1. Implementation Issues for HPV Vaccine
Howard Backer, MD, MPH
Chief, Immunization Branch
California Dept of Health Services
Chair, Association of Immunization Managers

2. Implementation of HPV Vaccine: Challenges
Financing
The vaccine that broke the bank
Infrastructure
New partners; New patients
Policy implications
School mandate and consent

3. Financing VFC: Uninsured and medicaid (age 9-18) COVERED
(age 19-26) LIMITED COVERAGE
Insured MOSTLY COVERED
Underinsured LIMITED COVERAGE
317 funding
State/local funding

4. AIM Survey Feb N = 50

5. California Funding Decisions
Public sector
All 11 through 18 years of age using combination of VFC and 317 dollars
MediCal 9-18 years
Governor’s budget proposal for MediCal yrs
Private sector
VFC eligible 11 through 18 years of age
All managed care, group insurance (by law)
Underinsured NOT covered
19-26 yr depends on health plan/insurance

6. Provider Financing Private providers on the ropes
Vaccine financing
VFC or Universal vs private/HMO insurance
Inventory investment
$100,000/mo for 5-6 MD practice
Vaccine and administration fee reimburse
Infrastructure-admin 20-25% above vaccine cost
Vaccination infrastructure
Trained staff
Storage, monitoring, loss insurance

7. Infrastructure Support
Adolescents: new and different strategies
Adolescent immunization staff
New public health/medical partners
Cross-over for other adult vaccines (HBV)
Non-traditional providers
Medical home model?

8. HPV Vaccine Workgroup Goal: Provide statewide leadership,
coordination and support for HPV vaccine
implementation efforts
Lead agencies: Immunization Branch
STD Control Branch
Cancer Control Branch
State partners: Office of Women’s Health
Department of Education
Maternal Child and Adolescent Health
Office of Family Planning
Office of AIDS

9. New partners
Enthusiastic but poor understanding of vaccine implementation issues
New VFC providers
Office infrastructure lacking
Staff education, storage and handling
Single vaccine interest against VFC rules
Quality assurance: AFIX—1 size fits all?
Ability to add new VFC requirements for certain providers

10. HPV Epidemiology-Surveillance
Infection
No reportable, no routine culture or testing, no reliable marker of infection
STD and GYN clinic studies
Major long-term outcome
Cancer registries and Pap results
Vaccine coverage and safety
Preventive practices
Pap screening
Sexual practices
KAB of parents and adolescents
Can’t follow closely on a yearly basis

11. Survey Data Sources
National Immunization Survey (U.S. estimates only, no state data)
Women’s Health Survey (CA adults)
California Health Interview Survey

12. School HPV Vaccine Requirement Discussions
“School vaccine mandates should only be used in appropriate settings and situations, taking into account multiple factors, including epidemiologic, economic, and ethical concerns.”
AIM Position Statement
School and Child Care Immunization Requirements, 2006

13. School mandate
At least 20 states (including CA) with legislation pending
Texas Governor Executive Order
Legislative initiative to override
Virginia initiative passed legislature
Federal legislation to restrict mandate
H. R To prohibit Federal funding or other assistance for mandatory human papillomavirus (HPV) vaccination programs

14. Vaccine development and FDA licensure
Defined process
Implementation period
Public health need as disease control measure
Ethical issues
Insurance coverage and additional funding
Public and Provider Acceptance
Supply
Vaccine safety
Burden on schools
ACIP Recommendation
School mandate

15. Acknowledgements Claire Hannan (AIM Executive Director)
Eileen Yamada, MP, MPH (Immunization)
Heidi Bauer, MD, MPH (STD)
Jenny Dai Biller, UCB Graduate Intern
Christina Sadorra