Improving adolescent health: focus on HPV vaccine acceptance

Young adults and acceptance of the human papillomavirus vaccine

OBJECTIVES

To determine whether young Dutch adults had ever heard of human papillomavirus (HPV) and whether they would accept vaccination, and to assess the factors influencing their decision.

STUDY DESIGN

Cross-sectional survey.

METHODS

Six hundred participants aged 18-25 years were recruited from two university departments and one non-university technical college.

RESULTS

One hundred and six (17.7%) participants had heard of HPV and 536 (94%) had heard of cervical carcinoma. Women had significantly more knowledge of cervical carcinoma than men. A medical education, knowledge of HPV, knowledge of cervical cancer and knowledge of the cervical screening programme were not significantly associated with acceptance of HPV vaccination, whereas gender and age did show a significant relationship. In total, 61% of the female participants and 48% of the male participants were willing to accept a 'catch-up' HPV vaccination.

CONCLUSIONS

This study found that average knowledge levels of HPV and cervical cancer were low. Despite this lack of knowledge, a small majority of the study population would accept a 'catch-up' HPV vaccination. Women and younger participants were significantly more willing to accept HPV vaccination. However, in these subgroups, acceptance of HPV vaccination seems to be affected by other, still unidentified, factors. These factors could be evaluated in a more qualitative orientated study. An educational campaign is needed to cover knowledge about HPV and cervical carcinoma, and beliefs and behaviours associated with the acceptance of vaccination.

The HPV vaccine: framing the arguments FOR and AGAINST mandatory vaccination of all middle school girls

BACKGROUND

Human papillomavirus (HPV), the virus responsible for cervical cancer, is the most common viral sexually transmitted infection in the United States. A vaccine was approved in 2006 that is effective in preventing the types of HPV responsible for 70% of cervical cancers and 90% of genital warts. Proposals for routine and mandatory HPV vaccination of girls have become sources of controversy for parents of school-aged youth, legislators, members of the medical community, and the public at large.

METHODS

The purpose of this article was to articulate the arguments used by advocates who either oppose or endorse routine, mandatory administration of the vaccine to school-aged girls, thereby assisting school health personnel in being effective participants in framing the relevant issues.

RESULTS

Controversy is grounded in moral, religious, political, economic, and sociocultural arguments including whether concerns that the vaccine increases sexual risk taking, sends mixed messages about abstaining from sexual intercourse, usurps parental authority, and increases the potential for development of new health disparities are offset by the value of administering a cost-effective, age-appropriate public health measure targeting a life-threatening problem.

CONCLUSIONS

Careful consideration of the medical evidence and public health implications is critical but understanding the context of the debate is no less important to the task of responding to public concerns. School health personnel have a role in the discussion about HPV immunization. Being able to articulate the arguments presented herein can help authorities' responsiveness to parents and community groups as the dialogue about this particular health issue evolves further.

Current issues in adolescent immunization

Based on the December 2006 Fondation Mérieux International Scientific Symposium, the current state of adolescent immunization is reviewed with a focus on the policy and programmatic issues that impact the acceptability, initiation, and successful implementation. Key questions are identified with proposed strategies to help achieve successful adolescent immunization programs. The role of current vaccines targeted to adolescents, such as those directed against invasive meningitis, pertussis, and the human papillomavirus, is reviewed as well as their role in rejuvenating interest in adolescent immunization, and more importantly, adolescent health as a whole.

Awareness, knowledge, and beliefs about human papillomavirus in a racially diverse sample of young adults

PURPOSE

To assess current levels and correlates of awareness, knowledge, and beliefs about human papillomavirus (HPV) in a racially diverse sample of young adults. Correlates of interest in HPV education and the HPV vaccine were also examined.

METHODS

A total of 124 students 18-26 years of age from two southeastern universities (including a historically black university) completed a survey assessing demographic characteristics, sexual history, awareness and knowledge of HPV, HPV-related beliefs (perceived risk of HPV infection, perceived shame associated with HPV infection), interest in learning more about HPV, and interest in the HPV vaccine (women only).

RESULTS

More than 75% of the sample had heard of HPV. Although some misunderstandings were observed, HPV knowledge was relatively high. Women reported greater awareness and knowledge of HPV than did men. Higher perceptions of risk were observed among sexually active participants and those with multiple sexual partners. Younger participants, men, and those with less HPV knowledge indicated they would feel more ashamed if diagnosed with HPV. Black/African-American and sexually active participants reported greater interest in HPV education. Greater interest in the HPV vaccine was observed among women who were sexually active, had multiple sexual partners, and felt vulnerable to HPV infection.

CONCLUSIONS

This study is one of the first to assess awareness, knowledge, and beliefs about HPV since the HPV vaccine was approved. Findings suggest that awareness of HPV may be increasing, yet many misconceptions remain. Continued efforts are needed to promote further understanding of HPV infection, the HPV vaccine, and the importance of routine cervical screening.

Parental acceptance of Human Papillomavirus vaccines

OBJECTIVE

To determine whether parents would accept Human Papillomavirus (HPV) vaccination for their children and which variables may influence their decision, including knowledge about cervical cancer and HPV.

STUDY DESIGN

Three hundred and fifty-six parents of children aged 10-12 years were interviewed regarding the acceptance of an HPV vaccine for their children and their knowledge of HPV and cervical cancer. All data were recorded anonymously. Results were compared using the chi(2)- and the Mann-Whitney test.

RESULTS

HPV vaccination would be accepted by 88% of the parents, preferably when the child is aged 10-12 years. Parents of children who received all the vaccinations of the National Vaccination Programme accepted HPV vaccination significantly more. Less than a third of all parents had heard of HPV, and 14% were aware of the causal relationship of HPV and cervical cancer. Knowledge of HPV and cervical cancer, religion, age, education, and marital status did not show any significant relation with HPV vaccine acceptance.

CONCLUSIONS

A majority of the parents would accept HPV vaccination. HPV vaccine acceptance seems to be dependent on vaccine acceptance in general, even more than on knowledge of HPV and its causal relation with cervical cancer. However, parents requested more information about cervical cancer, HPV, and HPV vaccination, before the HPV vaccine is introduced.

Moving forward: human papillomavirus vaccination and the prevention of cervical cancer

In June 2006, the Food and Drug Administration (FDA) approved the first human papillomavirus (HPV) vaccine. The vaccine was subsequently recommended by the Centers for Disease Control and Prevention's (CDC) Advisory Committee for Immunization Practices (ACIP) for routine vaccination of 11-12-year-old girls and catch-up vaccination of females 13-26 years of age. With the approval of the first HPV vaccine, cervical cancer now has a primary prevention tool. However, the availability of an HPV vaccine will not change the course of cervical cancer in this country unless there is both widespread demand by and access for the targeted populations. Demand will require recognition of the need for protection against HPV infection as well as a positive perception of the vaccine as safe and efficacious. General knowledge of HPV and its relationship to cervical cancer is limited; some parents and healthcare providers are hesitant to vaccinate preadolescent girls. Access to the expensive vaccine will not be increased without addressing financial constraints. Although the Vaccines for Children (VFC) program has added HPV to its vaccine plan, not all private insurers have approved coverage, and the uninsured and underinsured may have limited access. Moving forward will require a well-planned and executed public information campaign by trusted sources and the development of a comprehensive vaccine administration program. Although mandates would assure the broadest coverage, controversies surrounding mandates may deter work toward broad coverage. States should focus on developing a comprehensive program and then return to the mandate issue if coverage does not meet public health objectives.

[Prevention of human papillomavirus (HPV)-induced infections: access of adolescent girls to health care. A population-based, cross-sectional observational study]

INTRODUCTION

The human papillomavirus (HPV) is the most common cause of sexually transmitted infections worldwide, and its prevalence is highest among young women aged 17-25 years. It is the principal risk factor for cervical cancer. Systematic vaccination of adolescent girls should significantly reduce the incidence of this disease and its related mortality.

AIM

One of the objectives of the Enjeux study, a population-based survey, was to identify the place of young girls within the French health care system to help assess the optimal conditions for implementing anti-HPV vaccination.

METHODS

Data came from 5354 interviews of women aged 18-70 years, 320 of whom provided information about daughters aged 11-14 years and 406 about daughters aged 15-17 years. Among the latter, 318 were also interviewed and 294 completed a self-administered questionnaire.

RESULTS

The results showed that sexual activity was reported by approximately one third of the girls aged 15-17 years. At-risk behaviors in these girls included insufficient contraception (only 51% use condoms). Data on the medical management of the population of 11-17 year-old girls indicate that they have access to - and are integrated into - the health care system, with frequent medical visits. They see the general practitioner (GP) most frequently, followed by the school doctor. The frequency of general practice visits is similar in both age groups; more than 50% of the girls visit their GP more than twice a year. Vaccination is a frequent reason for these visits; gynecologic reasons are less frequent.

CONCLUSION

The results of this survey underline the central place of the GP in the health management of young girls aged 11 to 17 years.

Human papilloma virus immunization in adolescent and young adults: a cohort study to illustrate what events might be mistaken for adverse reactions

BACKGROUND

The large-scale implementation of human papilloma virus (HPV) immunization will be followed by cases of autoimmune diseases occurring in temporal association with immunizations. To anticipate events that might be mistakenly assumed to be caused by immunization, their prevalence was monitored before vaccine introduction.

METHOD

Cohort study carried out within a database of female adolescents (n = 214,896) and young adults (n = 221,472) followed in the pre-HPV vaccine era (2005), computing rates of emergency consultations, hospitalizations and outpatient consultations, and estimation of risks of coincident associations.

RESULTS

Immune-mediated conditions were a frequent cause (10.3%) of emergency room consultation by adolescent girls. Nonallergic immune-mediated conditions affected 86 per 100,000, diabetes ranking first. In 2005, 53 per 100,000 adolescents and 389 per 100,000 women were hospitalized for diseases of presumed autoimmune origin, thyroiditis being the most frequent diagnosis. If HPV immunization had been used with 80% coverage, 3 per 100,000 adolescents would have required emergency care for asthma/allergy within 24 hours and 2 per 100,000 for diabetes within 1 week of an injection. The risks of hospitalization in temporal association with immunization are 4 times higher for thyroiditis than for multiple sclerosis or Guillain-Barré's syndrome, and more than 20 times higher in young women than in adolescents.

CONCLUSION

The distinction between HPV vaccine-caused adverse reactions and events only observed by chance in temporal association is difficult. The prior use of population-based data allows for identification of issues of potential concern, for monitoring the impact of large-scale interventions and for addressing rapidly vaccine-safety issues that may compromise vaccine programs.

Influence of parent characteristics and disease outcome framing on HPV vaccine acceptability among rural, Southern women

OBJECTIVE

A new prophylactic vaccine protects against infection with HPV types that cause many cervical cancers and genital warts. This study explored the impact of framing the vaccine's benefits, with respect to the disease outcome being prevented, on women's HPV vaccination intentions for themselves and for an adolescent daughter.

METHODS

A cross-sectional study was conducted in a rural North Carolina area with a high cervical cancer mortality rate. A questionnaire was administered among female attendees of a low-income public clinic and a private OB/GYN office. Data were analyzed using a generalized estimable model.

RESULTS

Women reported high intentions to vaccinate against HPV. Women reported higher intentions to vaccinate adolescent daughters than themselves, and this relationship varied by how the HPV vaccine was framed (preventing HPV, cervical cancer, or genital warts). Older women reported lower vaccination intentions than younger women.

CONCLUSIONS

Rural women, especially those who are younger, may be more accepting of the HPV vaccine when it is framed as a cervical cancer vaccine. Messages to mothers about the HPV vaccine for their daughters might be made more effective by framing the vaccine in terms of cancer and sexually transmitted disease prevention.

Predictors of Human Papillomavirus Vaccination Acceptability Among Underserved Women

OBJECTIVES

The objectives of this study were to examine underserved women's acceptability of the forthcoming human papillomavirus (HPV) vaccines and to identify correlates of HPV vaccine acceptability.

STUDY DESIGN

A sample of primarily low-income minority women (n = 58) recruited from community health clinics completed a semistructured interview assessing health beliefs, vaccination attitudes, health behavior, and HPV vaccination intentions.

RESULTS

Personal acceptability of the HPV vaccines was generally high. Moreover, 100% of parents were interested in having their children vaccinated. Correlates of vaccination intentions included health beliefs and attitudes (perceived risk of HPV infection, perceived safety and effectiveness of HPV vaccines, perceived physician encouragement for vaccination) and previous health behavior (HIV testing). Independent predictors of vaccine acceptability were also identified.

CONCLUSIONS

The current study highlights key correlates of vaccine acceptability that may inform HPV vaccination campaigns for underserved populations.

HPV and cervical cancer prevention counseling with younger adolescents: implications for primary care

PURPOSE

Primary care clinicians will continue to play an important role in cervical cancer prevention, particularly with regard to administration of the newly licensed human papillomavirus (HPV) vaccine and continued administration of Papanicolaou tests. Little is known about the factors that influence cervical cancer prevention counseling, particularly in the adolescent encounter. We conducted a qualitative study to better understand the implications for counseling about cervical cancer prevention by primary care clinicians who care for adolescents.

METHODS

We conducted in-depth interviews with 37 primary care clinicians in New Mexico to understand the context in which they provide anticipatory guidance about sexual health risks as well as their attitudes about counseling for the forthcoming HPV vaccine.

RESULTS

Clinicians identified 4 categories of factors related to their counseling experiences with adolescents about HPV: (1) the need to build rapport with adolescent patients, (2) the presumption that adolescent patients engage in high-risk behaviors, (3) the situational delivery and complexity of HPV counseling, and (4) perceptions of clinician and community receptivity to the HPV vaccine.

CONCLUSION

Our findings show that conditions of the preadolescent and young adolescent visit pose a challenge to the successful integration of counseling about cervical cancer prevention in primary care. Counseling strategies that are designed to emphasize a preventive focus while including parents in the discussion at the time of vaccination and that are appropriate to populations with different cultural values and beliefs will help to enhance communication about cervical cancer prevention and the particular role of the HPV vaccine.

A cross-sectional survey to assess community attitudes to introduction of Human Papillomavirus vaccine

OBJECTIVE

A vaccine to prevent human papilloma virus (HPV) infection has been licensed recently in the United States of America and Australia. The aim of this study was to assess community attitudes to the introduction of HPV vaccine in the State of South Australia.

METHODS

A cross-sectional survey was conducted by computer-aided telephone interviews in February 2006. The survey assessed adult and parental attitudes to the introduction of HPV vaccine to provide protection against a sexually transmitted disease caused by HPV and against cervical cancer. Two thousand interviews were conducted in metropolitan and rural households.

RESULTS

Two per cent of respondents knew that persistent HPV infection caused cervical cancer and a further 7% were aware that the cause was viral. The majority of adults interviewed (83%) considered that both men and women should receive HPV vaccine and 77% of parents agreed that they would have their child/children immunised. Parents were mainly concerned about possible side effects of the vaccine (66%), with only 0.2% being concerned about discussing a sexually transmitted disease with their children and 5% being concerned that use of the vaccine may lead to promiscuity.

IMPLICATIONS

Our findings suggest that public health education campaigns for HPV vaccination will find a majority of parents receptive to their children being vaccinated, but attention must be paid to appropriate explanation about HPV infection as the cause of cervical cancer and education about the safety of the HPV vaccine.

Correlates of intent to be vaccinated against human papillomavirus: an exploratory study of college-aged women

This study identified correlates of human papillomavirus (HPV) vaccine acceptance among college-aged women. Data were collected by self-administered questionnaire. In multivariate analyses, women having vaginal sex (past 12 months) were nearly four times more likely to indicate acceptance (P = 0.0001). Those reporting ever having a sexually transmissible infection (STI; P = 0.03) and those indicating ever having an abnormal Pap test (P = 0.03) were more likely to indicate acceptance. Thus, three forms of 'exposure' (having sex, having an STI or abnormal Pap) may be linked to vaccine acceptance among young women attending universities. The findings suggest that opportunities may exist for clinic-based HPV vaccine promotion among this population of women.

HPV-vaccination against cervical carcinoma: will it really work?

Prophylactic HPV vaccination provides an opportunity to profoundly affect cervical cancer incidence worldwide. The quadrivalent HPV VLP 6, 11, 16, 18 vaccine (Gardasil) and the bivalent HPV VLP 16, 18 vaccine (Cervarix) are effective for prevention of HPV infection and cervical precancerous lesions. The quadrivalent vaccine is also effective for prevention of vulvar and vaginal lesions and genital warts. With the introduction of the vaccines general issues have to be raised such as optimal age for vaccination, duration of protection after vaccination, impact on cervical cancer screening, vaccination of males and feasibility of application to developing countries. The prospects of a vaccine which will protect against the most common viral sexually transmitted infection and thereby, protect against the complications of HPV infection such as cervical cancer is extremely appealing. The success of HPV vaccination as a major public health prevention opportunity, however, will entirely depend on efficient infrastructures to deliver the vaccines and on the acceptance by individuals, parents and health care providers.

Parental attitudes to pre-pubertal HPV vaccination

OBJECTIVES

To determine the acceptability of childhood HPV vaccination and examine demographic, cultural, and psychosocial predictors of vaccine acceptance.

DESIGN

School-based survey.

PARTICIPANTS

Questionnaires sent to 1205 mothers of 8-14-year-old girls. Responses from 684 were included in the analyses.

SETTING

Ten schools (seven primary, three secondary) in four areas of England.

RESULTS

Seventy-five percent of mothers would accept the vaccine for their daughter. Vaccine acceptance was higher in mothers who had experience of cancer in the family (OR=1.61, CI: 1.14-2.29), had older daughters (OR=1.15, CI: 1.04-1.27), perceived approval from husband/partner (OR=14.51, CI: 6.15-34.25) and believed vaccine acceptance would be more normative (OR=1.78, CI: 1.59-2.01). Having concerns about too many vaccinations (OR=0.22, CI: 0.15-0.31) or vaccine side effects (OR=0.37, CI: 0.28-0.50) and worry about increasing promiscuity (OR=0.47, CI: 0.36-0.62) emerged as deterrents. The modal preferred age was 12 years. Endorsing vaccination at earlier ages was predicted by feeling able to discuss related topics, including sex, at younger ages (OR=1.37, CI: 1.24-1.51) and concern about increasing promiscuity (OR=0.61, CI: 0.47-0.78).

CONCLUSIONS

Overall, there was a favourable response to HPV vaccination. Emphasising the widespread acceptance of the vaccine might promote acceptance further, as would information on immunological and social benefits of earlier vaccination.

Prospects for cervical cancer prevention by human papillomavirus vaccination

Recent clinical trials in young women have shown that subunit vaccines based on human papillomavirus (HPV) 16 and HPV18 L1 virus-like particles are approximately 100% effective in short-term prevention of persistent cervical infection and of cervical dysplasia by these major oncogenic types. These remarkable efficacy results, together with an excellent safety profile in thousands of vaccinated women, have led to the HPV prophylactic vaccine from one manufacturer having now been licensed for commercial use and the expectation that the vaccine from a second manufacturer will be approved in the near future. These vaccines seem to have great potential for reducing cervical cancer deaths and treatments to remove premalignant cervical lesions. However, before their public health effect can be fully estimated, several issues must be addressed. These include duration of protection, degree of cross-protection against nonvaccine types, efficacy in men, and vaccine availability to economically disadvantaged women.

The promise of the human papillomavirus vaccine does not confer immunity against ethical reflection

The recent announcement of an experimental vaccine against human papillomavirus (HPV) has raised great hopes and expectations. Promising trial results, however, should not obscure ethical issues related to a vaccine's ultimate dissemination. Although lay media might view an HPV vaccine as a panacea, a more complicated ethical reality exists, touching upon public knowledge, health care disparities, and parental consent for childhood vaccination.

Chapter 25: Education, training, and communication for HPV vaccines

As human papillomavirus (HPV) vaccines come to market, they will face education and training challenges similar to those of other new vaccines, along with HPV-specific issues. Recent studies document stark knowledge gaps about HPV at all levels--among policy makers, healthcare providers, parents, and teens--in both the industrialized and developing worlds. Pharmaceutical companies, public health advocates, medical trainers, and health educators need to understand their diverse audiences and respond appropriately to the needs of each. They also must use research-based communication strategies and materials to most effectively, and accurately, convey the need for an HPV vaccine and to manage expectations about how the vaccine can, and cannot, protect women and men.

Genital human papillomavirus infection

Over the past few decades, epidemiology and natural history studies have led to improved understanding of human papillomavirus (HPV) infection and to promising prevention strategies. HPV infection is the cause of anogenital warts and cervical cancer, as well as a proportion of other anogenital and head and neck cancers. Data from clinical trials have resulted in recommendations that support the use of an HPV test in the context of cervical cancer screening and management. Prophylactic HPV vaccine trials have demonstrated high efficacy, and an HPV vaccine that prevents cervical cancer precursors, cervical cancer, and anogenital warts caused by HPV types 6, 11, 16, and 18 was licensed for use in girls and women aged 9-26 years by the US Food and Drug Administration (FDA) in June 2006. In this article, we review genital HPV for the clinician, with a primary focus on the prevalence of HPV infection in the United States.

Chapter 27: Research needs following initial licensure of virus-like particle HPV vaccines

Human papillomavirus virus-like particle (HPV VLP) HPV vaccines currently evaluated for licensing are likely to be available soon. Licensure will be based on evidence that the vaccine is well tolerated and provides near complete type-specific protection against HPV infections and their resulting lesions in the first few years after vaccination. Several important questions will remain to be answered after licensure to guide vaccine implementation and to permit the rational evaluation of vaccination in cancer prevention programs. These include the long-term safety and efficacy of vaccination, the optimal ages for vaccination, efficacy against HPV types not included in the vaccine and against existing infections, and efficacy in males. Modulators of vaccine efficacy (e.g., HIV infection) and immune mechanisms of long-term protection also remain to be defined. The real-world effectiveness of vaccination programs will need to be assessed. Issues related to the implementation of a vaccine that targets pre-adolescents and early adolescents and to the acceptability of a cancer vaccine targeted against a sexually transmitted infection will need to be understood before vaccination programs can be successful. It is hoped that continued improvements to the current HPV vaccines will lead to the introduction in future years of second generation vaccines that simplify delivery and/or expand its coverage. Finally, the natural history of HPV types not covered in the candidate vaccines will need to be carefully studied following vaccination. Public health authorities in various countries will play a pivotal role in determining if these questions are answered in a timely manner.

Chapter 20: Issues in planning cervical cancer screening in the era of HPV vaccination

Human Papillomavirus (HPV) vaccines will likely have an impact as a preventive strategy for cervical cancer. Screening for precancerous lesions cannot be discontinued because vaccination will not protect against HPV types not included in the first generation of vaccines. Moreover, protection for the target types, 16 and 18, which are responsible for most cases of cervical precancerous lesions and cancer, and 6 and 11, which are responsible for a substantial proportion of low-grade lesions, cannot be expected to be absolute, and the likely implementation of HPV vaccination in young women will not impact older groups initially. Cervical cancer control programs will need to be re-evaluated because the addition of HPV vaccination will make the existing approach of high-frequency screening by cytology too costly and inefficient for most public health budgets. Simply making cytology screening less frequent may not be a viable strategy in light of potential problems that may plague cytology performance in conditions of low lesion prevalence. HPV testing has the performance characteristics that would make it an ideal primary screening test in such conditions. Cytology should be reserved for triage of HPV-positive cases because it is more likely to perform with sufficient accuracy in high-prevalence conditions. Another advantage of using HPV testing as a primary screening tool is the opportunity to create infection registries that can link test results from the same women over time, thus allowing an efficient and low-cost strategy to monitor long-term protection among vaccinated women.