Does HPV vaccination affect women's attitudes to cervical cancer screening and safe sexual behaviour?

Association of human papillomavirus vaccination with cervical cancer screening: A systematic review and meta-analysis

INTRODUCTION

Prophylactic vaccination and routine screening are effective at preventing most cases of cervical cancer. Globally, cervical cancer is the fourth most frequently diagnosed cancer among women. The aim of this study was to investigate the association between human papillomavirus virus (HPV) vaccination (1, 2, or 3 doses) and cervical cancer screening.

METHODS

PubMed (MEDLINE), Scopus, Web of Science, and Cochrane Library electronic databases were systematically searched from July 1, 2006, up to September 30, 2021. We pooled estimates using random-effects models. Heterogeneity between studies was quantified using Cochran Q test and I2 statistics. In total, 12 studies involving 2.4 million individuals were included in the meta-analysis.

RESULTS

In the adjusted estimates, uptake of HPV vaccination was associated with increased cervical cancer screening (pooled relative risk [RR]: 1.35; 95% confidence interval [CI]: 1.21, 1.50; n = 12). Between-study heterogeneity was large (I2 = 99%). Compared to unvaccinated, those who received 3 doses of HPV vaccine had the highest uptake of cervical cancer screening (RR: 1.85; 95% CI: 1.58, 2.17), followed by those who received 2 doses (RR: 1.34; 95% CI: 1.21, 1.47). No statistically significant association with screening was found for those who received a single dose of the HPV vaccine.

CONCLUSION

In this meta-analysis, uptake of HPV vaccination was associated with higher cervical cancer screening. It is plausible that vaccinated individuals are more likely to engage in preventive health behaviors. Healthcare providers should remind patients to continue with routine screening for cervical cancer regardless of their HPV vaccine status since vaccination does not protect against all HPV types.

The Effect of Perceived Vaccination on Students’ Online Learning Intentions: A Moderated Mediation Model

The current study proposed and tested a moderated mediation model to reveal the effect of perceived vaccination (PV) on students’ online learning intentions (SOLI) during the COVID-19 pandemic. A questionnaire was distributed to 663 full- and part-time students at Vietnamese universities, and 632 responses were analyzed. SPSS 20 software and Hayes SPSS Process Macro (model 5) were used to test five hypotheses, all of which were supported. The study found that students’ online learning intentions decreased after being fully vaccinated against COVID-19 and that perceived invulnerability played a mediating role in the relationship between perceived vaccination and students’ online learning intentions. The study also revealed that student age moderated a negative association between perceived vaccination and online learning intention, as this negative relationship was stronger for younger students than for older students. Theoretical and practical implications from our research contribute recommendations for governments, policymakers, and educators to consider adjusting educational management strategy, as well as adopting appropriate forms of learning in different epidemic contexts and vaccine coverage rates.

Cervical cancer screening varies by HPV vaccination status among a National Cohort of privately insured young women in the United States 2006-2016

Human papillomavirus (HPV) vaccination in young women is low. Women aged 21 to 65 years in the United States (U.S.) have not reached the Healthy People 2020 objective of 93% for cervical cancer screening. The main aim of this study was to investigate the association between HPV vaccination status and cervical cancer screening among privately insured women aged 21 to 26 years in the U.S.This was a retrospective cohort study using the IBM MarketScan database (2006-2016). The study population included 190,982 HPV-vaccinated women and 763,928 matched unvaccinated women. Adjusted incidence rate ratio (IRR) and the 95% confidence intervals (CIs) were obtained using the generalized estimating equations models with a Poisson distribution.Among a total of 954,910 women included in the analysis, age (mean [SD]) was 23.3 [1.6] years. During 967,317 person-years of follow-up, a total of 475,702 incidents of cervical cancer screening were identified. The incidence density rates of cervical cancer screening were 461 per 1000 person-years (PY) for unvaccinated women and 787 per 1000 PY for those who received 3 doses of the HPV vaccine. After adjusting for other covariates, the IRR of cervical cancer screening was 34% higher among HPV-vaccinated women with at least one vaccine dose than unvaccinated women (adjusted IRR = 1.34, 95% CI: 1.33-1.35; P < .0001). The IRR of cervical cancer screening varied by the dose of HPV vaccination. There was evidence of a linear dose-response relationship between the number of HPV vaccine doses and cervical cancer screening (P-trend < .0001). Compared with unvaccinated women, the IRR of cervical cancer screening were 14%, 39%, and 60% higher among those who received 1, 2, and 3 doses of the HPV vaccine, respectively.In this large retrospective cohort study of privately insured women, HPV-vaccinated women were more likely to be screened for cervical cancer compared with unvaccinated women.

Young Danish HPV vaccinated women's knowledge, barriers and facilitators towards cervical cancer screening: A qualitative study

Cervical cancer occurs more often in under-screened women, and participation rates in cervical cancer screening among young women are worryingly low worldwide. In Denmark only about half the women in their twenties participate in cervical cancer screening. 64-80% of women between 20 and 29 have been HPV vaccinated with a vaccine protecting against 70% of all cervical cancers. Thus screening is still an important supplement to HPV vaccination for the next decades. The aim of this study was to investigate knowledge, facilitators and barriers towards cervical cancer screening among young HPV vaccinated women in Denmark. This qualitative study used an anthropological approach, and data was collected using semi structured focus group interviews as this is an effective method for promoting self-disclosure among participants. Eight focus groups were conducted with participation of 49 HPV vaccinated women aged 20-29 years. We identified five main themes providing an understanding of the women's barriers and facilitators towards cervical cancer screening: Lack of knowledge about HPV and cervical cancer, the screening invitation, the GP as gatekeeper, the gynaecological examination and perceived relevance of cervical cancer screening. Former vaccination did not impact the women's reflection about screening attendance. We argue that systematic information and the attitude and tone of the GP are the primary facilitators for filling the knowledge gap we found among young HPV vaccinated women. As an important gatekeeper, the GP can explain, motivate and remind young women about the importance of a regular Pap smear.

Sexual behavior, clinical outcomes and attendance of cervical cancer screening by HPV vaccinated and unvaccinated sexually active women

Concerns were raised about HPV vaccination possibly leading to riskier sexual behavior. We assessed sexual behaviors, risk of sexually transmitted infection, and attendance to cervical cancer screening by HPV vaccinated and unvaccinated young women. In this analysis, 1475 questionnaires completed by women aged 17-29 years were included. The majority of respondents (67.9%) were vaccinated against HPV. The proportion of those vaccinated decreased with age: from 93.2% in those aged 17-19 to 72.9% in those aged 20-22, and 21.8% in 23-29-year olds. A higher proportion of unvaccinated respondents had at least one sexual intercourse under the age of 15 when compared to those vaccinated (30% vs. 23%, p < .0001). The number of sexual partners during the last 12 months was similar between vaccinated and unvaccinated participants. Vaccinated participants reported more condom use (45% versus 38%; p = .0002), and less sexually transmitted infections (10% versus 28%; p < .0001), and less anogenital condylomas (2.2% vs. 11.6%; p < .0001). A screening test has been reported by 51% and 77% of vaccinated and unvaccinated participants, respectively (p < .0001). The association between vaccination status and cervical cancer screening disappeared when adjusting for participants' age. The study results consolidate the existing body of data regarding the absence of an impact of HPV vaccination on sexual behavior or use of contraceptives.

Brazilian Protocol for Sexually Transmitted Infections 2020: human papillomavirus (HPV) infection

This article addresses human papillomavirus (HPV) infection, one of the topics covered by the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health. The Protocol and Guidelines have been developed based on scientific evidence and validated in discussions with specialists. This article presents epidemiological and clinical aspects and guidelines for health service managers and health workers about diagnosing and treating people with papillomavirus infection. This theme is a significant public health issue since it is the most prevalent sexually transmitted infection globally, capable of triggering the oncogenic process of cervical cancer and the possibility of anogenital warts. Important information is presented for gaining knowledge about HPV and action strategies for infection prevention and control, provision of quality care, and effective treatment of the disease. Infection by the human papillomavirus is the sexually transmitted infection of the highest contagion, superior to genital herpes and HIV.

No longer recommended for cervical screening: How women aged 18-24 feel about the renewed National Cervical Screening Program

BACKGROUND

Since December 2017, the Australian National Cervical Screening Program no longer recommends screening for women under 25 years of age.

AIM

To explore the attitudes of women under 25 years toward the changes.

METHODS

In December 2019, women aged 18-24, residing in Australia, were recruited via the social media platform Instagram and Facebook. Descriptive analysis, t-tests, χ² tests and multivariable regressions were used to analyse the data.

RESULTS

Five hundred and twelve women completed a cross-sectional web-based survey. Women who were older (22-24: 3.1 vs 18-21: 2.8, P < 0.001), sexually active (3.1 vs 2.7, P = 0.003), vaccinated against human papillomavirus (mean = 3.2 vs 2.7, P = 0.005) or who had screened previously (mean = 3.5 vs 2.8, P < 0.001) had significantly greater knowledge about the current cervical screening practices. Older women (odds ratio (OR) = 0.85, 95% CI 0.80-0.95) or those who had screened previously (OR = 0.51, 95% CI 0.31-0.83) were less positive about the delayed start age of screening and five-yearly screening (OR = 0.54, 95% CI 0.35-0.85). A significant association was determined between being sexually active (χ² (4) = 32.71, P < 0.001) and women who had screened previously (χ² (4) = 34.43, P < 0.001), with a greater intention to screen in the future. Regarding health information, 64.6% of women had never heard of the 'National Cervical Screening Program' website and 38.9% of the sample (n = 199/512) reported they had 'rarely' noticed any health information regarding cervical screening in the past 12 months.

CONCLUSION

Further work is required to rectify women's knowledge of cervical screening to ensure women under 25 are aware of the screening guidelines and reduce the potential for over-testing and overtreatment in this age group.

[Brazilian Protocol for Sexually Transmitted Infections 2020: human papillomavirus (HPV) infection]

This article addresses human papillomavirus (HPV) infection, this being one of the topics covered by the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health. The Protocol and Guidelines have been developed based on scientific evidence and validated in discussions with specialists. This article presents epidemiological and clinical aspects, as well as guidelines for health service managers and health workers about diagnosing and treating people with papillomavirus infection. This theme is an important public health problem, since it is the most prevalent sexually transmitted infection in the world, capable of triggering the oncogenic process of cervical cancer, as well as the possibility anogenital warts occurring. Important information is presented for gaining knowledge about HPV, as well as action strategies for infection prevention and control, provision of quality care and effective treatment of the disease.

Racial Disparities in Cervical Cancer Screening: Implications for Relieving Cervical Cancer Burden in Asian American Pacific Islander Women

BACKGROUND

While cervical cancer is considered preventable and the overall Papanicolaou (Pap) test utilization rate has gradually increased in the United States, certain Asian American Pacific Islander (AAPI) women consistently rate lower in Pap test receipt compared with non-Latina whites (NLWs), leading to a higher cervical cancer mortality rate for various AAPI women. Few studies, however, have focused on female AAPI college students' cervical cancer screening behavior in comparison with NLW students.

OBJECTIVE

This study aimed to investigate cervical cancer screening behaviors among college-aged females by (1) determining AAPIs' and NLWs' screening rates, (2) assessing their knowledge about Pap tests, and (3) discovering factors associated with Pap test receipt. Andersen's Health Behavioral Model was used as a theoretical framework.

METHODS

Using a simple random sampling strategy, 2270 female students (15% AAPIs, 85% NLWs) completed an online health survey.

RESULTS

Results indicate AAPI students had significantly lower Pap test knowledge and Pap test receipt rate compared with NLW students. Age, nativity, human papillomavirus vaccination completion, frequency of obstetrician/gynecologist (OB/GYN) visits, and the number of sexual partners were associated with AAPI students' lower rate of Pap test receipt, whereas the Pap test receipt rate for NLW students was influenced by the same factors with the addition of having increased prior knowledge about Pap tests.

CONCLUSION

Results show the importance of OB/GYN visits in obtaining Pap tests for AAPI and NLW students.

IMPLICATION FOR PRACTICE

Health practitioners should pay attention to students' race/ethnicity in their practice and provide corresponding ethnic group-specific preventive care.

HPV vaccination and sexual behaviour in healthcare seeking young women in Luxembourg

Introduction

Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) worldwide. Despite recommendations for HPV vaccination of young women from health authorities, parental concerns were raised whether vaccination could induce unsafe sexual behaviour in young women. Therefore, the primary aim of this study was to investigate if HPV vaccination in healthcare seeking adult women in Luxembourg was associated with unsafe sexual behaviour.

Methods

Seven hundred twenty-nine women (mean age = 22.5; range 18-43 years) were recruited either at Luxembourg family planning centres or at private gynaecology practices. All participants completed a questionnaire on vaccination status and sexual behaviour. Poisson and logistic regressions were used to study the association between sexual behaviour and vaccination status (N = 538). Both models were restricted to women younger than 26 years, since the first cohort being vaccinated would be 25 years old at the time of sampling. Assortativity of sexual mixing by age was also assessed for further transmission modelling for women <30 years reporting age of last/current sexual partner (N = 649). Women older than 29 years were excluded from the assortativity analysis due to restricted sample size.

Results

In total, 386/538 (71.8%) of participants reported receiving HPV vaccine. Vaccination uptake significantly varied by nationality and was higher in Portuguese 112/142 (78.9%) and in Luxembourgish 224/313(71.6%) residents, and lower in residents of other nationalities 50/83 (60.2%) (p = 0.011). HPV vaccination was not associated with unsafe sexual behaviour such as shorter relationship duration with current or last sexual partner (odds ratio (OR) = 1.05, 95% CI [0.94-1.16]), younger age of sexual debut (OR = 1.00, 95% CI [0.88-1.14]), increased number of lifetime sexual partners (OR = 0.95, 95% CI [0.87-1.03), higher age difference with sexual partner (OR = 1.01, 95% CI [0.95-1.08]), condom use (OR = 0.97, 95% CI [0.60-1.56]), nor with other factors like smoking (OR = 0.73, 95% CI [0.47-1.15]) and nationality. HPV vaccination was only associated with younger age (OR = 0.84, 95% CI [0.75-0.94]). Relationship duration, age of sexual debut, age difference with sexual partner, smoking, age and non-Portuguese foreign nationality were predictors of number of lifetime sexual partners. Assortativity analysis revealed that young women chose sexual partners who were 2.3 years older on average.

Conclusions

Our study found no association between unsafe sexual behaviour and HPV vaccination.

Human papilloma virus vaccination and attitudes towards contraception: a cross-sectional study

Objective: Human papilloma virus (HPV) vaccination may result in misconceptions that encourage young women to adopt risky contraceptive practices. The purpose of this article was to investigate whether HPV vaccination status was associated with choice of contraceptive method and adoption of risky sexual behaviour. Methods: Vaccinated and non-vaccinated visitors to a university department paediatric and adolescent gynaecology clinic were asked to anonymously fill in a survey comprising questions on sociodemographic characteristics, sexual history, opinions on contraception and attitudes towards contraception. Results: A total of 191 women were studied, 75 (39.3%) of whom had received the HPV vaccination and 116 (60.7%) of whom had not. The main contraceptive methods used in both groups were male condom (46%), emergency contraception (14%) and coitus interruptus (12%). The vaccinated group was less religious and had better educated mothers compared with the non-vaccinated group (relative risk [RR] 0.64; 95% confidence interval [CI] 0.45, 0.93; p = .016 vs RR 1.91; 95% CI 1.01, 3.63; p = .027, respectively). They also had an earlier sexual debut (RR 1.94; 95% CI 1.06, 3.55; p = .015), agreed that vaccination increased the safety of sex (RR 1.45; 95% CI 1.02, 2.05; p = .039) and considered the HPV vaccine a prerequisite to initiation of a sexual relationship (RR 1.87; 95% CI 1.34, 2.63; p < .001). Conclusion: HPV vaccination did not affect sexual behaviour, attitudes to condom use or choice of contraceptive method.

Australian women's cervical cancer screening attendance as a function of screening barriers and facilitators

RATIONALE

Cervical cancer screening registry data indicate that 43% of eligible Australian women did not screen in the latest reporting period (2014-2015). However, few prior empirical studies have examined whether the screening barriers and facilitators experienced by women can affect their screening attendance. Such information is required to inform the development of future tailored health promotion strategies.

OBJECTIVE

This study examined whether the cervical cancer screening barriers and facilitators identified by women were related to their screening history, from November 2015 and January 2016. At this time, Australian women typically undertook a Pap test every two years. They were deemed overdue for screening if they have not screened in the past 27 months (i.e., overdue by more than three months).

METHOD

In this study, a large sample (N = 338) of women were asked about their screening history including screening status (i.e., up-to-date vs. overdue) and prior screening (i.e., never screened vs. screened), and the psychological and practical screening barriers or facilitators they had experienced.

RESULTS

Logistic regression analysis indicated that screening status was related to a greater number of psychological barriers, but not practical barriers or facilitators. In contrast, prior screening was related to more practical and psychological screening barriers and fewer practical facilitators, but not psychological facilitators. Some individual psychological screening barriers (e.g., anxiety, embarrassment), practical barriers (e.g., lack of time) and practical facilitators (e.g., low cost of test) were related to women's screening status and prior screening.

CONCLUSIONS

Results suggest that addressing practical cervical cancer screening facilitators (e.g., reminder prompts) and psychological screening barriers may help to optimize screening attendance in women who have never screened or are overdue for cervical cancer screening.

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.

HPV Unvaccinated Status and HPV Sexual Risk Behaviour are Common among Canadian Young Adult Women and Men

OBJECTIVE

The current research focuses on sexual risk behaviour among young adult Canadians who have not been vaccinated against HPV.

METHODS

Six hundred and forty-six Canadian university undergraduates completed a self-administered survey assessing HPV vaccination status and sexual risk behaviour.

RESULTS

Five hundred and thirty-seven participants (154 men and 383 women aged 17-23) who met eligibility criteria were analyzed. 48.5% (n = 185) of female and 89.6% (n = 138) of male participants had not been vaccinated against HPV. In the unvaccinated cohort, 51.4% (n = 95) of women were coitally experienced, 49.2% (n = 91) reported experience with oral sex, and 6.5% (n = 12) reported experience with receptive anal intercourse. 55.1% (n = 76) of men were coitally experienced, 22.5% (n = 31) of men reported receptive oral sex, and 2.9% (n = 4) of men reported receptive anal intercourse. Using validated sexual risk behaviour cut-offs, we determined that in the female unvaccinated population, the proportion at significantly increased risk for genital warts, cervical, anal, and oropharyngeal cancer was 11.0%, 30.0%, 6.5%, and 49.2% respectively. In the male unvaccinated population, the proportion at significantly elevated risk for genital warts and anal cancer was 27.2% and 2.9% respectively.

CONCLUSION

Unvaccinated young Canadian women and men commonly engaged in sexual risk behaviours for HPV infection, engaged in sexual risk behaviours at a similar level as their vaccinated counterparts, and a substantial number were at elevated risk of HPV related morbidities at a young age. Findings contribute to an evidence-based case for redoubling efforts to encourage HPV vaccination among unvaccinated young Canadians who are at risk of HPV infection.

Cervical cancer risk perceptions, sexual risk behaviors and sexually transmitted infections among Bivalent Human Papillomavirus vaccinated and non-vaccinated young women in Uganda - 5 year follow up study

Background

Previous studies were conflicting regarding the associations between HPV vaccination, cervical cancer risk perceptions, high-risk sexual behaviors and STIs. This study compared the HPV-vaccinated and non-vaccinated young women in Uganda regarding cervical cancer risk perceptions, high-risk sexual behaviors, syphilis and HIV infections 5 years after vaccine implementation.

Methods

This was a population-based comparative cross-sectional survey conducted in Uganda. The 438 participants were sexually active young women aged 15–24 years and mean age was 18.6 (SD 1.4). The majority (53.0%) were HPV-vaccinated in 2008 without assessment of sexual activity prior to HPV vaccination. Upon verbal assessment of sexual activity at the time of follow-up, data were collected using a questionnaire and laboratory testing of blood samples for syphilis and HIV infections.

Results

There were no significant differences between the HPV-vaccinated and non-vaccinated groups regarding the prevalence of high-risk sexual behaviors, syphilis and HIV infections. Cervical cancer risk perceptions and age at sexual debut were nonetheless significantly lower among the vaccinated group compared to their non-vaccinated counterparts. However, HPV vaccination was not significantly associated to cervical cancer risk perceptions and early age at sexual debut in multivariate logistic regression analysis.

Conclusions

We found no associations between HPV vaccination, cervical cancer risk perceptions, high-risk sexual behaviors, syphilis and HIV infections among young women in Uganda 5 years after vaccine implementation. Young girls in the study population were found to be sexually active at a young age, affirming the importance of targeting girls of younger age for HPV vaccination.

Electronic supplementary material

The online version of this article (doi:10.1186/s12905-017-0394-y) contains supplementary material, which is available to authorized users.

Development and testing of the questionnaire CEC-61: Knowledge about cervical cancer in Chilean adolescents

Despite a clear association between human papillomavirus and cervical cancer, knowledge in adolescent populations regarding the disease and methods for its detection and prevention is deficient. The aim of this study was to develop and test a new questionnaire concerning knowledge on cervical cancer. An instrument was developed and validated to measure knowledge in 226 Chilean adolescents between April and June 2011. Content validity, construct validity, and reliability analysis of the instrument were performed. The new, validated instrument, called CEC-61 (Conocimientos en Cancer Cérvicouterino-61 items/Knowledge in Cervical Cancer-61 items), contains nine factors and 61 items. The new questionnaire explained 81% of the variance with a reliability of 0.96. The assessment of knowledge with a valid and reliable instrument is the first step in creating interventions for a population and to encourage appropriate preventive behavior. CEC-61 is highly reliable and has a clear factorial structure to evaluate knowledge in nine domains related to cervical cancer disease, cervical cancer risk, papilloma virus infection, the Papanicolaou test, and the papilloma virus vaccine.

The Need to Optimize Adolescent Immunization

The adolescent period heralds the pediatric patient's transition into adulthood. It is a time of dynamic development during which effective preventive care measures can promote safe behaviors and the development of lifelong health habits. One of the foundations of preventive adolescent health care is timely vaccination, and every visit can be viewed as an opportunity to update and complete an adolescent's immunizations.In the past decade, the adolescent immunization schedule has expanded to include 2 doses of quadrivalent meningococcal conjugate vaccine, 1 dose of tetanus, diphtheria, acellular pertussis, absorbed vaccine, 2 or 3 doses of human papillomavirus vaccine, depending on the child's age, and an annual influenza vaccine. In addition, during adolescent visits, health care providers can determine whether catch-up vaccination is needed to meet early childhood recommendations for hepatitis B; hepatitis A; measles, mumps, rubella; poliovirus; and varicella vaccines. New serogroup B meningococcal vaccines are now available for those at increased risk for meningococcal disease; in addition, these serogroup B meningococcal vaccines received a Category B recommendation for healthy adolescents, where individual counseling and risk-benefit evaluation based on health care provider judgements and patient preferences are indicated. This clinical report focuses on the epidemiology of adolescent vaccine-preventable diseases by reviewing the rationale for the annual universally recommended adolescent immunization schedule of the American Academy of Pediatrics, the American Academy of Family Physicians, the Centers for Disease Control and Prevention, and the American Congress of Obstetricians and Gynecologists. In addition, the barriers that negatively influence adherence to this current adolescent immunization schedule will be highlighted.

Human papillomavirus vaccination and subsequent cervical cancer screening in a large integrated healthcare system

BACKGROUND

Human papillomavirus vaccination may result in lowered intention to be screened for cervical cancer, potentially leading to gaps in screening coverage and avoidable cervical cancer diagnoses.

OBJECTIVE

The purpose of this study was to examine the association between human papillomavirus vaccination and subsequent cervical cancer screening initiation and adherence to recommended screening intervals to detect gaps in screening coverage and inform future prevention efforts.

STUDY DESIGN

A retrospective cohort study was conducted in 2 distinct cohorts of female members of Kaiser Permanente Southern California, which is a large integrated healthcare delivery system. Papanicolaou screening initiation was evaluated in women who reached 21 years from 2010-2013. Adherence to recommended screening intervals was evaluated in women who were 25-30 years old in 2010. All women were observed to the end of 2013 for the evaluation of their screening behaviors. History of human papillomavirus vaccination and Papanicolaou screening were obtained from electronic medical records. Adherence to recommended screening intervals was measured as ≥85% vs <85% of the observed "screening up-to-date" person-time. Multivariable Cox and logistic regression models were used to examine associations between vaccination history and screening initiation and interval adherence. Demographic characteristics, gynecologic health history, healthcare use, and characteristics of women's primary care providers were included as potential confounders in the analyses.

RESULTS

There were 27,352 and 41,328 women included in the screening initiation and screening interval adherence analyses, respectively. In comparison with unvaccinated women, adjusted hazard ratios (95% confidence intervals [CIs]) for screening initiation among women who had been vaccinated against human papillomavirus were 1.19 (95% CI, 1.11-1.28), 1.44 (95% CI, 1.34-1.53), and 1.57 (95% CI, 1.50-1.65) for 1, 2, and ≥3 doses, respectively. Adjusted odds ratios for screening interval adherence were 0.93 (95% CI, 0.83-1.04), 1.73 (95% CI, 1.52-1.97), and 2.29 (95% CI, 2.05-2.56), for 1, 2, and ≥3 doses, respectively.

CONCLUSION

Women who had been vaccinated against human papillomavirus in this community-based, integrated healthcare setting were more likely to be screened for cervical cancer than were unvaccinated women. Our findings underscore the need for targeted interventions among unvaccinated women who may be disproportionally affected by cervical cancer, despite the presence of population-based screening programs.

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.

•

A comparison of cervical cancer screening practices among mostly minority women

•

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

•

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

•

Current recommendations and screening purpose are areas for future interventions.

Human Papillomavirus Vaccination and Sexual Disinhibition in Females: A Systematic Review

CONTEXT

Some parents believe human papillomavirus (HPV) vaccination increases the chance of risky sexual behaviors among adolescents. This review summarizes the evidence available on adolescent girls and women engaging in risky sexual activity following HPV vaccination.

EVIDENCE ACQUISITION

Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted in 2014 and updated in 2015. Literature was searched for articles published between 2004 and 2015 in MEDLINE, PsycInfo, CINAHL, Cochrane Database, Web of Science, and EMBASE without language limits. Studies were screened according to predefined inclusion and exclusion criteria. Methodologic quality of the included articles was assessed.

EVIDENCE SYNTHESIS

The search resulted in 21 articles to be included in the review, with 527,475 participants. Included studies were conducted in 12 different countries using experimental and observational study designs. The review included data on girls aged as young as 11 years to women aged 40 years. Studies measured changes in sexual behaviors using a variety of outcomes, including age at sexual debut; risky sexual behaviors; use of condoms and contraception; and clinical indicators such as rates of sexually transmitted infections, HIV, and pregnancy terminations. Available data showed either no association between vaccination status and the outcomes of interest or a positive association between safer sexual behaviors, such as condom use and receipt of HPV vaccination. Methodologic quality of all but one study was moderate or weak.

CONCLUSIONS

This review did not find sufficient evidence to support compensatory sexual risk behaviors following HPV vaccination among adolescent girls or women.

Attitudes towards human papillomavirus vaccination among African parents in a city in the north of England: a qualitative study

BACKGROUND

Human papillomavirus (HPV) is sexually transmitted and has been conclusively linked to cervical cancer and genital warts. Cervical cancer is attributed to approximately 1100 deaths annually in UK, and is the second most common female cancer globally. It has been suggested that black African women are more predisposed to HPV infection and cervical cancer. A vaccine has been developed to reduce HPV infection, and in the UK, has been offered to 12-13 year old adolescent girls through schools as part of their childhood immunization programme since 2008. Upon programme initiation, it was noted that vaccine uptake was lower in schools where girls from ethnic minority groups were proportionately higher. The study's objectives were to explore factors influencing UK based African parents' acceptance or decline of the HPV vaccine, whether fathers and mothers share similar views pertaining to vaccination and any interfamily tensions resulting from differing views.

METHODS

A qualitative study was conducted with five African couples residing in north England. Face to face semi-structured interviews were carried out. Participants were parents to at least one daughter aged between 8 and 14 years. Recruitment was done through purposive sampling using snowballing.

RESULTS

HPV and cervical cancer awareness was generally low, with awareness lower in fathers. HPV vaccination was generally unacceptable among the participants, with fear of promiscuity, infertility and concerns that it's still a new vaccine with yet unknown side effects cited as reasons for vaccine decline. There was HPV risk denial as religion and good cultural upbringing seemed to result in low risk perceptions, with HPV and cervical cancer generally perceived as a white person's disease. Religious values and cultural norms influenced vaccine decision-making, with fathers acting as the ultimate decision makers. Current information about why the vaccine is necessary was generally misunderstood.

CONCLUSION

Tailored information addressing religious and cultural concerns may improve vaccine acceptability in African parents.

How does HPV vaccination status relate to risk perceptions and intention to participate in cervical screening? a survey study

BACKGROUND

Women in several countries will soon be covered by two preventive programmes targeting cervical cancer: HPV vaccination and cervical screening. The HPV vaccines are expected to prevent approximately 70 % of cervical cancers. It has been speculated, that HPV vaccinated women will not attend screening because they falsely think that the vaccine has eliminated their cervical cancer risk. The aim of this study was to investigate the association between HPV vaccination status and perceptions of cervical cancer risk; perceptions of vaccine effect; and intention to participate in cervical screening. Furthermore, to investigate associations between perceptions of cervical cancer risk and intention to participate in cervical screening.

METHODS

A random sample of Danish women from the birth cohorts 1993-1995 was invited to complete a web-based questionnaire concerning risk perceptions and intentions to participate in cervical screening. Main outcomes were: perceived lifetime-risk of cervical cancer; perceived HPV vaccine effect; and intention to participate in cervical screening.

RESULTS

HPV vaccinated women more often than unvaccinated women intended to participate in screening: adjusted odds ratio (OR) for being HPV vaccinated when intending to participate in screening of 3.89 (95 % CI: 2.50-6.06). HPV vaccinated women perceived cervical cancer risk to be higher than unvaccinated women did: adjusted OR of 0.11 (95 % CI: 0.03-0.39) and 0.51 (95 % CI: 0.33-0.78) for being HPV vaccinated while having the lowest perception of risk (in two different pre-specified dichotomisations). HPV vaccinated women perceived the vaccine effect to be larger than unvaccinated women did: adjusted OR of 0.31 (95 % CI: 0.18-0.51) and 0.37 (95 % CI: 0.25-0.53) for being HPV vaccinated while having the lowest perception of vaccine effect (in two different pre-specified dichotomisations). There were no associations between perceived cervical cancer risk and intention to participate in screening.

CONCLUSIONS

HPV vaccinated women more often than unvaccinated women intended to participate in screening and they perceived cervical cancer risk to be higher and the vaccine effect to be larger than unvaccinated women did. However, in our analyses, risk perceptions could not explain screening intentions neither among vaccinated nor among unvaccinated women.

Tempest in a teapot: A systematic review of HPV vaccination and risk compensation research

There has been some concern among parents and in the media that vaccinating children against human papillomavirus could be seen as giving children permission to engage in risky sexual behaviors (also known as sexual disinhibition). Several studies have found this concern to be unfounded but there have been no attempts to synthesize the relevant studies in order to assess if there is evidence of sexual disinhibition. The aim of this study was to synthesize recent literature examining sexual behaviors and biological outcomes (e.g., sexually transmitted infections) post-HPV vaccination. We reviewed literature from January 1, 2008-June 30, 2015 using PubMed, CINAHL, and Embase with the following search terms: [(sex behavior OR sex behavior OR sexual) AND (human papillomavirus OR HPV) AND (vaccines OR vaccine OR vaccination)] followed by a cited reference search. We included studies that examined biological outcomes and reported behaviors post-vaccination in both males and females. Studies were reviewed by title and abstract and relevant studies were examined as full-text articles. We identified 2,503 articles and 20 were eventually included in the review. None of the studies of sexual behaviors and/or biological outcomes found evidence of riskier behaviors or higher rates of STIs after HPV vaccination. Instead, the studies found that vaccinated compared to unvaccinated individuals were less likely to report vaginal intercourse without a condom (OR = 0.5; 95%CI = 0.4-0.6) and non-use of contraception (OR = 0.27; 95%CI = 0.15-0.48) and unvaccinated participants had higher rates of Chlamydia (OR = 2.3; 95%CI = 1.06-5.00). These results should be reassuring to parents and health care providers.

Prevention and early detection of cervical cancer in the UK

This literature review explores the prevention and early detection of cervical cancer in the UK. Current findings indicate that there is a risk for women under the age of 25 years, who may develop cervical cancer. There appears to be a gap in UK policy that may overlook these women, who are beneath the age for initial screening but exceed the age for vaccination. Despite the inextricable link between sexual activity and cervical cancer, cervical screening and sexual health promotion still appear to be disjointed, and the role of a sexually transmitted infection leading to the development of cervical cancer has not been emphasised enough in public health messages. Further training should be provided and its impact monitored, designed to address this anomaly in health promotion. There are many barriers to health promotion including, those of a societal, cultural and religious nature. Additional research is required to ascertain the types of educational and awareness interventions that would be most effective in promoting and encouraging positive sexual behaviours among young people, and to explore how these might be successfully implemented.

The Participation of HPV-Vaccinated Women in a National Cervical Screening Program: Population-Based Cohort Study

Background

Concerns have been raised that HPV-vaccination might affect women’s cervical screening behavior. We therefore investigated the association between opportunistic HPV-vaccination and attendance after invitation to cervical screening.

Methods

A cohort of all women resident in Sweden, born 1977-1987 (N=629,703), and invited to cervical screening, was followed October 2006 - December 2012. Invitations to screening were identified via the National Quality Register for Cervical Cancer Prevention, as was the primary outcome of a registered smear. Vaccination status was obtained from two nationwide health data registers. Hazard ratios (HR) were estimated using Cox regression adjusted for age, education level and income (HR_adj). Women were individually followed for up to 6 years, of which the first and second screening rounds were analyzed separately.

Results

Screening attendance after three years of follow-up was 86% in vaccinated women (N=4,897) and 75% in unvaccinated women (N=625,804). The crude HR of screening attendance in vaccinated vs. unvaccinated women was 1.31 (95% CI 1.27-1.35) in the first screening round. Adjustment for education and income reduced but did not erase this difference (HR_adj=1.09, 95% CI 1.05-1.13). In the second screening round, attendance was likewise higher in HPV-vaccinated women (crude HR=1.26, 95% CI 1.21-1.32; HR_adj=1.15, 95% CI 1.10-1.20).

Conclusions

HPV-vaccination is so far associated with equal or higher attendance to cervical screening in Sweden in a cohort of opportunistically vaccinated young women. Most but not all of the difference in attendance was explained by socioeconomic differences between vaccinated and unvaccinated women. HPV vaccine effectiveness studies should consider screening attendance of HPV-vaccinated women when assessing incidence of screen-detected cervical lesions.

Barriers to and facilitators of compliance with clinic-based cervical cancer screening: population-based cohort study of women aged 23-60 years

Objective

This study aims to identify possible barriers to and facilitators of cervical cancer screening by (a) estimating time and travel costs and other direct non-medical costs incurred in attending clinic-based cervical cancer screening, (b) investigating screening compliance and reasons for noncompliance, (c) determining women’s knowledge of human papillomavirus (HPV), its relationship to cervical cancer, and HPV and cervical cancer prevention, and (d) investigating correlates of HPV knowledge and screening compliance.

Materials and Methods

1510 women attending the clinic-based cervical cancer screening program in Stockholm, Sweden were included. Data on sociodemographic characteristics, time and travel costs and other direct non-medical costs incurred in attending (e.g., indirect cost of time needed for the screening visit, transportation costs, child care costs, etc.), mode(s) of travel, time, distance, companion’s attendance, HPV knowledge, and screening compliance were obtained via self-administered questionnaire.

Results

Few respondents had low socioeconomic status. Mean total time and travel costs and direct non-medical cost per attendance, including companion (if any) were €55.6. Over half (53%) of the respondents took time off work to attend screening (mean time 147 minutes). A large portion (44%) of the respondents were noncompliant (i.e., did not attend screening within 1 year of the initial invitation), 51% of whom stated difficulties in taking time off work. 64% of all respondents knew that HPV vaccination was available; only 34% knew it was important to continue to attend screening following vaccination. Age, education, and income were the most important correlates of HPV knowledge and compliance; and additional factors associated with compliance were time off work, accompanying companion and HPV knowledge.

Conclusion

Time and travel costs and other direct non-medical costs for clinic-based screening can be considerable, may affect the cost-effectiveness of a screening program, and may constitute barriers to screening while HPV knowledge may facilitate compliance with screening.

Effect of human papillomavirus (HPV) vaccination on clinical indicators of sexual behaviour among adolescent girls: the Ontario Grade 8 HPV Vaccine Cohort Study

BACKGROUND

Suboptimal human papillomavirus (HPV) vaccine coverage in some jurisdictions is partly attributed to fears that vaccination may increase risky sexual behaviour. We assessed the effect of HPV vaccination on clinical indicators of sexual behaviour among adolescent girls in Ontario.

METHODS

Using Ontario's administrative health databases, we identified a population-based cohort of girls in grade 8 in the 2 years before (2005/06 and 2006/07) and after (2007/08 and 2008/09) implementation of Ontario's grade 8 HPV vaccination program. For each girl, we then obtained data on vaccine receipt in grades 8 and 9 and data on indicators of sexual behaviour (pregnancy and non-HPV-related sexually transmitted infections) in grades 10-12. Using a quasi-experimental method known as regression discontinuity, we estimated, for each outcome, the risk difference (RD) and relative risk (RR) attributable to vaccination and to program eligibility.

RESULTS

The cohort comprised 260 493 girls, of whom 131 781 were ineligible for the program and 128 712 were eligible. We identified 15 441 (5.9%) cases of pregnancy and sexually transmitted infection and found no evidence that vaccination increased the risk of this composite outcome: RD per 1000 girls -0.61 (95% confidence interval [CI] -10.71 to 9.49) and RR 0.96 (95% CI 0.81 to 1.14). Similarly, we found no discernible effect of program eligibility: RD per 1000 girls -0.25 (95% CI -4.35 to 3.85) and RR 0.99 (95% CI 0.93 to 1.06). The findings were similar when outcomes were assessed separately.

INTERPRETATION

We present strong evidence that HPV vaccination does not have any significant effect on clinical indicators of sexual behaviour among adolescent girls. These results suggest that concerns over increased promiscuity following HPV vaccination are unwarranted and should not deter from vaccinating at a young age.

The association of human papillomavirus vaccination with sexual behaviours and human papillomavirus knowledge: a systematic review

Since the 2008 introduction of the human papillomavirus (HPV) vaccination programme for adolescent girls in the UK, parents and other groups have expressed fears that immunisation condones sexual activity, promotes promiscuity and encourages risky sexual behaviour. This study aimed to explore whether HPV vaccination programmes have increased knowledge surrounding HPV and associated disease and whether uptake has influenced sexual behaviour. MEDLINE, Embase, Cochrane Library and PsycINFO electronic databases were interrogated. Studies of behaviour, attitudes and knowledge associated with HPV vaccination (or vaccination intent) in subjects of any age and gender in programmes reflective of UK practice were included in the review (n = 58). The evidence regarding the association of HPV vaccination with high-risk sexual behaviour was varied, primarily due to the heterogeneous nature of the included studies. Young females typically exhibited better knowledge than males, and vaccinated respondents (or those with vaccination intent) had higher levels of knowledge than the unvaccinated. However, knowledge surrounding HPV and genital warts was generally poor. This review highlights the need to provide effective education regarding the HPV vaccine and HPV-associated disease to adolescents of vaccination age, nurses, teachers, parents and guardians to ultimately allow informed decisions to be made regarding receipt of the HPV vaccine.

Human papillomavirus (HPV) vaccination and subsequent sexual behaviour: evidence from a large survey of Nordic women

OBJECTIVE

To assess whether recipients and non-recipients of the human papillomavirus (HPV) vaccine subsequently differ in terms of sexual risk taking behaviour.

DESIGN

Cross-sectional survey. Sequential analyses constructed from self-reported age at vaccination, age at first intercourse and age at response.

SETTING

A random selection of women aged 18-46 years living in Denmark, Norway and Sweden in 2011-2012, eligible for opportunistic or organized catch-up HPV vaccination.

PARTICIPANTS

A total of 3805 women reported to have received the HPV vaccine and 40,247 reported not to have received it. Among vaccinees, 1539 received the HPV vaccine before or at the same age as sexual debut, of which 476 and 1063 were eligible for organized catch-up and opportunistic vaccination, respectively.

MAIN OUTCOME MEASURES

Self-reported sexual behaviour, compared by hazard ratios and odds ratios for women who received the HPV vaccine before or at the same age as sexual debut versus women who did not receive the HPV vaccine.

RESULTS

HPV vaccination did not result in younger age at first intercourse. Women who received the HPV vaccine before or at the same age as sexual debut did not have more sexual partners than did non-vaccinees. Non-use of contraception during first intercourse was more common among non-vaccinees than among HPV vaccinees. The results were similar for organized catch-up and opportunistic vaccinees.

CONCLUSION

Women who received the HPV vaccine before or at the same age as sexual debut did not subsequently engage more in sexual risk taking behaviour than women who did not receive the HPV vaccine.

Association between human papillomavirus vaccine status and other cervical cancer risk factors

Little is known about the relationship between HPV vaccine uptake and other risk factors for cervical cancer. This study aimed to measure the association between vaccine status and cervical cancer risk factors in adolescent girls. Girls (15-16 years) from the first two cohorts to be offered routine HPV vaccination in the NHS immunisation programme completed a survey 3 years post-vaccination. Recruitment took place at 13 schools in London. Of 2768 girls registered in Year 11, 1912 (69%) took part and provided analysable data. Questions assessed vaccine status, demographic characteristics, smoking status, sexual behaviour and intention to attend cervical screening. Overall, 78% had completed the three-dose vaccine course. There was no association between vaccine status and smoking behaviour or sexual experience. In adjusted analyses, girls from black or 'other' ethnic backgrounds were less likely to be fully-vaccinated than those from white backgrounds. Those with low intentions to attend cervical screening were less likely to be fully vaccinated than those with high intentions. Efforts will be needed to ensure that unvaccinated women understand the importance of cervical screening when they reach the age that screening begins. Ethnic inequalities in vaccine coverage need to be explored further.

Risk perception and sexual behavior in HPV-vaccinated and unvaccinated young Colombian women

OBJECTIVE

To compare sexual behaviors and risk perception between young women vaccinated for HPV and unvaccinated Colombian women.

METHODS

In a cross-sectional design study, 1436 women (231 adolescents, <18 years; 1205 young women, 18-26 years) completed a self-administered questionnaire between May 2011 and March 2012 in Bogotá, Colombia. Data from vaccinated and unvaccinated women were compared by descriptive statistics and multivariate models.

RESULTS

Sexual risk behaviors were not associated with vaccination after adjustment for risk perception, age, educational level, and HPV knowledge. By contrast, vaccination was associated with higher routine Pap smear screening (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.69-3.28), use of modern contraceptives (OR, 2.02; 95% CI, 1.26-3.22), and consistent use of condoms (OR, 1.49; 95% CI, 1.11-2.01). Vaccinated young women were more likely to have had sex (OR, 2.08; 95% CI, 1.56-2.78), but sexual debut among adolescents was not associated with vaccination. In bivariate and multivariate analyses, vaccination status was negatively associated with perceived risk of HPV infection, warts, and cervical cancer. There was no association between vaccination and perceived risk of sexually transmitted infections in any model.

CONCLUSION

No association was found between changes in risk perception after HPV vaccination and sexual risk behaviors.

Human papillomavirus vaccination and sexual behavior in young women

STUDY OBJECTIVE

To compare sexual attitudes and behaviors of young women who have received or declined the HPV vaccine.

DESIGN

Cross-sectional survey.

SETTING

Obstetrics and gynecology and pediatrics clinics at a large, Midwestern, academic health center.

PARTICIPANTS

223 young women (ages 13-24): 153 who had received HPV vaccination and 70 with no prior HPV vaccination.

MAIN OUTCOME MEASURES

Sexual behaviors; attitudes toward sexual activity.

RESULTS

Vaccinated young women were slightly but significantly younger than unvaccinated (mean age 19.2 vs 20.0). Both groups showed a large percentage of participants engaging in high-risk sexual behavior (75% vs 77%). The mean age at sexual debut was not significantly different between the groups (16.8 vs 17.0) nor was the average number of sexual partners (6.6 for both). Unvaccinated participants were more likely to have been pregnant (20% vs 8.6%, P = .016), although this difference was not significant in multivariate analysis CI [0.902-5.177]. Specific questions regarding high-risk sexual behaviors and attitudes revealed no significant differences between the groups.

CONCLUSION

We found that sexual behaviors, including high-risk behaviors, were similar between young women who had and had not received HPV vaccination. Our findings provide no support for suggestions that the vaccine is associated with increased sexual activity. Importantly, we found that young women in our population are sexually active at a young age and are engaged in high-risk behaviors, affirming the importance of early vaccination.

Equity in human papilloma virus vaccination uptake?: sexual behaviour, knowledge and demographics in a cross-sectional study in (un)vaccinated girls in the Netherlands

Background

In the Netherlands, human papillomavirus (HPV) vaccination is part of a national program equally accessible for all girls invited for vaccination. To assess possible inequalities in vaccine uptake, we investigated differences between vaccinated and unvaccinated girls with regard to various characteristics, including education and ethnicity, (both associated with non-attendance to the national cervical screening program), sexual behaviour and knowledge of HPV.

Methods

In 2010, 19,939 nationwide randomly-selected 16–17 year-old girls (2009 vaccination campaign) were invited to fill out an online questionnaire. A knowledge scale score and multivariable analyses identified variables associated with vaccination status.

Results

2989 (15%) of the selected girls participated (65% vaccinated, 35% unvaccinated). The participants were comparable with regard to education, ethnicity, most sexual risk behaviour and had similar knowledge scores on HPV transmission and vaccination. However, unvaccinated girls lived in more urbanised areas and were more likely to have a religious background. Irrespective of vaccination status, 81% of the girls were aware of the causal relationship between HPV and cervical cancer, but the awareness of the necessity of cervical screening despite being vaccinated was limited.

Conclusions

HPV vaccine uptake was not associated with knowledge of HPV and with factors that are known to be associated with non-attendance to the cervical cancer screening program in the Netherlands. Furthermore, most sexual behaviour was not related to vaccination status meaning that teenage unvaccinated girls were not at a disproportionally higher risk of being exposed to HPV. Routine HPV vaccination may reduce the social inequity of prevention of cervical cancer.

The Possible Effects on Socio-Economic Inequalities of Introducing HPV Testing as Primary Test in Cervical Cancer Screening Programs

Background: Screening with HPV is more effective than Pap test in preventing cervical cancer. HPV as primary test will imply longer intervals and a triage test for HPV positive women. It will also permit the development of self-sampling devices. These innovations may affect population coverage, participation, and compliance to protocols, and likely in a different way for less educated, poorer, and disadvantaged women.

Aim: To describe the impact on inequalities, actual or presumed, of the introduction of HPV-based screening.

Methods: The putative HPV-based screening algorithm has been analyzed to identify critical points for inequalities. A systematic review of the literature has been conducted searching PubMed on HPV screening coverage, participation, and compliance. Results were summarized in a narrative synthesis.

Results: Knowledge about HPV and cervical cancer was lower in women with low socio-economic status and in disadvantaged groups. A correct communication can reduce differences. Longer intervals will make it easier to achieve high-population coverage, but higher cost of the test in private providers could reduce the use of opportunistic screening by disadvantaged women. There are some evidences that inviting for HPV test instead of Pap increases participation, but there are no data on social differences. Self-sampling devices are effective in increasing participation and coverage. Some studies showed that the acceptability of self-sampling is higher in more educated women, but there is also an effect on hard-to-reach women. Communication of HPV positivity may increase anxiety and impact on sexual behaviors, the effect is stronger in low educated and disadvantaged women. Finally, many studies found indirect evidence that unvaccinated women are or will be more probably under-screened.

Conclusion: The introduction of HPV test may increase population coverage, but non-compliance to protocols and interaction with opportunistic screening can increase the existing inequalities.

Young Women's Sexual and Reproductive Health Post HPV Vaccination

In the present study the authors sought to explore, in greater depth, the impact that HPV vaccination has on college-aged women's reproductive and sexual health. Qualitative interviews were conducted with 30 HPV-vaccinated, college women and analyzed for reoccurring themes. Although findings revealed that women's HPV-related knowledge was suboptimal, most women correctly believed that they were still at risk for HPV after having received the vaccination. Women indicated that having the HPV vaccine made them more aware of sexually transmitted infections and prompted them to continue to take care of their sexual health. Women reported that having the HPV vaccine did not influence their condom use or birth control choices, and they believed that obtaining Pap smears was still important. These results help us to understand the impact of HPV vaccination on women's reproductive and sexual health. These findings are promising and reinforce the importance of educating women about behaviors that will help them maintain reproductive and sexually healthy lives.

Human papillomavirus vaccination and Pap testing profile in Manitoba, Canada

BACKGROUND

Females who receive the human papillomavirus (HPV) vaccine may believe they are protected from developing cervical cancer and no longer require screening. Concern has also been expressed that vaccinated females are those that would be screened regularly. This study assesses the Pap testing behavior of vaccinated and non-vaccinated females.

METHODS

For this population-based retrospective cohort study, vaccination and screening registries were linked for 3540 vaccinated females aged 15 years and over and 9592 matched non-vaccinated females. Conditional logistic regression, the Kaplan-Meier method and Cox regression were used to examine the association between vaccination and Pap testing.

RESULTS

Vaccinated females were more likely to have had a Pap test within the year prior to the index date than non-vaccinated females (15-19 years old: OR=1.38, 95% CI 1.20-1.59; 20+ years old: OR=2.34, 95% CI 1.98-2.76). In the three-year period after the index date, vaccinated females had a significantly higher cumulative probability of having a Pap test (83.3%) than non-vaccinated females (66.1%). Females who had a Pap test within three years prior to the index date were more likely to have a Pap test after the index date (vaccinated: HR=5.03, 95% CI 4.65-5.45; non-vaccinated HR=3.97, 95% CI 3.70-4.24). Being vaccinated had a significant effect on Pap testing (15-19 years old: HR=1.54, 95% CI 1.39-1.69; 20+ years old: HR=1.87, 95% CI 1.52-2.31). 80.1% of vaccinated females who had a Pap test prior to the index date also had one subsequent to it, compared to 70.1% for non-vaccinated females. 41.1% of females had not been vaccinated nor had a Pap test.

CONCLUSION

The majority of vaccinated females continue to participate in screening, and do so at a higher rate than non-vaccinated females. Renewed efforts need to be made to include the large proportion of non-vaccinated, non-screened females in vaccination and/or screening.

Barriers to receiving human papillomavirus vaccination among female students in a university in Hong Kong

This paper investigates, using a qualitative approach, barriers to receiving Human Papillomavirus (HPV) vaccine among female undergraduate students in a Hong Kong university. By conducting individual semi-structured interviews with 35 young women aged 19 to 23, seven intertwining perceptual, social and cultural, healthcare provider and financial barriers were identified. These barriers included the perception as being low-risk due to an absence of sexual contact, lack of confidence in the safety of the vaccine, suspicion of parents concerning the intention to get vaccinated, lack of positive discussion among peers, insufficient information from primary-care doctors, difficulty in choosing a suitable HPV vaccine and cost of the vaccine. Future HPV-vaccination promotion therefore not only needs to enhance risk perception and needs awareness of young women, but also educate parents and correct their misconceptions. As primary care doctors are the first line of contact with patients, providing more support to enhance their knowledge of the HPV vaccine and to encourage their enthusiasm in providing responsive disease-prevention education can motivate young women to get vaccinated.

Factors associated with HPV vaccination among adult women in Quebec

BACKGROUND AND OBJECTIVE

Human papillomavirus (HPV) infections are the most common sexually transmitted infections in North America and are associated with cervical cancer. A publicly-funded HPV immunization program was launched in the province of Quebec, Canada, in the fall of 2008. The aim of this study was to explore factors associated with HPV immunization among young adult women not targeted by this program.

METHODS

A questionnaire was mailed to 2400 24-y-old women randomly selected from the Quebec provincial health insurance database and 56% responded. Factors associated with vaccination status were analyzed using a multivariate logistic regression model.

RESULTS

Few women had received at least one dose of HPV vaccine among the 1347 respondents. Age at first sexual intercourse ≥ 20 y, participating in cervical cancer screening, higher education level, being born in Quebec and some positive beliefs about HPV were associated with vaccination.

CONCLUSIONS

The rate of immunization in women who had to pay for the HPV vaccine was very low and was associated with characteristics that are generally associated with a lower risk for HPV infection and cervical cancer. Efforts are needed to reach at-risk adult women.

Knowledge of HPV infection and vaccination among vaccinated and unvaccinated teenaged girls

OBJECTIVE

To assess the knowledge of teenaged girls on human papillomavirus (HPV) infection and vaccination 12 months after the start of a vaccine administration and information campaign.

METHODS

Between May 15 and June 15, 2009, an anonymous questionnaire was given to 629 girls attending a secondary school in a northeastern Italian city (286 were vaccinated against HPV, 343 were unvaccinated) to investigate their knowledge on HPV infection, transmission, prevention, vaccination, and post-vaccination behaviors. The responses were evaluated with respect to the vaccination status of the participants.

RESULTS

Vaccinated teenaged girls had no more knowledge than unvaccinated ones about the route of HPV transmission, and the relationship between HPV and AIDS. Vaccinated girls had less knowledge than unvaccinated girls about preventing transmission by condom (P=0.003) and about the correlation between HPV and penile cancer (P=0.034) and warts (P=0.001). Furthermore, compared with unvaccinated girls, more vaccinated girls believed that contraceptive pills might prevent HPV-related disease (P=0.001). Vaccinated girls better understood the importance of performing regular Pap smears after vaccination (P=0.021).

CONCLUSION

Knowledge on HPV infection and vaccination remains suboptimal, especially among vaccinated teenaged girls, despite a broad information campaign. Misconceptions about the utility of secondary prevention may increase risky sexual behaviors.

What the world's religions teach, applied to vaccines and immune globulins

For millennia, humans have sought and found purpose, solace, values, understanding, and fellowship in religious practices. Buddhist nuns performed variolation against smallpox over 1000 years ago. Since Jenner developed vaccination against smallpox in 1796, some people have objected to and declined vaccination, citing various religious reasons. This paper reviews the scriptural, canonical basis for such interpretations, as well as passages that support immunization. Populous faith traditions are considered, including Hinduism, Buddhism, Jainism, Judaism, Christianity, and Islam. Subjects of concern such as blood components, pharmaceutical excipients of porcine or bovine origin, rubella strain RA 27/3, and cell-culture media with remote fetal origins are evaluated against the religious concerns identified. The review identified more than 60 reports or evaluations of vaccine-preventable infectious-disease outbreaks that occurred within religious communities or that spread from them to broader communities. In multiple cases, ostensibly religious reasons to decline immunization actually reflected concerns about vaccine safety or personal beliefs among a social network of people organized around a faith community, rather than theologically based objections per se. Themes favoring vaccine acceptance included transformation of vaccine excipients from their starting material, extensive dilution of components of concern, the medicinal purpose of immunization (in contrast to diet), and lack of alternatives. Other important features included imperatives to preserve health and duty to community (e.g., parent to child, among neighbors). Concern that 'the body is a temple not to be defiled' is contrasted with other teaching and quality-control requirements in manufacturing vaccines and immune globulins. Health professionals who counsel hesitant patients or parents can ask about the basis for concern and how the individual applies religious understanding to decision-making about medical products, explain facts about content and processes, and suggest further dialog with informed religious leaders. Key considerations for observant believers for each populous religion are described.

Sexual activity-related outcomes after human papillomavirus vaccination of 11- to 12-year-olds

OBJECTIVE

Previous surveys on hypothesized sexual activity changes after human papillomavirus (HPV) vaccination may be subject to self-response biases. To date, no studies measured clinical markers of sexual activity after HPV vaccination. This study evaluated sexual activity-related clinical outcomes after adolescent vaccination.

METHODS

We conducted a retrospective cohort study utilizing longitudinal electronic data from a large managed care organization. Girls enrolled in the managed care organization, aged 11 through 12 years between July 2006 and December 2007, were classified by adolescent vaccine (HPV; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed; quadrivalent meningococcal conjugate) receipt. Outcomes (pregnancy/sexually transmitted infection testing or diagnosis; contraceptive counseling) were assessed through December 31, 2010, providing up to 3 years of follow-up. Incidence rate ratios comparing vaccination categories were estimated with multivariate Poisson regression, adjusting for health care-seeking behavior and demographic characteristics.

RESULTS

The cohort included 1398 girls (493 HPV vaccine-exposed; 905 HPV vaccine-unexposed). Risk of the composite outcome (any pregnancy/sexually transmitted infection testing or diagnosis or contraceptive counseling) was not significantly elevated in HPV vaccine-exposed girls relative to HPV vaccine-unexposed girls (adjusted incidence rate ratio: 1.29, 95% confidence interval [CI]: 0.92 to 1.80; incidence rate difference: 1.6/100 person-years; 95% CI: -0.03 to 3.24). Incidence rate difference for Chlamydia infection (0.06/100 person-years [95% CI: -0.30 to 0.18]) and pregnancy diagnoses (0.07/100 person-years [95% CI: -0.20 to 0.35]), indicating little clinically meaningful absolute risk differences.

CONCLUSIONS

HPV vaccination in the recommended ages was not associated with increased sexual activity-related outcome rates.

Human papillomavirus vaccination and sexual behaviour: cross-sectional and longitudinal surveys conducted in England

OBJECTIVE

To examine whether HPV vaccination influences sexual behaviour in adolescent girls, either by giving them a 'green light' to have sex, or because perceived protection afforded by the vaccine permits compensatory risky sexual behaviour.

DESIGN

Cross-sectional and longitudinal surveys.

SETTING

Seven English schools.

MAIN OUTCOME MEASURES

Self-reported sexual behaviour.

PARTICIPANTS

The cross-sectional survey included 1053 girls (mean age 17.1 years) who had (n=433 recruited in March 2010) or had not (n=620 recruited in March 2009) been offered the HPV vaccine. The longitudinal survey included 407 girls (mean age 17.5 years) who had been offered HPV vaccination and had either received at least one dose (n=148) or had not received any doses (n=259).

RESULTS

In the cross-sectional survey, the group of girls who had been offered the HPV vaccine were no more likely to be sexually active than the group of girls who had not been offered the HPV vaccine. In the longitudinal survey, the vaccinated group were no more likely to have changed their condom use or increased their total number of sexual partners than the unvaccinated group.

CONCLUSIONS

Neither being offered the HPV vaccine nor receiving it affected sexual behaviour.