PolicyLab

Human papillomavirus (HPV) causes more than 30,000 cases of cancer in the U.S. each year. Despite the availability of a safe, long-lasting, and highly effective vaccination, uptake of the HPV vaccine is substantially lower than other adolescent immunizations like the tetanus, diphtheria, and pertussis (whooping cough) vaccines. With many individuals currently experiencing delays in routine health care due to the COVID-19 pandemic, HPV vaccination rates have taken a further hit.

Simultaneous vaccination, the delivery of multiple vaccines during the same doctor’s office visit, is one important strategy to improve vaccine coverage. This practice is recommended because it ensures that patients get all due vaccines in fewer visits, minimizing the number of times they need to return to a provider’s office to stay up-to-date. In fact, the Centers for Disease Control and Prevention (CDC) estimated that the HPV vaccination rate among teenage girls would nearly double if the HPV vaccine was routinely given at the same visits when another vaccine was administered.

Opportunities to Give the HPV Vaccine Alongside the Flu Vaccine are Often Missed

Influenza (flu) vaccines are common in adolescent primary care and are frequently given at nurse-only visits—a distinct visit type not involving a pediatrician or nurse practitioner. These visits could provide an efficient opportunity to make sure a patient is caught up on HPV vaccinations, but we first need to know more about if and how often teens are getting HPV and flu vaccines during the same visit. With this in mind, our team examined how often opportunities to simultaneously administer the HPV vaccine with the flu vaccine were missed.

Using electronic health record (EHR) data from 48 pediatric primary care offices across the U.S., we explored how often an HPV-vaccine-eligible teen came into the office for a flu vaccine and did not receive an HPV vaccine. What we found is that, in a majority of the instances (58%) when an eligible teen received a flu vaccine, there was a missed opportunity to additionally administer the HPV vaccine. Missed opportunities were more common when the first HPV vaccine dose was due (69% vs. 31% for subsequent doses) and for sick and nurse-only visits compared to preventive visits (74% and 80% vs. 37%).

Challenges, Opportunities and Potential Strategies for Improvement

From this study, we learned that there is a significant need to develop strategies so teens are offered HPV vaccinations whenever they come to the office. This has become even more important amid the COVID-19 pandemic, when many teens may have fallen behind on their vaccinations overall. With public health messaging emphasizing the particular importance of the flu vaccine this year, now is an opportune time to leverage flu vaccine visits for delivery of the HPV vaccine and any other due vaccinations.

With public health messaging emphasizing the particular importance of the flu vaccine this year, now is an opportune time to leverage flu vaccine visits for delivery of the HPV vaccine and any other due vaccinations.

However, there are clearly barriers to overcome to co-administering the HPV vaccine with the flu vaccine, as our results suggest that prior to the pandemic flu vaccine visits were often not being utilized to deliver the HPV vaccine. For example, in the case of nurse-only visits, practices may be trying to keep pace with a large number of children scheduled for flu vaccination in a brief period of time. A concern may be that giving other vaccines will slow down a process primarily meant to address the flu. Additionally, a practitioner may not be immediately available to issue other vaccine orders or answer patient questions. Even at visits where a practitioner is present, time constraints and pressures to focus on the issue at hand (illness, injury, etc.) may make it difficult to assess which other vaccines are due and discuss them with the patient. This could be especially true when the patient or family expresses vaccine hesitancy that requires a more in-depth conversation.

Though these difficulties may seem daunting, strategies exist to overcome them. Some potential solutions I recommend considering include:

• Working with practice leadership to create standing orders for vaccines that allow qualified health care professionals (e.g., nurses) to give due vaccines without individual orders from a pediatrician or nurse practitioner.
• Easily visible vaccine prompts that make it clear to the clinician which vaccines are due at each visit. Prompts may be generated by the EHR or by a member of the staff (e.g., nurse or medical assistant).
• Training providers on concise communication techniques that they can use to talk to hesitant families.

More research is needed to determine how well these and other strategies work and how best to implement them without overburdening practices. Though key changes to office work flow may be required, doing so could greatly improve HPV vaccine coverage, protecting the health of children now and in the future.