1. Administration of the HPV Vaccine in Women’s Health Clinics Jolene Kay Bethune, RN, MSN

2. Purpose Purpose: Educate mothers of adolescent clients about the spread of HPV among teens Educate adolescent clients about the spread of HPV among teens Promote the administration of HPV vaccines

3. Disease Process According to the CDC, one in four female adolescents in the United States is infected with: Human Papillomavirus (HPV) Chlamydia Herpes Simplex Virus Trichomoniasis The most common STI was cancer- and genital wart-associated HPV.

4. Disease Process 40 types of HPV Type 16/18 – 70% of cervical cancer Types 6/11 – 90% of genital warts Type-specific vaccines are proving to be effective Protection from vaccines is expected to be long-lasting Pap smears will still be necessary to detect certain cancers not prevented by type-specific vaccines

5. Disease Process Condylomataacuminata, also known as genital warts, is associated with certain types of HPV Sites commonly affected include the urinary meatus, labia, vagina, cervix, penis scrotum anus and the perineal area Once exposure occurs, the incubation period is usually two to three months. Initially single, small papillary growths that may grow into large cauliflower-like masses Bleeding may occur if the wart is disrupted (Ignativicius & Workman, 2002, p. 1813) They may regress spontaneously or develop into cervical or genital dysplasia or cervical intraepithelial neoplasia (CIN). (Segala, Lea, & Davis, 2003).

6. Medical and Nursing Interventions The goals of medical management: Remove the warts Treat the symptoms Prevent progression of neoplasias No therapy has been shown to completely eradicate HPV There may be recurrences after treatment

7. Medical and Nursing Interventions Treatment includes provider or client applied podophilox 0.5% solution Provider-provided: Cryotherapy Podophyllin Trichloroacetic acid Sexual partners must also be treated; and clients must avoid sexual contact until external lesions are healed. (Ignativicius & Workman, 2002)

8. Medical and Nursing Interventions Due to the cellular composition of the young cervix, adolescent women are particularly vulnerable to HVP infection Adolescent immune response to HPV exposure is greater than in adults Adolescents respond best to vaccines.

9. Medical and Nursing Interventions HPV vaccines are now recommended for all women and for girls as young as 11 and 12 years old Doctors may give it to girls as young as nine years old; the rationale is to vaccinate girls early, before first sexual contact and possible exposure to HPV Given as a three-dose series; and may be given the same time as other vaccines

10. Educational Interventions Nursing management focuses on client education about: Mode of transmission Incubation period Treatment and complications Reduction of transmission with the use of condoms Prevention, with the use of vaccines

11. Project Intervention Poster presentation Brochure Shot record with calendar

12. Cost of Vaccine The HPV vaccine currently on the market: Three doses over six-month period $120 per dose $360 per patient for the series

13. Cost of Vaccine Covered under a federal program available to uninsured and Medicaid eligible children Available at health departments, public clinics, private doctors’ offices and hospitals Many large insurance companies will cover the cost of the vaccine because it is recommended by the CDC

14. Theoretical Basis Bandura: Social learning theory (or social cognitive theory) Focuses on how people learn from one another Encompasses observational learning, imitation and modeling (McEwen & Wills, 2007, p. 395) Young people acquired behaviors by watching and listening to others who influence them Modeled or imitated those behaviors

15. Theoretical Basis Bandura: Chosen because adolescents model behavior of their peers and people they admire A practitioner who is sensitive to the needs of adolescent clients becomes one that is trusted, admired and acceptable by clients The practitioner (and health promotion activities) becomes acceptable to members of the clients’ supportive networks

16. Theoretical Basis Harper, Callegari, Raine, Blum and Darney (Harper, Callegari, Raine, Blum, & Darney, 2004): Teenagers visiting clinics for contraception often involved others in their contraceptive decision-making (particularly their mothers, male partners and/or friends who the teens reported were supportive) Concluded that pregnancy prevention and counseling programs that integrate supportive networks for teenagers may help adolescents to use effective methods Other health promotion services offered in the course of clinic visits, like vaccines, (Wells, 2008) could become more acceptable to adolescent clients if the intervention is acceptable to the supportive network.

17. Review of Relevant Literature CDC (CDC, 2008) 26% of adolescent females was infected with STI HPV the most common (18.3%) 15% of infected had more than one STI 48% of infected were AA; 20% White; 20% Mexican Adolescent girls are at risk for HPV Vaccines for HPV 16/18 (responsible for 70% of cervical cancer) and 6/11 (responsible for nearly all genital warts) recommended for 11- and 12-year old girls

18. Review of Relevant Literature Tjalma, et al. (Tjalma, Arbyn, Paavonen, Van Waes, & Bogers, 2004) Explanation of HPV/link to CC Vaccine strategies Status of then terminated Phase II and Phase III trials Study results encouraging Continue CC screening for at least a generation Cost effectiveness of screening + vaccination

19. Review of Relevant Literature Sanfilippo and Lara-Torre (Sanfilippo & Lara-Torre, 2006) Teen Tool Kit developed by ACOG Adolescent-friendly environments HPV vaccines the most important new development

20. Review of Relevant Literature Quinn (Quinn, 2007) HPV 16/18 vaccine would have huge impact in reducing CC mortality/morbidity HPV testing/screening should be an adjunct to Pap smear programs

21. Recommendations Practice recommendations include: Patient education about HPV infection Patient education about HPV’s link to genital warts and cervical cancer Patient education about young women’s susceptibility to infection Patient education is essential to overcoming insufficient knowledge about, and acceptance of HPV vaccine.

22. Recommendations Practice recommendations also include: Vaccinating 11- and 12-year old girls before sexual activity commences and puts them at risk for infection Vaccinating women up to 26 years of age if they are infection-free Vaccinating women older than 26 years of age, although not approved by FDA Educating women older than 26 that vaccine is an off-label use for them

23. References Centers for Disease Control and Prevention (2008). Prevalence of sexually transmitted infections and bacterial vaginosis among female adolescents in the United States: data from the National Health and Nutritional Examination Survey (NHANES) 2003-2004; oral session, Thursday, March 13, 8:30 am central [oral abstract D4a - Embargo: Tuesday, March 11, 11:30 am central (12:30 pm ET)]. Retrieved April 19, 2009, from http://www.cdc.gov/stdconference/2008/media/summaries-11march2008.pdf Edelman, C. L., & Mandle, C. L. (2006). Health promotion throughout the life span (6 ed.). St. Louis, Missouri: Mosby. Harper, C., Callegari, L., Raine, T., Blum, M., & Darney, P. (2004). Adolescent clinic visits for contraception: support from mothers, male partners and friends. Perspectives on Sexual and Reproductive Health, 36(1), 20-6. Mayeaux, E. J. (2005). Overcoming barriers to HPV vaccine acceptance. The Journal of Family Practice Supplement, 54, 17-22. McEwen, M., & Wills, E. M. (2007). Theoretical Basis for Nursing (2 ed.). Philadelphia, Pennsylvania: Lippincott Williams & Wilkins.

24. References Pichichero, M. E. (2007). Who should get the HPV vaccine? Journal of Family Practice, 56(3), 197-202. Quinn, M. A. (2007). Should all women be vaccinated against human papillomavirus and what effect will this have on screening programs? Expert Review of Obstetrics and Gynecology, 2, 315-319. Ryan, S., Franzetta, K., & Schelar, E. (2008). Older sexual partners during adolescence: links to reproductive health outcomes in young adulthood. Perspectives on Sexual & Reproductive Health, 40(1), 17-26. Saca-Hazboun, H. (2008). HPV vaccines: are we ready to protect our children? ONS Connect, 23(10), 27. Sanfilippo, J. S., & Lara-Torre, E. (2006). The adolescent gynecology patient. Expert Review of Obstetrics and Gynecology, 1(1), 49-56. Tjalma, W., Arbyn, M., Paavonen, J., Van Waes, T. R., & Bogers, J. (2004). Prophylactic human papillomavirus vaccines: the beginning of the end of cervical cancer. International Journal of Gynecological Cancer, 14, 751-61.