CDC Telebriefing on National Immunization Survey- Teen results and HPV vaccination coverage among adolescents

OPERATOR: Excuse me, this is the conference coordinator. Please continue to hold. The conference will begin shortly. Please continue to hold while the others join. Thank you. 
Welcome and thank you for standing by. At this time all participants are in a listen-only mode. During the question and answer session please press star 1 on your phone. Today's conference call is being recorded. If you have any objections, you may disconnect at this time. I would like to turn today’s meeting to Benjamin Haynes. You may begin.

BENJAMIN HAYNES: Thank you, Rebecca. Thank you all for joining us this afternoon on a telebriefing on two MMWR articles released today by the CDC. One article is on the National, Regional, State and Selected Local Area Vaccination Coverage among Adolescents age 13 to 17 in the United States in 2013. The other is on Human Papillomavirus Vaccination Coverage among Adolescents in the U.S. from 2007 through 2013 and Postlicensure Vaccine Safety Monitoring from 2006 to 2014 in the United States. With us today is Dr. Anne Schuchat spelled s-c-h-u-c-h-a-t. Dr. Schuchat is an assistant surgeon general in the United States Public Health Service and the director of our National Center of Immunization and Respiratory Diseases. She will provide some brief opening remarks and then she'll take your questions. Dr. Schuchat?

ANNE SCHUCHAT: Thank you everyone for joining us. Today I wish I had good news, but what I need to report is a small increase in HPV vaccinations and other teen vaccinations. Today we're releasing new data from our 2013 National Immunization Survey of Teens or NIS- Teen. One report in this week's MMWR provides estimated coverage rates for three routine vaccines targeted at adolescents. This is the Tdap vaccine which protections against tetanus, diphtheria, pertussis or whooping cough, and the meningococcal conjugate vaccine, and the human papillomavirus or HPV vaccine.

A second report in today’s MMWR provides an in-depth look at HPV vaccination coverage and updates information on the safety of this vaccine. I'm going to discuss three areas briefly; new data on vaccine coverage among teen boys and girls from the NIS- Teen, missed opportunities for HPV vaccination and why strong recommendations from clinicians are so important. The MMWR articles include data on vaccination rates from the National Immunization Survey on Teens which is a very large, nationally representative survey that collects clinician-validated vaccination for adolescents who are 13 to 17 years of age. The reports today summarize information on 18,264 teens who had that doctor-validated vaccine history. The survey uses a random-digit dialed approach, but includes both landlines and starting in 2011, cellular telephone numbers and in the 2013 survey we had about one-third of the responses from landlines and two-thirds from cell phones.

Among teens 13 to 17 years of age, the 2013 survey found very small increases in each of the three routine teen vaccinations. HPV vaccination coverage for girls increased 3.5 percentage points from 53.8 percent in 2012 to 57.3 percent in 2013. Coverage for meningococcal conjugate vaccine increased 3.8 percentage points from 74 percent in 2012 to 77.8 percent in 2013. Tdap coverage was already high at 84.6 percent in 2012, but it increased another 1.4 percentage points to 86.0 percent in 2013. It is a relief that we did not continue to have flat lining HPV coverage in 2013. You may recall there was absolutely no improvement from 2011 to 2012. The increase we did see in the 2013 results was quite small at the national level. We looked intensively to see if there were any more encouraging signs, and as I had said, we were disappointed with the overall findings.

However, I'd like to highlight five states that did have significant, impressive increases in HPV coverage between 2012 and 2013. These states are Illinois, Michigan, New Hampshire, New Mexico and South Carolina. These individual states had increases ranging from 12 percentage points in Illinois to 18.5 percent in South Carolina. These states don't have commonalities on the surface. They literally reflect the north, south, east and west regions of the country, but each of these states took some action focused on HPV or teen vaccination that might have led to greater progress. The steps they took included working intensely with clinician organizations, immunization and cancer groups, conducting outreach to parents, implementing peer to peer clinician office visits on HPV vaccinations and using systems approaches like reminder recall and assessing vaccine coverage at the practice level then feeding back the information which we call AFIX or a-f-i-x.

In 2012 many other states are taking on these same kinds of activities so we'll need to see if that helps improve the national picture. The HPV vaccination report today describes missed opportunities for HPV vaccination. When a teen is in the doctor's office and receives another vaccine, but not HPV, that's a missed opportunity. Based on the survey we estimate that if every time an 11 or 12-year-old was getting another vaccine, HPV was given as well, HPV coverage by the 13th birthday would have been 91 percent instead of 47 percent. This data are for girls. Our system is clearly missing many opportunities to vaccinate against HPV-related cancers. We are urging clinicians to strongly recommend HPV vaccine the same way and the same day they recommended and administer meningococcal conjugate and Tdap vaccines.

The data show that a recommendation from a healthcare professional is strongly associated with teens getting vaccinated. One of the top five reasons parents listed for not getting the HPV vaccine for their son or daughter was that it hadn’t been recommended to them by their teen's doctor or nurse. The parents that vaccinated their daughter against HPV, 74 percent had received a recommendation from a healthcare professional, while 52 percent of parents that didn't vaccinate their daughter recalled the vaccine being recommended to them. HPV vaccination of boys is still being seen as fairly new and it appears from the 2013 survey data that fewer clinicians were recommending it routinely. A clinician recommendation was very important in boys, too. Seventy-two percent of parents that vaccinated their son received a recommendation compared to only 26 percent of parents that didn't vaccinate their son.

Let me briefly mention the other vaccine data. Vaccination with Tdap and meningococcal conjugate vaccine continues to be strong with 86 percent of teens having gotten Tdap and 77.8 percent having gotten the first meningococcal conjugate vaccine dose. In October 2010, the ACIP recommended a second dose of meningococcal vaccine for teens at age 16. Today's report includes the first estimate of uptick in the meningitis booster dose. We saw 29.6 percent of the teens who were eligible for a second dose that actually got one. So there's room for improvement there, too.

We encourage parents and caregivers to ask about vaccination every time they take their kids for a health care visit whether their children are babies and toddlers or tweens and teens. Recent outbreaks highlight the importance of adolescent immunization. Several areas are seeing increases in whooping cough this year and every single case of meningococcal meningitis is a medical emergency. Vaccines can't prevent all of those illnesses, but people who are vaccinated are much less likely to get these diseases. I know many parents are starting to think about their back-to-school chores. Stocking up on school supplies and scheduling sports physicals. This is a great time to make sure your teens have gotten all of the recommended vaccinations and all 11 or 12-year-olds, girls and boys, should be protected from meningitis, whooping cough and HPV-associated cancers.

The results we are reporting today are disappointing. There are about 14 million new HPV infections every year, most often acquired in people in their teens and 20s. HPV vaccine can prevent infections caused by vaccine-type strains. People who have persistent HPV infections can develop a variety of cancers and even in a setting of good national screening efforts. Every 20 minutes an American is diagnosed with an HPV-associated cancer. The HPV infections we don't prevent this year may be the first step in development of cancers for some of our nation's young people. Our continuing good results with Tdap and meningococcal vaccines show us that our system can reach high levels of adolescents with recommended vaccines, but the minimal progress with HPV vaccination reminds us there is a lot more we have to do. This year we don't have a big news story on teen vaccination results, but in this case no news is bad news for cancer prevention. I'd like to take questions, operator.

OPERATOR: Thank you. We'll begin the question and answer session. If you'd like to ask a question, please press star 1. Please unmute the phone and record your name clearly when prompted. To withdraw your request, press star 2, wait just a moment for our first question.
Our first question comes from Maggie Fox, NBC News. Your line is open.

MAGGIE FOX: Hi, thanks. Dr. Schuchat how much would it help if more school districts and more states required HPV vaccination for attendance? That seems to be one of the biggest factors driving vaccination, isn't it?

ANNE SCHUCHAT: Actually, we have very good coverage with the other vaccines and not all states require all of the vaccines. So the key, we think, are in the doctors' office or something and they have a chance to get a vaccine and they're not getting the HPV vaccine as frequently as they could.

MAGGIE FOX: Why do you think the doctors aren't recommending it?

ANNE SCHUCHAT: Actually, I think the doctors think that they're recommending it and what we think is that the doctors have some room for improvement in the way they talk about HPV. Often they'll talk about recommending Tdap and meningitis vaccines and initiating a conversation about HPV. We think it's a much better way to say “today there are three recommended vaccines: meningitis, Tdap and HPV.” Really mainstreaming the recommendation for HPV together with the other two recommended vaccines. We think that is a very clear way to send a strong recommendation and it's easy for parents to understand.

MAGGIE FOX: Thanks.

ANNE SCHUCHAT: Next question?

OPERATOR: Thank you. Our next question comes from Mike Stobbe with Associated Press.

MIKE STOBBE: Hi. Thank you for taking-- two questions other actually. I want to ask-- I was just going over the table in the HPV article.  One dose, HPV adolescent girls, 57.3 percent up from 53.8 percent. Looking at the confidence intervals, was that increase statistically significant or is it potentially considered flat? I see there was more of a jump for the three dose, and I have a follow-up question.

ANNE SCHUCHAT: Yes. That was statistically significant. The increase of three dose.

MIKE STOBBE: I'm sorry, for the one dose, though. Was that statistically significant?

ANNE SCHUCHAT: Yes. The one-dose increase was significant.

MIKE STOBBE: Okay. My other question, I think I understand, you know, when a new vaccine is introduced it could take years or many years for uptake-- for vaccination rates to reach the 90 percent plus level we see with vaccines like measles. Can you give us just a little bit more of a historical comparison. Is the lag for HPV more pronounced than we saw with measles and some of the other vaccines?

ANNE SCHUCHAT: There was good initial uptake or progress with HPV and then it plateaued much sooner than we would see with other vaccines. We often think of about a 10 percentage point increase per year the first few years after a vaccine is recommended.

MIKE STOBBE: Okay. Thank you.

ANNE SCHUCHAT: So it was an early plateau.

MIKE STOBBE: Thank you.

ANNE SCHUCHAT: Operator, next question?

OPERATOR: Our next question comes from Eben Brown with Fox News Radio.

EBEN BROWN: Hi. Good afternoon. Thank you for taking the call. Dr. Schuchat, what seems to be more the barrier to getting parents to agree to the HPV vaccine? Is it that doctors don't really talk about it much or is there still just parental opposition that we've seen when we saw it in political circles, but is that still a barrier or has more information made it to parents about what the vaccine can do for the child?

ANNE SCHUCHAT: We think that parents who aren't planning to vaccinate lack knowledge and didn't hear a clinician recommendation. Those were frequently reported as the reasons the parents weren't getting their children vaccinated. We don't think it's an issue of politics. We think this is something that most parents are very open to with clear communication. Did you have a follow-up question?

EBEN BROWN:  I do. Is there still concern of side effects to vaccines like Gardasil and what not?

ANNE SCHUCHAT: Questions about safety do come up in reasons that parents are hesitant about the HPV vaccine.  I think it's very important for people to know that over 67 million doses of HPV vaccine have been distributed in the United States and it has a very strong safety record. There have been intensive studies and reviews by independent groups and we think that the HPV vaccine is very safe and appears to be very effective and long lasting based on all of the data available today. Next question, operator?

OPERATOR: Our next question comes from Deborah Kotz with Boston Globe. Your line is open.

DEBORAH KOTZ: Hi there. Thanks for taking my question. I'm wondering, because the information has changed slightly since the HPV vaccine first came out in terms of protection against oral cancers. There has been wide *unintelligible* oral cancers and wondering if doctors are being instructed on when they do talk about the HPV vaccine to talk about these cancers especially in boys, because originally when it was approved in boys- it was thought to be a bit of an altruistic vaccine that will help them from spreading the infection to girls, but boys may have some sort of benefit from it as well. Whether that's something the CDC has been speaking to doctors about or trying to get them to communicate to parents.

ANNE SCHUCHAT: The HPV virus has now been associated with many different kinds of cancer and we're optimistic about the benefits of the vaccine from different types of cancers in both women and men. We are working closely with clinical organizations including the American Academy of Pediatrics and the American Academy of Family Physicians as well as cancer specialists and cancer organizations because we do think this range of cancers that the virus can cause are important for clinicians to understand. Most pediatricians don't see those cancers. We think it's important for people to understand that the vaccines they give can prevent very serious cancers that do occur in people in the U.S. despite our strong cervical cancer screening program. Did you have a follow-up question?

DEBORAH KOTZ: I do. One follow-up. Also in terms of the age. I've gotten this as a parent from my pediatrician saying you don't need to give it now, you can wait a few years and I believe there's information that finds that it's more beneficial to get it at a younger age. Is this something that the CDC is also instructing doctors that it should be emphasizing that the vaccine does work better in younger teens?

ANNE SCHUCHAT: We think there has been confusion about when is the best time to get the vaccine. There's very impressive antibody data that shows the teens at the 11 and 12-year-old age has much higher antibody response than do older teens or young adults. We see good efficacy even with lower levels of antibody, but we do think that 11 or 12 is the best time to get it because of the high antibody response and because it's well before exposure to the virus might occur. When people say let's talk about it, let's wait and we can do it later, so often teens are never back in the office and you really don’t know when they'll be exposed to the virus in their later years. So there are multiple reasons that 11 or 12 is a great time to get the vaccine when the other vaccines are recommended and as was mentioned earlier there are a number of states with middle school entry requirements meaning that the parents are coming in the doctor's office for a Tdap or meningitis vaccine. They can get the HPV vaccine series begin at that same visit. Next question, operator?

OPERATOR:  Our next question comes from Dan Childs from ABC News.

DAN CHILDS:  Thank you so much for taking my call. Just a quick question about the fact that we're looking at greater than or equal to one dose in this. We know that the HPV vaccine is a three-dose course, and we see the number for the three doses is still quite a bit smaller than those getting one dose. What are some of the challenges that-- that I guess, doctors and perhaps even parents face with regard to this and can this really be remedied by, I guess, asking or having the clinician talk about HPV at a single visit when, in fact, what we're talking about is three encounters with a health care professional?

ANNE SCHUCHAT: Right. There are several strategies to increase return visits. There's something called reminder recall where you can either use a registry or use an electronic health record or use a post-it note, but you can essentially routinely set people up to come back for follow of-up visits and then recall them if they're overdue for those visits. We also know there are communication efforts we can make separate from the doctor's office to help reinforce the series completion. I can say that a challenge is how busy teenagers are and to get a couple of visits scheduled can be very challenging between the teen's schedule and parent's schedule.

There are a number of issues being looked at right now. There are other countries that have changed their recommendations to have a two-dose series, instead of a three-dose series particularly when the series is initiated early before age 13 or 14 and that's not early, that's actually on time, but essentially changing to have a two-dose for the younger kids and a three-dose if you're initiating at 15 or later. In the United States our recommendations currently are a three-dose series, but we do have technology-like registries and electronic medical records to help get the kids back in the office. I also want to mention that pharmacies can often offer a vaccine and some states or some partnerships are beginning the series in the doctor's office and encouraging the follow-up doses to be given at a more convenient location in terms of day/night availability like a pharmacy. Our next question?

OPERATOR: Our next question comes from Beth Greenfield with Yahoo Health. The line is open.

BETH GREENFIELD: Hi. Thank you so much for taking my call. I would like to address one of the reasons given by some of the parents which was safety concerns, and I-- I'm sure this comes from many different media reports with various concerns from parents, and I’m wondering if you can please address reports I’ve seen which say that the National Vaccine Injury Compensation Program has awarded nearly $6 million total to 49 individuals based on HPV vaccine injuries including two deaths?

ANNE SCHUCHAT:  Let me say that every bad thing that happens after a vaccine is not caused by a vaccine. The vaccine injury compensation program has a table of injuries that they look at for side effects of vaccines that are associated with the vaccine and considered causally linked.

BETH GREENFIELD:  Okay.

ANNE SCHUCHAT:   HPV vaccine has been reviewed to understand what kind of after-effect or adverse event might be causally linked with the HPV vaccine and there are no serious ones that have been considered causally linked. While there have been some individuals who unfortunately have died in the period after getting an HPV vaccine, there's not considered to be an association between that. As I mentioned, about 67 million doses of HPV vaccine have been distributed in the U.S. and even though rates of fatalities and very serious complications or illnesses are rare in the teen years, some of what we may have been seeing may be coincidence.

So I think it's very important to say that we take seriously vaccine safety and do not consider it light to give vaccines to totally healthy people. There's no scientific causal relationship between the HPV vaccine and those long term events.  There are continued review, and this is the kind of thing that we don't stop after a vaccine is in widespread use. We continue to look for rare signals, but the preponderance of evidence does not suggest any kind of serious problem from the HPV vaccine or other teen vaccines. What I do need to say is that teenagers sometimes faint after vaccination. We think it's really important for the teens, the parents and the clinicians to observe them for 15 minutes or so after vaccine is given because kids are just running off and sometimes pass out and there actually was even a death from someone who fainted shortly after getting one of these vaccines and was in a car accident. So we think it's important to not jump off the table and run off and go about your business, but to actually rest for 15 minutes. So that's the kind of thing that is more common in teenagers after any vaccine than in babies and toddlers, but thanks for that question.  Operator, we have time for two more callers if there are any.

OPERATOR: Thank you. Our next question comes from Alyson Wycoff with AAP news.

ALYSON WYCOFF:  Thank you. Could you elaborate on the methods used by the five states that showed the best improvement in HPV vaccination rates and repeat those states, please?

ANNE SCHUCHAT:  The states are Illinois, Michigan, New Hampshire, New Mexico and South Carolina. They actually did different things. Some of the states worked with their American Academy of Pediatrics and American Academy of Family Physicians’ state chapters in promoting HPV vaccine. Some of the states used assessment, feedback, incentives and information exchange or basically measuring coverage and feeding it back to the clinicians as a way to improve clinician performance. Some used peer-to-peer physician office visits to raise awareness as a way to talk about the vaccine and to answer the question questions people had.

Some of them worked with cancer coalitions to put this into the strategic plans or priorities that the cancer groups like Cervical Cancer-Free South Carolina were using and some had general health initiatives that they incorporated HPV into. They did different things, but I think one commonality is that they focused on how in their local area they could improve coverage. Right now, CDC is working with a number of other states and of course, we're working with the American Academy of Pediatrics nationally to try to really turn the tide on preventing cancer and to really improve performance so that fewer teens will be going on to develop HPV-associated cancers when they grow up. Okay. Last question, operator?

OPERATOR:  We're taking our last question with Nicholas St. Fleur with NPR. Your line is open.

NICHOLAS ST. FLEUR: Hi. Yes, and thank you. My question is, what is the current, I guess, cost for these vaccinations and is that cost covered under the Affordable Care Act and if it's not, is the cost for some families a deterrent to receive in the vaccination and I also have a follow-up question.

ANNE SCHUCHAT:  Cost was not one of the top five reasons what we heard from the parents of boys and girls about why they were not planning to get their child vaccinated. I can say that the HPV vaccine, the Tdap vaccine and the meningitis vaccines are all part of the Vaccines for Children program which provides free vaccines to uninsured people. They're also covered by insurance plans as long as those plans were updated since September or basically since September 2010 all plans that had been updated have had to cover those vaccines. So we actually think pretty much all of the insurers cover them. That should not be a principal problem. You had a follow-up question?

NICHOLAS ST. FLEUR: Yes. My follow-up question is, I’ve heard reports that the CDC is looking to get about 80 percent of adolescents covered. Is that still the goal? Has the goal gone up? Has it stayed the same? What is the goal?

ANNE SCHUCHAT:  The Healthy People 2020 goal for teenagers hone in on the 13 to 15-year age group and the goal for most of the teen vaccines is to reach 80 percent coverage. It's a little bit higher for the two doses of varicella, I believe, but for the Tdap meningitis and HPV vaccine, it is to reach 80 percent coverage in 13 to 15-year-olds. For girls, it's actually the three doses to get to 80 percent and there's been an accepted proposal to add a Healthy People 2020 objective for boys as well. We hope in the future that we'll have a merged, single, adolescent target of 80 percent for all of those vaccines, but we do, right now, you know, for 80 percent coverage we think we can get there because we're already there with Tdap and in fact, in 18 states we're already there with meningitis. So we’re- I think it's 42 states for Tdap, 18 states for meningitis and zero states for HPV, so we have room for improvement there. I want to thank everybody for calling in and listening to our session about the teen vaccinations. As I said, we don't really have a big news story on teen vaccination results today, but in that case, no news is bad news for cancer prevention. Thank you all for calling in.

BENJAMIN HAYNES:  Thank you, Dr. Schuchat and thank you all for calling. A transcript will be available of the telebriefing this afternoon at www.cdc.gov/media, and if you have further questions you can call 404-639-3286 or email media@cdc.gov. Thank you.

OPERATOR: Thank you. Thank you all for attending today's conference. You may now disconnect. 

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES