Transcript for CDC Telebriefing: Many adolescents still not getting HPV vaccine

Large vaccination increases in some states offer clues to effective interventions

Please Note: This transcript is not edited and may contain errors.

DAVE DAIGLE:  Thank you, Victor.  Thanks everyone for joining us today to discuss the release of National Immunization Survey – Teen data.  We are joined today by Dr. Anne Schuchat who is our director for the National Center for Immunization and Respiratory Diseases.  She will begin with a short statement and then will take questions. 

DR. ANNE SCHUCHAT: Thanks, Dave.  And thank you everybody for joining us this afternoon for what has become my favorite topic, because this is an area that we have potential to do so much good for.  We can have a lot more impact than we are having now and I’m going to review some of the statistics as to why.  Today we are releasing new data from our 2014 NIS – Teen survey.  Today’s MMWR provides estimated coverage rates among adolescents for three routine vaccines targeted at adolescents.  We recommend vaccinating 11 and 12 year olds against meningitis, HPV-associated cancers and whooping cough.  Today, I will update on coverage for the quadrivalent meningococcal conjugate vaccine, the human papilloma virus and the Tdap vaccine (which protects against Tetanus, Diphtheria and Pertussis or whooping cough).  The MMWR article includes data from the National Immunization Survey on Teen Vaccination.  The NIS Teen is a large nationally representative survey that collects provider- validated vaccination information for adolescents who are 13 to 17 years old.  There are 20,827 teens included in the survey results on which I am presenting.  Our results are based on random digit dial sample of land lines and cell phones.  And this year we changed the methods a little bit and updated our definition of adequate provider-reported data.  This gives us a bigger sample but required us to apply the same approach to 2013 survey data, so that we could compare the changes in rates.  This new definition is more inclusive than the one used in earlier reports and it makes it somewhat difficult to compare every year since 2006.  So what I’m going to focus on today is comparing 2013 and 2014.  Here are the core results.  Among teens 13 to 17 years old the survey found small increases in each of the three routine vaccinations.  Tdap coverage was already 84.7% in 2013, but increased another 2.9 percentage points to 87.6 in 2014.  Coverage for the quadrivalent meningococcal conjugate vaccine increased 2.7 percentage points from 76.6% to 79.3% in 2014.  From 2013 to 2014, HPV vaccination coverage for girls increased 3.3 percentage points from 56.7% to 60% in 2014.  Starting at a much lower level, HPV vaccination coverage for boys increased from 33.6% in 2013 to 41.7% in 2014, an increase of 8.1 percentage points.  So for those of you writing quickly you can see that HPV first-dose coverage in girls 13 to 17 at 60% is 27.6 percentage points lower than Tdap coverage and 19.3 percentage points lower than quadrivalent meningococcal conjugate vaccine coverage. 

Next, I want to go into details about HPV vaccination results since this is where we have much more work left to do in order to achieve impact on health.  We are seeing patchwork progress.  There is still quite a range in HPV vaccine coverage across the country and you can see maps on the websites and MMWR to see this patchwork and this range across the country.  Rhode Island achieved the highest rate for first-dose HPV coverage among girls with 76%, while Kansas had the lowest rate at 38.3%.  While there was a 3.3% increase nationally for first-dose HPV vaccine coverage among teenage girls, a handful of geographic areas made significant progress in improving uptick with increases ranging from 13% to 23 percentage points increase.  The state and local areas which saw significant increases are spread around the country.  Four states saw significant increases in first-dose coverage.  Those states were Illinois, Montana, North Carolina and Utah.  Two of the six local areas that we surveyed, Chicago and D.C., also saw significant increases from 2013 to 2014.  They saw increases from 20.5% to 22.8%.  I should mention one more local area, Philadelphia, already had among the highest HPV first- dose coverage rates in 2013 at 77.5% and in 2014 they increased to 80.3%.  The large increases in these areas show us that it is possible to make real progress in a variety of settings.  But the areas that saw significant improvements had conducted a number of activities aimed at raising coverage and their experience suggests a combination of strategies is needed, since different approaches may reinforce each other.  Their approaches included establishing links between cancer groups and immunization groups, educating clinicians, adopting practice-based quality improvement efforts and providing feedback on how to include coverage, conducting public communication campaigns and using their registries or immunization information systems to send out reminders to parents about upcoming shots.  We have good news in this handful of areas that we are using a variety of practices to strengthen HPV cancer protection.  We know now it is possible to do much better but overall there is much more we need to do.  I am frustrated that in 2014 four out of ten adolescent girls and six out of ten adolescent boys had not even started the HPV vaccine series and are vulnerable to cancers caused by HPV.  High Tdap and quadrivalent meningococcal conjugate vaccine rates show it is possible to achieve rates with the current infrastructure and that starts with reducing missed opportunities to give HPV vaccine.  So I want to stress to clinicians and parents that 11 and 12 year olds are recommended to get HPV vaccine.  That’s not too young to start the series.  That’s strongly recommended at that age rather than waiting until your child is 16 or 17.  And this year we did not see any progress in HPV vaccination by age 13.  So the progress we are reporting is based on improvements on vaccination at older ages.  I’m urging clinicians to get into the routine of recommending cancer prevention at 11 to 12 years of age.  Our research shows that an effective recommendation from a health care professional is crucial to a parent’s decision to get HPV vaccine for their child and the way to give an effective recommendation is to recommend HPV vaccine in the same way and same day you recommend other routinely recommended teenage vaccines.  I want to encourage parents to ask about vaccination every time you take your child to the health care provider whether your children are babies and toddlers or preteens and teens.  I know many parents are starting to think about their back-to-school lists and it’s a great time to make sure your preteens have gotten all of their recommended vaccines.  All 11 or 12 year olds girls and boys should be protected from meningitis, whooping cough and HPV-associated cancers.  This year measles has gotten a lot of news, through measles outbreaks that the media covered.  Those outbreaks are a reminder to make sure all children have received both doses of MMR (measles, mumps and rubella vaccine) and that is something that we also track with the NIS-Teen survey. 

The last few years you have heard those of us at CDC express our disappointment in stagnating rates of HPV vaccination and last year we reported the 2013 data did show a small improvement nationwide.  This year the new data for 2014 show continued improvement based on substantial improvement in a handful of areas.  I know that in 2015 many more states have been adopting the approaches that were used in Illinois, Montana, North Carolina, Utah, D.C. and Chicago and I hope that next year we will see the same kind of improvements in the rest of the country.  Instead of just patchwork progress we have a chance to blanket the country with protection from HPV associated cancers.  Let me turn things back over to Dave and the moderator. 

DAVE DAIGLE.  Thank you.  Victor, at this time we are ready for questions. 

OPERATOR: At this time we will begin the question and answer session.  To ask questions please press star 1 and record your name clearly when prompted.  To withdraw your questions press star 2.  One moment please for incoming questions.  Once again for questions over the phone lines it is star 1 and record your name at the prompt.  We do have a few queueing up.  It will just be a few moments. 

Our first question comes from Mike Stobbe with The Associated Press.  Your line is open. 

THE ASSOCIATED PRESS, MIKE STOBBE:   Hi, Dr. Schuchat, thank you for taking my question.  You said something about we didn’t — you didn’t see progress in the 11 to 12 year olds.  That threw me for a second.  I thought the survey was 13 to 17 year olds.  Can you tell me more about what you were referring to?  Is there a different survey data of 11 and 12?  What were those numbers that haven’t been improving?  And I have a follow up. 

DR. ANNE SCHACHT: Thank you Mike. The question is about vaccination by age 13.  The NIS – Teen survey finds out about vaccination among about 20,000 people who are between the age of 13 and 17.  Unlike many surveys, it goes back to the doctor’s office or the pharmacist and figures out what doses were given at what date.  We are able to calculate the age that a person received a vaccine.  So in that population 13 to 17 you can figure out if anybody were vaccinated by age 13, which would indicate that they were vaccinated when they were either 11 or 12.  When we look at the adolescents in the survey age 13 years and compare results for 2013 and 2014 we really didn’t see a significant change.  The coverage in that group of 13 for first dose HPV in females 6% in the 2013 revised definition to 2014 level of 51.1.  So that 0.5 difference is not significant.  Not statistically significant. That increase that we saw, the increase of 3.3 percentage points, was the overall change among all 13 to 17 year olds regardless of what age they were vaccinated.  And you can see in the MMWR… tables that we have higher coverage in older teens compared to younger teens.  We know that initially people were wondering is it to soon at 11 or 12 to give the vaccine. But it is not too soon but the right time to give it.  Our performance monitor measures really look at that — three doses given by age 13.  We do want to remind parents and clinicians that the 11 and 12 year olds who are getting the meningitis and Tdap vaccine need the HPV vaccine. 

DAVE DIAGLE: You had a follow up? 

THE ASSOCIATED PRESS, MIKE STOBBE:  I guess I will make my follow up.  I didn’t quite hear what she said. Dr. Schuchat’s voice cut out.  What did you say?  It went from 49.6% to 51.1%?  Is that what you said? 

DR. ANNE SCHACHT: I’m sorry Mike.  It went from 50.6% to 51.1%. 

THE ASSOCIATED PRESS, MIKE STOBBE:  First dose girls by age 13?

DR. ANNE SCHUCHAT: By age 13. 

THE ASSOCIATED PRESS, MIKE STOBBE:  Ok. Thank you. 

DAVE DIAGLE: Next question, please, Victor. 

OPERATOR: This is our next question from Dennis Thompson with HealthDay.  Your line is open. 

HEALTHDAY, DENNIS THOMPSON: Thank you for taking my call.  My question. I wanted to ask about what you perceive as being the road blocks to more kids getting HPV vaccination.  All the road blocks. In specific is cost a factor or are insurance companies now covering HPV vaccines or is it something else? 

DR. ANNE SCHUCHAT:  Thank you for that question.  We think the principal road block is providers not recommending the vaccine, not providing a strong recommendation the same way they recommend Tdap and meningitis vaccine.  Surveys of parents identify not receiving a recommendation as a critical gap.  We have asked parents about whether cost was an issue and that is not showing up in our list of the top concerns.  The Vaccines for Children (VFC) program and U.S. and private insurance covers the HPV vaccine.  The HPV vaccine is covered by private insurance when it is provided by an in-network provider – with no copays and no deductibles and the VFC provides that vaccine for free to uninsured children or Medicaid eligible kids.  So we don’t think — although the HPV vaccine is costly compared to other teenage or childhood vaccines– we don’t believe the cost is the principal barrier. But we think a provider recommendation is really important and that parents are looking to hear that when they are waiting for that on the doctor visits.  Next question. 

OPERATOR: Our next question comes from Heather Tesoriero with CBS News.  Your line is open. 

CBS NEWS, HEATHER TESORIERO: The vaccine may be effective at prevention after someone has been infected with HPV, may be effective from preventing occurrence.  Does the CDC have position on the vaccine’s use for that? 

DR. ANNE SCHUCHAT:   The vaccine is recommended to prevent HPV-associated cancers and to prevent genital warts associated with HPV.  And the large trials that were done to support licensure did not find benefit against vaccine type HPV after exposure.  The principal benefit — in fact, all of the benefit in the very large randomized control trial of key precancer end points was among people who were not already infected with the HPV vaccine types.  So we took this as a preventive vaccine and not as a vaccine for treatment after you have already been exposed or infected by the virus.  There are several different HPV types and so a person who has gotten an infection with one of the types might still benefit from the vaccine because it has multiple types that it protects against.  But we don’t think that the vaccine will prevent cancers after you have already been infected with the cancer-causing types.  So that is why we strongly recommend the vaccine for kids at 11 or 12 well before they are going to be exposed to any types of HPV virus. 

DR. ANNE SCHUCHAT:  Next question, please.  

DAVE DAIGE: Next question, Victor.

OPERATOR:  Our next question from Nadia Popavich with The Guardian. 

THE GUARDIAN, NADIA PAPAVICH:  I wanted to ask about the comment but you changed some of the ways you conducted the survey which makes it difficult to compare against other years before 2013.  In the article there is like a big chart that says it’s         [inaudible] with selected vaccines from 2006 to 2014.  Would you recommend against looking at the differences between the various years and just keeping 2013 to 2014? 

DR. ANNE SCHUCHAT: The definition changed.  We basically made it less restrictive in terms of how much documentation we had to find in the providers’ office.  So that meant that some kids in 2013 or ’14 that might not have been included in our final survey would now be included.  It really has very minimal change on the trends that we see, but we sort of restarted the clock at 2013 in terms of the graph in the MMWR so you can see year by year 2013 versus 2014 with the same eligible kids.  You know, our analysts ran this many, many ways.  We don’t think the trends that we have been seeing over time are different than we used to say.  But we were focusing on vaccines that are pretty minor in terms of the focus in what was considered adequate provider record.  And we also had a very long telephone questionnaire.  So by simplifying the questionnaire we ended up being able to have a greater sample size and don’t feel that it’s biased our findings at all.  I think the principle, the statistics reported for 2014 are great ones to cite and the change in terms of the improvement between 2013 and ’14 is fine to cite.  If you want to cite the longer trends for vaccines it is probably fine but the statistical folks wanted to caution people.  I think that the other comment is that online there is much more data for specific years and specific vaccines…we didn’t have enough space in the actual article.  Things like MMR and other age groups are all online tables. 

DAVE DAIGLE: Thank you, Nadia.  Next question, please Victor. 

OPERATOR: Once again, for any questions over the phone line please press star 1 and record your name at the prompt.  Our next question comes from Kylie Gumpert.  Your line is open. 

REUTERS, KYLIE GUMPERT: Hi there.  My question has to do with the higher rates of coverage between non-white adolescents and those below the poverty line.  I thought that was interesting.  I am wondering why that might be or whether that is mostly due to margin of error or lower trends in sample size? 

DR. ANNE SCHUCHAT: So the trends in HPV coverage between those living below the poverty line and those at or above the poverty line are different than what we see with most vaccines.  There are a couple of things that may factor into that.  There may be differences in provider behavior in some practices where many kids are lower income.  In terms of really reducing missed opportunities there may be a better practice in those settings of saying, I don’t know how many times I’m going to have to speak with this family and vaccinate this child.  Maybe using best practices of making sure that they get the doses in when recommended.  A second factor may be that many low income children are eligible for the Vaccines for Children (VFC) program and may be that providers don’t hesitate when they have the VFC- eligible children to offer the vaccine because they don’t have to worry about reimbursement.  The vaccine is already provided free through the public health system.  It could be cost related in terms of upfront cost that the VFC manages versus downstream costs of getting reimbursed by an insurer.  It is not a margin of error problem.  There are significant differences in terms of the higher coverage for HPV vaccine in those living below the poverty level versus at or below the poverty level.  It used to be that we had much higher coverage in people above the poverty level despite the program being there.  But as the program has gotten more and more mature we are seeing less and less disparity between poor children and wealthier kids.  With HPV it may be many factors that are different in different communities and different populations but we have seen for multiple years that HPV vaccination rates have been higher in those who are poor.  I do want to mention that they start off with a pretty big difference but as we get to the second and third dose we see that difference narrowing.  So we think that it’s really important to get people back in for completing the series and that might be something that is not going as well for those living within poverty.  We think it’s important that this is a multi-dose series that needs to be completed. 

DAVE DAIGEL: Thank you Kylie.  Victor, I think that is the end of our queue. 

OPERATOR: Yes, Sir. 

DAVE DAIGEL:  I think that concludes our telebriefing for today.  I want to thank everybody for joining us and let you know if you have questions or would like to follow up you can call (404) 639-3286 and then we will have a transcript available later on of the teleconference.  Thank you, Victor. 

OPERATOR: thank you, sir.  And thank you for your participation in today’s conference.  You may now disconnect.  

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES