# Presentation: 059482

## Local Health Department Perspectives on HPV Vaccine Implementation

- Poki Stewart Namkung, MD, MPH
- President
- National Association of County &
- City Health Officials (NACCHO)
- Health Officer
-  Santa Cruz County Health Services Agency
- NVAC Meeting
- Washington, DC
- 26 September 2006

## NACCHO Overview

- National voice of local public health
- Nonprofit membership organization serving the ~3000 city/county/district/tribal public health agencies
- Formed in 1994
- Focus on providing education, research, information, and technical assistance to our members

**Notes:**
This involves working closely with state and federal governmental public health agencies as well as our other partners. 

## NACCHO HPV Activities

- Hosted 2 partner meetings this year
- Developed Web page dedicated to these vaccines and the diseases they can help prevent
- A special issue of NACCHO *Exchange *dedicated to HPV vaccines, cervical cancer, and associated issues
- Working with C-CHANGE
- Working with Partnership to End Cervical Cancer
- Surveyed a sample of our membership re: key issues/concerns around implementing HPV vaccines

**Notes:**
We hosted partner meetings in March & September of this year, developed a Web page within our Web site to pull together the universe of information that’s out there so that our members can have a single site to access it all – the scientific articles, updates from FDA and CDC, tools developed by public health agencies, etc. 
The special issue of Exchange, NACCHO’s quarterly thematic publication, will be coming out this week in hard copy and also available on our Web site (many of the partners have articles published in that issue). 
We also sponsored an intern from C-CHANGE this summer to work on bridging the gaps within our NACCHO-specific practice areas (e.g., immunization-STD-chronic disease)

## NACCHO Activities  HPV Partners Meeting #1

- March 16 – communications
- Representatives: vaccine manufacturers, academia, provider groups, professional organizations, faith-based organizations, and governmental public health
- Goal
- Collaborate to examine steps that can be taken as individual organizations and collectively to promote consistent messages to the general public, providers, parents, and others to increase awareness of the vaccines, cervical cancer, and the various associated issues
- Outcomes
- Communications checklist, reference notes
- Helped make all our partners aware of the spectrum of issues, across areas of practice, to share with their constituents
- Active participation and follow-up

**Notes:**
This meeting started the dialogue re: consistent messages and sharing of tools and resources across various areas of practice – cancer control & prevention, STD & teen pregnancy prevention, adolescent health, immunization, and infectious disease among others. 
The more we talked, the more we realized that we desperately need a comprehensive, integrated, and coordinated adolescent health platform to address the wide spectrum of issues pertinent to this age-group.  
Adolescent health care is very episodic and not at all coordinated – evidenced by the dialogue at the meeting. 
Building bridges and making connections where none existed before – all in the effort to improve adolescent health. That’s why we need these meetings to try to come to an agreement and consensus, but even if falling short of that we come to an understanding of what’s necessary to get to the next step. 

## NACCHO Activities HPV Partners Meeting #2

- September 14 - implementation
- Follow-up meeting with a wider array of partners focusing on HPV and the implementation of the vaccines.
- Goals
- Costs/financing
- School mandates
- share information, updates, and strategies on collaborative activities among stakeholders to address many of the opportunities and challenges discussed at the March 2006 meeting.
- Outcomes
- Clearly articulated and identified barriers
- Brainstormed strategies to address barriers

**Notes:**
So that realization led to a follow-up meeting to discuss how we’d move now that one of the vaccines had FDA approval and had been included in the routine IZ schedule via ACIP. 
We hosted a broader array of partner organizations and had a very open and honest dialogue (and in some instances, debate) about the key issues regarding implementation of HPV vaccines and reaching key populations. 

## Key LHD Issues

- Costs – how do providers cover this expensive vaccine, given the limitations of VFC and 317 funding?
- Costs – how do we vaccinate those girls and women who fall outside of public assistance coverage?
- Costs – how does HPV vaccine “fit” into the spectrum of adolescent-focused recommended vaccines?

**Notes:**
From the survey, we heard from 105 diverse LHDs and their responses were consistent with what we heard from the partners at the March & September meetings regarding key concerns – costs, financing, educating the public & providers, and school mandates. 
The most pressing was how to make sure we reach the girls and women who need this vaccine the most – the population that does not have continuous care, does not get screened for HPV, cervical or any other cancers – those who fall way outside of every public and private safety net we have. 

## Barriers/Issues

- Expense of the vaccines
- Building a real adolescent health platform that includes these important vaccinations to assure universal access
- LHDs: Cost of personnel (and lack of personnel in some cases) to implement and operationalize new immunization recommendations
- LHD roles
- Assess the need in the community
- Distribute the vaccines
- Prioritization decisions and processes
- Educate providers – all aspects of vaccine usage, storage, and handling
- Work with schools and other settings where adolescents are vaccinated
- Provide accountability by auditing our local providers
- Collecting all those data and reporting them up to our state and federal counterparts

**Notes:**
This is the list of key barriers/issues about costs and financing; one that is unique to local public health is the cost of personnel as the local health dept. is a key point of implementation  for girls and women who received doses in the public sector. It is probably a key concern in those jurisdictions that implement school entry requirements. 

## Key LHD Issues

- School mandates – state by state
- What is the spectrum of opinions on mandating HPV for school entry?
- How do we stay off the slippery slope of “choice?”
- How do LHDs and others effectively address parental hesitancy within the issue of mandates?
- What is the reaction from school officials?

**Notes:**
Some states have moved forward with this – such as Michigan introducing legislation to require HPV vaccination for 6th grade girls; 
others are still in the throes of thinking through the issues; 
and others are actively “waiting” to see what uptake looks like and will use school entry regulations only as a means to assure access if uptake amongst key demographics is lagging. 
Many of our members are discussing aspects of school mandates writ large – what is the objective? 
To prevent communicable diseases such as pertussis and measles? Or to improve vaccination rates of all routinely recommended vaccines? Or a mix of both? 
NACCHO’s immunization working group is drafting a policy statement around school mandates because this is just one of many vaccines that will draw up such questions. 
Exemptions (beyond the medical and religious) are another concern – we don’t want to open that door because if you do it for one vaccine, then groups opposed to mandates will want the “opt-out” choice for all the vaccines. 
 We are fortunate to have had NASBE at our first meeting, because we got their perspective on the school mandates issue – which we often overlook when making these provisions. We must take into consideration the practical aspects of implementing these mandates before making the policy. 

## Barriers/Issues

- Fluidity and difficulty of reaching higher-risk adolescents and dealing with the groups opposed to immunization mandates of any sort
- Hepatitis B vaccine as a model for implementing HPV vaccine
- We always want to keep some of missteps and failures in mind so that we learn from them
- Do we want to spend 20 years to get it right this time?

**Notes:**
But even school entry requirements have their limitations. 
We have to be vigilant, resourceful, and creative in making sure we reach ALL who need these vaccines. 
We will have to deal with those issues as well as the very organized groups opposed to immunization mandates of any sort. 
And we need to look at our history and pull out some of the lessons from implementing HepB vaccine – which took YEARS to get right after fits and starts and many many stumbles along the way. 

## Action Items

- Actively continue to work and dialogue with our partners
- Develop, identify, disseminate, and warehouse tools and resource that our members can easily access and use, Be an active resource and partner in pilot demonstrations
- Advocate for public patient assistance programs that include vaccines
- Provide advocacy tools for our members to work more effectively with their city/county councils and/or state legislatures regarding funding for delivery of immunization services

**Notes:**
And how will we go about implementing these vaccines? 
These are action items NACCHO and partners will be working on as we plan to reconvene in the spring of 2007 for a third, more evaluative, meeting – examining what has gone right, what has gone wrong, what lessons have been learned, and continuing the effort to share, discuss, and disseminate successful models that address the key concerns – reaching vulnerable girls and women, financing options, and education/outreach tools and messages and monitoring the evolution of our thinking on school mandates. 

## Thank YouNACCHOwww.naccho.org(202) 783-5550

**Notes:**
You can access all the information I discussed – meeting summary notes, survey results, etc, via this Web address.