Florida Department of Health in St. Johns County
Increase HPV Immunization for Florida Department of Health in St. Johns County Clients
At the Florida Department of Health in St. Johns County, an opportunity was identified to improve the acceptance rate for the HPV vaccine in our immunization clinic. By retraining our nursing and support staff as well as partnering with our school district, FDOH-St. Johns was able to utilize and adapt the evidence-based practices developed by the CDC to increase our vaccination of HPV eligible children in our clinic from 44% in 2015 to 80% in 2016.
St. Johns County is located in Northeast Florida and is part of the Jacksonville metropolitan area. The City of St. Augustine is the county seat and is the nation's Oldest Cityâ€ drawing approximately 6.5 million visitors to the county annually. The U.S. Census Bureau estimates the 2015 population of St. Johns County to be approximately 226,640 (89% White; 6% Black; 6% Hispanic), with a median income of $64,346. Since 2000, St. Johns County has experienced an almost 65% growth in population, three times greater than that of Florida, and almost six times that of the Nation. In 2015, DOH-St. Johns County (www.stjohns.floridahealth.gov) employs approximately 65 fulltime employees, provided clinical services of public health significance to 3,630 clients as well as essential public health services to the residents and visitors to the county. The Agency is led by the Director and Health Officer, Dawn C. Allicock, MD, MPH and a small Senior Leadership Team.
Services provided by DOH-St. Johns CHD include: Disease Control and Health Protection via Surveillance & Outbreak Investigations and Epidemiology (STD, TB, HIV/AIDS, Hepatitis, Reportable Diseases); Clinical Services (Immunizations, Pediatric Dental Services, Communicable Disease Management and Treatment, HIV/AIDS Medical Management, and Family Planning Services) Women and Infants Case Management Services (WIC, Healthy Start Program Services, and Pregnancy Referral/Linkage Services); Environmental Public Health Services (Sanitary Nuisance Investigation, Drinking Water & Community Facilities, Septic System Permitting); Public Health Preparedness and Response; Public Health Statistical Analysis and PH Informatics; and Community Health Assessment and Health Improvement Planning.
For the past five years, St. Johns County has been ranked the healthiest county in Florida, by the Robert Wood Johnson Foundation's County Health Rankings report. However, despite the many strengths and advantages enjoyed by members of the community, St. Johns County consistently underperforms the Nation, the State and several of its peer counties for HPV vaccination rates. In 2015, Department of Health (DOH) immunization data shows that only 9.14% of the current St Johns County eligible population has completed the HPV series. The majority of children in St. Johns County receive their immunizations from their pediatricians; however, FDOH-St. Johns provided immunization services to 1,277 clients in 2015. Of those clients, 326 were provided to children in need of their adolescent vaccines, including Meningococcal, HPV, and TDAP. In 2015, only 145 of the 326 children (44%) received an HPV vaccine along with their school required TDAP, which represented a missed opportunity with over half of our adolescent clients. For some children, that opportunity may represent their only chance to receive this cancer prevention vaccine.
In March of 2016, FDOH-St. Johns began an initiative to increase the acceptance rate of the HPV vaccine within our immunization clinic to greater than 75% of all HPV eligible children. The plan included retraining of all nursing staff to utilize the CDC's evidence-based methodology for an effective recommendation to clients that makes the connection between the HPV vaccine and cancer prevention, as well providing nursing staff with tools for addressing parental concerns. The plan also included collaborating with the school district to ensure standardized messaging as well as facilitation of needed vaccinations.
As a result of this effort, FDOH-St. Johns was able to increase the percentage of HPV eligible children who received the vaccine from 44% in 2015 to 80% in 2016, to date, exceeding our goal of 75%. The success of our initiative resulted from a multi-pronged approach to retraining the nursing staff, which included attendance at a 2 day St. Johns HPV Summit, follow-up presentations by subject matter experts as well as an individual personally impacted by cervical cancer and weekly role-playingâ€ exercises as a part of our staff meetings. The public health impact of this dramatic improvement in the acceptance rate of the HPV vaccine will result in fewer cases of HPV infection in our county, reducing the disease burden of genital warts as well as cervical and other HPV related cancers.
Problem Statement: Human Papillomavirus causes infection of the skin and mucous membranes, and it is the most common sexually transmitted disease in the United States. It is responsible for over 90% of the cases of genital warts and 81% of cervical cancers diagnosed in this country. There are about 26,000 cases of HPV related cancers diagnosed each year, and 4,000 women die annually from HPV related cervical cancer. As of 2015, only 44% of the DOH-St. Johns eligible clients had initiated the HPV series. This compares to a 61% rate statewide and 63% nationally.
Target Population: The Advisory Committee on Immunization Practices (ACIP) recommends that the first dose of HPV vaccine be given at ages 11 -12, and a second dose be administered at least 6 months after the first. Beginning the immunization series between 11-12 years of age causes a stronger immune response, and therefore our target population in this case are children presenting to the FDOH-St. Johns Immunization clinic primarily in that age range.
Past Efforts: The state of Florida school required TDAP immunization is due at the same time and for the same age group as HPV. In 2014, the immunization clinic saw 323 children in that age group, in 2015, the clinic saw 326 children in that age group, and in 2016, to date, we have seen 290. In 2014 and 2015 where the HPV vaccination rate for eligible children was 35% and 44%, respectively, the HPV vaccine was routinely presented to parents as an optionalâ€ vaccine, in contrast to the requiredâ€ TDAP vaccine. While immunization clinic nurses could speak to the importance and efficacy of the HPV vaccine, the message parents received, inadvertently, was that the HPV vaccine was not as important as the TDAP, and perhaps not even necessary, as it was not requiredâ€.
Current Efforts: In December of 2015, FDOH-St. Johns was awarded a NACCHO grant to improve the HPV vaccination rate in our community, and as a part of that grant, a St. Johns County HPV Summit was held in April of 2016. All nurses in the agency were afforded the opportunity to attend the lunch and learnâ€ with Dr. Tommy Schechtman, president of the Florida chapter of the American Academy of Pediatrics. Dr. Schechtman shared the CDC guidelines, based on extensive research, regarding importance of a strong provider recommendation as well as the components of an effective recommendation. As a result of this Summit an action plan to increase HPV immunization rates was developed and actions added to the immunization action plan originally developed in 2014 to increase the vaccination rate of all children in our community (See Action Plan Below).
Action Plan Name: Improve Immunization rates in St. Johns County
Target 2015/2016: Exceed 2014-2015 2 year old immi percentage up to date (95%) and move from bottom quartile to top quartile on immunization rates of kindergarteners and 7th graders
Status: In Progress
Action Plan Details:
1. Continue daily monitoring, weekly report out of 2 year old immi rate.
Owner: Karen Watts.
Completion by? Ongoing.
Status: On schedule.
Comments: Rate remains > 95% 2 year olds fully immunized
2. HPV Grant / action planning meeting
Owner: Karen Watts
Completion by: 6/20/16
Comment: See action plan for ongoing HPV activities
3. Implement HPV action plan
Owner: Karen Watts
Completion by: 1/1/17
Status: On schedule
Comment: See HPV action plan
4. Continue to work with school district on ensuring all kindergarten and 7th grade students have received all recommended vaccines
Owners: Karen Watts, St. Johns County School District (SJCSD)
Completion by: 2/15/17
Status: On Schedule
Comments: SJCSD (Melissa Petty)and Karen Watts â€“ per Melissa, ongoing efforts to work temp exemptions have been successful, awaiting updated reports.
5. Develop and implement program 17 (adult vaccine) as a part of holistic NCM model in all clinics
Owner: Karen Watts
Completion by: 11/1/16
Status: On schedule
Comments: Developing process, obtaining clarification from state immi staff (Dearline Thomas Brown)
Following the summit, HPV vaccination became a standing agenda item at our weekly staff meeting, and two guest speakers were brought in to further reinforce and clarify the best practices for developing an effective vaccination program that protects the health of our community. By retraining all nursing staff, FDOH-St. Johns ensured consistent, effective messaging around the HPV vaccine.
Many clients at DOH St. Johns receive services from several programs; for example, they receive pediatric dental services, are enrolled in WIC, and also come to the immunization clinic. In February of 2016, In keeping with the CDC's guideline regarding consistent messaging of the HPV vaccine, all staff participated in a training as a part of a monthly First Fridayâ€ staff development event regarding HPV and the HPV vaccine. At that time, staff received training about one primary message to share - HPV vaccination is cancer prevention. This messaging was easy for staff to remember, and appropriate for non- medical staff to share. Additionally, to increase HPV immunization opportunities, immunization walk-in clinics were added to the existing scheduled clinics. Empowering all staff at DOH-St. Johns with the information and resources they need regarding the HPV vaccine contributed to the success of the practice and allowed us to exceed the goal to vaccinate 75% of HPV eligible children in 2016.
By creatively and innovatively applying the evidence based CDC research, toolkits and materials, as well as the CDC Morbidly and Mortality Weekly Report (MMWR) recommendations regarding HPV vaccinations to retrain the nursing staff, DOH-St. Johns was able to achieve breakthrough performance. The staff viewed the You are the Keyâ€ CDC presentation, received the Tips and Timesaversâ€ handout from the CDC for responding to parental concerns, received a copy of the CDC MMWR on HPV vaccination, and were made responsible for presenting one handout from the CDC HPV vaccination toolkit to the other nurses during our weekly meetings. Following this learning, weekly role playing exercises were conducted with staff, and the clinical manager observed all immunization nurses in clinic to check for proper messaging of the HPV vaccine. This resulted in a dramatic increase in HPV vaccine initiation in our clinic.
Results: DOH-St. Johns HPV Immunizations (Data obtained from Florida Shots System)
Number of Eligible 11 to 12 year old clients: 412 ('13) 323 ('14) 326 ('15) 290 (â€˜16YTD)
Number receiving HPV Vaccination: 175 ('13) 113 ('14) 145 ('15) 232 (â€˜16YTD)
% Receiving HPV Vaccination: 42% ('13) 35% ('14) 44.5% ('15) 80% (â€˜16YTD)
As previously mentioned, in December of 2015, DOH-St. Johns received one of 12 NACCHO grants aimed at increasing the HPV vaccination rate in our community. As a part of the grant, St. Johns conducted a 1.5 day HPV Summitâ€, facilitated by NACCHO and attended by key partners in our community. The Summit and Action Planning meeting was attended by a number of key community partners, including the St. Johns County School District Health Services Director, Nova Southeastern University, Physician Assistant Training Program Director, Healthy Families Program Director, and a local pediatrician's office, along with leadership from the State Immunization Section of the Department of Health, and a Health Officer from a neighboring County. The agenda for the summit is listed below:
St. Johns HPV Summit Agenda
HPV Vaccination Strategic Action Planning Participant Agenda
April 13-14 Â¦ Doubletree Hilton in Historic St. Augustine
8:30-9:00 AM Breakfast
9:00-10:00 AM Welcome & Overview - Dr. Dawn Allicock, MD, MPH, DOH-St. Johns Director, provides welcoming remarks. NACCHO will facilitate introductions and provide an overview and context for the meeting. Dr. Tommy Schechtman will provide an overview of HPV facts and guidelines, followed by a brief Q&A.
10:10-10:30 AM Strategic Visioning - Participants will be facilitated through an activity to declare the committee's desired future state in the next three years. This activity will help articulate what the committee would ideally like to achieve in 3 years as a result of its actions and set the foundation for action planning.
10:30-10:45 AM Break
10:45-12:00 PM Understanding the Current Reality: Environmental Scan & Analysis
Karen Watts, RN, will present data around the current state of HPV vaccination rates in St. Johns County. Through a facilitated SWOT analysis activity, participants will deep diveâ€ into the current reality and identify the existing strengths, weaknesses, opportunities, and threats contributing to HPV vaccination rates.
12:00-1:30 PM * Lunch â€“ Keynote speaker, Dr. Tommy Schechtman, president of Florida chapter of the American Academy of Pediatrics
1:30-2:30 PM Understanding the Current Reality: Environmental Scan & Analysis (con't)
Through a facilitated SWOT analysis activity, participants will identify the existing strengths, weaknesses, opportunities, and threats contributing to HPV vaccination rates.
2:30-2:45 PM Break
2:45-4:30pm Identifying Strategic Priorities - Participants will individually and collectively brainstorm innovative and tangible actions that will move the group toward the vision, given the current reality identified from the SWOT analysis. This session will result in broad strategic focus areas for action and will guide the development of the action plan.
4:30 to 4:45PM Closing Day 1
8:30-9:00 AM Breakfast
9:00-9:15 AM Welcome and Recap
9:15-11:15 AM Strategic Action Planning - Participants will use the strategic priority areas identified on Day 1 to develop components of a strategic action plan including SMART objectives, concrete strategies, and steps for implementation.
11:15-11:30 AM Break
11:30-12:00 PM Confirm Commitment and Circles of Engagement - Upon reflection of the day, participants will determine and confirm their level of commitment to this HPV initiative and determine additional partners that should be engaged.
12:00-12:30 PM Resolve and Conclude
CE Credit Statement:
Suwannee River Area Health Education Center, Inc. is a Florida Board of Nursing approved provider of continuing education. CE Broker Provider ID #50-1922. This program meets the requirements for up to 1.5 contact hours.
The participation of others in the community, in particular the School District, was key to the success of our immunization initiative. Although the focus of our HPV vaccination campaign at DOH-St. Johns primarily involved the retraining of the nursing staff, it also involved the cooperation and participation of all employees as well as key community partners to ensure consistent messaging in the community.
In addition to our internal actions taken as a part of our campaign to increase HPV vaccination in the clinic, DOH-St. Johns drew upon their experience with key stakeholders to further develop and maintain partnerships to support vaccinations. In response to the 2014 l school-aged vaccination rates for St. Johns County, DOH St Johns initiated an Immunization Action Plan which includes working with community partners. As a part of that action plan, the DOH St Johns clinical nursing supervisor and lead epidemiologist gave a presentation to all St. Johns County School District School nurses regarding needed immunizations, ACIP's vaccination recommendations and ways to appropriately provide education to parents regarding the HPV and meningococcal vaccines utilizing the CDC's recommendations. By positioning ourselves as the subject matter expertsâ€ in the community, we were able to build upon that existing strong relationship with the district, which contributed to success of our model practice. The St. Johns County School District participated in our St. John's HPV summit in April, and then carried the messaging and lessons learned to all nurses in the district. Also, as a part of our back to schoolâ€ campaign, the school was able to send families directly to us for vaccinations, during all regular business hours. Finally the results of our HPV vaccination campaign were shared with the District's Health Services Director to continue to foster the collaboration necessary to sustain and improve upon our success. As a result of this key partnership, we have been able to dramatically increase the HPV vaccination rate with our clients at DOH-St. Johns.
As previously stated, our model practice, focused on the retraining of all nursing staff to increase the vaccination rate of HPV eligible children seen at DOH-St. Johns in 2016. The goal was to achieve a 75% success rateâ€ in acceptance of the vaccine when children were seen for their school required TDAP vaccine. As previously shared in this application, in 2016, DOH-St. Johns administered 290 TDAP vaccines to children in our target population, and of those, 232 children also received the HPV vaccine. This 80% success rate in HPV vaccine initiation, higher than both the state and the nation, represents breakthrough performance when compared to data from 2015, which showed an acceptance rate of 42%, and 2014, which showed an acceptance rate of 35%. In addition to the morbidity and mortality caused by genital warts and precancerous changes to the cervix and cervical cancer, there are substantial financial costs associated with HPV related disease. Genital warts costs an average of $300.00 to treat, removal of precancerous cells from the cervix costs an average of $1,500 to $1,700.00, and treatment for cervical cancer routinely costs in excess of $100,000.00. By increasing the HPV vaccination rate in our community, we impact not only the quality of life enjoyed by our residents, but also reduce the financial burden associated with the treatment of the preventable complications of HPV related disease.
In order to sustain and build upon the success of our 2016 HPV vaccination campaign, DOH-St. Johns requires all newly hired nursing staff to receive extensive training related specifically to the HPV vaccine and the importance of a strong recommendation using the CDC's evidence based resources and tools. In addition, yearly refresherâ€ nurse training will be required of all nursing staff, as well as ongoing role play exercises as well as direct observation by the clinical manager of at least 10 immunization clients per month. All newly hired staff at DOH-St. Johns receive information regarding the HPV vaccine as a part of their new employee orientation during the clinical walk-a-mileâ€, and the clinical manager will present any new information as well as share results with all staff a minimum of once yearly. Finally, DOH-St. Johns will continue to collaborate with the St. Johns County School District through our Health Leadership Council to ensure that children being fully immunized continues to be a focus area for the County as a whole. On November 16, 2016, during the visioningâ€ exercise conducted as St. Johns County begins it's Community Health Assessment, the goal of 100% of all children in our community being fully immunized was identified, ensuring the continued discussion among our community leaders to build upon our success and share the best practices we have developed with all providers in the community.
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