Preventive Medicine 76 (2015) 126
Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Letter to the Editor Philanthropic support of HPV vaccination efforts Keywords: Human Papilloma Virus Quadrivalent vaccine Philanthropy Health disparities
As healthcare providers from sites that participated in the Kansas City area free HPV vaccine program, we are delighted that Harper and colleagues chose to examine the impact of our program on their patients (Harper et al., 2014). Dr. Harper is a leading international HPV vaccine expert, and her attention to evaluate this geographically limited program is a source of pride to the health philanthropies that provided funding. While unnamed in the article, the Health Care Foundation of Greater Kansas City and the REACH Healthcare Foundation funded the free vaccine program to enable un/underinsured 9–26 year-old females in their service area to receive Gardasil® (HPV4). At that time, HPV4 was the only approved vaccine and was available solely for females. Our program provided vaccine to eligible females who did not qualify for other free programs (e.g., VFC) or could not afford the costs from their health care providers. Between August, 2007 and January, 2011 the program provided at least one dose of HPV4 to 9784 individuals at 33 safety net and public health department clinics. We are concerned that Harper and colleagues portray the free vaccine without a necessary broader context. For example, the free program continued two years longer at their sites, Truman Medical Center (TMC), than the timeframe they chose for analysis. The result is that they missed 46% of cases relevant to addressing their research question. Second, during the timeframe selected, the free program was not as active at TMC as compared to other clinics. This perhaps reflects less enthusiastic support by clinicians in offering HPV4 or relatively fewer patients who needed free vaccine. Third, while HPV4 completion rates at TMC sites are relevant to their clinics' performance, the authors fail to include important information about where and how eligible youth and women could use the program. There were many additional sites where initiators could have received subsequent doses of HPV4 because recipients did not have to maintain site-specific eligibility. Some did not return to TMC for subsequent dose(s) and some had received their first or second dose elsewhere. This resulted in incomplete vaccination profiles using only TMC's data and these cases were excluded from their analysis. While specifications of how to define “timely completion” vary, the free program had 8.9% completers (3 doses) using Harper's definition. This compares to published rates of 34% (Rahman et al., 2014), 10.1% (Nomura & Rahman, 2014) and 14% (Laz et al., 2012) for 9–17 year-old girls. Harper's conclusion that free vaccine did not specifically increase youth completion rates is technically correct. But the overall program
http://dx.doi.org/10.1016/j.ypmed.2014.11.032 0091-7435/© 2015 Published by Elsevier Inc.
achieved a level of vaccination that obliterates the disparity gap usually present for this population. The combined, overall HPV4 completion rate for both youth and adult participants was 37%, a rate that rivals that of insured youth and women in our country and comes close to matching the completion rate report for the entire Midwest (38.4%) (Hirth et al., 2012). In other words, the free vaccine performed no better (or worse) than vaccine completion rates for less vulnerable populations. We see this as a monumental achievement in reducing disparities for poor youth and women. The Kansas City experience of funding a multi-year, safety netoriented free HPV4 program stands to inform other locations considering whether free vaccine will have an impact on cervical cancer prevention (Tiggelaar & Rafalski, 2014). Because Pap smear screening is not recommended in females younger than 21 regardless of age at sexual debut, options for prevention must include HPV vaccination. We argue that providing it free to vulnerable females clearly has an impact on population health. This program, coupled with decreasing risk factors, increasing awareness, and continued promotion of US guidelines for age-appropriate screening we believe will have substantial impact on cervical cancer in underserved women. Conflict of interest statement The authors declare that there are no conflicts of interests.
References Harper, D.M., Verdenius, I., Harris, G.D., et al., 2014. The influence of free quadrivalent papillomavirus vaccine (HPV4) on the timely completion of the three dose series. Prev. Med. 61, 20–25. Rahman, M., McGrath, C.J., Berenson, A.B., 2014. Geographic variation in human papillomavirus vaccination uptake among 13–17 year old adolescent girls in the United States. Vaccine 32 (21), 2394–2398 (May 1). Nomura, K., Rahman, M., 2014. HPV vaccine uptake among Asian American girls aged 9–17 years during 2008–2010. Int. J. Gynaecol. Obstet. 126 (1), 91–92. Laz, T.H., Rahman, M., Berenson, A.B., 2012. An update on human papillomavirus vaccine uptake among 11–17 year old girls in the United States: National Health Interview Survey, 2010. Vaccine 30 (24), 3534–3540. Hirth, J.M., Tan, A., Wilkinson, G.S., Berenson, A.B., 2012. Completion of the human papillomavirus vaccine series among insured females between 2006 and 2009. Cancer 118 (22), 5623–5629. Tiggelaar, S.M., Rafalski, M., 2014. HPV knowledge and vaccine acceptability in Appalachian Tennessee and Kentucky, USA. J. Fam. Plann. Reprod. Health Care 40 (1), 75 (January).
Bridget McCandless Health Care Foundation of Greater Kansas City, USA *Corresponding author at: MD Health Care Foundation of Greater Kansas City 2700 East 18th Street #220, Kansas City, MO 64127, USA. Brenda R. Sharpe REACH Healthcare Foundation, USA
Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Letter to the Editor Philanthropic support of HPV vaccination efforts Keywords: Human Papilloma Virus Quadrivalent vaccine Philanthropy Health disparities
As healthcare providers from sites that participated in the Kansas City area free HPV vaccine program, we are delighted that Harper and colleagues chose to examine the impact of our program on their patients (Harper et al., 2014). Dr. Harper is a leading international HPV vaccine expert, and her attention to evaluate this geographically limited program is a source of pride to the health philanthropies that provided funding. While unnamed in the article, the Health Care Foundation of Greater Kansas City and the REACH Healthcare Foundation funded the free vaccine program to enable un/underinsured 9–26 year-old females in their service area to receive Gardasil® (HPV4). At that time, HPV4 was the only approved vaccine and was available solely for females. Our program provided vaccine to eligible females who did not qualify for other free programs (e.g., VFC) or could not afford the costs from their health care providers. Between August, 2007 and January, 2011 the program provided at least one dose of HPV4 to 9784 individuals at 33 safety net and public health department clinics. We are concerned that Harper and colleagues portray the free vaccine without a necessary broader context. For example, the free program continued two years longer at their sites, Truman Medical Center (TMC), than the timeframe they chose for analysis. The result is that they missed 46% of cases relevant to addressing their research question. Second, during the timeframe selected, the free program was not as active at TMC as compared to other clinics. This perhaps reflects less enthusiastic support by clinicians in offering HPV4 or relatively fewer patients who needed free vaccine. Third, while HPV4 completion rates at TMC sites are relevant to their clinics' performance, the authors fail to include important information about where and how eligible youth and women could use the program. There were many additional sites where initiators could have received subsequent doses of HPV4 because recipients did not have to maintain site-specific eligibility. Some did not return to TMC for subsequent dose(s) and some had received their first or second dose elsewhere. This resulted in incomplete vaccination profiles using only TMC's data and these cases were excluded from their analysis. While specifications of how to define “timely completion” vary, the free program had 8.9% completers (3 doses) using Harper's definition. This compares to published rates of 34% (Rahman et al., 2014), 10.1% (Nomura & Rahman, 2014) and 14% (Laz et al., 2012) for 9–17 year-old girls. Harper's conclusion that free vaccine did not specifically increase youth completion rates is technically correct. But the overall program
http://dx.doi.org/10.1016/j.ypmed.2014.11.032 0091-7435/© 2015 Published by Elsevier Inc.
achieved a level of vaccination that obliterates the disparity gap usually present for this population. The combined, overall HPV4 completion rate for both youth and adult participants was 37%, a rate that rivals that of insured youth and women in our country and comes close to matching the completion rate report for the entire Midwest (38.4%) (Hirth et al., 2012). In other words, the free vaccine performed no better (or worse) than vaccine completion rates for less vulnerable populations. We see this as a monumental achievement in reducing disparities for poor youth and women. The Kansas City experience of funding a multi-year, safety netoriented free HPV4 program stands to inform other locations considering whether free vaccine will have an impact on cervical cancer prevention (Tiggelaar & Rafalski, 2014). Because Pap smear screening is not recommended in females younger than 21 regardless of age at sexual debut, options for prevention must include HPV vaccination. We argue that providing it free to vulnerable females clearly has an impact on population health. This program, coupled with decreasing risk factors, increasing awareness, and continued promotion of US guidelines for age-appropriate screening we believe will have substantial impact on cervical cancer in underserved women. Conflict of interest statement The authors declare that there are no conflicts of interests.
References Harper, D.M., Verdenius, I., Harris, G.D., et al., 2014. The influence of free quadrivalent papillomavirus vaccine (HPV4) on the timely completion of the three dose series. Prev. Med. 61, 20–25. Rahman, M., McGrath, C.J., Berenson, A.B., 2014. Geographic variation in human papillomavirus vaccination uptake among 13–17 year old adolescent girls in the United States. Vaccine 32 (21), 2394–2398 (May 1). Nomura, K., Rahman, M., 2014. HPV vaccine uptake among Asian American girls aged 9–17 years during 2008–2010. Int. J. Gynaecol. Obstet. 126 (1), 91–92. Laz, T.H., Rahman, M., Berenson, A.B., 2012. An update on human papillomavirus vaccine uptake among 11–17 year old girls in the United States: National Health Interview Survey, 2010. Vaccine 30 (24), 3534–3540. Hirth, J.M., Tan, A., Wilkinson, G.S., Berenson, A.B., 2012. Completion of the human papillomavirus vaccine series among insured females between 2006 and 2009. Cancer 118 (22), 5623–5629. Tiggelaar, S.M., Rafalski, M., 2014. HPV knowledge and vaccine acceptability in Appalachian Tennessee and Kentucky, USA. J. Fam. Plann. Reprod. Health Care 40 (1), 75 (January).
Bridget McCandless Health Care Foundation of Greater Kansas City, USA *Corresponding author at: MD Health Care Foundation of Greater Kansas City 2700 East 18th Street #220, Kansas City, MO 64127, USA. Brenda R. Sharpe REACH Healthcare Foundation, USA
