Implementation of the Australian HPV vaccination program for adult women: Qualitative key informant interviews

On the contextual nature of vaccine safety monitoring: Adverse events reporting after HPV-vaccination in Denmark, 2015

BACKGROUND

In 2013-15, Denmark experienced an increase in reported suspected adverse events following vaccination (AEFI) against human papilloma virus (HPV). Dedicated centres ("One Access") were established in order to standardize management of patients who experienced medically unexplained physical symptoms after HPV vaccination. Since One Access was targeted patients with suspected AEFI after HPV vaccination, we used this opportunity to estimate completeness in AEFI reporting to the Danish Medicines Agency (DMA), and explore the topic of AEFI reporting from the perspective of physicians working at the centres to better understand health professionals' reporting behaviour.

METHODS

The study consisted of a quantitative and a qualitative part. In the quantitative analysis, we used the Danish civil registry number to merge a line-list of all One Access patients referred in 2015 with total number of patients who had reported suspected serious AEFI following HPV vaccination to the DMA in the years 2009-2015. We conducted four semi-structured interviews with doctors representing three out of five regions. The Theoretical Domains Framework together with empirical data from two clinical fieldtrips guided the formation of the qualitative study.

RESULTS

Among 1577 One Access patients, only 404 (26%) were reported to the DMA. We found significant regional differences in reporting completeness (p < 0.001) and differences between regions when looking at reporters' backgrounds (healthcare professionals vs non-professionals; p = 0.004). We identified several factors of importance for reporting behaviour amongst physicians, mainly under the domains of Knowledge, Motivation & Goals, and Environmental Context.

CONCLUSIONS

Despite an official aim of homogenous case management, reporting of suspected AEFI was incomplete with large regional differences. The qualitative study corroborated that reporting behaviour was contextual. This observation represents an important caveat in interpreting data from AEFI reporting, in particular when these data are used for research or policymaking.

Asking about human papillomavirus vaccination and the usefulness of registry validation: a study of young women recruited using Facebook

BACKGROUND

Australia was the first country to implement a government-funded National Human Papillomavirus (HPV) Vaccination Programme. We assessed HPV vaccine uptake comparing self-reported and Register validated estimates, and the knowledge and attitudes of young women with regards to HPV vaccination post-implementation of the programme.

METHODS

Females, aged 16-25 years living in Victoria, Australia, were recruited using targeted advertising on Facebook from May to September 2010, to complete a web-based questionnaire.

RESULTS

Geographic distribution, Indigenous and socio-economic status of the 278 participants were representative of the target population. Overall, 210/278 (76%) had heard of HPV vaccines, with 162/278 (58%) reporting receipt of at least one dose of vaccine, and 54 (19%) unsure. Verification of HPV vaccination status of 142 consenting participants (51%) showed 71% had received at least one dose. Main reasons for vaccination were for protection against HPV infection and cervical cancer (96%) and because it was free (87%), whereas unvaccinated women were uncertain of their eligibility (50%), concerned about adverse reactions (32%), or perceived that vaccination was not needed if they were monogamous (32%).

CONCLUSION

The potential utility of a vaccination register in the context of a national programme is apparent from the large proportion of young women who were unsure of their vaccine status. HPV vaccine knowledge among participants was relatively high suggesting the national programme has successfully communicated to the majority of eligible women, the purpose and limitations of the vaccine. Vigilance is needed to ensure that young women follow through with Pap testing in vaccine eligible cohorts. The ongoing vaccination programme for pre-adolescent girls and boys should communicate to parents that those with one sexual partner can still acquire HPV and that the safety of the vaccine is now well demonstrated.

Decreased management of genital warts in young women in Australian general practice post introduction of national HPV vaccination program: results from a nationally representative cross-sectional general practice study

Objectives

Since the introduction of Australia's human papillomavirus vaccination program, the management rate of genital warts in sexual health clinics and private hospitals has decreased in women of vaccine-eligible age. However, most genital warts in Australia are managed in general practice. This study examines whether a similar decrease occurred in Australian general practice after the introduction of the program.

Methods

Analysis of a nationally representative cross-sectional database of Australian general practice activity (1,175,879 patient encounters with 11,780 general practitioners). Genital warts management rates were estimated for the periods before and after introduction of the program (Pre-program, July 2002-June 2006; Post-program, July 2008-June 2012). Control conditions included genital herpes and gardnerella/bacterial vaginosis in female patients and genital herpes and urethritis in male patients. Trends in management rates by year, pre-vaccine (July 2000-June 2007) and post-vaccine (July 2007-June 2012) were also calculated.

Results

Management rate of genital warts among women potentially covered by program (aged 15–27 years) decreased by 61% from 4.33 per 1,000 encounters in the Pre-program period to 1.67 in the Post-program period. Trend analysis of the post-vaccine period showed, among women of vaccine eligible age, a significant year-on-year reduction in the rate of genital warts management (p<0.0001) and a significant increase in the management rate of control conditions per year (p<0.0001). For all other age-sex groups there was no significant change in the management rate of genital warts between the Pre- and Post-program periods.

Conclusion

The large decrease in general practice management of genital warts in women of vaccine-eligible age highlights the success of the program in the wider community.

HPV vaccination in women aged 27 to 45 years: what do general practitioners think?

Background

Although the Human Papillomavirus (HPV) vaccine is registered in Australia for females aged 9 to 45 years, females aged 27 to 45 years have shown limited vaccine uptake. Our study explored general practitioners’ (GPs) views concerning HPV vaccination of females in this age group, with particular focus on the barriers and the facilitators to the delivery of the HPV vaccine.

Methods

Semi-structured telephone interviews were conducted with 24 randomly selected general practitioners from metropolitan Melbourne. Questions were based on a theoretical framework that explained the barriers and facilitators to professional behaviour change.

Results

According to the GPs, the major barriers to the uptake of the HPV vaccine included the cost of the vaccine, time constraints, and the three-dose schedule. Other barriers that were identified included GPs’ and patients’ beliefs that females in this age group were at low risk of contracting HPV, lack of awareness about the vaccine, and uncertainty about the benefits of this vaccine for females in this age group. In contrast, the facilitators that were identified included the availability of the vaccine on site, the availability of vaccine clinics or nurses for administering the vaccine, the availability of information related to the vaccine either on site or online, and positive opinions from experts in the field.

Conclusions

Our study has identified some of the barriers and facilitators to the delivery and uptake of the HPV vaccine in females aged 27 to 45 years, as perceived by GPs. Further studies should be conducted to determine which of these should be targeted or prioritised for intervention. The views of women in this age group should also be considered as these would also be influential in designing effective intervention strategies for improving the delivery and uptake of the HPV vaccine.

Development of a theory-based instrument to identify barriers and levers to best hand hygiene practice among healthcare practitioners

Background

A theoretical approach to assessing the barriers and levers to evidence-based practice (EBP) with subsequent tailoring of theoretically informed strategies to address these may go some way to positively influencing the delay in implementing research findings into practice. Hand hygiene is one such example of EBP, chosen for this study due to its importance in preventing death through healthcare associated infections (HCAI). The development of an instrument to assess barriers and levers to hand hygiene and to allow the subsequent tailoring of theoretically informed implementation strategies is reported here.

Methods

A comprehensive list of barriers and levers to hand hygiene were categorised to the Theoretical Domains Framework (TDF) in a Delphi survey. These items formed the basis of an instrument that was tested to establish validity and reliability. The relationship between self-reported compliance with hand hygiene and barriers and levers to hand hygiene was also examined along with compliance according to where the barriers and levers fit within the domains of the TDF framework.

Results

A 33-item instrument that tested well for internal consistency (α = 0.84) and construct validity (χ²/df = 1.9 [p < 0.01], RMSEA = 0.05 and CFA = 0.84) was developed. The relationship between self-reported compliance with hand hygiene moderately correlated with barriers identified by participants (total barrier score) (r = 0.41, n = 276, p <0.001). The greater the number of barriers reported, the lower the level of compliance. A one-way between groups multivariate analysis of variance was performed to investigate differences between those adopting high or low compliance with hand hygiene. Compliance was highest for this sample of participants among practitioners with high levels of motivation, strong beliefs about capabilities, when there were positive social influences, when hand hygiene was central to participants’ sense of professional identity and was easier to remember to do.

Conclusions

This study has produced encouraging findings suggesting the potential for improved hand hygiene and resulting effects on the human and financial costs of healthcare associated infection. This study identifies a further potential use for the TDF.

"HPV? Never heard of it!": a systematic review of girls' and parents' information needs, views and preferences about human papillomavirus vaccination

BACKGROUND AND OBJECTIVE

Two human papillomavirus vaccines were licenced in 2006/2007 for cervical cancer prevention. National vaccination programmes for schoolgirls were subsequently introduced in some European countries, North America and Australia. To understand factors influencing vaccine uptake and to inform the development of appropriate UK educational materials, we aimed to synthesise evidence of girls' and parents' information needs, views and preferences regarding HPV vaccination.

DESIGN

Systematic review and mixed method synthesis of qualitative and survey data.

DATA SOURCES

Twelve electronic databases; bibliographies of included studies 1980 to August 2011.

REVIEW METHODS

Two reviewers independently screened papers and appraised study quality. Studies were synthesised collaboratively using framework methods for qualitative data, and survey results integrated where they supported, contrasted or added to the themes identified.

RESULTS

Twenty-eight qualitative studies and 44 surveys were included. Where vaccination was offered, uptake was high. Intention to decline was related to a preference for vaccinating later to avoid appearing to condone early sexual activity, concerns about vaccine safety and low perception of risk of HPV infection. Knowledge was poor and there were many misconceptions; participants tried to assess the potential benefits and harms of vaccination but struggled to interpret limited information about HPV in the context of existing knowledge about sexually transmitted infections and cancer. Conclusion Many girls and their parents have limited understanding to an extent that impinges on their ability to make informed choices about HPV vaccination and could impact on future uptake of cervical screening. This is a considerable challenge to those who design and provide information, but getting the messages right for this programme could help in developing patient information about other HPV related cancers.

Knowledge, attitude and practice of malaysian medical and pharmacy students towards human papillomavirus vaccination

Human Papillomavirus (HPV) infection is one of the most common sexually transmitted infections and oncogenic HPV is the main cause of cervical cancer. However, HPV vaccination is already available as the primary preventive method against cervical cancer. The objective of this study was to determine the level of knowledge, attitude and practice of HPV vaccination among Universiti Kebangsaan Malaysia (UKM) and Universiti Malaya (UM) students. This study was conducted from March until August 2009. Pre-tested and validated questionnaires were filled by the third year UKM (n=156) and UM (n=149) students from medical, dentistry and pharmacy faculties. The results showed that the overall level of knowledge on HPV infection, cervical cancer and its prevention among respondents was high and the majority of them had positive attitude towards HPV vaccination. Medical students had the highest level of knowledge (p<0.05). Very few students (3.6%) had already taken the vaccine with no significant difference between the two Universities (p=0.399). In conclusion, the knowledge and attitude of the respondents were high and positive, respectively. Only few students took HPV vaccination. Thus, more awareness campaigns and HPV vaccination services should be provided at universities' campuses with the price of the HPV vaccine reduced for the students.

Knowledge of human papillomavirus and cervical cancer among young women recruited using a social networking site

OBJECTIVES

Human papillomavirus (HPV) is the commonest sexually transmitted infection. Despite the significant morbidity and mortality associated with HPV-related diseases, previous studies have demonstrated low HPV knowledge in the general population. The objectives of this study were to assess knowledge of cervical cancer and HPV among young women and investigate predictors of high knowledge.

METHODS

Female subjects, aged 16-25 years living in Victoria, Australia, were recruited using targeted advertising on Facebook from May to September 2010. A web-based questionnaire was used in a cross-sectional pilot study for a large longitudinal study on women's health, The Young Female Health Initiative.

RESULTS

A total of 278 women completed the questionnaire. The geographic region, indigenous status and socio-economic status of participants were representative of the target population. Overall, 63% knew what HPV was, but only 48% knew it was a common virus. Predictors of high HPV knowledge on multivariate analyses were older age (adjusted OR (aOR) 2.78, 95% CI 0.77 to 10.04), higher socio-economic status (aOR 1.39, 95% CI 0.66 to 2.95), being Australian-born (aOR 3.10, 95% CI 1.15 to 8.36), older age at first vaginal intercourse (aOR 1.84, 95% CI 0.66 to 5.14), awareness of HPV vaccines (aOR 2.16, 95% CI 0.68 to 6.85) and chlamydia (aOR 2.57, 95% CI 1.11 to 5.94), and self-reported HPV vaccination status (aOR 1.83, 95% CI 0.76 to 4.41).

CONCLUSIONS

HPV and cervical cancer knowledge among participants were relatively high compared with other studies conducted both worldwide and in Australia. However, deficits in knowledge exist and warrant address in educational initiatives.

The impact of new vaccine introduction on immunization and health systems: a review of the published literature

We conducted a systematic review of the published literature to examine the impact of new vaccine introduction on countries' immunization and broader health systems. Six publication databases were searched using 104 vaccine and health system-related search terms. The search yielded 15,795 unique articles dating from December 31, 1911 to September 29, 2010. Based on review of the title and abstract, 654 (4%) of these articles were found to be potentially relevant and were referred for full review. After full review, 130 articles were found to be relevant and included in the analysis. These articles represented vaccines introduced to protect against 10 different diseases (hepatitis A, hepatitis B, Haemophilus influenzae type b disease, human papilloma virus infection, influenza, Japanese encephalitis, meningococcal meningitis, Streptococcus pneumoniae disease, rotavirus diarrhea and typhoid), in various formulations and combinations. Most reviewed articles (97 [75%]) reported experiences in high-income countries. New vaccine introduction was most efficient when the vaccine was introduced into an existing delivery platform and when introduced in combination with a vaccine already in the routine childhood immunization schedule (i.e., as a combination vaccine). New vaccine introduction did not impact coverage of vaccines already included in the routine childhood immunization schedule. The need for increased cold chain capacity was frequently reported. New vaccines facilitated the introduction and widespread use of auto-disable syringes into the immunization and the broader health systems. The importance of training and education for health care workers and social mobilization was frequently noted. There was evidence in high-income countries that new vaccine introduction was associated with reduced health-care costs. Future evaluations of new vaccine introductions should include the systematic and objective assessment of the impacts on a country's immunization system and broader health system, especially in lower-income countries.

HPV16 is associated with younger age in women with cervical intraepithelial neoplasia grade 2 and 3

OBJECTIVE

To evaluate if women with HPV16 positive CIN2 and CIN3 are diagnosed at a younger age.

METHODS

We conducted a population-based cohort study including more than 40,000 women having a liquid based cervical cytology sample taken as part of routine screening. HPV analysis was performed using Hybrid Capture 2 and LiPAv2. The study population was linked to the Danish Pathology Data Bank to retrieve information on subsequent cervical histology. We included HR HPV positive CIN2/3 samples, comprising 173 CIN2 and 467 CIN3 lesions. Due to a high number of multiple concurrent HPV infections, the causative HPV type was assigned to a hierarchically group.

RESULTS

In CIN3, the estimated proportion of lesions positive for HPV16 was 68.1% among women aged 20 years and decreased to 38.9% among women aged 50 years. A decrease in HPV16 positivity with increasing age was also observed in CIN2. In a multinomial logistic regression analysis, young age was strongly associated with HPV16 positivity in CIN3 lesions (OR=0.46 per 10 year increase in age, 95% CI: 0.32-0.65). The proportion of HPV16 and/or 18 positive lesions among women diagnosed with CIN2 and CIN3 below 30 years of age was 44% and 75%, respectively.

CONCLUSIONS

HPV16 positivity was significantly associated with younger age at diagnosis of CIN3. In a population vaccinated against HPV16 and 18, we will experience a shift to older ages in cervical precancerous lesions. These findings may imply that cervical cancer screening programs could start at an older age in HPV vaccinated populations.

"Is cancer contagious?": Australian adolescent girls and their parents: making the most of limited information about HPV and HPV vaccination

INTRODUCTION

Australia has implemented a nation-wide program providing HPV vaccination to girls at school. To date, there are no published studies that explore knowledge about HPV and HPV vaccine post-implementation of the national school-based HPV vaccination program.

METHODS

A purposive sample of schools was selected to reflect a range of vaccination coverage (high versus lower uptake), and different school types (Catholic, Independent or Government). Semi-structured focus groups and interviews were conducted with girls and their parents respectively, until saturation was reached. Transcripts were analysed, letting themes emerge from the data.

RESULTS

A core theme from both girls and parents was lack of knowledge. Supporting themes were lack of knowledge of HPV, lack of knowledge of vaccine, and realisation of their lack of knowledge. Their lack of knowledge was common in three areas: what HPV is, how HPV is transmitted, and the HPV and cervical cancer connection. The lack of knowledge about HPV vaccination was reflected in what the vaccine protects against, how the vaccine works, HPV vaccination recommendations, the vaccine and Pap smear connection, and myths about HPV vaccination. Both girls and parents wanted more information, had a tendency to defer responsibility, and parents expressed judgment of themselves as parents.

DISCUSSION

Low levels of knowledge and understanding about HPV vaccination among adolescents and parents have implications for adolescents' future health practices, including sexual risk behaviour, condom usage, and cervical screening. Reasons for the low levels of knowledge are explored, as are implications for school-based educational interventions.

Monitoring the control of human papillomavirus (HPV) infection and related diseases in Australia: towards a national HPV surveillance strategy

This paper describes a possible multifaceted approach to human papillomavirus (HPV) related surveillance in Australia following implementation of a national HPV vaccination program. We describe eight main components: monitoring of vaccine coverage, vaccine safety, type-specific HPV infection surveillance, cervical cytology (Pap screening) coverage and screen detected lesion prevalence, cervical cancer incidence and mortality, genital wart incidence, incidence of recurrent respiratory papillomatosis, and knowledge, attitudes and beliefs about HPV and HPV vaccination. Australia is well placed to monitor the impact of its HPV vaccination program as well as to measure vaccine effectiveness with existing HPV vaccines, cervical screening and cancer registries.

National survey of general practitioners' experience of delivering the National Human Papillomavirus Vaccination Program

Background: Between 2007 and 2009, Australian general practitioners (GPs) were involved in implementing a population-based human papillomavirus (HPV) vaccination program. We investigated GPs’ experiences of delivering the HPV vaccine to women aged 18–26. Methods: We posted a survey to 1000 GPs. The survey was informed by 12 domains incorporating constructs from psychological theories that focus on individual and environmental barriers and facilitators to effective implementation of evidence-based practice by health professionals. Results: The response rate was 32%. The 298 vaccinating GPs were positive about HPV vaccine implementation as part of their professional role as a worthwhile initiative within existing general practice infrastructure. They had more negative views about some aspects of program organisation, such as the timelines and potential adverse impacts on cervical screening rates. Vaccine safety was not a key concern. Actual levels of knowledge about HPV were moderate (mean score 3.41 out of 6 (s.d. 0.99)) and contrasted with self-rated knowledge, which was high (93% perceived their knowledge to be adequate). Notably, there were unrealistic expectations about the likely reduction in Pap abnormalities due to vaccination, which is important to clarify to avoid loss of confidence in the vaccine when this reduction does not eventuate. Conclusions: Australian GPs viewed HPV vaccination of women aged 18–26 years as an integrated part of their routine practice, with positive attitudes regarding its benefits and achievability. GPs are well placed to implement mass immunisation programs as long as they are supported by effective and timely communication strategies and resources.