Insights on HPV Vaccination Coverage in the Southeast United States by sjcrh

Insights on HPV Vaccination Coverage in the Southeast United States

HPV Vaccination Roundtable of the Southeast

At a Glance: HPV Vaccination Coverage in the United States

The rate of HPV vaccination coverage has historically been

Every year, millions of individuals in the U.S. are exposed to HPV, a

the lowest in Southeastern states (Alabama, Arkansas, Florida,

virus that is linked to six different types of cancer that can affect

Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South

anyone. Approximately 13 million Americans will become infected

Carolina, Tennessee, Virginia, and West Virginia), the District of

with HPV each year, and over 40,000 individuals will develop HPV

Columbia, and Puerto Rico. In 2022, St. Jude Children’s Research

cancers.1, 2 Fortunately, there is a vaccine available that is safe,

Hospital, the American Cancer Society (ACS), and the National

effective, and proven to help prevent more than 90% of the cancers

HPV Vaccination Roundtable convened select representatives

caused by HPV.3 However, too many vaccine-eligible individuals are

from these states and jurisdictions to form the HPV Vaccination

not getting vaccinated as recommended.

Roundtable of the Southeast and discuss strategies, approaches, and evidence-based interventions to improve HPV vaccination and prevent HPV cancers in this region of the United States (U.S.). The HPV Vaccination Roundtable of the Southeast is focused on:

NATIONAL AVERAGE COMPLETION RATE

= 63%

• Current conditions surrounding HPV vaccination and HPV cancer prevention • Replicating

HPV

vaccination

success

stories

across

the Southeast • Overcoming

challenges

facing

HPV

vaccination

the Southeast • Identifying opportunities to improve HPV vaccination coverage in each state, jurisdiction, or territory and the overall region

60% Southeast Region Average Completion Rate 2

FIGURE 1: HPV VACCINATION RATES AMONG ADOLESCENTS IN SOUTHEASTERN STATES 13 – 17 YEARS OF AGE (2022) The rate of HPV vaccination coverage has historically been the

Initiation

Completion

National

76%

63%

adolescents in the Southeastern U.S. have lower HPV vaccination

SE Region

75%

60%

uptake rates compared to the national average, and in more than

State

lowest among Southeastern states. On average, children and

half of the twelve states in the region, series completion rates for children and adolescents are between 1% and 24% lower than

Alabama

77%

59%

Arkansas

75%

56%

District of Columbia

87%

78%

Florida

76%

59%

Georgia

71%

62%

Kentucky

66%

55%

Louisiana

80%

67%

Mississippi

61%

39%

North Carolina

73%

55%

South Carolina

70%

54%

Tennessee

74%

64%

Virginia

78%

63%

West Virginia

70%

52%

Puerto Rico

88%

70%

the national average, which still falls below the Healthy People 2030 goal of 80% of all adolescents (aged 13 to 15) in the U.S. completing the HPV vaccination series (Figure 1). A range of factors impact HPV vaccination uptake, including age, sex, race, ethnicity, insurance coverage type, vaccine mandates, and coverage of other childhood and adolescent vaccines. However, this trend extends beyond vaccination rates – data indicate that states in the Southeastern U.S. have higher rates of uninsurance and lower utilization of preventive services such as primary care, wellness, and dental visits, all of which have led to higher HPV cancer incidence rates in the region.4, 5 Notably, within the region, Arkansas, Florida, South Carolina, and West Virginia have some of the lowest utilization rates of cervical cancer screenings among adults. These factors have likely contributed to Southeastern states having some of the highest overall HPV cancer incidence rates in the region (Figure 2).6 Further, Arkansas has the lowest rates of well-child visits and the third highest rate of uninsured children in the region, while Florida has the highest rates of both uninsured children and adults when compared to other Southeastern states.7, 8

Source: CDC VaxView, 2022 Note: Vaccination rates highlighted in green are below the national average.

FIGURE 2: HPV CANCER INCIDENCE IN SOUTHEASTERN STATES COMPARED TO THE UNITED STATES PER 100,000 PEOPLE (2020) 18

National Average

Source: “State Data Profiles,” St. Jude Children’s Research Hospital, 2023

Case Studies and Best Practices States across the Southeast are utilizing a variety of evidencebased initiatives to raise HPV vaccination coverage and reduce the incidence of HPV cancers. The following highlights a few observed best practices and replicable efforts that Southeastern states have implemented aimed at improving HPV vaccination uptake.

INCREASED MEDICAID ELIGIBILITY Medicaid and the Children’s Health Insurance Program (CHIP) provide children and adolescents enrolled in the program access to comprehensive health benefits and services, including Early Periodic Screening Diagnostic and Treatment (EPSDT) benefits that cover services that help prevent, screen for, diagnose, or treat illnesses including well-child exams; hearing, vision, and dental screenings; and other services.9, 10 These benefits also cover all Advisory Committee on Immunization Practices (ACIP)-recommended immunizations, including the HPV vaccine.11 However, Southeastern states have some of the lowest Medicaid income eligibility levels for children and adolescents, ranging between 133-143% of the Federal Poverty Level (FPL). In comparison, the average income eligibility level is 151% FPL for children across all states that have not expanded Medicaid and 195% FPL for children across all states that have expanded Medicaid. Within the Southeast region, only Arkansas, Louisiana, the District of Columbia, and most recently North Carolina have expanded Medicaid, covering adults up to 138% FPL and providing low-income individuals, parents, and families with access to comprehensive health care benefits and services. The Affordable Care Act’s (ACA) Medicaid expansion and the related “welcome mat” effect, in which newly eligible parents who gained access to Medicaid under the ACA also enrolled or re-enrolled their previously eligible children for program coverage, have directly contributed to increased HPV vaccination coverage and series completion in children and adolescents.12

EXPANDING ACCESS TO HPV VACCINATION IN SOUTH CAROLINA AND MISSISSIPPI

HPV VACCINATION AWARENESS AND EDUCATION STRATEGIES IN ARKANSAS AND ALABAMA

Long-standing and systemic barriers to health care services, including limited proximity to physician offices or vaccination sites, transportation challenges, and high costs of care, continue to play a significant role in HPV vaccination coverage. Partners in states across the Southeast are finding innovative solutions that target these barriers and increase access to the HPV vaccine. For example, the Medical University of South Carolina (MUSC) introduced a community health van aimed at increasing access to the HPV vaccine and other childhood vaccinations in underserved communities. In its first year, the community health van reached children in 21 of South Carolina’s 46 counties. Additionally, the mobile unit has been brought onto school grounds to help school nurses offer and recommend the HPV vaccine and other immunizations.13, 14

Parents’ and caregivers’ lack of awareness of the benefits and importance of HPV vaccination often influences their decision to not initiate the vaccine series for their children. To improve parents’ and caregivers’ understanding of HPV vaccination and cancer prevention, partners in several Southeastern states are employing education-focused strategies. The Arkansas Immunization Actional Coalition, for example, developed an HPV toolkit for communities to host education workshops about HPV, the HPV vaccine, and cancer prevention with the goal of increasing acceptance of the vaccine. The toolkit was shared with trusted messengers in local communities, including faith-based leaders, school nurses, and school Parent Teacher Associations (PTA) to educate parents and caregivers and encourage them to initiate and complete the HPV vaccination series.16, 17

Other states are leveraging a range of provider types, including pharmacists, to expand access to care and increase HPV vaccination opportunities. After Mississippi’s Medicaid program started allowing pharmacists to administer the HPV vaccine, for example, the University of Mississippi School of Pharmacy started an HPV Free Campus Project to educate students about the HPV vaccine and encourage them to get vaccinated at the on-campus pharmacy. After much success, in 2022, the program received funding to create a toolkit to help other Mississippi colleges and universities implement similar on-campus HPV vaccination campaigns. Additionally, the School of Pharmacy developed five presentation slides on HPV and HPV vaccination that were incorporated into the required curriculum for all freshman students.15

Likewise, parents’ and caregivers’ decision to vaccinate their children often remains contingent upon a strong provider recommendation. Therefore, increasing HPV vaccination education among providers and practice staff can empower them to make informed and compelling recommendations to parents and caregivers regarding the HPV vaccine. Efforts led by Alabamabased nonprofit organization VAX 2 STOP CANCER demonstrate the positive impact of provider education; since January 2020, the non-profit organization has trained nearly 300 providers and staff at 76 practices in 26 Alabama counties to raise HPV vaccination rates.18 As a result, participating practices reported a 10% average increase in HPV vaccination completion rates among 9- to 13-yearold patients over a 12-month period.19

The Analysis The HPV Cancer Prevention Program at St. Jude Children’s

national direct health care expenditures by more than $6.3 million in

Research Hospital partnered with FTI Consulting to examine

the Southeastern states. In addition, the increased HPV vaccination

public policy decisions and related factors that drive HPV

series completion and reduced HPV cancer incidence could reduce

vaccination coverage across the U.S. Using the results of the

the two-year national direct health care expenditures by more

analysis, FTI Consulting developed five policy recommendations

than $8.3 million.20 It’s crucial to emphasize that the cost savings

to improve HPV vaccination coverage:

analysis undertaken in this study adopts a conservative approach,

• Leverage meningococcal conjugate vaccination as a model for HPV vaccination education and recommendations.

concentrating exclusively on the two-year cancer treatment costs linked to the HPV vaccine.21

• Expand health care provider and practice staff education and training related to HPV vaccination and strengthen HPV vaccination recommendations for parents and caregivers. • Improve recruitment efforts to enroll various health care provider types at the state level in the federal Vaccines for Children (VFC) program. • Expand the resources available to improve HPV vaccination

The increased HPV vaccination series completion and reduced HPV cancer incidence could reduce the two-year national direct health care expenditures by more than

$8.3 MILLION

data collection and reporting through state immunization information systems (IIS). • Engage in efforts to preserve and expand eligibility for Medicaid. FTI Consulting also performed a cost savings analysis for four actionable policy factors: (1) average meningococcal conjugate vaccination coverage; (2) Medicaid eligibility expansion; (3) access to VFC providers; and (4) access to pediatricians. This analysis projects that the increased HPV vaccination series initiation and reduced HPV cancer incidence that would result from addressing these policy factors could reduce the two-year 8

Special Section: Medicaid, Redeterminations and Unintended Consequences To prevent HPV cancers, it is imperative to expand access to

Expanding Medicaid income eligibility for children will be

health insurance coverage for individuals and families with lower

especially important as states continue to redetermine

incomes through increased Medicaid eligibility levels. Medicaid

individuals’ and families’ eligibility for the program following

and CHIP have led to increased childhood vaccination rates

the end of continuous enrollment in Medicaid earlier this

and significantly lowered the incidence of life-altering diseases

year. As of January 9, 2024, more than 14.3 million Medicaid

like HPV cancers. However, Medicaid income eligibility for

enrollees have been disenrolled,24 nearly 2.5 million of which

children varies by age in all 50 states and D.C., with some states

are children.25 Further, several Southeastern states, including

having much lower eligibility limits than others. Thirty-two

Arkansas, Florida, and Georgia, have some of the highest rates

states have eligibility levels for the state’s Medicaid program

of child and adolescent Medicaid disenrollment in the country,26

that are below 200% of the FPL. Expanding Medicaid income

emphasizing the importance of ensuring that pathways exist

eligibility in these 32 states could address coverage limitations

to preserve, protect, and expand access to comprehensive and

and improve cancer prevention, generating approximately

affordable insurance coverage in the region.27

$9 million in savings due to increased HPV vaccination series completion and reduced incidence of HPV cancers.21, 23

FIGURE 3: MEDICAID ELIGIBLITY LEVELS FOR CHILDREN 6 – 18 YEARS OLD IN SOUTHEASTERN STATES (2022)28 Medicaid eligibility levels below 200% FPL

Medicaid eligibility levels above 200% FPL

350% 300% 250% 200% 150% 100% 50% 0%

Call to Action The evidence is indisputable: HPV vaccination is cancer prevention. Representatives of Southeastern states should continue to work with partners and advocates to pursue policy change at multiple levels to address systemic barriers to HPV vaccination coverage and change the story to frame HPV vaccination as a cancer prevention tool in the Southeast. As Southeastern states work to increase HPV vaccination coverage and lower HPV cancer incidence in the region, there are a few key factors that partners and policymakers should consider.

• Representatives of Southeastern states should continue to exchange best practices and align on consistent messaging and communications related to HPV vaccination with peers. At the same time, leaders should also concentrate efforts on

LEARN MORE Scan the QR code or read the full report: stjude.org/hpv-policy-summary

identifying strategies for collective impact in the region at large. • Partners,

advocates,

and

policymakers

should

develop and deploy evidence-based policy change and interventions geared toward the unique barriers to HPV vaccination and needs of communities within Southeastern states. • Key vaccination and cancer prevention stakeholders throughout the region, as well as trusted information sources at the local level, should be engaged in HPV vaccination efforts and the development and implementation of action plans for increasing HPV vaccination coverage.

Read more about the HPV Vaccination Roundtable of the Southeast: https://www.stjude.org/research/comprehensive-cancer-center/hpv-cancerprevention-program/hpv-roundtable-southeast.html#sectioned_content719dfe5a-1fb2-433b-8fc7-38af3c8e8048=1

Sources 1 Centers for Disease Control and Prevention. (2023, February 10). HPV infection. Centers for Disease Control and Prevention. Retrieved July 20, 2023, from https://www.cdc.gov/hpv/parents/about-hpv. html 2 Centers for Disease Control and Prevention. (2023, September 12). HPV-associated cancer statistics. Centers for Disease Control and Prevention. Retrieved December 22, 2023, from https://www.cdc.gov/ cancer/hpv/statistics/cases.html

Centers for Disease Control and Prevention. (2021, November 1). Cancers caused by HPV are preventable. Centers for Disease Control and Prevention. Retrieved July 20, 2023, from https://www.cdc.gov/ hpv/hcp/protecting-patients.html

4 U.S. News & World Report. (n.d.). Health care access rankings. Retrieved September 12, 2023, from https://www.usnews.com/news/best-states/rankings/health-care/healthcare-access 5 St. Jude Children’s Research Hospital. (2023, November). HPV Vaccination Roundtable of the Southeast. Retrieved on December 28, 2023, from https://www.stjude.org/research/comprehensive-cancer-center/hpv-cancer-prevention-program/hpv-roundtable-southeast.html#sectioned_contentea23491e-7e70-4fa3-a1a5-31d341d729d9=12 6 Centers for Disease Control and Prevention and the National Cancer Institute. (2020). State Cancer Profiles. Centers for Disease Control and Prevention and the National Cancer Institute. Retrieved December 28, 2023, from https://statecancerprofiles.cancer.gov/risk/index.php?topic=women&risk=v11&race=00&datatype=0&type=risk&sortVariableName=default&sortOrder=default#results

Center for Children & Families (CCF) of the Georgetown University Health Policy Institute. (2022). The Children’s Health Care Report Card. Retrieved December 28, 2023, from https://kidshealthcarereport. ccf.georgetown.edu/

KFF. (2022). Health Insurance Coverage of Adults 19-64. Retrieved December 28, 2023, from https://www.kff.org/other/state-indicator/adults-19-64/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

15 St. Jude Children’s Research Hospital. (2023, November). HPV Vaccination Roundtable of the Southeast. Retrieved on December 28, 2023, from https://www.stjude.org/research/comprehensive-cancer-center/ hpv-cancer-prevention-program/hpv-roundtable-southeast.html#sectioned_content-ea23491e-7e704fa3-a1a5-31d341d729d9=12 16 Arkansas Immunization Action Coalition. (n.d.). Vaccine Education Workshops. Retrieved December 28, 2023, from https://www.immunizear.org/vaccine-workshop-toolkits-dev 17 St. Jude Children’s Research Hospital. (2023, November). HPV Vaccination Roundtable of the Southeast. Retrieved December 28, 2023, from https://www.stjude.org/research/comprehensive-cancer-center/ hpv-cancer-prevention-program/hpv-roundtable-southeast.html#sectioned_content-ea23491e-7e704fa3-a1a5-31d341d729d9=12

VAX 2 STOP CANCER. (n.d.). Pediatric Provider Education. Retrieved December 28, 2023, from https:// www.vax2stopcancer.org/pediatric-provider-education

St. Jude Children’s Research Hospital. (2023, November). HPV Vaccination Roundtable of the Southeast. Retrieved December 28, 2023, from https://www.stjude.org/research/comprehensive-cancer-center/ hpv-cancer-prevention-program/hpv-roundtable-southeast.html#sectioned_content-ea23491e-7e704fa3-a1a5-31d341d729d9=12

Cost savings realized as a result of increased HPV vaccination initiation and the subsequently reduced incidence of HPV cancers; cost savings estimates based on average direct cancer treatment costs (i.e., medical care services such as physician services, diagnostic tests, and hospitalization expenses) during the first two years after diagnosis. Non-medical costs and non-cost outcomes, such as productivity loss, caregiver burden, and mortality, are excluded from cost-saving estimates.

Medicaid.gov. (n.d.). Medicaid, Children’s Health Insurance Program, & Basic Health Program Eligibility Levels. Medicaid.gov. Retrieved July 27, 2023, from https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-childrens-health-insurance-program-basic-health-program-eligibility-levels/index.html

9 Medicaid.gov. (2023, March). March 2023 Medicaid & CHIP Enrollment Data Highlights. Medicaid.gov. Retrieved July 20, 2023, from https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html

10 Center on Budget and Policy Priorities. (2018, January 19). Medicaid Works for Children. Retrieved December 28, 2023, from https://www.cbpp.org/research/health/medicaid-works-for-children#medicaid-improves-access-to-care-cbpp-anchor

Does not include potential cost savings in Puerto Rico.

The change in the observed factor occurs over one year - the net cost savings over the lifetimes of the individuals diagnosed with HPV cancers would be much larger.

24 KFF. (2023, December 20). Medicaid Enrollment and Unwinding Tracker. Retreieved December 28, 2023, from https://www.kff.org/report-section/medicaid-enrollment-and-unwinding-tracker-overview/

KFF. (2023, December 20). Medicaid Enrollment and Unwinding Tracker. Retreieved December 28, 2023, from https://www.kff.org/report-section/medicaid-enrollment-and-unwinding-tracker-overview/#children-disenrollments

Centers for Disease Control and Prevention. (2023, November 17). ACIP Vaccine Recommendations and Guidelines. Centers for Disease Control and Prevention. Retrieved December 28, 2023, from https://www.cdc.gov/vaccines/hcp/acip-recs/index.html

Center on Budget and Policy Priorities. (2023, December 20). Unwinding Watch: Tracking Medicaid Coverage as Pandemic Protections End. Retrieved December 28, 2023, from https://www.cbpp.org/research/ health/medicaid-works-for-children#medicaid-improves-access-to-care-cbpp-anchor

Hawkins, S.S., Horvath, K., Cohen, J. et al. (2021). Associations between insurance-related affordable care act policy changes with HPV vaccine completion. BMC Public Health, 21, 304. https://doi. org/10.1186/s12889-021-10328-4

Center for Children & Families (CCF) of the Georgetown University Health Policy Institute. (2023, December 21). What is the impact of unwinding on Medicaid enrollment? Retrieved December 28, 2023, from https://ccf.georgetown.edu/unwinding-enrollment-data/

Hollings Cancer Center. (2023, May 3). Community health van increases access to a vaccine that helps to prevent six types of cancer. Retrieved December 28, 2023, from https://hollingscancercenter.musc. edu/news/archive/2023/05/03/vaccine-van 13

St. Jude Children’s Research Hospital. (2023, November). HPV Vaccination Roundtable of the Southeast. Retrieved on December 28, 2023, from https://www.stjude.org/research/comprehensive-cancer-center/hpv-cancer-prevention-program/hpv-roundtable-southeast.html#sectioned_contentea23491e-7e70-4fa3-a1a5-31d341d729d9=12

28 Puerto Rico provides Medicaid coverage to children and adolescents under age 19 whose incomes are below 266% of the Puerto Rico Poverty Level (PRPL), which was approximately 85% FPL in 2021. https:// www.macpac.gov/wp-content/uploads/2020/08/Medicaid-and-CHIP-in-Puerto-Rico.pdf