Throughout the month of August, NACCHO’s National Immunization Awareness Month (NIAM) Blog Series highlights the importance of immunizations across the lifespan. This week’s NIAM Blog Series post takes us to Florida, where high rates of human papilloma virus (HPV)-associated cancers and low HPV vaccination rates led the Florida Department of Health in Broward County (DOH-Broward) to take action.

The Problem
The Centers for Disease Control and Prevention (CDC) estimates that nearly 40,000 HPV-associated cancers occur in the United States each year – 23,300 among women and 16,500 among men – and that these cancers are responsible for more than 90% of anal and cervical cancers, about 70% of vaginal and vulvar cancers, and more than 60% of penile cancers.

In the state of Florida, these statistics are all too familiar.

According to CDC data (2006-2010), Florida ranks in the top third of states in HPV-associated cervical cancer, anal cancer in males and females, and oropharyngeal cancer in males; while ranking in the mid-third of states in HPV-associated penile cancer and vaginal cancer. The state’s high rates of HPV-associated cancers have a lot to do with its low rates of HPV vaccination coverage. In 2013, CDC data indicated that HPV vaccination rates of adolescent girls (ages 13-17) in Florida was between 30-37.6%, placing Florida among the lower third in state ranking. In fact, that same year, Florida had the lowest coverage for =1 HPV vaccine dose (39.4%) compared to the rest of the nation’s states.

The connection between the low rates of HPV vaccination and high rates of HPV-associated cancers led Broward County – which represents 9% of the State’s population and is the second most populous county in Florida – to take action to increase HPV vaccination rates.

The Intervention
In May 2015, DOH-Broward and the Broward County Immunization Action Coalition (the Coalition) held a community planning meeting to develop an action plan to increase HPV vaccine rates in Broward County. The Coalition, which was developed in 1996 through the leadership of DOH-Broward, was established to develop, implement, and monitor immunization strategies that further the goals of providing complete protection against, and eventual elimination of, vaccine-preventable diseases.

DOH-Broward Immunization Clinic

As part of the community action plan, stakeholders agreed that DOH-Broward could offer HPV vaccine at its annual back-to-school immunization point of dispensing (POD). Consequently, DOH-Broward offered HPV vaccine during the 2015 and 2016 back-to-school immunization PODs, hosting extended night and weekend hours to maximize community reach. In addition, DOH-Broward attended a Broward County Pediatric Society meeting to educate providers about recommending the HPV vaccine as part of routine immunization clinical visits and speaking about the vaccine as cancer prevention. Further, by developing and distributing an HPV palm card to the community and providers, DOH-Broward was able to increase awareness of HPV and the HPV vaccine.

Through this series of activities, DOH-Broward produced a major shift in the county’s HPV vaccination rates.

The Impact
Prior to the intervention, DOH-Broward was only providing HPV vaccine at its immunization clinics and had not engaged the county’s provider community. However, by distributing more than 5,000 palm cards, offering the HPV vaccine at PODs, and making it a part of routine immunizations, the health department was able to increase vaccine acceptance in doses administered from 2015 (1,772) to 2016 (4,217), representing a 138% increase.

During the 2016 POD, 1,640 HPV vaccines were provided as compared to 903 in 2015 – an 81% increase. Of those, 1,256 were initial doses, 228 were second doses and 156 were third dose. HPV vaccine rates have also significantly increased at DOH-Broward clinics, which saw a 196.5% increase in doses provided from 2015 (869) to 2016 (2,577). Of those, 1,236 were initial doses, 944 were second doses, and 397 were third dose.

While this intervention is still relatively new, the hope is that DOH-Broward’s continued efforts to drive HPV immunization rates up will eventually help to curb the rates of HPV-associated cancers.

Best Practices & Lessons Learned
While increasing awareness and expanding opportunities for the community to receive the HPV vaccine had much to do with DOH-Broward’s success, there were other contributing factors. In particular, training immunization nurses on to reference HPV as cancer prevention rather than STD prevention was critical. When HPV becomes a part of routine vaccination and is presented as cancer prevention, parents are more apt to agree to the vaccination for their child. Further, the engagement of stakeholders and partners during the community planning meeting produced up-front buy-in that will allow DOH-Broward to continue increasing HPV vaccination uptake and vaccines delivered.

NACCHO is pleased to support local health departments in their participation of NIAM. Download NACCHO’s updated Guide to HPV Resources for Local Health Departments and be sure to check out our previous posts in the NIAM Blog Series:

• Breaking Down Barriers to Access to Increase Immunization Rates
• Leveraging Partnerships to Increase Maternal Immunization
• Increasing Adult Immunizations through Education and Outreach

• NIAM Blog Series 2017: Increasing Immunization through School-Located Clinics

For more information about vaccines for teens and preteens, check out resources from the Centers for Disease Control and Prevention.