In interviews with providers and staff from clinics serving rural adolescent populations, we found a high level of support for earlier HPV-9 at ages 9 and 10 years of age. Interviewees suggested that their clinic procedures could reasonably be adapted to start recommending vaccine earlier than the CDC-recommended 11–12 years, with additional staff education needed. While EMR data from participating clinics show that fewer than half of patients had completed the HPV series by age 13, there is evidence that patients who initiated earlier were more likely to have completed vaccination, and to have completed on time. According to interviews with key informants from urban academic settings, some providers are already successfully providing HPV-9 earlier, and lessons learned can possibly be adapted to other primary care settings to improve the coverage of on-time HPV-9.
One important consideration of earlier HPV-9 recommendations is whether clinic personnel are aware that it can be administered to 9- and 10-year-olds. Prior studies on clinic personnel experiences with earlier HPV-9 did not measure their initial awareness of this option, which might have implications for its perceived acceptability.12,13,20,21 In our study, two interviewees were not aware that 11 years was not the minimum age for HPV-9, suggesting that they had not previously considered vaccinating younger patients and that they had no preconceived notions about the practice. Furthermore, even among interviewees who were aware of the FDA approval for 9- and 10-year-olds, several could not initially describe any benefits to earlier HPV-9. Continuing education for providers and clinic staff should emphasize not only that HPV-9 is indicated for younger patients, but also that emerging data suggest that it can lead to better on-time coverage and optimal prevention.
The two key informants from two academic clinics were in different stages of implementation of earlier HPV-9 vaccination: one had developed a protocol for early vaccination, including an alternative vaccine schedule, whereas the other simply introduced HPV-9 earlier. These differing approaches could reflect differences in the perceived importance of tracking adolescent vaccination rates between pediatrics and family practices. Tracking patient vaccination rates using EMR or immunization registries is an evidence-based practice to motivate providers to vaccinate their patients in a timely manner,22–26 and only the pediatrician key informant emphasized QI metrics as a motivator to vaccinate earlier. In contrast, family practitioners tend to see fewer adolescent patients than pediatricians and are possibly less likely to report or fulfill QI measures related to adolescent vaccines, including HPV-9.27–29 While this pilot study cannot draw firm conclusions on the differences in motivations between pediatrics and family practices, more research on this topic is warranted.
Some practice-based challenges make it difficult to start recommending and administering HPV-9 at ages 9–10. Interviewees reported relying on notifications from EMR or NCIR to determine when a patient was due for vaccination. While NCIR indicates an “earliest date” for vaccination at age 9, based on the patient’s recorded age, the “recommended date” is age 11 in accordance with CDC recommendations.30 Changes to these recommended ages identified by these alert systems might impel staff and providers to recommend vaccination to 9- and 10-year-olds without making any additional efforts. This successful change has been documented in a prior study of QI measures in a primary care network based in Columbus, Ohio, and more information is needed to understand how software programming decisions and modifications can be made in different clinic systems.12
This pilot study included a small number of clinics, all of which were affiliated with or proximal to a large, well-resourced academic center, and do not represent the experiences of clinics in more remote areas and with fewer pediatric providers. In addition, all participating clinics had sophisticated EMR that could be programmed to indicate when vaccines were due. One limitation of this data is that clinic EMR do not capture vaccinations that happened outside of the clinic system, and vaccination coverage based on EMR is likely underreported. Clinics with more rudimentary systems or paper records would have to identify other strategies for identifying vaccine-eligible 9- and 10-year-olds and monitoring vaccine receipt. However, the alternative vaccination timeline proposed by one of the key informants (i.e., providing HPV and Tdap vaccination at age 10, and HPV and Men4 vaccination at age 11 during annual well-child visits), could be implemented in any primary care clinic, with no need for additional tracking or alerts.
HPV-9 of 9- and 10-year-olds carries several advantages and could be facilitated with provider education and support. However, while modifications to vaccination schedules can be implemented without major disruptions to current practice, it can be difficult to build support for such changes in settings with high patient volumes and limited time. This exploratory qualitative study provides insight regarding the current status of how HPV-9 vaccine is perceived by providers in real world settings and allows the research team to find effective methods to promote earlier HPV-9 as an effective, convenient, and acceptable practice for patients in rural settings.