Surprising Ways to Increase HPV Vax Rates

How are you feeling about your HPV vax efforts?

If you already know that the HPV vaccine is critical and you’re frustrated that coverage is falling short, SKIP PART ONE.

However, if you would like to improve your coverage and you’d like to have the majority of the strategy work already done for you, DO NOT SKIP PART TWO.

PART ONE: THE SAD STALL-OUT OF THE HPV VACCINE

One look at the graph below from the CDC’s latest TeenVaxView shows the problem with implementing the HPV vax – it’s stalled out at just over 60%, meaning that, every year, over a million and a half of our kids will exit their teenage years unshielded from some of the worst cancers, not to mention warts in all the places you’d least like to find a wart. As Dr. Scott Hamstra, STChealth’s Medical Advisor, put it in an earlier article, “With HPV, you don’t just get cancer, you have a horrible experience of cancer. To be sure, all cancer is bad, yet unlike fairly ‘invisible’ cancers in the lung or colon; with HPV it’s wickedly visible on our face and neck or in our intimate private areas. Both the cancer and the treatment can be devastating.”

Picture saying this to someone entering adulthood without benefit of the vaccine: “Ah, shucks, we missed you. Sorry. Hope it works out okay. Fingers crossed, right?” Now say it a million and a half times every year.

PART TWO: WHAT WORKS — HIGH TECH & LOW (!) TECH

What got us rethinking HPV vaccine schedules was hearing Dr. Jamilia Sherls speak at the most recent Thought Leadership Conference hosted by STChealth. She’s an advanced public health nurse and the Director of Washington State’s Office of Immunization. Her team’s work on the “HPV@9” project enlivened the conference. Then, we were able to have a follow-up conversation with Dr. Sherls, along with Dr. Sherri Zorn, a pediatrician who is a member of the Washington Chapter of the American Academy of Pediatrics, serves with the state’s HPV task force and a partner in the HPV@9 effort.

Early in her conference remarks, Dr. Sherls stated that their experiments with lowering the age for HPV vaccinations were “proof of concept that starting at age 9 is a simple, successful, and sustainable strategy to increase on-time HPV vaccination rates.” A review of those efforts shows that it certainly was successful and sustainable… but, simple? Yes, now it is. The folks in Washington have been working on this since 2017 and have done the work that makes implementation much easier for anyone else.

First, let’s start with the results:

As Dr. Sherls put it, “Our numbers speak for themselves.” And what are those numbers telling us?

Since changing the forecast to age 9 in January, 2023, statewide HPV initiation rates increased almost 11 points at 9-10, while also increasing 5 points at 11-12. 

And this in a time of decreasing childhood vaccination rates since the pandemic. (Data as of 12/31/25)

To understand how they did it, let’s start with Dr. Sherls’s summary of their two pilot programs:

Following up on those early successes, the DOH and the Task Force have continued to test supporting resources. Here’s a partial list of what they’ve tried, then and since:

• Changing the IIS forecaster to age 9 (and, where possible, changing the EHR system to match)
• Provider training
• DOH website support information/materials
• Webinars for providers
• Immunization schedule posters
• HPV posters
• HPV brochures
• HPV fliers
• Provider awards program
• Mailers to parents

That’s a lot, right? So we wondered if someone wanted to start their own HPV@9 effort, which of these might they prioritize? It turns out that the team surveyed providers on what they thought was most important. Based on 131 responses, Dr. Zorn described what they learned:

“We asked which Department of Health resources have been helpful to increase HPV vaccination rates in their practice. The IIS forecast was the number one thing that helped them. As the forecast went to age 9, it gave permission and encouragement to begin HPV at 9 — and many clinics and organizations aligned EHR’s to match the IIS forecast. And the second resource they mentioned was immunization schedule posters — having posters where it says very clearly HPV is between ages 9 and 12 — that was important.”

So we have providers seeing on their screens that the HPV vaccine is due, while parents are seeing it on the wall.

Dr. Sherls added to those two: “I think it really does take a multi-pronged approach. And I would say if I had to choose, I would definitely recommend educational resources for both providers and families The mailers that we sent to parents go over the importance of vaccinating earlier at age 9 — or if they’re not 9, at 11 and 12 – and emphasizes the vaccine’s benefits: prevention of cervical cancer and other HPV associated cancers. They also contain information that addresses common questions.”

As you see in Dr. Sherls’s chart below, the mailer led to a 17% increase in the vaccine being administered.

Dr Zorn offered thoughts on why this is so helpful: “Some parents don’t even know about the HPV vaccine. They never heard of it: they’re like, ‘Huh, really prevents cancer — didn’t know.’ So they’re just not aware of it, much less the importance for cancer prevention. Sending out the mailers ahead of time allows parents to be a little bit more prepared, so hopefully they’ll have heard of it, and then they’re ready to either say ‘yes’, or ask questions and gather more information so they feel comfortable making that decision.”

NEXT STEPS TO “SIMPLE, SUCCESSFUL AND SUSTAINABLE”

If you’re ready to expand your own efforts, you’d probably want to start with changing the IIS and EHR forecasters and some provider training to go along with it, plus those posters and mailers. The folks in Washington are happy to share their work at…

www.doh.wa.gov/hpv-at-nine

You’ll find the materials there, many translated into several languages. As Dr. Sherls pointed out, they were produced as part of federally funded programs, so there are no copyright concerns with sharing the resource materials.

BONUS TOPIC: BUT WHAT ABOUT ONE DOSE?

While we’ll save for another time the debate about HPV being one dose or two (Washington State is sticking with recommending two), we did ask whether it might affect the age recommendation at 9 versus 11, and we wanted to share the insights from Dr. Zorn:

“The question is, if we did move to one dose, would we still want to start at 9? The short answer is ‘yes, start at 9:00 with the goal of completing HPV vaccine before age 13.’ Starting at 9 offers more time and opportunities to get vaccinated — and, as a bonus, many providers share that it often results in easier conversations with parents.

“If you wait until 11 to recommend HPV, you’re going to miss some kids. At age 11, here are other school- required shots, and some parents say, ‘I don’t want that many shots, let’s postpone HPV because I don’t think my kid will be sexually active.’ Life gets busy and they may not return to their doctor for a few years. Some kids don’t have a doctor’s appointment at 11 or 12 — they might get their shots at the pharmacy or school clinic and may not be offered HPV at that time. And, importantly, some parents have hesitancy and need more time to feel comfortable with HPV vaccination. All these are missed opportunities for on- time vaccination. So, yes, start at 9. Give parents and patients the choice of when they want to get it done — we know that nine works great, 10 works great, 11 works great, 12 works great. You have four years to get in the one or the two doses and then they’re protected for life.”

* * * *

STATS OF THE MONTH

A Public Health Learning Moment: Data Blues?

By Bill Davenhall, Geomedicine Analyst

If, for the past decade or so, you’ve relied on health-relevant data that others have collected and disseminated to support your work in health, healthcare or the human services, a learning moment has just arrived. Here’s how we got there:

1946 – The World Health Organization, along with the United Nations and the World Bank, recognized the need to track health expenditures and consumption patterns of health services in order to compare the relative progress by each nation in serving human health needs.

1964 –The United States  began to fully participate in what is known as the NHEA system (National Health Expenditure Accounts) which would  produce the first comprehensive estimates of U.S. national health expenditures. Its roots began here: the U.S. Department of Health, Education, and Welfare (predecessor to HHS), then the Social Security Administration (SSA), followed by the Office of Research and Statistics, and then, in 1977, the Health Care Financing Administration (HCFA) under the Department of Health, Education and Welfare (later HHS). The actual NHEA production shifted to the National Health Statistics Group located within the Actuary’s Office of HCF who took primary responsibility for compiling and publishing the accounts annually to Congress and the public.  In 2001, HCFA was officially renamed the Centers for Medicare & Medicaid Services (CMS) to better reflect its broader mission beyond just financing, and CMS continues through the present day to manage the program. (Sounds like a possible “Lego kit” don’t you think?)

2026 – Well, the NHEA is likely to disappear in the withdrawal of the U.S. from the WHO, coupled with the intentional reduction of governmental employment across many Federal statistical and data handling work groups. We don’t really know what the loss of this critical body of national account data, or maintenance of its collection methods and professional management staff will be. Quality estimates of health expenditure data may be at stake – impacting many organizations besides just governmental. If the data disappear, I wonder what organizations who relied on this important data set will do? (Imagine, if you will, a future WHO publication that has a footnote identifying the U.S. as a “non-reporting nation”?) The NHEA has helped the entire world, not just the U.S., compare and contrast its national health expenditures; thus, it has become one of the most respected ways policy decisions at the highest levels of government, as well as many players across the health ecosystem, understand the scope and changes in the investment of public and private funds in keeping a nation healthy.

What’s my suggested treatment plan for the future “data deserts” appearing in the US health ecosystem?

1. Learn as much as you can now about the national consensus (using AI products) of the usefulness of any data you rely on today in your work – guide your assumptions by asking your AI resource better questions. Yes, get better at asking the right questions.
2. Reduce your span of interest in working with data that could be slowed down or eliminated, but increase your diligence in watching for replacement or surrogate data. Worry more about how you will replace core data elements that you use most frequently.
3. Look for data that health-related businesses need to have on hand for planning, marketing, distribution, and site selection.  Think about who else might need immunization data and collaborate on work-arounds. Don’t procrastinate — a lot of health data takes years to be ready for use.
4. Organize data hackathons using AI to find your invitees – open it up to creative AI gurus. Accelerate how you explore solutions when you are not even sure what the problem is.
5. “Never waste a crisis.” A crisis brings out the best in most people, in most places. It’s a good time for creative collaborations to be forged. Many digitally enlightened developers have resources to help support “after-action” collaborations. 

As always, I appreciate 2^nd opinions!