Goal 3: Maximize Access to HPV Vaccination Services
Ensuring that HPV vaccination is affordable and convenient for all U.S. adolescents will support optimal vaccine uptake. Access barriers likely play a role in low and uneven HPV vaccine uptake in the United States. These barriers—and approaches for addressing them—may differ across geographic regions, populations, and clinical settings. National, regional, and local efforts are needed to understand and address existing and potential barriers to access.
Coverage for HPV Vaccination Costs Must Be Maintained
The HPV vaccine is among the most expensive vaccines in the United States,1 but multiple sources of private and public financing ensure that the cost of the vaccine is covered for nearly all age-eligible adolescents.2 The Affordable Care Act requires private insurance plans and marketplace plans to cover all ACIP-recommended immunizations, including the HPV vaccine, with no consumer cost sharing.3 The vaccine also is available through the Vaccines for Children (VFC) Program for children under age 19 who are Medicaid-eligible, uninsured, underinsured, or American Indian/Alaska Native. HPV vaccine costs also are covered by Medicaid, state Children’s Health Insurance Programs, and Merck-sponsored patient assistance programs.2 The Panel Chair asserts that insurance coverage for preventive services must be maintained to ensure that cost does not limit U.S. adolescents’ access to HPV vaccination.
Alternative Settings May Expand Access to HPV Vaccination in Some Situations
Ideally, all adolescents would receive regular care—including immunizations—from a provider with whom they have an ongoing relationship. However, many adolescents do not receive regular preventive care through medical homes.4 In its 2012-2013 report, the Panel recommended that, for those adolescents, HPV vaccination be promoted and facilitated in venues outside the medical home, citing pharmacies and schools as potential sites within the “medical neighborhood” that could increase access to HPV vaccination. Since that time, these venues have been explored by various groups in different settings, and a clearer picture of the associated challenges and opportunities has emerged.
Both pharmacies and schools have potential to provide convenient access to HPV vaccination. Nearly 90 percent of U.S. residents live within five miles of a community pharmacy;5 pharmacies often have longer operating hours and shorter wait times than doctors’ offices and many provide walk-in vaccinations. Schools also provide the opportunity to reach the vast majority of adolescents, and school-based HPV vaccination programs have been highly successful in many countries around the world.6 In the United States, pharmacies and schools have not played major roles in HPV vaccination to date due to several challenges (see Challenges Associated with HPV Vaccination in Pharmacies and Schools).
Given these challenges, it is unlikely that HPV vaccination in pharmacies or schools will contribute to substantial increases in national HPV vaccination rates in the near future. However, alternative settings may expand access in some situations. Offering and promoting HPV vaccination in schools, pharmacies, and other sites within the medical neighborhood may be particularly useful in rural areas, which have fewer primary care physicians per capita than urban areas and greater obstacles to access.7 School-located programs have helped increase coverage rates in some areas (see School Program Increases HPV Vaccination in Rural North Dakota).8,9 The small but growing number of school-based health centers—which provide comprehensive healthcare services, have dedicated staff, and often serve large numbers of VFC-eligible students—may be able to more easily overcome the most common barriers to school-located vaccination.9,10
State and local laws, local cultural factors, potential partner organizations, and available resources should be considered when exploring options to increase access to HPV vaccination. Providers and programs in alternative settings should communicate and coordinate with primary care providers to the extent possible, including reporting all administered vaccine doses to the state’s immunization information system (IIS). The Panel Chair supports the call by the National Vaccine Advisory Committee11 for greater investment and commitment to promote interoperability of electronic health record systems and IIS. Once interoperability is achieved, states should consider requiring providers to report vaccinations to IIS to ensure that all vaccine providers have access to complete, timely information.
Challenges Associated with HPV Vaccination in U.S. Pharmacies and Schools
- Restricted authority in some states—Pharmacists in 48 states and the District of Columbia have authority to administer the HPV vaccine, but 11 of these states do not allow HPV vaccination of 11- and 12-year-old children and several other states require a physician prescription or protocol.
- Inadequate insurance coverage—Many private insurance plans do not cover or provide inadequate coverage for vaccine administration within pharmacies. Relatively few pharmacists are VFC providers. Some states do not enroll pharmacies in VFC, while pharmacies in other states may elect not to participate in the program due to the cumbersome requirements.
- Low demand—Pharmacists who stock the HPV vaccine report providing very few doses, and parents consider doctors’ offices to be a better environment than pharmacies for adolescent vaccination.
- Complicated billing—Students within a school or school district may be covered by a range of private insurance plans and public programs, which makes billing cumbersome and costly.
- Competing priorities—Schools have limited resources and must focus these resources on education and other priorities (e.g., transporting students, meals).
- Low demand—Surveys of parents suggest support for school-located vaccination, but most say they prefer their adolescents to be vaccinated in providers’ offices. Participation in school-located HPV vaccination programs to date has generally been low in the United States.
Sources: Islam JY, Gruber JF, Lockhart A, et al. Opportunities and challenges of adolescent and adult vaccination administration within pharmacies in the United States. Biomed Inform Insights. 2017;9:1178222617692538. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28469431; Barden S. National HPV Vaccination Roundtable Pharmacy-located HPV Vaccination Pilot Project: final report. Lansing (MI): Michigan Pharmacists Association; 2018. Available from: http://hpvroundtable.org/wp-content/uploads/2018/02/Pharmacy-located-HPV-Vaccination-Pilot-Final-Report_MI.pdf; Curry S, Vanderpool R, Lopez K, et al. National HPV Vaccination Roundtable Pharmacy-Located HPV Vaccination Pilot Project: final report. Carrboro (NC): Cancer Prevention and Control Research Network; n.d. Available from: http://hpvroundtable.org/wp-content/uploads/2018/02/CPCRN_Pharmacy-located-HPV-Vaccination_Pilot-Project-Findings-from-IA_KY_OR.pdf; Hastings TJ, Hohmann LA, McFarland SJ, et al. Pharmacists' attitudes and perceived barriers to human papillomavirus (HPV) vaccination services. Pharmacy (Basel). 2017;5(3). Available from: https://www.ncbi.nlm.nih.gov/pubmed/28970457; Shah PD, Marciniak MW, Golden SD, et al. Pharmacies versus doctors' offices for adolescent vaccination. Vaccine. 2018;36(24):3453-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29748030; American Pharmacists Association. Pharmacist authority to immunize by type of immunization [Internet]. Washington (DC): APhA; [updated 2018 Jan 18; cited 2018 Jun 28]. Available from: https://www.pharmacist.com/immunization-center; Daley MF, Kempe A, Pyrzanowski J, et al. School-located vaccination of adolescents with insurance billing: cost, reimbursement, and vaccination outcomes. J Adolesc Health. 2014;54(3):282-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24560036; Kempe A, Allison MA, Daley MF. Can school-located vaccination have a major impact on human papillomavirus vaccination rates in the United States? Acad Pediatr. 2018;18(2S):S101-S5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29502627
School Program Increases HPV Vaccination in Rural North Dakota
Access to healthcare is limited in many rural counties in North Dakota. In 2012, some of these counties had rates of HPV vaccine series completion as low as 10 percent. To address this, the North Dakota cancer control and state immunization programs partnered with local public health units, schools, and communities to implement an in-school vaccination program. Vaccinations were provided during school hours in 20 middle and high schools in 4 counties. Parents provided information on insurance coverage and Vaccines for Children Program eligibility. Public health units billed insurance companies, Medicaid, or parents, as appropriate, to cover vaccine costs and administration fees. In one participating county, coverage rates increased by 18 percent within two years, and the program became self-sustaining in three years. The success of this program was attributed to the strong collaborative efforts of the North Dakota state immunization and comprehensive cancer control programs to inform parents of the need for the vaccine and increase access to it.
Sources: Pastir J. School HPV immunization clinics increase vaccination rates in North Dakota. Atlanta (GA): Centers for Disease Control and Prevention; 2017 Nov 30. Available from: https://nccd.cdc.gov/nccdsuccessstories/showdoc.aspx?s=14291&dt=0; Personal communication with Janna Pastir (Comprehensive Cancer Prevention and Control Program, North Dakota Department of Health, Bismarck, ND) and Molly Howell (Division of Disease Control, North Dakota Department of Health, Bismarck, ND). 2018 Aug.
- Centers for Disease Control and Prevention. CDC vaccine price list [Internet]. Atlanta (GA): CDC; [cited 2018 Jun 1]. Available from: https://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-management/price-list/index.html
- The Henry J. Kaiser Family Foundation. The HPV vaccine: access and use in the U.S. [Fact Sheet]. San Francisco (CA): KFF; 2017 Oct. Available from: http://files.kff.org/attachment/fact-sheet-the-hpv-vaccine-access-and-use-in-the-u-s
- U.S. Department of Health and Human Services. Where and how to get vaccines [Internet]. Washington (DC): DHHS; [cited 2018 Apr 16]. Available from: https://www.hhs.gov/ash/oah/adolescent-development/physical-health-and-nutrition/vaccines/where-and-how-to-get-vaccines/index.html
- Rand CM, Goldstein NPN. Patterns of primary care physician visits for U.S. adolescents in 2014: implications for vaccination. Acad Pediatr. 2018;18(2S):S72-S8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29502641
- National Association of Chain Drug Stores. Home page [Internet]. Arlington (VA): NACDS; [cited 2018 Jun 28]. Available from: https://www.nacds.org
- Brotherton JML, Bloem PN. Population-based HPV vaccination programmes are safe and effective: 2017 update and the impetus for achieving better global coverage. Best Pract Res Clin Obstet Gynaecol. 2018;47:42-58. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28986092
- Petterson SM, Phillips RL, Bazemore AW, Koinis GT. Unequal distribution of the U.S. primary care workforce. Washington (DC): Robert Graham Center; 2013 Jun 1. Available from: https://www.graham-center.org/rgc/publications-reports/publications/one-pagers/unequal-distribution-2013.html
- Pastir J. School HPV immunization clinics increase vaccination rates in North Dakota. Atlanta (GA): Centers for Disease Control and Prevention; 2017 Nov 30. Available from: https://nccd.cdc.gov/nccdsuccessstories/showdoc.aspx?s=14291&dt=0
- Kempe A, Allison MA, Daley MF. Can school-located vaccination have a major impact on human papillomavirus vaccination rates in the United States? Acad Pediatr. 2018;18(2S):S101-S5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29502627
- School-Based Health Alliance. 2013-2014 digital census report [Internet]. Washington (DC): the Alliance; [cited 2018 Jun 29]. Available from: http://censusreport.sbh4all.org
- National Vaccine Advisory Committee. Strengthening the effectiveness of national, state, and local efforts to improve HPV vaccination coverage in the United States: recommendations of the National Vaccine Advisory Committee. Washington (DC): NVAC; 2018 Jun 25. Available from: https://www.hhs.gov/sites/default/files/2018_nvac_hpv-report_final_remediated.pdf