Why are U.S. girls getting meningococcal but not human papilloma virus vaccines? Comparison of factors associated with human papilloma virus and meningococcal vaccination among adolescent girls 2008 to 2012

Regional differences in provider recommendation of HPV vaccines among 13-to-17 year old adolescents from 2019 to 2021

PURPOSE

The prevalence of recommendation of human papillomavirus (HPV) vaccination by health care providers has improved over the last decade. However, research to determine whether the COVID-19 pandemic affected the progress in recommendation among adolescents across the U.S. regions has been limited. Therefore, the present study was conducted to determine if region was associated with provider recommendation of HPV vaccines in 2019-2021 and whether changes in recommendations varied by region.

METHOD

Using a cross-sectional design to examine National Immunization Survey-Teen (2019-2021) data, logistic regression and moderation analyses were performed to model region variation in HPV vaccine recommendations (n = 50,739 respondents).

RESULTS

The odds of recommendation were higher in the Midwest (aOR, 1.17 [95% CI, 1.06-1.29]), and Northeast (aOR, 1.38 [95% CI, 1.23-1.56]) regions than in the South region. Also, the odds of provider recommendation were higher in 2020 (aOR,1.16 [95% CI, 1.03-1.30]) than in 2019. Other variables-sex, age, race/ethnicity, health insurance status, and poverty status-were associated with recommendation of HPV vaccination.

CONCLUSION

Although the improvement in recommendation from 2019 to 2020 is an important public health gain, recommendation in the South still lags behind that in other regions. More efforts are needed to improve HPV vaccination recommendations in this region.

Parent-reported provider recommendation of HPV vaccination among minority adolescents before and during the COVID-19 pandemic: Findings from the National Immunization Survey-Teen, 2019-2021

Provider recommendation of human papillomavirus (HPV) vaccination among adolescents has steadily improved over the years, however, limited research has been conducted to examine if the COVID-19 pandemic disrupted this positive trend in parent-reported provider recommendation among minority adolescents. Therefore, we conducted the present study to determine if there is an association between the pandemic and parent-reported provider recommendation of HPV vaccine among non-Hispanic black and Hispanic adolescents. We also examined whether any changes in parent-reported provider recommendation in the years 2019, 2020, and 2021 differed by race or ethnicity. Using a cross-sectional design to examine data from the National Immunization Survey-Teen (2019-2021), a moderation analysis and logistic regression analysis were performed to model race-specific variation in parent-reported provider recommendation (n = 50,739). We found that Hispanic parents had lower odds (aOR = 0.80 [0.71, 0.91]) of reporting receiving a recommendation compared to non-Hispanic white parents. We also found that the odds of parent-reported provider recommendation were higher in 2020 (aOR = 1.15 [1.03-1.29]) than in 2019. Other variables-age, region, sex, health insurance status, and poverty status-were all associated with parent-reported provider recommendation. These findings demonstrated that the pandemic may not have triggered any race-related gap in the recommendation of HPV vaccines, however, more pandemic-resilient public health efforts are needed to improve parent and provider communication regarding HPV vaccination of adolescents.

Understanding barriers to vaccination against invasive meningococcal disease: a survey of the knowledge gap and potential solutions

INTRODUCTION

Invasive meningococcal disease (IMD) is a leading cause of life-threatening bacterial meningitis and septicemia. Evidence points to a knowledge gap among parents, teenagers, and healthcare providers (HCPs) regarding IMD and available vaccines, including those against the highly prevalent serogroup B.

AREAS COVERED

An online survey was conducted between March 27 and April 12, 2019, to gather insights into the knowledge that parents/guardians have about IMD vaccines. The children were aged 2 months-10 years in Australia, Brazil, Germany, Greece, Italy, and Spain, 5-20 years in the UK, and 16-23 years in the US. The findings were discussed in the context of the available literature and solutions were proposed to minimize the knowledge gap and the barriers to vaccination against IMD.

EXPERT OPINION

The survey demonstrated that parents have a good understanding of IMD but a limited understanding of the different serogroups and vaccines. The available literature highlighted multiple barriers to IMD vaccine uptake; these may be reduced through education of HCPs, clear recommendations to parents by HCPs, the use of technology, and disease-awareness initiatives that engage parents through physical and digital channels. Further studies are warranted to assess the impact of the COVID-19 pandemic on IMD vaccination.

Clinic-level differences in human papillomavirus vaccination rates among rural and urban Oregon primary care clinics

PURPOSE

Human papillomavirus (HPV) infection contributes to vaccine-preventable malignancies. Rural populations experience lower HPV vaccination rates despite similar rates of other childhood vaccinations. Individual- and clinic-level characteristics likely contribute to this disparity, but little is known about the separate roles of each. We compared clinic-level HPV vaccination rates among rural versus urban primary care clinics, identified factors associated with HPV vaccination, and separately assessed the impact of individual- and clinic-level characteristics on rural disparities in HPV vaccination.

METHODS

This cross-sectional study included 537 Oregon primary care clinics participating in the Vaccines for Children (VFC) program during 2019. Vaccination status was assessed using Oregon's ALERT Immunization Information System and included HPV vaccine ≥ 1 dose for ages 11 and 12; HPV vaccination up to date (UTD) for ages 13-17, and coadministration with tetanus, diphtheria, and acellular pertussis (Tdap). Rural versus urban clinic-level outcomes were assessed using negative binomial regression.

FINDINGS

Participating clinics were 24.5% rural and 75.6% urban. Family medicine clinics comprised 71.1%; pediatrics, 16.9%; and mixed, 12.1%. Across clinics, the average proportion of patients qualifying for VFC was 43%, and non-White patients were 14.1%. The mean rate of HPV vaccine ≥1 dose was lower among rural clinics (46.9% vs 51.1%, P = .039), as was vaccination UTD (40.5% vs 49.9%, P < .001). Adjusting for differences in individual- and clinic-level characteristics, rural disparities were no longer statistically significant.

CONCLUSIONS

Both individual- and clinic-level characteristics play a role in rural disparities in HPV vaccination, and modifiable clinic-level differences may be opportune targets to address these disparities.

HPV Vaccination Adherence in Working-Age Men: A Systematic Review and Meta-Analysis

BACKGROUND

Human papillomavirus (HPV) infection is the most common sexually transmitted viral infection in the world. HPV vaccination adherence rates in men are generally lower than in women. The aim of this systematic review and meta-analysis was to assess adherence to HPV vaccination in young working-age males (18-30 years old).

METHODS

A systematic review was performed using three databases: PubMed, Scopus, and Web of Science, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

After duplicate removal, the initial search resulted in 478 eligible papers. With the exclusion of 425 papers after screening the abstracts, full texts of 53 articles were reviewed. Subsequently, 45 were excluded. Among the eight studies included, four (50%) examined the vaccination adherence in young adults through data registered in nationwide insurance or private companies' databases, three (37.5%) in young adults in different settings through data collected from surveys and questionnaires, and one (12.5%) an HPV vaccination campaign in a family medicine residency practice.

CONCLUSION

Adherence to HPV vaccination in men of working age (18-30 years) does not appear to be adequate (pooled prevalence 11%). In order to achieve a higher level of compliance, it is important to place an emphasis on vaccination campaigns in schools as well as in the workplace, after consultation with and approval from local, regional, and federal public health agencies.

Tdap-HPV vaccination bundling in the USA: Trends, predictors, and implications for vaccine series completion

The Centers for Disease Control and Prevention (CDC) promotes taking a 'bundling approach' (i.e., administering Tetanus, diphtheria toxoids, and acellular pertussis [Tdap] and human papillomavirus [HPV] vaccines in the same way and on the same day) for adolescent vaccinations. Recent trends and patterns in Tdap-HPV vaccination bundling in the USA remain undocumented. In addition, the implications of bundling Tdap-HPV vaccination for HPV vaccine series completion remain unknown. To address these critical knowledge gaps, we performed a retrospective study using a nationwide sample of privately insured adolescents (Optum's de-identified Clinformatics® Data Mart Database). Tdap-HPV vaccination bundling (per 100 Tdap vaccination encounters) during 2014-2018 was estimated overall, for 50 states, and by adolescents' age, sex, and provider specialties. Survival model estimated the likelihood of series completion among 9-14-year-old adolescents. From 2014 to 2018, 560,806 adolescents received a Tdap vaccine of which 172,604 (30.8%) received the HPV vaccines on the same day. Tdap-HPV vaccination bundling (per 100 Tdap vaccinations) increased nationally, from 22.9 in 2014 to 39.1 in 2018 (Ptrend < 0.001); bundling was lowest in New York and New Jersey. The likelihood of receiving the Tdap and HPV vaccines bundled was higher for young and female adolescents. Adolescents who received their first HPV vaccine bundled with the Tdap vaccine were more likely to complete the series compared to those who received it alone (Hazards Ratio = 1.45; 1.43-1.48). HPV vaccination bundling has increased in recent years in the USA. The increased likelihood of HPV vaccine series completion provides important evidence supporting the adoption of same-day Tdap-HPV vaccine administration in clinical practice to boost HPV vaccination coverage.

Disparities in Healthcare Providers' Recommendation of HPV Vaccination for U.S. Adolescents: A Systematic Review

Infrequent provider recommendations continue to be a key barrier to human papillomavirus (HPV) vaccination, including among adolescents at higher risk for future HPV cancers. To inform future interventions, we sought to characterize disparities in health care providers' HPV vaccine recommendation for U.S. adolescents. We systematically reviewed studies published in 2012-2019 that assessed provider HPV vaccine recommendations for adolescents aged 9-17. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we identified 52 eligible studies and used a standardized abstraction form to assess recommendation prevalence by adolescent demographic characteristics. Studies consistently found that fewer parents of boys than girls reported receiving HPV vaccine recommendations (14 studies, range of difference: -11 to -35 percentage points). Studies also found fewer recommendations for adolescents who were younger (2 studies, -3% to -12% points), non-White (3 studies, -5% to -7% points, females only), lower income (3 studies, -1% to -8% points), or uninsured (1 study, -21% points, males only). Studies identified geographic disparities in southern and rural areas. In conclusion, findings from this systematic review identify disparities in HPV vaccine recommendation that may contribute to suboptimal vaccine uptake. Efforts to improve providers' HPV vaccine communication should focus on increasing recommendation consistency, especially for lower-income, non-White, and rural adolescents.

Relative contributions of parental intention and provider recommendation style to HPV and meningococcal vaccine receipt

We described the relative contributions of parental intention and provider recommendation style to HPV and meningococcal vaccine receipt. Parent-child dyads that were eligible for both meningococcal and HPV vaccines participated in pre-visit surveys and consented to audio recording of their clinical interactions with healthcare providers related to vaccination. Surveys were analyzed for parent and child demographics and parental intention to vaccinate children with HPV and/or meningococcal vaccines. Audio recordings were analyzed for provider recommendation style, defined as indicated (provider stated vaccine was due at that visit) or not, and for child receipt of vaccines. Linear and logistic regression models were used to determine the relative contributions of parental intention and provider recommendation style to vaccine receipt. 56 parents/child dyads participated. 79% of children received HPV vaccines, and 93% received meningococcal vaccines. After controlling for demographic variables, parental intention did not differ by vaccine type. However, providers were less likely to use an indicated recommendation for HPV than for meningococcal vaccine. After controlling for demographic factors, parental intention, and provider recommendation style, vaccine type (HPV or meningococcal) was no longer associated with vaccine receipt Differences that were previously attributed to vaccine-specific factors may be explained by parents' and providers' roles in vaccine receipt. These findings suggest that interventions and policy recommendations regarding adolescent vaccination should focus on increasing parental demand for vaccines and ensuring that providers present all vaccines as the medical standard of care.

Why human papilloma virus vaccination coverage is low among adolescents in the US? A study of barriers for vaccination uptake

Introduction

Cervical cancer and Human papillomavirus (HPV) affects women, men, and children of all races, ethnicities, and backgrounds. The objective of this study is to examine the association between adolescent (13-17 years) HPV vaccination uptake and the key factors influencing the uptake rates of HPV vaccination.

Materials and Methods

The 2016 NIS-Teen data, an annual survey conducted by the CDC to monitor vaccination uptake in the United States is used for this study. Multivariable logistic regression model was used to estimate the relationship between various factors and HPV vaccine uptake.

Results

Male adolescents were 0.26 times less likely to get the HPV vaccines; adolescents covered by private health insurance were 0.18 times less likely to get HPV vaccines; Hispanic adolescents were 1.47 times more likely, adolescents from other races including Asians were 1.75 times more likely to get vaccinated for HPV compared to non-Hispanic white adolescents. Adolescents from the low-income families were 1.21 times more likely to get vaccinated for HPV; adolescents from North-eastern regions of the United States were 1.62 times more likely to get vaccinated; adolescents who were not recommended for vaccination by the family physicians were 0.43 times less likely to get HPV vaccination; adolescents who did not have any safety concerns and concerns about side effects were 3.24 times more likely to get the HPV vaccine; adolescents from households that did have not orthodox religious beliefs were 13.67 times more likely to get vaccinated.

Conclusions

Vaccination uptake rates are low for adolescents in the US and the results of this study identified important barriers which need to be addressed in order to improve vaccine uptake rates among the target groups which are less likely to get vaccinated. Also, knowing the sociodemographic and community level factors associated with HPV vaccination uptake status, health planners can better plan strategies to improve HPV vaccination in their local settings.

Evaluating the impact of multilevel evidence-based implementation strategies to enhance provider recommendation on human papillomavirus vaccination rates among an empaneled primary care patient population: a study protocol for a stepped-wedge cluster randomized trial

Background

Each year, human papillomavirus (HPV) causes 30,000 cancers in the USA despite the availability of effective and safe vaccines. Uptake of HPV vaccine has been low and lags behind other adolescent vaccines. This protocol describes a multilevel intervention to improve HPV vaccination rates.

Methods

Using a cluster randomized trial, we will evaluate the independent and combined impact of two evidence-based implementation strategies with innovative enhancements on HPV vaccination rates for female and male patients. The clusters are six primary care sites providing care to pediatric populations. We will use a stepped-wedge cluster randomized design, including process evaluation, to test the hypothesis that compared with the current course of care and a practice-level intervention using reminder-recall interventions coupled with provider-level audit and feedback with education increases HPV vaccination rates in exposed clusters. The factorial design allows us to use a single trial to test these two interventions and to assess each individually and in combination. Our design has four 12-month steps. The first step will be a baseline period; data collected during it will provide a within-practice control group for each cluster. Second, two clusters will be randomly assigned to receive intervention 1 (reminder and recall), and two clusters will be randomly selected to receive intervention 2 (audit and feedback with education). Third, the other two clusters will be randomly allocated to intervention 1 or 2. Clusters initially with intervention 1 will be randomly allocated to 1 + 2 or 1; clusters initially with intervention 2 will be randomly allocated to 1 + 2 or 2. Fourth, all clusters will receive both interventions. To ensure balance of patient numbers across interventions, we will use block randomization at the first step, with the six clusters grouped into three pairs according to volume. Our primary outcome will be vaccination rates.

Discussion

Results of our clinical trial and process evaluation will provide evidence showing whether practice- and provider-level interventions improve HPV vaccination rates and will offer insight into contextual factors associated with direction and magnitude of trial outcomes.

Trial registration

ClinicalTrials.gov, NCT03501992, registered April 18, 2018.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0778-x) contains supplementary material, which is available to authorized users.

Black mother's intention to vaccinate daughters against HPV: A mixed methods approach to identify opportunities for targeted communication

OBJECTIVE

The cervical cancer disparity continues to exist and has widened between Black and non-Hispanic White women. Human Papillomavirus (HPV) vaccines could potentially reduce this disparity, yet remain underused among Black female adolescents. We investigated psychosocial and cultural factors associated with Black mothers' intentions to vaccinate their daughters against HPV, and explored views toward a HPV vaccine mandate.

METHODS

In this quantitative dominant, mixed methods study, cross sectional surveys (n=237) and follow-up semi-structured interviews (n=9) were conducted with Black mothers of daughters. A 2-step logistic regression determined factors associated with Black mothers' intention. Thematic content analysis determined emerging themes.

RESULTS

Perceived susceptibility (p=.044), perceived barriers (p<.001), and subjective norms (p=.001) were significant predictors of maternal HPV vaccination intentions. Follow-up interviews provided insight into factors influencing mothers' intentions. Mothers with low intentions did not perceive their daughter to be currently sexually active or in near future, thus, not at HPV risk. Pediatricians were identified as the most influential person on maternal decision-making if there was a pre-existing relationship. However, many mothers had not received a pediatricians' recommendation for their daughters. Barriers influencing mother's decision-making include knowledge, daughters' age, and mistrust in pharmaceutical companies and physicians. Mothers were not in favor of the HPV vaccine mandate.

CONCLUSIONS

Findings demonstrate the need to develop and evaluate physician-led interventions on HPV and vaccine importance, and engage these mothers in intervention development to build trust between physicians, researchers, and Black mothers to improve HPV vaccine uptake in Black female adolescents.

Parents Who Decline HPV Vaccination: Who Later Accepts and Why?

OBJECTIVE

Parental declination contributes to low human papillomavirus (HPV) vaccination coverage among US adolescents, resulting in missed opportunities for cancer prevention. We sought to characterize parents' acceptance of HPV vaccination after declination ("secondary acceptance").

METHODS

In September 2016, we conducted an online survey with a national sample of parents of children ages 11 to 17 years. For those who reported having ever declined HPV vaccination for their children (n = 494), our survey assessed whether they accepted the vaccine at a subsequent visit. We used multivariable logistic regression to assess correlates of secondary acceptance.

RESULTS

Overall, 45% of parents reported secondary acceptance of HPV vaccination, and an additional 24% intended to vaccinate in the next 12 months. In multivariable analyses, secondary acceptance was associated with receiving follow-up counseling about HPV vaccination from a health care provider (odds ratio, 2.16; 95% confidence interval, 1.42-3.28). However, only 53% of parents overall reported receiving such counseling. Secondary acceptance was also associated with receiving a higher quality HPV vaccine recommendation from a provider during the initial discussion and greater satisfaction with provider communication, as well as higher vaccination confidence. Among the reasons for secondary acceptance, parents most commonly reported the child getting older (45%), learning more about HPV vaccine (34%), and receiving a provider recommendation (33%).

CONCLUSIONS

Our findings suggest secondary acceptance of HPV vaccination is common, with more than two-thirds of parents in this national sample accepting or intending to accept HPV vaccination after declination. Providers should seek to motivate secondary acceptance by delivering repeated, high-quality recommendations for HPV vaccination.

Belief About Mandatory School Vaccinations and Vaccination Refusal Among Ohio Appalachian Parents: Do Demographic and Religious Factors, General Health, and Political Affiliation Play a Role?

PURPOSE

To examine how demographic, general health, religious, and political characteristics influenced beliefs about mandatory school vaccinations and history of vaccination refusal for children among Ohio Appalachian parents.

METHODS

In 2013 and 2014, baseline data were obtained from parents (n = 337) of girls aged 9-17 from 12 counties in rural Ohio Appalachia enrolled in the Community Awareness, Resources and Education (CARE II) Project. Multivariate logistic regression models were used to identify correlates of parental beliefs about mandatory school vaccinations and history of refusing a doctor-recommended vaccine for their child(ren).

RESULTS

About 47% of parents agreed that parents should have the right to refuse mandatory school vaccinations for their child(ren). Participants who reported their political affiliation as Republican (OR = 2.45, 95% CI: 1.28-4.66) or Independent (OR = 3.31, 95% CI: 1.70-6.44) were more likely to agree that parents should have the right to refuse school-mandated vaccinations than parents who reported their political affiliation as Democrat. Approximately 39% of parents reported ever refusing a vaccine for their child(ren). Participants who were female (OR = 3.90, 95% CI: 1.04-14.58) and believed that parents should have the right to refuse mandatory school vaccinations (OR = 3.27, 95% CI: 1.90-5.62) were more likely to report ever refusing a vaccine for their child(ren).

CONCLUSION

The study findings provide information to better understand factors related to vaccination refusal among parents in Appalachia Ohio that can be used to design interventions to improve vaccination uptake.

Association of both consistency and strength of self-reported clinician recommendation for HPV vaccination and HPV vaccine uptake among 11- to 12-year-old children

PURPOSE

We tested the hypotheses that consistency and strength of clinician recommendation of the human papillomavirus (HPV) vaccination would be associated with vaccine delivery rates.

METHODS

From October 2015 through January 2016, we conducted a survey of primary care clinicians (n=227) in Southeastern Minnesota to evaluate clinician behaviors regarding HPV vaccination. The survey response rate was 41.0% (51 clinical sites). We used the Rochester Epidemiology Project, a clinical data linkage infrastructure, to ascertain clinical site-level HPV vaccination rates. We examined associations of clinician self-reports of both the consistency and strength of their recommendations for HPV vaccination for patients aged 11-12years (n=14,406) with site-level vaccination rates.

RESULTS

The majority of clinicians reported consistently (always or usually) recommending the HPV vaccine to females (79.0%) and to males (62.2%); 71.9% of clinicians reported strongly recommending the vaccine to females while 58.6% reported strongly recommending to males. Consistency and strength of recommending the HPV vaccine was significantly higher among those practicing in pediatrics and board certified in pediatrics compared to family medicine. Higher rates of initiation (1 dose) [Incidence Rate Ratio (IRR)=1.05; 95% CI (1.01-1.09)] and completion (3 doses) [IRR=1.08; 95% CI (1.02-1.13)] were observed among clinical sites where, on average, clinicians more frequently reported always or usually recommending the vaccine for females compared to sites where, on average, clinicians reported recommending the vaccine less frequently. Similarly, higher rates of initiation [IRR=1.03; 95% CI (1.00-1.06)] and completion [IRR=1.04; CI (1.00, 1.08)] were observed among sites where clinicians reported strongly recommending the vaccine to females more frequently compared to sites where, on average, clinicians reported strongly recommending the HPV vaccine less frequently; similar associations were observed for male initiation [IRR=1.05; CI (1.02,1.08)] and completion [IRR=1.05; 95% CI (1.01, 1.09)].

CONCLUSIONS

Consistency and strength of HPV vaccination recommendation was associated with higher vaccination rates.

Using the 4 Pillars™ Practice Transformation Program to increase adolescent human papillomavirus, meningococcal, tetanus-diphtheria-pertussis and influenza vaccination

OBJECTIVES

To report the results of an intervention using the 4 Pillars™ Practice Transformation Program (4 Pillars™ Program) to increase adolescent vaccinations including human papillomavirus vaccine (HPV) and influenza vaccines, which remain underutilized in this population.

STUDY DESIGN

Eleven pediatric and family medicine practices, previously control sites from a randomized controlled cluster trial, with ≥50 adolescent patients participated. The 4 Pillars™ Program was the foundation of the intervention. De-identified demographic, office visit and vaccination data were derived from electronic medical record extractions for patients whose date of birth was 4/1/1997 to 4/1/2004 (ages 11-17years at baseline). Vaccination rates for HPV, influenza, tetanus-pertussis-diphtheria (Tdap) and meningococcal (MenACWY) vaccines were determined for all eligible patients pre- and post intervention (i.e., vaccination rates on 4/1/2015 and 4/30/2016).

RESULTS

Among 9473 patients ages 11-17years at baseline (4/1/2015), mean pre-intervention vaccination rates for HPV initiation and completion, meningococcal, Tdap and influenza vaccines were below national levels. Rates increased significantly post intervention (P<0.001) for HPV initiation which increased 17.1 percentage points (PP) from 51.4%; HPV completion increased 14.8PP from 30.7%, meningococcal vaccine uptake increased 16.6PP from 79.1%, Tdap vaccine uptake increased 14.6PP from 76.9%. Influenza vaccine uptake did not increase significantly (2.3PP from 40.1%). In the regression using generalized estimating equations, odds of vaccination were higher for younger, non-white adolescents for all vaccines; being in a smaller practice decreased the odds of Tdap vaccination but increased the odds of influenza vaccination.

CONCLUSION

Clinically and statistically significant improvements in HPV series initiation and completion, and meningococcal and Tdap vaccinations were observed in primary care practices implementing the 4 Pillars™ Practice Transformation Program. Clinical Trial Registry Number: NCT02165722.

Improving adolescent HPV vaccination in a randomized controlled cluster trial using the 4 Pillars™ practice Transformation Program

OBJECTIVE

Uptake of meningococcal vaccine (MCV) and tetanus, diphtheria and pertussis (Tdap) vaccine among adolescents has approached Healthy People 2020 goals, but human papillomavirus (HPV) vaccination has not. This study evaluated an intervention using the 4 Pillars™ Practice Transformation Program to increase HPV, MCV and Tdap uptake among adolescents in primary care practices.

METHODS

Practices with at least 50 patients 11-17years old with estimated vaccination rates less than national goals, were assigned to intervention (n=11) and control (n=11) groups in a randomized controlled cluster trial; 9 intervention and 11 control sites completed the study. The baseline and active study periods were 7/1/2013-6/30/2014 and 7/1/2014-3/31/2015, respectively. Vaccination and demographic data for patients who had a visit in both study periods were derived from de-identified EMR extractions. Primary outcomes were vaccination rates and percentage point (PP) changes. Data were analyzed in 2015-16.

RESULTS

Among the cohort of 10,861 adolescent patients, 38% were 11-13years old; 50% were female; 18% were non-white; and 64% were commercially insured. Average baseline HPV initiation rates were 52.5% for intervention and 61.8% for control groups. After 9months, the intervention sites increased HPV initiation 10.2PP compared with 7.3PP in control sites (P<0.001); HPV series completion rates did not differ between groups. Implementation of >10 strategies to improve rates significantly increased the likelihood of HPV series initiation (OR=2.06, 95% CI=1.43, 2.96).

CONCLUSIONS

Using >10 strategies from the 4 Pillars™ Practice Transformation Program is effective for increasing HPV series initiation among adolescents. Clinical trial registry number: NCT02165722.

Important considerations in adolescent health maintenance: long-acting reversible contraception, human papillomavirus vaccination, and heavy menstrual bleeding

PURPOSE OF REVIEW

The present article addresses recent research related to three key facets of adolescent preventive care and health maintenance: long-acting reversible contraception, human papillomavirus vaccination, and heavy menstrual bleeding.

RECENT FINDINGS

Recent studies suggest that long-acting reversible contraception use results in significantly lower rates of unintended pregnancies, and is well tolerated by nulliparous adolescent females. Additionally, a strong recommendation from a pediatric primary care provider is extremely effective in ensuring human papillomavirus vaccination prior to sexual debut. Finally, heavy menstrual bleeding is often under-recognized in adolescents, and evaluation and treatment of these patients are variable.

SUMMARY

Based on the recent literature findings, the pediatric primary care provider should be encouraged to, first, recommend long-acting reversible contraception for prevention of unintended pregnancy in adolescent patients; second, strongly endorse vaccination to protect against human papillomavirus in all patients prior to sexual debut; and, third, screen adolescent females for signs and symptoms of heavy menstrual bleeding.

HPV vaccination initiation after the routine-recommended ages of 11-12 in the United States

BACKGROUND

Since 2006, routine HPV vaccination has been recommended for females aged 11-12 in the US. However not much is known about the extent of and factors associated with HPV vaccination after the ages of 11-12.

METHODS

Provider-verified data on 8,710 females aged 13-17 were analyzed from the 2013 NIS-Teen survey. 2013 data was utilized since it was the first year one can fully evaluate the age at vaccination through age 17 for females who could receive the HPV vaccine at age 11.

RESULTS

Among HPV vaccinated females who were 17 in 2013, 47% (95%CI=43%-50%) received their first dose after age 12, and 24% (95%CI=21%-26%) received their first dose after age 14. The HPV vaccine was more likely to be initiated later than the meningococcal and Tdap vaccines (p<0.05), and later HPV vaccine initiation was more common among those having a more highly educated mother and those not receiving a check-up/well visit between the ages of 11 and 12 in adjusted analyses (p-values<0.05). Females initiating the HPV vaccine late were more likely to not receive three doses (RR=1.90, 95%CI=1.76-2.04).

CONCLUSIONS

HPV vaccination is commonly initiated after the age of 12 in the US, which could limit the vaccine's population-level effectiveness.

The content and context of physicians' communication with males about human papillomavirus vaccination

A physician's recommendation for human papillomavirus (HPV) vaccine is a key predictor of vaccine uptake; however, little is known about how physicians communicate about HPV vaccine with male patients. We sought to describe physicians' HPV vaccine communication practices with males who are of vaccine-eligible age (9-26 years). We surveyed representative samples of pediatric and family medicine physicians in Florida, and assessed whether physicians present HPV vaccine as optional or routine, and as a vaccine that prevents cancer. We also assessed the type of visit during which physicians discuss HPV vaccine with adolescent males and whether other healthcare providers in the practice discuss HPV vaccine or make the initial recommendation. We received 367 completed surveys (50.7% response rate). Few physicians (29.9%) reported they typically present HPV vaccine as routine to males ages 11-12 years, who constitute the target group for routine vaccination. When discussing HPV vaccination, many physicians reported somewhat or strongly emphasizing cancer prevention (80.0%). Physicians most often discussed HPV vaccine when they saw patients for well-child visits (93.0%) and least often at acute care visits (15.3%). Over half reported that at least one other healthcare professional in their practice discusses (56.1%) or makes the initial recommendation for (54.9%) HPV vaccination. Many physicians in our sample are presenting HPV vaccine as optional rather than routine and are missing opportunities to communicate with males about the vaccine. Our findings identify areas for future interventions to improve physicians' HPV vaccine communication and, ultimately, increase the use of this cancer-preventing vaccine.

Providers' beliefs about the effectiveness of the HPV vaccine in preventing cancer and their recommended age groups for vaccination: Findings from a provider survey, 2012

BACKGROUND

The human papillomavirus (HPV) vaccine was recommended in 2007 by the Advisory Committee on Immunization Practices (ACIP) to preadolescent and adolescent girls. Vaccination initiation was recommended at age 11-12 years with the option to start at age 9. Catchup vaccination was recommended to females aged 13-26 previously not vaccinated. However, vaccination coverage remains low. Studies show that the HPV vaccine can prevent cervical, vulvar, vaginal, anal and some oropharyngeal cancers and that provider recommendation of vaccines can improve low vaccination rates.

METHODS

Using data from 2012 DocStyles, an annual, web-based survey of U.S. healthcare professionals including physicians and nurse practitioners (n=1753), we examined providers' knowledge about the effectiveness of the HPV vaccine in preventing cancer and their vaccine recommendation to all age-eligible females (9-26 years). Descriptive statistics and Chi-square tests were used to assess differences across specialties.

RESULTS

Knowledge about HPV vaccine effectiveness in preventing cervical cancer was highly prevalent (96.9%), but less so for anal, vaginal, vulvar and oropharyngeal cancers. Only 14.5% of providers recommended the vaccine to all age-eligible females and 20.2% recommended it to females aged 11-26 years. Knowledge assessment of cancers associated with HPV and vaccination recommendations varied significantly among providers (p<0.01). Providers more frequently recommended the vaccine to girls older than 11-12 years.

CONCLUSIONS

Improving providers' knowledge about HPV-associated cancers and the age for vaccination initiation, communicating messages focusing on the vaccine safety and benefits in cancer prevention and on the importance of its delivery prior to sexual onset, may improve HPV vaccine coverage.

An update on barriers to adolescent human papillomavirus vaccination in the USA

Human papillomavirus is the most common sexually transmitted infection in the USA. It is the primary cause of almost all cervical cancers as well as several other cancers that affect both men and women. Adolescents of both genders can now prevent transmission of the most common oncogenic strains of human papillomavirus by obtaining a safe, three-dose vaccine series. However, despite its potential to save lives and reduce severe morbidity, many US adolescents have not been vaccinated. This is in contrast to other countries where high rates of vaccination are already reducing rates of cervical intra-epithelial neoplasia and genital warts. This article describes barriers recently reported among families in the USA and concludes with suggestions for improving uptake.

Knowledge of HPV and HPV Vaccine among Women Ages 19 to 26

OBJECTIVE

To describe knowledge about human papillomavirus (HPV) and HPV vaccination among women ages 19 to 26 seeking a variety of services at reproductive health centers. A secondary objective was to identify common sources of HPV information.

METHODS

Ten reproductive health centers enrolled 365 women ages 19 to 26 in a randomized, controlled trial to determine the effect of automated reminder messages on HPV vaccine completion. Using responses from a 61-item self-administered baseline questionnaire completed before initiating the HPV vaccine, this subanalysis assessed participants' knowledge regarding HPV and the HPV vaccine.

RESULTS

Knowledge of HPV prevention, transmission, and disease outcomes among the study population was highly variable. The mean HPV knowledge score was 11.0 of a possible 19 (SD = 3.8). Most participants (77%) had heard of the HPV vaccine before completing the questionnaire and indicated that their primary sources of information about the vaccine were television ads (61%), health care providers (52%), and friends (45%).

CONCLUSIONS

Despite a relatively high awareness of the vaccine, specific knowledge regarding HPV and the HPV vaccine varied substantially and participant scores highlighted knowledge gaps among vaccine-eligible young women. Media, health care providers, and friends were identified by participants as sources of information and may influence their knowledge of HPV and the HPV vaccine.