 Okay. So, like I, Marie introduced me. I'm Priscilla Lopez. I'm with the Texas Vaccines for Children's Program. I am the VFC coordinator. Now, a lot of y'all are the AFIX coordinator. And some of y'all might not know what AFIX is, but I'll introduce that and explain it in a little bit later. But first and foremost, I wanted y'all to get out the blue folder that's in your bag. And my slides are going to be in there as well. But something that we added in there is a vaccine safety packet. Our staff worked very hard to get reliable resources for y'all to reference in your daily activities in your clinics if a parent has any issues or hesitancy with the vaccines. There's a lot of information, a lot of reliable information in there for you to rely to your parents about that. And then also my business card, if you ever need more information about the grant or the presentation that I'm about to give, you can always just give me a call and we'll talk about that also. So first, I do want to congratulate Metropolitan Health District. They were awarded the CDC Increasing HPV Vaccine Coverage Grant. It was very time-consuming, I can say the least Kenya, to apply for this grant. But we thought it was very important for San Antonio and our VFC providers to just have a lot of amazing resources that CDC can provide. So like I said earlier, we are with the AFIX team. And a lot of y'all might not know what AFIX is, but I have the definition for you right here. So for the Center of Disease Control and Prevention's AFIX is a research supported continuous quality improvement process. AFIX works collaboratively with providers to increase and sustain high immunization coverage and incorporate evidence-based immunization practices at the immunization provider level. What does that mean? So here in San Antonio we do things a little bit differently. So we do what's called a combined VFC. We also, we combine TVFC with AFIX. So how many of you here know Gloria? Oh yeah, let's give her a hand. Give her a hand too. I see somebody clapping for Gloria. Yay! So Gloria, what she does is she comes in and she goes over just one or two questions about Pair, about your storage units, and then after that she gives you a coverage level. That coverage level portion of her visit is AFIX. So what she does is she does an assessment of the coverage levels within your practice depending on how many patients that she pulls. And then following her, Brittany comes up. And Brittany is in the back. Some of y'all probably met her. She's quite new, but she's making her rounds to our providers. What she does is she brings you a lot of information, a lot of quality improvement plans. She also brings you the findings of Gloria's visit. And then after that, depending on your coverage level, you'll receive an incentive. And then exchange of information is when she comes back three to six months later either through the phone or in person and just talks about any ways that she can help y'all improve y'all's coverage levels or help you meet requirements for the TVFC program. So that is us. Okay, so I wanted to talk a little bit about our grant real quick. So currently without the grant, 15% of our TVFC enrolled providers receive an AFIX adolescent visit ages 13 to 18. What does that include? That includes an adolescent coverage level, missing immunization list, a coverage level certificate, an HPV resource and posters, and a QI plan. But with this grant, we're able to do up to 100% of our TVFC providers, depending on how many patients you have within that age range. We're able to do an adolescent visit for you. We're going to be hiring four new staff members additionally. This grant is a two-year grant. So the staff will be with us for two years, so that way we can offer additional services to the providers that we have enrolled. So we're going to be offering an additional AFIX visit only. So it's not going to be a compliance visit. It's just going to be talking about coverage levels, so it'll be a lot shorter visit. We try to minimize how many times we go into your office because we know that your time is very valuable. We're going to have limited clinician to clinician AFIX visits, meaning that we're going to have clinicians who have successfully either communicated about HPV or talked to other providers about HPV. And they're going to be coming into your clinic and talking about the best practices that they've seen or what they've seen nationally done and just different ways to talk to you about how we can improve our HPV coverage levels locally and then within your own clinic. Also, we're going to be providing an immunization report card. What that report card is going to have is going to have the HP 2020 goals, your coverage level and then what we have nationally for our HP 2020 goals for HPV. Also, you're going to get a missing immunization list. You currently get that right now with your adolescents, but this one's more extensive. It's going to have your HPV as well. So who in your clinic is eligible for an HPV dose? The first one. Who is due for their second dose and who's due for their third dose? So it's just more easy or more convenient for you to call those patients in instead of going through all of your files, finding out which patients are going to be eligible for HPV. Also, we're going to be giving you HPV bilingual resources, posters and a toolkit. That's going to have a lot of information, especially for our bilingual parents who come in. We've seen a lot of children translate for their parents and we think that somewhere our information gets lost in translation when we talk about the importance of HPV. So we're going to be having a lot of bilingual resources for you to give to parents and I think that's going to be very significant. There's going to be quarterly updates and a newsletter talking about HPV statewide, local wide and nationwide. Just about any updates is going to happen, especially with our program. We're going to have provider staff meeting appearances. If you are having a quarterly, monthly or weekly meeting and you would like someone from the HPV grant to come and talk to your whole staff about where we stand as a city with HPV goals or where we would like to go or if you need any more resources or if you would like for them to do a presentation for your new staff members and talk about what HPV is, then they'll be able to do that as well. And then also an adolescent provider recognition breakfast or luncheon. We're not too sure which one we're going to do yet, but me and Kenya are working on that and we want to just provide something for y'all to be recognized on your very hard efforts that you've done. So what is our purpose for this grant? Our purpose is to increase HPV coverage levels and decrease HPV related cancers. Now in order for us to do so, we need to know where we stand. And I know Mark talked about our coverage levels rates, but I put everything concise here in this slide. And if you can see US, you know, we're meeting everything that's required of HP 2020 goals. But if you look at the HPV nationally, it's not that pretty. And then you look at Bear County and you see our rates and you're thinking, well, we're kind of where Houston is, we're kind of where Texas is, we're kind of where US is. But if you look at the bottom of the worldwide HPV vaccination rates, United States is not doing so good. And if you look, Rwanda is at 99% and United Kingdom is at 86%. I think that says, so it just kind of puts it into a realistic kind of point of view of where we stand, not only in our nation, but across the world. So let's talk about some of the things that cause cancer causes by HPV. Now here, just because of time, I did include this in the slides that you have. So I'm going to be skimming through them. Total estimated cancer deaths here in Texas 2015. It was 1273 deaths due to HPV cancers. That is 1273 mothers, sisters, brothers, aunts, uncles. And that's 1000 too many. So with something that's so easily prevented by a vaccine, I think we need to do our part in pushing that for people. I'm pretty sure somebody that you know very closely has been affected by that. If not cervical cancer, a different kind of cancer, and if a vaccine is available, I think that's very important for us to push that, even if you would get a little pushback from your parents. Try to make it very clear on what this vaccine is preventing. So a very interesting question was given to parents and they asked the parents, what value do you place on these vaccines? So from 0 to 10, what do you think these vaccines down here, what value do you place on them? So if you skim over to HPV, parents are thinking that the value is about a nine. It's pretty valuable. This vaccine, what it does is pretty good. Then we ask those doctors, what value do you think parents have on these vaccines? And the result was a little bit shocking and a little sad. So if you see down to HPV, doctors were thinking that parents placed a five when parents actually placed a nine value on the HPV vaccine. So I know a lot of doctors are a little hesitant to talk about it. Other doctors are full blown out talking about it. But I think if we all, with the resources that are going to be provided with this grant, I think we can all start pushing HPV even to those parents who are a little hesitant. But with the resources and a little bit of education, I think we can reach them. So again, what is our purpose? Our purpose is to increase HPV and decrease HPV-related cancers. And to end, I have my little nephew right there. So I talked to him about HPV just a little bit because I know he doesn't understand too much. But I told him that once he grows up and he gets his vaccine, he's going to turn into Buzz Lightyear because he's going to be a superhero. And we're going to buzz out HPV together. And he is all for it. So if you have any questions, you can talk to me. I know I'm standing in between your break. So just grab me and pull me aside and we'll talk about what we can offer you. So my business card is there as well, if you want to give me a call later. Thank you so much for inviting me to speak today. It's a real pleasure to get to come to San Antonio to have a whole new audience of individuals. First, I want to tell you that I do not have any relevant conflicts of interest. I am not a speaker for any pharmaceutical companies. So I can come to you today to speak with you openly and honestly about vaccines. I was asked specifically to talk about vaccine hesitancy with regard to HPV vaccine. There is only one manufacturer for HPV9. So I did want to mention that. So with regard to objectives today, we will be talking briefly about the history of vaccine hesitancy vaccine refusal. We'll be talking about the misinformation, specifically with regard to some of the information that your district attorney spread and that has come with the movie vaxed. And also with regard to HPV. We're going to be talking about just the epidemiology of vaccine hesitancy, alternate immunization schedules. And then I'm going to talk with you about a method that you can use in your office and wherever you work or even with any vaccine concerned individual that you come across to really talk about vaccine hesitancy. So just a little bit about vaccine concerns. When do you all think most vaccine concerns began? Jenny McCarthy? Is that the beginning? No? Earlier? Yes? How much earlier? How about polio? How about hundreds of years ago? Smallpox? Most people don't realize that vaccine hesitancy goes back to the days of smallpox. And there were concerns even back then that the idea of exposing someone to a disease that in making them sick, it was just simply counter-intuitive. And people people got really upset about this. And they also felt it was a violation of God's will that if you were supposed to get sick and die from smallpox, then you should die that natural death and you should not change the natural course of events. And I think I heard someone say, oh my word, but yes, that that was what they felt. And but then there were also fears of contracting the actual disease from the vaccine. And in honestly, the science was not known about how it worked. We didn't understand antigen antibody responses back then. So you can understand how general the general public didn't know. And what people did then is they took a little bit of the infected material from a sick person and rubbed it between the thumb and the forefinger, as you can see here. And and then that person did get a very small case, basically, of smallpox. And then they actually did make them immune. And the data showed not only from the what then became the United States, but also in England at the time, you were much more likely to survive if you had been variolated than if you got a wild type or natural smallpox. So even at the time, there were the pro inoculators and the anti inoculators. And it's interesting that Benjamin Franklin's family, they actually owned a newspaper. And his family was part of the anti inoculators group. And the pro inoculators were made up of a doctor named Dr. Boylston. And if any of you have been in Boston, you've probably driven on Boylston Street. And so he was part of the pro inoculator group. So this went back and forth. And if you read some of this old some of this is scanned in on the internet in the older English, some of their banter basically was in old newspapers at the time. So very fast forward because there's been many things that have happened since then. Someone mentioned polio and there was an incident called the cutter incident when there was batches of polio vaccine that were released before they were completely inactivated. And that was in the race to create a polio vaccine. And that did create a big star because children were harmed in that process. And then we did have in the 1970s, a whole group of parents who felt that their children had been harmed from the wholesale DTP vaccine. So that was misinformation. But there have been movements along the way created by different issues. But that does kind of bring us to your district attorney, Nikola Hood, who came out this was in late August and said that he felt that his child had been harmed by vaccines. And so this was really I wanted to place this in a little context for you. There has been a movie that has come through Texas and has really gone through the nation and it's called Vaxt. Have any of you seen Vaxt? Okay, one person has seen Vaxt. So Vaxt, I heard also standing outside is going to be coming back through San Antonio. And I understand most all of you are active vaccinators. And I think that you should be very well aware of what is in this movie. Because if you don't understand vaccines, understand how they work, understand vaccine safety. If you are a novice walking into this movie, it will scare you. And it's been designed, filmed by people who know how to make movies that scare people. And the producer of this movie is Del Big Tree. And he was the producer for the Doctors TV show that was filmed in the afternoon. One of the producers is also Andrew Wakefield. And Andrew Wakefield was the person who produced a who had a small article in the journal Lancet. We're going to talk a little bit more about that. He's been kicked out of the United Kingdom and then came to Austin and started a small autism treatment center outside of Austin called the Thoughtful House and attracted a lot of parents who were seeking alternative therapies for their children with autism. And this movie from the minute that you start to listen to it, I promise you is misinformation from the beginning to the end and the question and answer session that they conduct purposefully afterwards is scripted, completely full of misinformation. And they report that they have parents in there who report that their children were harmed by vaccines, especially MMR and that their children have regressive autism because of it. The movie was really has been whist through Texas. It has been ushered back through because of a group Texans for vaccine choice. And are some of you aware of Texans for vaccine choice? Okay. So Texans for vaccine choice has become a much more vocal group in Texas. They started about 18 months ago, and they have over 8500 followers on Facebook. And they believe that it should be a parent's choice and liberty to choose whichever vaccine they want. My my iPad went dead. And so they very simply believe that it that it's all about your kid and not about our children, that it's not really the community effect. And so with that, they have really co opted the movie faxed and the creators of the movie vaxed have really called it not a movie but a movement. Next slide. I can't change it. Okay. So what is the main point of the movie? Well, one of their main points is this article that they have really targeted. And this was a journal article from Pediatrics back in the early 2000s, where these group of individuals from the CDC actually looked at a group of children from the Atlanta area from Georgia. And they looked at birth certificate data. So kids who had been born in Georgia, and they compared it to children who were enrolled in early intervention. And they said, let's look at kids, their vaccination coverage, and then the incidence of autism. So there was this guy named Hooker, who was very, who's very prominent in the movie. And he's the one who says that the CDC did this all wrong. And Hooker says, I'm going to reanalyze this information. And he gets ahold of it. And he says that if you reanalyze this information, in fact, the children with who are African American have a big increase in autism. If you got MMR in these African American children, excuse me. So I want to point out to you, in fact, there is no CDC cover up. These individuals at the CDC who do this type of research are very committed to the type of research that they do. And the Hooker's analysis was actually flawed, because they look at very small bits of data. And they can he conducts comparisons when statistically you're not supposed to be conducting it. He does the wrong kind of analysis based on how the type of study data was done. And he really ignores the fact that this data was actually conducted or gathered in from Georgia, from a time that the children were actually actually lacking vaccinations. And there were children who simply did not get their one year old MMRs. And they were under vaccinated. Many of you may work in inner city areas where children are not coming in at 12 months of age to get their vaccines because their parents have lack of access, lack of Medicaid. And so to get in the early childhood intervention program, they had to go get an MMR. So this was a confounding variable. And Hooker simply overlooks this in his analysis completely. Next slide, please. So where did where did Nicole hood probably get the idea that vaccines cause autism anyway? Well, a lot of parents have heard this and it really did come from Andrew Wakefield a long time ago. And it was from a paper that he did publish in the late 1990s. And he had a case here, a very small case series of children. And he was he he did very bad things in conducting this research. He actually recruited these children from a birthday party to actually get them to participate in this research, these very small group of children. He actually was trying to license his own MMR vaccine at the time of this study. But he he made this hypothesis up anyway that the current MMR vaccine actually caused bowel dysfunction that then went on to cause these neurodevelopmental disabilities. There was a whole group of authors on this original paper. And not too far after the original paper was published, a big group of the author said in fact, this research was all wrong. We should have never published this. And eventually the Lancet, which is a big medical journal said we should have never even published this article. And they actually retracted the entire study. So there was an interesting guy named Brian Deere, who did an entire expose on Andrew Wakefield. I encourage you to look Brian Deere up. And there was a series of three journal articles saying what a total charlatan Andrew Wakefield is. He was and he still is. And it's important to know that Texans for vaccine choice have really gotten together with Andrew Wakefield. And one of the pictures that I showed you before Andrew Wakefield was actually on our capital steps in Austin during the last legislative session. So despite doing bad things, you know, trying to license his own vaccine, you know, not doing research without institutional review board recruiting kids from birthday parties. He's still in Texas. And and that's that's what he is doing. So why do most parents think that MMR could be implicated at all in their child's developmental disabilities? Well, it's really a matter of timing. Children start with language development early in their development. Most healthy babies will start with babbling at about four months of age. They'll start making raspberry like sounds like and then by about six months of age, they'll start to make repetitive vowel and consonant sounds like mama or da da da. But a lot of parents don't really realize that this is not happening for their child until they're maybe around other children when actual words are being formed and their child doesn't have words and other words besides mama and dad are really occur between 12 and 15 months of age. So it's really a matter of timing that MMR is given at a year of age. And that's when parents start to not see other words coming into play. So parents look back and say, hmm, what happened just recently that I'm not seeing my child have words and what else just happened? And they'll say, well, they just got an MMR vaccine. And I think it's just serendipitous that they didn't blame it on varicella or one of the booster doses that we give at that time. But it's also largely because of Andrew Wakefield's paper that he published and all of the stir that it created in Western Europe that parents have made this connection. So I want to point out to you that there is a huge body of literature, not just the paper from Georgia that this vaxed movie has has thrown under the bus, basically. But there are all of these other articles in addition. And there have been now millions of children who have been studied who have received vaccine MMR, especially and other vaccines, but have received MMR who have not received MMR from all over the world. And there has been no link between autism or other developmental disabilities and any vaccine. So the Institute of Medicine has actually looked at this entire body of literature. And this is how the Institute of Medicine words their their their statements. They've reviewed the body of literature and found that the evidence favors a rejection of a causal relationship between MMR vaccine and autism. So we have to be careful when we talking about is there a cause and effect relationship. And they're saying, no, we are rejecting the idea that there is a cause and effect relationship between MMR vaccine and autism. Okay. So what about thimerosal? And this just came up in my clinic visit. I was in clinic all day on Monday. And dad was refusing the influenza vaccine. He goes, what about that mercury? I heard about that mercury. Well, here we are again. So thimerosal. What about thimerosal? So it's important to understand that back in the 1930s, we before then we didn't have any preservative in our vaccines. And there's were actually cases of people who got septic and died because of multi dose vials that got bacteria in them. And the vial got super infected. And then persons were given tainted vaccine with bacteria. And these people got septic and died. So we found that Ethel mercury was a preservative that we could put in vaccine vials that prevented bacteria from growing and that we could actually then store the vial and it wouldn't become infested with bacteria. So it's important to understand that Ethel mercury is different than methyl mercury. Methyl mercury is the type of mercury that pregnant women are supposed to not have. That's the type of mercury that you get from fish that eat other fish. Methyl mercury has a long half life and can cross the blood brain barrier, whereas Ethel mercury does not cross the blood brain barrier due to its molecular size. And some people say, well, that's just splitting hairs too much methyl and Ethel and it's still mercury, right? So I think you've read this already. So I'm going to quote Dr. Ari Brown and she's the author of baby 411, which is a very popular parenting book. And she's also a pediatrician in Austin. Although the names may sound the same, methyl mercury and Ethel mercury are different. An analogy that is the difference between methyl alcohol and Ethel alcohol. Methyl alcohol is anaphrase and Ethel alcohol is a Bud Light. So many of us, you know, operate on this presumption often and that you don't drink anaphrase and you might have a sip of wine or beer. So there is also a whole body of literature looking at children who have received vaccines with Ethel mercury in them. And again, there is no causal relationship between the receipt of a thimerosal containing vaccine and autism. And the Institute of Medicine has looked at this also no cause and effect relationship between those two. So do vaccines overwhelm the immune system? Are we giving too many too soon? And this was Jenny McCarthy's big mantra, too many too soon overwhelming the immune system. It's important that you all remember, especially as we're getting into cough and flu season, that an average upper respiratory infection exposes a child to about six to ten different antigens at a time. In a case of strep throat, 25 to 50. So I tell parents, babies are born being ready to be in the world and our immune systems are ready to fight infection. And there's a gentleman, a very famous vaccinologist infectious disease, Dr. Paul Offit. And he is estimated that at any one time, your body can probably fight off 10 thousand plus antigens at any one time. So compared to a little viral infection or a case of strep throat, that's nothing. So well, how does that compared to what we expose children to in vaccinations? Well, I want you to look at the left hand side of this particular side and compare it to the far right hand side of the side. And as you can see, when we used to give the smallpox vaccine, which some of you may have received, it was a much more scientifically less pure vaccine, and it had a lot more of the actual viral components in it. And children were exposed to much more of the antigens, if you will. And so with whole cell pertussis. But currently, we don't give smallpox a vaccine anymore because it's been eradicated from the earth. And we use a cellular pertussis. So as you can see in the column in the in the far right hand corner, it's it's much less common or the number of antigens is much fewer that we actually expose children to. So there is no way that your immune system is overwhelmed during the time that you are actually vaccinated. So do vaccines cause other chronic diseases? And again, there are no studies that have shown any relationship between childhood diabetes, asthma, allergies, peanut allergies, sudden infant death syndrome, multiple sclerosis. All of these have been fad thoughts at various times. I can tell you when I was in medical school hepatitis B and multiple sclerosis was sort of a fad idea. Another fad that went through was the juvenile diabetes and vaccines. All of these have actually been disproven. And again, there's a body of literature to go along with this. So so all of this is really leads towards vaccine refusal. And again, to quote Paul Offit, he was in the Wall Street Journal and I thought that this was really apropos who is choosing not to vaccinate. And he wrote, no group has lower immunization route rates than Malibu and Marina del Rey. And these are very nice areas in California, home to some of the wealthiest and most exclusive suburbs in the country. At the Kabbala Children's Academy in Beverly Hills, 57% of children are unvaccinated at the Waldorf Early Childhood Center in Santa Monica. It's 68% immunization rates that can be found in Chad or South Sudan. But parents in Beverly Hills in Santa Monica see vaccines as unnatural. That kind of sounds like what we heard back in the 1700s, right? Something that conflicts with their healthy lifestyle, fringe pediatricians willing to cater to their irrational beliefs. These parents are almost uniformly highly educated, but they are making an uneducated choice. It's also a dangerous choice because they're unwilling to learn from history. We are starting to relive it. And children are victims of our ignorance and ignorance that ironically is cloaked in education, wealth and privilege. So what is really happening across the United States with regard to vaccine exemptions? Well, I want to talk a little bit about state laws. State laws really play a significant role in vaccine exemptions. The states that you see in white only have currently medical exemptions. And that is West Virginia, Mississippi and California. If you've heard that California recently overturned their law, they used to have all three types, but after the measles exemption and a doctor who was in their legislature, Dr. Pan, they actually changed their legislation to only be medical. But in Texas, we are a green state. So we have all three types of exemptions. We have religious, medical and philosophical. When the philosophical exemption means that for reasons of your person, your own conscience, if you do not want to vaccinate, you can actually get an affidavit and I'll show you what it looks like from the state health department. And every other year you turn that in and you do not have to vaccinate your child. So I want to show you what this has done to immunization coverage. And this is a slide that shows the number of children that have exempted at kindergarten from one or more vaccines. And as you can see in Texas, we're kind of a middle blue colored state. You can see farther to the West Coast. It gets darker blue. It's that means more exemptions up in the Great Lakes area. It's also dark blue and it's also dark blue up in the far upper Northeast area. And I think it's important to pay attention to the hashed areas and that shows where MMR coverage is less than 90 percent. And MMR coverage less than 90 percent is really important because MMR is so contagious that we really have to have herd coverage at 95 percent or greater. So if you'll take a good look at that slide where we're medium blue and dark blue and I'm going to go back to where we have conscientious exemption laws. The green and people call conscientious or non medical. Do you see the relationship between the two. Yes. Yeah. So that's a real problem and we're we have to work on that as a nation because non medical exemptions are really playing a role in where our vaccine coverage is dropping. So just as Paul Offit mentioned who are the characteristics of these parents are choosing to exempt their children. And studies have shown that they are primarily non Hispanic white parents generally privately insured more often married with mothers age over 30 most often English speaking with some air some levels of higher education and generally somewhat higher income. So this is what looks like for the state of Texas. So back in 2003 that's when we passed our philosophical exemption law non medical exemption. And you can see that we only had two to three thousand kids at kindergarten who were exempting from immunization. And this last the most recent report from the state we are about at forty five thousand kids who entering a kindergarten are now reporting exemptions for immunization. So this is this is a big problem. So for those of you haven't seen it this is the affidavit from the state. This is what it looks like currently for our state. And we're we're to parents get these ideas. Well this is a gentleman by the name of Dr. Sears. And he's published a book he's actually a board certified pediatrician in California. And he's published a book the vaccine book. And to get this I had to buy his book unfortunately. And he's published two vaccine schedules and alternative vaccine schedule. And you can see it delays some various immunization. It delays hepatitis B. It delays polio delays the chickenpox vaccine. So you don't give varicella a year you give it at two years. The there is no meningococcal vaccine at eleven years. It delays it till sixteen years. And the one that is really worse is the selective schedule. And you can see it's missing a whole lot of doses. And I want to point out that there is absolutely no science behind any of any alternative schedule that any parent walks to you in with. Whether they printed it off the Internet there's no science behind these these vaccination schedules either one of these or others leave children vulnerable during the time that they need it most. It's so important to understand. So sometimes I have had parents that come into me and they'll say well I'm just don't want to give all of the two month old vaccines today. How do you pick. How do you pick. Well I'm going to not give the you know pneumococcal vaccine today. Well you know you could their child could come down with that tonight. How am I going to not choose him. How am I not going to choose pertussis. All of them could happen any time. They're all risky. And that's what parents don't understand that by waiting time their child could get sick and these illnesses are associated with death. And that's why the medical that's why medical scientists. Went through the research and development to actually produce these vaccines because they were associated with death. And that's where the parents really misunderstand this. So how is HPV vaccine refusal a little bit different. And I think it's a little bit different because parents are misunderstanding safety. These are just quick Google searches. If you do just a Google search on HPV vaccine safety the first couple of hits like literally the first couple are OK. But I'm telling you page two of Google is scary on HPV vaccine safety. And this is some of the misinformation that comes up study reveals unavoidable danger. And it comes up with multiple sclerosis. I showed you that on an earlier slide that you know is previous associations of you know scares a primary Oval variant failure. Just lots of nonsensical things. But this is actually from a CDC study where they asked parents what their concerns were. Lack of knowledge. They thought that wasn't needed and this is it goes back to provider recommendation. But again you can see that safety concerns are really up there for HPV. And we know that HPV coverage really lacks lags behind that of the meningitis and the T that vaccines that are given also at age 11. And I think some of you have attended whole conferences on HPV vaccine. But just to quickly mention that the the first dose recommendation of first dose coverage for girls is in the purple and that is sixty three percent of nationally three dose for girls is 42 percent one dose for boys 50 percent and three dose for boys at twenty nine percent. And this is just simply unacceptable. These diseases whether it's cervical cancer or head and neck cancer are killing individuals. These are this is HPV is causing death for not children but older adults. And when I think about this as a pediatrician to me this is like talking about obesity as a pediatrician I can choose to ignore obesity. But eventually the obesity in a child is going to come back and kill that child early whether it's from early heart disease hypertension their obstructive sleep apnea will cause all of the rest joint disease something bad is going to happen to that child if I choose to ignore it and not do something about it. Same thing with HPV these numbers these children those kids because 80 percent of all people are exposed to HPV eventually in my practice a girl is going to get cervical dysplasia and then come down with cervical cancer same thing with head and neck a girl or a boy is going to get head and neck cancer that person may be 50 60 70 years and I may be dead by then but it is my job to make sure that that does not happen. I'll get off my soapbox now. Okay. All right. So how does Texas compared to other states and you can see that we're kind of in this middle color area for girls on the left and boys on the right. We've got states that are around us that are doing a lot better. So I think we can too. And I think Priscilla covered your coverage information. Bear County is kind of right in the middle of my slide. But I think we can all agree that we need to do better. So just briefly just to again to emphasize the recommendation that we are supposed to give it at age 11 to 12. And I want to just mention why is that. Well it's because your immune system actually responds the best. And I didn't want to put up the big scientific slide with all of the antibody titers. But your antibody titers at ages 10 10 and a half are phenomenal compared to they are by the time you're even 16 18 and in the 20s it's not so good. So when you're a 10 year old your immune system is on fire. It is amazing. But when you get a little bit older it's just not as great. So they actually studied the vaccine between ages nine and 26 and found it safe and effective. That's why we have those age ranges. And at the earlier ages when you get your best bang for your buck from from a purely immunologic standpoint. And that's why we want to do that. And from an insurance standpoint that's why the heathest measures are started 11 and finished by 13. So you really get all the doses and while the immune systems working the best. Did I emphasize this enough. I hope so. So again to get back to HPV vaccine safety. So what did the so right after we came out with HPV for we there were some early reports and I think that this is where some of that early safety concerns came in that there were reports of adverse events. And I do want to point out that in any population there's going to be death in a in a study population compared to a healthy population. In your study population there's going to be kids that get in car accidents just like in your healthy population that you're comparing to. There's going to be kids that get cancer or the kids that get in car accidents. So when you actually look at the actual data the things that actually stood out that were statistically different between the vaccinated group and the unvaccinated group were kids that actually had syncope or fainting and actually kids that had clots that formed. So that those were the only differences between the kids that got vaccinated and the kids that didn't. So that's really where we started to focus in a lot of our efforts. To date and this is from recent CDC information there have been seventy nine million doses of quadrivalent HPV given. There have been adverse reports turned into VAERS and the ninety two percent of those reports to VAERS were all considered non serious. And the most common reported symptoms were injection site reactions for so redness swelling dizziness syncope and those may include tonic-clonic movements which I'm going to talk to you a little bit more about nausea and headache. So what about post-vaccination syncope. It's important to see that you can see where we started to recommend the adolescent platform for vaccines on my slide the first arrow the MCB-4 and the T-DAP and you'll start to see that there's increasing reports to VAERS of more syncope way before we started to introduce HPV which is in one of the later arrows. So as soon as we start vaccinating more teenagers more often at age eleven we start to see more syncope. Well why is that. So teenagers know what's going on. They're they're aware I actually have a almost my daughter will be eleven in November. You're not getting past her. I mean you walk in with a needle she knows my daughter knows she gets every vaccine known to man but she they they know they know and they say am I getting a shot this time am I getting a shot this time and they also get worked up. So it doesn't matter what's in the needle they just get worked up they get worked up over a blood draw my little girl. She she got a she got a TB skin test actually and she held it all in and then we walk out of the doctor's office she burst into tears in the hallway and I was like what is this about and it was because she was so worked up in there and then she burst into tears just a few months ago. So these are these are real kids they act more like adults than they do like little kids in that sense. So what is really happening here. So they they experience anxiety and fear and this goes into your midbrain and it sends in a signal for you to vasodilate which then lets all of the blood pool in your lower extremities and it also makes your heart great rate go lower and it can result in syncope. There's just no way to tell so I think that you can see how with a if you faint you can have seizure like movements and it was interesting. I walked into my I have a 21 year old I walked into her graduation dinner and this one parent's daughter had gotten an HPV vaccine and she was going off to college the girls were all going to college and this mother was saying my daughter had a seizure and how awful it was and she had I was so sad they got there before I did because that this entire room of parents was just petrified that this had happened and if there was anyone who had additional doses of HPV left I can guarantee you no one else got them because of this description of what happened to this girl. But I think it's important for you all to understand this can be normal when you have hypoperfusion to your cerebral cortex and this is a normal event that can happen with a fainting episode. So what about HPV nine. Well this this vaccine was actually just like any vaccine has to be studied before it's licensed and you can see that pain is very common as is swelling at the injection site redness. So those were those were known side effects and I want you to see the difference between boys and girls and girls have generally more side effects than boys. And I'm not really proud of this. I'm going to be honest with you. But because I think girls go girls but they generally had more side effects than boys. So when you're seeing patients this is just something that you should remember. So some people don't really understand that we have multiple different programs that follow vaccines once they've been licensed. So not only do we have the vaccine adverse event reporting system that many of you are familiar with. We have other different systems that all coordinate to look for any rare side effects after a vaccine has been licensed. There's a vaccine did safety data link program. There is the clinical immunization safety assessment project and the prism group. And all of these are large different ways that CDC can collect safety data after a and the FDA after a vaccine has been licensed to look for rare effects. So there have been they we have continued to look for any different things that are happening. And with HPV Guillain-Barre has not been found. There's no association no association with any of these issues stroke of appendicitis autoimmune disorders multiple sclerosis any demyelining diseases or death. And the current concerns that you'll see on the Internet is primary ovarian insufficiency. And this is when your ovaries fail early in life. And there's been no safety data to support this complex regional pain syndrome. And this is when you get a repetitive pain in a certain area of your body again no evidence after 80 million doses. And then POTS disease. Some of you may have heard of this. And again there's no safety data to support that and there's either. So what is my advice for you you really do need to tell patients that I'm totally honest with my patients. It causes pain in 90% of people. This one hurts more than others. And if any of you are on the front line of vaccinating you know that. Tell kids that. Sit down your your anxious kids or lay them down. I had a girl who was hyperventilating a couple months ago. And like her dad had to come to the appointment because she wasn't going to come by herself. I said doctors orders you must lay down. So lay those kids down. Swelling and redness are very common. Fever and hematomas are less common. Headache in some but really serious adverse events are extraordinarily rare. And the American Academy Pediatrics really does recommend the 15 minute waiting period. And so do I because that will make sure that those children have a chance to settle down after that vaccine is given. And then you won't have a child who suddenly stands up in faints right there. So what do you tell parents. HPV is safe. It's the HPV nine is similar to what we were giving before. And it's important to tell families this vaccine is not new. That's what I hear from people. Oh it's new. No it's nine years old. Almost a whole decade has passed. A lot has happened in a decade. Local local of adverse events are common. That's why you do need to tell people it's going to hurt. But the scientific studies like crazy things that you read on the Internet that I showed you at first are not supported at all. So communication strategies. It's really important that when you're talking to families whether it's about HPV or MMR and autism. That you use presumptive dialogue. And there's a gentleman by the name of Doug Opel up in Seattle who's actually done videotape studies with providers and parents. And even if you're a fence sitter or a vaccine resident parent you are much more likely to be accepting of a vaccine if the provider walks in the room and just says we're going to vaccinate today or let's get our HPV Tdap and meningitis vaccines today. Then you know would you like to consider giving HPV today. And that would be a participatory type of a recommendation. So it's also important with your HPV always remember your bundled recommendation. You give it as part of all three together. And it's much more likely to be accepted. I've gone through that. There's a lady by the name of Allison Singer who's really been on the forefront of how to talk about vaccines. And she has a daughter who's profoundly affected by autism. I encourage you to look up Allison. This is Allison's picture. And she's really put forth this case method where C is for corroborate and the corroborate is probably the hardest piece of the of her method. And so after you've listened to kind of what the parents real concern is. So a parent may say to you I'm worried about giving HPV vaccine because I'm worried that might might make my child sexually active. Then you have to offer some sort of a statement to them. And that is not really frankly agreeing with them or supporting their statement. But it's somehow finding what your role is in the office. You may want to say well I hear your concern and I just attended a conference all about HPV. And as the office manager in this practice I have learned that HPV is very safe after listening to a speaker at this conference and doing my own reading. I am very confident in the safety vaccine and I'm going to have the doctor in our practice speak to you specifically. But I want you to know HPV vaccine is safe. So really tell the person who you are. And again this is not to brag but it's to show them your knowledge and to give them confidence in your recommendation. I actually already shared a little science and kind of my recommendation there. But you want to keep it relevant to the point that they mentioned whether it's safety or if it's the sexuality issue with regard to HPV really direct the science you share directly back to their point. Don't get off topic and talk about something else because that's the only thing you know. And that's why on this on this whole issue you need to be very well versed. So if it's a parent talking about MMR and autism or thimerosal you need to be very targeted in how you are directing the information. I think vaccine information statements of course it's part of the law that you give it to them. But vaccine information statements can be very helpful in what information you give to parents. So if you're not sure what to say it's always a good backup to use your vaccine information statement. So these are just some model languaging I wanted to share with you. So one one sample of thing a parent might say my daughter doesn't need the HPV vaccine. We teach abstinence in our family and she won't be sexually active till marriage. So you could say I'm really glad that you're having conversation these conversations with your daughter teaching abstinence is important. And in the in that. And I say this because of the area of Texas we're in you need to find some common ground. That said we won't know if her future husband is practice abstinence until marriage. Unfortunately as a mother-in-law you might be the last person to find out the truth of vaccinating your daughter against HPV will protect her from any exposure for this virus that could cause cervical or throat cancer in the years into their marriage. As a mother it's important to make decisions now that will protect her later. So it's example not the only example but just one example of something you could say. I'm worried that if I vaccinate my child it's like giving them permission to have sex. And again relative to HPV and we will be giving your son or daughter the HPV vaccine along with Tdap and meningitis vaccines again I kind of message back to the bundled recommendation to the child it's just another shot. We give tetanus vaccine to kids and they don't go looking for rusty nails do they a little humor. Scientific studies have actually looked at that looked at this proving that the HPV vaccine does not increase rates of sexual activity in teens. That's the science. So you can give the vaccine today knowing that the vaccine will not make your child promiscuous. So those are kind of examples of kind of going through that with explain advice. And really the explain advice is you want to come back and say let's vaccinate today. This is your bring it home moment to make sure that you're vaccinating today. And you need to be clear and confident. But if you are to polarizing they may just pull away and back off. Sometimes parents will use what I call the contingency statement and a contingency statement is oh well I've running late we don't have time to get a vaccination or I've got to talk with her dad he's at work we can't bother him. And the contingency statement is a parent looking for an out. And I will tell you that is sort of that is a conversation ender for you. The best thing you can do is just ask them to reappoint them in a week make a definite time for them to come back so that that conversation isn't lost. I'm a bit shameless. And I will go all the way to the end I think we're taught medicine to not really talk about ourselves but I will go to the end and I will say I am a mother of a 21 year old a 17 year old and an almost 11 year old and I vaccinated my children against everything and and so I vaccinated my son even before the vaccine was recommended for boys and and I'll tell I'll tell parents that and that the vaccine is safe I wouldn't want a day to go by without having given them vaccine vaccines and my 11 year old will be vaccinated at her well child check. So I think it's also important to make it salient and I'm going to go ahead and just finish and then I have a little video that I'd like to show you but I'm going to ask Monica if there's time. Where's Monica. Monica is in the back. Is there a time Monica. Are you sure. OK because I'm going I think I've only got a few minutes left so. Let me finish and then we're going to show a video but we have a video that we've just finished producing and we also have some books about HPV. They're on the back table they're free for you. You're I brought tons more copies than a people in the room and please I'd love for you to take these and share these with people maybe who have refusing vaccination. So if you leave today please grab some. We have them in Spanish also and I'll leave some of my business cards in the back and if you'll email me we can get you a Spanish copy also. So can you persuade how how how much can you push this. It is actually ethical to persuade and we've actually I've actually done a co-presentation with an ethicist about this and because the benefits of vaccination in general for any vaccine including HPV so far outweigh any risks it is ethical to be very persuasive. So it's OK. It's an important to realize you are a very influential messenger to parents. So don't be afraid to make a very strong recommendation like you heard me get on my soapbox. It's OK to be on a soapbox because these parents need to hear from you because I'm telling you the internet is also very powerful in the privacy of their bedroom so make sure that your voice is known. Sometimes parents will be very adamant in the other direction or you may meet people who are or are not pro-vaccine or anti-vaccine. Don't let that get to you. Those people will sometimes trying to wear you down. Just don't let that get to you because there's a lot of parents who care about your message and don't want their child to get cancer or any of these other horrible illnesses. So what does the AAP recommend they came out with a new statement. They do recommend intensive education. They do want you to go to kind of every every end to educate families. Keep them in your practice. But it is OK to dismiss a family if every measure has been taken and there is a eventually a lack of trust or trusting relationship that in a physician feels that they need to dismiss a family. It's always important to listen respectfully and to parents' concerns. But dismissal can be an option and it's important to use the AAP refusal to vaccinate form including for HPV. And I want to mention why that's important. Many many years down the line when you're no longer around and this person may have had an OBGYN or an internist they may develop dysplasia or cancer and say well that person really didn't explain to me what my risk was. Well you don't want to be in that role of having said I didn't really explain the risk because you might have. But a lot of charts simply say DTAP and meningitis and make no mention of HPV because a parent refuses it. And I would really encourage you to really think about use of refusal to vaccinate. This is not a new vaccine. The safety data is clear. AAP statements and CDC recommendations have been used in a court of law. And so physicians need to take a heed of that. So if a parent on multiple episodes is continuing to refuse HPV they are really opening their child up for risk and they need to document that they are refusing it and they are taking on that risk not yet. So I'd like to play the video for you if I could. This is a seven minute video about HPV. I first heard about the HPV vaccination when I was in high school. I was just using my own knowledge as an 18 year old high school student that, oh, I don't need this. It's not going to happen to me. It's really hard to describe 33 or 32 radiation treatments and the effect they have on you. But it's like going maybe 20 rounds with Muhammad Ali. I got a phone call from my doctor. And his first words to me were you need to get your personal stuff in order. It brought me to, I don't want to say the brink of death, but it was probably the hardest point in my life to go through those treatments. I guess that's the one big thing I'm really emotional about is the fact that my family had to go through what they had to go through while I was going through it. It's not just just about me. They're also affected as well. My first symptom was a lump under my jaw. I had stage 4 cancer which was from the tonsils HPV 16 started with chemotherapy and then they bring in the heavy weight, which is the radiation. I have no chest muscle. My neck's a mess. I'm in pain. I have headaches. My feet hurt. My hands hurt. I can't look over my shoulder. This is as good as my voice is ever going to get. I'm miserable compared to how great I was before I got HPV, before I got throat cancer. The initial cancer was diagnosed with pap smear. They went ahead with the hysterectomy and I was told that if the cancer was going to come back, it would come back within the first year. But it was less than 1% chance of it coming back. At 1% 1% is 1% and when that 1% is you, I foolishly thought that once we'd beaten the cancer, I was done. But the colostomy never went away. Then I developed a fistula. The disease and what comes with it is always at the beginning of your mind. I discovered a lump in my neck or close to my throat on the way to work one day. Went in and did biopsy about five, six days later and they pretty much knew what they were seeing. And she kind of said there's probably HPV. Really, at this point, we'd never heard of HPV. And we had never heard of, you know, any kind of throat cancer that wasn't related to smoking or drinking. You see the strong man who always faces the world who's your rock fall apart, both physically, mentally, emotionally. They don't really do a good job of warning you what you're going to go through after you're through with the treatment. There was a point that I went through that, oh my God, another night to go through this. And now it's it's coming better, but it's not the same, not the same. When I was first diagnosed with cervical cancer and learned that I had to have a hysterectomy, I had a five year old child and an 18 month old child and my husband at the time and I were actually trying for another child. It was a devastating diagnosis emotionally, as well as, you know, difficult physically, just going through the surgery. I didn't ever expect that my stage zero cervical cancer would recur. Then seven years later, I found a lump in my neck and they determined that my cervical cancer was back with a vengeance. It had spread to my lymph nodes throughout my body and then four years later, just this past May, I had a PET scan and they found a lymph node in my pelvis that lit up and after the biopsy was positive for cervical cancer. So I've had two recurrences of my cervical cancer. Telling my children was probably the hardest thing that I had to do. So you know, it's not anything that you ever want to tell your children that my cancer was back. I remember from the appointment, the only thing that really stood out to me was, you know, if your tests come back normal, we'll send you something in the mail. If there's something abnormal, you'll receive a phone call and my phone call came the next day. So I was not HPV free and in fact, I was already I think in stage two dysplasia. And so it was something where they wanted me to come back in and immediately have a biopsy and I did have some of the strains that would have been preventable if I had been vaccinated. They immediately decided to do a leap procedure. It consists of burning away the lining of the service, which sounded horrible, absolutely horrible. About a year later, once again, dysplasia came up, another leap procedure. So now my last pap smear has come back. Fine. But we're doing another one actually next week just to verify my husband and I want to start a family and, you know, there's definitely concerns that are there as to how that might affect me since every person is so different and how they are affected by HPV. I could go back when I was 18 and tell her, I would say, you don't know where life is going to take you. You have all these thoughts and plans, but your plans are not what's going to happen. It's not just white females. It's males and head and neck cancers and all kinds of cancers. And the more knowledge we have and the more knowledge we have about the importance of the HPV vaccine, the less people will go through what I'm currently going through and have gone through three times already. I didn't have an option. There was no vaccine for me. You've got a vaccine. If we don't use it, if we don't protect our kids with this, this is our fault. I have to go through what I had to go through and a lot of other people that have to go through the same thing. It's preventable. You would not want to go through this hell and there's no other description for it. But hell, it's you are not the same person after you've gone through a cancer like this. Get your sons and daughters vaccinated. It could save their lives. It's cancer prevention, plain and simple. You're listening to the voice of cancer talk. Get them vaccinated. So they don't go through what thousands of men and women are going through now. Thank you.