This story is part of The Salt Lake Tribune’s ongoing commitment to identify solutions to Utah’s biggest challenges through the work of the Innovation Lab.
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When a child steps into Dr. Neal Davis’ office, the patient’s first question usually is:
“Do I have a shot today?”
Davis, a Murray pediatrician and a father, likes to reply:
“That’s such a good question. Let’s start by thinking about what shots do.”
The immune system is like an army, Davis will say. “This shot is like giving spy information to that army. So when they get attacked by that particular germ, they can recognize it quickly and fight it quickly.”
When it comes to the human papillomavirus vaccine in particular, his message to parents and kids is simple: It’s cancer prevention in a shot.
Davis is just one of many doctors, researchers, public health officials and cancer survivors trying to improve HPV vaccination rates — which prevents six types of HPV-related cancers, including penile, throat, cervical and vulvar.
This mission is especially important in Utah, where initial reception of the vaccine was frosty, and where rates have lagged behind much of the country.
But that’s changing.
Through consistent text message campaigns, health care provider training and public messaging efforts, the state’s HPV vaccination rates have steadily and dramatically improved.
Once 47th in the nation, Utah leapt up to 33rd place for up-to-date HPV vaccination rates of 13 to 17-year-olds between 2020 and 2021. About 61.4% of teens in Utah fully completed the vaccine series of three shots.
“These diseases aren’t just a cold or the flu that you bounce back from,” said Shlisa Hughes, of the Association for Utah Community Health.
“These are deaths. These are debilitating,” she said. “These are life-changing diseases that we can prevent by a simple vaccine.”
What are the misconceptions?
Deanna Kepka, an investigator at the Huntsman Cancer Institute, began focusing on HPV vaccines around 2008. She researches evidence-based methods that boost rates and combats misconceptions about the vaccine.
“I became passionate about it because prior to work in HPV, I worked in HIV,” Kepka said. “And I felt like this was a virus, also a sexually transmitted infection, that was very poorly understood in the United States and around the world.”
In the Mountain West the HPV vaccine, despite nearly two decades of FDA approval, has lagged behind meningococcal and Tdap (tetanus, diphtheria and pertussis) vaccinations, the infant and early childhood vaccines most parents are familiar with. The disparity in rates is a sign opportunities are being missed to inoculate children of vaccine-accepting parents.
This disparity is an issue because 8 out of 10 people are infected with the human papillomavirus at some point in their lives.
(American Cancer Society)
Often, our bodies can spontaneously eliminate the virus, but in cases when they do not, the virus can evolve into a persistent infection that can then lead to cancer. Each year nearly 35,000 people in the U.S. develop HPV-related cancers.
Lower vaccination rates in the region could be due to everything from a perception that vaccinating kids conflicts with conservative cultural values to busy parents not realizing their children could benefit from the shot.
When first introduced in Utah some 15 years ago, the HPV vaccine faced hostile reaction from conservative legislators and interest groups. The message that the vaccine would encourage teens’ promiscuous behavior showed up in public hearings and in lawmakers’ votes.
Initially marketed toward adolescent girls in order to prevent cervical cancer, researchers also now know that the vaccine prevents a longer list of cancers from oropharyngeal (the back of the throat) to penile, and both boys and girls benefit from inoculation. Boosting rates among boys has also been a critical goal for Kepka and other community partners.
Short, simple, focused
Kepka’s work isn’t purely academic — she’s personally trained somewhere between 700 and 800 health clinicians and team members and leads the Intermountain West HPV vaccination coalition, launched in 2014. The coalition now includes more than 400 members, from primary care specialists to parents, across the region who meet each month.
“I spend probably 10 to 20 hours a month on outreach and education around HPV,” she said. “And I’ve been doing this for 10 years.”
She teaches providers to keep their message short, simple and focused on cancer prevention. Starting vaccination at ages 9 or 10 has also been helpful, partly because most kids are still on the doorstep of puberty and spurious associations between vaccines and values are less likely.
Kepka also works with health care providers and systems to create “a culture of pro vaccination,” so every person in a physician’s office is on the same page.
“Treating every visit like a vaccination visit is key,” Kepka said.
In 2016, 49.7% of kids received their first dose and in 2017 that figure rose to 58.8%. The following years saw modest improvements in rates.
Then, the CDC’s 2021 National Immunization Survey estimated an astounding 80.9 % of Utah children had received their first dose that year.
Wary to outright celebrate the improvement in first-dose vaccination rates, Kepka said she’ll feel more confident when more supporting data is collected in the coming years. “But I think one of the reasons we’re doing better is we’ve had a lot of momentum around HPV in Utah.”
Both Intermountain Healthcare and the University of Utah health systems are both pushing HPV vaccination at earlier ages and with the state and county health department-launched education campaigns.
“I think we’re getting a lot of key players involved in making this a priority and just normalizing this vaccine as another vaccine that kids need to get,” Kepka said.
In the past three years, the Association for Utah Community Health has been improving HPV vaccination awareness, Hughes said. She is now quality improvement director at the organization.
Hughes works with community health centers, which offer free and low-cost care across the state. Her work involves better tracking of which children are missing out on second doses and creating automated systems to send texts and alerts that tell parents when their child is due for a shot.
“If you had a vaccine that prevented breast cancer, if you had a vaccine that prevented liver cancer you would want it,” she said.
How did everyone come together?
National organizations have also been working to improve vaccination rates.
In 2018, the American Cancer Society launched an HPV Cancer Free initiative with a goal of eliminating vaccine preventable cancers and fully vaccinating 80% of 13-year-olds in the United States by 2026. That will also mark 20 years since the FDA approved and released the first HPV vaccine.
Hannah Nein, senior program manager of the American Cancer Society’s Mountain West HPV project, said one way this goal plays out in Utah is through “onboarding clinics through a year-long quality improvement project.” One quality improvement technique includes starting vaccinations at ages 9 and 10. “It was very well accepted in Utah and we had some really large health systems adopt and really work to implement that,” Nein said.
They also offer training, like how to utilize “motivational interviewing” which Nein explains is “really just getting to the bottom of any concerns that anyone might have and really addressing them.”
Even dentists have gotten involved in HPV vaccination efforts in Utah. Shane Perry, professor in the department of dental hygiene at Weber State University, teaches his students to conduct oral cancer screenings and ask patients if they’ve received the HPV vaccine.
“It’s safe. It’s effective, and it’s long lasting,” Nein said. “It’s really exciting to see Utah really embracing this and protecting our adolescents.”
Occasionally a parent, noting that HPV is a sexually transmitted virus, will say that their child doesn’t need the vaccine because they “teach family values and that’s not something that’s going to impact their life,” Davis, the pediatrician, said. (The CDC states in one fact sheet “even people with only one lifetime sex partner can get HPV.”)
In those cases he’ll tell them, “‘that’s wonderful. And those are values that I teach my kids too, and I’ve given all of my kids the HPV vaccine.’”
No one can predict the future, he said.
If there’s a key takeaway, Davis said, it’s that accurate information focusing on the vaccine’s goal is important.
A cancer survivor’s story
Educating Utahns on the prevalence of HPV-related cancers is also a big part of improving HPV vaccination rates.
“80% of people will experience an HPV infection at some point in their lifetime,” said the American Cancer Society’s Nein. “We all just need to understand that this is really common.”
That’s where patient advocates like Mandy Murry come in.
Murry, who grew up in Salt Lake City, was diagnosed with cervical cancer at age 22 and had to get a partial hysterectomy. She had ovarian cancer twice — once at 25 and then again at 26.
She remembers feeling like she “had to be OK without really feeling OK.”
It took Murry a while to heal. She moved away from Utah, started her own business and practiced yoga.
Murry wouldn’t learn until her mid-thirties that she had been infected much earlier with HPV, which physicians believe was the likely cause of the cervical cancer. She met Kepka soon after her diagnosis and got involved with efforts to change the narrative around the disease.
“I truly believe that if I would have had the vaccine, I wouldn’t have had that cervical cancer and gone through everything that I went through,” Murray said.
She started speaking at medical conferences, explaining that factors outside of her control resulted in contracting HPV as a child.
Murry can see the impact her story has on others. Combined with the powerful data collected for two decades proving the vaccine’s efficacy, her personal account has helped to change lives. “I’ve got to tell my story,” Murry said. “I’ve got to help people.”
