An update on human papillomavirus vaccine uptake among 11-17 year old girls in the United States: National Health Interview Survey, 2010

Are HPV Vaccines Well Accepted among Parents of Adolescent Girls in China? Trends, Obstacles, and Practical Implications for Further Interventions: A Five-Year Follow-Up Study

BACKGROUND

In 2020, the WHO proposed the global strategic goal of accelerating the elimination of cervical cancer (CC). One of the key strategies is that, by 2030, 90% of girls will complete HPV vaccination by age 15. In 2017, HPV vaccines were first marketed in China.

OBJECTIVES

This study aimed to explore the changes in parents' knowledge about CC, HPV, HPV vaccines, and acceptance of HPV vaccination 5 years after the introduction of HPV vaccines into China. Associated factors and reasons for refusal by parents were also explored.

METHODS

A school-based follow-up study was conducted among parents in China from May 2018 to May 2023. Comparison using Chi-square tests was performed to measure the changes. Univariate and multivariate analyses were used to explore factors associated with HPV vaccination among teenage girls.

RESULTS

The overall cognitive level in terms of CC- and HPV-related knowledge among parents increased, and they expressed more willingness to vaccinate their daughter (35.4% in 2018 vs. 56.6% in 2023). The HPV vaccination rate among teenage girls remained at a low level (4.4% in 2018, 9.8% in 2023). The main obstacles reported by parents were limited knowledge (42.0%), scarcity of the HPV vaccine (29.2%), waiting until their daughter was older (27.5%), safety concerns (14.7%), high cost (9.0%), and effectiveness concerns (4.6%). Parents who are elderly, local residents, have received HPV vaccines themselves, have had experience of vaccinating their children with influenza vaccines, and have a higher knowledge level of CC, HPV and HPV vaccines are more likely to vaccinate their children with HPV vaccines.

CONCLUSIONS

Although we observed an increment in parents' knowledge level in terms of CC, HPV, HPV vaccines, and HPV vaccine uptake over the past 5 years, the HPV vaccine coverage among girls still falls short of the WHO's 2030 target. Comprehensive intervention strategies, including tailored health education among adolescents and their parents, doctor recommendations, and providing financial subsidies or free HPV vaccines are needed in China.

Factors associated with first-generation immigrant parents' unwillingness to vaccinate their daughters for HPV

Purpose

Human papillomavirus (HPV) vaccination rates for children of immigrant parents are substantially lower than US peers. This study aimed (1) to assess the prevalence of immigrant parents' unwillingness to vaccinate their daughters, (2) to compare by race/ethnicity the prevalence of immigrant parents' unwillingness to vaccinate their daughters, and (3) to examine predictors of the unwillingness stratified by race/ethnicity.

Method

This study conducted a secondary analysis of data from the Health Information National Trends Survey (HINTS). HPV-related data were extracted and analyzed from first-generation immigrant parents (n = 784) with daughters 11-12 years of age.

Results

The frequency of unwillingness was high for all racial/ethnic groups (43-58%). Non-Hispanic White and Asian parents who were aware of or heard about the HPV vaccine were less likely to be unwilling to vaccinate their daughters. Also, older Hispanic immigrant parents were more likely to be unwilling to vaccinate their daughters for HPV.

Conclusion

To curb future incidences of HPV-related cervical cancers among second-generation immigrant women, efforts are needed to encourage first-generation immigrant parents to presently vaccinate their daughters for HPV.

Sociocultural-psychological predictors influencing parents' decision-making regarding HPV vaccination for their adolescent daughters in mainland China: An extended TPB model

Introduction

Enhancing human papillomavirus (HPV) vaccine uptake rates to protect women's health is an important public health issue worldwide. China has taken a series of measures in recent years to promote HPV vaccination among school-aged girls, but the vaccine uptake rate remains low. Investigating the factors influencing vaccination-related decision-making of adolescent girls' parents is key to solving the problem. This study aimed to examine the influence of sociocultural-psychological predictors, including exposure to HPV-related stories (positive/negative), affective reactions (pride/regret), injunctive norms on the Internet and perceived moral obligation, on parents' HPV vaccination-related decision-making for girls aged 13-15 years in mainland China.

Methods

A cross-sectional online survey using quota sampling was conducted in February 2022. Four hundred and five valid and qualified questionnaires were obtained. Partial least squares structural equation modeling was performed by SmartPLS 3 (i) to evaluate the reliability and validity of the measurement models of 11 constructs, and (ii) to test the effect relationships of the sociocultural-psychological predictors on parents' intention to vaccinate their daughters.

Results

The study findings showed that parental decision-making regarding HPV vaccination was influenced by sociocultural and psychological factors. At the level of individual psychological factors, exposure to positive stories was significantly associated with perceived vaccine effectiveness (β = 0.331, t = 8.448, p < 0.001), which strongly predicted the attitude toward vaccination (β = 0.521, t = 8.133, p < 0.001); anticipated pride had more positive influence on vaccination-related decision-making (β = 0.156, t = 2.176, p < 0.05) than anticipated regret. In terms of social influence, injunctive norms on the Internet had a significantly positive influence on vaccination intention (β = 0.127, t = 2.382, p < 0.05), similar to descriptive norms (β = 0.135, t = 3.358, p < 0.01). Perceived moral obligation at the cultural level was the strongest predictor of parental decision-making regarding HPV vaccination (β = 0.193, t = 2.139, p < 0.05).

Discussion

This study is the first in mainland China to systematically examine the sociocultural-psychological predictors of parents' decision-making to vaccinate their 13-15-year-old daughters against HPV. A new extended TPB model with a sociocultural-psychological approach was developed. This model can support the investigation of factors affecting HPV vaccine uptake rates in the mainland Chinese population and similar populations and help to understand the differences in vaccination-related decision-making between Eastern and Western cultures. Furthermore, the study provided some suggestions for HPV vaccination communication campaigns targeting adolescent girls' parents.

Health literacy and its association with human papilloma virus vaccination among adults: Findings from the behavioral risk factor surveillance system

Health literacy is associated with the utilization of preventive health services. We examined the association between health literacy (HL) levels and receipt of at least one dose of the human papilloma virus (HPV) vaccination. We analyzed the data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS) among adults aged 18 to 32. The primary outcome variable was the 'yes/no' response to the question that assessed whether the participant received at least the first dose of HPV vaccination. The primary independent variable was a summative HL score (range 3 through 12) we created for each respondent by adding the scores for all three HL questions. We performed bivariate and multivariable (logistic regression) analyses to examine the relationship between study variables. The analytical sample of 6,731 adults aged 18 to 32 met the eligibility criteria. Regression analyses showed that the odds of having received at least one dose of HPV vaccination increased by 13% for every unit increase in health literacy score (Odds ratio: 1.13, 95% CI:1.06-1.21, p < .0001). Age, gender, marital status, race/ethnicity, insurance status, and having regular access to a personal doctor were predictors of HPV vaccination status. This study showed that higher levels of HL may contribute to the uptake of at least one dose of the HPV vaccine. Health care and public health organizations, health care professionals, and policymakers should emphasize improving the health literacy levels of the patients and the public to increase the uptake of the HPV vaccine.

Exploring Cultural Factors of Human Papillomavirus Vaccination Acceptance in African Americans: An Integrative Review

INTRODUCTION

Human papillomavirus (HPV) vaccine can prevent HPV-related cancers. However, African Americans (AA) have a 30% higher incidence of HPV-related cervical cancer than Whites. The purpose of this integrative review is to explore cultural factors and beliefs impacting HPV vaccine decisions in AA adults.

METHODOLOGY

The Whittemore & Knafl model guided this review. Databases searched were PubMed, CINAHL, and Embase. Key terms included "human papillomavirus," "vaccine," "cultural values," "African American," and "adult." Inclusion criteria were AAs aged 18 years and over living in the United States.

RESULTS

A total of 634 articles were identified, and 20 studies published from 2010 to 2020 were used. Common factors influencing HPV vaccine decisions included religion, knowledge, physician recommendation, social network, attitudes, mistrust, benefits, and safety.

DISCUSSION

Limitations included omission of articles lacking AA representation, limited databases searched, and one-author-evaluated studies. Future studies to discover additional cultural factors influencing HPV vaccine acceptance are critical.

Development and Implementation of an HPV Vaccination Survey for American Indians in Cherokee Nation

Improving human papillomavirus (HPV) vaccination rates is a public health priority and a crucial cancer prevention goal. We designed a survey to estimate HPV vaccination coverage and understand factors associated with HPV vaccination among American Indian adolescents aged 9 to 17 years in Cherokee Nation, United States. The final survey contains 37 questions across 10 content areas, including HPV vaccination awareness, initiation, reasons, recommendations, and beliefs. This process paper provides an overview of the survey development. We focus on the collaborative process of a tribal-academic partnership and discuss methodological decisions regarding survey sampling, measures, testing, and administration.

Geographic Variation in Human Papillomavirus Vaccination Initiation and Completion Among Young Adults in the U.S

INTRODUCTION

This study explores how human papillomavirus vaccination initiation and completion among men and women aged 18-34 years varies by geographic region.

METHODS

Data from the 2015-2017 Behavioral Risk Factor Surveillance System were analyzed. Geographic regions for the selected states were defined as South, Northeast, and Midwest/West. Human papillomavirus vaccination initiation was defined as receipt of ≥1 dose, and completion was defined as receipt of ≥3 doses. Weighted, multivariable logistic regression models estimated the association between geographic region and vaccine uptake, adjusting for sociodemographic, health, and healthcare factors. Analyses were performed in November 2019.

RESULTS

A total of 18,078 adults were included in the study, 80% of whom resided in the South. The overall vaccination initiation rate was 23.4%, and the completion rate was 11.0%. Initiation was higher among those who resided in the Northeast (38.6%), followed by Midwest/West (23.8%), and lowest for those in the South (21.8%) (p<0.0001). Completion rates followed the same trend as initiation. In the adjusted models, compared with the adults residing in the Northeast, those living in the South were less likely to initiate (AOR=0.47, 95% CI=0.40, 0.55) and complete (AOR=0.56, 95% CI=0.46, 0.68) human papillomavirus vaccination.

CONCLUSIONS

Human papillomavirus vaccine uptake was low for all regions, but vaccine uptake was significantly lower in the South region. This demonstrates the need to identify barriers specifically associated with the Southern population, which may include differing levels of education and insurance. Such work is especially pertinent because many Southern states face increased risk of human papillomavirus-associated cancers such as cervix and oral cavity and pharynx cancers.

Educational intervention for increasing knowledge of human papillomavirus and vaccination amongst parents of first year high school students in Croatia

BACKGROUND

In Croatia, the human papillomavirus (HPV) vaccine became available through a publicly funded national programme during the 2015/2016 school year among boys and girls in the first year high school. Improved parental awareness of HPV and vaccination could help increase the uptake of the vaccination. The primary aim of this study is to establish the importance of educating parents for a greater response to the voluntary vaccination.

METHODS

Parents of students in the first year of high school evaluated the educational lessons in the spring of 2016 in 11 counties coordinated by the Croatian Institute of Public Health: total of 36 doctors from 11 counties. Statistical significance was tested using chi-squared test.

RESULTS

In total, 3350 evaluations were submitted (82.7%). Parents with a positive attitude towards vaccination following the education more often stated the lesson contributed to this attitude than parents with a negative attitude (P < 0.001). Results show that counties with highest attendance had highest rates of vaccination (Sisačko-moslovačka 1.74 highest and Dubrovačko-Neretvanska 0.03 lowest).

CONCLUSION

Our study shows that parents have the impression an educational lesson can contribute to the development of their positive attitude towards vaccination. Further research should be aimed at disparities and how to target these with appropriate interventions.

Association of human papillomavirus vaccination with exposure to dental or medical visits

BACKGROUND

Human papillomavirus (HPV) infection is associated with oropharyngeal cancers. The Centers for Disease Control and Prevention (CDC) estimate that >15,000 new cases of HPV-associated oropharyngeal cancers are diagnosed in the United States annually. We evaluated an association between HPV vaccination and dental visits in the previous year.

METHODS

Data were analyzed from the 2012, 2014, and 2016 Massachusetts Behavioral Risk Factor Surveillance System (MA-BRFSS) datasets. We created four categories of exposures to healthcare services in the past 12 months: a) both medical and dental visits, b) medical visit only, c) dental visit only, d) neither. Outcomes were HPV vaccination ever or influenza vaccination within the past 12 months. Logistic regression, controlled for race and education, was used to measure the association between medical/dental visits and vaccination status. Separate models were generated by sex.

RESULTS

Crude and adjusted odds ratio of influenza and HPV vaccination were highest among males and females with both medical and dental visits. Women with both medical and dental provider visits had 3.7 times higher odds of being vaccinated for influenza and 1.7 times higher odds of being vaccinated for HPV. There were no differences in crude or adjusted odds among both males and females if the type of healthcare visits were only medical or only dental.

CONCLUSION

No difference in association between vaccination and medical or dental healthcare exposures suggests that oral health professionals might partner in promotion of positive health behaviors, including HPV vaccination. The type of provider did not affect the outcome as per this study.

HPV Vaccine Delivery Practices by Primary Care Physicians

BACKGROUND AND OBJECTIVES

To examine, among pediatricians and family physicians (FPs) (1) human papillomavirus (HPV) vaccine delivery practices, (2) delivery experiences, and (3) attitudes regarding new 2-dose HPV vaccination schedules.

METHODS

We surveyed nationally representative networks of pediatricians and FPs by Internet or mail from July 2018 to September 2018. Multivariable regression was used to assess factors associated with refusal or deferral rates of ≥50% among 11- to 12-year-old patients.

RESULTS

The response rate was 65% (302 pediatricians and 228 FPs included). Pediatricians who strongly recommended the HPV vaccine ranged from 99% for patients ≥15 years old (female) to 83% for those 11 to 12 years old (male); FPs ranged from 90% for patients ≥15 years old (female) to 66% for those 11 to 12 years old (male) (P < .0001 between specialties). Sixty-five percent of pediatricians and 42% of FPs always or almost always used presumptive style when discussing the HPV vaccine (P < .0001). Overall, 40% used standing orders and 42% had electronic alerts. Among pediatricians, the proportion reporting a refusal or deferral rate ≥50% was 19% for female patients and 23% for male patients 11 to 12 years old; FPs reported 27% and 36%, respectively. In the multivariable regression (both sexes), refusal or deferral was associated with physicians not strongly recommending the HPV vaccine to 11- to 12-year-old patients, not using a presumptive style, perceiving less resistance when introducing the HPV vaccine to a 13-year-old patient versus an 11- or 12-year-old patient, and anticipating an uncomfortable conversation when recommending the HPV vaccine to an 11- or 12-year-old patient. Eighty-nine percent of pediatricians and 79% of FPs reported that more adolescents <15 years old are completing the HPV series now that only 2 doses are recommended.

CONCLUSIONS

Although most physicians strongly recommend the HPV vaccine to 11- to 12-year-old patients, our data reveal areas for improvement in recommendation and delivery methods. Most physicians perceive that the 2-dose schedule is resulting in higher HPV completion rates.

Insurance reimbursements for human papillomavirus vaccination in the private sector, 2007-2014

This study aims to assess payments to private providers for HPV vaccination. We used the 2007–2014 MarketScan Commercial Claims and Encounters Database and included 3,456,180 HPV vaccination visits made by adolescents aged 11–17 years and enrolled in a non-capitated insurance plan in 37 states. We examined insurance reimbursements and its time trend for vaccine purchase and vaccine administration. Using the vaccine purchase price published by the Centers for Disease Control and Prevention (CDC) and the vaccination payment recommended by the American Academy of Pediatrics (AAP), we evaluated the financial concerns of administering HPV vaccines among private providers. In 2007–2014, the mean vaccine purchase reimbursement was $159.17 and the mean vaccine administration reimbursement was $23.91. During the study period, vaccine purchase reimbursements did not significantly change, but vaccine administration reimbursements increased. On average, 89.9% of the HPV claims received vaccine purchase reimbursements greater than the CDC-published price and 14.1% of HPV claims received vaccine purchase reimbursements above the AAP-recommended payment. Our results suggest that private providers are likely to receive sufficient reimbursements to cover the costs of administering HPV vaccines. However, the profit margin is likely to be small.

Are we speaking the same language? an argument for the consistent use of terminology and definitions for childhood vaccination indicators

Vaccination indicators are used to measure the health status of individuals or populations and to evaluate the effectiveness of vaccination programs or policies. Ensuring that vaccination indicators are clearly and consistently defined is important for effective communication of outcomes, accurate program evaluation, and comparison between different populations, times, and contexts. The purpose of this commentary is to describe commonly used vaccination indicators and to highlight inconsistencies in how childhood vaccine researchers use and define these terms. The indicators we describe are vaccine coverage, uptake, and rate; vaccination status, initiation, and completion; and up-to-date, timely, partial, and incomplete vaccination. We conclude that many vaccination indicators are not explicitly defined within published research studies and/or are used quite differently across studies. We also note that the choice of indicator in a given study is often driven by program or vaccine specific factors, may be constrained by data availability, and should be chosen to best reflect the outcome of interest. We conclude that the use of consistent language and definitions would promote more effective communication of research findings. We also propose some standardized definitions for common indicators, with the goal of provoking discussion and debate on the issue.

Barriers to HPV Vaccination Among Unvaccinated, Haitian American College Women

Background: Haitian women residing in the United States are disproportionately affected by cervical cancer. Human papillomavirus (HPV) vaccine has been licensed in the United States since 2006. Vaccination rates are less than optimal overall, and the rates are particularly low among young black women. We investigated barriers to HPV vaccination in a sample of Haitian American college women. Methods: Thirty self-identified Haitian American women, aged 17-26 years, were recruited from a large university campus in southeastern United States (n=30). They completed in-depth face-to-face interviews. The research team analyzed the transcripts using thematic analysis. Results: More than half of the participants (n=18) had not yet initiated the HPV vaccine series. Most of the unvaccinated participants stated that they had received a provider recommendation for the vaccine. Lack of provider recommendation, negative vaccine perception and attitudes, and side effect concerns constituted barriers to vaccination. Conclusions: Haitian American college women at high risk of cervical cancer have cited several barriers to HPV vaccination, with the most prominent being lack of physician recommendation. Healthcare providers should continue recommending the vaccine to college women as many of them may not have received a recommendation. When recommending the HPV vaccine, discussions should be framed with the intent to positively influence HPV vaccine perceptions and ultimately vaccine attitudes.

On surmounting the barriers to HPV vaccination: we can do better

The major impediment to increased human papillomavirus (HPV) vaccination coverage in young males and females is lack of health care provider recommendation. Despite its efficacy in preventing cervical cancer, HPV vaccination in females (49.5%) and males (37.5%) ages 13 through 17 falls well below the Centers for Disease Control and Prevention's (CDC) Healthy People 2020 target of 80% coverage. Parents' willingness to vaccinate their child has been shown to be much higher when physicians share personal vaccination decisions for their own children as well as what other parents have done at that particular clinic. Furthermore, the vaccine must be presented presumptively as a "bundle" along with the rest of the standard adolescent vaccine panel. Multiple exemplars presented including in several European countries, low-income countries and Rwanda, demonstrate that school-based health care systems dramatically increase vaccination coverage. Finally, acceptability for vaccination of males must improve by increasing provider recommendation and by presenting the HPV vaccine as a penile, anal and oropharyngeal cancer prevention therapy in males and not merely a vaccine to prevent cervical cancers in females. Paediatricians, obstetrician/gynaecologists and primary care physicians should consider these data as a call-to-action. Key messages   • Despite recent efforts in the US, only 49.5% of females and only 37.5% of males ages 13 through 17 have received all recommended HPV vaccine doses. These numbers fall well below the 80% target set forth by the Healthy People 2020 initiative.   • According to the CDC, if health care providers increase HPV vaccination rates in eligible recipients to 80%, it is estimated that an additional 53,000 cases of cervical cancer could be prevented during the lifetime of those younger than 12 years. Furthermore, for every year that the vaccination rate does not increase, an additional 4400 women will develop cervical cancer.   • First and foremost, healthcare providers (HCPs) must make a strong recommendation to vaccinate patients and these recommendations must become routine, including for males.   • It is clear that HPV vaccination rates improve significantly when vaccine administration occurs at designated, well-organized sites such as school-based vaccination programmes. Furthermore, HPV vaccination should be a high school requirement and offered in the standard adolescent vaccine panel as a bundle with Tdap and MenACWY vaccines in order to promote maximum adherence.   • Finally, research on immunogenicity and antibody titre longevity needs to be done in newborns. The HPV vaccine may be recommended in the newborn panel of vaccines to avoid any issues of sexualization and misplaced fears of sexual disinhibition, akin to the success of the Hepatitis B vaccine in the 1980s.   • The HPV vaccine is a vaccine against cancer and should be aggressively marketed as such. As healthcare providers, we need to make every effort to overcome barriers, real or perceived, to protecting our population from potential morbidity and mortality associated with this virus.

HPV Literacy and Associated Factors Among Hmong American Immigrants: Implications for Reducing Cervical Cancer Disparity

Previous studies show that certain minority and ethnic communities experience low human papillomavirus (HPV) vaccination rates despite a higher cervical cancer burden. HPV is known to be responsible for almost all cervical cancer cases. Hmong Americans, a growing Asian American population, appear to be at increased risk. The cervical cancer incidence rate among Hmong American women is three times higher than other Asian/Pacific Islanders and more than four times higher than Non-Hispanic Whites. Despite such alarming statistics, there is limited research focusing on HPV literacy and its associated factors in the Hmong American community. This study's objectives are to investigate: (1) the level of HPV knowledge among Hmong Americans; (2) HPV vaccination initiation and completion rates of Hmong Americans; and (3) factors associated with HPV literacy in the Hmong American community. Andersen's Behavioral Model of Health Services Use was used as the study's theoretical framework. A self-administered paper and online health survey was completed by192 Hmong Americans living in a major metropolitan area in Minnesota. Results revealed a mean score of 4.76 (SD 1.67) for the 7-item questionnaire measuring HPV knowledge. The HPV vaccination initiation rate was 46.3 % (n = 56), with 32.7 % completing the recommended three doses. Multiple regression analysis found that participants' level of education, number of doctor visits, and cervical cancer screening literacy were significantly associated with HPV knowledge. This study's results indicate the important role of health providers in educating Hmong Americans patients about HPV and cervical cancer prevention to decrease the cervical cancer burden in this high-risk population.

A systematic review of factors influencing human papillomavirus vaccination among immigrant parents in the United States

To critically appraise factors influencing human papillomavirus (HPV) vaccination among immigrant parents in the United States, a comprehensive search of electronic databases and reference lists was conducted. The findings from 22 articles were ordered based on a socioecological model. About 30% of children initiated and 14% completed a three-dose series. Correlates of HPV vaccine initiation rates included lack of information, concerns about vaccine safety and promiscuity, providers' recommendations, school mandates, financial issues, immigration laws, and living in disadvantaged neighborhoods. Upstream initiatives embracing cultural descriptors could facilitate HPV vaccination, reducing HPV-related disparities in cancer among immigrants in the US.

The Power and Pitfalls of Big Data Research in Obstetrics and Gynecology: A Consumer's Guide

IMPORTANCE

Research in obstetrics and gynecology (OB/GYN) increasingly relies on "big data" and observational study designs. There is a gap in practitioner-relevant guides to interpret and critique such research.

OBJECTIVE

This guide is an introduction to interpreting research using observational data and provides explanations and context for related terminology. In addition, it serves as a guide for critiquing OB/GYN studies that use observational data by outlining how to assess common pitfalls of experimental and observational study designs. Lastly, the piece provides a compendium of observational data resources commonly used within OB/GYN research.

EVIDENCE ACQUISITION

Review of literature was conducted for the collection of definitions and examples of terminology related to observational data research. Data resources were collected via Web search and researcher recommendations. Next, each data resource was reviewed and analyzed for content and accessibility. Contents of data resources were organized into summary tables and matched to relevant literature examples.

RESULTS

We identified 26 observational data resources frequently used in secondary analysis for OB/GYN research. Cost, accessibility considerations for software/hardware capabilities, and contents of each data resource varied substantially.

CONCLUSIONS AND RELEVANCE

Observational data sources can provide researchers with a variety of options in tackling their research questions related to OB/GYN practice, patient health outcomes, trends in utilization of medications/procedures, or prevalence estimates of disease states. Insurance claims data resources are useful for population-level prevalence estimates and utilization trends, whereas electronic health record-derived data and patient survey data may be more useful for exploring patient behaviors and trends in practice.

Timing Is Everything: Exploring Parental Decisions to Delay HPV Vaccination

The delayed uptake of the human papillomavirus (HPV) vaccine offers an opportunity to explore how temporality and risk are at work in everyday life. Drawing from a mixed-methods study with parents ( N = 50) in Northern California, this study explored parents' decision to delay HPV vaccination for their children among parents who had not yet vaccinated ( n = 27). At the core of these decisions were temporal assessments of risk whereby parents weighed their child's (perceived) present risk of HPV exposure against the uncertain perceived risks of the vaccine itself. Our findings are promising as they indicate that given time, and the continued growth of evidence regarding the safety and effectiveness of HPV vaccination, completion rates should increase. However, our results also suggest that vaccination delays are not merely a matter of scientific doubt but also based on parents' (potentially inaccurate) perceptions of their child's sexual readiness, and thus potentially more difficult to overcome.

Human Papillomavirus Vaccination in Washington State: Estimated Coverage and Missed Opportunities, 2006-2013

OBJECTIVE

Human papillomavirus (HPV) causes almost all cervical cancer in women and contributes to vaginal, anal, oropharyngeal, and penile cancer morbidity and mortality. Although vaccines effective in preventing up to nine types of HPV are available, vaccination rates are low nationally. We assessed HPV vaccination coverage by age, sex, and county using Washington State Immunization Information System data.

METHODS

We calculated on-time dose coverage by county and statewide among adolescents aged 11-12 years and assessed coverage by age 18 years. We calculated missed opportunities as the number of visits at which doses of other adolescent vaccines were administered without administration of the first dose of HPV vaccine (HPV1).

RESULTS

In 2013, HPV vaccination coverage estimates with one, two, and three doses (HPV1-3) for adolescents aged 11-12 years were 48.5%, 32.4%, and 18.3% among girls and 31.2%, 17.1%, and 8.1% among boys. The three-dose HPV vaccine coverage estimate increased to 40.1% among girls by age 18 but was unchanged for boys. Coverage estimates varied by age, sex, and county. One-third of eligible unvaccinated girls and two of five eligible boys aged 11-17 years had at least one missed opportunity to receive HPV1.

CONCLUSION

Despite a recommendation to vaccinate adolescents aged 11-12 years, HPV vaccination is often delayed and coverage levels among all age groups are below national target levels. Improved understanding of the variability of HPV vaccination coverage rates by age, sex, and county can inform targeted interventions statewide.

A study of physicians' experiences with recommending HPV vaccines to adolescent boys

Assessing physicians' experiences in HPV vaccine recommendation and delivery to adolescent boys is essential to providing an understanding of the issues of vaccine acceptance and an insight for policymakers to enhance HPV vaccinations among adolescent boys. Between January and April 2014 a mail survey was conducted using physicians in Malaysia known to provide either one or both HPV vaccine (Gardasil and Cervarix) immunisation services. A total of 357 completed questionnaires were received (response rate 22.5%). Of these, 335 physicians see adolescent boys aged 11 to 18 years old in their practice. Only 26.3% (n = 88) recommended the HPV vaccine to these boys. A total of 46.6% (n = 41) have successfully given the HPV vaccine to adolescent boys. A lack of proper guidelines from the health authorities regarding the recommendation of HPV vaccine to the boys (37.2%) and a lack of awareness of the availability of the vaccine for boys (32.8%) were the most commonly cited reasons for non-recommendation. Impact statement Recommending the HPV vaccine for adolescent boys remains a challenge for physicians. Our study provides evidence of challenges and barriers faced by Malaysian physicians who recommend the HPV vaccines (Gardasil and Cervarix) in their practices. In this study, physicians reported HPV vaccine uptake by adolescent boys was very poor. A lack of proper guidelines from the health authorities regarding the recommendation of HPV vaccine to boys and a lack of awareness of the availability of the vaccine for boys were the most commonly cited reasons for non-recommendation. Physicians viewed that support and encouragement from the health authorities are needed to promote the recommendation of the HPV vaccine to adolescent boys. Physicians were also of the opinion that the lay public should be educated about the availability of the HPV vaccine for boys, and its benefits, safety and efficacy, and the high susceptibility of boys to getting HPV infections. The findings provide insights that could be helpful to policymakers or high-level decision-makers of the potential strategies to enhance HPV uptake among adolescent boys.

Factors Associated With Parents' Intent to Vaccinate Adolescents for Human Papillomavirus: Findings From the 2014 National Immunization Survey-Teen

Introduction

While factors associated with receipt of human papillomavirus (HPV) vaccination have been well characterized, less is known about the characteristics associated with parents’ intent to have their adolescent children vaccinated. This study aimed to examine factors associated with parental intention toward HPV vaccination.

Methods

We analyzed data on 10,354 adolescents aged 13 to 17 years from the 2014 National Immunization Survey–Teen. Weighted multivariable logistic regression was used to examine associations between sociodemographic characteristics of mothers and adolescents, as well as a health care provider recommendation with parents’ intention to have their children receive HPV vaccine.

Results

Among unvaccinated adolescents, Hispanic ethnicity (boys adjusted odds ratio [AOR], 1.87, 95% confidence interval [CI], 1.34–2.61; and girls AOR, 1.57; 95% CI, 1.05–2.35), mothers with less than a high school diploma (boys AOR, 2.41; 95% CI, 1.58–3.67; and girls AOR, 1.86; 95% CI, 1.02–3.38), and having a health care provider recommend the vaccine (boys AOR, 1.87; 95% CI, 1.52–2.31; and girls AOR, 1.38; 95% CI, 1.05–1.82) were significantly associated with parents’ intention to have their adolescent child vaccinated within the next 12 months. In addition, non-Hispanic black race was a significant predictor of parents’ intent to vaccinate for boys (AOR, 1.89; 95% CI, 1.35–2.65).

Conclusion

Maternal education and Hispanic ethnicity were the strongest predictors of parental intent to vaccinate against HPV, followed by provider recommendation. As HPV vaccination rates in the United States remain below the Healthy People 2020 goal, messages may need to be targeted based on maternal education, race/ethnicity, and provider recommendation.

Human Papillomavirus Vaccination Among Adults and Children in 5 US States

CONTEXT

The Centers for Disease Control and Prevention Advisory Committee for Immunization Practices has recommended human papillomavirus (HPV) vaccines for use in children and young adults for preventing HPV-related diseases, but HPV vaccine coverage is low in the United States.

OBJECTIVE

To assess HPV vaccination among US adults and children and to identify characteristics associated with HPV vaccination.

METHODS

We used the 2010 Behavioral Risk Factors Surveillance System data to examine HPV vaccine initiation and completion among adults aged 18 to 26 years and children aged 9 to 17 years in 5 US states. We performed a multivariate logistic regression to evaluate factors associated with HPV vaccination.

RESULTS

We assessed the HPV vaccination status of 706 women and 560 men and 2201 girls and 2292 boys. In 2010, a total of 258 (41.6%) women and 21 (4.3%) men had initiated HPV vaccination. Of those vaccinated women, 182 (75%) completed the 3-dose vaccine series. Rural residence (adjusted odds ratio [aOR] = 0.37) and not having a Papanicolaou test (aOR = 0.44) were negatively associated with HPV vaccine initiation among women. Women who were aged 18 to 20 years (aOR = 2.93) were more likely to complete HPV vaccination. A total of 612 (24.6%) girls and 86 (5.2%) boys received 1 or more doses of HPV vaccines; 308 (50.3%) vaccinated girls and 14 (10.8%) vaccinated boys completed the vaccine series. Younger age (9-12 years: aOR = 0.09) and not receiving a seasonal influenza vaccine (aOR = 0.44) were negatively related to HPV vaccine initiation in girls. Girls were less likely to initiate and complete HPV vaccination if their parents did not have a routine checkup within 1 year.

CONCLUSION

HPV vaccination in the United States remains below the Healthy People 2020 objective (80%). To increase HPV vaccination, strategies still need to focus on improving access to HPV vaccines and utilization of health services.

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.

Factors associated with parental reasons for "no-intent" to vaccinate female adolescents with human papillomavirus vaccine: National Immunization Survey - Teen 2008-2012

Background

1) To identify socio-demographic factors associated with parental “no-intent” for their 13–17 year old unvaccinated daughter to receive the human papillomavirus (HPV) vaccine series within the next twelve months, 2) to describe patterns in “no-intent” by socio-demographic factors, and 3) to identify socio-demographic factors associated with parental reasons for “no-intent”.

Methods

Data from 2008–2012 National Immunization Survey - Teen (NIS - Teen) were examined in this study. Parents with “no-intent” to vaccinate their daughters were asked to identify reasons for their decision. All responses were categorized into five domains identified as barriers to receive the HPV vaccine series: 1) Safety and Effectiveness Concerns; 2) Systemic Barriers; 3) Vaccine Misinformation; 4) Lack of Knowledge about the Vaccine; and 5) Socio-cultural Barriers. Multivariable logistic regression models were performed to address the study objectives.

Results

Number of people in the household, household income, mother’s age, education, health insurance, recommendation of a health care provider, and the survey year were significantly associated with parental “no-intent”. Race/ethnicity, mother’s education, marital status, recommendation of a health care provider, household income, age of the unvaccinated daughter, and the survey year, were significantly associated with one or more domains identified as barriers to receive the HPV vaccine.

Conclusions

This study identified sub-groups of parents across different socio-demographic factors with “no-intent” for their adolescent daughters to receive the HPV vaccine. Developing strategies that target educational tools towards the identified sub-groups of parents about the purpose, safety, and efficacy of the HPV vaccine, and HPV infection, may help increase HPV vaccine acceptance, initiation and completion rates.

Hispanic mothers' beliefs regarding HPV vaccine series completion in their adolescent daughters

Rates of human papillomavirus (HPV) vaccine series completion among adolescent Hispanic females in Texas in 2014 (∼39%) lag behind the Healthy People 2020 goal (80%). This qualitative study identifies Hispanic mothers' salient behavioral, normative and control beliefs regarding having their adolescent daughters complete the vaccine series. Thirty-two mothers of girls (aged 11-17) that had received at least one dose of the HPV vaccine, completed in-depth interviews. Six girls had received one dose of the HPV vaccine, 10 girls had received two doses, and 16 girls had received all three doses. The questions elicited salient: (i) experiential and instrumental attitudes (behavioral beliefs); (ii) supporters and non-supporters (normative beliefs) and (iii) facilitators and barriers (control beliefs). Directed content analysis was employed to select the most salient beliefs. Mothers: (i) expressed salient positive feelings (e.g. good, secure, happy and satisfied); (ii) believed that completing the series resulted in positive effects (e.g. protection, prevention); (iii) believed that the main supporters were themselves, their daughter's father and doctor with some of their friends not supporting series completion and (iv) believed that vaccine affordability, information, transportation, ease of scheduling and keeping vaccination appointments and taking their daughter's immunization card to appointments were facilitators. This study represents the first step in building theory-based framework of vaccine series completion for this population. The beliefs identified provide guidance for health care providers and intervention developers.

Attitudes Regarding HPV Vaccinations of Children among Mothers with Adolescent Daughters in Korea

The aim of this study, carried out before the beginning of human papillomavirus (HPV) vaccinations as a National Immunization Program (NIP) in Korea in 2016, is to assess the ranges of perceptions and personal experience and their influences on attitudes regarding HPV vaccinations of children, among mothers of adolescent (9-14 years of age) daughters in Korea. From November 2015 to February 2016, we distributed a written questionnaire to mothers who had daughters aged 9-14 years. The questionnaire consisted of several questions, related to knowledge of HPV, personal experiences of HPV vaccination, and attitudes toward HPV vaccinations of their adolescent daughters. Of the 260 questionnaires distributed, 140 participants returned answered ones. And although only 51% of participants were aware that cervical cancer is highly related with HPV infection, 70% said they were willing to vaccinate their daughters, showing that awareness does not coincide with intention to vaccinate. Among the participants showing negative attitudes, 50% were concerned about the vaccination side effects. The more the participants' pre-knowledge about HPV infection, and about the relationship of HPV to cervical cancer, the more positive their attitudes (P = 0.002, P < 0.001). Our study showed that, as the level of education rose, the proportion of mothers with negative attitudes toward vaccinating their adolescent daughters rose as well. Thus, the provision of correct education by health care providers and accurate information through active advertising may play an important role in increasing the vaccination rate among adolescent girls in Korea.

HPV vaccine completion and dose adherence among commercially insured females aged 9 through 26 years in the US

BACKGROUND

Although HPV vaccination has been recommended for use in girls and young women since 2007, HPV vaccine uptake is low in the US.

METHODS

We conducted a retrospective cohort study using the 2008-2011 MarketScan data to examine HPV vaccine completion and dose adherence among commercially insured females aged 9-26 years. We performed multivariable logistic regression models to examine factors related to HPV vaccine completion and HPV vaccine dose adherence.

RESULTS

Among 378,484 females aged 9-26 years who initiated HPV vaccination, only 29.4% completed HPV vaccination. Compared with females receiving vaccines from primary care providers, those receiving vaccines from OB/GYN providers were more likely to complete the vaccine series. Age at HPV vaccine initiation, health insurance plan, seasonal pattern, and flu vaccination were also significantly associated with vaccine completion. Among 111,286 females who completed HPV vaccination, 62.4% received all doses within 30 days of the recommended schedules. Similar factors relating to HPV vaccine completion were consistently associated with HPV vaccine dose adherence. However, younger age (<22 years) and receipt of flu vaccine were negatively related to HPV vaccine dose adherence.

CONCLUSIONS

Intervention programs to improve HPV vaccine reminding system and reduce logistic barriers for both physicians and patients are warranted.

Identifying Hispanic mothers' salient beliefs about human papillomavirus vaccine initiation in their adolescent daughters

Guided by the Integrative Model of Behavioral Prediction, we identify mothers' salient beliefs regarding their daughters' initiation of the human papillomavirus vaccine series. In all, 34 Hispanic mothers responded to elicitation questions. Salient beliefs included the following: (1) feeling secure, happy, relieved, concerned, and fear about vaccinating; (2) believing that vaccinating prevents and protects from human papillomavirus but may result in side effects and sexual disinhibition; (3) identifying the daughter, father, mother, aunt, friends, and grandmothers as supporters/non-supporters; and (4) affordability, transportation, clinic distance, and making appointments as facilitators/barriers. This study begins the process of building a model of human papillomavirus vaccine initiation for this population.

Concomitant Adolescent Vaccination in the U.S., 2007-2012

INTRODUCTION

Concomitant (same-day) delivery of two or more vaccines to adolescents is effective, safe, and efficient. Increasing concomitant vaccination could improve coverage for recommended adolescent vaccines, but little is known about who receives vaccines concomitantly.

METHODS

Data came from healthcare provider-verified records on 70,144 adolescents (aged 13-17 years) in the 2008-2012 versions of the National Immunization Survey-Teen who had received at least one dose of tetanus, diphtheria, and acellular pertussis (Tdap) booster; meningococcal conjugate vaccine (MenACWY); or human papillomavirus (HPV) vaccine. Separately for each vaccine, multivariable logistic regression identified adolescent and household correlates of concomitant versus single vaccination, stratified by adolescent sex. Vaccination took place in 2007-2012, data collection in 2008-2012, and data analysis in 2015.

RESULTS

Among vaccinated adolescents, 51%-65% of girls and 25%-53% of boys received two vaccines concomitantly. Concomitant uptake of each vaccine increased over survey years (e.g., 2012 vs 2008: girls' Tdap booster, OR=1.88, 95% CI=1.56, 2.26; boys' Tdap booster, OR=2.62, 95% CI=2.16, 3.16), with the exception of HPV vaccination among boys. Additionally, concomitant vaccination was less common as adolescents got older and in the Northeast (all p<0.05). For MenACWY and HPV vaccine, concomitant uptake was less common for girls whose mothers had higher versus lower education and for boys who lived in metropolitan versus non-metropolitan areas (all p<0.05).

CONCLUSIONS

Missed opportunities for concomitant adolescent vaccination persist, particularly for HPV vaccine. Future interventions targeting groups with low rates of concomitant vaccination could improve population-level coverage with recommended vaccines.

Racial and Ethnic Group Knowledge, Perceptions and Behaviors about Human Papillomavirus, Human Papillomavirus Vaccination, and Cervical Cancer among Adolescent Females

STUDY OBJECTIVE

Human papillomavirus (HPV) vaccines provide an opportunity to greatly reduce the burden of cervical cancer. Although there has been improvement in uptake, there are notable ethnic/racial disparities. This qualitative study was conducted to better understand factors related to vaccine uptake among female adolescents from 3 racial/ethnic groups: African American (AA), Hispanic, and Caucasian. Findings can inform the development of optimal messages and strategies for clinical and population-based interventions.

DESIGN AND SETTING

This mixed-methods descriptive study included completion of a brief structured survey and focus group discussion. Six focus groups were conducted with female adolescents, 2 each in the AA, Hispanic, and Caucasian groups. Brief structured survey questions and the focus group protocol addressed knowledge, perceptions, and behaviors related to HPV, HPV vaccination, and cervical cancer.

PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES

Participants were 60 female adolescents (ages 13-19, mean age = 16.6 years) recruited from high schools, public health clinics, and churches.

RESULTS

Themes across questions were remarkably similar among AA, Hispanic, and Caucasian participants. Each group had high awareness of the terms HPV, HPV vaccination, and cervical cancer, but with little in-depth knowledge about these topics. There was a high acceptance of HPV vaccination. Misperceptions about optimal cervical cancer prevention strategies such as simply knowing one's partner and good hygiene were most common among Hispanic adolescents. Awareness about Pap testing was most common among Caucasian adolescents.

CONCLUSION

Predominantly uniform perceptions of HPV vaccines across racial/ethnic groups suggest a "one size fits all" approach will likely have greater reach with cervical cancer prevention messaging than culturally tailored interventions.

A Drosophila Model of HPV E6-Induced Malignancy Reveals Essential Roles for Magi and the Insulin Receptor

Cervical cancer is one of the leading causes of cancer death in women worldwide. The causative agents of cervical cancers, high-risk human papillomaviruses (HPVs), cause cancer through the action of two oncoproteins, E6 and E7. The E6 oncoprotein cooperates with an E3 ubiquitin ligase (UBE3A) to target the p53 tumour suppressor and important polarity and junctional PDZ proteins for proteasomal degradation, activities that are believed to contribute towards malignancy. However, the causative link between degradation of PDZ proteins and E6-mediated malignancy is largely unknown. We have developed an in vivo model of HPV E6-mediated cellular transformation using the genetic model organism, Drosophila melanogaster. Co-expression of E6 and human UBE3A in wing and eye epithelia results in severe morphological abnormalities. Furthermore, E6, via its PDZ-binding motif and in cooperation with UBE3A, targets a suite of PDZ proteins that are conserved in human and Drosophila, including Magi, Dlg and Scribble. Similar to human epithelia, Drosophila Magi is a major degradation target. Magi overexpression rescues the cellular abnormalities caused by E6+UBE3A coexpression and this activity of Magi is PDZ domain-dependent. Drosophila p53 was not targeted by E6+UBE3A, and E6+UBE3A activity alone is not sufficient to induce tumorigenesis, which only occurs when E6+UBE3A are expressed in conjunction with activated/oncogenic forms of Ras or Notch. Finally, through a genetic screen we have identified the insulin receptor signaling pathway as being required for E6+UBE3A induced hyperplasia. Our results suggest a highly conserved mechanism of HPV E6 mediated cellular transformation, and establish a powerful genetic model to identify and understand the cellular mechanisms that underlie HPV E6-induced malignancy.

Human papillomaviruses (HPV) are the causative agents of cervical cancer, one of the leading causes of cancer death in women worldwide. The E6 oncoprotein encoded by HPV has been implicated in the progression of primary tumors to metastatic disease and we have developed a new model in the fruit fly (Drosophila melanogaster) to study the cellular effects of E6. The E6 protein recruits an E3 ubiquitin ligase (UBE3A) to induce the degradation of a number of cellular proteins, including members of the MAGUK family of scaffolding proteins that control the structure and polarity of epithelial cells: Dlg, Scribble and Magi. Expression of E6 and human UBE3A in the wing and eye of Drosophila disrupted these tissues. Similar to human cells we found that Drosophila Magi was a major E6 degradation target and that overexpression of Magi rescued the tissue disruption. However, Drosophila p53 was not degraded by E6/UBE3A, making our fly model potentially useful for studying the p53-independent activities of the E6+UBE3A complex. When we paired E6 expression with oncogenic proteins, including activated Ras, we observed that epithelia were transformed into mesechymal-like cells that left the epithelium and spread through the body. As a test of the potential of our system, we carried out a pilot genetic screen and identified the insulin receptor as a strong modulator of the E6-mediated disruption of Drosophila tissues. Therefore, we have developed a new system and approach to help us better understand the mechanisms that underlie how HPV infection leads to cell transformation and cancer.

The Role of Physician Recommendations and Public Policy in Human Papillomavirus Vaccinations

BACKGROUND

Immunization rates for human papillomavirus (HPV) infections remain low among teenagers despite strong evidence of the effectiveness of vaccines. Physician recommendations of the vaccine are far from universal. Several states have enacted policies that mandate HPV vaccination or distribute educational materials.

OBJECTIVES

To provide policy makers, physicians, and researchers information on the relative importance of physician recommendations and early state-level policies to promote HPV vaccinations among targeted age groups.

METHODS

We first use probit models to determine the strongest correlates of immunization in a nationally representative US sample of teenagers. We then use instrumental variable probit models to determine the direct role that physician recommendations play in vaccination using plausibly exogenous physician encounters that are likely not the result of more health-conscious parents seeking out information on the vaccine.

RESULTS

We show that children in the targeted age range who are more likely to encounter physicians for reasons other than seeking out the vaccine, such as through mandatory wellness exams or previous asthma diagnoses, are significantly more likely to get the vaccine. There is no consistent evidence that the state policies we analyze have been effective.

CONCLUSION

Encouraging recommendations by physicians may be the most effective path toward increasing HPV vaccination. State-level mandates and policies are yet to exhibit effectiveness.

Parents' Recall and Reflections on Experiences Related to HPV Vaccination for Their Children

Human papillomavirus (HPV) vaccination coverage remains suboptimal in the United States. We conducted in-depth interviews with parents of adolescents from an urban primary care center serving a low-income minority population to describe their experiences. We identified the following themes: (a) parents of unvaccinated children generally had not discussed the vaccine with providers and had low awareness; (b) among unaware parents, provision of brief information generally resulted in positive comments about the vaccine; (c) vaccine was typically not requested by parents but rather offered by providers; (d) strength of the recommendations from providers varied, and vaccine was sometimes presented as optional or low priority; (e) parents had low awareness of the three-dose regimen and poor recall about completion; and (f) limited understanding of why boys should be vaccinated. More than 7 years after the introduction of HPV vaccine, there is substantial room for improving the way it is recommended and discussed by providers.

Comparing human papillomavirus vaccine knowledge and intentions among parents of boys and girls

BACKGROUND/OBJECTIVE

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. Previous research suggests some differences between male and female adolescents in correlates of vaccine receipt and reasons for non-vaccination; few studies examine both sexes together. This analysis assessed knowledge and attitudes related to HPV disease and vaccination, intention to vaccinate, and reasons for delayed vaccination or non-vaccination among parents of boys and girls 13-17 y old in 50 states, the District of Columbia, and selected local areas.

METHODS

National Immunization Survey-Teen 2013 data were analyzed and gender differences examined.

RESULTS

In this sample, adolescent boys were more likely than girls to be unvaccinated and less likely to have completed the HPV vaccination series (p < 0.005 for both). Parents of girls were more likely than parents of boys to report a provider recommendation for HPV vaccination (65.0% vs. 42.1%). Only 29% of girls' parents reported a provider recommendation to begin vaccination by 11-12 y old. Among unvaccinated teens, parental intention to vaccinate in the next 12 months did not differ by sex, but reasons for vaccination or non-vaccination did. Many parents do not know the recommended number of HPV doses.

CONCLUSIONS

Gender differences in provider vaccination recommendations and reasons for vaccination might partially explain differential HPV uptake by male and female adolescents. Clinicians should offer strong recommendations for HPV vaccination at 11-12 y old for both girls and boys. To reduce missed opportunities, HPV vaccination should be presented in the context of, and given concurrently with, other routinely administered vaccines.

Human Papillomavirus Infection and Vaccination

Human papillomavirus (HPV) is an infection that can be sexually transmitted and result in health consequences including genital warts and cancers. Two vaccines, Gardasil® [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant] and Cervarix™ [Human Papillomavirus Bivalent (Types 16 and 18) Vaccine], have been approved for the prevention of HPV and HPV-related diseases.

OBJECTIVES

To explore facilitators and barriers associated with HPV vaccine utilization and compliance regarding vaccine series completion in school-aged, adolescent, and young adult females in the United States; to discuss HPV infection and highlight the safety and efficacy of the HPV vaccine; and to illustrate delivery strategies that can improve immunization rates and review implications for healthcare providers.

METHODS

A literature review was performed using health-related online databases (CINAHL, MEDLINE, PubMED, Web of Science, EBSCOHost and Google Scholar) and archival searching to identify current vaccination rates and factors associated with vaccine uptake.

RESULTS

Despite the availability of vaccines that prevent cancer, acceptance and utilization rates of both HPV vaccines are less than recommended by the Advisory Committee for Immunization Practices (ACIP). Some of the barriers to HPV vaccination include lack of provider recommendation, negative parent or patient attitudes and beliefs, cost, and missed clinical opportunities. The primary facilitator to HPV vaccination is a strong provider recommendation.

CONCLUSIONS

Healthcare providers can enhance HPV vaccine utilization by taking an active role with patients. Strategies include education and advocacy for receiving the vaccine, maximizing access to the HPV vaccine, and implementing new strategies for vaccine-delivery.

Factors influencing completion of multi-dose vaccine schedules in adolescents: a systematic review

BACKGROUND

Completion of multiple dose vaccine schedules is crucial to ensure a protective immune response, and maximise vaccine cost-effectiveness. While barriers and facilitators to vaccine uptake have recently been reviewed, there is no comprehensive review of factors influencing subsequent adherence or completion, which is key to achieving vaccine effectiveness. This study identifies and summarises the literature on factors affecting completion of multi-dose vaccine schedules by adolescents.

METHODS

Ten online databases and four websites were searched (February 2014). Studies with analysis of factors predicting completion of multi-dose vaccines were included. Study participants within 9-19 years of age were included in the review. The defined outcome was completion of the vaccine series within 1 year among those who received the first dose.

RESULTS

Overall, 6159 abstracts were screened, and 502 full texts were reviewed. Sixty one studies were eligible for this review. All except two were set in high-income countries. Included studies evaluated human papillomavirus vaccine, hepatitis A, hepatitis B, and varicella vaccines. Reported vaccine completion rates, among those who initiated vaccination, ranged from 27% to over 90%. Minority racial or ethnic groups and inadequate health insurance coverage were risk factors for low completion, irrespective of initiation rates. Parental healthcare seeking behaviour was positively associated with completion. Vaccine delivery in schools was associated with higher completion than delivery in the community or health facilities. Gender, prior healthcare use and socio-economic status rarely remained significant risks or protective factors in multivariate analysis.

CONCLUSIONS

Almost all studies investigating factors affecting completion have been carried out in developed countries and investigate a limited range of variables. Increased understanding of barriers to completion in adolescents will be invaluable to future new vaccine introductions and the further development of an adolescent health platform. PROSPERO reg# CRD42014006765.

Correlates of Human Papillomavirus Vaccine Completion Among Adolescent Girl Initiators

OBJECTIVE

To examine correlates of vaccine series completion among young adolescent US girls who initiated the human papillomavirus (HPV) vaccine.

METHODS

We analyzed National Immunization Survey-Teens 2012 provider-verified data to examine correlates of HPV vaccine completion among 13- to 17-year-old girls who initiated HPV vaccine in 2012 (N = 4548).

RESULTS

The weighted vaccine series completion rate among 13- to 17-year-old girl initiators was 66.7% (95% confidence interval [CI], 64.0-69.3). Adolescent girls who were older, residents of the Northeast (adjusted prevalence ratio [aPR], 1.36; 95% CI, 1.07-1.73), and had provider-verified seasonal influenza vaccination in the past year (aPR, 1.67; 95% CI, 1.32-2.11) and provider recommendation (aPR, 1.40; 95% CI, 1.10-1.77) were more likely to complete the 3-dose vaccine series.

CONCLUSIONS

Parents of younger adolescent girls need to be educated about the importance of completing the 3-dose HPV vaccine series. Provider recommendation for the vaccine would also facilitate series completion.

[Safety of human papillomavirus 6, 11, 16 and 18 (recombinant): systematic review and meta-analysis]

Objective:

To identify and quantify the adverse effects associated with the recombinant human papillomavirus (types 6, 11, 16 and 18) vaccine in adolescents.

Data source:

Systematic review of randomized clinical trials from PubMed, SciELO and Lilacs databases. Articles investigating the safety of the vaccine in subjects under 18 years and comparing the recombinant human papillomavirus types 6, 11, 16 and 18 vaccine with a control group were included. Meta-analyses were performed for the outcomes of pain, erythema, swelling and fever, using clinical trials with maximum Jadad score.

Data synthesis:

Fourteen studies were included. The most common adverse effects related to the human papillomavirus vaccine were effects with no severity (pain, erythema, edema, and fever). Five studies were used for the meta-analyses: pain-risk difference (RD)=11% (p <0.001); edema-RD=8% (p <0.001); erythema-RD=5% (p <0.001); fever-RD=2% (p <0.003).

Conclusions:

The recombinant human papillomavirus types 6, 11, 16 and 18 vaccine was safe and well tolerated. The main adverse effects related to vaccination were pain, erythema, edema and fever. The low frequency of severe adverse effects encourages the administration of the vaccine in the population at risk.

Knowledge, perceptions, and decision making about human papillomavirus vaccination among Korean American women: a focus group study

OBJECTIVE

As one of the fastest growing ethnic minority groups in the United States, Korean American (KA) women experience a heightened cervical cancer burden. The advent of the human papillomavirus (HPV) vaccine offers an unprecedented opportunity to eliminate cervical cancer disparities in KA women. However, the uptake of HPV vaccine among KA adolescents remains suboptimal. Hence, we set out to explore knowledge, perceptions, and decision making about HPV vaccination among KA women.

METHODS

We conducted four focus groups of 26 KA women who participated in a community-based, randomized, controlled trial to promote breast and cervical cancer screening. Focus group data were analyzed using qualitative content analysis.

RESULTS

Four main themes emerged from the focus groups: 1) limited awareness and knowledge of HPV vaccine, 2) perceptions and beliefs about HPV vaccination (acceptance, negative perceptions, ambivalence), 3) patterns of decision making about HPV vaccination (hierarchical, peer influenced, autonomous, and collaborative), and 4) promoting HPV education and information sharing in the Korean community.

CONCLUSION

KA women are generally positive toward HPV vaccination, but lack awareness and knowledge about HPV. Culturally tailored HPV education programs based on KA women's decision-making patterns and effective information sharing by trustworthy sources in comfortable environments are suggested strategies to promote HPV vaccination in the KA community. The findings point to the need for a multilevel approach to addressing linguistic, cultural, and system barriers that the recent immigrant community faces in promoting HPV vaccinations. In the development of targeted interventions for KA women, educational strategies and patterns of decision making need to be considered.

Regional variations in HPV vaccination among 9-17 year old adolescent females from the BRFSS, 2008-2010

Human papillomavirus (HPV) vaccine uptake among 18-26 y old women varies by geographic region in the US. However, little is known about regional variations in vaccination among girls who are in the vaccine's targeted age groups. Regional variation in HPV vaccination among female adolescents (9-17 y old) was examined using cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS) between 2008 and 2010. Multivariable logistic regression estimated the association of region of residence (10 states included questions about adolescent HPV vaccination) with uptake and completion of the 3-shot HPV vaccine series. Among 7,849 adolescents, 26.9% initiated, and 55.2% of initiators completed the series. Adolescents from Northeast/Midwest/West states were 1.74 (95% CI: 1.45-2.10) times more likely to have initiated HPV vaccination compared to the South/Southwestern states. Among initiators, vaccine series completion did not vary significantly between the South/Southwestern and Northeast/Midwest/West states. Flu vaccination was associated with increased odds of initiation in both regions and completion of the HPV vaccine series in the South/Southwestern states only. Girls 9-10 and 11-12 y old were less likely to have initiated and 11-12 y olds were less likely to have completed the HPV vaccine series compared to 13-17 y olds. The observed regional variations in vaccination could cause rates of cervical cancer to remain higher in the South/Southwest and widen currently observed regional disparities in cervical cancer rates.

Human papillomavirus vaccine uptake among males 11-26 years in United States: findings from the National Health and Nutrition Examination Survey, 2011-2012

Anogenital human papillomavirus (HPV) infection is the leading sexually transmitted infection in the United States. In October 2011, the quadrivalent HPV vaccine (HPV4) was recommended for males in the U.S. We analyzed a subsample of 11–26 year old (N = 1012) males, from the National Health and Nutritional Examination Survey 2011–2012 dataset, to examine HPV vaccine uptake. The initiation rates in the 11–17 years and the 18–26 years age-groups were 10.7% (95% confidence interval (CI): 8.09–16.6%) and 5.5% (95%CI: 3.1–9.5%) respectively. The corresponding HPV vaccine completion rates were 39.3% (16.7–67.7%) for the 11–17 year old males and 59.1% (37.2–77.6) for the 18–26-year-old males. Despite a slight increase, HPV vaccine uptake remained low among males. These findings can help in HPV vaccination policy in the United States, with a focus on informational messages directed toward young males and their parents in order to increase uptake of HPV vaccine.

Immunization Coverage Among Juvenile Justice Detainees

This study sought to (1) quantify the baseline immunization coverage of adolescents entering the juvenile justice system and (2) assess the effect of detention-based care on immunization coverage in youth. A cross-sectional retrospective chart review was performed of 279 adolescents detained at a large juvenile detention facility. Only 3% of adolescents had received all study immunizations prior to detention. Before detention, immunization coverage was significantly lower than that for the general adolescent population for all vaccines except the first doses of hepatitis A and varicella-zoster virus vaccines. Subsequent to detention, most individual immunization coverage levels increased and were significantly higher than in the general adolescent population. The routine administration of immunizations in the juvenile justice setting can help detained youth achieve levels of immunization coverage similar to their nondetained peers.

Human papillomavirus vaccination of females in a large health claims database in the United States, 2006-2012

PURPOSE

Information on vaccine utilization from a variety of sources is useful to give a status of the vaccine program and define opportunities to improve uptake. We evaluated MarketScan Commercial Claims and Encounters database on human papillomavirus (HPV) vaccine initiation and completion of all three doses among girls/women from 2006 to 2012.

METHODS

Data were obtained from the 2006-2012 MarketScan Commercial Claims and Encounters database. The study population included female enrollees aged 11-26 years who were continuously enrolled in the same private insurance plan from 2006 to 2012 (n = 407,371). We evaluated overall and yearly vaccine initiation and completion, demographic characteristics associated with vaccine initiation, clinical visits in which vaccine was given, and missed opportunities for vaccination.

RESULTS

By the end of 2012, 36.9% of females aged 11-26 years had received at least one HPV vaccine dose. Vaccination coverage was highest among females aged 17-18 years (49.3%) and aged 15-16 years (43.1%) and lowest among females aged 11-12 years (16.8%). Between 2007 and 2012, 96.1% of the 246,192 unvaccinated females had at least one missed opportunity (a heath care visit without HPV vaccine administered).

CONCLUSIONS

Over a 6 year period, HPV vaccine initiation was lowest in the girls aged 11-12 years. Importantly, most (96.1%) unvaccinated females had at least one missed vaccination opportunity, and providers and health systems should focus efforts on using existing visits for vaccination.

Correlates of HPV knowledge among low-income minority mothers with a child 9-17 years of age

STUDY OBJECTIVE

To assess the level of HPV knowledge among low income, minority mothers with a child between the ages of 9-17 y.

DESIGN

Women who sought care at a university-based clinic and had at least 1 child aged 9 to 17 years were approached. A total of 638 mothers were recruited. Only those who had heard of HPV were included in the correlation analyses (n = 468).

MAIN OUTCOME MEASURES

HPV knowledge was assessed utilizing a self-administered questionnaire consisting of 20 questions.

RESULTS

There were differences between those who had heard of HPV and those who had not. More of those who had not heard of HPV were Hispanic (63%), low-income (89%), and did not graduate high school (59%). Of those who had heard of HPV, the majority did not answer 50% of questions correctly. Few knew the vaccine could prevent genital warts (19.7%). Factors independently associated with HPV knowledge included age, personal history of HPV, cervical dysplasia or cervical cancer, acquiring knowledge from ≥ 2 sources, having known someone with HPV or cervical cancer, having seen a brochure on the vaccine, and having seen an advertisement for the vaccine.

CONCLUSIONS

Knowledge regarding HPV is low among low-income women with children in the target age range for HPV vaccination. Increased awareness should focus on genital warts and other cancers, since this population has virtually no knowledge of other health outcomes related to HPV infection. Educational programs tailored to this population need to be developed to increase vaccination.

High school females and those with other vaccinations most likely to complete the Human Papillomavirus vaccine

OBJECTIVE

Adolescent females' HPV vaccine completion in the U.S. is low. More recent research is needed to investigate factors that relate to HPV vaccine completion among female adolescents in the United States.

METHODS

Provider-validated data from the 2012 National Immunization Survey-Teen for females ages 13-17 years (N = 9058) were analyzed from February-May 2014 using survey sample weighted statistics. A multivariable Poisson regression estimated prevalence ratios (PR) for factors influencing HPV vaccine completion: mother's education, poverty status, adolescent's grade, facility type, and receipt of other adolescent vaccinations.

RESULTS

In multivariable models, 9-12th grade daughters were more likely to complete HPV vaccination than 6-8th grade daughters (PR = 1.81, 95% CI = 1.58-2.06). Those seen in hospital facilities completed HPV vaccination 1.3 times more (PR = 1.29, 95% CI = 1.02-1.62) and those seen in private facilities were 1.2 times more likely to complete (PR = 1.22, 95% CI = 1.01-1.48), than those seen in public facilities, respectively. Compared to those without recommended adolescent vaccinations, receipt of seasonal influenza vaccination related to HPV vaccine completion (PR = 1.71, 95% CI = 1.54-1.89), as did receipt of TDAP vaccination (PR = 1.17, 95% CI = 1.03-1.33) and Meningitis vaccination (PR = 2.74, 95% CI = 2.20-3.42).

CONCLUSIONS

Adolescent females in high school, seen in private/hospital facilities, and up to date on other recommended adolescent vaccinations are most likely to complete the HPV vaccine.