Starting HPV Vaccine at Age Nine in Washington State: A Process Description

Background:

The human papillomavirus (HPV) vaccine is one of the safest, most effective vaccines available, preventing more than 90% of future HPV-attributable cancers, especially when the series is completed before the thirteenth birthday. The Advisory Committee on Immunization Practices (ACIP) recommends HPV vaccine routinely at age 11 or 12 but notes that vaccination can start at age nine. There are several benefits of starting HPV vaccine at age nine including a robust immune response, easier conversations for providers and more time to complete the series by age 13. Most importantly, starting HPV vaccination at age nine has been shown to increase rates of completion by age 13.

Program background:

In 2022, the Washington State Vaccine Advisory Committee (VAC) passed a motion to take action to encourage HPV vaccination at age nine. The motion included changing the state’s Immunization Information System (IIS) forecasting to alert providers that HPV vaccine is due starting at age nine, tracking and publishing HPV vaccination coverage rates for children aged nine and 10, and encouraging providers to routinely start HPV vaccination at age nine via communications, as well as printed and electronic HPV vaccine materials issued by the Washington State Department of Health (DOH).

Once the motion passed and the IIS change was implemented six months later, DOH began educating providers on why HPV vaccination starting at age nine is important.

Evaluation Methods and Results:

DOH sent over 27,000 e-letters to health care providers, local health jurisdictions, childhood vaccine providers, and school nurses to provide awareness and a rationale for the change in IIS forecasting. The letter encouraged providers to implement any needed structural or organizational changes to start vaccinating at age nine and linked to evidence-based materials developed and curated by DOH and Washington HPV Free Taskforce. Several “Age 9” materials were translated into the state’s top five languages (Spanish, Russian, Ukrainian, Vietnamese, and Marshallese).

Since preteens and adolescents may see their dentist up to twice yearly, dental providers are in a unique position to educate about HPV’s link to oropharyngeal cancers and the importance of HPV vaccination for cancer prevention. Therefore, an additional 33,000 e-letters were sent to dental providers, with tailored tools to help them start conversations about the importance of on-time HPV vaccination starting at age nine.

Conclusions:

With IIS changes and tailored resources, health care and dental providers are better prepared to confidently recommend HPV vaccine starting at nine. Prior to the IIS change, providers reported concerns that it might conflict with the ACIP guideline. Now, health care providers share that the change in IIS gives them direction and authority to administer HPV at nine.

Implications for research and/or practice:

As a result of implementing the VAC motion, Washington state expects to see an increase in initiation and completion of the HPV vaccine series and a larger percentage of people protected from HPV-attributable cancers. The Washington state model can provide insight and a framework for other regions to encourage providers to routinely begin HPV vaccination at age nine.