Strategy
The Washington Department of Health (DOH) contracted with the Washington Chapter American Academy of Pediatrics (AAP) (WCAAP) to conduct a quality improvement (QI) program with several cohorts aimed at increasing HPV vaccination rates among pre-teens by initiating at age nine. This approach aligns with guidelines endorsed by leading health organizations.
Challenge
HPV vaccination rates continue to lag behind other adolescent vaccinations, leaving many youth unprotected. The HPV vaccine is routinely recommended for youth aged 11 or 12 years old and allowed as early as nine years old. On-time vaccination is important to ensure the highest level of protection against HPV prior to exposure. Despite widespread availability of HPV vaccines, coverage remains relatively low. Timely HPV vaccination in preteens could prevent 90% of HPV-related cancers.
Additionally, recent research shows that no cases of invasive cervical cancer were identified in women who received HPV vaccination at age 12 or 13. The Washington DOH contracted with the WCAAP to conduct a quality improvement program with several cohorts aimed at increasing HPV vaccination rates among pre-teens by initiating at age 9. This approach aligns with guidelines endorsed by leading health organizations.
Solution
Starting HPV vaccination at age 9 is an emerging best practice to help support on-time HPV vaccination. Children who receive the first dose at ages 9–10 are more likely to complete the series on time than those who start later. Additional programmatic benefits of early initiation include easier conversations with parents, more flexibility in spacing adolescent vaccines, and increased opportunities to vaccinate. Starting at age 9 is endorsed by the AAP, National HPV Vaccination Roundtable, the American Cancer Society, and the Washington State Department of Health, among others, and fits within recommendations from the CDC Advisory Committee on Immunization Practices (ACIP).
WCAAP recruited clinics into a quality improvement cohort. Clinics offered free continuing education (CE) and maintenance of certification (MOC) credits. Interventions included staff/provider training, including:
- Announcement Approach training
- Printed materials (posters, cue cards, stickers)
- Workflow steps to initiate HPV vaccination at age 9
- Optional electronic health record (EHR) optimization
- Standing orders and outreach
- Monthly meetings for clinic leaders
- Expert coaching via Zoom, email, and phone
The target population affected by this initiative was children aged 9–10 years old. WCAAP recruited nine clinics serving 5,283 children aged 9-10. Cohort 4 took place from February to July 2025, with nine clinics in Washington state. All sessions were virtual. The contract cost (inclusive of staffing and materials) was about $200,000. Additionally, the DOH IQIP Coordinator’s time was about $14,000. The resulting total was $214,000.
The implementation timeframe was February to July 2025. Partners for this initiative included WCAAP, who served as a contractor and lead for intervention, and participating pediatric/family practice clinics as the intervention cohort.
Outcome
Cohort 4 demonstrated that initiating HPV vaccination at age 9 is both feasible and impactful. Seven hundred and fifteen HPV doses were administered to 9-10-year-olds. The combined age 9-10 HPV coverage rate for the first dose of HPV increased from 4 to 14% across the cohort.
Data:
- All nine clinics met the goal of a ≥5 percentage point increase in HPV coverage at ages 9-10.
- The median increase was +8 percentage points with a range of +5 to +18 percentage points.
- The percent of providers who are very or extremely confident in making effective HPV vaccine recommendations at age 9–10 increased from 74 to 94%.
- Training: 48 providers and 102 staff completed 1-4 eLearning modules, earning up to 3.5-4 hours of continuing education (CME/CNE/CE). A total of 448 modules were completed.
- MOC Credit: Awarded to 31 of 34 participating physicians.
- Highly Rated by Providers: 4.7/5 stars for time well spent and 4.7/5 stars for ease of implementation.
Supplemental Materials