Vaccination coverage among U.S. adolescents aged 13-17 years eligible for the Vaccines for Children program, 2009

Policy Approaches for Increasing Adolescent HPV Vaccination Coverage: A Systematic Review

CONTEXT

US jurisdictions have enacted a wide range of policies to address low human papillomavirus (HPV) vaccination coverage among adolescents, but it is unclear which policies are effective.

OBJECTIVE

To systematically review the impact of governmental policies on adolescent HPV vaccination coverage.

DATA SOURCES

PubMed, Embase, and Scopus databases.

STUDY SELECTION

Eligible studies, published from 2009 to 2022, evaluated the impact of governmental policies on HPV vaccination coverage among adolescents ages 9 to 18.

DATA EXTRACTION

Two investigators independently extracted data on study sample, study design and quality, policy characteristics, and HPV vaccination outcomes. We summarized findings by policy type: school-entry requirements (SERs), federally-funded policies related to the Vaccines for Children program and Medicaid, educational requirements, and others.

RESULTS

Our search yielded 36 eligible studies. A majority of studies evaluating HPV vaccine SERs found positive associations between SERs and HPV vaccination coverage (8 of 14), particularly for SERs in Rhode Island and Washington, DC. All studies evaluating SERs for other adolescent vaccines observed positive spillover effects for HPV vaccination (7 of 7). Federally-funded policies related to Vaccines for Children and Medicaid were consistently associated with higher HPV vaccination coverage (7 of 9). Relatively few studies found associations between educational requirements and HPV vaccination coverage (2 of 8).

LIMITATIONS

Studies used limited vaccination data sources and non- or quasi-experimental designs. Some studies had no or poorly matched comparison groups.

CONCLUSIONS

Our findings suggest promise for SERs and federally-funded policies, but not educational requirements, for increasing HPV vaccination coverage among adolescents.

Human Papillomavirus Vaccine Impact on Cervical Precancers in a Low-Vaccination Population

INTRODUCTION

Demonstrating human papillomavirus vaccine impact is critical for informing guidelines to increase vaccination and decrease human papillomavirus‒related outcomes, particularly in states with suboptimal vaccination coverage, such as Tennessee. This study examines the trends in high-grade cervical lesion incidence among Tennessee Medicaid-enrolled women aged 18-39 years and the subset of women who were screened for cervical cancer.

METHODS

Using a validated claims-based model to identify incident cervical intraepithelial neoplasia Grades 2 or 3 or adenocarcinoma in situ events, annual age group‒specific incidence rates from Tennessee Medicaid billing data, 2008-2018, were calculated. Significant trends were determined by Joinpoint. Analyses were conducted in 2020.

RESULTS

From 2008 to 2018, high-grade cervical lesion incidence significantly declined in women aged 18-20 years (average annual percentage change= -31.9, 95% CI= -38.6, -24.6), 21-24 years (average annual percentage change= -12.9, 95% CI= -22.3, -2.4), and 25-29 years (average annual percentage change= -6.4, 95% CI= -8.1, -4.6). Among screened women, rates significantly declined for ages 18-20 years (average annual percentage change= -20.3, 95% CI= -25.3, -15.0), 21-24 years (average annual percentage change= -10.2, 95% CI= -12.6, -7.8), and 25-29 years (average annual percentage change= -2.6, 95% CI= -3.9, -1.2). Trends from 2008 to 2018 were stable for older age groups (30-34 and 35-39 years).

CONCLUSIONS

Results show reductions in high-grade cervical lesion incidence among ages most likely to have benefited from the human papillomavirus vaccine. Declines among young, screened women suggest causes other than reduction in screening. Evidence of vaccine impact in populations with low-vaccination coverage, such as Tennessee, is promising.

Human Papillomavirus Vaccination Prevalence Among Adults Aged 19-45 Years: An Analysis of the 2017 National Health Interview Survey

INTRODUCTION

In 2018, the U.S. Food and Drug Administration extended the licensure for human papillomavirus vaccination to include everyone aged 27-45 years. In 2019, the Advisory Committee on Immunization Practices issued a recommendation that adults aged 27-45 years and their providers engage in shared clinical decision making about human papillomavirus vaccination. In addition, in 2019, the Advisory Committee on Immunization Practices reiterated that all previously unvaccinated individuals receive catch-up vaccination through age 26 years. This study estimates the pre-recommendation prevalence of human papillomavirus vaccination and factors associated with vaccination in 2 age groups (19-26 years [young adults] and 27-45 years [mid-adults]), forming a baseline to monitor future coverage among U.S. adults.

METHODS

The final sample included 9,744 individuals (2,522 young adults and 7,222 mid-adults) who participated in the 2017 National Health Interview Survey. The main outcomes were receipt of 1 or more human papillomavirus vaccination and whether the participant had been vaccinated as an adult. Demographic characteristics and healthcare factors were included as covariates in statistical analyses.

RESULTS

Population estimate of receiving 1 or more human papillomavirus vaccine doses among young adults was 36.3% (female: 51.5%, male: 21.2%; p<0.001) and 9.7% for mid-adults (females: 15.8%, males: 3.2%; p<0.001). In the best-fit model, age was inversely associated with vaccination for mid-adults (female: OR=0.84, 95% CI=0.81, 0.86; male: OR=0.86; 95% CI=0.82, 0.90) and male young adults (OR=0.79, 95% CI=0.71, 0.88). Of the entire vaccinated sample aged 19-45 years, 26.6% had received their first vaccination as an adult (95% CI=23.9, 29.4).

CONCLUSIONS

These data emphasize the continued need for vaccinating adolescents aged 11-12 years given that few adults were vaccinated against human papillomavirus.

Trends in anogenital wart incidence among Tennessee Medicaid enrollees, 2006-2014: The impact of human papillomavirus vaccination

Introduction

Evidence of human papillomavirus (HPV) vaccine impact on anogenital warts (AGWs) by race or urbanicity in the US is lacking. We evaluated HPV vaccine impact in Tennessee by assessing AGW trends among Tennessee Medicaid (TennCare) enrollees aged 15–39 years from 2006-2014.

Methods

Persons with incident AGWs were identified using diagnosis/pharmacy codes from TennCare billing claims. We calculated sex-specific annual AGW incidence by age group, race, and urbanicity; estimated annual percent changes (APCs) using log-linear models; and performed pairwise comparisons by race and urbanicity.

Results

AGW incidence decreased among females aged 15–19 (APC = −10.6; P < 0.01) and 20–24 years (APC = −3.9; P = 0.02). Overall trends were similar between Whites and Blacks, and between those living in metropolitan statistical areas (MSAs) and non-MSAs. Rates among males aged 15–19 years began decreasing after 2010. Among enrollees aged 25–39 years, rates increased or were stable.

Conclusions

Following introduction of the HPV vaccine in 2006, AGWs decreased among age groups most likely to be vaccinated. The change in trend among young males after 2010 suggests early herd effects. Our findings indicate vaccine effects and support the importance of improving adherence to current vaccination recommendations for preventing AGWs and other HPV-related diseases.

Association of Provider Recommendation and Human Papillomavirus Vaccination Initiation among Male Adolescents Aged 13-17 Years-United States

OBJECTIVE

To assess human papillomavirus (HPV) vaccination coverage among adolescents by provider recommendation status.

STUDY DESIGN

The 2011-2016 National Immunization Survey-Teen data were used to assess HPV vaccination coverage among male adolescents by provider recommendation status. Multivariable logistic analyses were conducted to evaluate associations between HPV vaccination and provider recommendation status.

RESULTS

HPV vaccination coverage among male adolescents increased from 8.3% in 2011 to 57.3% in 2016. Likewise, the prevalence of provider recommendation increased from 14.2% in 2011 to 65.5% in 2016. In 2016, HPV coverage was higher in male adolescents with a provider recommendation than in those without a provider recommendation (68.8% vs 35.4%). In multivariable logistic regression, characteristics independently associated with a higher likelihood of HPV vaccination included receipt of a provider recommendation, age 16-17 years, black or Hispanic race/ethnicity, any Medicaid insurance, ≥2 physician contacts in the previous 12 months, and urban or suburban residence. Participants with a mother with some college or a college degree, those with a mother aged 35-44 years, and those who did not have a well-child visit at age 11-12 years had a lower likelihood of HPV vaccination.

CONCLUSIONS

Receiving a provider recommendation for vaccination was significantly associated with receipt of HPV vaccine among male adolescents, indicating that a provider recommendation for vaccination is an important approach to increase vaccination coverage. Evidence-based strategies, such as standing orders and provider reminders, alone or in combination with health system interventions, are useful for increasing provider recommendations and HPV vaccination coverage among male adolescents.

Examination of universal purchase programs as a driver of vaccine uptake among US States, 1995-2014

BACKGROUND

Immunization against numerous potentially life-threatening illnesses has been a great public health achievement. In the United States, the Vaccines for Children (VFC) program has provided vaccines to uninsured and underinsured children since the early 1990s, increasing vaccination rates. In recent years, some states have adopted Universal Purchase (UP) programs with the stated aim of further increasing vaccination rates. Under UP programs, states also purchase vaccines for privately-insured children at federally-contracted VFC prices and bill private health insurers for the vaccines through assessments.

METHODS

In this study, we estimated the effect of UP adoption in a state on children's vaccination rates using state-level and individual-level data from the 1995-2014 National Immunization Survey. For the state-level analysis, we performed ordinary least squares regression to estimate the state's vaccination rate as a function of whether the state had UP in the given year, state demographic characteristics, other vaccination policies, state fixed effects, and a time trend. For the individual analysis, we performed logistic regression to estimate a child's likelihood of being vaccinated as a function of whether the state had UP in the given year, the child's demographic characteristics, state characteristics and vaccine policies, state fixed effects, and a time trend. We performed separate regressions for each of nine recommended vaccines, as well as composite measures on whether a child was up-to-date on all required vaccines.

RESULTS

In the both the state-level and individual-level analyses, we found UP had no significant (p < 0.10) effect on any of the vaccines or composite measures in our base case specifications. Results were similar in alternative specifications.

CONCLUSIONS

We hypothesize that UP was ineffective in increasing vaccination rates. Policymakers seeking to increase vaccination rates would do well to consider other policies such as addressing provider practice issues and vaccine hesitancy.

Impact of Provider Recommendation on Tdap Vaccination of Adolescents Aged 13-17 Years

INTRODUCTION

Tetanus, diphtheria, and acellular pertussis (Tdap) vaccination has been recommended for adolescents in the U.S. since 2006. Information on Tdap vaccination by provider recommendation is limited. The purpose of this study is to assess recent Tdap vaccination by provider recommendation status among adolescents aged 13-17 years.

METHODS

The 2013 National Immunization Survey-Teen data (N=18,948) were analyzed in 2016 to assess national and state-specific Tdap vaccination coverage disparities among adolescents by provider recommendation status, and other demographic and access to care variables. Multivariable logistic regression analysis and predictive marginal modeling evaluated associations between Tdap vaccination and provider recommendation status and other factors among adolescents aged 13-17 years.

RESULTS

Overall, only 56.9% of adolescents aged 13-17 years received a provider recommendation for Tdap. Coverage was significantly higher among adolescents with a provider recommendation (88.6%) compared with those without a provider recommendation (80.5%) (p<0.05). Multivariable logistic regression showed that characteristics independently associated with a higher likelihood of Tdap vaccination included receiving a provider recommendation, Hispanic ethnicity, having two to three physician contacts in the past 12 months, having one or two vaccination providers, and receiving vaccinations from more than one type of facility (p<0.05).

CONCLUSIONS

Provider recommendations were significantly associated with Tdap vaccination among adolescents aged 13-17 years. However, 43% of parents of adolescents did not receive a provider recommendation. Evidence-based strategies such as standing orders and provider reminders alone or health systems interventions in combination should be taken to improve provider recommendation and Tdap vaccination coverage.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Influence of Gender and Gender-Specific Recommendations on Adolescent Human Papillomavirus Vaccination

INTRODUCTION

The human papillomavirus (HPV) vaccine was introduced for female adolescents prior to male adolescents. Understanding coverage patterns related to gender-specific recommendations and factors associated with early adoption and timely completion may be important for future vaccines.

METHODS

Retrospective analysis of HPV vaccine initiation (one or more dose) and completion (three or more doses) patterns in adolescents aged 11-18 years using 2009-2013 New York Citywide Immunization Registry data. Log binomial models assessed patient-specific (age, insurance) and practice-specific (facility type, number of adolescents, poverty level) variables on early adoption (within 1 year of recommendation) and timely completion (within 12 months) by gender.

RESULTS

Of 1,494,767 adolescents, 50.2% were male, 57.5% were vaccinated in private practices, 58.7% in practices with more adolescents, and 48.8% in highest poverty locations. More female (54.0%) than male (33.5%) adolescents initiated vaccination (p<0.001). Of those, 56.1% received three or more doses, 34.1% within 12 months (30.0% male, 36.8% female, p<0.001). In 2009-2012, the proportion of still-eligible male adolescents who newly initiated increased from 0.1% to 17.0%; rates for female adolescents increased from 15.4% to 17.3%. Vaccination initiation within 1 year of gender-specific recommendations was similar (27.4% female, 27.3% male). For both genders, the uninsured were less likely to have early adoption and timely completion. Being publicly insured was associated with early adoption in both genders, but with timely completion in male adolescents only. Being seen in a public facility and in a practice with more adolescents was also associated with early adoption.

CONCLUSIONS

Changing HPV vaccine recommendations had minimal cross-gender impact. Early adoption and timely completion patterns were mostly similar across genders.

HPV vaccination coverage of teen girls: the influence of health care providers

BACKGROUND

Between 2010 and 2014, the percentage of 13-17 year-old girls administered ≥3 doses of the human papilloma virus (HPV) vaccine ("fully vaccinated") increased by 7.7 percentage points to 39.7%, and the percentage not administered any doses of the HPV vaccine ("not immunized") decreased by 11.3 percentage points to 40.0%.

OBJECTIVE

To evaluate the complex interactions between parents' vaccine-related beliefs, demographic factors, and HPV immunization status.

METHODS

Vaccine-related parental beliefs and sociodemographic data collected by the 2010 National Immunization Survey-Teen among teen girls (n=8490) were analyzed. HPV vaccination status was determined from teens' health care provider (HCP) records.

RESULTS

Among teen girls either unvaccinated or fully vaccinated against HPV, teen girls whose parent was positively influenced to vaccinate their teen daughter against HPV were 48.2 percentage points more likely to be fully vaccinated. Parents who reported being positively influenced to vaccinate against HPV were 28.9 percentage points more likely to report that their daughter's HCP talked about the HPV vaccine, 27.2 percentage points more likely to report that their daughter's HCP gave enough time to discuss the HPV shot, and 43.4 percentage points more likely to report that their daughter's HCP recommended the HPV vaccine (p<0.05). Among teen girls administered 1-2 doses of the HPV vaccine, 87.0% had missed opportunities for HPV vaccine administration.

CONCLUSION

Results suggest that an important pathway to achieving higher ≥3 dose HPV vaccine coverage is by increasing HPV vaccination series initiation though HCP talking to parents about the HPV vaccine, giving parents time to discuss the vaccine, and by making a strong recommendation for the HPV. Also, HPV vaccination series completion rates may be increased by eliminating missed opportunities to vaccinate against HPV and scheduling additional follow-up visits to administer missing HPV vaccine doses.

Geographic Factors and Human Papillomavirus (HPV) Vaccination Initiation among Adolescent Girls in the United States

BACKGROUND

This study is among the first to explore geographic factors that may be associated with human papillomavirus (HPV) vaccine uptake in the United States.

METHODS

Data from the 2011 and 2012 National Immunization Survey-Teen for 20,565 female adolescents aged 13 to 17 years were analyzed to examine associations of HPV vaccine initiation (receipt of at least one dose) with ZIP code-level geographic factors. Logistic regression including individual and geographic factors was used to estimate the odds of HPV vaccine initiation.

RESULTS

Approximately 53% of girls initiated the HPV vaccine in both years. Girls in high poverty communities had higher HPV vaccine initiation compared with those in low poverty communities [61.1% vs. 52.4%; adjusted OR (AOR), 1.18; 95% confidence intervals (CI), 1.04-1.33]. Initiation was higher among girls in communities where the majority of the population was Hispanic (69.0% vs. 49.9%; AOR, 1.64; 95% CI, 1.43-1.87) or non-Hispanic mixed race (60.4% vs. 49.9%; AOR, 1.30; 95% CI, 1.17-1.44) compared with majority non-Hispanic white communities. Interactions between individual-level race/ethnicity and community racial-ethnic composition indicated significantly higher odds of initiation among Hispanic girls living in Hispanic communities compared with Hispanic girls living in predominantly non-Hispanic White (NHW) (AOR, 2.23; 95% CI, 1.87-2.65) or non-Hispanic Black (NHB) (AOR, 1.90; 95% CI, 1.20-3.04) communities, respectively.

CONCLUSION

Initiation rates of HPV vaccination among teen girls were highest in the poorest communities and among Hispanics living in communities where the racial-ethnic composition was predominantly Hispanic or mixed race.

IMPACT

Given low HPV vaccination rates in the United States, these results provide important evidence to inform public health interventions to increase HPV vaccination.

Preexisting Chronic Health Conditions and Health Insurance Status Associated With Vaccine Receipt Among Adolescents

PURPOSE

Four vaccines are routinely recommended for adolescents: tetanus, diphtheria, and acellular pertussis (Tdap); human papillomavirus (HPV); meningococcal-conjugate (MCV4); and a yearly seasonal influenza vaccine. Vaccination promotion and outreach approaches may need to be tailored to certain populations, such as those with chronic health conditions or without health insurance.

METHODS

In a controlled trial among middle and high school students in Georgia, 11 schools were randomized to one of three arms: no intervention, parent education brochure, or parent education brochure plus a student curriculum on the four recommended vaccines. Parents in all arms were surveyed regarding their adolescent's vaccine receipt, chronic health conditions, and health insurance status.

RESULTS

Of the 686 parents, most (91%) reported their adolescent had received at least one of the four vaccines: Tdap (82%), MCV4 (59%), current influenza vaccine (53%) and HPV (48%). Twenty-three percent of parents reported that their adolescent had asthma. Most parents reported that their adolescent's insurance was Medicaid (60%) or private insurance (34%), and 6% reported no insurance. More adolescents with a chronic health condition received any adolescent vaccine than adolescents without a chronic health condition (p < .0001). Among those with no insurance, fewer had received any adolescent vaccine than those with Medicaid or private insurance (p < .0001).

CONCLUSIONS

The federal Vaccines for Children program offers recommended vaccines free to eligible children (including those without health insurance). Our findings suggest that parents may not be aware of this program or eligibility for it, thus revealing a need for education or other fixes.

Children and Adolescents Unvaccinated Against Measles: Geographic Clustering, Parents' Beliefs, and Missed Opportunities

OBJECTIVE

We evaluated the extent to which children and adolescents were not vaccinated against measles ("unvaccinated"), clustering within U.S. counties, and factors associated with unvaccination, including parents' vaccine-related beliefs and missed opportunities.

METHODS

We analyzed data from the 2010-2013 National Immunization Survey (NIS) and NIS-Teen Survey of households with 19- to 35-month-old children and 13- to 17-year-old adolescents, respectively. We used provider-reported vaccination histories to assess measles vaccination status.

RESULTS

In 2013, 7.5% of children and 4.5% of adolescents were unvaccinated against measles. Four-fifths (80.0%) of unvaccinated children lived in counties containing 41.9% of the nation's children, and 80.0% of unvaccinated adolescents lived in counties containing 30.4% of the nation's adolescents. Multivariable statistical analyses found that 74.6% of children who were unvaccinated against measles missed being vaccinated for reasons other than parents' negative vaccine-related beliefs, and 89.6% could be deemed as having at least one missed opportunity for being vaccinated against measles because they were administered at least one dose of other recommended vaccines after 12 months of age. Among adolescents, multivariable analyses found that only demographic factors, not vaccine-related parental beliefs, were independently associated with being unvaccinated.

CONCLUSIONS

Reasons other than negative vaccine-related beliefs, including missed opportunities, accounted for the vast majority of unvaccinated children and adolescents.

Influenza vaccination coverage of Vaccine for Children (VFC)-entitled versus privately insured children, United States, 2011-2013

BACKGROUND

The Vaccines for Children (VFC) program provides vaccines at no cost to children who are Medicaid-eligible, uninsured, American Indian or Alaska Native (AI/AN), or underinsured and vaccinated at Federally Qualified Health Centers or Rural Health Clinics. The objective of this study was to compare influenza vaccination coverage of VFC-entitled to privately insured children in the United States, nationally, by state, and by selected socio-demographic variables.

METHODS

Data from the National Immunization Survey-Flu (NIS-Flu) surveys were analyzed for the 2011-2012 and 2012-2013 influenza seasons for households with children 6 months-17 years. VFC-entitlement and private insurance status were defined based upon questions asked of the parent during the telephone interview. Influenza vaccination coverage estimates of children VFC-entitled versus privately insured were compared by t-tests, both nationally and within state, and within selected socio-demographic variables.

RESULTS

For both seasons studied, influenza coverage for VFC-entitled children did not significantly differ from coverage for privately insured children (2011-2012: 52.0%±1.9% versus 50.7%±1.2%; 2012-2013: 56.0%±1.6% versus 57.2%±1.2%). Among VFC-entitled children, uninsured children had lower coverage (2011-2012: 38.9%±4.7%; 2012-2013: 44.8%±3.5%) than Medicaid-eligible (2011-2012: 55.2%±2.1%; 2012-2013: 58.6%±1.9%) and AI/AN children (2011-2012: 54.4%±11.3%; 2012-2013: 54.6%±7.0%). Significant differences in vaccination coverage among VFC-entitled and privately insured children were observed within some subgroups of race/ethnicity, income, age, region, and living in a metropolitan statistical area principle city.

CONCLUSIONS

Although finding few differences in influenza vaccination coverage among VFC-entitled versus privately insured children was encouraging, nearly half of all children were not vaccinated for influenza and coverage was particularly low among uninsured children. Additional public health interventions are needed to ensure that more children are vaccinated such as a strong recommendation from health care providers, utilization of immunization information systems, provider reminders, standing orders, and community-based interventions such as educational activities and expanded access to vaccination services.

Hepatitis B vaccination among adolescents 13-17 years, United States, 2006-2012

BACKGROUND

Hepatitis B (HepB) vaccination is the most effective measure to prevent HBV infection. Routine HepB vaccination was recommended for infants in 1991 and catch-up vaccination has been recommended for adolescents since in 1995. The purpose of this study is to assess HepB vaccination among adolescents 13-17 years.

METHODS

The 2006-2012 NIS-Teen were analyzed. Vaccination trends and coverage by birth cohort among adolescents were evaluated. Multivariable logistic regression and predictive marginal models are used to identify factors independently associated with HepB vaccination.

RESULTS

HepB vaccination coverage increased from 81.3% in 2006 to 92.8% in 2012. Coverage varied by birth cohort and 79-83% received vaccination before 2 years of age for those who were born during 1995 and 1999. Among those who had not received vaccination by 11 years of age, for the 1993-1995 birth cohorts, 9-15% were vaccinated during ages 11-12 years, and 27-37% had been vaccinated through age 16 years. Coverage among adolescents 13-17 years in 2012 ranged by state from 84.4% in West Virginia to 98.7% in Florida (median 93.3%). Characteristics independently associated with a higher likelihood of HepB vaccination included living more than 5 times above poverty level, living in Northeastern or Southern region of the United States, and having a mixed facility as their vaccination provider. Those with a hospital listed as their vaccination provider and those who did not have a well-child visit at age 11-12 years were independently associated with a lower likelihood of HepB vaccination.

CONCLUSIONS

Efforts focused on groups with lower coverage may reduce disparities in coverage and prevent hepatitis B infection. Parents and providers should routinely review adolescent immunizations. Routine reminder/recall, expanded access in health care settings, and standing order programs should be incorporated into routine clinical care of adolescents.

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

BACKGROUND

Human papilloma virus (HPV) vaccination rates in the United States remain low, compared with other recommended adolescent vaccines. We compared factors associated with intention to receive and receipt of HPV and meningococcal vaccines and completion of the HPV vaccine series among U.S. adolescent girls.

METHODS

Secondary analysis of data from the National Immunization Survey-Teen for 2008 through 2012 was performed. Multivariable logistic modeling was used to determine factors associated with intent to receive and receipt of HPV and meningococcal vaccination, completion of the HPV vaccine series among girls who started the series, and receipt of HPV vaccination among girls who received meningococcal vaccination.

FINDINGS

Provider recommendation increased the odds of receipt and intention to receive both HPV and meningococcal vaccines. Provider recommendation was also associated with a three-fold increase in HPV vaccination among girls who received meningococcal vaccination (p<.001), indicating a relationship between provider recommendation and missed vaccine opportunities. However, White girls were 10% more likely to report provider recommendation than Black or Hispanic girls (p<.01), yet did not have higher vaccination rates, implying a role for parental refusal. No factors predicted consistently the completion of the HPV vaccine series among those who started.

CONCLUSION

Improving provider recommendation for co-administration of HPV and meningococcal vaccines would reduce missed opportunities for initiating the HPV vaccine series. However, different interventions may be necessary to improve series completion.

Prophylactic papillomavirus vaccines

Human papillomaviruses (HPV) are the causative agents of cervical cancer, the third most common cancer in women. The development of prophylactic HPV vaccines Gardasil® and Cervarix® targeting the major oncogenic HPV types is now the frontline of cervical cancer prevention. Both vaccines have been proven to be highly effective and safe although there are still open questions about their target population, cross-protection, and long-term efficacy. The main limitation for a worldwide implementation of Gardasil® and Cervarix® is their high cost. To develop more affordable vaccines research groups are concentrated in new formulations with different antigens including capsomeres, the minor capsid protein L2 and DNA. In this article we describe the vaccines' impact on HPV-associated disease, the main open questions about the marketed vaccines, and current efforts for the development of second-generation vaccines.

Adolescent immunization coverage and implementation of new school requirements in Michigan, 2010

OBJECTIVES

We examined the effect of Michigan's new school rules and vaccine coadministration on time to completion of all the school-required vaccine series, the individual adolescent vaccines newly required for sixth grade in 2010, and initiation of the human papillomavirus (HPV) vaccine series, which was recommended but not required for girls.

METHODS

Data were derived from the Michigan Care Improvement Registry, a statewide Immunization Information System. We assessed the immunization status of Michigan children enrolled in sixth grade in 2009 or 2010. We used univariable and multivariable Cox regression models to identify significant associations between each factor and school completeness.

RESULTS

Enrollment in sixth grade in 2010 and coadministration of adolescent vaccines at the first adolescent visit were significantly associated with completion of the vaccines required for Michigan's sixth graders. Children enrolled in sixth grade in 2010 had higher coverage with the newly required adolescent vaccines by age 13 years than did sixth graders in 2009, but there was little difference in the rate of HPV vaccine initiation among girls.

CONCLUSIONS

Education and outreach efforts, particularly regarding the importance and benefits of coadministration of all recommended vaccines in adolescents, should be directed toward health care providers, parents, and adolescents.

Association between maternal preventive care utilization and adolescent vaccination: it's not just about Pap testing

STUDY OBJECTIVE

To examine the association between maternal preventive care utilization and human papillomavirus (HPV) vaccine uptake by their adolescent daughters.

DESIGN

A cross-sectional study using immunization records from administrative claims and the state health department's immunization information system from June 2006 through May 2011.

PARTICIPANTS

Commercially-insured Michigan females aged 13-17 in May 2011 and their mothers. Mothers were identified using relationship information on the insurance contract.

MAIN OUTCOME MEASURES

Using logistic regression, we investigated whether initiating and/or completing the HPV vaccine series were associated with maternal preventive care utilization (Papaniculou testing, mammograms, primary care office visits) independently and using a combined maternal preventive care utilization index.

RESULTS

Among 38,604 mother-daughter pairs, 36% of daughters initiated and 22% completed the HPV vaccine series. Maternal utilization of each recommended service was modestly associated with both daughter's initiation and completion of the HPV vaccine. Effect estimates for receipt of Papaniculou test on vaccine initiation (OR = 1.07, 95% CI = 1.06-1.08) were not any higher than for mammograms (OR = 1.10, 95% CI = 1.08-1.11) or primary care office visits (OR = 1.07, 95% CI = 1.06-1.09). Using a maternal preventive care utilization index, vaccine uptake increased with an increasing number of received services.

CONCLUSIONS

Maternal receipt of recommended preventive care, which may reflect general attitudes toward prevention, is as or more predictive of daughter's vaccination status than cervical cancer screening alone. Engaging women in broad routine preventive care practices may have additional positive effects on adolescent HPV vaccination beyond those achieved through cervical cancer prevention efforts alone.

A population-level assessment of factors associated with uptake of adolescent-targeted vaccines in Michigan

PURPOSE

Increases in adolescent vaccine coverage are needed. The aim of this study was to identify population-level clinical and demographic factors associated with adolescent vaccination.

METHODS

A retrospective analysis of data from the Michigan Care Improvement Registry (MCIR), a statewide immunization registry, was performed for 2006-2010. The sample included 1,252,655 adolescents aged 11-18 years. Vaccine coverage levels were calculated for tetanus-diphtheria-acellular pertussis (Tdap), meningococcal conjugate (MCV4), flu (seasonal influenza), and human papillomavirus, females only (HPV) vaccines. For the subset of adolescents enrolled in Medicaid, claims data were used to obtain information about the type of visits in which vaccines were administered.

RESULTS

As of 2010, statewide coverage levels for Tdap and MCV4 vaccines were 46.0% and 46.5%, respectively whereas only 15% of females had completed the HPV vaccine series. Only one in four female adolescents were up to date for all three of these vaccines. Statewide coverage among adolescents for flu vaccine during the 2009-2010 season was 8%. Age was the most significant predictor of HPV vaccination, whereas health care-associated factors (provider type and childhood immunization history) were the strongest predictors for the other three vaccines. Older adolescents were less likely to have received the flu vaccine but more likely to have receive HPV vaccine doses than younger adolescents. Among Medicaid-enrolled adolescents, most Tdap, MCV, and first-dose HPV vaccines, but only 29% of flu doses, were administered during preventive visits.

CONCLUSIONS

Noted variability in adolescent vaccine coverage by age, vaccine type, and health care-associated factors provides a framework for developing future outreach activities to increase adolescent vaccine use.

Human papillomavirus vaccine introduction--the first five years

The availability of prophylactic human papillomavirus (HPV) vaccines has provided powerful tools for primary prevention of cervical cancer and other HPV-associated diseases. Since 2006, the quadrivalent and bivalent vaccines have each been licensed in over 100 countries. By the beginning of 2012, HPV vaccine had been introduced into national immunization programs in at least 40 countries. Australia, the United Kingdom, the United States, and Canada were among the first countries to introduce HPV vaccination. In Europe, the number of countries having introduced vaccine increased from 3 in 2007 to 22 at the beginning of 2012. While all country programs target young adolescent girls, specific target age groups vary as do catch-up recommendations. Different health care systems and infrastructure have resulted in varied implementation strategies, with some countries delivering vaccine in schools and others through health centers or primary care providers. Within the first 5 years after vaccines became available, few low- or middle-income countries had introduced HPV vaccine. The main reason was budgetary constraints due to the high vaccine cost. Bhutan and Rwanda implemented national immunization after receiving vaccine through donation programs in 2010 and 2011, respectively. The GAVI Alliance decision in 2011 to support HPV vaccination should increase implementation in low-income countries. Evaluation of vaccination programs includes monitoring of coverage, safety, and impact. Vaccine safety monitoring is part of routine activities in many countries. Safety evaluations are important and communication about vaccine safety is critical, as events temporally associated with vaccination can be falsely attributed to vaccination. Anti-vaccination efforts, in part related to concerns about safety, have been mounted in several countries. In the 5 years since HPV vaccines were licensed, there have been successes as well as challenges with vaccine introduction and implementation. Further progress is anticipated in the coming years, especially in low- and middle-income countries where the need for vaccine is greatest. This article forms part of a special supplement entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

Factors associated with receipt of two doses of varicella vaccine among adolescents in the United States

BACKGROUND

In 2006, routine two-dose varicella vaccination for all children was recommended, including a second dose catch-up program for older children and adolescents. Recent studies have shown that a second dose of the vaccine provides incremental protection against varicella disease.

METHODS

This study is a cross-sectional analysis of data collected in the National Immunization Survey-Teen 2010 combined with publicly available data related to state immunization requirements. Bivariate and multivariable logistic regression analyses were performed to examine individual-level and state-level factors associated with receipt of two doses of varicella vaccine among 10,542 adolescents 13 to 17 years of age with no history of varicella.

RESULTS

Overall, 58.1% of adolescents without any history of varicella had received two doses of varicella vaccine. Coverage varied widely among states, ranging from 19.7% in South Dakota to 85.3% in Rhode Island. In the multivariable model, receipt of two doses of varicella vaccine was significantly associated with younger age, higher maternal education level, private health insurance, more frequent health care visits, receipt of both quadrivalent meningococcal conjugate and tetanus, diphtheria, and acellular pertussis vaccinations, and residing in a state with two-dose policies for middle school entry. Vaccines for Children program-eligible adolescents were less likely to have received two doses.

CONCLUSION

Two-dose varicella vaccination coverage remained low among adolescents in 2010, despite the universal recommendation. Programs that are aimed specifically at Vaccines for Children program-eligible adolescents, state policies requiring two doses for middle school entry, and broad education and implementation of the adolescent vaccination platform may help to improve varicella vaccination coverage.

Reasons for not vaccinating adolescents: National Immunization Survey of Teens, 2008-2010

OBJECTIVE

To determine the reasons adolescents are not vaccinated for specific vaccines and how these reasons have changed over time.

METHODS

We analyzed the 2008-2010 National Immunization Survey of Teens examining reasons parents do not have their teens immunized. Parents whose teens were not up to date (Not-UTD) for Tdap/Td and MCV4 were asked the main reason they were not vaccinated. Parents of female teens Not-UTD for human papillomavirus vaccine (HPV) were asked their intent to give HPV, and those unlikely to get HPV were asked the main reason why not.

RESULTS

The most frequent reasons for not vaccinating were the same for Tdap/Td and MCV4, including "Not recommended" and "Not needed or not necessary." For HPV, the most frequent reasons included those for the other vaccines as well as 4 others, including "Not sexually active" and "Safety concerns/Side effects." "Safety concerns/Side effects" increased from 4.5% in 2008 to 7.7% in 2009 to 16.4% in 2010 and, in 2010, approaching the most common reason "Not Needed or Not Necessary" at 17.4% (95% CI: 15.7-19.1). Although parents report that health care professionals increasingly recommend all vaccines, including HPV, the intent to not vaccinate for HPV increased from 39.8% in 2008 to 43.9% in 2010 (OR for trend 1.08, 95% CI: 1.04-1.13).

CONCLUSIONS

Despite doctors increasingly recommending adolescent vaccines, parents increasingly intend not to vaccinate female teens with HPV. The concern about safety of HPV grew with each year. Addressing specific and growing parental concerns about HPV will require different considerations than those for the other vaccines.

Improving immunization delivery using an electronic health record: the ImmProve project

OBJECTIVE

Though an essential pediatric preventive service, immunizations are challenging to deliver reliably. Our objective was to measure the impact on pediatric immunization rates of providing clinicians with electronic health record-derived immunization prompting.

METHODS

Operating in a large, urban, hospital-based pediatric primary care clinic, we evaluated 2 interventions to improve immunization delivery to children ages 2, 6, and 13 years: point-of-care, patient-specific electronic clinical decision support (CDS) when children overdue for immunizations presented for care, and provider-specific bulletins listing children overdue for immunizations.

RESULTS

Overall, the proportion of children up to date for a composite of recommended immunizations at ages 2, 6, and 13 years was not different in the intervention (CDS active) and historical control (CDS not active) periods; historical immunization rates were high. The proportion of children receiving 2 doses of hepatitis A immunization before their second birthday was significantly improved during the intervention period. Human papillomavirus (HPV) immunization delivery was low during both control and intervention periods and was unchanged for 13-year-olds. For 14-year-olds, however, 4 of the 5 highest quarterly rates of complete HPV immunization occurred in the final year of the intervention. Provider-specific bulletins listing children overdue for immunizations increased the likelihood of identified children receiving catch-up hepatitis A immunizations (hazard ratio 1.32; 95% confidence interval 1.12-1.56); results for HPV and the composite of recommended immunizations were of a similar magnitude but not statistically significant.

CONCLUSIONS

In our patient population, with high baseline uptake of recommended immunizations, electronic health record-derived immunization prompting had a limited effect on immunization delivery. Benefit was more clearly demonstrated for newer immunizations with lower baseline uptake.

Provider factors associated with disparities in human papillomavirus vaccination among low-income 9- to 17-year-old girls

BACKGROUND

Many women who develop cervical cancer are eligible for or are participants of Medicaid. Providing human papillomavirus (HPV) vaccination to girls enrolled in Medicaid may reduce cervical cancer disparities in low-income and minority women. This study evaluated provider characteristics associated with HPV vaccination among 9- to 17-year-old female Medicaid enrollees.

METHODS

A random sample of 800 providers from the Florida Medicaid Master Provider File was mailed a survey in October 2009 that evaluated demographic and practice characteristics, HPV information and knowledge, barriers to HPV vaccination, vaccine practices, and vaccine recommendation practices. To measure HPV vaccination, Medicaid claims data were used to calculate the proportion of eligible patients who received at least 1 dose of the vaccine from participating providers within the study period. Provider factors associated with vaccination at the bivariate level were evaluated in a multiple linear regression model.

RESULTS

The response rate was 68.3% (N = 485). After excluding ineligible respondents, the current analysis included 433 providers. HPV vaccination prevalence ranged from 0% to 61.9% (M = 20.4, standard deviation = 14.5). HPV vaccination rates were higher among providers who were pediatricians, had a private practice, practiced in a single specialty setting, were providers under the Vaccines for Children program, saw primarily non-Hispanic white patients, used 2 or more strategies for vaccine series completion, and did not refer out for HPV vaccination.

CONCLUSIONS

Despite financial coverage for Medicaid-eligible girls, HPV vaccination rates are low. Study findings can be used to target health services interventions to providers least likely to administer HPV vaccine to female Medicaid enrollees.

Medicaid reimbursement and the uptake of adolescent vaccines

BACKGROUND

In light of low adolescent vaccination rates, state-level policies that could improve vaccine coverage should be evaluated. Approximately 1/3 of adolescents are eligible, primarily through Medicaid enrollment, to receive vaccines from state-administered Vaccines for Children (VFC) programs. We investigated whether Medicaid reimbursement, the scope of implementation of VFC programs (i.e. limited or universal purchase), and/or presence of school-based vaccine mandates were associated with adolescent vaccination levels.

METHODS

We performed a cross-sectional analysis of state-level associations between these policies and 2009 National Immunization Survey-TEEN vaccination rates for tetanus-containing, meningococcal conjugate (MCV4), and among females only, human papillomavirus (HPV) vaccines.

RESULTS

Medicaid reimbursement was not associated with vaccine coverage rates after adjusting for presence of vaccine-related school mandates, type of VFC program, proportion of adolescents attending preventive care visits, and state-specific distribution of insurance coverage. Participation in a more expansive VFC program (universal or universal-select) was significantly associated with HPV vaccine coverage, but not tetanus-containing vaccine or MCV4, among states that had mandates for any vaccines.

CONCLUSIONS

Our results suggest that, contrary to what has been shown for childhood vaccines, raising Medicaid reimbursement rates may not improve adolescent vaccine utilization. Instead, other policy changes may be more effective, such as expansion of VFC programs into universal purchase programs, further implementation of school-based vaccine mandates and efforts to raise preventive care visits among adolescents.