Update on barriers to human papillomavirus vaccination and effective strategies to promote vaccine acceptance

Provider Perceptions and Use of Audit-Feedback and Communication Strategies to Improve Human Papillomavirus Vaccine Uptake

OBJECTIVE

Human papillomavirus (HPV) vaccine uptake remains suboptimal among US adolescents. A cluster randomized trial was conducted at six primary care practices in southeast Minnesota to assess the impact of parent reminder-recall letters and provider audit-feedback reports on 11-12-year-old HPV vaccine uptake. Audit-feedback reports included access to a web toolkit with instruction on two communication approaches. We evaluated the process of the audit-feedback report intervention to inform future adaptations.

METHODS

We sent a survey to providers assigned to the intervention and asked about their use and perceptions of the reports, web toolkit, the communication approaches, and HPV vaccine recommendation.

RESULTS

Surveys from 95 providers were analyzed. Most (97.9%) recalled receiving audit-feedback reports, with 92.4% finding them somewhat to very easy to understand, 86% somewhat to very familiar with their content and objectives, and 69.9% using them five or more times in the past year. Few respondents (11.6%) recalled receiving access to the web toolkit. Web analytics showed that the toolkit was rarely used. Most reported familiarity with communication approaches but less than half reported that these positively impacted the tone of the clinical encounter. Higher familiarity with audit-feedback reports (OR=2.58) and perceived peer approval about using presumptive language (the first of two communication approaches) to recommend HPV vaccination (OR=2.16) correlated with higher frequency of vaccine recommendation.

CONCLUSIONS

Implementation of the audit-feedback reports showed good acceptability. Low utilization of the web toolkit suggests a need to further examine provider preferences on delivery and usability of training materials.

Global parental acceptance, attitudes, and knowledge regarding human papillomavirus vaccinations for their children: a systematic literature review and meta-analysis

BACKGROUND

This systematic literature review aims to summarize global research on parental acceptance, attitudes, and knowledge regarding human papillomavirus vaccinations.

METHODS

The literature search was conducted in PubMed, Web of Science and Scopus, and included publications from 2006 to 2023. Study quality was assessed using the Newcastle-Ottawa Scale. The Grading of Recommendations Assessment, Development, and Evaluation guidelines were used to assess the strength of evidence for the primary outcome. Meta-analyses were performed using random-effects models to estimate pooled parental acceptance of HPV vaccinations. Studies were stratified by study years, and a subgroup analysis was conducted to estimate vaccine acceptance rates by world regions. Additionally, sensitivity analyses examined the role of parents in accepting HPV vaccinations for children of different sexes.

RESULTS

Based on 86 studies, we found that parents generally supported HPV vaccinations for their children, yet HPV vaccine acceptance rates showed high variation (12.0 to 97.5%). The subgroup analysis revealed geographical variations in pooled parental HPV vaccine acceptance rates, with the highest rate observed in Africa (79.6%; 95% CI: 73.5-85.2; I² = 98.3%; p < 0.01) and the lowest in North America (56.7%; 95% CI: 49.3-64.0; I² = 99.4%; p < 0.01). Sensitivity analyses showed that acceptance was higher for daughters than for sons, with mothers more willing to get their daughters vaccinated. The proportion of parents reporting barriers or benefits regarding HPV vaccinations varied widely (0.3-95.8%) between study regions. Across all world regions, fear of adverse effects and concerns about vaccine safety were the main barriers, whereas the desire to protect their children from cancer was a significant predictor of vaccine acceptance. Knowledge levels varied widely (6.5 to 100%) between world regions and according to the questions asked. In most studies, knowledge e.g., that HPV is sexually transmitted, and that HPV vaccination provides protection against cervical cancer, ranged from moderate to high.

CONCLUSIONS

The results indicated moderate parental acceptance of HPV vaccines. Public knowledge of HPV infection should be promoted, and special efforts should be made to minimize the existing barriers and increase vaccination accessibility and uptake.

Barriers to cervical cancer prevention in a safety net clinic: gaps in HPV vaccine provider recommendation and series completion among Ob/Gyn patients

Objective

The primary objective of this study was to evaluate patients' knowledge regarding HPV vaccination and vaccine uptake in a diverse patient population. The secondary objective was to evaluate factors influencing the decision to vaccinate, potential barriers to vaccination, and to assess whether HPV vaccines were offered to or discussed with eligible patients in a safety net Obstetrics and Gynecology (Ob/Gyn) clinic.

Methods

A 28-item survey was developed using Likert scale survey questions to assess patient agreement with statements regarding HPV and the vaccine. The surveys were administered to patients in the Ob/Gyn outpatient clinics from May 2021 through September 2022. Additionally, pharmacy data were reviewed and chart review was performed as a quality improvement initiative to assess the impact of expanded HPV vaccine eligibility to patients with private insurance on vaccine uptake. Descriptive statistics were performed.

Results

304 patients completed surveys from May 2021 through September 2022. The median age of respondents was 32 (range 18-80). 16 (5%) were Non-Hispanic White, 124 (41%) were Hispanic White, 58 (19%) were Non-Hispanic Black, 6 (2%) were Hispanic Black, 29 (9.5%) were Haitian, 44 (14%) were Hispanic Other, 7 (2%) were Non-Hispanic Other, 20 (6.6%) did not respond. 45 (14%) patients were uninsured. Many patients (62%) reported that a physician had never discussed HPV vaccination with them. Seventy nine percent of patients reported they had never received the HPV vaccine, and 69% of patients reported that lack of a medical provider recommendation was a major barrier. Among patients to whom HPV vaccination had been recommended, 57% reported that the vaccine was not available the same day in clinic.

Conclusion

Our study demonstrated that many patients never had a provider discuss HPV vaccination with them and never received the HPV vaccine. Additionally, amongst those who did initiate HPV vaccination, completion of the series remains a key barrier. Ensuring that providers discuss HPV vaccination and that patients receive HPV vaccines, along with expanding access to and convenience of HPV vaccination are critical aspects of preventing cervical cancer.

Improving clinician communication to increase adolescent HPV vaccination rates

ABSTRACT

Despite the proven effectiveness of human papillomavirus (HPV) vaccination, this vaccine is underused in the United States and is associated with many disparities and barriers to acceptance. Adolescent HPV vaccination rates failed to meet the Healthy People 2020 goal of 80% vaccine coverage when nearly all other routine adolescent vaccines met or were near this goal. When introducing the HPV vaccine series, many clinicians use a conversational approach, although years of research show that an announcement approach is more effective at increasing HPV vaccination rates. This article reviews current HPV vaccine communication practices used by clinicians and recommends evidence-based best practices to improve adolescent HPV vaccination rates in the United States.

Screening for High-Risk Human Papillomavirus Reveals HPV52 and HPV58 among Pediatric and Adult Patient Saliva Samples

Previous research has demonstrated that the human papillomavirus (HPV) can infect a wide range of human tissues, including those within the oral cavity. High-risk oral HPV strains have been associated with the development and progression of oral cancers, including oral squamous cell carcinomas. Although many studies have examined the prevalence of the high-risk strains HPV16 and HPV18, far fewer have assessed the prevalence of other high-risk HPV strains. An approved study protocol was used to identify HPV52 and HPV58 among clinical samples (n = 87) from a saliva biorepository. Quantitative polymerase chain reaction (qPCR) and validated primers for HPV52 and HPV58 were used to facilitate this screening. This screening demonstrated that a total of n = 4/45 or 8.9% of adult saliva samples harbored high-risk HPV52, and n = 2/45 or 4.4% tested positive for high-risk HPV58. In addition, a total of n = 6/42 or 14.3% of the pediatric saliva samples tested positive for high-risk HPV, including n = 5/42 or 11.9% with HPV52 and n = 3/42 or 7.1% for HPV58. These data demonstrate the presence of the high-risk oncogenic HPV52 and HPV58 strains among both adult and pediatric clinical patient samples. More detailed longitudinal research must be conducted to determine whether this prevalence may be increasing or decreasing over time. In addition, these data strongly support public health prevention efforts, such as knowledge and awareness of the nine-valent HPV vaccine covering additional high-risk strains, including HPV52 and HPV58.

Extracting factors associated with vaccination from Twitter data and mapping to behavioral models

Social media platform, particularly Twitter, is a rich data source that allows monitoring of public opinions and attitudes toward vaccines.Established behavioral models like the 5C psychological antecedents model and the Health Belief Model (HBM) provide a well-structured framework for analyzing shifts in vaccine-related behavior. This study examines if the extracted data from Twitter contains valuable insights regarding public attitudes toward vaccines and can be mapped to two behavioral models. This study focuses on the Arab population, and a search was carried out on Twitter using: ' تلقيحي OR تطعيم OR تطعيمات OR لقاح OR لقاحات' for two years from January 2020 to January 2022. Then, BERTopicmodeling was applied, and several topics were extracted. Finally, the topics were manually mapped to the factors of the 5C model and HBM. 1,068,466 unique users posted 3,368,258 vaccine-related tweets in Arabic. Topic modeling generated 25 topics, which were mapped to the 15 factors of the 5C model and HBM. Among the users, 32.87%were male, and 18.06% were female. A significant 55.77% of the users were from the MENA (Middle East and North Africa) region. Twitter users were more inclined to accept vaccines when they trusted vaccine safety and effectiveness, but vaccine hesitancy increased due to conspiracy theories and misinformation. The association of topics with these theoretical frameworks reveals the availability and diversity of Twitter data that can predict behavioral change toward vaccines. It allows the preparation of timely and effective interventions for vaccination programs compared to traditional methods.

Determinants of human papillomavirus vaccine hesitancy among Lebanese parents

INTRODUCTION

Human papillomavirus (HPV) is the most common sexually transmitted infection. HPV is responsible for cancer of cervix uteri. Despite its safety and immunogenicity, HPV vaccine hesitancy is one of the most challenging topics that pediatricians face.

METHODS

We aimed to describe the impact of knowledge, attitude, and practice towards vaccines in general, on practice related to HPV vaccination in Lebanon. A questionnaire addressed to parents of students (3-18 years of age) was distributed in 2 public and 2 private schools randomly selected from the greater Beirut area during the school year 2017-2018. Questionnaires covered knowledge, attitude, and practices of vaccination in general and HPV vaccine in particular.

RESULTS

Out of 400 distributed questionnaires, 306 (76.5%) were returned. Of the 185 parents aware of HPV vaccine, 60% hadn't given or were not planning to give the HPV vaccine to their children. Of parents not in favor of HPV vaccine, 7.5 thought that vaccines aren't necessary versus none among those in favor of HPV vaccine(p = 0.02). Thirteen percent of those not in favor of HPV vaccine thought that vaccines are not safe versus 2.7% in the group in favor (p = 0.02). An effect of gender on vaccine acceptance was noted: mothers vs fathers and daughters vs sons. Lack of recommendation by pediatricians and the thought that too little is known about the vaccine were the most selected reasons for parents not wanting to vaccinate their children against HPV, whereas cost and religious and cultural beliefs seemed to have no impact.

CONCLUSION

Most parents in our study did not vaccinate or weren't willing to vaccinate their children against HPV even when they were in favor of vaccines in general. Physician recommendation was shown to be one of the most important predictors of vaccination. Effort should be put into educating parents about the importance of the vaccine and its well-established safety and efficacy regardless of gender. Lebanese physicians should also be educated and empowered to recommend HPV vaccine more strongly and consistently.

Mindfulness-Based Stress Reduction (MBSR) for Chronic Pain Management in the Community Pharmacy Setting: A Cross-Sectional Survey of the General Public's Knowledge and Perceptions

Patient access to mindfulness-based stress reduction (MBSR), a complementary and integrative health approach that is proven to reduce chronic pain, can be increased via community pharmacy-based implementation. However, the general public's awareness and preferences regarding MBSR as a treatment option for chronic pain, including provider roles (pharmacist vs. non-pharmacist), are unclear. Therefore, the purpose of this study was to assess the U.S. general public's knowledge, attitudes, barriers, and programmatic preferences regarding MBSR for chronic pain management, particularly in the community pharmacy setting. A cross-sectional, anonymous online survey was distributed to U.S. adults ≥18 years via the Amazon Mechanical Turk (MTurk) online survey platform. The survey instrument was informed by Anderson's framework for health service utilization. Measures were assessed using multiple-choice and 5-point Likert-type scales (1 = strongly disagree, 5 = strongly agree). Primary outcome measures included: (1) knowledge and awareness of MBSR (12-items); (2) confidence in seeking out MBSR for pain (5-items); (3) barriers to receiving MBSR (11-items); (4) beliefs about MBSR in general (12-items); (5) beliefs about community pharmacy-delivered MBSR (15-items); and (6) preferences for MBSR classes/programs (6-items). Outcomes were analyzed using descriptive statistics, and influential factors associated with mean beliefs regarding community pharmacy-delivered MBSR for chronic pain management were assessed via multiple linear regression. Of the 302 survey respondents, the majority were white (79.1%) and female (50.7%), with a mean age of 44.65 years. Respondents' self-rated MBSR knowledge (mean [SD] scale score: 2.30 [0.68]) and confidence (2.65 [0.87]) were low, although perceived barriers to access were low overall (2.22 [0.53]). Beliefs regarding the use of MBSR for treatment of chronic pain were positive in general (3.67 [0.71]), but more negative regarding community pharmacy-delivered MBSR (2.38 [0.56]). Confidence in seeking out MBSR (β = 0.297, 95% CI = 0.219 to 0.375; p < 0.001) and current opioid use (β = 0.419, 95% CI = 0.147 to 0.690; p = 0.003) were positively associated with beliefs regarding pharmacy-delivered MBSR, while annual household income (β = -0.124, 95% CI = -0.244 to -0.004; p = 0.043) and level of bodily pain (β = -0.149, 95% CI = -0.291 to -0.008; p = 0.039) exerted statistically significant negative influences. Respondents preferred a hybrid MBSR class format including both online and in-person components (29.7%) as well as both group and individual session options (43.7%). In conclusion, further education is necessary to increase the public's perception of community pharmacies as a resource for complementary and integrative health.

Parent-reported Barriers and Parental Beliefs Associated with Intentions to Obtain HPV Vaccination for Children in a Primary care Patient Population in Minnesota, USA

Human papillomavirus (HPV) vaccine uptake among adolescents remains suboptimal in the US. The COVID-19 pandemic posed new challenges to increase HPV vaccination rates. To characterize parent-reported barriers to obtain HPV vaccination for their children and to identify psychosocial factors associated with parents' intention to vaccinate their children for HPV, we administered parent surveys between April 2020 and January 2022 during a randomized pragmatic trial assessing the impact of evidence-based implementation strategies on HPV vaccination rates for adolescent patients at six Mayo Clinic primary care practices in Southeast Minnesota. A total of 342 surveys were completed (response rate 34.1%). Analyses were focused on parents of unvaccinated children (n = 133). The survey assessed the main reason the child did not receive the HPV vaccine, parental beliefs about the vaccine, and the parent's intention to vaccinate the child for HPV in the next 12 months. Frequently reported awareness and access barriers to HPV vaccination included not knowing the child was due (17.8%) and COVID-19 related delay (11.6%). Frequently reported attitudinal barriers include the belief that the child was too young for the vaccine (17.8%) and that the vaccine is not proven to be safe (16.3%). Injunctive social norm (Adjusted-OR = 3.15, 95%CI: 1.94, 5.41) and perceived harm beliefs (Adjusted-OR = 0.58, 95%CI: 0.35, 0.94) about the HPV vaccine were positively and negatively associated with HPV vaccination intention, respectively. Our findings suggest that continued efforts to overcome parental awareness, access, and attitudinal barriers to HPV vaccination are needed and underscore the importance of utilizing evidence-based health system-level interventions.

Human Papillomavirus Vaccine Hesitancy in the United States

Although the US Advisory Committee on Immunization Practices recommends vaccinating adolescents against the human papillomavirus (HPV) to prevent HPV-associated cancers, vaccine initiation and completion rates are suboptimal. Parental and provider hesitancy contributes significantly to low HPV vaccine uptake. This review describes sources of HPV vaccine hesitancy using a World Health Organization framework that categorizes determinants of vaccine hesitancy as follows: contextual factors (historical, sociocultural, environmental, or political factors), individual and group factors (personal perception or influences of the social/peer environment), and vaccine/vaccination-specific issues (directly related to vaccine or vaccination).

Formative Research on HPV Vaccine Acceptance among Health Workers, Teachers, Parents, and Social Influencers in Uzbekistan

Human papillomavirus (HPV) vaccines effectively prevent cervical cancer, most of which results from undetected long-term HPV infection. HPV vaccine introduction is particularly sensitive and complicated given widespread misinformation and vaccination of young girls before their sexual debut. Research has examined HPV vaccine introduction in lower- and middle-income countries (LMICs), but almost no studies attend to HPV vaccine attitudes in central Asian countries. This article describes the results of a qualitative formative research study to develop an HPV vaccine introduction communication plan in Uzbekistan. Data collection and analysis were designed using the Capability, Opportunity, and Motivation for Behaviour change (COM-B) mode for understanding health behaviours. This research was carried out with health workers, parents, grandparents, teachers, and other social influencers in urban, semi-urban, and rural sites. Information was collected using focus group discussions (FGDs) and semi-structured in-depth interviews (IDIs), and data in the form of participants' words, statements, and ideas were thematically analysed to identify COM-B barriers and drivers for each target group's HPV vaccine-related behaviour. Represented through exemplary quotations, findings were used to inform the development of the HPV vaccine introduction communication plan. Capability findings indicated that participants understood cervical cancer was a national health issue, but HPV and HPV vaccine knowledge was limited among non-health professionals, some nurses, and rural health workers. Results on an opportunity for accepting the HPV vaccine showed most participants would do so if they had access to credible information on vaccine safety and evidence. Regarding motivation, all participant groups voiced concern about the potential effects on young girls' future fertility. Echoing global research, the study results highlighted that trust in health workers and the government as health-related information sources and collaboration among schools, municipalities, and polyclinics could support potential vaccine acceptance and uptake. Resource constraints precluded including vaccine target-aged girls in research and additional field sites. Participants represented diverse social and economic backgrounds reflective of the country context, and the communication plan developed using research insights contributed to the Ministry of Health (MoH) of the Republic of Uzbekistan HPV vaccine introduction efforts that saw high first dose uptake.

Missed Opportunities for Human Papillomavirus Vaccination by Parental Nativity, Minnesota, 2015-2018

OBJECTIVES

Human papillomavirus (HPV) vaccination coverage in the United States is far below coverage for other routine adolescent vaccines. We examined whether missed opportunities for HPV vaccination among adolescents differ by parental nativity (country of origin) in Minnesota.

METHODS

We retrospectively analyzed birth record and immunization information data for adolescents in Minnesota born during 2004-2007 using data from January 1, 2015, through December 31, 2018. Using logistic regression, we assessed the association between parental nativity and missed opportunities for HPV vaccine initiation, or receipt of other vaccines without receipt of the HPV vaccine. We adjusted for parent/child demographic and vaccination characteristics. We defined nativity as the number of non-US-born parents and maternal region of birth.

RESULTS

Adolescents with mothers born in Eastern Europe (adjusted odds ratio [aOR] = 2.33; 95% CI, 2.01-2.73) and Africa (aOR = 1.36; 95% CI, 1.28-1.43) had greater adjusted odds of missed opportunities for HPV vaccination than adolescents with US-born mothers. However, adolescents with mothers from Latin America and the Caribbean had lower odds of missed opportunities than adolescents with US-born mothers (aOR = 0.61; 95% CI, 0.58-0.65). Adolescents with 1 or 2 non-US-born parents had lower odds of missed opportunities for HPV vaccination than adolescents with 2 US-born parents (1 parent: aOR = 0.92; 95% CI, 0.88-0.96; 2 parents: aOR = 0.90; 95% CI, 0.87-0.94).

CONCLUSIONS

Future studies should evaluate outreach to groups with HPV vaccination disparities and identify other drivers of missed opportunities among adolescents with US-born parents, such as multiparity.

Attitudes and behaviors of obstetricians and gynecologists toward HPV vaccination: a 7-year follow-up survey in Japan

BACKGROUND

In Japan, the government suspended HPV vaccine recommendation in 2013, resulting in dropping vaccination uptake to almost zero. We conducted four serial surveys on our colleague' attitude to HPV vaccination between 2014 and 2021. Here, we evaluate the result of the survey in 2021 and compare it to previous surveys.

METHODS

The subjects were 567 obstetricians and gynecologists who had been trained in our university hospital or our affiliated hospitals. We used a questionnaire similar in format to those used in 2014, 2017, and 2019.

RESULTS

A total of 340 doctors (60.0%) completed the survey. Among them, 93.2% (317/340) of respondents thought that the government should restart HPV vaccination recommendation, and that 63.2% (215/340) think male teenagers should also vaccinate against HPV. The percentage of teenaged daughters inoculated with HPV vaccination after Japanese government had suspended its recommendation was 43.5% (20/46), an increasing trend from the previous surveys. 39 out of the 46 daughters (84.8%) would be expected to receive full HPV vaccination after they take junior high school entrance examination or after 9-valent HPV vaccination is designated as a national routine-immunization.

CONCLUSION

This study revealed increasing number of our colleagues think HPV vaccination is necessary for prevention of cervical cancer. The Japanese government's decision to resume its recommendation of the HPV vaccine in November 2021 will lead to a change in the public's thinking and behavior toward the HPV vaccine.

HPV Vaccine Hesitancy Among Medical Students in China: A Multicenter Survey

Human papillomavirus (HPV) is the most common genital tract virus infection and can cause genital warts and cervical cancer. This multicenter study examined HPV information sources, vaccine hesitancy, and the association between the two variables. An online survey of HPV information sources and vaccine hesitancy was conducted among Chinese medical students. The World Health Organization (WHO) Vaccine Hesitancy 3Cs model was used to evaluate reasons for respondents' vaccine hesitancy. A probit model was used to investigate the association between vaccine information sources and vaccine hesitancy. The reported rate of vaccine hesitancy was 62.36%. Convenience was the primary factor for vaccine hesitancy in medical students, and 19% used a single source to obtain vaccine information. A multivariate analysis revealed that master degree and above were 33% less likely to be hesitant about the HPV vaccine than first grade students. Respondents receiving HPV information through doctor were 8% less likely to report vaccine hesitancy than those receiving information from other information channels. HPV vaccine hesitancy requires more attention. Future studies could examine whether increasing vaccination locations and dissemination of information about the safety and effectiveness of HPV vaccines as well as using Internet media would help reduce medical students' vaccine hesitancy and expand HPV vaccine coverage.

An Evidence-based Protocol to Improve HPV Vaccine Initiation Rates at a County Immunization Clinic

Human Papillomavirus (HPV) is responsible for 26,900 cancer cases yearly, including genital and oropharyngeal cancers. Despite providing nearly 100% protection against cancer-causing strains of HPV, only 68.9% of teenagers receive even one dose of the HPV9 vaccine. To increase HPV9 vaccine series initiation rates among 11-14 year-olds. Vaccine rates were examined before and after multi-modal protocol implementation at a nurse-run, walk-in immunization clinic. Initiation increased from 17.9% in 2017 to 35.5% in 2018. Use of same way/same day recommendation practices and inclusion of non-clinician staff could improve quality of care and decrease HPV-related disease.

Understanding confidence in the human papillomavirus vaccine in Japan: a web-based survey of mothers, female adolescents, and healthcare professionals

Vaccine confidence reflects social, individual, and political factors indicating confidence in vaccines and associated health systems. In Japan, the government ceased proactive recommendation of the human papillomavirus (HPV) vaccine in June 2013, only several months after the recommendation had begun. Seven years later, as of October 2020, the suspension persists and vaccine coverage has precipitously declined, resulting in many young women being continually exposed to the risk of preventable HPV-related diseases. Accordingly, understanding stakeholder opinions on HPV vaccination issues is critical for informing strategies to improve HPV vaccine confidence and acceptance. In October 2019, we performed a nationwide, web-based survey of 1646 mothers of HPV-vaccination–eligible girls, 562 female adolescents aged 15–19 years, and 919 healthcare professionals (HCPs) in Japan. This survey captured key elements of vaccine confidence (i.e., importance, effectiveness, and safety of the HPV vaccine), awareness, and the willingness to receive (in HPV-vaccination–eligible girls) or recommend (in HCPs) the HPV vaccine, and the factors responsible for these decisions. HPV vaccine confidence was generally higher among HCPs than among mothers or female adolescents. Nearly half of all stakeholders were neutral regarding their willingness to receive/recommend the HPV vaccine. The seriousness of cervical cancer and the HPV vaccine’s effectiveness or safety were important deciding factors for receiving/recommending the HPV vaccine. Besides these factors, sufficient information and free vaccination were crucial. Our results suggest several factors that could help shape public policy and communication strategies to improve HPV vaccine confidence and acceptance in Japan.

Perceived Barriers and Trends in HPV Vaccination via Patient Survey Responses at Kalamazoo, Michigan's Federally-Qualified Health Center

Human Papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the United States. Despite numerous studies proving the safety and efficacy of the HPV vaccine, immunization rates remain low, especially among underserved populations. To identify factors contributing to low HPV vaccination rates, patients at a federally qualified health center in Kalamazoo MI were surveyed. Surveys were administered during routine patient visits to determine self-reported vaccination status and vaccination barriers. A total of 98 vaccine-eligible (males/females, ages 9-26 years old) patients/guardians completed the survey. In all, 46% of respondents completed the multi-dose vaccination course, and 56% of those identified as female. White patients reported higher vaccination rates (50%) than patients of color (45%). Of those vaccinated, the most common reason was "physician recommendation" (39%). Those not fully vaccinated most commonly reported being "too young" (39%). Importantly, individuals who had begun, but not completed, the vaccination course reported that their provider had not spoken to them about future vaccines in the series (74%). This study revealed disparities in vaccination rates between the sexes and racial groups, and emphasized the influential role of physician's recommendation on vaccination. Interestingly, other frequently cited barriers to vaccination-an association with sex, personal/religious beliefs, efficacy-proved to be insignificant barriers for this population. Instead, age-related misunderstandings and lack of consistent physician communication about vaccination provided significant barriers. Based on our results, education and reminders about the HPV vaccine by providers is a significant tool to maximize vaccination coverage.

HPV vaccination and Native Americans: protocol for a systematic review of factors associated with HPV vaccine uptake among American Indians and Alaska Natives in the USA

INTRODUCTION

The nine-valent human papillomavirus (HPV) vaccine could prevent an estimated 92% of the cancers attributable to HPV types targeted by the vaccine. However, uptake of the HPV vaccine among American Indian and Alaska Native (AI/AN) adolescents has been low. AI/ANs also bear a disproportionate burden of cervical and other HPV-associated cancers. Increasing HPV vaccination rates is a national priority, but reviews and national surveys on HPV vaccination factors are lacking for the AI/AN population. The objective of this systematic review is to assess factors associated with HPV vaccination among AI/ANs in the USA.

METHODS AND ANALYSIS

A systematic review is proposed to synthesise the current literature on HPV vaccination factors in AI/ANs from 1 July 2006 until 30 September 2019. As applicable, controlled vocabulary terms, keywords and special features (eg, limits, explode and focus) will be incorporated into database searches. To maximise the identification of relevant studies, citation indexes and databases that index dissertations, preprints and grey literature are included. Studies will be screened and selected independently in two stages. In stage 1, titles and abstracts will be screened. In stage 2, full-text articles will be screened and selected. A data extraction form and quality assessment tool will be piloted, revised and implemented. If available, measures of frequency and association will be presented. A narrative synthesis of the included studies will also be undertaken and reported.

ETHICS AND DISSEMINATION

As our review will use publicly available data and publications, an Institutional Review Board review will not be required. We will disseminate the findings from this review through peer-reviewed publication(s) and conference presentation(s).

POTENTIAL AMENDMENTS

In the event of amendments to the protocol, we will provide the date, rationale, and description of the change for each amendment.

PROSPERO REGISTRATION NUMBER

CRD42020156865.

Application of GIS Spatial Analysis and Scanning Statistics in the Gynecological Cancer Clustering Pattern and Risk Screening: A Case Study in Northern Jiangxi Province, China

OBJECTIVE

The incidence of gynecological cancer is high in China, and the effects of related treatments and preventive measures need to be improved.

METHODS

This study uses GIS spatial analysis methods and a scanning statistical analysis to study the major gynecological cancers in northern Jiangxi Province from 2016 to 2018.

RESULTS

The incidence and spatial pattern of cervical cancer, ovarian cancer, and uterine cancer had agglomeration characteristics and changes during the study period. The gynecological cancer had a spatial autocorrelation and agglomeration in its spatial pattern. The Moran's Index of the overall gynecological cancer incidence rate was 0.289 (p = 0.005). Ripley's L(d) function showed that the agglomeration radius was between 51.40 and 52.82 km. The results of the kernel density estimation showed that the cases of gynecological cancer were concentrated in the central and northeastern areas of the study area. The overall county-level incidence of gynecological cancer varied from 0.26 to 11.14 per 100,000. The results of the gravity center analysis showed that the spatial distribution of the gravity center point of gynecological cancer had moved toward the east during the past three years. The results of a hotspot analysis showed that there were five hotspot areas that had gynecological cancers. The most likely clusters of gynecological cancer at the county level in northern Jiangxi Province were distributed in the adjacent areas of Jiujiang, Yichun, and Nanchang, with a relative risk of 1.85.

CONCLUSION

The research shows that GIS can display the distribution of cancer cases and can use spatial analysis methods and scanning statistical techniques to obtain key areas of cancer incidence. These results can provide data and key areas for the formulation of regional public health policies and provide recommendations for cancer screening and the rational allocation of health resources.

"There's Always Next Year": Primary Care Team and Parent Perspectives on the Human Papillomavirus Vaccine

Acceptance of the human papillomavirus (HPV) vaccination among parents and clinicians is high, but uptake remains low. Little is known about organizational and primary care team factors that influence the uptake of the HPV vaccine. Interviews with clinicians, clinic support staff, and parents of adolescent patients were conducted to better understand the interrelationships among the people and the organizational processes that influence HPV vaccine uptake at the point of care. Between July 2016 and February 2017, semi-structured interviews of 40 participants (18 clinicians, 12 clinic support staff, and 10 parents of adolescent patients) in a primary care network were conducted. Organizational structures and processes, such as electronic provider reminders, availability of "vaccination only" appointments, and knowledgeable primary care team members contributed to HPV vaccine uptake. Consistently high support of HPV vaccination was found among key informants; however, rather than refuse HPV vaccination, parents are opting to delay vaccination to a future visit. When parents express the desire to delay, clinicians and care team members described often recommending addressing HPV vaccination at a future visit, giving parents the impression that receiving the vaccine was not time-sensitive for their child. Discordance in HPV vaccination recommendations among providers and clinic support staff may contribute to delayed HPV vaccination. Strong, high-quality HPV vaccine recommendations are needed from all primary team members. Clinic interventions to accelerate HPV vaccine uptake may benefit from a team-based approach where every member of the primary care team is delivering the same consistent messaging about the importance of timely HPV vaccination.

Changing attitudes in Japan toward HPV vaccination: a 5-year follow-up survey of obstetricians and gynecologists regarding their current opinions about the HPV vaccine

In Japan, the governmental recommendation for HPV vaccination was suspended in June 2013 because of media reports of so-called adverse vaccine events. The HPV vaccination rate in Japan prior to this suspension was almost 70%, but fell afterward to almost zero. To explore ways to bolster HPV vaccination, between 2014 and 2019 we conducted three serial surveys of the opinions of obstetricians and gynecologists about HPV vaccination. This study aimed to discuss the changing attitudes found in this 5-year follow-up survey. In August 2014, January 2017, and June 2019, we posted questionnaires to about 570 obstetricians and gynecologists practicing in Osaka, Japan. All three surveys used the same structured and closed-ended questionnaire, including questions about their personal opinions regarding HPV vaccination. We compared our new results to those of the previous two surveys. The response rate for the latest survey was 51.1% (293/573), which was equivalent to the previous two surveys. Among the responders, 83.3% (244/293) now thought that the Japanese government should restart its HPV vaccine recommendation, and 84.6% (248/293) were already recommending HPV vaccines for teenagers in their daily care. Eleven of 30 doctors (36.7%) had their own teenage daughters vaccinated against HPV after the suspension of recommendation. The rate has maintained an increasing trend from the previous two surveys. This study indicated that the attitude of obstetricians and gynecologists in Japan toward HPV vaccination has changed positively over 5 years. The results should serve as an encouragement to resume the governmental recommendation of HPV vaccines.

Routine Childhood Vaccines Given From 1 through 18 Years of Age

In addition to the vaccines due in the first year of life, the US Advisory Committee on Immunization Practices recommends that children continue to receive vaccines regularly against a variety of infectious diseases. Starting at 12 to 15 months of life, these include the two-dose measles-mumps-rubella vaccine series and the two-dose varicella vaccine series. Also in the second year of life, infants should begin the two-dose hepatitis A vaccine series and complete the Haemophilus influenzae type B vaccine series as well as the pneumococcal conjugate vaccine series. Before 19 months of life, infants should receive the third dose of the poliovirus vaccine and the fourth dose of diphtheria-tetanus-acellular pertussis (DTaP) vaccine. The final doses of poliovirus and tetanus-diphtheria-acellular pertussis vaccines are both due at 4 to 6 years of life. Before each influenza season, every child should receive the influenza vaccine. Those less than 9 years of age who previously received less than two doses need two doses a month apart. At 11 to 12 years of life, all should get two doses of the human papillomavirus vaccine, the adolescent/adult version of the tetanus-diphtheria-acellular pertussis vaccine, and begin a two-dose series of meningococcal ACWY vaccine. Each of these vaccines is due when the vaccine works to protect against both an immediate risk as well as to provide long-term protection. Each vaccine-preventable disease varies in terms of the nature of exposure, the form of the morbidity, the risk of mortality, and potential to prevent or ameliorate its harm.

Knowledge of human papillomavirus among dental providers: A mixed methods study

Dental professionals are encouraged by the American Dental Association (ADA) to recommend the HPV vaccine to eligible patients. To better understand their comfort level in following this recommendation, we conducted a mixed methods study of dentists and dental hygienists. A total of 173 providers were surveyed and 8 interviewed. The majority felt they had an important role in preventing HPV-related OPC and that they should educate their patients and encourage HPV vaccination. However, most providers had low knowledge about HPV and expressed a need to obtain more information on the topic. In particular, they desired information about the HPV vaccine, its connection to cancer and where to refer patients for vaccination. They also wanted access to visual aids to help them bring up the topic. This study demonstrates the need to develop and disseminate educational programs for dental providers so they can assist with efforts to raise HPV vaccination rates.

Vaccine hesitancy in the French population in 2016, and its association with vaccine uptake and perceived vaccine risk-benefit balance

Vaccine hesitancy (VH) is prominent in France. Objectives: This study aimed to estimate the prevalence and socio-demographic correlates of VH in sub-groups of the French population and to investigate the association of VH with both vaccine uptake and perceived risk–benefit balance (RBB) for four vaccines. Methods: During the 2016 Health Barometer – a national cross-sectional telephone survey in a representative sample of the French population – parents of 1–15 year-old children, parents of 11–15 year-old girls and elderly people aged 65–75 years were asked about VH (using three questions adapted from the World Health Organization definition), vaccine uptake and perceived RBB for measles and hepatitis B (children’s parents), human papillomavirus (girls’ parents) and seasonal influenza (elderly people) vaccines. Results: A total of 3,938 parents including 959 girls' parents – and 2,418 elderly people were interviewed. VH prevalence estimates were 46% (95% confidence interval (CI): 44–48) among parents, 48% (95%CI: 45–51) among girls’ parents and 35% (95% CI: 33–36) among elderly people, with higher estimates associated with high education level, children’s age (10–15 years), and, for the elderly, poor perception of health status. VH was associated with uncertainty about and/or an unfavourable perception of vaccines’ RBB for the four vaccines and with lower self-reported vaccine uptake, except for human papillomavirus vaccine in girls. Results were confirmed by multivariable analysis. Conclusion: Further research is needed to study the association between VH and vaccine uptake for other vaccines, and to design and validate measurement tools to monitor VH over time.

Completion of the Human Papillomavirus Vaccination Series Among Adolescent Users and Nonusers of School-Based Health Centers

OBJECTIVES

Uptake and completion of the human papillomavirus (HPV) vaccine series among adolescents are suboptimal in the United States. We examined immunization registry data to determine completion of the 3-dose HPV vaccine series among adolescents in Seattle, Washington, born during 1995-2000 who received ≥1 dose of HPV vaccine.

METHODS

Immunization data included the administrating facility, which identified adolescents who used school-based health centers (SBHCs) for any HPV vaccine dose. We calculated completion of the 3-dose series at any time and on time by the 13th birthday. We stratified analyses by sex and assessed differences in on-time and any-time completion between users and nonusers of SBHCs.

RESULTS

Overall, 67.9% (8612 of 12 676) of females and 41.8% (3560 of 8521) of males with ≥1 dose of HPV vaccine completed the 3-dose series. Compared with female SBHC nonusers, female SBHC users had 37% higher odds of completing the series at any time (adjusted odds ratio [aOR] = 1.37; 95% CI, 1.19-1.58) and 33% higher odds of completing the series on time (aOR = 1.33; 95% CI, 1.08-1.64). Compared with male SBHC nonusers, male SBHC users had 45% higher odds of completing the series at any time (aOR = 1.45; 95% CI, 1.23-1.70) and 79% higher odds of completing the series on time (aOR = 1.79; 95% CI, 1.11-2.89).

CONCLUSION

Adolescent SBHC users had higher odds of completing the HPV vaccine series than adolescents who received all doses in traditional health care settings. SBHCs should be leveraged to increase adolescent immunization rates.

Regional variations in human papillomavirus prevalence across time in NHANES (2003-2014)

INTRODUCTION

The consequences of low human papillomavirus (HPV) vaccination in Census regions with higher incidence of cervical cancer may contribute to continued disparities. Our purpose was to evaluate regional variations in HPV prevalence across time.

METHODS

Repeated cross-sectional data from the National Health and Nutrition Examination Survey (NHANES), 2003-2014 were examined. Participants included females 14 to 34 years old who provided adequate vaginal samples for HPV DNA typing (N = 6387). Region of residence and HPV vaccination status associations with HPV prevalence were examined using chi-square and multivariable logistic regression. HPV types were grouped according to vaccine-type HPV (types 6, 11, 16, 18) and risk (high or low-risk). Time and vaccination status were included in subsequent models for post-licensure survey cycles (2007-2014) to assess their effects on observed associations.

RESULTS

No decreases in vaccine-type HPV prevalence were found between the prevaccine cycles (2003-2006) and early post-licensure cycles (2007-2010, p > 0.05). Vaccine-type HPV prevalence decreased in late post-licensure years (2011-2014) compared to prevaccine years (2003-2006, p = 0.001). The highest prevalence of vaccine-type HPV occurred in the South (8.6%) and Midwest (8.6%), followed by the West (4.8%), and the Northeast (3.5%) in late post-licensure years. Lower odds of vaccine-type HPV across time in post-licensure survey cycles were found to be attributable to time, and more strongly to HPV vaccination.

CONCLUSIONS

There were regional variations in vaccine-type HPV prevalence between prevaccine and post-licensure years. These decreases appeared to be at least partially attributable to HPV vaccination. Programs are needed to address geographical disparities in HPV vaccination.

Perceptions of nurses on human papillomavirus vaccinations in the Republic of Korea

BACKGROUND

In June 2016, the Republic of Korea included free human papillomavirus (HPV) vaccinations for all 12-year-old girls in its national immunization program.

PURPOSE

This study investigated perceptions of nurses on HPV vaccination and their intent to vaccinate preteens at the best ages.

METHODS

Recruited for the survey were 514 health teachers (181, 35.2%), public health nurses (168, 32.7%), and clinical nurses (165, 32.1%). Factor-analysis was conducted to validate the Vaccine-Hesitancy Scale for Korean nurses. Related variables associated with vaccine-acceptance were examined using the Kruskal-Wallis test and Spearman's rho coefficients, due to lack of normalization.

RESULTS

Factor-analysis results showed that two factors of positive acceptance (7 items) and negative acceptance (3 items) accounted for 67.46% of the total variance, and explained 47.4% and 20.1%, respectively. Nurses who positively accepted HPV vaccine differed significantly in agreement to vaccinate girls or boys. For the proper vaccination age, a significant difference emerged between answers for girls and vaccine-acceptance scores, whereas no difference emerged between answers for boys and the scores. The vaccinated status of respondents significantly related to higher HPV vaccine acceptance, although age, religion, marital status, education, and working duration did not.

CONCLUSIONS

This study showed that vaccine-acceptance levels reflect nurses' attitudes and opinions about HPV vaccination for girls and boys.

HPV vaccination, knowledge, and attitudes among young cervical cancer survivors in the Deep South

INTRODUCTION

Although FDA approved for over 10 years, uptake of the human papillomavirus (HPV) vaccination has been slow, particularly among states in the Deep South with high cervical cancer incidence and mortality. The purpose of this study was to explore variables associated with cervical cancer among survivors who were age-eligible for the HPV vaccine and to assess HPV vaccination history, barriers, perceptions, and other associated behaviors within this cohort.

METHODS

A mixed methods strategy was used for the study, first identifying eligible cervical cancer survivors from our institution and abstracting demographic and clinicopathologic medical record data. Twenty-three participants from this cohort then completed semi-structured qualitative telephone interviews regarding HPV vaccination participation, knowledge, and attitudes. Interviews were audio-recorded, transcribed, and analyzed using thematic content analysis.

RESULTS

Of the 464 cervical cancer patients treated at our institution from 2011 to 2016, 137 (30%) were under age 40 at diagnosis. Seventy-seven women with invasive disease were identified (median age = 33 years), and 56% had been seen by a gynecologist within 5 years of diagnosis. Forty-six of these women met eligibility criteria for inclusion in the qualitative interview, of which 23 successfully completed (response rate = 50%). Of those interviewed, the majority (84%) reported current access to regular medical care. While 90.9% did not receive any doses of HPV vaccination, 78.3% stated they likely would have been vaccinated if it had it been recommended. Four major themes were identified within the interviews: HPV knowledge, vaccine acceptability, healthcare engagement, and provider communication.

CONCLUSIONS

Qualitative interviews revealed significant missed opportunities for prevention since most participants stated they would have been vaccinated if given the option. Substantial gaps in knowledge and mixed understanding HPV's association with cervical cancer were observed, demonstrating potential missed opportunities for education and communication between providers of multiple specialties and their patients.

Examining strategies for improving healthcare providers' communication about adolescent HPV vaccination: evaluation of secondary outcomes in a randomized controlled trial

There is a critical need for campaigns and interventions to increase rates of human papillomavirus (HPV) vaccination among U.S. adolescents. Healthcare providers are key stakeholders in parents' HPV vaccine decision-making. The current study presents the evaluation of secondary outcomes in a multi-component communication-based intervention to improve healthcare providers' communication about HPV vaccination. Evaluation was conducted via surveys of providers participating in a 12-month randomized controlled trial. Findings suggest use of communication components (combined use of the presumptive approach [PA] with all patients, and motivational interviewing and a fact sheet with vaccine hesitant parents) contributed to providers in the intervention group reporting higher perceived levels of parental HPV vaccine acceptance than control providers, as well as increased vaccination rates in the intervention arm in the main RCT.

Evaluation of the Implementation of a Multicomponent Intervention to Improve Health Care Provider Communication About Human Papillomavirus Vaccination

OBJECTIVE

To evaluate the relative use, usefulness, and facilitators and barriers to use as perceived by providers of 5 different components in a human papillomavirus vaccine communication intervention-which was found to be effective at improving human papillomavirus vaccination rates.

METHODS

Four serial surveys of 108 providers (doctor of medicine, nurse practitioner, or doctor of osteopathic medicine) from intervention clinics involved in the study assessed the use and usefulness of the 5 communication intervention components during a 12-month period.

RESULTS

Survey response rates were 79% to 86%. The fact sheet (64%-77%) and motivational interviewing techniques (MI; 86%) were the most used components-use was sustained during the 12-month period. These components also were perceived as somewhat or very useful by most providers, and this perceived usefulness increased over time (very or somewhat useful at end of study, 97% fact sheet, 98% MI, respectively). Although fewer providers reported using the Web site (15%-42%), or disease images (6%-17%), when these were used, most providers (67%-87%) felt they were somewhat or very useful. The decision aid was not used frequently (17%-41% of providers), and 43% of providers felt it was not very or not at all useful. Facilitators and barriers were identified for each component. The fact sheet and MI were perceived as the easiest to integrate into the clinic workflow.

CONCLUSIONS

The fact sheet and MI were the most used and most useful intervention components. Both were easy to integrate into clinic workflow, and their use was sustained over time. Dissemination of similar interventions in the future should focus on these 2 specific components.

Impact of human papillomavirus vaccination on racial/ethnic disparities in vaccine-type human papillomavirus prevalence among 14-26 year old females in the U.S

BACKGROUND

Low human papillomavirus (HPV) vaccination rates early after introduction, particularly among low income and minority adolescents, may have resulted in disparities in vaccine-type HPV prevalence (types 6, 11, 16, 18). The purpose of this study was to examine racial/ethnic variations in HPV prevalence, and evaluate how HPV vaccination has affected vaccine-type HPV prevalence across time.

METHODS

This study was a retrospective analysis of 6 cycles of the National Health and Nutrition Examination Survey (NHANES) data (2003-2014). Results on HPV status from vaginal samples of 14-26 year old females who responded about HPV vaccination were used to determine HPV prevalence. Prevaccine HPV prevalence was compared to post-licensure prevalence. Racial/ethnic comparisons were made across time, and models were developed to examine the role of HPV vaccination in observed variations for vaccine-type HPV prevalence.

RESULTS

Among 4080 females, 29.7% were black, 25.6% were Mexican American, 8.9% were Hispanic, and 35.8% were white. Compared to prevaccine years (2003-2006), vaccine-type HPV did not decrease until late post-licensure years (2011-2014; 14.2% vs. 5.2%, p < 0.001). Most of the decrease occurred among white females between prevaccine and late post-licensure periods (15.2% vs. 4.1%, p < 0.001). Although a decrease in prevalence was observed among black females during the same periods (16.9% vs. 9.8%, p < 0.05), it was not as large as among white females. Prevalence decreased among Mexican Americans (8.2 vs. 4.0, p > 0.05) during the same periods, but the difference was not significant. Interactions between race and time were significant (p < 0.001), with uneven vaccination between black and white females contributing to the disparities observed.

CONCLUSIONS

HPV vaccination was low in among black and Mexican American females, which contributed to disparities in HPV prevalence. Increasing vaccination among all adolescents, particularly 11-12 year olds, is important because most children this age will not have been exposed.

Provider and Parent Perspectives on Enhanced Communication Tools for Human Papillomavirus Vaccine-Hesitant Parents

OBJECTIVE

Human papillomavirus (HPV) vaccine initiation and completion rates remain far below the Healthy People 2020 goal, suggesting that additional tools and training may be needed to help medical staff provide a quality recommendation. As part of a larger pragmatic trial, we conducted a qualitative study to understand how a multifaceted communication intervention used by medical staff with HPV vaccine-hesitant parents can improve HPV vaccination rates in the primary care setting.

METHODS

At 8 primary care intervention clinics in the Denver metro area, medical staff and parents of adolescent boys and girls ages 11 to 17 years eligible to start the HPV vaccine series at a recent well care visit were recruited for study participation. Focus groups with medical staff and in-depth interviews with hesitant parents were conducted during the post-intervention period. All data were recorded, transcribed, and analyzed using established qualitative methods.

RESULTS

Twenty parents and 46 medical staff participated. All parents and medical staff felt that the overall intervention was beneficial and should continue to be used and preferred the HPV vaccine fact sheet component. Medical staff reported that communication trainings (intervention component) that taught a presumptive approach and motivational interviewing were the most beneficial for introducing the HPV vaccine and for countering HPV vaccine hesitancy, respectively. Least favorable components were the decision aid, disease images, and parent website.

CONCLUSIONS

Select components of a multifaceted communication intervention were seen as beneficial to HPV vaccine-hesitant parents and medical staff. Future studies should look at how to implement these intervention components in a greater number of primary care settings.

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.

Dental provider practices and perceptions regarding adolescent vaccination

OBJECTIVE

To assess dental providers' clinical practices and perceptions regarding adolescent vaccinations.

METHODS

We surveyed 234 dental providers in an integrated health care setting in Portland, Oregon, in March-April 2015. We assessed participants' knowledge of adolescent vaccines, barriers to recommending vaccines, and their perceived role in the promotion of vaccination and preventive medical care.

RESULTS

Over 80 percent of respondents correctly identified influenza, tetanus-diphtheria-acellular pertussis, and human papillomavirus as vaccinations recommended for adolescents; 60 percent correctly identified meningococcal conjugate. Forty-four percent of providers reported previously discussing vaccination with their adolescent patients. Lack of knowledge (66 percent), uncertainty about whether patients would accept recommendations (62 percent), and lack of time (61 percent) were commonly reported barriers. While few providers expressed personal concerns about the safety (13 percent) and effectiveness (10 percent) of adolescent vaccines, most believed parents had concerns about safety (70 percent) and effectiveness (60 percent). Although 80 percent endorsed the premise that providers should discuss preventive medical care with their patients, only 54 percent said they should discuss vaccinations specifically.

CONCLUSIONS

Dental providers reported several barriers to recommending vaccines. While comfortable with discussing preventive medical care in general, providers are less comfortable making vaccine recommendations to their patients. Vaccine recommendations are not a traditional practice among dental providers and may require additional education and communication tools.

HPV vaccination in Japan: results of a 3-year follow-up survey of obstetricians and gynecologists regarding their opinions toward the vaccine

Background

In Japan, the cervical cancer preventative HPV vaccination rate has dramatically declined, directly as a result of repeated broadcasts of so-called adverse events and the resulting suspension of the government’s recommendation. Our previous survey of obstetricians and gynecologists in Japan regarding their opinions toward HPV vaccination revealed that these key specialists were as negatively influenced by the reports of purported negative events as were the general population. Here, we report a 3-year follow-up survey of these clinicians.

Methods

We reused the same questionnaire format as used in our 2014 survey, but added new questions concerning opinions regarding a WHO statement and reports of a Japanese nation-wide epidemiological study related to the adverse events, released in 2015 and 2016, respectively.

Results

The response rate was 46% (259/567): 5 (16.1%) of 31 doctors had inoculated their own teenaged daughters during the time period since the previous survey, despite the continued suspension of the governmental recommendation, whereas in the previous survey none of the doctors had done so. Among the respondents, the majority claimed awareness of the recent pro-vaccine WHO statement (66.5%), and of the report of a Japanese epidemiological study (71.5%), and a majority affirmed they currently held positive opinions of the safety (72.7%) and effectiveness (84.3%) of the HPV vaccine.

Conclusions

Our re-survey of Japan’s obstetricians and gynecologists regarding their opinions about the HPV vaccine found that their opinions have changed, potentially leading to a more positive future re-engagement for HPV vaccination in Japan.

Expanded strain coverage for a highly successful public health tool: Prophylactic 9-valent human papillomavirus vaccine

Human papillomavirus is considered the causative factor for cervical cancer, which accounts for approximately 5% of the global cancer burden and more than 600,000 new cases annually that are attributable to HPV infection worldwide. The first-generation prophylactic HPV vaccines, Gardasil® and Cervarix®, were licensed approximately a decade ago. Both vaccines contain the most prevalent high-risk types, HPV16 and 18, which are associated with 70% of cervical cancer. To further increase the type coverage, 5 additional oncogenic HPV types (31, 33, 45, 52 and 58) were added to the existing Gardasil-4 to develop a 9-valent HPV vaccine (9vHPV), Gardasil 9®, increasing the potential level of protection from ∼70% to ∼90%. The efficacy of the vaccine lies primarily in its ability to elicit type-specific and neutralizing antibodies to fend off the viral infection. Therefore, type-specific and neutralizing murine monoclonal antibodies (mAbs) were used to quantitate the antigenicity of the individual vaccine antigens and to measure the antibody levels in the serum samples from vaccinees in a type- and epitope-specific manner in a competitive immunoassay. Assays for 9vHPV are extended from the proven platform used for 4vHPV by developing and adding new mAbs against the additional types. In Phase III clinical trials, comparable safety profile and immunogenicity against the original 4 types were demonstrated for the 9vHPV vaccine, and these were comparable to the 4vHPV vaccine. The efficacy of the 9vHPV vaccine was established in trials with young women. Immunobridging for younger boys and girls was performed, and the results showed higher immunogenicity in the younger age group. In a subsequent clinical trial, the 2-dose regimen of the 9vHPV vaccine used among girls and boys aged 9-14 y showed non-inferior immunogenicity to the regular 3-dose regimen for young women (aged 16-26 years). Overall, the clinical data and cost-effectiveness analysis for the 9vHPV vaccine support its widespread use to maximize the impact of this important, life-saving vaccine.

Primary Prevention of Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Guideline

PURPOSE

To provide resource-stratified (four tiers), evidence-based recommendations on the primary prevention of cervical cancer globally.

METHODS

The American Society of Clinical Oncology convened a multidisciplinary, multinational panel of oncology, obstetrics/gynecology, public health, cancer control, epidemiology/biostatistics, health economics, behavioral/implementation science, and patient advocacy experts. The Expert Panel reviewed existing guidelines and conducted a modified ADAPTE process and a formal consensus-based process with additional experts (consensus ratings group) for one round of formal ratings.

RESULTS

Existing sets of guidelines from five guideline developers were identified and reviewed; adapted recommendations formed the evidence base. Five systematic reviews, along with cost-effectiveness analyses, provided evidence to inform the formal consensus process, which resulted in agreement of ≥ 75%.

RECOMMENDATIONS

In all resource settings, two doses of human papillomavirus vaccine are recommended for girls age 9 to 14 years, with an interval of at least 6 months and possibly up to 12 to 15 months. Individuals with HIV positivity should receive three doses. Maximal and enhanced settings: if girls are age ≥ 15 years and received their first dose before age 15 years, they may complete the series; if no doses were received before age 15 years, three doses should be administered; in both scenarios, vaccination may be through age 26 years. Limited and basic settings: if sufficient resources remain after vaccinating girls age 9 to 14 years, girls who received one dose may receive additional doses between age 15 and 26 years. Maximal, enhanced, and limited settings: if ≥ 50% coverage in the priority female target population, sufficient resources, and cost effectiveness, boys may be vaccinated to prevent other noncervical human papillomavirus-related cancers and diseases. Basic settings: vaccinating boys is not recommended.

It is the view of the American Society of Clinical Oncology that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Predictors of Adults' Knowledge and Awareness of HPV, HPV-Associated Cancers, and the HPV Vaccine: Implications for Health Education

High human papillomavirus (HPV) prevalence and low HPV vaccine uptake are significant public health concerns. Disparities in HPV-associated cancers and HPV vaccine uptake rates suggest the need for additional research examining factors associated with vaccine acceptance. This study assessed HPV awareness and knowledge and identified sociodemographic characteristics associated with HPV knowledge at the population level. Data from adult men ( n = 1,197) and women ( n = 1,906) who participated in the National Cancer Institute's 2014 Health Information National Trends Survey were analyzed. Multivariable regression was used to identify predictors of four HPV knowledge categories: (1) general knowledge, (2) cervical cancer knowledge, (3) "other" cancer knowledge (i.e., anal, oral, penile), and (4) vaccine knowledge. Significant gender differences in awareness and knowledge of HPV and the HPV vaccine were revealed. Most participants (>70%) knew that HPV could cause cervical cancer, but fewer (14.9% to 31.5%) knew of the association between HPV and "other" cancers. Women were more likely to report that a health care provider recommended vaccination. Significant predictors of general HPV and HPV vaccine knowledge included gender, education, income, race, and other sociodemographic characteristics. Age and income predicted cervical cancer knowledge. Knowledge of "other" HPV-associated cancers was predicted by having a child under 18 years in the household and relationship status. HPV knowledge appears to be socially patterned. Low HPV knowledge among men and some racial minorities suggests a need for further intervention. Health education should emphasize risks of noncervical HPV-associated cancers. Patient-provider communication that includes education, counseling, and clear recommendations favoring vaccination may improve uptake.

Practical Approaches to Optimize Adolescent Immunization

With the expansion of the adolescent immunization schedule during the past decade, immunization rates notably vary by vaccine and by state. Addressing barriers to improving adolescent vaccination rates is a priority. Every visit can be viewed as an opportunity to update and complete an adolescent's immunizations. It is essential to continue to focus and refine the appropriate techniques in approaching the adolescent patient and parent in the office setting. Health care providers must continuously strive to educate their patients and develop skills that can help parents and adolescents overcome vaccine hesitancy. Research on strategies to achieve higher vaccination rates is ongoing, and it is important to increase the knowledge and implementation of these strategies. This clinical report focuses on increasing adherence to the universally recommended vaccines in the annual adolescent immunization schedule of the American Academy of Pediatrics, the American Academy of Family Physicians, the Centers for Disease Control and Prevention, and the American Congress of Obstetricians and Gynecologists. This will be accomplished by (1) examining strategies that heighten confidence in immunizations and address patient and parental concerns to promote adolescent immunization and (2) exploring how best to approach the adolescent and family to improve immunization rates.

DLG1 polarity protein expression associates with the disease progress of low-grade cervical intraepithelial lesions

Human Discs large tumour suppressor (DLG1) participates in regulating cell polarity and proliferation, suggesting an important connection between epithelial organization and cellular growth control. However, it was demonstrated that DLG1 could acquire oncogenic attributes in some specific contexts. In this work, we evaluated the expression of DLG1 and its contribution to the progress of cervical lesions in order to investigate a potential role of this polarity protein in human oncogenic processes. We analyzed cervical biopsies from women with low-grade squamous intraepithelial lesion (LSIL) diagnosis (n=30), for DLG1 expression by immunohistochemistry. These results were correlated with the clinical monitoring of the patients during a 24-month follow-up period. Our data indicate that while all LSIL patients with a DLG1 staining pattern similar to normal tissues are significantly more likely to regress (n=23, Pattern I), all LSIL biopsy specimens showing a diffuse and intense DLG1 staining likely progress to high-grade lesions (n=4, Pattern II). Finally, all persistent LSIL analyzed showed an undetermined DLG1 staining, with a diffuse distribution without a strong intensity (n=3, Pattern III). We found a significant association between the expression pattern of DLG1 and the evolution of the lesion (p<0.00001). This work contributes to the knowledge of DLG1 biological functions, suggesting that its expression may have an important role in the progression of early dysplastic cervical lesions, giving prognostic information.

Chemical Synthesis, Versatile Structures and Functions of Tailorable Adjuvants for Optimizing Oral Vaccination

Oral vaccines have become a recent focus because of their potential significance in disease prevention and therapy. In the development of oral vaccine-based therapeutics, synthetic materials with tailorable structures and versatile functions can act as antigen conveyers with adjuvant effects, reduce the time cost for vaccine optimization, and provide high security and enhanced immunity. This review presents an overview of the current status of tailoring synthetic adjuvants for oral vaccination, modification strategies for producing effectors with specific structures and functions, enhancement of immune-associated efficiencies, including the barrier-crossing capability to protect antigens in the gastrointestinal tract, coordination of the antigens penetrating mucosa and cell barriers, targeting of concentrated antigens to immune-associated cells, and direct stimulation of immune cells. Finally, we focus on prospective synthetic adjuvants that facilitate the use of oral vaccines via two approaches, namely, in vivo antigen expression and cancer immunotherapy.

Missing the Target for Routine Human Papillomavirus Vaccination: Consistent and Strong Physician Recommendations Are Lacking for 11- to 12-Year-Old Males

BACKGROUND

Rates of routine human papillomavirus (HPV) vaccination of adolescent males in the United States are low. Leading health organizations advocate consistent and strong physician recommendations to improve HPV vaccine dissemination. This study describes the prevalence and correlates of consistent and strong physician recommendations for HPV vaccination of adolescent males.

METHODS

We surveyed pediatric and family medicine physicians in Florida about their HPV vaccine recommendations for male vaccine-eligible age groups (11-12, 13-17, 18-21 years). Descriptive statistics compared consistency and strength of HPV recommendations across age groups. Multivariable logistic regression examined factors associated with consistent and strong recommendations for 11- to 12-year-olds.

RESULTS

We received 367 completed surveys (51% response rate). Physicians most often consistently and strongly recommended HPV vaccine to males ages 13 to 17 (39%) compared with ages 11 to 12 (31%) and 18 to 21 (31%). Consistent and strong recommendation for 11- to 12-year-old males was more likely to be delivered by Vaccine for Children providers and less likely among physicians who reported more personal barriers to vaccination, particularly concerns about vaccine safety, concerns about adding vaccines to the vaccine schedule, and difficulty in remembering to discuss HPV vaccination.

CONCLUSIONS

Physicians' current consistency and strength of HPV vaccine recommendations do not align with national recommendations. Interventions to improve HPV vaccine recommendations must also consider the influence of physicians' personal barriers to HPV vaccine delivery.

IMPACT

As one of the first studies to examine both consistency and strength of physicians' HPV vaccine recommendations for males, our findings can inform future interventions focused on facilitating physicians' recommendations. Cancer Epidemiol Biomarkers Prev; 25(10); 1435-46. ©2016 AACR.