School-based Human Papillomavirus Vaccination Program in the Rio Grande Valley: Continuation and Expansion in Hidalgo, Cameron, and Willacy Counties

Need: The human papillomavirus (HPV) vaccine serves as an effective primary prevention strategy [1] to reduce morbidity and mortality of HPV-associated diseases (cervical, oropharyngeal, vulvar, vaginal, penile, and anal cancers, and anogenital warts). However, there are an estimated 46,143 new cases of HPV-associated cancers diagnosed in the U.S. in each year [2] and estimated 4,280 HPV-associated cancer deaths from these cases. Moreover, the lifetime medical costs of diseases attributable to HPV infections acquired in 2018 surpass $770 million [3]. Morbidity, mortality, and direct costs could decrease if vaccination increased [4]. However, in 2020, only 61.4% of adolescent girls and 56.0% of adolescent boys were fully vaccinated [5]. This is far below the Healthy People 2030 goals of 80% series completion by age 13. Texas ranks 31 out of 50 states and the District of Columbia in terms of Up-To-Date (UTD) HPV vaccination among female and male adolescents aged 13-17 years [6]. The need for targeted interventions to increase HPV vaccination in the Rio Grande Valley (RGV) is especially critical given the relatively low vaccination rate, one of the highest burdens of HPV-associated cervical cancer in the nation, and the disproportionate affect in low-income, rural, and minority individuals [7]. In this area, a 93.5% Hispanic population [8] has lower health insurance rates [9-11] compared to the US average. Barriers to HPV vaccination include limited knowledge about HPV/HPV-associated diseases, no insurance, cost, logistics (access, scheduling outside work hours, alternative settings, transportation), vaccine acceptance/cultural values, and no provider recommendation [7, 12-14]. Low access to healthcare services, due to cost, logistical barriers, and medical underservice, is an important contributor to the low rates of HPV vaccine uptake in the RGV [15, 16]. Particularly in rural areas and areas with low access to healthcare services, such as the RGV, HPV vaccinations in nontraditional settings (such as school-located vaccination programs, school health centers, pharmacies) can improve HPV vaccine uptake. School-based vaccination programs have demonstrated success in providing other recommended vaccines [7, 17, 18] and may address low prioritization for vaccinations by school nurses [19]. Overall Project Strategy: Our evidence-based intervention, which has been employed successfully in several counties in the RGV (CPRIT projects PP200057, PP190023, and PP160097) provides the HPV vaccine in an alternative setting (schools) and creates support for HPV vaccination through education and outreach. Our model centers around a collaboration between academic medical institutions from the Texas Medical Center, county health departments, and school districts to employ school-based and community-based education and adolescent vaccination events. Specific Goals: This proposal looks to expand our successful model to Cameron and Willacy Counties, to provide services to 14 additional schools from 8 school districts. The broad aim of the expansion is to reduce obstacles to HPV vaccination in the underserved area of the RGV and improve prioritization of HPV vaccination after the COVID-19-caused decline. Our specific goals are to increase HPV vaccination uptake in a cohort of students aged 11-15 in school districts in Hidalgo, Cameron, and Willacy Counties to match the 2020 National Immunization Survey (NIS)-Teen rates for Texas by expanding our school-based HVP vaccination program to additional counties in the RGV. Activities will include the continuation of our outreach and education campaign in Hidalgo County and expanding to Cameron and Willacy Counties; a school-based HPV vaccination program in 6 school districts; and expansion of program activities and support services (follow-up navigation, data collection, tracking, systems improvement, Immtrac efficiency). Significance & Impact: Our 2016 school-based pilot program in Starr County and two current CPRIT-funded projects in Hidalgo, Jim Hogg and Zapata counties have provided strong evidence for our model to increase HPV vaccine uptake. Through our initial CPRIT-funded prevention grant in the Rio Grande City Consolidated Independent School District (RGCCISD) in 2016, we demonstrated that school-based vaccination programs can dramatically improve HPV vaccination rates in the RGV, with school-level HPV vaccine initiation rates increasing from 20.0%-41.5% to 67.3%–69.8% and completion rates increasing from 8.8%-17.7% to 41.5%–44.1% [20]. In 2019, we expanded our program to the Pharr-San Juan-Alamo ISD (PSJAISD) in Hidalgo County prioritizing 8 middle schools. As of June 30th, 2022, we have achieved initiation rate of 53.0% and completion of 34.5% for students in the PSJA ISD. Additionally, support services have demonstrated that compared to students initiating outside our program, we had a smaller number of students receiving the incorrect number of doses (7.1% vs 46.6%).