Human Papillomavirus Vaccine Uptake: Increase for American Indian Adolescents, 2013-2015

A systematic literature review of human papillomavirus vaccination strategies in delivery systems within national and regional immunization programs

The uptake of human papillomavirus (HPV) vaccine remains suboptimal despite being a part of routine vaccination within national immunization program(s). This indicates probable challenges with the implementation of HPV immunization program(s) in various countries. The objective of this systematic literature review (SLR) was to identify implementation strategies for HPV vaccination within national and regional immunization programs worldwide with an aim to provide guidance for countries targeting to increase their HPV vaccine coverage rate (VCR). A comprehensive literature search was conducted across Medline and Embase and included articles published between January 2012 and January 2022. Of the 2,549 articles retrieved, 168 met inclusion criteria and were included in the review. Strategies shown to improve HPV vaccination uptake in the reviewed literature include campaigns to increase community awareness and knowledge of HPV, health care provider trainings, integrating HPV vaccination within school settings, coordinated efforts via multi-sectoral partnerships, and vaccination reminder and recall systems. Findings may help national authorities understand key considerations for HPV vaccination when designing and implementing programs aiming to increase HPV VCR in adolescents.

Addressing the burden of cervical cancer for Indigenous women in Latin America and the Caribbean: a call for action

Cervical cancer, primarily caused by human papillomavirus (HPV) infection, poses a significant global health challenge. Due to higher levels of poverty and health inequities, Indigenous women worldwide are more vulnerable to cervical cancer than their non-Indigenous counterparts. However, despite constituting nearly 10% of the population in Latin America and the Caribbean (LAC), the true extent of the burden of cervical cancer among Indigenous people in this region remains largely unknown. This article reviews the available information on cervical cancer incidence and mortality, as well as HPV infection prevalence, among Indigenous women in LAC. The limited existing data suggest that Indigenous women in this region face a heightened risk of cervical cancer incidence and mortality compared to non-Indigenous women. Nevertheless, a substantial knowledge gap persists that must be addressed to comprehensively assess the burden of cervical cancer among Indigenous populations, especially through enhancing cancer surveillance across LAC countries. Numerous structural, social and cultural barriers hindering Indigenous women's access to HPV vaccination and cervical cancer screening worldwide have been identified and are reviewed in this article. The discussion highlights the critical role of culturally sensitive education, community engagement, and empowerment strategies in overcoming those barriers. Drawing insights from the success of targeted strategies in certain high-income countries, the present article advocates for research, policies and healthcare interventions tailored to the unique context of LAC countries.

Cervical Cancer: Preventable Deaths Among American Indian/Alaska Native Communities

American Indian/Alaska Native (AI/AN) individuals have twice the mortality rate of cervical cancer than the general US population. Participation in prevention programs such as cervical cancer screening and human papillomavirus (HPV) vaccination are under-utilized in this population. There are high rates of established cervical cancer risk factors among this community, with AI/AN people having a higher likelihood of infection with high-risk HPV strains not included in the 9-valent vaccine. There is a need for more robust and urgent prevention and treatment efforts in regard to cervical cancer in the AI/AN community.

Persistent cervical cancer disparities among American Indian/Alaska Native women: a systematic scoping review exploring the state of the science in this population

PURPOSE

American Indian/Alaska Native (AI/AN) populations experience significantly higher incidence and mortality rates of cervical cancer. The objective of this systematic scoping review is to characterize the volume and nature of research being conducted specific to the AI/AN population regarding cervical cancer and related clinical themes.

METHODS

This scoping review was conducted in collaboration with the Pacific Northwest Evidence-based Practice Center. Search strategies identified eligible publications from 1990 through 4 February 2022. Two reviewers independently abstracted study data, including clinical area, number of participants and percent inclusion of AI/AN, intervention or risk factor, outcomes reported, Indian Health Service (IHS) Region, and funding source. We used published algorithms to assess study design.

RESULTS

Database searches identified 300 unique citations. After full-text evaluation of 129 articles, 78 studies and 9 secondary publications were included (total of 87). Approximately 74% of studies were observational in design, with cross-sectional methodology accounting for 42.7% of all included studies. The most common clinical theme was cervical cancer screening. The most common intervention/exposure was risk factor, typically race (AI/AN compared with other groups) (69%). For studies with documented funding sources, 67% were funded by the US Government.

CONCLUSION

Of the small number of publications identified, the majority are funded through government agencies, are descriptive and/or cross-sectional studies that are hypothesis generating in nature, and fail to represent the diversity of the AI/AN populations in the US. This systematic scoping review highlights the paucity of rigorous research being conducted in a population suffering from a greater burden of disease.

Cancer statistics for American Indian and Alaska Native individuals, 2022: Including increasing disparities in early onset colorectal cancer

American Indian and Alaska Native (AIAN) individuals are diverse culturally and geographically but share a high prevalence of chronic illness, largely because of obstacles to high-quality health care. The authors comprehensively examined cancer incidence and mortality among non-Hispanic AIAN individuals, compared with non-Hispanic White individuals for context, using population-based data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries. Overall cancer rates among AIAN individuals were 2% higher than among White individuals for incidence (2014 through 2018, confined to Purchased/Referred Care Delivery Area counties to reduce racial misclassification) but 18% higher for mortality (2015 through 2019). However, disparities varied widely by cancer type and geographic region. For example, breast and prostate cancer mortality rates are 8% and 31% higher, respectively, in AIAN individuals than in White individuals despite lower incidence and the availability of early detection tests for these cancers. The burden among AIAN individuals is highest for infection-related cancers (liver, stomach, and cervix), for kidney cancer, and for colorectal cancer among indigenous Alaskans (91.3 vs. 35.5 cases per 100,000 for White Alaskans), who have the highest rates in the world. Steep increases for early onset colorectal cancer, from 18.8 cases per 100,000 Native Alaskans aged 20-49 years during 1998 through 2002 to 34.8 cases per 100,000 during 2014 through 2018, exacerbated this disparity. Death rates for infection-related cancers (liver, stomach, and cervix), as well as kidney cancer, were approximately two-fold higher among AIAN individuals compared with White individuals. These findings highlight the need for more effective strategies to reduce the prevalence of chronic oncogenic infections and improve access to high-quality cancer screening and treatment for AIAN individuals. Mitigating the disparate burden will require expanded financial support of tribal health care as well as increased collaboration and engagement with this marginalized population.

Barriers and supports for uptake of human papillomavirus vaccination in Indigenous people globally: A systematic review

Despite the availability of effective and safe human papillomavirus (HPV) vaccines that reduce the incidence and impact of cervical cancer and other cancers, HPV vaccine coverage rates remain persistently low and the cervical cancer burden disproportionately high among Indigenous people globally. This study aimed to systematically identify, appraise, and summarize the literature on documented barriers and supports to HPV vaccination in Indigenous populations internationally. Forty-three studies were included and an inductive, qualitative, thematic synthesis was applied. We report on 10 barrier themes and 7 support themes to vaccine uptake, and provide a quantitative summary of metrics. Focusing on Indigenous perspectives reported in the literature, we propose recommendations on community-research collaboration, culturally safe intergenerational and gender-equitable community HPV vaccine education, as well as multi-level transparency to ensure informed consent is secured in the context of reciprocal relationships. Although the voices of key informant groups (e.g., HPV-vaccine eligible youth and community Elders) are underrepresented in the literature, the identification of barriers and supports to HPV vaccination in a global Indigenous context might help inform researchers and health policy makers who aim to improve HPV vaccine uptake in Indigenous populations.

Barriers and Factors Associated with HPV Vaccination Among American Indians and Alaska Natives: A Systematic Review

American Indian and Alaska Native (AI/AN) persons bear a disproportionate burden of human papillomavirus (HPV)-associated cancers and face unique challenges to HPV vaccination. We undertook a systematic review to synthesize the available evidence on HPV vaccination barriers and factors among AI/AN persons in the United States. We searched fourteen bibliographic databases, four citation indexes, and six gray literature sources from July 2006 to January 2021. We did not restrict our search by study design, setting, or publication type. Two reviewers independently screened the titles and abstracts (stage 1) and full-text (stage 2) of studies for selection. Both reviewers then independently extracted data using a data extraction form and undertook quality appraisal and bias assessment using the modified Mixed Methods Appraisal Tool. We conducted thematic synthesis to generate descriptive themes. We included a total of 15 records after identifying 3017, screening 1415, retrieving 203, and assessing 41 records. A total of 21 unique barriers to HPV vaccination were reported across 15 themes at the individual (n = 12) and clinic or provider (n = 3) levels. At the individual level, the most common barriers to vaccination-safety and lack of knowledge about the HPV vaccine-were each reported in the highest number of studies (n = 9; 60%). The findings from this review signal the need to develop interventions that target AI/AN populations to increase the adoption and coverage of HPV vaccination. Failure to do so may widen disparities.

Interventions to Improve Immunization Coverage Among Children and Adolescents: A Meta-analysis

BACKGROUND AND OBJECTIVES

Vaccinations are recognized as a feasible, cost-effective public health intervention for reducing the burden and associated mortality of many infectious diseases. The purpose of this study was to evaluate the effectiveness of potential interventions to improve the uptake of vaccines among children and adolescents.

METHODS

We performed a literature search until December 2020. Eligible studies were identified using Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, and other sources. We included studies conducted on children and adolescents aged 5 to 19 years. Studies comprised of hospitalized children and those with comorbid conditions were excluded. Two authors independently performed the meta-analysis.

RESULTS

Findings from 120 studies (123 articles), of which 95 were meta-analyzed, reveal that vaccination education may increase overall vaccination coverage by 19% (risk ratio [RR], 1.19; 95% confidence interval [CI], 1.12-1.26), reminders by 15% (RR, 1.15; 95% CI, 1.11-1.18), interventions for providers by 13% (RR, 1.13; 95% CI, 1.07-1.19), financial incentives by 67% (RR, 1.67; 95% CI, 1.40-1.99), and multilevel interventions by 25% (RR, 1.25; 95% CI, 1.10-1.41). The impact of school-based clinics and policy and legislation on overall vaccination coverage is still uncertain, and no impact of a multicomponent intervention on overall vaccination coverage was found.

CONCLUSIONS

Educational interventions, reminders, provider-directed interventions, financial incentives, and multilevel interventions may improve vaccination coverage among school-aged children and adolescents.

Human papillomavirus dose reminder preferences among parents from a diverse clinical sample: a qualitative study

Reminders are an important method for encouraging patients to return for follow-up visits, such as for successive doses of the human papillomavirus (HPV) vaccine. However, patients may have preferences for different types of reminders. This study examined which reminder methods parents of pediatric patients found most useful and their thoughts on how the reminders helped them to complete their children’s HPV vaccine series. This qualitative study was conducted on a purposively sampled group of parents who participated in a multi-level intervention intended to improve uptake and completion of the HPV vaccine series. Parents who agreed to participate were interviewed by phone using semi-structured interviews about their satisfaction with different program components, including reminders they received. Interviews were conducted between May 26, 2016 and October 18, 2017. Thematic analyses of data were conducted using NVivo software. Among 269 program participants invited to participate in the interviews, 157 agreed (58.4%) and 89 were successfully interviewed (33.1%). Participants thought that reminders were effective at helping them return for follow-up visits to ensure their children received all recommended HPV vaccine doses. Although most parents preferred texts, many also favored other reminder methods by themselves or in combination with texts. Parents suggested that the reminders indicate the purpose of the appointment and for which child. Reminders are an important part of a multi-component intervention that aims to increase completion of the HPV vaccine series. Program enrollees prefer different types of reminders, so offering several options may improve returns for follow-up doses.

A Systematic Review of Interventions to Improve HPV Vaccination Coverage

Human papillomavirus (HPV) infection is the most common sexually transmitted infection worldwide. Although most HPV infections are transient and asymptomatic, persistent infection with high-risk HPV types may results in diseases. Although there are currently three effective and safe prophylactic HPV vaccines that are used across the world, HPV vaccination coverage remains low. This review evaluates the effects of the interventions to improve HPV vaccination coverage. We searched the Cochrane Central Register of Controlled Trials, PubMed, Web of Science, Scopus, and the World Health Organization International Clinical Trials Registry Platform and checked the reference lists of relevant articles for eligible studies. Thirty-five studies met inclusion criteria. Our review found that various evaluated interventions have improved HPV vaccination coverage, including narrative education, outreach plus reminders, reminders, financial incentives plus reminders, brief motivational behavioral interventions, provider prompts, training, training plus assessment and feedback, consultation, funding, and multicomponent interventions. However, the evaluation of these intervention was conducted in high-income countries, mainly the United States of America. There is, therefore, a need for studies to evaluate the effect of these interventions in low-and middle-income countries, where there is a high burden of HPV and limited HPV vaccination programs.

Quantitative and qualitative assessment of an all-inclusive postpartum human papillomavirus vaccination program

BACKGROUND

A postpartum human papillomavirus vaccination program was locally implemented to address low initiation rates among young adults. Within 20 months, the program achieved high vaccine initiation and series completion rates. Based on the program's success, it was expanded to all 36 counties served by a public hospital.

OBJECTIVE

This study aimed to conduct a quantitative and qualitative evaluation to examine the success and limitations of the program when expanded from 1 county to 36 counties, many of which are home to rural and medically underserved communities.

STUDY DESIGN

Patient navigators reviewed the electronic medical records and immunization registry records of women aged ≤26 years, who delivered an infant at the public hospital, to determine whether they needed to initiate or complete the human papillomavirus vaccine series. Eligible women were counseled and offered the human papillomavirus vaccine during their hospital stay. Patient navigators scheduled follow-up injections in addition to the mother's postpartum or her infant's well-child visits, made reminder phone calls, and rescheduled missed appointments. Descriptive statistics, including frequencies and proportions, were used for patients approached in the initial and expansion programs. Frequencies from the initial and expansion programs were examined separately. Qualitative interviews were conducted with the clinic staff to evaluate the program. The qualitative analyses were conducted using NVivo (QSR International, Melbourne, Australia, version 10).

RESULTS

Both initial and expanded programs achieved vaccine completion rates above 70%. Of the 2631 eligible postpartum women enrolled in the initial program, 785 (30%) had already been fully vaccinated. Of the remaining 1846 women, 1265 (69%) women received their first dose, and 196 (11%) women received their second or third dose on the postpartum unit. Of the 1461 women who received at least 1 dose through the initial program, 1124 (77%) completed all 3 doses. Of the 4330 eligible postpartum women enrolled in the expanded program, 886 (21%) had already been fully vaccinated. Of the remaining 3444 women, 2284 (66%) received their first dose, and 343 (10%) received their second or third dose on the postpartum unit. Of the 2627 women receiving at least 1 dose through the expanded program, 1932 (74%) completed all 3 doses. Clinic staff interviewed felt the program benefited the postpartum unit and clinics, because it increased patient knowledge of the vaccine, increased patient volume for vaccination, and gave healthcare providers more time to focus on other tasks.

CONCLUSION

Human papillomavirus vaccination on the postpartum unit is an effective way to increase catchup rates and is well accepted by healthcare providers. High completion rates can be achieved if adequate support is provided, even among patients residing in rural or underserved areas who need extensive support to access primary healthcare services. Although this particular program may be considered costly, it is overall effective because the vaccine prevents 5 different types of cancer in women. The inclusion of human papillomavirus vaccination in routine postpartum care is a relatively easy way to reach many adults not vaccinated at a younger age and could help address low vaccination rates among young women in the United States, including hard-to-reach populations.

Achieving cervical cancer elimination among Indigenous women

Achieving the World Health Organisation (WHO) cervical cancer elimination target of fewer than four new cases per 100,000 woman-years requires scaling up HPV vaccination of girls, cervical screening, and pre-cancer and cancer treatment. We reviewed data from four high-income colonised countries (Australia, Canada, Aotearoa New Zealand (NZ), and the United States (US)) to identify how each is currently performing compared to the cervical cancer incidence elimination and triple-intervention targets, nationally and in Indigenous women. We also summarise barriers and enablers to meeting targets for Indigenous women. To achieve elimination, cervical cancer incidence must be reduced by 74% in Indigenous women in Australia, and 63% in Maori women in NZ; data were not published in sufficient detail to compare incidence in Indigenous women in Canada or the US to the WHO target. Only Australia meets the vaccination coverage target, but uptake appears comparatively equitable within Australia, NZ and the US, whereas there appears to be a substantial gap in Canada. Screening coverage is lower for Indigenous women in all four countries though the differential varies by country. Currently, only Australia universally offers HPV-based screening. Data on pre-cancer and cancer treatment were limited in all countries. Large inequities in cervical cancer currently exist for Indigenous peoples in Australia, Canada, New Zealand and the US, and elimination is not on track for all women in these countries. Current data gaps hinder improvements. These countries must urgently address their systemic failure to care and provide health care for Indigenous women.

Coverage rates of the children vaccination programme in Greenland

In order to estimate the current coverage rate among all children in Greenland, we conducted an observational cross-sectional study identifying all children in Greenland eligible for a vaccination between 1 March 2018 and 16 June 2019. we found an overall national coverage of 85.4%. The national coverage for the vaccinations given at birth was 97.1%, dropping to 94.3%, 87.7% and 83.6% at ages 3, 5 and 12 months. Among children eligible for the Measles, Mumps and Rubella-vaccinations, the national coverage was 76.9% for children aged 15 months and 64.1% for children aged 4 years, but dropping to 40.9% in the districts. At preschool, the national coverage was 79.9%. Among the 12-year-old, the national coverages of the two vaccinations against Human Papilloma Virus were 88.4% and 71.6%, respectively, and for the three Hepatitis B-vaccinations 89.8%, 84.1% and 69.6%. A subgroup-analysis and test of an SMS-reminder system in Nuuk improved the coverage from 57.8% to 75.5% locally. Overall, we found a high national coverage rate among the newborn in Greenland. The national coverage rates of the remaining vaccinations were below the WHO-recommendations, however with great regional differences.Abbreviations: CVP: Children Vaccination Programme; BCG: Bacille Calmette-Guerin; EMR: Electronic medical Record system; DTPHiB: Diphtheria, Tetanus, Pertussis, Polio, Haemophilus influenza B; HBV: Hepatitis B; HPV: Human Papilloma Virus; MMR: Measles, Mumps, Rubella; SMS: Short Text Message; WHO: World Health Organization; GVAP: Global Vaccine Action Plan; EVAP: The WHO European Vaccine Action Plan.

Increasing HPV Vaccination Uptake among Adolescents: A Systematic Review

Human Papillomavirus (HPV) vaccination is a well-known fundamental strategy in the prevention of cervical cancer, as it is always caused by HPV infection. In fact, primary prevention of the infection corresponds to primary prevention of HPV-related cancers and other diseases. Since an effective prevention at the population level is the final goal, it is mandatory for healthcare systems to achieve a high HPV vaccination coverage among the adolescents to reduce the circulation of the virus and the burden of HPV-related diseases. This research identified, through a systematic literature review, 38 papers on strategies adopted to increase HPV vaccination coverage among adolescents. The evaluated strategies targeted adolescents/parents and/or healthcare providers and could be grouped in three main types: (1) reminder-based, (2) education, information, and communication activities, and (3) multicomponent strategies. Several types of strategy, such as those relied only on reminders and integrating different interventions, showed a positive impact on vaccination coverage. Nonetheless, the heterogeneity of the interventions suggests the importance to adapt such strategies to the specific national/local contexts to maximize vaccination coverage.

A clinical update on vaccines: focus on determinants of under-immunization and special considerations for adolescents

PURPOSE OF REVIEW

The current article reviews recent literature related to pediatric and adolescent vaccination, specifically focusing on social determinants of under-immunization, expanding adolescent immunization rates, and new recommendations surrounding the meningococcal serotype B vaccine (MenB).

RECENT FINDINGS

Vaccine refusals and vaccine-preventable diseases have been rising in some parts of the world, and appear to be linked to household factors, such as a family's socioeconomic status. Adolescents have lower immunization rates than younger children. Newer vaccines targeted at adolescents, such as the MenB vaccine, have yet to be widely accepted by pediatric providers, parents, and patients.

SUMMARY

Pediatric healthcare providers should attempt to increase local immunization rates by vaccinating children at all eligible office visits and utilizing electronic health record decision-support tools. Although the number of families who choose not to vaccinate their children may be rising, providers can be innovative (e.g. incorporate digital vaccine reminder systems) and increase their familiarity with new vaccine recommendations to continue to prevent serious vaccine-preventable diseases.

Human Papillomavirus Prevalence Among American Indian Women of the Great Plains

BACKGROUND

High-risk human papillomavirus (hrHPV) causes cervical cancer. In the United States, approximately 40% of women aged 14-59 years from all racial and ethnic groups are infected with HPV, and prevalence typically declines with age. However, American Indian (AI) women are insufficiently sampled to permit a population-specific estimate of hrHPV prevalence.

METHODS

Vaginal swabs were self-collected by 698 AI women aged 21-65 years from a tribal community in the Great Plains. We estimated the population prevalence of hrHPV and identified predominant genotypes.

RESULTS

The combined prevalence of hrHPV genotypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68 was 34.8%. HPV-51 (7.6%), HPV-58 (5.3%), HPV-52 (4.3%), HPV-18 (4.3%), and HPV-16 (3.9%) were most prevalent. hrHPV prevalence declined with age, from 42.2% in women aged 21-24 years to 27.9% in women aged 50-65 years.

CONCLUSIONS

HPV-51 was the single most prevalent oncogenic genotype. The combined prevalence of hrHPV among AI women in our sample was high, particularly among women aged 50-65 years, for whom hrHPV prevalence was approximately triple that of other races. Cervical cancer screening efforts should be increased, particularly among women from the community aged 30 years and older.