Younger age at initiation of the human papillomavirus (HPV) vaccination series is associated with higher rates of on-time completion

HPV vaccine-related articles shared on Facebook from 2019 to 2021: Did COVID make a difference?

Objective

HPV vaccination is recommended for children beginning at age 9 to prevent several types of cancer. Many parents turn to Facebook for health information. This study describes changes in HPV vaccine-related articles shared on Facebook amidst the COVID-19 pandemic.

Methods

HPV-related articles shared on Facebook (2019-2021) were collected using Buzzsumo, a social media analytics tool and analyzed using content analysis. Articles were categorized by valence, misinformation, evidence types, persuasive tactics, and framing. We quantified these data and tested for difference by article year.

Results

Of the 138 included articles, 51% had positive valence towards the vaccine and 36% had negative valence. In 2021, there was a significant increase in positive messaging (72% vs. 44% in 2019/2020; p < 0.01) and misinformation decreased from 50% in 2019 to 24% in 2021 (p = 0.04). Persuasive strategies were more common in 2019 than in later years.

Conclusion

Despite decreased engagement in 2021, more positive HPV vaccine messaging was observed, although a quarter of articles still contained misinformation. Our results can inform strategies for communicating with parents about the HPV vaccine.

Innovation

Our study is the first to analyze HPV-related articles linked on Facebook and to assess for differences during the pandemic.

Estimating the time required to reach HPV vaccination targets across Europe

BACKGROUND

Cervical cancer (CC) is one of the most common causes of cancer-related deaths in women. The World Health Organization (WHO) has called for the CC elimination as a public health priority and has urged countries to achieve a 90% vaccine coverage rate of human papilloma virus (HPV) vaccination among 15-year-old girls by 2030.

RESEARCH DESIGN AND METHODS

Regression models were fitted to the WHO HPV vaccine coverage rate data to estimate when the 90% vaccine coverage rate target would be achieved in 22 European countries.

RESULTS

The mean vaccine coverage rate of included countries was 62.2% (SD: 18.3). Nine countries (Iceland, Norway, Portugal, Ireland, Hungary, Spain, Sweden, Denmark, and Switzerland) are expected to achieve a 90% vaccine coverage rate by 2030. Six countries (Estonia, Cyprus, Netherlands, France, Germany, and Italy) are expected to reach a 90% vaccine coverage rate between 2030 and 2040 whereas seven countries (Belgium, Bulgaria, Finland, Latvia, Luxembourg, Malta, and Slovenia) are not expected to achieve the 90% vaccine coverage rate target by 2040.

CONCLUSION

The majority of European countries are not on track to achieve 90% vaccine coverage rate by 2030. To achieve this, a significant increase in the annual vaccine coverage rate growth rate is required.

Approximate maximum likelihood estimation in cure models using aggregated data, with application to HPV vaccine completion

Research into vaccine hesitancy is a critical component of the public health enterprise, as rates of communicable diseases preventable by routine childhood immunization have been increasing in recent years. It is therefore important to estimate proportions of "never-vaccinators" in various subgroups of the population in order to successfully target interventions to improve childhood vaccination rates. However, due to privacy issues, it may be difficult to obtain individual patient data (IPD) needed to perform the appropriate time-to-event analyses: state-level immunization information services may only be willing to share aggregated data with researchers. We propose statistical methodology for the analysis of aggregated survival data that can accommodate a cured fraction based on a polynomial approximation of the mixture cure model log-likelihood function relying only on summary statistics. We study the performance of the method through simulation studies and apply it to a real-world data set from a study examining reminder/recall approaches to improve human papillomavirus (HPV) vaccination uptake. The proposed methods may be generalized for use when there is interest in fitting complex likelihood-based models but IPD is unavailable due to data privacy or other concerns.

HPV vaccine standing orders and communication in primary care: A qualitative study

BACKGROUND

Standing orders may improve HPV vaccination rates, but clinical staff's readiness to use them has not been well-explored. We sought to explore benefits and challenges to using HPV vaccine standing orders for adolescents ages 9 to 12, understand clinical staff roles in communication about HPV vaccine, and how standing orders can reduce barriers contributing to vaccine disparities among racial and ethnic marginalized groups.

METHODS

Participants were a sample of 16 U.S. nurses, medical assistants, and healthcare providers working in primary care, recruited from June to September 2022. Trained staff conducted virtual, semi-structured qualitative interviews. We analyzed the resulting data using reflexive thematic analysis.

RESULTS

Themes reflected benefits and challenges to using HPV vaccine standing orders and strategies to address clinic barriers to improve vaccine access and HPV vaccine communication. Benefits included faster and efficient clinic flow; fewer missed vaccine opportunities and promotion of early vaccination; and normalization of HPV vaccination as routine care. Challenges included possible exacerbation of existing HPV vaccine communication and recommendation barriers; and how the complexity of the vaccine administration schedule lessens nurses' and medical assistants' confidence to use standing orders. Strategies to address vaccine access barriers included using nurse-only visits to empower nurse autonomy and catch up on HPV vaccination; engaging clinical staff to follow up with overdue children; and educating parents on HPV vaccine before their child is vaccine eligible.

CONCLUSION

Using HPV vaccine standing orders can promote autonomy for nurses and medical assistants and address vaccine access barriers. Clinical staff engagement and clinic support to mitigate existing vaccine communication barriers are needed to empower staff to use of HPV vaccine standing orders.

Assessing the long-term implications of age 9 initiation of HPV vaccination on series completion by age 13-15 in the US: projections from an age-structured vaccination model

Introduction

Routine human papillomavirus (HPV) vaccination in the US is recommended at ages 11 or 12 years and can be given at age 9. Vaccination completion rates among adolescents 13-15 years in the US remain below the 80% goal. This study evaluated the long-term effects of increasing proactive HPV vaccination initiation rates at age 9 years in completion rates of adolescents.

Methods

An age-structured vaccination model was developed and parametrized based on the National Immunization Survey-Teen (NIS-Teen) survey data. The model projected vaccination coverage (by vaccination status and age group), for 20 years, for a routine initiation scenario (no increase in initiation rates of 9-year-olds) and different proactive initiation (increased age 9 initiation) scenarios. The time to reach a completion rate of 80% for 13-15-year-olds was estimated. The model also generated projections stratified for subgroups of interest.

Results

Results indicated that vaccine completion rates of 80% in 13-15-year-olds may not be achieved by 2040 under current trends of routine initiation at ages 11 or 12 years. However, increasing initiation rates in 9-year-olds by 1% and 3% annually could shorten the time to achieve 80% completion by 4 and 8 years, respectively. Stratification analyses showed that increasing initiation rates in 9-year-olds can also reduce disparities across subgroups in the time to achieve vaccination completion targets.

Discussion

Increasing HPV vaccination initiation rates in 9-year-olds by as little as 1%-3% annually may be an effective strategy to improve HPV vaccination completion rates in adolescents by age 15 and reach the Healthy People goal of 80% completion much earlier.

Current status and future directions for the development of human papillomavirus vaccines

The development of human papillomavirus (HPV) vaccines has made substantive progress, as represented by the approval of five prophylactic vaccines since 2006. Generally, the deployment of prophylactic HPV vaccines is effective in preventing newly acquired infections and incidences of HPV-related malignancies. However, there is still a long way to go regarding the prevention of all HPV infections and the eradication of established HPV infections, as well as the subsequent progression to cancer. Optimizing prophylactic HPV vaccines by incorporating L1 proteins from more HPV subtypes, exploring adjuvants that reinforce cellular immune responses to eradicate HPV-infected cells, and developing therapeutic HPV vaccines used either alone or in combination with other cancer therapeutic modalities might bring about a new era getting closer to the vision to get rid of HPV infection and related diseases. Herein, we summarize strategies for the development of HPV vaccines, both prophylactic and therapeutic, with an emphasis on the selection of antigens and adjuvants, as well as implications for vaccine efficacy based on preclinical studies and clinical trials. Additionally, we outline current cutting-edge insights on formulation strategies, dosing schedules, and age expansion among HPV vaccine recipients, which might play important roles in addressing barriers to vaccine uptake, such as vaccine hesitancy and vaccine availability.

Effect of age at initiation of the human papillomavirus vaccine on the association between race/ethnicity and completion of the vaccine series

BACKGROUND

Up-to-date (UTD) of the human papillomavirus (HPV) vaccine series has been low despite 2016 recommendations for 2 doses among initiators <15 years of age and 3 doses for 15+ year olds. This study examined how age at initiation affected the association between race/ethnicity and UTD among adolescent HPV vaccine initiators. We also examined how administration of other adolescent vaccines affected UTD.

METHODS

A secondary analysis of The National Immunization Survey - Teen data between 2016 and 2020 was conducted. Characteristics associated with initiation of the vaccine series was examined and used to evaluate UTD among initiators. All data were weighted. Associations between characteristics and HPV vaccine initiation were examined using Rao Scott chi-square tests and univariable logistic regression. Multivariable binary logistic regression models stratified by race/ethnicity calculated the strength of association between independent variables and odds of initiation and UTD among initiators.

RESULTS

The final sample size was 99,719 with 67,855 (68.1 %) initiating HPV vaccination. Among HPV vaccine initiators, Hispanic and black adolescents had lower odds of UTD. However, 9-10-year-old initiators had increased odds (aOR: 5.71; 95 %CI: 3.78-8.63) of UTD compared to 12-year-old initiators. Increased odds of UTD among initiators younger than 12 years were found across racial/ethnic groups. Flu vaccination was associated with decreased odds of UTD among white (aOR: 0.76; 95 %CI:0.65-0.88) and black adolescents (aOR: 0.67; 95 %CI: 0.46-0.96).

CONCLUSION

Strong recommendations to ensure patients are UTD on the HPV vaccine series are essential to improving UTD among all adolescents and follow-up should occur when administering other vaccines to reduce missed opportunities.

Who are vaccine champions and what implementation strategies do they use to improve adolescent HPV vaccination? Findings from a national survey of primary care professionals

BACKGROUND

Implementation science researchers often cite clinical champions as critical to overcoming organizational resistance and other barriers to the implementation of evidence-based health services, yet relatively little is known about who champions are or how they effect change. To inform future efforts to identify and engage champions to support HPV vaccination, we sought to describe the key characteristics and strategies of vaccine champions working in adolescent primary care.

METHODS

In 2022, we conducted a national survey with a web-based panel of 2527 primary care professionals (PCPs) with a role in adolescent HPV vaccination (57% response rate). Our sample consisted of pediatricians (26%), family medicine physicians (22%), advanced practice providers (24%), and nursing staff (28%). Our survey assessed PCPs' experience with vaccine champions, defined as health care professionals "known for helping their colleagues improve vaccination rates."

RESULTS

Overall, 85% of PCPs reported currently working with one or more vaccine champions. Among these 2144 PCPs, most identified the champion with whom they worked most closely as being a physician (40%) or nurse (40%). Almost all identified champions worked to improve vaccination rates for vaccines in general (45%) or HPV vaccine specifically (49%). PCPs commonly reported that champion implementation strategies included sharing information (79%), encouragement (62%), and vaccination data (59%) with colleagues, but less than half reported that champions led quality improvement projects (39%). Most PCPs perceived their closest champion as being moderately to extremely effective at improving vaccination rates (91%). PCPs who did versus did not work with champions more often recommended HPV vaccination at the earliest opportunity of ages 9-10 rather than later ages (44% vs. 33%, p < 0.001).

CONCLUSIONS

Findings of our national study suggest that vaccine champions are common in adolescent primary care, but only a minority lead quality improvement projects. Interventionists seeking to identify champions to improve HPV vaccination rates can expect to find them among both physicians and nurses, but should be prepared to offer support to more fully engage them in implementing interventions.

Human Papillomavirus Vaccine Completion by 13: A Quality Improvement Initiative in a Large Primary Care Network

OBJECTIVE

Fewer than 40% of U.S. children complete the human papillomavirus (HPV) vaccine series before their 13th birthday. In our large pediatric primary care network, HPV vaccine completion rate by age 13 was 30%. We hypothesized that a phased quality improvement (QI) initiative would increase rates of HPV vaccine completion by age 13 across our network.

METHODS

This QI initiative was conducted in a network of 30 practices located across two states, in urban and suburban settings, consisting of teaching and non-teaching clinics, and ranging in size from three to 50 providers per office. We used a phased approach incorporating multicomponent network-wide and iterative practice-specific interventions. Key interventions included: updating clinical decision support to default order HPV vaccine due at preventive visits starting at age nine instead of 11, data audit and feedback to providers and practices, encouraging use of a strong provider recommendation, and standing orders.

RESULTS

From April 2019 to October 2022, HPV vaccine completion by age 13 across our network increased from 30% to 55% and met criteria for special cause variation on statistical process control charts. A gap in median HPV vaccine completion by age 13 between patients with public insurance and patients with private or commercial insurance decreased from 9% to 1%.

CONCLUSION

A QI initiative was associated with a sustained increase in HPV vaccine series completion by age 13 and reduced variation in care across a large network of 30 primary care practices.

A Multivariate Probit Regression of the Uptake of Adolescent Vaccines Among Racial/Ethnic Minority Adolescents Before and During the COVID-19 Pandemic

PURPOSE

The uptake of adolescent vaccines has improved over the years. However, research of the effects of the COVID-19 pandemic on this uptake among racial/ethnic minority adolescents has been limited. This study was conducted to compare the probability of uptake of the human papillomavirus (HPV); tetanus, diphtheria, and acellular pertussis (Tdap); and quadrivalent meningococcal conjugate (MenACWY) vaccines among racial/ethnic minority adolescents ages 13-17 years in 2019, 2020, and 2021.

METHODS

Using a cross-sectional design to examine data from the National Immunization Survey-Teen (2019-2021), multivariate probit regression was used to model variation in uptake of these three adolescent vaccines (n = 38,128). The outcome measures were HPV, Tdap, and MenACWY vaccine uptake.

RESULTS

The probability of uptake of HPV vaccine was higher in 2020 (Coef = 0.09 [95% confidence interval (CI), 0.03-0.16]) and 2021 (Coef = 0.07 [95% CI, 0.00-0.15]) than in 2019. The probability of uptake of MenACWY vaccine was higher in 2020 (Coef = 0.08 [95% CI, 0.02-0.15]) than in 2019. The probability of uptake of recommended vaccines varied among racial/ethnic minorities with non-Hispanic Black adolescents exhibiting higher probability of uptake of HPV vaccine (Coef = 0.10 [95% CI, 0.01-0.19]) than Tdap vaccine. U.S. Census region and insurance status were associated with the uptake of all recommended vaccines.

DISCUSSION

Progress in the uptake of these recommended vaccines may not have been interrupted by the COVID-19 pandemic. Also, disparities in uptake of the recommended vaccines still exist despite increased uptake during the pandemic. Future research should examine the disparities as well as examine regional differences in the uptake of these three adolescent vaccines.

HPV vaccine initiation at 9 or 10 years of age and better series completion by age 13 among privately and publicly insured children in the US

The US Advisory Committee on Immunization Practice recommends routine human papillomavirus (HPV) vaccination at 11-12 years of age, but states that vaccination may be initiated as early as 9 years. Our primary goal was to assess whether initiating HPV vaccination at 9-10 years of age, compared to 11-12, was associated with a higher rate of series completion by 13 years of age, and to identify factors associated with series completion by age 13. The study used vaccine claims and other data from the IBM MarketScan Commercial Claims and Encounters (privately insured) and IBM MarketScan Multi-State Medicaid (publicly insured) databases. Participants were 9-12 years of age and initiated HPV vaccination between January 2006 and December 2018 (publicly insured) or February 2019 (privately insured). Among 100,117 privately insured individuals, those initiating the HPV vaccination series at 9-10 years of age had a significantly higher series completion rate by 13 years of age than did those initiating at 11-12 years of age (76.2% versus 48.1%; p < .001). The same pattern was observed for 115,863 publicly insured individuals (70.4% versus 40.0%; p < .001). Provider and health care plan type, female sex, race/ethnicity, and wellness checks or non-HPV vaccinations during the baseline period were significantly associated with series completion by 13 years of age. Proactive initiation of HPV vaccination at 9-10 years of age was associated with higher rates of series completion by 13 years of age. These findings can inform provider education and other interventions to encourage timely HPV vaccination series completion.

Framing of national HPV vaccine recommendations and willingness to recommend at ages 9-10

Proactive HPV vaccination at age 9 better prevents infection and improves vaccine series completion. Because national organizations recommend starting the vaccine at different ages, we sought to understand the impact of these recommendation frames. In 2022, we surveyed 2,527 US clinical staff (45% physicians) who provide HPV vaccine for children. We randomized respondents to one of three frames based on HPV vaccine recommendations of national organizations or a no-recommendation control, and assessed willingness to recommend HPV vaccine for children ages 9-10. Respondents also reported perceived benefits of HPV vaccination at ages 9 or 12. Recommending HPV vaccination "at ages 11-12" led to lower willingness to vaccinate at ages 9-10 than control (37% vs. 54%, p < .05). Recommending vaccination "at ages 9-12" led to similar willingness as control. However, "starting at age 9" led to higher willingness than control (63% vs. 54%, p < .05). Results were similar across respondents' training, specialty, or years in practice, or their clinic's rurality or healthcare system membership. More common benefits of recommending at age 9 than 12 were avoiding the topic of sex (24% vs. 10%, OR = 2.78, 95%CI: 2.23, 3.48) and completing the vaccine series before age 13 (56% vs. 47%, OR = 1.44, 95%CI: 1.23, 1.68). Less common benefits for age 9 were having parents ready to talk about HPV vaccine and agreeing to vaccination (both p < .05). An effective way to encourage proactive HPV vaccination is to say that it starts at age 9. Aligning national recommendations to start at age 9 can promote timely vaccination.

Engaging health plans to prioritize HPV vaccination and initiate at age 9

Health plans can influence pediatric and primary care providers and patients to understand HPV vaccination coverage and increase HPV vaccination uptake. By initiating vaccination at age nine, health plans can lay the groundwork for on-time HPV cancer prevention by age 13. In 2022, the American Cancer Society engaged 28 health plans in a 12-month HPV vaccination learning collaborative in which plans set their own quality improvement targets, implemented multi-pronged interventions, and joined quarterly best-practice sharing calls. Twenty-five of the 28 plans reported including a focus on ages 9 to 10. Preliminary pre-intervention data illustrate that vaccination rates from participating plans follow national trends and reaffirm existing gaps for HPV vaccination. Health plan interventions to address HPV vaccination are consistent with best practices but could be maximized to target initiation at ages 9-10 by using provider and patient reminders, targeted provider education, and dose-specific provider pay for performance and patient incentive programs. Health plans should explore future capacity to analyze non-HEDIS required data, including HPV initiation and HPV vaccination data for adolescents below age 13.

The association of initiating HPV vaccination at ages 9-10 years and up-to-date status among adolescents ages 13-17 years, 2016-2020

Recent guidelines from the American Cancer Society stress HPV vaccination series initiation at the youngest opportunity, i.e., age 9 years. There are limited data on the association between initiating HPV vaccination at ages 9-10 years and up-to-date (UTD) status. In this study, we compare nationally representative UTD HPV vaccination rates between adolescents who initiated the series younger (ages 9-10 years) vs. older (≥ age 11 years). Five years of pooled data (2016-2020) from National Immunization Survey-Teen were used to estimate the UTD HPV vaccination prevalence among younger vs. older initiating 13-17-year-olds. Adjusted logistic regression models estimated prevalence ratios (aPRs), differences (aDs), and difference in differences (aDDs) in prevalence of being UTD to assess the overall association of age at initiation with being UTD and differences in sociodemographic predictors of being UTD among younger vs. older initiators. UTD prevalence for younger initiators was 93% compared with 72% among older initiators (aPR: 1.27,95%CI: 1.24,1.31). Among older initiators, UTD prevalence was significantly different by sex, insurance status, and current age; no such differences were observed among younger initiators. Results indicate that younger initiation is associated with a 27% higher UTD prevalence, highlighting the importance of promoting younger initiation, particularly among those with health-care barriers.

Implementing interventions to start HPV vaccination at age 9: Using the evidence we have

Human papillomavirus (HPV) vaccination is routinely recommended for adolescents aged 11 or 12 years but can begin at age 9. On-time HPV vaccination by the thirteenth birthday has proven to be effective in preventing HPV cancer and pre-cancer. However, HPV coverage rates continue to lag behind other routinely recommended vaccinations for adolescents. A promising approach to improving coverage is to start HPV vaccination at age 9. This approach has been endorsed by the American Academy of Pediatrics and the American Cancer Society. Benefits of this approach include increased time to complete vaccination series by the thirteenth birthday, additional spacing of recommended vaccines, and a more concentrated focus on cancer prevention messaging. While promising, little is known about how and if existing evidence-based interventions and approaches can be used to promote starting HPV vaccination at age 9. Implementation science frameworks offer scientific direction in how to adapt current and develop new interventions to promote starting HPV vaccination at age 9 and accelerate dissemination and prevent HPV cancers.

Optimizing timing of adolescent vaccines: Impact of initiating HPV vaccination before Tdap or meningococcal vaccination on timely completion of the HPV vaccine series

To explore the impact on timely series completion of initiating the HPV vaccine series prior to other vaccines in the adolescent platform (Tdap or meningococcal vacccines), we created a cohort of children aged 9 in 2015 who were continuously enrolled through the age of 13 (2019) from a national administrative database of employee-sponsored insurance in the United States (MarketScan). Logistic regressions were used to predict the odds of HPV vaccine series completion among those who started the series prior to, concurrent with, or after receiving Tdap or meningococcal vaccination. The cohort included 100,857 eligible children. Compared with adolescents who received their HPV and Tdap or HPV and meningococcal vaccinations concurrently, those who received HPV prior to other vaccines had higher completion (aOR = 1.38 for Tdap, aOR 1.62 for meningococcal), while those who received their HPV vaccination after other vaccines had lower odds of HPV vaccine series completion (aOR = 0.68 for Tdap, aOR = 0.62 for meningococcal). Other factors associated with series completion included female sex, residing in an urban (vs. rural) area, residing in the Northeast, and receiving primary care from a pediatrician (vs. family medicine physician). These data indicate that beginning the HPV vaccine series prior to the adolescent platform may improve on-time series completion.

HPV vaccine recommendations by age: A survey of providers in federally qualified health centers

Clinician recommendation remains a critical factor in improving HPV vaccine uptake. Clinicians practicing in federally qualified health centers were surveyed between October 2021 and July 2022. Clinicians were asked how they recommended HPV vaccination for patients aged 9-10, 11-12, 13-18, 19-26, and 27-45 y (strongly recommend, offer but do not recommend strongly, discuss only if the patient initiates the conversation, or recommend against). Descriptive statistics were assessed, and exact binomial logistic regression analyses were utilized to examine factors associated with HPV vaccination recommendation in 9-10-y-old patients. Respondents (n = 148) were primarily female (85%), between the ages of 30-39 (38%), white, non-Hispanic (62%), advanced practice providers (55%), family medicine specialty (70%), and practicing in the Northeast (63%). Strong recommendations for HPV vaccination varied by age: 65% strongly recommended for ages 9-10, 94% for ages 11-12, 96% for ages 13-18, 82% for age 19-26, and 26% for ages 27-45 y. Compared to Women's Health/OBGYN specialty, family medicine clinicians were less likely to recommend HPV vaccination at ages 9-10 (p = .03). Approximately two-thirds of clinicians practicing in federally qualified health centers or safety net settings strongly recommend HPV vaccine series initiation at ages 9-10. Additional research is needed to improve recommendations in younger age groups.

Does HPV vaccination initiation at age 9, improve HPV initiation and vaccine series completion rates by age 13?

Vaccination for Human Papillomavirus (HPV) is important to reduce rates of cervical and oropharyngeal cancer. We aimed to evaluate if a program to initiate HPV vaccination at 9 years improved initiation and completion rates by 13 years of age. Data on empaneled patients aged 9-13 years from January 1, 2021 to August 30, 2022 were abstracted from the electronic health record. Primary outcome measures included HPV vaccination initiation and series completion by 13 years of age. The secondary outcome measure was missed opportunities for HPV vaccination. In total, 25,888 patients were included (12,433 pre-intervention, and 13,455 post-intervention). The percentage of patients aged 9-13 with an in-person visit who received at least 1 dose of HPV vaccine increased from 30% pre-intervention to 43% post-intervention. The percentage of patients who received 2 doses of vaccine increased from 19.3% pre-intervention to 42.7% post-intervention. For the overall population seen in-person, initiation of HPV vaccination by age 13 years increased from 42% to 54%. HPV completion increased as well (13% to 18%). HPV vaccination initiation at 9 years of age may be an acceptable and effective approach to improving vaccination rates.

Multi-level quality improvement strategies to optimize HPV vaccination starting at the 9-year well child visit: Success stories from two private pediatric clinics

HPV vaccination rates remain far below goal, leaving many adolescents unprotected against future HPV-related cancers. Starting HPV vaccine at age 9 may improve timely preteen vaccination. The "HPV Vax at 9" Quality Improvement intervention paired HPV vaccination with 9- and 10-year well child visits and was piloted at two pediatric clinics (n = 9 sites) in Washington between 2018 and 2022. Supporting interventions included standardized immunization schedule posters in exam rooms, electronic medical record supports, provider and staff training, strong provider recommendations, printed educational resources, and peer-to-peer champion coaching. Provider and clinic acceptance was high with HPV vaccine administration occurring at 68-86% of the 9- and 10-year well child visits. During the first year, HPV initiation rates at age 9-10 increased by 30% or more at each clinic. Sustained improvements in initiation and series completion were seen with completion at age 11-12 rising as much as 40% from 22 to 62%. Downward pressure of the COVID-19 pandemic on HPV vaccination rates was mitigated. Pairing HPV vaccine with 9- and 10-year well child visits, posting the standardized immunization schedule, and instituting EMR supports for HPV at 9 may be effective and sustainable strategies to simplify clinic workflows and increase timely HPV vaccination.

Mothers' perceptions and attitudes about HPV vaccination initiation among 9- and 10-year-olds

HPV vaccination has potential to prevent 90% of HPV-associated cancers. The Advisory Committee on Immunization Practices recommends HPV vaccination for 11- and 12-year-olds, but vaccine initiation can start at age 9. The purpose of this study was to explore perceptions about starting HPV vaccination at a younger age to inform future interventions that promote initiation at ages 9 and 10 years. This was part of a larger study about vaccine hesitancy among racially/ethnically diverse parents of adolescents in the Greater Newark Area of New Jersey. We thematically analyzed transcripts from 16 interviews with English- and Spanish-speaking mothers who had at least one child ≤ 10 years. Analyses focused on perceptions of HPV-related disease risk, attitudes toward HPV vaccination need, and vaccine confidence specifically for 9- and 10-year-olds. Few parents with young adolescents reported receiving vaccination recommendations, and only one reported series initiation before age 11. Mothers' hesitation about younger HPV vaccination initiation revolved around: 1) low perceived necessity among English-speaking mothers due to young adolescents not being sexually active, 2) concerns about potential side effects associated with vaccinating prepubescent adolescents, and 3) a desire for adolescents to be old enough to provide assent. Participants were not opposed to younger initiation but wanted and relied on pediatricians to inform them about vaccination for younger adolescents. These findings suggest mothers are willing to vaccinate at younger ages after clear provider recommendations. Equipping providers with evidence about vaccine safety and cancer prevention communication strategies may promote initiation and timely completion at younger ages.

Effect of immunization registry-based provider reminder to initiate HPV vaccination at age 9, Washington state

Human papillomavirus (HPV) vaccination rates are lower than Tetanus-diphtheria-pertussis (Tdap) and Meningococcal conjugate (MenACWY) rates, although the Advisory Committee on Immunization Practices recommends all three vaccines be given routinely at age 11-12. Evidence is mounting that children who initiate HPV vaccination starting at age 9 are more likely to complete the series on time. Washington state implemented a provider reminder through its immunization information system (WAIIS) in January 2023 to increase HPV vaccine initiation at 9-years-old by updating the forecasted recommended age for HPV from age 11 to 9. The effectiveness of provider reminders when implemented via an immunization information system (IIS) is poorly understood. We evaluated the impact of this forecast update using a seasonally adjusted interrupted time series regression of weekly HPV initiations at 9-years-old before and after implementation. We also examined time series trends of vaccine administration between 2018 and 2023 for HPV initiation at age 9, as well as Tdap, MenACWY and HPV initiation at age 11. The WAIIS forecast update doubled the weekly rate of HPV initiation among 9-year-olds in Washington state, although the weekly count of initiation at 9 remains far lower than initiations at 11. Jurisdictions wanting to increase HPV vaccine initiation at earlier ages should consider updating their forecast algorithm and investing in complementary evidence-based strategies such as provider and parent education, and clinic-based quality improvement efforts. The reach of IIS forecaster updates may be enhanced by working with administrators of electronic medical record systems to ensure parity of provider prompts with IIS.

Age nine is possible: Improving age 9 HPV initiation through a national quality improvement initiative during the COVID-19 pandemic

The American Cancer Society collaborated with a range of healthcare partners in 2020-2022 to implement quality improvement clinical interventions with the goal of improving HPV vaccination rates among adolescents' ages 9-13. 2020 was the first cohort for which partners had been asked to submit HPV rate data for patients' ages 9-12. At least 80% of the partners across all reported project years were able and willing to report HPV rates for these ages. Partners submitted HPV initiation rates at the beginning and end of the 12-month project year along with project activities, including evidence-based interventions (EBIs) implemented. Mean initiation rates for ages 9-10 significantly increased 4.1% during 2020 compared to non-significant rate increases of 2.6% and 2.0% for ages 11-12 and age 13, respectively. In 2021, ages 9-10 initiation saw a non-significant increase of 2.2%, whereas ages 11-12 and age 13 decreased non-significantly by 0.3% and 0.1%, respectively. The 2022 cohort saw significant initiation rate increases of at least 4% across all ages, potentially a promising result of the myriad back on track HPV vaccination campaigns designed to reverse the damage of the COVID-19 pandemic on adolescent immunizations. These findings demonstrate an effective adaptation of quality improvement in increasing HPV vaccination coverage among younger ages even during a national pandemic.

County-level correlates of completed HPV vaccination in Indiana

The Healthy People 2030 goal is for 80% of all adolescents to complete their HPV vaccination series. Per the 2021, National Immunization Survey-Teen (NIS-Teen), 61.7% of adolescents have completed the series, and Indiana lags below the national average (55.2%). The present study estimated the 2-dose HPV vaccine series completion rates across Indiana counties among individuals aged 9-14 years who received their first dose of vaccine and determined what factors were associated with series completion at the county level. The association of county-level sociodemographic and health measures with series completion was also examined. Data were extracted from the Indiana Immunization Information System (IIS), administered by the Indiana Department of Health. All vaccine providers are required to report all immunizations to the system for any patient under age 19 years. All Indiana children ages 9-14 years at the time of first dose who had initiated HPV vaccination in 2017 or 2018 were included. Two-dose series completion was evaluated through October of 2020, allowing a minimum gap of 22 months from first dose administration. All statistical analyses were conducted at the county-level. The Indiana HPV vaccination series completion rate among individuals that received the first dose was on average 73% across counties, ranging from 55.7% to 90.4%. Higher series completion was positively associated with primary care providers per capita, participation in mammography screening among Medicare enrollees, median household income, life expectancy, percentage of residents with some college, percentage of adults up-to-date with colonoscopy screening, and percentage of adults with flu vaccine. There was wide variability in series completion across Indiana counties. HPV series completion was associated with county-level sociodemographic and health measures, particularly variables reflecting difficulties with access to care and lack of financial resources.

Acceptability and readiness to promote human papillomavirus vaccination at ages 9-10 years: a feasibility study among North Carolina clinics

While 9-valent human papillomavirus (HPV) vaccination is approved by the US Food and Drug Administration for use in adolescents as young as age 9, providers typically recommend it at ages 11-12. Studies suggest that recommending HPV vaccination at 9 or 10 years of age could increase up-to-date vaccination by age 13, which could especially benefit rural populations with reduced access to primary health care and lower HPV vaccination coverage than urban areas. This study aimed to assess the feasibility of the age-9 recommendation of HPV vaccination in rural clinics. We conducted in-depth interviews with providers and staff from two primary care clinics in central North Carolina to understand attitudes toward recommending HPV vaccination to 9- and 10-year-olds. All interviewees agreed that HPV vaccination was important for cancer prevention and should be recommended before the onset of sexual activity, agreeing that HPV vaccination could be initiated before age 11 to improve timeliness and completion of the vaccination series. However, opinions were mixed on whether HPV vaccination should be initiated as young as 9 years old. Two key informants recruited from two university-affiliated clinics described their experiences recommending HPV vaccination to 9- and 10-year-olds, including a modified vaccination schedule that promotes HPV vaccination during routine well-child visits, prior to pubertal onset, and alongside other recommended adolescent vaccines. Age-9 recommendation and administration of HPV vaccination is possible with minimal changes to current clinical practices and could increase the convenience and acceptability of HPV vaccination in under-vaccinated settings.

How to make effective HPV vaccine recommendations starting at age 9

This article provides best and promising practices for recommending HPV vaccination at age 9 as a way to ensure high uptake. An effective method for recommending HPV vaccination is the Announcement Approach, which consists of 3 evidence-based steps. The first step, Announce, involves noting that the child is 9 years old, saying they are due for a vaccine that prevents 6 HPV cancers, and saying you'll vaccinate today. This adapted version of the Announce step simplifies the bundled approach used at ages 11-12 that emphasizes the prevention of meningitis and whooping cough in addition to HPV cancers. For hesitant parents, the second step, Connect and Counsel, involves finding common ground with the parent and communicating the value of starting HPV vaccination at the first opportunity. Finally, for parents who decline, the third step is to Try Again at a later visit. Using the Announcement Approach at age 9 stands to increase HPV vaccine uptake, save time, and lead to high family and provider satisfaction.

Influences of sociodemographic characteristics and parental HPV vaccination hesitancy on HPV vaccination coverage in five US states

BACKGROUND

In the United States (US), half of new human papillomavirus (HPV) infections occur among young people aged 15-24 years. Despite the effectiveness of HPV vaccination in protecting against HPV-associated cancers, its coverage among adolescents remains suboptimal. This study examined the association of sociodemographic characteristics and HPV vaccination hesitancy with HPV vaccination coverage in five US states with disproportionately low adolescent coverage rates compared to the national average.

METHODS

Responses to an online Qualtrics survey from 926 parents of children aged 9-17 years in Arkansas, Mississippi, Missouri, Tennessee, and Southern Illinois in July 2021 were analyzed using multivariate logistic regression to estimate the association of sociodemographic characteristics and HPV vaccination hesitancy with HPV vaccination coverage.

RESULTS

Of the parents, 78 % were female, 76 % were non-Hispanic White, 61.9 % lived in rural areas, 22 % were classified as HPV vaccine hesitant, and 42 % had vaccinated their oldest child between the ages of 9-17 years against HPV. Children of vaccine hesitant parents were less likely to have received any doses of the HPV vaccine than children of non-vaccine hesitant parents (AOR: 0.17, 95 % CI:0.11-0.27). Male children were less likely to have initiated the HPV vaccine series than female children (AOR: 0.70, 95 % CI:0.50-0.97). Older children (13-17 vs 9-12 years), receiving the meningococcal conjugate or most recent seasonal influenza vaccine were all associated with higher likelihoods of receiving any doses of the HPV vaccine (AOR: 6.01, 95 % CI:3.98-9.08; AOR: 2.24, 95 % CI:1.27-3.95; AOR: 2.41, 95 % CI:1.73-3.36, respectively).

CONCLUSIONS

Adolescent HPV vaccination coverage remains low in our targeted states. Children's age, sex, and parental vaccine hesitancy were significantly associated with likelihood of HPV vaccination. These findings offer the opportunity for targeted interventions among parents in regions with low vaccine uptake and underscore the importance of developing and implementing strategies to address parental HPV vaccination hesitancy to improve uptake in the US.

Perceived Barriers and Use of Evidence-Based Practices for Adolescent HPV Vaccination among East Texas Providers

Adolescents living in rural areas are less likely to be up to date on the human papillomavirus (HPV) vaccine, which can prevent cervical cancer. We administered a telephone survey to 27 clinics in rural East Texas to assess perceived barriers to HPV vaccination and current use of evidence-based interventions to promote HPV vaccination. Perceived barriers were assessed using a 5-point Likert scale and clinical implementation of evidence-based practices was determined. Findings are reported using descriptive statistics. The most commonly reported barriers were missed vaccination opportunities due to the pandemic (66.7%), followed by vaccine hesitancy due to the pandemic (44.4%) and due to the HPV vaccine specifically (33.3%). Fewer than a third of clinics reported using the evidence-based strategies of use of a “refusal to vaccinate” form (29.6%), having an identified HPV vaccine champion (29.6%), and recommending the HPV vaccine at age 9 (22.2%). While many clinics surveyed currently implement evidence-based practices to promote HPV vaccination, there is a need and desire for additional HPV vaccination interventions in East Texas clinics.

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.

Assessment of human papillomavirus vaccination rates of adolescents in California, 2018-2019

Accurate documentation of state-level human papillomavirus (HPV) vaccination is required for public health planning and to inform corrective actions. To examine the representativeness of the California Immunization Registry, we compared the National Immunization Survey (NIS)-Teen, commercial HMOs in California, Medi-Cal, and California Immunization Registry data for HPV vaccine series completion. Our objectives were to evaluate the vaccine registries, compare and report their completeness, and make recommendations on how to improve and use these studies. Vaccination values were extrapolated for all adolescents aged 13 to 17 years from 2018 to 2019 from NIS-Teen, adolescents aged 13 years from 2018 to 2019 reported in the California Immunization Registry, and adolescents aged 13 years for 2018 for commercial HMOs and Medi-Cal. HPV series completion among 13-year-olds in 2018 for commercial HMOs was 50 %, Medi-Cal was 45 %, and the California Immunization Registry was 28 %, with NIS-Teen rates for 13 to 17-year-olds at 50 % in 2018 and 54 % in 2019. Both rural and urban geographic regions were found to have low completion rates of the HPV series, with trends ranging from 13 % to 45 %. The California Immunization Registry's lower HPV vaccine series completion among 13-year-olds compared to the other reporting sources is most likely due differences in reporting and data collection. Importantly, this data will serve as a comparator for future, similar studies of various sources of HPV vaccination rates following the passing of Bill-1797, which will mandate immunization reporting starting in January 2023.

Acceptability and readiness to promote human papillomavirus vaccination at ages 9-10 years: A pilot study among rural North Carolina clinics

While 9-valent human papillomavirus vaccination (HPV-9) is approved by the U.S. Food and Drug Administration for use in adolescents as young as age 9, providers typically recommend it at ages 11-12 per Centers for Disease Control and Prevention recommendations. Studies suggest that recommending HPV-9 at 9 or 10 years of age could increase up-to-date vaccination by age 13, which could benefit rural populations with reduced access to primary health care and lower HPV-9 coverage than urban areas. This pilot study aimed to assess the feasibility of earlier recommendation of HPV-9 in rural clinics. We conducted in-depth interviews with providers and staff from two primary care clinics in central North Carolina, to understand attitudes toward recommending HPV-9 to 9- and 10-year-olds. All interviewees agreed that HPV-9 was important for cancer prevention and should be recommended before the onset of sexual activity, and agreed that HPV-9 could be initiated before age 11 to improve timeliness and completion of the vaccination series. However, opinions were mixed on whether it should be initiated as young as 9-years-old. Two key informants recruited from two urban clinics described their experiences recommending HPV-9 to 9- and 10-year-olds, including a modified vaccination schedule that promotes HPV-9 during routine well-child visits, prior to pubertal onset, and alongside other recommended adolescent vaccines. Earlier recommendation and administration of HPV-9 is possible with minimal changes to current clinical practices and could increase convenience and acceptability of HPV-9 in under-vaccinated settings.

Raising the HPV Vaccination Rate in Rural Northern New England Using Local Opinion Leaders

The human papillomavirus is associated with a range of cancers. A vaccine introduced in 2006 has dramatically decreased the incidence of these cancers, but Americans still experience over 47,000 new cases of HPV-related cancers each year. The situation is worse in rural areas, where vaccination rates lag the national average, making HPV a significant health disparity issue. This article lays out an evidence-based HPV vaccine-promotion strategy that will serve as part of a campaign to improve health equity in rural northern New England in a process that is repeatable and sustainable. The campaign includes the following elements: partnerships with state departments of health and trusted community opinion leaders, evidence-based storytelling, local social media, traditional media, and school-based pop-up vaccination clinics. Borrowing from marketing and social marketing frameworks and guided by public health perspectives, we begin with psychographic and geodemographic information about our target audience, followed by a discussion about relevant models, frameworks, and research related to persuasive storytelling. We conclude with the outline of a guidebook to foster the creation of persuasive stories as part of a sustainable, replicable HPV vaccination campaign.

An opportunity to increase human papillomavirus vaccination rates: Change the guidelines

Given the low rates of Human Papillomavirus (HPV) vaccination initiation and timely series completion in 11- and 12-year old children, we sought to assess potential opportunities for initiating routine vaccination at a younger age. A cross-sectional study of Latino parents of HPV vaccine-eligible 9- or 10-year-old children in New York City assessed whether there were opportunities to discuss the HPV vaccine during their most recent primary care provider (PCP) visit. Parents were approached between November, 2016 and January, 2018. Of 86 parents who participated, 97% reported having visited the child's PCP in the previous year for an annual checkup and 85% reported that they had neither discussed the HPV vaccine nor received a recommendation for the vaccine during that visit. In a population of Latino parents, predominantly Mexican immigrants with less than a high school education and limited English proficiency, most 9- to 10-year-old children followed the recommendation for an annual PCP visit. Lowering the recommended age for routine vaccination with the HPV vaccine to 9 - 10 years of age should be considered as an important strategy to increase HPV vaccination rates in this and other populations.

Why the American Academy of Pediatrics recommends initiating HPV vaccine at age 9

The American Academy of Pediatrics (AAP) recommends starting the human papillomavirus (HPV) vaccine series between 9 and 12 years, at an age that the provider deems optimal for acceptance and completion of the vaccination series. This recommendation differs from the Advisory Committee on Immunization Practices (ACIP), which recommends HPV vaccination be initiated at age 11 or 12 years, stating the series can be started at age 9 years. This commentary discusses the reasoning behind AAP's decision to differ from ACIP, as the AAP and ACIP schedules are essentially harmonized for all other vaccines. Reasons include recognition that (1) vaccination uptake is suboptimal; (2) offering vaccination earlier offers provider's flexibility in introducing the vaccine; (3) initiating the vaccine at age 9 or 10 may be preferable for parents or adolescents who do not want to receive ≥3 concomitant vaccines at age 11 or 12; (4) earlier initiation may disentangle HPV recommendations from discussions of sexuality; (5) earlier recommendation might alleviate HPV vaccine hesitancy "fatigue;" (6) the immune response is robust at younger ages with no evidence of waning protection; and (7) there is a dearth of evidence supporting starting the recommendation at age 11 or 12 within the "adolescent immunization platform."

Human papilloma virus vaccination and cervical cancer screening coverage in managed care plans - United States, 2018

Human papilloma virus (HPV) vaccination for adolescents aged 11-12 years and cervical cancer screening for women aged 21-65 years are recommended to help prevent cervical cancer. The purpose of this study was to describe 2018 National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) data for the United States on HPV vaccination and cervical cancer screening from 275 commercial preferred provider organizations (PPOs), 219 commercial health maintenance organizations (HMOs), and 204 Medicaid HMOs. The Centers for Disease Control and Prevention and NCQA analyzed the data in 2021. The HEDIS® measure for HPV vaccination was the percentage of male and female adolescents aged 13 years who completed HPV immunization (2- or 3-dose series) on or before their 13th birthday. The measure for cervical cancer screening was the percentage of women screened either with cervical cytology within the last 3 years for women aged 21-64 years or with cervical cytology/HPV co-testing within the last 5 years for women aged 30-64 years. Nationally, the mean rate for HPV vaccination in 2018 was 37.8% in Medicaid HMOs, 30.3% in commercial HMOs, and 24.9% in commercial PPOs. The mean rate for cervical cancer screening was 75.9% in commercial HMOs, 72.6% in commercial PPOs, and 60.3% among Medicaid HMOs. Medicaid HMOs reported higher HPV vaccination rates but lower cervical cancer screening rates than commercial plans. These differences raise questions about explanatory factors and how to improve prevention performance by plan category.

Social determinants of human papillomavirus vaccine series completion among U.S. adolescents: A mixed-methods study

Introduction

Human papillomavirus (HPV) vaccination can significantly reduce HPV-associated cancers. In the US, two doses are recommended for vaccine completion for younger adolescents. However, series completion rates remain below the nation's goal of 80% coverage. Multi-faceted factors may influence adolescent series completion. The purpose of this study was to identify individual-level, relationship-level, and community-level factors of timely series completion among adolescents, ages 11–14, initiating the HPV vaccine series in 2017.

Methods

A convergent, mixed-methods design was used combining adolescent electronic health record data (n = 803) and qualitative interviews with adolescents and their parents (n = 32) to assess timely series completion within 14-months (e.g., January 2018 to February 2019). Multivariable logistic regression analysis examined individual-level and community-level factors influencing timely series completion. Directed content analysis was used to identify relevant themes and subthemes. We provided an integrative summary to assess patterns of convergence or divergence between quantitative and qualitative data.

Results

In the quantitative phase, 61.0% of adolescents completed the vaccine series and 47.3% completed it on-time. Higher odds of timely series completion were among younger adolescents at vaccine initiation (aOR = 1.82, 95%CI = 1.07, 3.11) and lower among adolescents who were Black (aOR = 0.57, 95%CI = 0.37, 0.89) and Hispanic (aOR = 0.54, 95%CI = 0.30, 0.95) compared to Non-Hispanic White adolescents and those without private insurance (aOR = 0.56, 95%CI = 0.37, 0.85). Qualitative findings revealed increased risk for HPV at sexual debut as a motivator for timely series completion. Family/peers and healthcare providers influenced timely series completion among minority adolescents. Community-level factors were not significantly associated with timely series completion, however, qualitative findings revealed lack of transportation as a barrier to timely series completion.

Conclusion

Multi-level factors continue to influence timely series completion, despite fewer doses needed for series completion. Innovative strategies are needed to improve care coordination for receiving vaccine doses, patient-provider communication about series completion and increase access to HPV vaccine.

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Access barriers create challenges for teens to complete the HPV vaccine series.

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Racial/ethnic disparities in adolescent HPV vaccine series completion exist.

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Family and healthcare providers influence parents' decisions for series completion.

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Parents and adolescents continue to misunderstand the HPV vaccine schedule.

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Despite barriers, parents and teens are motivated to finish the HPV vaccine series.

Adherence to the Recommended HPV Vaccine Dosing Schedule among Adolescents Aged 13 to 17 Years: Findings from the National Immunization Survey-Teen, 2019–2020

The 9-valent human papillomavirus (9-vHPV) vaccine uptake rate among adolescents has improved over the years; however, little is known about the adherence to the recommended dosing schedule. This study examines the prevalence and factors associated with adherence to the recommended 9vHPV vaccination dosing schedule among adolescents aged 13 to 17 years. The cross-sectional study was conducted using the 2019–2020 National Immunization Survey-Teen. The parents of 34,619 adolescents were included in our analyses. The overall up-to-date (UTD) prevalence was 57.1%. The UTD prevalence was 60.0% among females and 54.2% among males. Adolescents aged 16 years had the highest UTD prevalence of 63.0%. The UTD prevalence was 61.6% among Hispanics and 54.7% among non-Hispanic Whites. Overall, compared to females, males had 14% lower odds of UTD. The odds of UTD were 1.91 times, 2.08 times, and 1.98 times higher among adolescents aged 15–17 years, respectively, compared to those aged 13 years. Moreover, region, poverty, insurance status, mothers’ educational level, and provider recommendation were associated with UTD. Our findings show that adherence to the recommended 9vHPV vaccine schedule is low in the US. Targeted public health efforts are needed to improve the rates of adherence to the recommended 9vHPV dose schedule.

Challenges to Adolescent HPV Vaccination and Implementation of Evidence-Based Interventions to Promote Vaccine Uptake During the COVID-19 Pandemic: "HPV Is Probably Not at the Top of Our List"

INTRODUCTION

The COVID-19 pandemic has prevented many adolescents from receiving their vaccines, including the human papillomavirus (HPV) vaccine, on time. However, little is known about the impact of the pandemic on implementation of clinic-level evidence-based interventions (EBIs) that help to improve HPV vaccine uptake. In this qualitative study, we explored the pandemic's impact on EBI implementation and HPV vaccine delivery.

METHODS

During August-November 2020, we interviewed clinic managers in a rural, midwestern state about their experiences implementing EBIs for HPV vaccination during the COVID-19 pandemic. We used a multipronged sampling approach with both stratified and purposive sampling to recruit participants from Vaccines for Children clinics. We then conducted a thematic analysis of transcripts.

RESULTS

In interviews (N = 18), 2 primary themes emerged: decreased opportunities for HPV vaccination and disruption to HPV-related implementation work. Most participants reported decreases in opportunities to vaccinate caused by structural changes in how they delivered care (eg, switched to telehealth visits) and patient fear of exposure to COVID-19. Disruptions to EBI implementation were primarily due to logistical challenges (eg, decreases in staffing) and shifting priorities.

CONCLUSION

During the pandemic, clinics struggled to provide routine care, and as a result, many adolescents missed HPV vaccinations. To ensure these adolescents do not fall behind on this vaccine series, providers and researchers will need to recommit to EBI implementation and use existing strategies to promote vaccination. In the long term, improvements are needed to make EBI implementation more resilient to ensure that progress does not come to a halt in future pandemic events.

Missed opportunities for concomitant HPV vaccination among childhood cancer survivors

PURPOSE

Childhood cancer survivors are at higher risk of human papillomavirus (HPV)-related second cancers than adolescents without cancer, yet their HPV vaccination uptake is lower. Using a statewide sample, we evaluated whether survivors are at higher risk of missed opportunities for concomitant HPV vaccination.

METHODS

From statewide healthcare data, we identified encounters where vaccines were received. Concomitant HPV vaccine missed opportunities were defined as a vaccine encounter where the HPV vaccine was not administered, although eligibility criteria were met. From these encounters, our sample included 327 survivors identified from the Utah Cancer Registry, diagnosed 2000-2016 at ages 0-9, and a birth year and sex-matched sample without cancer from the general population (n = 1,911). Mixed-effects Poisson regression estimated the rate of concomitant missed opportunities per vaccine encounter and 95% confidence intervals by vaccine encounter type (all vaccines, flu shot only, or adolescent/catch-up) from 2013 to 2016.

RESULTS

Survivors had more concomitant HPV vaccine missed opportunities than the population sample (70.0% vs. 59.0%). On average, survivors were 12% more likely to have missed opportunities at vaccine encounters and 4% more likely at flu shot only encounters. The predicted excess risk of concomitant missed opportunities for survivors ranged from 0.5 per10 vaccine encounters to 1.1 per10 vaccine encounters. Higher parental education, rurality, younger first vaccine age, and chemotherapy were associated with missed opportunities.

CONCLUSIONS

Childhood cancer survivors have more missed opportunities for concomitant HPV vaccination than a population sample. As flu shots should be administered annually, providers have a regular opportunity to recommend and deliver the HPV vaccine to survivors.

Recommending Human Papillomavirus Vaccination at Age 9: A National Survey of Primary Care Professionals

OBJECTIVE

Several US health organizations, including the American Academy of Pediatrics, now encourage primary care professionals to recommend human papillomavirus (HPV) vaccination before the traditionally targeted ages of 11 to 12 years as a strategy to increase vaccination timeliness. To understand the feasibility of this approach, we sought to evaluate primary care professionals' current recommendation timing and willingness to recommend HPV vaccination at age 9.

METHODS

A national sample of 1047 primary care professionals completed our online survey in 2021. Respondents were physicians (71%), advanced practitioners (17%), and nurses (12%).

RESULTS

About one-fifth (21%) of primary care professionals reported that they already routinely recommend HPV vaccination at ages 9 to 10. Among the remaining 822 respondents, over half (61%) reported being somewhat or more willing to start recommending at age 9. Willingness was higher among those working in family medicine versus pediatrics (adjusted odds ratio [aOR]: 1.40, 95% confidence interval [CI] 1.03, 1.92), but lower among those with ≥20 years of practice experience versus ≤9 years (aOR: 0.65, 95% CI 0.44, 0.96). Many primary care professionals believed age 9 recommendations would have the advantage of protecting adolescents before HPV exposure (67%) or increasing vaccination timeliness (55%). The most commonly perceived disadvantage was that parents are not ready to talk about HPV vaccination at age 9 (73%).

CONCLUSION

Over two-thirds of primary care professionals in our national sample reported they recommend HPV vaccination at ages 9 to 10 or are somewhat or more willing to do so. Training may be needed to help primary care professionals address perceived parental hesitancy toward age 9 recommendations.

Long-Term Multilevel Intervention Impact on Human Papillomavirus Vaccination Rates Spanning the COVID-19 Pandemic

OBJECTIVE

The aim of the study was to evaluate the long-term sustainability of a multilevel intervention and the COVID-19 pandemic impact on adolescent human papillomavirus (HPV) vaccination coverage.

MATERIALS AND METHODS

In 2016, a pediatric and family medicine practice within a federally qualified health center completed a multilevel intervention, Development of Systems and Education for Human Papillomavirus Vaccination. We examined the intervention impact on HPV vaccine initiation and completion rates among adolescents 10-18 years between March 2016 and October 2020. We determined the total number of HPV vaccine doses administered monthly. Data were plotted on statistical process control charts.

RESULTS

Vaccine initiation increased from an average of 14% to an average of 42% for 10-year-old patients and from an average of 72% to an average of 92% for 11- to 12-year-old patients between March 2016 and January 2017 and remained stable through March 2020. Complete vaccination by age 13 years increased from 62% to 88% through October 2020.

CONCLUSIONS

This intervention led to continued improvement for on-time HPV vaccination coverage 4 years after intervention completion.Clinical Trial Registration: This trial has been registered at http://www.clinicaltrials.gov (identifier NCT02812732).

Factors Associated With Human Papillomavirus Vaccine Series Completion Among Adolescents

INTRODUCTION

Most cancers associated with the human papillomavirus are preventable through vaccination. However, adolescent series completion rates are at 75.8%. Two vaccine doses are recommended for adolescents, but factors influencing 2-dose series completion are not well explored. The purpose of this study is to examine individual-level and community-level factors associated with timely human papillomavirus vaccine series completion among adolescents in the Southeastern U.S.

METHODS

Series completion was assessed from January 2018 to February 2019 among a cohort of adolescents initiating vaccination in 2017. Factors influencing overall series completion and timely series completion were assessed using multivariable logistic regression.

RESULTS

Among the sample, 64.4% completed the vaccine series and 53.8% completed it timely (e.g., 14 months). Higher odds of series completion were among adolescents who were younger at vaccine initiation (AOR=1.94, 95% CI=1.50, 2.50), who traveled moderate distances to the clinic (AOR=1.62, 95% CI=1.03, 2.56), and who lived in low-deprivation neighborhoods (AOR=1.85, 95% CI=1.31, 2.60), and lower among Hispanic (AOR=0.62, 95% CI=0.45, 0.87) and non-Hispanic Black (AOR=0.66, 95% CI=0.54, 0.81) adolescents and among those without private insurance (AOR=0.68, 95% CI=0.56, 0.83). Timely series completion resulted in similar findings; however, lower odds were among Hispanic (AOR=0.63, 95% CI=0.43, 0.95) and non-Hispanic Black (AOR=0.68, 95% CI=0.50, 0.92) adolescents than among non-Hispanic other adolescents.

CONCLUSIONS

Individual-level and community-level factors continue to influence adolescent series completion, despite a reduction in doses. Future research is needed to understand racial/ethnic and regional disparities in human papillomavirus vaccine series completion and to develop interventions to promote series completion.

Factors Associated With Human Papillomavirus Vaccine Series Completion Among Adolescents

INTRODUCTION

Most cancers associated with the human papillomavirus are preventable through vaccination. However, adolescent series completion rates are at 75.8%. Two vaccine doses are recommended for adolescents, but factors influencing 2-dose series completion are not well explored. The purpose of this study is to examine individual-level and community-level factors associated with timely human papillomavirus vaccine series completion among adolescents in the Southeastern U.S.

METHODS

Series completion was assessed from January 2018 to February 2019 among a cohort of adolescents initiating vaccination in 2017. Factors influencing overall series completion and timely series completion were assessed using multivariable logistic regression.

RESULTS

Among the sample, 64.4% completed the vaccine series and 53.8% completed it timely (e.g., 14 months). Higher odds of series completion were among adolescents who were younger at vaccine initiation (AOR=1.94, 95% CI=1.50, 2.50), who traveled moderate distances to the clinic (AOR=1.62, 95% CI=1.03, 2.56), and who lived in low-deprivation neighborhoods (AOR=1.85, 95% CI=1.31, 2.60), and lower among Hispanic (AOR=0.62, 95% CI=0.45, 0.87) and non-Hispanic Black (AOR=0.66, 95% CI=0.54, 0.81) adolescents and among those without private insurance (AOR=0.68, 95% CI=0.56, 0.83). Timely series completion resulted in similar findings; however, lower odds were among Hispanic (AOR=0.63, 95% CI=0.43, 0.95) and non-Hispanic Black (AOR=0.68, 95% CI=0.50, 0.92) adolescents than among non-Hispanic other adolescents.

CONCLUSIONS

Individual-level and community-level factors continue to influence adolescent series completion, despite a reduction in doses. Future research is needed to understand racial/ethnic and regional disparities in human papillomavirus vaccine series completion and to develop interventions to promote series completion.

Trends in HPV Vaccination Initiation and Completion Within Ages 9-12 Years: 2008-2018

BACKGROUND AND OBJECTIVES

Routine human papillomavirus (HPV) vaccination is recommended at ages 11 to 12 years and may be initiated as early as 9 years of age.

METHODS

Data were derived from the National Immunization Survey-Teen, spanning 2008-2018. Using health care provider-verified vaccination histories, we examined trends in human papillomavirus vaccination up-to-date (HPV-UTD) rates within ages 9 to 12 years. Furthermore, we assessed vaccination status by sociodemographic factors and US state of residence.

RESULTS

Overall, amid evidence of recent stagnation, HPV vaccination between ages 9 to 12 increased over the years. Initiation rates rose from 17.3% in 2008 to 62.8% in 2018, and HPV-UTD rates rose from 13.5% in 2011 to 32.8% in 2018. After the inception of gender-neutral HPV vaccination, HPV-UTD rates between 2011 and 2018 rose by 31.9% among boys and only 6.6% among girls. For most of the study period, non-Hispanic Black and Hispanic individuals had higher rates of initiation and HPV-UTD than non-Hispanic white individuals. In 2018, vaccination initiation rates exceeded 70% in several states; however, HPV-UTD rates in most US states were <50%, excluding Rhode Island (61.6%), Colorado (58.7%), Hawaii (53.5%), District of Columbia (53.2%), and Ohio (50%).

CONCLUSIONS

HPV vaccination within ages 9 to 12 years is suboptimal. To leverage the substantial benefits of HPV vaccination within this age range, it is imperative that conscious efforts are taken at the national and state levels to promote HPV vaccination for this age group.

Human papillomavirus vaccine series follow-through: comparison of four clinics in an academic medical center

Objective The Centers for Disease Control & Prevention (CDC) recommends that the human papillomavirus (HPV) vaccine series be initiated at ages 11-12 years, but many children never follow-through with the series. By examining differences in clinic-specific vaccine series follow-through rates across four clinics, we aimed to identify best practices related to communication around the vaccine and pathways to follow-through. Methods We used the electronic medical record (EMR) to retrospectively analyze HPV vaccine follow-through at four clinic settings. We limited the sample to children ages 11-17 who received a dose of the vaccine series at any of the clinics between January 2015 and June 2018. The primary outcome was follow-through of the HPV vaccine series within 18 months of initiation. Results A total of 3,813 patients were included in this study, 29% of which followed through with the HPV vaccine series. There was significant variability of vaccine follow-through among the clinics (p<0.001), with the Med/Peds clinic having the highest rate of follow-through (32%). After adjusting for confounding variables, multivariable analysis found that Med/Peds and Family Medicine had higher odds of HPV vaccine series follow-through than the Pediatrics clinic. Conclusions We found that the likelihood of vaccine series follow-through was highest when the series was started in the Med/Peds and Family Medicine clinics, compared to Pediatrics and Adolescent Medicine. These results suggest that further qualitative research is needed to understand what communication strategies are most effective at facilitating HPV vaccine uptake among adolescents, and how the most effective strategies can be shared among clinics.

Improving HPV Vaccination Rates: A Stepped-Wedge Randomized Trial

OBJECTIVES

To evaluate the effectiveness of a stepped-wedge randomized trial of Development of Systems and Education for Human Papillomavirus Vaccination (DOSE HPV), a multilevel intervention.

METHODS

DOSE HPV is a 7-session program that includes interprofessional provider education, communication training, data feedback, and tailored systems change. Five primary care pediatric and/or family medicine practices completed interventions between 2016 and 2018; all chose to initiate vaccination at ages 9 to 10. We compared vaccination rates in the preintervention, intervention, and postintervention periods among 9- to 17-year-olds using random-effects generalized linear regression models appropriate for stepped-wedge design, accounting for calendar time and clustering of patients by providers and clinic. Outcomes included (1) the likelihood that eligible patients would receive vaccination during clinic visits; (2) the likelihood that adolescents would complete the series by age 13; and (3) the cumulative effect on population-level vaccine initiation and completion rates. Postintervention periods ranged from 6 to 18 months.

RESULTS

In the intervention and postintervention periods, the adjusted likelihood of vaccination at an eligible visit increased by >10 percentage points for ages 9 to 10 and 11 to 12, and completion of the vaccine series by age 13 increased by 4 percentage points (P < .001 for all comparisons). Population-level vaccine initiation coverage increased from 75% (preintervention) to 84% (intervention) to 90% (postintervention), and completion increased from 60% (preintervention) to 63% (intervention) to 69% (postintervention).

CONCLUSIONS

Multilevel interventions that include provider education, data feedback, tailored systems changes, and early initiation of the human papillomavirus vaccine series may improve vaccine series initiation and completion beyond the conclusion of the intervention period.

Human papillomavirus vaccination 2020 guideline update: American Cancer Society guideline adaptation

The American Cancer Society (ACS) presents an adaptation of the current Advisory Committee on Immunization Practices recommendations for human papillomavirus (HPV) vaccination. The ACS recommends routine HPV vaccination between ages 9 and 12 years to achieve higher on-time vaccination rates, which will lead to increased numbers of cancers prevented. Health care providers are encouraged to start offering the HPV vaccine series at age 9 or 10 years. Catch-up HPV vaccination is recommended for all persons through age 26 years who are not adequately vaccinated. Providers should inform individuals aged 22 to 26 years who have not been previously vaccinated or who have not completed the series that vaccination at older ages is less effective in lowering cancer risk. Catch-up HPV vaccination is not recommended for adults aged older than 26 years. The ACS does not endorse the 2019 Advisory Committee on Immunization Practices recommendation for shared clinical decision making for some adults aged 27 through 45 years who are not adequately vaccinated because of the low effectiveness and low cancer prevention potential of vaccination in this age group, the burden of decision making on patients and clinicians, and the lack of sufficient guidance on the selection of individuals who might benefit.

Dimensions of Sexual Orientation as Predictors of STI-Related Outcomes Among Women: An Examination of 2011-2017 National Survey of Family Growth Data

Background: To estimate sexual orientation associated disparities in sexually transmitted infection (STI)-related outcomes across multiple dimensions of sexual orientation. Methods: Using pooled 2011-2017 National Survey of Family Growth data (N = 16,854), we performed bivariate and multivariable logistic and multinomial regression analyses to estimate associations between sexual identity, behavior in the past 12 months, and attraction, and past-year STI treatment, receipt of the human papillomavirus (HPV) vaccine, and age at first HPV vaccination in cisgender women. Results: Bisexual-identified women (adjusted odds ratio [AOR] = 1.53, 95% confidence interval [CI] = 1.10-2.14) and who were sexually active with both men and women in the past 12 months (AOR = 1.64, 95% CI = 1.03-2.55) had significantly higher odds of past-year STI treatment, compared with their nonsexual minority counterparts. Lesbian-identified women (AOR = 0.44, 95% CI = 0.27-0.75) and women with female partners only (AOR = 0.32, 95% CI = 0.12-0.87) had significantly decreased odds of having initiated the HPV vaccine compared with their heterosexual counterparts. Women with both male and female partners who initiated the HPV vaccine had significantly higher odds of having received the vaccine during the latest age range, 18-25 years old (AOR = 2.32, 95% CI = 1.21-4.45) compared with women with male partners only. Conclusions: Sexual minority women continue to be at risk for poor sexual health outcomes, and these outcomes differ by specific components of sexual orientation.

Provider Experience Recommending HPV Vaccination Before Age 11 Years

OBJECTIVES

To describe health care providers' experiences recommending human papillomavirus (HPV) vaccination before age 11 years as part of a multisession intervention to improve HPV vaccination coverage.

STUDY DESIGN

Between 2016 and 2018, we conducted 30-minute qualitative interviews with intervention participants approximately 1 month after intervention completion. Interviews explored participants' experiences with new strategies, including changing the age of routine recommendation. Thematic analysis of interview transcripts involved both deductive and inductive approaches.

RESULTS

Twenty-six participants at 5 clinical sites were interviewed. Most were female (88%) primary care providers (46%), and worked 1.5-3.0 clinical days weekly. Many providers described initial skepticism about recommending vaccination before age 11 years, fearing that removing the HPV vaccine from the adolescent bundle with tetanus and meningitis vaccines would decrease parental acceptance. However, providers uniformly reported high parental acceptance owing to reduced stigma relating to sexual activity and the opportunity to administer fewer shots at each visit. Providers also noted that initiating vaccination earlier increased opportunities to complete the series and decreased the need for resource-intensive vaccine recall programs.

CONCLUSIONS

Providers had positive experiences recommending HPV vaccination before age 11 years. Routine recommendation before age 11 years may offer advantages related to fewer shots per visit, fewer missed opportunities, and reduction of parental concerns related to sexual activity.

Human papillomavirus vaccination coverage, policies, and practical implementation across Europe

BACKGROUND

Our objectives were to describe Human Papillomavirus vaccination coverage rates (HPV-VCR), policies, and practical steps for programme implementation that may be linked to high uptake in the population targeted by routine programmes across 30 European Union/European Economic Area Member States and Switzerland.

METHODS

Information from institutional websites and from articles indexed in Medline between 01/2006 and 01/2017 was reviewed and extracted using a standardised form. In 12/2017, a cross-sectional survey was administered to national experts, in order to update the compiled information.

RESULTS

Data were available in 31 countries, and validated by national experts in 28 of them. National vaccination programmes targeted girls 9-15 years of age in 30 countries and boys in 11 countries. HPV-VCR in girls was monitored in 25 countries: VCR was reported ≥71%(high) in ten countries, 51-70% in seven, 31-50% in four, and ≤30%(very low) in four. In high VCR countries, HPV vaccination was mainly delivered through school health services, and invitation and reminders to attend for vaccination were used. In areas with very low VCR, vaccination tended to be opportunistic and no reminders were used.

CONCLUSION

According to our findings, school delivery within structured vaccination programmes and the use of reminders tended to be associated with highest HPV-VCR.