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Human Papillomavirus Vaccine: An Opportunity for Minnesota Pharmacists to Impact Public Health

By Ann M. Philbrick, PharmD, BCPS, BCACP; Caitlin K. Frail, PharmD, MS, BCACP; Taeho Greg Rhee, PhD, MSW

The most common sexually transmitted infection in the United States is human papillomavirus (HPV).1 In 2013-2014, the prevalence of any genital HPV in adults age 18-59 was 42.5%.1 In some instances, HPV infection can cause chronic conditions (e.g., malignant genital warts) or cancer in many sites in the body, including the cervix, vagina, vulva, penis, anus, rectum, and oropharynx.2 It is estimated that HPV is attributed to 19,400 female and 12,100 male new cancer cases each year in the United States.2 In Minnesota, the incidence rate of all HPV-associated cancers was 10.2% in 2008-2012.3

Fortunately, a vaccine exists that can reduce the incidence of HPV associated cancers. Currently, the only HPV vaccine available in the United States is the nine-valent formulation, Gardasil®. The HPV vaccine is recommended for routine administration in females and males at 11 to 12 years of age, however it may be given as early as age nine. It is recommended for initiation in females age 13 to 26 and males age 13 to 21 who have not previously been vaccinated. Males age 22 to 26 may also be considered for the vaccine.4 It is given as a three-dose series; however, recent CDC recommendations have indicated a two-dose series to be sufficient in adolescents who initiate the vaccine prior their fifteenth birthday.4,5 (For more information regarding how to apply these new recommendations, please visit this site.

Despite studies that have demonstrated HPV vaccine to be safe and effective in preventing HPV-associated cancers, state and national HPV vaccination rates remain low. According to a national survey of adolescents aged 13 to 17 years in 2015, 62.8% of females and 49.8% of males received at least one dose of HPV vaccine.6 This was reduced to 41.9% for females and 28.1% for males when considering adolescents who had received at least three doses of HPV vaccine, which is well below the Healthy People 2020 goals of 80% coverage with three doses of HPV vaccine for adolescent females and males.7 This same survey found that Minnesota HPV vaccination coverage among adolescents was also low, with 65.5% of females and 57.1% of males receiving one or more doses of HPV vaccine and 44.5% of females and 22.4% males receiving at least three doses.6

In 2015, a change to Minnesota Statute 151.01 subdivision 27 allowed pharmacists to provide HPV vaccine to patients aged 13 years or older (previously aged 18 years) under a standing protocol and according to ACIP recommendations. With this change, the doors were opened to allow pharmacists to impact HPV vaccination rates in Minnesota. In addition, when Minnesota Statute 151.01 subdivision 27 was updated in 2015 to expand the age range for pharmacist-administered vaccinations, it also added pharmacy requirements with respect to the Minnesota Immunization Information Connection (MIIC). In Minnesota, pharmacists are required to report administered vaccinations to MIIC, as well as access a patient’s MIIC history when considering administration of a vaccine (with the exception of influenza vaccine in patients age 9 and older). More information about MIIC in pharmacies can be found here.

The Minnesota Department of health has operated the MIIC since 2002. MIIC is a secure, electronic system that centralizes patients’ vaccinations into one record.8 In 2015, 83.6% of adolescents age 11 to 17 had at least two vaccinations reported to MIIC, and 95.4% of adults aged 19 years and older had at least one vaccine reported to MIIC. This was above the national averages of 72% and 39%, respectively.9 While there is no mandate to submit data to MIIC (outside of the pharmacy statute), 87% of providers participate in MIIC, making it a reliable source of immunization data.

In order to examine how Minnesota Statute 151.01 subdivision 27 impacted HPV vaccination rates in Minnesota, recently we looked at MIIC data for HPV vaccinations recorded in a pharmacy one year prior, and one and a half years after July 2015, when the law took effect. Prior to the law being enacted, pharmacies reported two and 33 doses to MIIC for patients age 13 to 18 years and 19 to 30 years, respectively. After the law was enacted, these numbers increased to 28 and 149 doses for patients age 13 to 18 years and 19 to 30 years, respectively. It should be noted that these were MIIC entries originated from pharmacies. In most cases, this suggests a pharmacist provided the vaccine, but in some instances, it could indicate the pharmacy adding a vaccine history for a patient. We believe that this is the case for the vaccinations given to those ages 13 to 18 prior to July 2015.

While these numbers represent only a small portion of the total HPV vaccines administered in Minnesota, it does show a potential capacity for providing HPV immunizations in a community pharmacy. Pharmacists should consider adding HPV vaccinations to their current immunization efforts as it provides a unique opportunity for an unmet need in the community. There remains significant vaccine hesitancy surrounding the HPV vaccine; pharmacists can be advocates and a source of information about the vaccine to parents and patients. Despite not being able to offer the vaccine at the recommended age of 9, pharmacies can serve as a location to administer subsequent doses after the patient turns 13. MIIC can help identify these patients. Additionally, pharmacies frequently offer longer business hours than medical clinics, thereby offering a more convenient location for subsequent doses. Through providing HPV vaccines and education to patients, Minnesota pharmacists have the potential to help stamp out HPV and its associated diseases.


References

1. National Center for Health Statistics. Prevalence of HPV in adults age 18-69; United States, 2011-2014. NCHS Data Brief No. 280, April 2017. Available: https://www.cdc.gov/nchs/products/databriefs/db280.htm Accessed: April 24, 2017.

2. Centers for Disease Control and Prevention. How many cancers are linked with HPV each year? Available: https://www.cdc.gov/cancer/hpv/statistics/cases.htm Accessed: April 24, 2017.

3. Centers for Disease Control and Prevention. Human papillomavirus-associated cancers – United States, 2008 – 2012. MMWR. 2016;65(26)661-6.

4. Centers for Disease Control and Prevention. Use of a 9-valent human papillomavirus (HPV) vaccine: update recommendations of the advisory committee on immunization practices. MMWR. 2015;64(11);300-4.

5. Centers for Disease Control and Prevention. Use of a 2-dose schedule for human papillomavirus vaccination – updated recommendations of the advisory committee on immunization practices. MMWR. 2016;65(49):1405-8.

6. Centers for Disease Control and Prevention. National, regional, state, and selected local area vaccination coverage among adolescents age 13-17 years –United States, 2015. MMWR. 2016;65(33):850-8.

7. Healthy People 2020. Immunization and Infectious Disease. Available: https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives Accessed: May 24, 2017.

8. McKinney ZJ. The merits of MIIC – Minnesota’s Immunization Information System excels at population health surveillance. Minnesota Medicine. 2017;May-Jun:20-2.

9. Centers for Disease Control and Prevention. IISAR data participation rates and maps. Available: https://www.cdc.gov/vaccines/programs/iis/annual-report-iisar/rates-maps-table.html Accessed: April 24, 2017.

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