HPV Vaccine Toolkit: Increasing HPV Vaccine Uptake Among Adolescent Clients in the Family Planning Setting

Preconception and Preventive Health Sexually Transmitted Infections Teen Pregnancy Prevention Program Title X Family Planning Program
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Welcome to the Toolkit

Human Papillomavirus (HPV) Vaccination

Human papillomavirus (HPV) can cause six different kinds of cancer—including cervical and oropharyngeal. The HPV vaccine, however, can prevent more than 90% of the cancers caused by HPV—an estimated 33,700 cases every year—from ever developing and save thousands of lives.

The HPV vaccine is recommended for routine vaccination at ages 11 or 12 years old; it can be administered to children as young as nine years old, and catch-up HPV vaccination is recommended for all people through 26 years of age. For adults older than 26 years, vaccination is not recommended for everyone. Adults 27 to 45 years of age may receive the vaccine after discussing it with their health care provider1, particularly if they did not get adequately vaccinated when they were younger. Generally, HPV vaccination of people 27 to 45 years of age provides less benefit, often due to the fact people in this age range have already been exposed to HPV.2

Vaccination started before age 14 has been found to be most effective, and only requires two doses. A two-dose schedule is recommended for those who receive their first dose before their 15th birthday, while a three-dose schedule is recommended for people who receive their first dose after their 15th birthday and/or live with certain conditions that compromise the immune system.3

Increasing HPV vaccination of adolescents continues to be a top priority. Healthy People 2030 set the goal that 80% of adolescents be vaccinated for HPV. Currently, only 58.5% of adolescents across the nation have been vaccinated and are fully protected.

1 https://www.cdc.gov/vaccines/hcp/admin/downloads/ISD-job-aid-SCDM-HPV-shared-clinical-decision-making-HPV.pdf

2 https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html

3  https://www.cdc.gov/hpv/hcp/schedules-recommendations.html

Illustration of a woman sitting on an exam table in a doctor's office.

This toolkit describes three approaches to increasing HPV vaccination—especially among adolescents— at a Title X-funded family planning site. Family planning sites can increase HPV vaccination by:

  1. Adding HPV vaccination to existing services
  2. Increasing the number of clients (especially adolescents) receiving the HPV vaccine
  3. Increasing and improving referrals for vaccination off-site

These approaches, along with suggested action steps and supportive resources, are described below. Tools and resources in this toolkit should be used in relation to your site’s needs and priorities.

The most direct way for a family planning site to increase HPV vaccination rates is to offer the vaccine. This approach includes first conducting background research into the site’s state rules, regulations, and third-party payer coverage of the vaccine. With this information, a site will be able to better determine the financial implications of adding HPV vaccination to existing services.

Strategy 1: Conduct research and understand regulatory context in which vaccines are provided.

Action Steps Supportive Resources

Review state-specific HPV legislation and statutes and school immunization requirements.

Health Insurance Marketplace plans and most other private insurance plans cover the cost of HPV vaccines. Provide free or reduced-fee vaccine services in accordance with Title X Program Expectations on how clients should be charged and with the Vaccines for Children program.

Collecting Copays and Applying Sliding Fee Scales: A Job Aid for Front Desk Staff

Strategy 2: Identify the potential costs and revenue associated with providing the HPV vaccine.

Action Steps Supportive Resources

Review current Medicaid and private insurance (third-party payer) contracts to determine if HPV vaccination is reimbursable. If not, request HPV vaccination as a covered service.

Identify the expected cost of the vaccine, using the CDC Vaccine Price List, and determine the most economical way of purchasing the vaccine, such as through the 340B Program.

Develop an estimate of the potential volume, costs, and revenue associated with provision of HPV vaccination services.

A family planning site that already offers HPV vaccination can become more efficient, thus increasing the number of clients getting vaccinated. This approach includes implementing three strategies, to be pursued simultaneously, that will help to ensure that all adolescents are vaccinated. The strategies are to:

  1. use every opportunity to vaccinate;
  2. maintain active immunization tracking; and
  3. communicate effectively with clients and parents/guardians.

Strategy 1: Use every opportunity to vaccinate.

Action Steps Supportive Resources

Train all staff on HPV vaccine guidelines, effectiveness, and safety. Include information about minimum intervals, contraindications, and shared clinical decision-making.

Ensure staff are familiar with frequently asked questions and screening resources for contraindications (teens and adults) regarding the vaccine.

Reducing Missed Opportunities for HPV Vaccinations at Title X Sites Webinar

Ensure all staff are familiar with their roles and responsibilities for increasing provision of HPV vaccination. National HPV Vaccination Roundtable: HPV Vaccination Action Guides.

Post the most recent version of the CDC/ACIP U.S. Recommended Immunizations for Children 7–18 Years Old (or that of a state health department) prominently in the office and in all exam rooms.

Use all client encounters to assess need for—and provide—HPV and other vaccines. Use normalizing language to explain and administer multiple adolescent vaccinations, including the HPV vaccine, during one visit.

Using Normalizing Language to Encourage HPV Vaccination Among Adolescent Clients

Uso de un lenguaje normalizador para fomentar la vacunación contra el VPH entre clientes adolescentes

Identify a designated immunization champion on staff to monitor HPV vaccination rates and keep clinical staff current on recommendations.

Establish a system to order the HPV vaccine, so that it is consistently available in your on-site inventory.

Establish a standardized workflow and standing orders for administering the HPV vaccine.

Develop a policy that allows for widespread access to vaccination. The policy should:

Strategy 2: Maintain active immunization tracking.

Action Steps Supportive Resources

Flag adolescent client’s medical file and/or electronic health record (EHR) to indicate eligibility to begin HPV vaccine. Review client’s immunization record prior to visit.

Update and document the client’s vaccination status at all visits.

Ask new clients for previous immunization records and update their medical file/EHR accordingly.

Provide clients with immunization record cards.

Keep a log of clients who are due for dose 2 or 3 of the HPV vaccine. Whenever a HPV vaccine is not given, document this within their medical file/EHR and schedule a follow-up visit.

Strategy 3: Communicate effectively with clients and parents/guardians.

Action Steps Supportive Resources

Use normalizing language to explain the importance of getting the HPV vaccine to adolescent clients and their parents/guardians. Highlight for parents/guardians that HPV vaccination is cancer prevention.

Using Normalizing Language to Encourage HPV Vaccination Among Adolescent Clients

Uso de un lenguaje normalizador para fomentar la vacunación contra el VPH entre clientes adolescentes

HPV Vaccine: Same Way Same Day App

Identify and address the parent/guardian/client’s specific concern about the HPV vaccine (e.g.,  Reasons to Get the HPV Vaccine, safety, and efficacy).

Counseling Patients and Parents on the HPV Vaccine Podcast

Schedule the visit for the next dose before the client leaves the office.

Ask parents who refuse the HPV vaccine to sign a refusal form acknowledging the risks of not vaccinating and then document this refusal in the client’s record. If vaccination is declined, recommend the HPV vaccine again at each future visit.

Sometimes a family planning site may decide that offering the HPV vaccine is not feasible but remains committed to increasing HPV vaccination among adolescents. In these instances, the strategy is to develop a referral system.

Strategy 1: Establish a referral system for HPV vaccination services.

Action Steps Supportive Resources

Expand the site’s existing referral system to include HPV vaccination providers.

Establishing and Providing Effective Referrals for Clients: A Toolkit for Family Planning Providers

Establish referral agreements (memoranda of understanding) with local HPV vaccination providers.

Title X Sample MOU Template

Maintain contact information for local HPV vaccination providers.

Local Resource List

Train staff on how to make effective referrals.

Referral Quality Staff Observation Activity, Instructions, and Handouts