen Ehresmann, Mary Beth Hance, and Jeffrey McCollum). We appreciate the efforts of Lauren Chambers for her administrative oversight in facilitating working group meetings, editing report drafts, facilitating the review process, and providing overall staff support. We also thank Jordan Broderick for her assistance with report review and editing. We thank Dr Angela Shen of the National Vaccine Program Office for offering insights throughout the working group process and report development process. We thank Prajakta Adsul, Ellen Bateman, Noel Brewer, Rebecca Coyle, Jillian Doss-Walker, Gretchen Forsell, Claire Hannan, Sarah Shafir, Kimberly Sharp-Scott, and Letitia Thompson for sharing their subject matter expertise in presentations to the working group. We thank the members of the NVAC for providing comments on the report draft. Finally, we thank the public for submitting feedback during the public comment period.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

National Vaccine Advisory Committee. Overcoming barriers to low HPV vaccine uptake in the United States: recommendations from the National Vaccine Advisory Committee. Public Health Rep. 2016;131(1):17–25.

President’s Cancer Panel. Accelerating HPV vaccine uptake: urgency for action to prevent cancer. https://deainfo.nci.nih.gov/advisory/pcp/annualReports/HPV/PDF/PCP_Annual_Report_2012-2013.pdf. Published 2014. Accessed April 27, 2018.

Meites

Kempe

Markowitz

. Use of a 2-dose schedule for human papillomavirus vaccination—updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405–1408.

National Committee for Quality Assurance. NCQA updates quality measures for HEDIS 2017. NCQA: measuring quality, improving health care. http://www.ncqa.org/newsroom/details/ncqa-updates-quality-measures-for-hedis174-2017?ArtMID=11280&ArticleID=45&tabid=2659. Published 2017. Accessed April 27, 2018.

Faye

Roth

. Human papillomavirus vaccination coverage among female adolescents in managed care plans—United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64(42):1185–1189.

Pickering

Baker

Freed

. Immunization programs for infants, children, adolescents, and adults: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2009;49(6):817–840.

Rosen

Shepard

Kahn

. US health care clinicians’ knowledge, attitudes, and practices regarding human papillomavirus vaccination: a qualitative systematic review. Acad Pediatr. 2018;18(2S):S53–S65.

Reiter

Gerend

Gilkey

. Advancing human papillomavirus vaccine delivery: 12 priority research gaps. Acad Pediatr. 2018;18(2S):S14–S16.

Stokley

Szilagyi

. Raising human papillomavirus vaccination rates. Acad Pediatr. 2018;18(2):S1–S106.

10.

Gee

Weinbaum

Sukumaran

Markowitz

. Quadrivalent HPV vaccine safety review and safety monitoring plans for nine-valent HPV vaccine in the United States. Hum Vaccin Immunother. 2016;12(6):1406–1417.

11.

National Committee for Quality Assurance. HEDIS and Quality Compass. http://www.ncqa.org/HEDISQualityMeasurement/WhatisHEDIS.aspx. Accessed April 25, 2018.

12.

US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2020: immunization and infectious diseases objectives. https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives. Published 2018. Accessed April 27, 2018.

13.

Walker

Elam-Evans

Singleton

. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years—United States, 2016. MMWR Morb Mortal Wkly Rep. 2017;66(33):874–882.

14.

Reagan-Steiner

Yankey

Jeyarajah

. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years—United States, 2015. MMWR Morb Mortal Wkly Rep. 2016;65(33):850–858.

15.

White

Thompson

White

. Cancer screening test use—United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(8):201–206.

16.

Rand

Goldstein

NPN

. Patterns of primary care physician visits for US adolescents in 2014: implications for vaccination. Acad Pediatr. 2018;18(2S):S72–S78.

17.

Dorell

Yankey

Jeyarajah

. Delay and refusal of human papillomavirus vaccine for girls, National Immunization Survey—Teen, 2010. Clin Pediatr (Phila). 2014;53(3):261–269.

18.

Farmar

Love-Osborne

Chichester

Breslin

Bronkan

Hambridge

. Achieving high adolescent HPV vaccination coverage. Pediatrics. 2016;138(5):e1–e7.

19.

Hswen

Gilkey

Rimer

Brewer

. Improving physician recommendations for HPV vaccination: the role of professional organizations. Sex Transm Dis. 2017;44(1):42–47.

20.

National HPV Vaccination Roundtable. Resource library. http://hpvroundtable.org/resource-library/#filter=.clinicians. Published 2017. Accessed May 4, 2018.

21.

National HPV Vaccination Roundtable. HPV roundtable organizations. http://hpvroundtable.org/roundtable-member-organizations. Published 2017. Accessed April 16, 2018.

22.

National HPV Vaccination Roundtable. State coalitions and roundtables guide. http://hpvroundtable.org/state-coalition-guide/. Published 2017. Accessed April 16, 2018.

23.

Centers for Disease Control and Prevention. Immunization information systems annual review: immunization information systems (IIS). https://www.cdc.gov/vaccines/programs/iis/annual-report-iisar/index.html. Accessed May 14, 2018.

24.

Centers for Medicare & Medicaid Services. Medicare and Medicaid programs: electronic health record incentive program—stage 3 and modifications to meaningful use in 2015 through 2017. Final rules with comment period. Fed Regist. 2015;80(200):62761–62955.

25.

Makaroff

Xierali

Petterson

Sipman

Puffer

Bazemore

. Factors influencing family physicians’ contribution to the child health care workforce. Ann Fam Med. 2014;12(5):427–431.

26.

Shipman

Lan

Chang

Goodman

. Geographic maldistribution of primary care for children. Pediatrics. 2011;127(1):19–27.

27.

National Institutes of Health. Environmental influences on Child Health Outcomes (ECHO) program: sites for the IDeA States Pediatric Clinical Trials Networks. https://www.nih.gov/echo/clinical-sites-idea-states-pediatric-clinical-trials-network. Published 2016. Accessed April 24, 2018.

28.

Jetty

Moore

Coffman

Petterson

Bazemore

. Rural family physicians are twice as likely to use telehealth as urban family physicians. Telemed J E Health. 2018;24(4):268–276.