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HPV Vaccine Awareness and use Among Practicing Obstetrician-Gynecologists in Western New York
**215**
Block “II” 2007
ABSTRACT The CDC recommends routine HPV vaccination of females 11 to 12 years of age and catch up vaccination of females age 13-26 years old. The prevalence of HPV infection is the highest among females age 20 to 24 years, a group that does not have contact with pediatricians 1. The goal of this project is to survey Western New York area obstetrician-gynecologists to examine their knowledge, attitudes and practice pattern with respect to the HPV vaccine. The future goal is to use these data to identify deficits in physician knowledge and to implement practice change that facilitates vaccine provision by obstetrician-gynecologists to women that may not have contact with other medical providers. BACKGROUND OF PROBLEM Cervical cancer is a common source of mortality and morbidity worldwide. It is now largely preventable with vaccination. In 2006 the incidence of cervical cancer in the US was 9,710. In the same year, 3,700 women died due to cervical cancer1 . A woman’s estimated lifetime cervical cancer risk in the US is 3.67% and her lifetime risk of dying from the disease is 1.26%1. In Monroe County, the situation is no different. The incidence of cervical cancer is 5.9
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Zimmerman, K. HPV vaccine and its recommendations, 2007. The Journal of Family Practice, vol. 56, no 2. February 2007.
Page 2 per 100,000 females, with an average annual death rate of 5.8 or 1.4 per 100,000 females 2. The main cause of cervical cancer is HPV infection. HPV is the most common sexually transmitted infection in the US1. HPV prevalence in the general population is 20 million, and 6.2 million people are infected yearly1 . The options to prevent infection include limiting sexual practices that increase exposure (condom use, monogamy) and the HPV vaccine1. While limiting sexual practice is ideal, nearly 60% of 12 th grade females report sexual activity – and HPV infection even occurs among virgins1 . HPV is a problem worldwide, and due to lack of universal screening and prevention programs, there are 370,000 cases of cervical cancer, with 50% mortality3. The cost to societies is enormous both on a human level and financial level. The HPV vaccine offers a way to reduce these costs. It has been estimated that vaccinating 12 year-old females in the US would reduce cervical cancer incidence by 95.4%3. This, in turn, would add 6.1 quality-adjusted days of life per woman and have a cost-effectiveness ratio of $14,583 per quality-adjusted life year3. The same study showed that Pap testing vaccinated women every 3 to 4 years costs less than a novaccine policy, which in turn could allow less frequent Pap screening by physicians. The HPV vaccine is safe and effective. It is a quadrivalent vaccine against viral types 6, 11, 16, 18. It is highly effective in preventing persistent HPV infection, cervical cancer precursor lesions, vaginal and vulvar cancer precursor lesions, and genital warts.4 HPV has
also been associated with anogenital cancers as well as oral cavity and pharyngeal cancers 4. The CDC recommends vaccinating females age 11-12 years old and catch up vaccination of females
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New York State Cancer Registry, New York State department of Health. http://www.health.state.ny.us/statistics/cancer/registry/vol1/v1cmonroe.htm 3 Taira, A. et al. Evaluating Human Papillomavirus Vaccination Programs. Emerging Infectious Diseases, vol 10, no 11, November 2004. 4 CDC MMWR Recommendations and Reports, Quadrivalent Human Papillomavirus Vaccination. March 23, 2007. 56(RR02);1-24.
Page 3 13-26 years old1 . Unlike pediatricians, obstetrician-gynecologists have not been targeted for vaccine-implementation programs until recently and are now confronted with catch up vaccination group of women 13-26 years old5. Previous studies have shown that obstetrician-gynecologists do not practice their perceived responsibilities regarding vaccine-preventable diseases5. Most physicians surveyed felt that vaccine prevention should be within the scope of their responsibilities, but actual practice differed. A quarter of obstetricians did not give any vaccines to their patients in office while slightly more than half of gynecologists did not administer any vaccines3. Hurdles to providing these services include the perception by Ob-Gyn’s that they are not primary care providers, and the opinion that vaccines are not within their realm of practice. A lack of knowledge about CDC recommendations and discomfort with vaccine administration also contribute to decreased vaccine provision 3. The Ob-Gyns in the aforementioned study practiced in Michigan and were surveyed regarding a variety of immunizable diseases. The goal of our survey is to examine physicians in Western New York specifically about the HPV vaccine – their knowledge of the human papilloma virus, the vaccine, CDC recommendations, and their perspective on their responsibility to provide the vaccine. BACKGROUND OF COMMUNITY Rochester physicians were initially chosen due to the proximity of Strong Memorial Hospital and University of Rochester medical school where the investigators are based. Additionally, Rochester leads New York state in rates of gonorrhea and chlamydia 6 and one can
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Gonik, B. et al. The Obstetrician-Gynecologist’s Role in Vaccine-Preventable Diseases and Immunization. Obstetrics and Gynecology. Vol. 96, no. 1 July 2000 pp 81-84. 6 New York State Department of Health. http://www.health.state.ny.us/statistics/diseases/communicable/std/abstracts/docs/2004.pdf
Page 4 extrapolate that rates of HPV will similarly be increased (currently routine reporting of HPV does not exist in the United States).4 Due to the likelihood of a small sample size, we decided to expand the survey population to include Ob-Gyns in Western New York who are members of the American College of Obstetrics and Gynecology (ACOG). ACOG is the professional society for Obstetrician-Gynecologists. Previous studies have examined the Ob-Gyn’s role in vaccine-preventable diseases which include Hepatitis B, Tetanus/Diptheria, Measles/Mumps/Rubella, pneumococcus, varicella and influenza. No studies, however, have examined physician’s views on the HPV vaccine. This vaccine presents different challenges due to the administration schedule (an initial vaccine to be followed at 2 months and 6 months afterward) and at the same time a unique opportunity. Recently, the Ob-Gyn has become considered a primary caregiver and may be the only health care provider for a large number of women from adolescence to menopause 5 . Importantly, these physicians may be the most appropriate group to provide the HPV vaccine to this large group of women. The HPV vaccine is still in its infancy and there is not a uniform vaccination program that exists on a local level, in Monroe County, or on a national level. We set out to identify what is preventing vaccine provision, with the plan in the future to use this knowledge to aid in establishing a vaccination program. PROJECT DESCRIPTION AND METHODS The population to be examined is practicing Obstetrician-Gynecologists in Western New York who are members of the ACOG. The purpose of our project is to gather information from physicians and use this data to implement HPV vaccination programs in Rochester with the hope to expand to a larger area. First, a survey was designed utilizing previous studies regarding
Page 5 immunization practices and Ob-Gyn’s. We then tailored the survey to be more exact for the HPV vaccine. We would like to use the informatics core for help with the survey layout. The physicians will then be mailed anonymous paper surveys with the option to answer to be completed and mailed back in self-stamped envelopes. They will also have the option of completing the survey online. Each physician will receive a number to help track response rates, but the PI and Study Coordinator will be blinded to this. This study is of minimal risk to subjects and the PI will be responsible for safety monitoring. We are currently in the process of applying for IRB and GCRC approval. A full description of the study protocol is currently being finished.
PARTNERSHIPS Anne Kearn, Monroe County Department of Health, AKern@monroecounty.gov
RSRB approval HSPP approval was sought due to the plan to include this survey data in future research. The HSPP application was submitted on 9/9/07 and approved on 9/12/07. RSRB approval is currently being sought, with the submission to occur before the 2 nd Monday in October.
IMPLEMENTATION The major hurdles to implementation were time. Getting HSPP approval and RSRB approval was time consuming. Designing the actual survey and meeting with Information Technology staff at the GCRC was as well. Designing a study protocol and covering every
Page 6 requirement was too much to complete in 4 weeks, but should be finished by the October deadline.
SUSTAINABILITY The project is not so much sustainable, but further projects can be created once we analyze the data. Future options include community education about the virus and the vaccination and educational sessions for physicians.
RESULTS/DISCUSSION/RECOMMENDATIONS For this project the primary goal was to design a survey that would address physician knowledge and knowledge deficits about the HPV vaccine. The next step of the project is to send out the surveys. Data collection and analysis will follow. In the future, I hope to continue this project by collecting and analyzing the data. The hope is to publish the results and possibly extend the survey nationwide to get a better representation of social and political variables. After this is done, specific projects can be created to address the problems identified by physicians. Also, community educational programs would be a great way of complementing physician education programs. Without community involvement and recruitment, there won’t be women to administer the vaccine to.
IMPACT SECTIONS IMPACT ON MY CAREER: In the field of Obstetrics and Gynecology, the HPV vaccine is revolutionary. It is providing the opportunity to effectively eradicate multiple cancers. A large barrier lies with
Page 7 physicians at this point – which is why we sought out to identify the problems that they are experiencing with the vaccine. This project emphasizes the importance of continuing education for physicians. The HPV vaccine is new and physicians may not be aware of it. Potential public health implications are enormous, especially in the Rochester area since HPV prevalence is likely high. If we can decrease the incidence of HPV infection, then the results on Ob-Gyn practice will be large. It will help decrease health expenditures by decreasing the number of procedures and will also free physicians to focus on different aspects within their practice. It is the perfect example of preventive medicine at work. There is the hope of publishing the results of this survey and possibly expanding the project nationwide. Every level of care can be affected by future projects and it exemplifies the U of R’s commitment to public health. This is primary prevention at its best!
IMPACT ON THE TARGET COMMUNITY: The potential impact on Rochester (and the country) of expanding provision of the HPV vaccine is enormous. Currently we have a large number of women who can be helped by the vaccine – but who may not have a health care provider to administer the vaccine. With this survey, we can use the data and custom-fit initiatives to provide health care to this group. Since national rates of HPV infection are not tracked, the results will be evident by the incidence of new cases of cervical cancer and mortality. These results however will not be reflective of the HPV vaccine because there is a bimodal incidence of cervical cancer, with women developing cervical changes in their 20’s as well as their 40’s and 50’s. The true impact of the HPV vaccine will not
Page 8 be statistically secure for several decades until 11 and 12 year old females that have received the vaccine reach middle age.
PROJECT PARTNERS Dr. Sireesha Reddy, OB-GYN at SMH.
Page 9 REFERENCES: 1. Zimmerman, K. HPV vaccine and its recommendations, 2007. The Journal of Family Practice, vol. 56, no 2. February 2007. 2. New York State Cancer Registry, New York State department of Health. http://www.health.state.ny.us/statistics/cancer/registry/vol1/v1cmonroe.htm 3. Taira, A. et al. Evaluating Human Papillomavirus Vaccination Programs. Emerging Infectious Diseases, vol 10, no 11, November 2004. 4. CDC MMWR Recommendations and Reports, Quadrivalent Human Papillomavirus Vaccination. March 23, 2007. 56(RR02);1-24. 5. Gonik, B. et al. The Obstetrician-Gynecologist’s Role in Vaccine-Preventable Diseases and Immunization. Obstetrics and Gynecology. Vol. 96, no. 1 July 2000 pp 81-84. 6. New York State Department of Health. http://www.health.state.ny.us/statistics/diseases/communicable/std/abstracts/docs/2004.pdf