Since the introduction of the human papillomavirus (HPV) vaccine in 2006, HPV vaccination uptake has lagged behind that of other recommended adolescent vaccines such as tetanus, diphtheria, and acellular pertussis (Tdap) and meningococcal conjugate (MenACWY).¹ HPV vaccine is routinely recommended for adolescents at age 11 or 12 years for protection from cancers and other diseases caused by HPV infection.² Ideally, preteens should finish the series by their 13th birthday. Vaccination can also be started as early as 9 years of age.² Adolescents who get the first dose of HPV vaccine before their 15th birthday need two doses of HPV vaccine to be protected against HPV cancers; teens and young adults who start the series on or after age 15 years need three doses.² HPV vaccination is currently recommended for girls and women through age 26 years who were not previously vaccinated, and is also recommended for boys and men through age 21 years who were not previously vaccinated.²

From 2011 to 2012, HPV vaccination coverage estimates among females were unchanged, according to the National Immunization Survey-Teen.¹ HPV vaccination coverage estimates for ≥1 dose was 53.8% for females and 20.8% for males.¹ However, coverage for ≥1 dose of Tdap was 84.6%, and ≥1 dose of MenACWY was 74.0% among adolescents in 2012. Because of this low coverage, Centers for Disease Control and Prevention (CDC) engaged several national provider organizations to improve HPV vaccination rates among adolescents aged 11–12 beginning in 2014. These multiyear projects with national partners, including the Academic Pediatric Association (APA), the American Academy of Pediatrics (AAP), the American Cancer Society (ACS), the National Area Health Education Centers Organization (NAO), and the National Association of County and City Health Officials (NACCHO), focus on several key strategies such as educating providers on effective HPV vaccine recommendations, prioritizing HPV vaccination, forming strong partnerships, developing and disseminating HPV vaccination resources for members and the public, and quality improvement (QI). APA, AAP, ACS, and NAO have 5-year projects from 2014 to 2019, while NACCHO had a 2-year project that took place from 2014 to 2016.

Studies consistently showed that an effective recommendation from a provider is the single best predictor of vaccination for any vaccine, including the HPV vaccine.³ Partner organizations helped strengthen the provider recommendation for HPV vaccine by direct outreach to and education of its members and targeted audiences. The purpose of this report is to showcase the HPV vaccination work that APA, AAP, ACS, NAO, and NACCHO have done throughout these 5-year projects.

APA nurtures the academic success and career development of child health professionals engaged in research and improvement science, and provides educational scholarship to enhance the health and well-being of all children.⁴ The National Immunization Project with the APA (NIPA) is a large-scale, practice-based QI program.⁵ NIPA’s project goals are to increase the number of providers who make an effective recommendation for the HPV vaccine for adolescents aged 11–18 years (with an emphasis on 11- and 12-year-olds), to assess HPV vaccination status at every health care visit, and to implement practice change to increase immunization rates.⁵ This goal is reached through a QI learning collaborative. Participants from the Continuity Research Network (CORNET) and the National Improvement Partnership Network (NIPN) sites receive trainings and help NIPA achieve project goals. CORNET is a national, practice-based research network composed of pediatric residency continuity practices. NIPN is a network of more than 20 states that have developed “improvement partnerships” to advance quality and transform health care for children and families. APA also offers HPV-focused Grand Rounds to explain the importance of HPV vaccination and describe current vaccination rates; discuss the rationale for vaccinating all adolescents at ages 11–12; provide useful communication strategies to inform parents about HPV; develop a plan to increase practices’ HPV vaccination rates; and help providers locate resources that are relevant to current immunization practice. Grand Rounds is a teaching tool for medical education, consisting of presenting medical problems and treatments of a patient to an audience of doctors, residents, and medical students.⁶

AAP strives to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults.⁸ Activities for this project include provider education, QI, and local efforts aimed at promoting an effective provider recommendation for the HPV vaccine. The AAP partnership led to state chapters being prepared to effectively improve immunization rates and greatly expand collaborations with partners and organizations. AAP also offers a forum for health care professionals to learn and improve QI skills and gain self-efficacy around HPV vaccination through Extension for Community Healthcare Outcomes (ECHO). ECHO is a telementoring hub-and-spoke platform that leverages technology to connect experts (hub) with primary care providers in local communities (spoke).⁹ Participants’ QI work is presented for discussion and problem-solving. ECHO has been implemented in select AAP state chapters.⁹ From 2015 to 2017, QI activities through the hub-and-spoke initiative have reached over 600 practices.

ACS is a nationwide, community-based voluntary health organization dedicated to eliminating cancer as a major health problem.¹⁰ ACS’s Vaccinate Adolescents against Cancers (VACs) project focuses efforts on reaching health systems and providing technical assistance and QI training. Since 2015, over 250 Cancer Control staff members have engaged key stakeholders as conveners, connectors, and change-makers to prioritize HPV vaccination.¹¹ The VACs program engages health systems, payers, and federally qualified health centers (FQHCs) to increase HPV vaccination through clinic-level interventions and QI efforts to improve system-wide processes and educate providers regarding the role of HPV vaccination in cancer prevention.¹¹ Additionally, VACs, in partnership with state health departments and other state-based entities, facilitates system changes that increase the availability and utilization of HPV vaccination.

NAO represents a network of more than 300 AHEC program offices and centers that serve over 85% of the US counties.¹³ The AHEC mission is to enhance access to quality health care, particularly primary and preventive care, by improving the supply and distribution of health care professionals via strategic partnerships with academic programs, communities, and professional organizations.¹⁴ NAO provides education to health professionals to strengthen HPV vaccination recommendations, resulting in a decrease in missed opportunities to vaccinate adolescents aged 11–12.

One AHEC entity per state was selected to carry out state and local HPV project training activities in coordination with four project specialists in the areas of marketing, partnership development, continuing education, and AHEC integration.¹⁴ AHECs use their unique niche in serving the rural and underserved to reach health care providers and students that do not have access to large-scale QI projects most often available in urban settings. Over 71% of health care professionals trained at AHEC events serve rural/frontier and/or urban underserved populations. AHECs have also historically leveraged multiple partnerships, including CDC national partners, public health training centers, educational institutions, health profession programs, and local, state, and national immunization and cancer coalitions.

NACCHO seeks to improve public health by being a leader, partner, catalyst, and voice-for-change to local health departments (LHDs) around the nation.¹⁶ Beginning in 2014, NACCHO worked with 20 LHDs in states with some of the lowest HPV vaccination rates and assisted them in action planning and implementing initiatives to increase HPV vaccination rates in their communities.¹⁷ NACCHO designed an action planning process that engaged LHDs in conducting an environmental scan of their community resources, identifying key community stakeholders, and developing strategic focus areas. NACCHO also provided ongoing technical assistance and capacity-building support over a 1–2-year timeframe. LHDs participated in an initial action planning meeting and in-person meetings that provided opportunities to receive information from experts in the field and national partner organizations. To provide convenient access to existing HPV promotional materials and strategies, NACCHO developed the Guide to HPV Resources for Local Health Departments,¹⁸ a collection of HPV resources and practice-based tools. NACCHO continues to update this guide to provide up-to-date resources.

Five national partners have worked toward improving HPV vaccination rates among adolescents for several years. These partners have shown increased HPV vaccination rates among individual projects, and also have educated providers on effective HPV vaccine recommendations, developed and disseminated HPV vaccination resources for members and the public (Table 1), and led several QI initiatives. Additionally, all partners have participated or collaborated with the National HPV Vaccination Roundtable, which is a coalition of organizations and experts dedicated to reducing the incidence of and mortality from HPV cancers in the United States.³⁰

Since 2013, there has been a steady increase in HPV vaccination. The latest HPV vaccination coverage estimates in the 2017 National Immunization Survey-Teen showed that most parents are choosing to have their children vaccinated against HPV. In 2017, 66% of teens aged 13–17 years received one or more doses of HPV vaccine, an increase of 5 percentage points from 2016.³¹ Forty-nine percent of teens are up-to-date on all recommended doses of HPV vaccine.³¹ It is encouraging to see the progress that is being made every year with HPV vaccination rates among adolescents.

While HPV vaccination rates continue to increase around the United States, the national partners are working to sustain HPV vaccination activities after select projects end in 2019. In addition to working with members throughout their organizations, partners also collaborated with each other to ensure consistent HPV vaccination messages were being disseminated. By working together and sharing knowledge, states and communities can function better to increase HPV vaccination rates among adolescents. HPV vaccination rates may still be lagging compared with Tdap and MenACWY vaccines,³¹ but the efforts these partners have put in have helped in training providers, disseminating HPV vaccination educational materials, and bettering each organization’s effectiveness as a whole. This prioritization of HPV vaccination outreach from the national partners could set an example for other organizations wanting to increase HPV vaccination rates and protect adolescents from future HPV-associated cancers.