An alert to Latin America: Current human papillomavirus vaccination trends highlight key barriers to successful implementation

Parental Justifications for Not Vaccinating Children or Adolescents against Human Papillomavirus (HPV)

Vaccination coverage against Human Papillomavirus (HPV) is low compared with uptake of other vaccines in many countries, including Brazil. The aim of this study was to examine the main reasons provided by parents or guardians of a target population that did not have the first dose of HPV vaccine in a small rural Brazilian municipality, and to verify the factors associated with the reasons for non-vaccination. This is a cross-sectional study with interviews based on the Health Belief Model (HBM), conducted with parents and guardians of 177 unvaccinated children or adolescents. The outcome of interest was the main reason for not vaccinating the child/adolescent. The exposure factors of interest were knowledge about HPV and its prevention as well as sociodemographic characteristics. The main justifications for not vaccinating were lack of information (62.2%), fear or refusal (29.9%), and logistical issues (7.9%). The justifications associated with adolescents’ sex, fear, or refusal were mentioned by 39.3% (95% CI: 28.8–50.6%) of parents or guardians of girls and by 21.5% (95% CI: 13.7–31.2%) of parents or guardians of boys. The main barrier to HPV vaccination is lack of information. Further training of health professionals in clarifying the benefits of vaccination and differentiating the risks between boys and girls could encourage uptake.

HPV vaccination in Latin America: Coverage status, implementation challenges and strategies to overcome it

Cervical cancer remains a leading cause of morbidity and mortality amongst females in Latin America (LATAM). Cervical cancer is a preventable disease and HPV vaccination is a main key strategy towards its elimination. This study analyzes HPV vaccine implementation current status and the main barriers to achieve adequate coverage in the region. Data from the nineteen sovereign states of LATAM (comprised of all Portuguese and Spanish-speaking nations located south of the United States) were collected, including year of HPV vaccine implementation, gender and age targets, the number of doses included in the public program and coverage by dose. Sixteen out of the 19 evaluated countries have already implemented HPV vaccination programs. However, despite its proven efficacy and safety, HPV vaccine uptake in LATAM has been lower than expected. There is an evident decline in adhesion, mainly regarding the second dose. Several reasons are probably involved, of note: limited knowledge of HPV and HPV vaccine, misguided safety concerns, high cost, cultural barriers, and the Covid19 pandemic. Proper strategies to overcome these barriers are needed to ensure successful uptake. Effective policies are: adopting the one dose schedule, delivering the vaccine on both health center and schools, and advising health professionals to recommend the vaccine. Further research regarding HPV vaccine hesitancy in Latin America is needed.

Recommendations for the prevention, screening, diagnosis, staging, and management of cervical cancer in areas with limited resources: Report from the International Gynecological Cancer Society consensus meeting

Introduction

Nearly 85% of cervical cancer new cases are diagnosed in limited resources countries. Although several strategies have been proposed to reduce the disease burden, challenges remain to provide the best possible care. We report recommendations from an expert consensus meeting convened to address from prevention to management of cervical cancer in limited resources countries.

Methods

The expert panel, composed by invited specialists from 38 developing countries in Africa, Asia, Eastern Europe, Latin America, and the Middle East, convened in Rio de Janeiro in September 2019, during the Global Meeting of the International Gynecological Cancer Society (IGCS). Panel members considered the published scientific evidence and their practical experience on the topics, as well as the perceived cost-effectiveness of, and access to, the available interventions. The focus of the recommendations was on geographic regions rather than entire countries because medical practice varies considerably in the countries represented. Resource limitation was qualified as limited access to qualified surgeons, contemporary imaging or radiation-oncology techniques, antineoplastic drugs, or overall funding for provision of state-of-the-art care. Consensus was defined as at least 75% of the voting members selecting a particular answer of the multiple-choice questionnaire, whereas the majority vote was considered as 50% to 74.9%.

Results

Consensus was reached for 25 of the 121 (20.7%) questions, whereas for 54 (44.6%) questions there was one option garnering between 50% to 74.9% of votes (majority votes). For the remaining questions, considerable heterogeneity in responses was observed.

Discussion

The implementation of international guidelines is challenging in countries with resource limitations or unique health-care landscapes. The development of guidelines by the health care providers in those regions is more reflective of the reality on the ground and may improve medical practice and patient care. However, challenges remain toward achieving that goal at political, economic, social, and medical levels.

Characteristics of patients diagnosed with cervical cancer in Brazil: preliminary results of the prospective cohort EVITA study (EVA001/LACOG 0215)

OBJECTIVES

Cervical cancer is the fourth most common cancer in women worldwide. Epidemiological and quality of life (QoL) data in patients with cervical cancer from low- and middle-income countries are scarce. We aimed to describe sociodemographic and clinicopathological characteristics and quality of life of patients with cervical cancer at diagnosis in Brazil.

METHODS

EVITA is a prospective cohort study of newly diagnosed patients with cervical cancer from May 2016 to December 2017, stages I-IVB, from 16 Brazilian sites representing the five Brazilian regions. At baseline, medical evaluation was performed and European Organization for Research and Treatment of Cancer (EORTC) QLQ-CX24/C30 questionnaires were administered.

RESULTS

A total of 631 patients were included. Mean±SD age was 49.3±13.9 years; skin color was non-white in 65.3%, and 68.0% had ≤8 years of formal education. In total, 85.1% of patients had a Pap smear. The main reasons reported by patients for not having a Pap smear were: lack of interest (46.9%), shame or embarrassment (19.7%), lack of knowledge (19.7%), and difficulty with access (9.1%). Most patients were diagnosed with locally advanced or metastatic disease (FIGO clinical stage II-IV in 81.8%- stage II in 35.2%, stage III in 36.1%, and stage IV in 10.5%). Patients with clinical stage III-IV had worse physical functioning and role functioning.

CONCLUSIONS

Cervical cancer in Brazil is usually diagnosed at an advanced stage. Most patients have low formal education and are unemployed. Lack of interest was identified as a main reason for not having a screening test, and limited access was reported as a reason by <10% of the patients. Awareness campaigns must be a governmental priority, specially focused on the needy population, along with wide access to treatment.

The shot, the message, and the messenger: COVID-19 vaccine acceptance in Latin America

Herd immunity by mass vaccination offers the potential to substantially limit the continuing spread of COVID-19, but high levels of vaccine hesitancy threaten this goal. In a cross-country analysis of vaccine hesitant respondents across Latin America in January 2021, we experimentally tested how five features of mass vaccination campaigns-the vaccine's producer, efficacy, endorser, distributor, and current population uptake rate-shifted willingness to take a COVID-19 vaccine. We find that citizens preferred Western-produced vaccines, but were highly influenced by factual information about vaccine efficacy. Vaccine hesitant individuals were more responsive to vaccine messengers with medical expertise than political, religious, or media elite endorsements. Citizen trust in foreign governments, domestic leaders, and state institutions moderated the effects of the campaign features on vaccine acceptance. These findings can help inform the design of unfolding mass inoculation campaigns.

Panorama of Gynecologic Cancer in Brazil

PURPOSE

Little is known, or has been published previously, regarding consolidated data on the epidemiology of gynecologic cancers (GC) in Brazil. This article describes the incidence, morbidity, and mortality of women in Brazil affected with GC between the years of 2000 and 2017.

METHODS

Incidence, morbidity, and mortality data from patients with a diagnosis of one out of the five most common GC, cervical (CC), uterine (UC), ovarian (OC), vulvar (VvC), and vaginal (VgC), were obtained from three governmental sources of data.

RESULTS

From 2000 to 2015 CC, OC, and VgC incidence rates (IRs) decreased, whereas the IRs for UC and VvC remained relatively stable. Data from 382,932 women with GC were analyzed. Most patients presented with locally advanced or advanced disease at diagnosis: 60.1% of patients with CC, 31.2% of patients with UC, 67.2% of patients with OC, 45.2% of patients with VvC, and 67.0% of patients with VgC. Time from diagnosis to first treatment was ≥ 60 days in 58.0% of patients with CC, 58.5% of patients with UC, 27.0% of patients with OC, 55.3% of patients with VvC, and 52.7% of patients with VgC. Regarding mortality rates (MRs), with the exception of CC, UC, and VvC, which showed a slight decrease, MRs remained stable between 2000 and 2017.

CONCLUSION

A comparison with international data indicates that Brazilian patients are diagnosed with more advanced disease and face a longer delay between diagnosis and first treatment. Despite advances in screening and treatment, GC mortality has not decreased satisfactorily in this country.

In the Name of Prevention: Maternal Perspectives on School-Based HPV Vaccination in Rural Southern Chile

Purpose

Since the introduction of the HPV vaccine in Chile in 2014, there have been few studies exploring community perspectives on the vaccine, specifically of parents of adolescents. This study sought to identify maternal factors and family dynamics that affect HPV vaccination behavior.

Participants and Methods

Participants were recruited at an OB/GYN clinic in Linares, Chile. Participation was voluntary, and eligibility required 1) having an adolescent daughter between 9 and19 years-old and 2) demonstrating a willingness to discuss HPV-related topics. Thirty semi-structured interviews were conducted to generate qualitative data analyzed using Grounded Theory methodology.

Results

Three thematic constructs emerged from the interviews. Mothers’ motivations to vaccinate centered on disease prevention and trust in the medical system but were influenced by notions of sexual liberalism and promiscuity. Second, participants desired, but often had trouble finding, adequate information about vaccine safety and turned to the internet. Third, joint decision making in the family about vaccination led to open family discussions about sex and sexuality.

Conclusion

Chile’s school-based opt-out HPV vaccination program engenders a unique landscape of maternal decision-making, risk-benefit analysis, information-seeking, and at-home discussion. More studies are needed around the variable role of fathers in the decision-making process.

Human papillomavirus vaccine and risky sexual behavior: Regression discontinuity design evidence from Brazil

This study aims to analyze the hypothesis of moral hazard caused by vaccination against human papillomavirus (HPV), regarding girls' beginning of sex life and, once they have begun their sex life, to understand whether it reduces the probability of girls using a condom in their first sexual intercourse. The data are from the 2015 National Survey of School Health (PeNSE). The model used is the regression discontinuity, with the discontinuity in the age of the girls who were able to participate in the public vaccination campaign. The results of the so-called Fuzzy-RDD show that the campaign was effective in increasing the likelihood of vaccination by 26.7-27.6 percentage points. There is no observable effect on young women initiating their sex lives or refraining from using condoms. The results are tested by several robustness methods. This is the first work to use quasi-experimental models in a developing country with low vaccination coverage in Latin America and show that it is necessary to increase awareness campaigns with parents, so they will know that there is no effect of vaccination on the beginning of sex life and condom use.

Barriers and facilitators to the HPV vaccine among mothers of adolescent girls: a qualitative study conducted in Trinidad and Tobago

Cervical cancer is a major public health problem in Latin America and the Caribbean and the human papillomavirus (HPV) vaccine may prevent thousands of cases of cervical cancer. The current study explored barriers and facilitators that affected the acceptance of the HPV vaccine by mothers of adolescents. This paper explores the qualitative findings from a larger mixed-methods study. Six focus groups were conducted (N = 33) throughout Trinidad and Tobago with mothers of adolescent girls. Three major themes emerged: a) cervical cancer and vaccine knowledge, b) barriers to uptake, and c) rephrasing the vaccine strategy. Data indicated that no widespread strategies to educate the population about the vaccine had occurred. Barriers to uptake of the vaccine were related to a lack of information on the efficacy and safety of HPV vaccines. Parents were unaware that the HPV caused cervical cancer. It is recommended that physicians and other health professionals be used to deliver targeted messages to parents and adolescents to improve uptake of the vaccine.

Human Papillomavirus (HPV) and the quadrivalent HPV Vaccine among Brazilian adolescents and parents: Factors associated with and divergences in knowledge and acceptance

BACKGROUND

Low national immunization coverage (44.64%) requires strengthening the vaccination campaign to improve knowledge about HPV and its vaccine among adolescents and parents/guardians. Our aim is to evaluate factors related to knowledge about HPV, its vaccine, acceptability and divergences among Brazilian adolescents and parents/guardians.

METHODS

A cross-sectional study was performed at a health unit of Sao Paulo University, Brazil, from 2015 to 2016. The convenience sample comprised 1047 individuals, including 74% (n = 776) adolescents and 26% (n = 271) parents/guardians, who answered a survey (knowledge about HPV, its vaccine, barriers and acceptability).

RESULTS

The main source of information for adolescents was school (39%, n = 298); for parents/guardians, it was health professionals (55%, n = 153). Parents/guardians were 2.48 times more likely than adolescents to know that HPV caused changes in the Pap smear test [RR 2.48, 95% CI 2.03-3.01 (p < 0.001)], 1.43 times likely to be aware that HPV was a sexually transmitted infection [RR 1.43, 95% CI 1.22-1.68 (p < 0.001)], and 2.77 times likely to be informed that the HPV vaccine decreased the chance of having genital warts [RR 2.77, 95% CI 2.22-2.47 (p < 0.001)]. Girls knew more about the topic than boys (RR 1.67; 95% CI 1.10-2.60); education increased parents' knowledge [(RR 3.38; 95% CI 1.71-6.69)].

CONCLUSION

Female adolescents and parents/guardians with a higher level of education are factors related to suitable knowledge about HPV and its vaccine among Brazilian respondents. There were differences between parents/guardians and adolescents in HPV awareness, clinical implications, vaccine knowledge and vaccine acceptance.

[Social considerations affecting acceptance of HPV vaccination in Colombia. A systematic review]

OBJECTIVE

To identify social factors influencing the acceptance of human papilloma virus (HPV) vaccination in the Colombian population before and after the unexpected and poorly defined event of unknown etiology which occurred in 2014.

METHODS

A systematic review of the literature was conducted in the following databases: Scopus, Web of Science, Medline via PubMed, Embase, Online Health Library (Biblioteca Virtual en Salud) and Ovid, and also in Google Scholar, academic repositories and in Colombian health institutions, using the terms "recombinant tetravalent vaccine against Human Papilloma Virus types 6, 11, 16, 18", "Colombia", "Papilloma" in order to primarily identify systematic reviews, quantitative and qualitative studies, narrative reviews, focusing on social aspects such as education, access, relationship with healthcare staff and role of the media which may have acted as barriers or facilitators for the acceptance of HPV vaccination in Colombia between 2006-2018. A narrative synthesis of the data was made.

RESULTS

Twenty-four documents were included. The importance attached by parents, adolescents, providers and the media to having greater knowledge about HPV and its association with cervical cancer was identified. The relevance of good communication among healthcare professions and the community to enable adequate sharing of information regarding the risks and benefits of the vaccines was recognized. The inclusion of the vaccine in health insurance plans made access easier. The media must be involved as facilitators in vaccination programs.

CONCLUSIONS

Education regarding HPV, patient-centered healthcare and adequate media coverage influence the acceptance of HPV vaccination in the Colombian population. Close follow-up of any vaccine-related adverse events is required.

Long-term Immunogenicity and Safety of the AS04-adjuvanted Human Papillomavirus-16/18 Vaccine in Four- to Six-year-old Girls: Three-year Follow-up of a Randomized Phase III Trial

BACKGROUND

The burden of human papillomavirus (HPV) diseases is high in Latin America. HPV vaccines licensed from 2006 onwards offer protection against most HPV-related cancers, especially when introduced into national immunization programs. Barriers to optimal vaccine uptake are, however, lowering the impact of adolescent HPV vaccination programs. Immunization of children might overcome these barriers and be a strategy of choice for some countries.

METHODS

This multicenter phase III randomized, controlled, single-blind study (NCT01627561) was conducted in Colombia, Mexico and Panama to assess safety and immunogenicity of 2-dose vaccination with AS04-adjuvanted HPV-16/18 vaccine in girls 4-6 years of age. We report safety outcomes and anti-HPV-16/18 antibody titers measured by enzyme-linked immunosorbent assay in HPV-vaccinated girls that were followed over a 36-month period.

RESULTS

Over 36 months (ie, 30 months after the second vaccine dose), among 74 girls included in the HPV group, 1 serious adverse event unrelated to vaccination has been reported. No withdrawal because of (serious) adverse events has been reported. At month 36, all girls in the per-protocol-cohort were still seropositive for anti-HPV-16 and anti-HPV-18 with geometric mean concentrations of 1680.6 and 536.4 enzyme-linked immunosorbent assay units/mL, respectively.

CONCLUSIONS

The AS04-adjuvanted HPV-16/18 vaccine administered according to a 2-dose schedule to girls 4-6 years of age induced a high and sustained immunologic response with an acceptable safety profile during the 30 months following vaccination.

Exploitation of Neisseria meningitidis Group B OMV Vaccines Against N. gonorrhoeae to Inform the Development and Deployment of Effective Gonorrhea Vaccines

Have potential clues to an effective gonorrhea vaccine been lurking in international disease surveillance data for decades? While no clinically effective vaccines against gonorrhea have been developed we present direct and indirect evidence that a vaccine is not only possible, but may already exist. Experience from Cuba, New Zealand, and Canada suggest that vaccines containing Group B Neisseria meningitides outer membrane vesicles (OMV) developed to control type-specific meningococcal disease may also prevent a significant proportion of gonorrhea. The mechanisms for this phenomenon have not yet been elucidated but we present some strategies for unraveling potential cross protective antigens and effector immune responses by exploiting stored sera from clinical trials and individuals primed with a meningococcal group B OMV vaccine (MeNZB). Elucidating these will contribute to the ongoing development of high efficacy vaccine options for gonorrhea. While the vaccine used in New Zealand, where the strongest empirical evidence has been gathered, is no longer available, the OMV has been included in the multi component recombinant meningococcal vaccine 4CMenB (Bexsero) which is now licensed and used in numerous countries. Several lines of evidence suggest it has the potential to affect gonorrhea prevalence. A vaccine to control gonorrhea does not need to be perfect and modeling supports that even a moderately efficacious vaccine could make a significant impact in disease prevalence. How might we use an off the shelf vaccine to reduce the burden of gonorrhea? What are some of the potential societal barriers in a world where vaccine hesitancy is growing? We summarize the evidence and consider some of the remaining questions.

Aging and the cancer burden in Latin America and the Caribbean: Time to act

OBJECTIVE

To describe the cancer burden in adults aged 65 years and older in Latin America and the Caribbean to serve as rational for improving cancer control planning among region's older population.

MATERIALS AND METHODS

Using the up-to-date GLOBOCAN estimates for 2018, we describe the cancer burden including key patterns for the major cancer sites among adults aged 65 years and older in Latin America and the Caribbean. We also predict the future burden in 2040 by applying population projections, assuming no changes in incidence rates over time.

RESULTS

In 2018, an estimated 679,000 new cancer cases occurred among older adults in LAC, representing almost half (48%) of the total incidence burden (43% in Central America, 49% in South America, and 52% in the Caribbean). Prostate, colorectum, and lung were the most common cancers among older males in South America and the Caribbean, with non-melanoma skin cancer ranking third in Central America. Among older females, the most common sites were breast, colorectum, and non-melanoma skin cancer, except in the Caribbean, where lung cancer ranked third. Overall, the number of new cancer cases among older adults in the region is expected to double by 2040, reaching 1.6 million new cases.

CONCLUSION

Our findings highlight the need for an urgent adaptation of healthcare systems across LAC by improving training in geriatrics for the oncology workforce, and by including older adults in clinical guidelines, insurance schemes, and cancer prevention policies.

Intersectional nativity and racial/ethnic disparities in human papillomavirus vaccination initiation among U.S. women: a national population-based study

BACKGROUND

Overall, foreign-born women are less likely than U.S.-born women to have initiated human papillomavirus (HPV) vaccination. However, foreign-born women are a racially/ethnically diverse population, and race/ethnicity is an independent predictor of HPV vaccination.

METHODS

Using 2011-2015 National Health Interview Survey data, we used multivariable logistic regression to estimate odds ratios for foreign-born black, Latina, and Asian women compared to foreign-born white women and U.S.-born white women, adjusting for sociodemographic factors. We added socioeconomic factors followed by health care access indicators, which we conceptualized as potential mediators, to each model to assess whether they helped explain observed disparities.

RESULTS

Foreign-born Asian ([odds ratio=] 0.43; [95% confidence interval:] 0.29-0.65) and Latina (0.46; 0.32-0.68) women had significantly lower adjusted odds of initiating HPV vaccination compared to foreign-born white women. Foreign-born white (0.64; 0.45-0.90), black (0.44; 0.29, 0.67), Latina (0.29; 0.24-0.35), and Asian (0.28; 0.21-0.38) women had significantly lower adjusted odds of HPV vaccination initiation compared to U.S.-born white women. Socioeconomic factors only explained HPV vaccination initiation disparities between foreign-born Latina women and foreign-born and U.S.-born white women. Health care access indicators modestly explained disparities between foreign-born white, black, and Latina women and U.S.-born white women only.

CONCLUSIONS

We observed pronounced HPV vaccination initiation disparities among foreign-born women in relation to race/ethnicity and between foreign-born women from minoritized racial/ethnic backgrounds and U.S.-born white women. Research on nativity disparities in HPV vaccination should take into account race/ethnicity, and vice versa. Interventions that seek to facilitate HPV vaccination among foreign-born women are needed and should address the unique needs of those from minoritized racial/ethnic backgrounds to promote cancer equity.

HPV Knowledge and Vaccine Initiation Among Mexican-Born Farmworkers in North Carolina

The human papilloma virus (HPV) vaccine is an effective but underused cancer prevention tool. This study assessed knowledge of HPV and HPV vaccine initiation among Mexican-born farmworkers in North Carolina. Interviewer-administered questionnaires were conducted with 100 Latino farmworkers and 100 nonfarmworker Latino North Carolina residents in 2015 as part of an ongoing community-based participatory research project. Farmworkers had low levels of knowledge about HPV and the HPV vaccine. They had a similar amount of HPV and HPV vaccine knowledge compared to nonfarmworkers. Farmworkers and nonfarmworkers learned about the HPV vaccine from different sources. Adolescent children of farmworkers and nonfarmworkers had low HPV vaccine initiation. However, for children living in the United States with farmworker parents, vaccine initiation was high. To prevent HPV-related cancers and improve health equity, interventions are needed in order to increase HPV education and vaccine initiation among children of Mexican-born farmworkers and nonfarmworkers. Public health programs should look for partners outside the traditional health care setting to reach underserved populations. Other key strategies include promoting catch-up vaccines, improving patient-provider communication, and providing case management services.