Human papillomavirus and cervical cancer behavioral surveillance in the US

Knowledge and Perceptions of Greek Students about Human Papilloma Virus, Vaccination and Cervical Cancer Screening

INTRODUCTION

Human papillomavirus (HPV) is the main cause of cervical cancer; the level of HPV-related knowledge among young students remains however questionable. The purpose of the present study was to investigate knowledge pertaining to HPV, cervical cancer screening, and vaccination among students in the Nursing Department and Department of Social Work of the Hellenic Mediterranean University of Crete, Greece.

METHODS

This was a questionnaire-based, cross-sectional study involving 371 first-year and third-year students of the two Departments. Multivariate linear and logistic regression analysis was performed to examine factors associated with knowledge related to HPV, cervical cancer screening, and HPV vaccination.

RESULTS

Only 22.1% of students knew all the ways of HPV transmission and only 5.9% knew the whole spectrum of cancers that HPV could cause. The vaccination rate for HPV was 33.7%. The majority of students used the Internet as the main source of information (62.3%). Students' sociodemographic characteristics, including age, marital status, and Department of studies were associated with knowledge about HPV.

CONCLUSIONS

The present study highlights knowledge gaps and indicates the need for thorough health education strategies on HPV, targeting families and young people.

Exacerbating disparities?: Cervical cancer screening and HPV vaccination

The human papillomavirus (HPV) vaccine is a powerful tool in cancer prevention. In combination with cervical cancer screening programs, this vaccine has the potential to nearly eliminate death from cervical cancer. However, this remarkable public health success can only be realized if vaccines reach those most at risk-unscreened women. Vaccinating only those already well-screened would have little impact on cervical cancer mortality, exacerbate disparities, and be a striking public health failure. We use data from the Behavioral Risk Factor Surveillance System optional Adult HPV Vaccination module between 2013 and 2016 to assess the association between HPV vaccine status and cervical cancer screening behavior. Only 27% of eligible women had received any HPV vaccination. Uninsured women were less likely to be vaccinated (aOR: 0.48, 95% CI:0.30-0.76) and less likely to be screened (aOR: 0.41, 95% CI:0.28-0.60) than insured women. Vaccinated women were more than twice as likely to be up to date on screening than unvaccinated women (aOR: 2.14, 95% CI:1.46-3.12). Younger women were 49% less likely to be up to date on screening (aOR: 0.51, 95% CI:0.37-0.71), but over 4 times more likely to be vaccinated (aOR: 4.44, 95% CI:3.20-6.17) than older women. Unvaccinated, unscreened women are at continued risk for cervical cancer. Uninsured women were most likely to be in this group. Concerted efforts should be focused on increasing vaccination and screening in this population. Cancer prevention innovations, like the HPV vaccine, must reach at-risk populations to avoid further protecting the protected and failing to reduce existing health disparities.

Healthcare providers' beliefs and attitudes regarding risk compensation following HPV vaccination

Background

Provider recommendation is a significant predictor of HPV vaccine uptake. Prior research suggests that concerns regarding risk compensation could cause some providers to hesitate recommending the HPV vaccine.

Methods

During 15–30 min semi-structured interviews in early 2015, 22 U.S. pediatric providers were asked about their beliefs regarding sexual risk compensation and cervical cancer screening following HPV vaccination. Providers were asked if these beliefs result in reservations recommending the vaccine. Interviews were audio-recorded, transcribed, and analyzed using inductive content analysis.

Results

None of the providers believed the HPV vaccine would result in risky sexual behavior. Half indicated it was better to start vaccination early, before sexual activity was a worry. Others noted that patients’ risky behavior decisions happen independently of vaccination. When providers were asked if they were concerned about decreased cervical cancer screening, half said they did not know and some stated they had never thought about it before. The main themes addressed were the significant time lapse between vaccination and screening and that women tend to get over-screened as opposed to under-screened.

Conclusion

Providers were generally in favor of HPV vaccination and do not perceive risk compensation as a barrier to HPV recommendation.

Knowledge of Greek adolescents on human papilloma virus (HPV) and vaccination: A national epidemiologic study

The aim of the present study was to identify the sexual behavior, attitudes, beliefs, and knowledge on sexually transmitted infections (STIs) focused on human papilloma virus (HPV) in the Greek adolescent population. The participants were 4547 adolescents, a representative sample for Greek territory with a mean age of 17 years. After written permission from Greek ministry of education each student completed a questionnaire with 36 questions. The fields covered were demographic characteristics, sexual life data, and basic knowledge on HPV. In the present study, 43% and 75% of the participants knew about HPV or cervical cancer, while more than 6 out of 10 did not know the association between the 2. More than 60% of the participants could not answer correctly neither about HPV infection and cervical cancer frequency in sexually active women, nor about protection methods against HPV and cervical cancer. This study shows that the low vaccination coverage of the Greek population may be due to lack of information and awareness of the adolescents and their parents. It is our duty to increase our efforts in order to better educate the population and vaccinate the population as early as possible in their reproductive years.

Differences in cervical cancer screening knowledge, practices, and beliefs: An examination of survey responses

Among the identified barriers to HPV vaccination is the concern that women may compensate for their reduced susceptibility to cervical cancers by reducing cervical cancer screening. This exploratory study examined the relationship between cervical cancer screening rates and HPV vaccination. We conducted a cross-sectional survey using a convenience sample of women aged 21–35 attending a local minority health fair in July 2015. Data were analyzed in 2015–2016. Outcomes assessed were: receiving a Pap test within the last three years, awareness and comfort with current Pap test recommendations, and knowledge regarding the purpose of a Pap test. A total of 291 women were included in the analyses. Mean age was 28.5 years and 62% were non-Hispanic black. 84% had received a Pap test in the last three years and 33% had received at least one HPV vaccine. Logistic regression results showed that women who had been vaccinated did not have lower odds of having a Pap test in the past three years (OR = 1.32; 95% CI = 0.66–2.65). In an adjusted regression model controlling for age and race, vaccinated women were significantly more likely to have had a Pap test (AOR = 3.06; 95% CI = 1.37–6.83). Yet only 26% of women knew the purpose of a Pap test and the proportion who answered correctly was higher among non-Hispanic white women. Women who have been vaccinated for HPV are more likely to have been screened for cervical cancer. These results suggest areas for more robust studies examining pro-health attitudes, behaviors, and communication regarding vaccination and preventive screening.

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A comparison of cervical cancer screening practices among mostly minority women

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HPV vaccinated participants didn't have lower rates of cervical cancer screening.

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Knowledge about the purpose of a Pap test was low especially among minority women.

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Current recommendations and screening purpose are areas for future interventions.

Trends in cervical cancer incidence in younger US women from 2000 to 2013

OBJECTIVE

This study aimed to assess the temporal trends in invasive cervical cancer (ICC) incidence rates among 21-25year-olds. US guidelines no longer recommend screening prior to age 21, and concerns have been raised that delayed screening initiation may increase ICC incidence among young women.

METHODS

This study utilized ICC incidence data from 18 US population-based cancer registries in SEER from 2000 to 2013 and Pap test prevalence data from the Behavioral Risk Factor Surveillance System from 1996 to 2012. Trends were evaluated with annual percent changes (APCs) using Joinpoint regression.

RESULTS

The prevalence of never having a Pap test before age 21 increased from 22.0% in 1996-2004 to 38.3% in 2006-2012 (APC=+5.48, 95%CI=+4.20, +7.50). Despite this decline in screening, ICC incidence among 21-23year olds significantly declined between 2000 and 13 (APC=-5.36, 95%CI=-7.83,-2.82), particularly from 2006 to 2013 (APC=-9.70, 95%CI=-15.79, -3.17). ICC incidence remained constant among 24-25year olds (APC=+0.45, 95%CI=-2.00, 2.97). Compared to women born in 1978-1985, women born in 1986-1991 had a higher prevalence of never receiving a Pap test prior to 21 (35.4% vs. 22.1%, p<0.001), but a lower ICC incidence at 21-23 (0.98 vs. 1.55 per 100,000, p<0.001).

CONCLUSION

While US females born in 1986-1991 were less likely to receive a Pap test before age 21, diagnoses of ICC in the early 20s were rare and lower than for those born in earlier years. This provides reassurance that the updated guidelines to delay screening until 21 has not resulted in a population-level increase in ICC rates among young women.

Screening for Cervical Cancer and Sexually Transmitted Diseases Among HIV-Infected Women

BACKGROUND

Women living with HIV infection are at higher risk for cervical cancer, an AIDS-defining diagnosis. We examined the prevalence of cervical cancer and sexually transmitted disease (STD) screening among human immunodeficiency virus (HIV)-infected women and factors associated with the receipt of Papanicolaou (Pap) tests.

METHODS

We did a cross-sectional analysis of weighted data from a sample of HIV-infected adults receiving outpatient medical care. We used matched interview (report of Pap test) and medical record data (STD screenings) from HIV-infected women. We performed logistic regression to compute adjusted prevalence ratios and 95% confidence intervals for the association between demographic, behavioral, and clinical factors and receipt of Pap tests among HIV-infected women.

RESULTS

Data were available for 2,270 women, who represent 112,894 HIV-infected women; 62% were African American, 17% were Hispanic/Latina, and 18% were white. Most (78%) reported having a Pap test in the past year. Among sexually active women (n = 1234), 20% reported sex without condoms, 27% were screened for gonorrhea, and 29% were screened for chlamydia. Being screened for STDs was less likely among women who did not have a Pap test in the past year (adjusted prevalence ratios 0.82, 95% confidence interval 0.77-0.87). Women who were ≥50 years of age and reported income above federal poverty level, no sexual activity, depression, no HIV care from an obstetrician/gynecologist, and no documented STD tests, were less likely to report a Pap test (p < 0.05).

CONCLUSIONS

Screening for cervical cancer and STDs among HIV-infected women is suboptimal. Clinical visits for Pap tests are an important opportunity for HIV-infected sexually active women to also receive STD screenings and counseling regarding condoms.

Promoting HPV Vaccination in Safety-Net Clinics: A Randomized Trial

OBJECTIVES

Evaluate effects of a multicomponent intervention (human papillomavirus [HPV] vaccine-specific brochure and recalls) on HPV vaccination and secondarily examine if race/ethnicity moderates effects.

METHODS

Unvaccinated girls aged 11 to 18 years attending 4 safety-net pediatric clinics and their parent/guardian (n = 814 dyads) were randomized to (1) active comparison (general adolescent vaccine brochure), or (2) intervention consisting of a HPV vaccine-specific brochure, telephone recalls to parents who declined, and recalls to patients overdue for doses 2 and 3. HPV 1-dose and 3-dose coverages were assessed via electronic health records 12 months after randomization. Multivariate logistic regressions estimated adjusted odds and marginal predicted vaccine coverage by study arm and race/ethnicity.

RESULTS

Intent-to-treat analyses found no main effect of the HPV vaccine-specific brochure on 1-dose coverage (42.0% vs 40.6%); however, secondary analyses found race/ethnicity was a significant moderator such that the intervention was effective only for Hispanic individuals (adjusted odds ratio [AOR] 1.43; 95% confidence interval [CI] 1.02-2.02), and not effective for black individuals (AOR 0.64; 95% CI 0.41-1.13). Recalls to parents who declined the vaccine during the index visit were not effective, but recalls to patients overdue for doses 2 and 3 were effective at increasing 3-dose coverage regardless of race/ethnicity (AOR 1.99; 95% CI 1.16-3.45).

CONCLUSIONS

Educational materials describing only the HPV vaccine were effective for Hispanic but not black individuals. Future research should test mechanisms that may mediate intervention effects for different racial/ethnic groups, such as different informational needs or vaccine schemas (experiences, beliefs, norms).

Perception of human papillomavirus infection, cervical cancer and HPV vaccination in North Indian population

BACKGROUND

Human Papillomavirus (HPV) -associated cervical cancer is the second-most common cancer in women worldwide but it is the most frequent gynaecological cancer and cancer associated death in India women. The objective of this study was to assess knowledge about cervical cancer, HPV, HPV vaccine, HPV vaccine acceptance among school and undergraduates students and their parent's perception about acceptance of HPV vaccine in Northern part of India (Delhi and NCR regions).

MATERIALS AND METHODS

A qualitative questionnaire based survey among 2500 urban/rural students aged 12-22 years was conducted.

RESULTS

Overall, a low frequency (15%) of HPV and cervical cancer awareness was observed in students and their parents. However, the awareness was much higher in females belonging to urban setup compared to boys with a perception that HPV causes cervical cancer in women only. Additionally, only (13%) participants who were aware of cervical cancer and HPV) were willing to accept HPV vaccination. Apparently, parents of female students were two times more willing to accept HPV vaccination for their ward than male students (p<0.001; OR 95%CI = 2.09 (1.58-2.76).

CONCLUSION

Cervical cancer and HPV awareness among school, undergraduate students and also to their parents was found to be very low in this part of India. The level of awareness and education appears to be insignificant determinants in rural compared to urban setup. Better health education will be needed to maximize public awareness for cervical cancer prevention.

Cervical cytology screening among low-income, minority adolescents in New York City following the 2009 ACOG guidelines

OBJECTIVES

In December 2009, the American College of Obstetricians and Gynecologists recommended that cervical cancer screening begin at age 21 for young women. In this study, we examine receipt of first lifetime Papanicolaou (Pap) test and predictors of over-screening among adolescents within a large urban ambulatory care network.

METHODS

We compared the proportion of first lifetime Pap test of adolescents aged 13-20years between June 2007 - November 2009 (n=7700) and December 2009-June 2012 (n=9637) using electronic health records. We employed multivariable regression models to identify demographic and health care factors associated with receiving a first lifetime Pap test at age <21years in the post-guideline period (over-screening).

RESULTS

The proportion of Pap tests declined from 19.3% to 4.2% (p<0.001) between the two periods. Multivariable logistic regression results showed receiving care from gynecologic/obstetric/family planning clinics compared to pediatric clinics, having more clinic encounters, and older age were associated with over-screening in the post-guideline period.

CONCLUSIONS

We found that guideline adherence differed by clinic type, insurance status, and health care encounters. In the quickly evolving field of cervical cancer control, it is important to monitor practice trends as they relate to shifts in population-based guidelines, especially in high-risk populations.

Effects of socioeconomic status and health care access on low levels of human papillomavirus vaccination among Spanish-speaking Hispanics in California

Little is known about the effect of language preference, socioeconomic status, and health care access on human papillomavirus (HPV) vaccination. We examined these factors in Hispanic parents of daughters aged 11 to 17 years in California (n = 1090). Spanish-speaking parents were less likely to have their daughters vaccinated than were English speakers (odds ratio [OR] = 0.55; 95% confidence interval [CI] = 0.31, 0.98). Adding income and access to multivariate analyses made language nonsignificant (OR = 0.68; 95% CI = 0.35, 1.29). This confirms that health care use is associated with language via income and access. Low-income Hispanics, who lack access, need information about free HPV vaccination programs.

Cognitive testing of human papillomavirus vaccine survey items for parents of adolescent girls

OBJECTIVE

Many studies have been conducted to understand what factors are associated with human papillomavirus (HPV) vaccine acceptability and completion of the 3-dose vaccination series, but few have examined whether people understand the survey items used to assess these relationships. Through a multisite collaborative effort, we developed and cognitively tested survey items that represent constructs known to affect vaccine acceptability and completion.

MATERIALS AND METHODS

Investigators from 7 research centers in the United States used cognitive interviewing techniques and in-person and telephone interviews to test 21 items. Four rounds of testing, revising, and retesting were conducted among racially and ethnically diverse parents (n = 62) of girls between the ages of 9 and 17 years.

RESULTS

The final survey contained 20 items on attitudes and beliefs relevant to HPV vaccine. Some parents misinterpreted statements about hypothetical vaccine harms as statements of fact. Others were unwilling to answer items about perceived disease likelihood and perceived vaccine effectiveness, because they said the items seemed to have a "right" answer that they did not know. On the basis of these and other findings from cognitive testing, we revised the wording of 14 questions to improve clarity and comprehension. We also revised instructions, response options, and item order.

CONCLUSIONS

Cognitive testing of HPV vaccine survey items revealed important differences between intended and ascribed item meaning by participants. Use of the tested survey questions presented here may increase measurement validity and researchers' ability to compare findings across studies and populations. Additional testing using quantitative methods can help to further validate these items.

Human papillomavirus vaccine use among adolescent girls and young adult women: an analysis of the 2007 California Health Interview Survey

BACKGROUND

Administration of the human papillomavirus (HPV) vaccine is recommended for adolescent girls and young adult women. Little is known about the factors associated with vaccination. This study examined prevalence and correlates of HPV vaccine initiation (≥1 dose) among a statewide representative sample of adolescent and young adult females living in California.

METHODS

HPV vaccination data on 3615 parents of adolescent girls aged 12-17 and 2068 young adult women aged 18-27 from the 2007 California Health Interview Survey (CHIS) were examined by sociodemographic, healthcare access, and health behavior factors using chi-square and multivariable logistic regression models.

RESULTS

Nineteen percent of adolescent girls and 11% of young adult women had initiated the HPV vaccine series. In both groups, lower educational attainment (parental/own) was associated with lack of vaccine initiation. For adolescents, vaccine initiation was also significantly lower among those whose parents had low incomes or no usual source of care. For young adults, initiation was lower among the older group and those who spent less time in the United States, had public insurance, had no recent provider visit, or had fewer sexual partners.

CONCLUSIONS

In a statewide representative sample, different correlates of early initiation of HPV vaccination emerged for Californian adolescent girls and young adult women. These different patterns may be due to differential access to programs that provide free or low-cost HPV vaccines. Because several of these factors are associated with disparities in use of Pap tests, disparities will persist or even worsen unless greater effort is placed on vaccinating populations at highest risk for cervical cancer.

Human papillomavirus vaccine uptake among 9- to 17-year-old girls: National Health Interview Survey, 2008

BACKGROUND

Since 2006, the human papillomavirus (HPV) vaccine has been routinely recommended for preadolescent and adolescent girls in the United States. Depending on uptake patterns, HPV vaccine could reduce existing disparities in cervical cancer.

METHODS

HPV vaccination status and reasons for not vaccinating were assessed using data from the 2008 National Health Interview Survey. Households with a girl aged 9-17 years were included (N = 2205). Sociodemographic factors and health behaviors associated with vaccine uptake were assessed using multivariate logistic regression.

RESULTS

Overall, 2.8% of 9- to 10-year-olds, 14.7% of 11- to 12-year-olds, and 25.4% of 13- to 17-year-olds received at least 1 dose of HPV vaccine; 5.5% of 11- to 12-year-olds and 10.7% of 13- to 17-year-olds received all 3 doses. Factors associated with higher uptake in multivariate analysis included less than high school parental education, well-child check and influenza shot in the past year, and parental familiarity with HPV vaccine. Parents' primary reasons for not vaccinating were beliefs that their daughters did not need vaccination, that their daughters were not sexually active, or had insufficient vaccine knowledge. More parents with private insurance (58.0%) than public (39.8%) or no insurance (39.5%) would pay $360-$500 to vaccinate their daughters.

CONCLUSIONS

Less than one quarter of girls aged 9-17 years had initiated HPV vaccination by the end of 2008. Efforts to increase HPV uptake should focus on girls in the target age group, encourage providers to educate parents, and promote access to reduced-cost vaccines.

Multilevel correlates for human papillomavirus vaccination of adolescent girls attending safety net clinics

BACKGROUND

Adolescent HPV vaccination in minority and low income populations with high cervical cancer incidence and mortality could reduce disparities. Safety-net primary care clinics are a key delivery site for improving vaccination rates in these populations.

PURPOSE

To examine prevalence of HPV initiation (≥ 1 dose), completion (receipt of dose 3 within 12 months of initiation), and receipt of 3 doses in four safety-net clinics as well as individual-, household-, and clinic-level correlates of initiation.

METHODS

We used multilevel modeling to investigate HPV initiation among 700 adolescent females who sought primary care in four safety-net clinics in Dallas, Texas from March 2007 to December 2009. Data were abstracted from patients' paper and electronic medical records.

RESULTS

HPV vaccine uptake varied significantly by clinic. Across clinics, initiation was 36.6% and completion was 39.7% among those who initiated. In the total study population, only 15.7% received all three doses. In multivariate, two-level logistic regression analyses, initiation was associated with receipt of other adolescent vaccines, influenza vaccination in the year prior to data abstraction, being sexually active, and having more chart documentation (presence of health maintenance questionnaire and/or immunization record). There was no association between initiation and age, race/ethnicity, or insurance status.

CONCLUSIONS

In four urban safety-net clinics, HPV initiation rates paralleled 2008 national rates. The correlation of HPV initiation with other adolescent vaccines underscores the importance of reviewing vaccination status at every health care visit. HPV vaccine uptake in safety-net clinics should continue to be monitored to understand impact on cervical cancer disparities.

Minimally abnormal Pap testing and cervical histology in HIV-infected women

OBJECTIVE

To assess the underlying histology of HIV-infected women with minimally abnormal Pap tests compared to HIV-uninfected women by evaluating their colposcopic and histologic outcomes.

METHODS

Retrospective analysis was performed to identify HIV-infected women who had at least one cervical Pap test from 2002 through 2008 at Boston Medical Center. We identified women who underwent colposcopy within 6 months of a minimally abnormal Pap test (atypical squamous cells of undetermined significance with positive high-risk human papillomavirus testing [ASCUS/HPV+] or low-grade squamous intraepithelial lesion (LSIL)). Our outcome was the proportion of HIV-infected women with histologic cervical intraepithelial neoplasia 2 or worse (CIN2+). We then compared these outcomes to those of a cohort of HIV-uninfected women from the same institution.

RESULTS

There were 655 HIV-infected women who had Pap testing in the study time frame, and 146 (22%) had a minimally abnormal Pap test (ASCUS/HPV+ or LSIL). Of the 90 HIV-infected women who had subsequent colposcopy within 6 months, colposcopy was negative for 20 (22%), CIN1 for 41 (46%), and CIN2+ for the remaining 29 (32%). During the same time period, there were 747 HIV-uninfected women who underwent colposcopy within 6 months of a minimally abnormal Pap test. Colposcopy was negative for 336 (45%), CIN1 for 254 (34%), and CIN2+ for 157 (21%). After adjusting for differences in age and race, the HIV-infected women were more likely to have CIN2+ after a minimally abnormal Pap test (p=0.002) (adjusted odds ratio [OR] 2.17, 95% confidence interval [CI] 1.33-3.62). There were no diagnosed cases of cervical cancer.

CONCLUSIONS

HIV-infected women have higher rates of underlying CIN2+ for minimally abnormal Pap tests compared with HIV-uninfected women.

Validity of parent-reported vaccination status for adolescents aged 13-17 years: National Immunization Survey-Teen, 2008

OBJECTIVE

The validity of parent-reported adolescent vaccination histories has not been assessed. This study evaluated the validity of parent-reported adolescent vaccination histories by a combination of immunization card and recall, and by recall only, compared with medical provider records.

METHODS

We analyzed data from the 2008 National Immunization Survey-Teen. Parents of adolescents aged 13-17 years reported their child's vaccination history either by immunization card and recall (n = 3,661) or by recall only (n = 12,822) for the hepatitis B (Hep B), measles-mumps-rubella (MMR), varicella (VAR), tetanus-diphtheria/tetanus-diphtheria-acellular pertussis (Td/ Tdap), meningococcal conjugate (MCV4), and quadrivalent human papillomavirus (HPV4) (for girls only) vaccines. We validated parental report with medical records.

RESULTS

Among the immunization card/recall group, vaccines with > 20% false-positive reports included MMR (32.3%) and Td/Tdap (36.9%); vaccines with > 20% false-negative reports included VAR (35.2%), MCV4 (36.0%), and Tdap (41.9%). Net bias ranged from -25.0 to -0.1 percentage points. Kappa values ranged from 0.22 to 0.92. Among the recall-only group, vaccines with > 20% false-positive reports included Hep B (33.9%), MMR (61.4%), VAR (26.2%), and Td/Tdap (60.6%); vaccines with > 20% false-negative reports included Hep B (58.9%), MMR (33.7%), VAR (51.6%), Td/Tdap (25.5%), Tdap (50.3%) MCV4 (63.0%), and HPV4 (20.5%). Net bias ranged from -46.0 to 0.5 percentage points. Kappa values ranged from 0.03 to 0.76.

CONCLUSIONS

Validity of parent-reported vaccination histories varies by type of report and vaccine. For recently recommended vaccines, false-negative rates were substantial and higher than false-positive rates, resulting in net underreporting of vaccination rates by both the immunization card/recall and recall-only groups. Provider validation of parent-reported vaccinations is needed for valid surveillance of adolescent vaccination coverage.

Knowledge and intention to participate in cervical cancer screening after the human papillomavirus vaccine

BACKGROUND

If women who receive the human papillomavirus (HPV) vaccine are unduly reassured about the cancer prevention benefits of vaccination, they may choose not to participate in screening, thereby increasing their risk for cervical cancer. This study assesses adult women's knowledge of the need to continue cervical cancer screening after HPV vaccination, describes Pap test intentions of vaccinated young adult women, and evaluates whether knowledge and intentions differ across groups at greatest risk for cervical cancer.

METHODS

Data were from the 2008 Health Information National Trends Survey (HINTS) and the 2008 National Health Interview Survey (NHIS), which initiated data collection approximately 18 months after the first FDA approval of an HPV vaccine. We calculated associations between independent variables and the outcomes using chi-square tests.

RESULTS

Of 1586 female HINTS respondents ages 18 through 74, 95.6% knew that HPV-vaccinated women should continue to receive Pap tests. This knowledge did not vary significantly by race/ethnicity, education, income, or healthcare access. Among 1101 female NHIS respondents ages 18-26 who had ever received a Pap test, the proportion (12.7%; n=139) who reported receipt of the HPV vaccine were more likely than those not vaccinated to plan to receive a Pap test within three years (98.1% vs. 92.5%, p<0.001).

CONCLUSIONS

US adult women possess high knowledge and intention to participate in Pap testing after HPV vaccination. The vast majority of young adult women who received the HPV vaccine within its first two years on the market intend to participate in cervical cancer screening in the near future. Future studies are needed to examine whether those vaccinated in adolescence will become aware of, and adhere to, screening guidelines as they become eligible.

The roles of social domains, behavioral risk, health care resources, and chlamydia in spatial clusters of US cervical cancer mortality: not all the clusters are the same

BACKGROUND

While high-risk geographic clusters of cervical cancer mortality have previously been assessed, factors associated with this geographic patterning have not been well studied. Once these factors are identified, etiologic hypotheses and targeted population-based interventions may be developed and lead to a reduction in geographic disparities in cervical cancer mortality.

METHODS

The authors linked multiple data sets at the county level to assess the effects of social domains, behavioral risk factors, local physician and hospital availability, and Chlamydia trachomatis infection on overall spatial clustering and on individual clusters of cervical cancer mortality rates in 2000-2004 among 3,105 US counties in the 48 states and the District of Columbia.

RESULTS

During the study period, a total of 19,898 cervical cancer deaths occurred in women aged 20 and older. The distributions of county-level characteristics indicated wide ranges in social domains measured by demographics and socioeconomic status, local health care resources, and the rate of chlamydial infection. We found that overall geographic clustering of increased cervical cancer mortality was related to the high proportion of black population, low socioeconomic status, low Papanicolaou test rate, low health care coverage, and the high chlamydia rate; however, unique characteristics existed for each individual cluster, and the Appalachian cluster was not related to a high proportion of black population or to chlamydia rates.

DISCUSSION

This study indicates that local social domains, behavioral risk, and health care sources are associated with geographic disparities in cervical cancer mortality rates. The association between the chlamydia rate and the cervical cancer mortality rate may be confounded by other factors known to be a risk for cervical cancer mortality, such as the infection with human papillomavirus. The findings will help cancer researchers examine etiologic hypotheses and develop tailored, cluster-specific interventions to reduce cervical cancer disparities.

Human papillomavirus (HPV) awareness and vaccination initiation among women in the United States, National Immunization Survey-Adult 2007

OBJECTIVES

To report awareness of human papillomavirus (HPV) and HPV vaccine among women aged 18-49 years and, for recommended women aged 18-26 years, estimate initiation of HPV vaccination and describe factors associated with vaccination initiation among a national sample.

METHODS

Data were analyzed from the National Immunization Survey-Adult, a nationally representative telephone survey conducted May-August 2007. Questions were asked about awareness of HPV and HPV vaccine and vaccine receipt.

RESULTS

A total of 1102 women aged 18-49 years were interviewed, 168 were aged 18-26 years. Overall, awareness of HPV (84.3%) and of HPV vaccine (78.9%) were high. Among women 18-26 years of age, vaccination initiation (> or =1 dose) was 10%. Factors associated with vaccination included not being married, living > or =200% of the federal poverty index, having health insurance, and vaccination with hepatitis B vaccine. HPV vaccination initiation among women aged 27-49 years was 1%.

CONCLUSIONS

Awareness of HPV and HPV vaccine were high. Two to 5 months after national HPV vaccination recommendations were published, one in ten women 18-26 years old had initiated the HPV vaccine series. Women at a higher socio-economic level were more likely to receive the vaccination. Vaccination initiation and completion will likely increase over the next years. Monitoring uptake is important to identify sub-groups that may not be receiving the vaccination.

Cancer registries and monitoring the impact of prophylactic human papillomavirus vaccines: the potential role

The recent US Food and Drug Administration licensure of a prophylactic vaccine against oncogenic human papillomavirus (HPV) types 16 and 18, the first of its kind, poses unique challenges in postmarketing vaccine surveillance, especially in measuring vaccine effectiveness against biologic endpoints of HPV infection. Historically, the national system of population-based cancer registries in the US has provided high-quality data on cancer incidence and mortality for the most important biologic endpoints, namely, anogenital cancers and some oral cavity/oropharyngeal cancers. There also has been some data collection on cancer precursors; however, this activity has been inconsistent and of lower priority. Because effectiveness against HPV-associated cancers will not be measurable for several decades, strengthening and possibly expanding the capacity of registries to collect precancer data, which are earlier manifestations of infection, must be considered. Collecting type-specific data on HPV-associated precancers and cancers. While keeping in mind the current limitations of registry operations, they discuss resources that may be needed to implement and sustain these types of activities.