Need: The human papillomavirus (HPV) vaccine serves as an effective primary prevention strategy [1] by reducing morbidity and mortality of HPV-associated diseases (cervical, oropharyngeal, vulvar, vaginal, penile, anal cancer, anogenital warts) [2-10]. The overall annual direct medical cost of routine screening and treatment of HPV-associated disease is $8 billion (2010 USD). Direct costs could decrease if vaccination increased [11]. It is recommended for girls and boys aged 11-12, with catch-up doses for those aged 13-26 [8, 10]. US completion rates (49.5% for girls and 49.3% for boys aged 13-17 years) [12] are not reaching Healthy People 2020 goal of 80% of 13-15-year-olds fully vaccinated...

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Need: The human papillomavirus (HPV) vaccine serves as an effective primary prevention strategy [1] by reducing morbidity and mortality of HPV-associated diseases (cervical, oropharyngeal, vulvar, vaginal, penile, anal cancer, anogenital warts) [2-10]. The overall annual direct medical cost of routine screening and treatment of HPV-associated disease is $8 billion (2010 USD). Direct costs could decrease if vaccination increased [11]. It is recommended for girls and boys aged 11-12, with catch-up doses for those aged 13-26 [8, 10]. US completion rates (49.5% for girls and 49.3% for boys aged 13-17 years) [12] are not reaching Healthy People 2020 goal of 80% of 13-15-year-olds fully vaccinated [13] to prevent 53,000 more cervical cancer cases over the lifetime of those ?12 years [14, 15]. 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 [10, 16-18]. HPV-associated diseases disproportionately affect low-income, rural, and minority individuals in the Rio Grande Valley (RGV) of Texas [10]. Residents have higher cervical cancer incidence and mortality rates and higher uninsurance rate [19-21]. HPV vaccination rates in these counties are incredibly low given the excess burden of disease. Provider recommendation is the strongest determinant of HPV vaccination among adolescents, but inadequate access to healthcare services is a contributing factor. HPV vaccinations in nontraditional settings (school-located mass vaccination programs, school health centers, pharmacies) can improve HPV vaccine uptake and increase access in low resource [10, 22] and rural areas. [17, 23]. School-based vaccination programs have demonstrated success in providing other recommended vaccines, eg, influenza, tetanus, meningitis [10, 24, 25]. Through our CPRIT-funded prevention grant in our pilot school district, Rio Grande City Consolidated Independent School District (RGCCISD, expiring this year), we demonstrated that school-based vaccination programs can dramatically improve HPV vaccination rates in the RGV, with HPV vaccine initiation rates increasing to 65.5%-69.0% and completion rates increasing to 41.5%-43.1%. in 2019, we expanded to the Pharr-San Juan-Alamo ISD (PSJA ISD) in Hidalgo County. This proposed grant will cover RGCCISD and 5 new school districts across 4 counties and aims to reduce common obstacles to HPV vaccination. Overall Project Summary: This project aims to increase HPV vaccination uptake in Starr, Hidalgo, Jim Hogg, and Zapata Counties to match the 2018 National Immunization Survey (NIS)-Teen rates for Texas by expanding CPRIT activities. Activities will include the continuation of our outreach and education campaign in Starr, Hidalgo, and Cameron Counties expanding to Jim Hogg and Zapata Counties; school-based HPV vaccination program in six school districts; and expansion of program activities and support services (follow-up navigation, data collection, tracking, systems improvement). Compared to students initiating outside our program, we had better completion rates and less students receiving the incorrect number of doses. Our unique model centers around a strong collaboration between academic medical institutions, county health departments, and school districts to employ school-based and community-based education events. Our evidence-based intervention provides the HPV vaccine in an alternative setting (schools) and creates support for HPV vaccination through education and outreach. Specific Goals: Goal 1- Increase HPV vaccine initiation and completion rates to a minimum of 59.9% and 43.5% respectively (statewide 2018 NIS-Teen HPV vaccination rates) for all students (females and males) in 16 middle schools from 6 school districts across 4 counties in the RGV. Goal 2- Increase HPV vaccine completion rates among middle school students in each school district (RGCCISD, Roma ISD, San Isidro ISD, La Joya ISD, JHCISD, and ZCISD) who initiate HPV vaccination through our school-based HPV vaccination program by 25% above baseline. Goal 3- Increase knowledge and awareness of the HPV vaccine among RGV parents/guardians and healthcare providers by 25% compared to baseline. During the grant period, we estimate 756 events reaching 29,937 unique individuals and providing 21,637 HPV doses for 11,904 students (11,904 dose 1; 9,733 doses 2 and 3). Significance & Impact: Our two currently funded CPRIT projects provide strong evidence supporting school-based health programs to increase HPV vaccine uptake along the Texas-Mexico border. We vaccinated both genders at the recommended ages, doubled HPV vaccination rates, addressed the target audience to improve vaccine uptake and reduce future HPV-associated cancers, worked with migrant and rural population, and replicated our efforts in other Texas schools.

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