Authority of Pharmacists to Administer Human Papillomavirus Vaccine: Alignment of State Laws With Age-Level Recommendations

Impacts of the US CDC recommendation on human papillomavirus vaccine uptake, 2010-2015

Objectives

As one type of vaccine policy, the effectiveness and spillover effects of the US CDC vaccine recommendations are inadequately evaluated. This study aims to fully evaluate its impacts on male adults, in addition to children, using better data.

Design

A before-after study design to examine the CDC's 2011 HPV vaccine recommendation for men aged 11-21.

Data analysis

Individual-level data included the 2010-2015 US National Health Interview Survey full sample of 7,000 male children aged 11-18, younger adults aged 19-21 and 22-25, and older adults aged 26-60. Pooled cross-sectional surveys contained individual-level vaccination, socioeconomic, and demographic information. Outcome variable is an individual HPV vaccination status, measured as individual probability of HPV vaccination. Dummy regressions were estimated by a Linear Probability Model (LPM) with fixed effects for target and non-target age groups.

Results

The policy was significantly associated with a 14.8% (p < 0.001) increased individual likelihood of HPV vaccination for men aged 11-21. It was also associated with a modest spillover effect, a 5.6% (p < 0.001) increased individual likelihood for men aged 22-25 and marginally for men aged 26-60. African American men and men with poor health were 2.7 and 15.4% less likely to uptake HPV vaccines than white men and men with good or fair health, respectively.

Conclusion

This study complements the existing policy evaluation literature on HPV vaccine recommendation among male children by including adults and using better data. Findings offer comprehensive evidence of the effectiveness and spillover effects of this recommendation type of federal-level policy, provide policy lessons for other vaccines, and identify vulnerable subpopulations as targets for future policies.

Design, delivery and effectiveness of health practitioner regulation systems: an integrative review

BACKGROUND

Health practitioner regulation (HPR) systems are increasingly recognized as playing an important role in supporting health workforce availability, accessibility, quality, and sustainability, while promoting patient safety. This review aimed to identify evidence on the design, delivery and effectiveness of HPR to inform policy decisions.

METHODS

We conducted an integrative analysis of literature published between 2010 and 2021. Fourteen databases were systematically searched, with data extracted and synthesized based on a modified Donabedian framework.

FINDINGS

This large-scale review synthesized evidence from a range of academic (n = 410) and grey literature (n = 426) relevant to HPR. We identified key themes and findings for a series of HPR topics organized according to our structures-processes-outcomes conceptual framework. Governance reforms in HPR are shifting towards multi-profession regulators, enhanced accountability, and risk-based approaches; however, comparisons between HPR models were complicated by a lack of a standardized HPR typology. HPR can support government workforce strategies, despite persisting challenges in cross-border recognition of qualifications and portability of registration. Scope of practice reform adapted to modern health systems can improve access and quality. Alternatives to statutory registration for lower-risk health occupations can improve services and protect the public, while standardized evaluation frameworks can aid regulatory strengthening. Knowledge gaps remain around the outcomes and effectiveness of HPR processes, including continuing professional development models, national licensing examinations, accreditation of health practitioner education programs, mandatory reporting obligations, remediation programs, and statutory registration of traditional and complementary medicine practitioners.

CONCLUSION

We identified key themes, issues, and evidence gaps valuable for governments, regulators, and health system leaders. We also identified evidence base limitations that warrant caution when interpreting and generalizing the results across jurisdictions and professions. Themes and findings reflect interests and concerns in high-income Anglophone countries where most literature originated. Most studies were descriptive, resulting in a low certainty of evidence. To inform regulatory design and reform, research funders and governments should prioritize evidence on regulatory outcomes, including innovative approaches we identified in our review. Additionally, a systematic approach is needed to track and evaluate the impact of regulatory interventions and innovations on achieving health workforce and health systems goals.

The interface between U.S. primary care clinics and pharmacies for HPV vaccination delivery: A scoping literature review

Completion of the Human Papilloma Virus (HPV) vaccine series remains low. Partnerships between primary care (PC) clinics and local pharmacies could boost vaccination rates. We conducted a scoping literature review to address what is known and what gaps exist on the interface between U.S. primary care clinics and pharmacies for HPV vaccination. We searched Ovid MEDLINE ALL file and Cumulative Index to Allied Health Literature for articles published between 1/1/2010 and 12/31/2020. Search subjects included: 1) Pharmacy HPV Vaccination, 2) Pharmacy/PC Collaboration, and 3) Pharmacy/PC Collaboration vaccination. We developed an abstraction form to collect information on research methods, settings, strengths, weaknesses and findings. We screened 407 articles for inclusion; 17 met inclusion criteria: 13 (76.5%) reported on observational/descriptive studies; 4 articles (23.5%) reported on intervention studies, none of which were conducted in rural areas. Observational studies focused on willingness to be vaccinated for HPV and facilitators and barriers for vaccination, especially at pharmacies. Many studies concluded that knowledge about and comfort with HPV vaccine administration were needed for all vaccination stakeholders (clinicians, pharmacists, parents, and patients). Intervention studies were small with weak study designs, many of which revealed that pharmacists were not successful in integrating services into broader primary care systems. Challenges included getting physicians to sign standing order protocols, poor service delivery due to engagement barriers, and low parental demand for pharmacists to administer the vaccine. In conclusion, larger more discerning studies are needed to fully understand the potential of primary care and pharmacy interactions for HPV vaccination.

National and State-Specific Estimates of Settings of Receiving Human Papillomavirus Vaccination Among Adolescents in the United States

PURPOSE

Human papillomavirus (HPV) vaccination in the United States has been recommended for girls since 2006 and for boys since 2011. However, settings of receiving HPV vaccination have not been assessed. The purpose of this study is to assess settings of receiving HPV vaccination among adolescents in order to understand what strategies are needed to improve vaccination uptake.

METHODS

Data from the 2018 National Immunization Survey-Teen (NIS-Teen) were analyzed to assess place of HPV vaccination overall, and by gender, quarter, and other selected variables among adolescents in the United States. The 2016-2018 NIS-Teen data were combined to assess state-specific place of HPV vaccination.

RESULTS

Among vaccinated adolescents aged 13-17 years, a doctor's office was the most common place where HPV vaccination was received (79.2%), followed by clinics, health centers, or other medical facilities (13.5%), health department (4.1%), hospital or emergency room (2.3%), schools (.5%), and pharmacies or stores (.4%). Overall, 99.1% of adolescents aged 13-17 years received HPV vaccination at medical settings and only .9% at nonmedical settings. Reported vaccination in nonmedical settings by state ranged from less than .1% in Delaware, Florida, and New Hampshire to 4.1% in North Dakota, with a median of 1.0%.

CONCLUSIONS

Doctor's offices were the most common medical setting for adolescents to receive HPV vaccination. Less than 1% of adolescents received vaccination at nonmedical settings. Continuing work with medical and nonmedical settings to identify and implement appropriate strategies are needed to improve HPV vaccination coverage among adolescents.

Expanding access to HPV vaccination in South Carolina through community pharmacies: A geospatial analysis

OBJECTIVE

Human papillomavirus (HPV)-associated cancer rates are higher in rural areas. Despite the preventive benefits of HPV vaccination, uptake is lower among rural populations. Community-based pharmacies with a strong presence in rural communities may be ideal for improving HPV vaccination access. Our objective was to determine whether spatial access to pharmacies among adolescents and young adults in South Carolina varied by rurality and geographic access to primary care providers.

METHODS

Geographic information systems methods were used to evaluate spatial access to community-based pharmacies among persons aged 10-24 years in South Carolina census tracts (CTs). CTs were categorized as metropolitan, micropolitan, or small-town and isolated rural CTs using rural-urban commuting area codes and as health provider shortage areas (HPSAs) or not. Descriptive and spatial statistics were calculated to compare access across CT groupings and to evaluate geospatial clustering.

RESULTS

Areas of highest access clustered among the metropolitan CTs. Whereas spatial access was higher in metropolitan than micropolitan CTs, there was no difference in spatial access between metropolitan and small-town and rural CTs. In general, HPSA-designated areas had lower spatial access to pharmacies than non-HPSA-designated areas. However, in micropolitan areas, there was no difference in spatial access to pharmacies based on HPSA designation.

CONCLUSION

Spatial access to pharmacies among small town and rural areas was comparable to urban areas as was HPSA-designated micropolitan areas and non-HPSA micropolitan areas. This suggests that pharmacies are equally accessible to both urban and rural populations in South Carolina, but additional research is needed to identify effective strategies to promote the uptake of and the availability of HPV vaccination in pharmacies (e.g., insurance coverage) and to ensure patients are educated on the benefits of HPV vaccinations and its availability in nonprimary care settings.

Exploring Opportunities to Leverage Pharmacists in Rural Areas to Promote Administration of Human Papillomavirus Vaccine

Rural pharmacists have been identified as potential partners, along with health care providers, schools, and public health agencies, in administering and promoting the human papillomavirus (HPV) vaccine. We sought to understand the role of pharmacists in this work. We interviewed 11 pharmacists working at independently owned pharmacies in Iowa to explore their perspectives on HPV vaccine administration and promotion. Most pharmacists agreed that HPV vaccination was within their professional scope. They identified factors that facilitate vaccine administration (eg, accessibility of pharmacies). They also reported personal barriers (eg, lack of information, concerns about safety) and organizational barriers (eg, time and staff capacity). Future work should focus on alleviating barriers and building on strengths to improve vaccination rates and ultimately prevent HPV-related cancers.

State statutes and regulations related to human papillomavirus vaccination

A cross-sectional analysis of human papillomavirus (HPV) vaccine statutes and regulations from states and the District of Columbia in the United States (U.S.) was conducted from September–November 2018 to advance analyses of policy impact on HPV vaccination uptake. A search was conducted using WestlawNext, a legal research database. Statutes and regulations relevant to the study were analyzed and coded based on their legal attributes into ten broad coding questions and several sub-questions. Of the 212 laws identified by the initial search string, 93 (43.9%) reference HPV vaccination in statute or regulation. An additional three laws were added following subsequent review. There was a total of 52 statutes and 44 regulations from 34 states and the District of Columbia. Most laws were related to developing and distributing HPV vaccination materials for parents, and mechanisms to fund and reimburse for the vaccination. This study can be used by policymakers in jurisdictions that are considering establishing HPV vaccination promotion interventions in state law and highlighting the limited statutory and regulatory efforts that have been implemented to promote HPV vaccination. Importantly, this study can also be used to conduct evaluations of the efficacy of statutory and regulatory strategies in increasing HPV vaccination rates.

Policy opportunities to increase HPV vaccination in rural communities

Rural communities experience health disparities, including elevated incidence and mortality of human papillomavirus (HPV)-associated cancers and correspondingly low HPV vaccination rates. There are numerous policy strategies that are available at multiple levels - patient, provider, clinic, community, state, and national - to address geographic, clinical, and communication barriers to HPV vaccination across rural America. Examples include policy development, implementation, and evaluation of healthcare provider and clinic-based assessment and education initiatives; school entry requirements; school, pharmacy, and community-based vaccination programs; evidence-based, community-driven communication efforts; and increased interventional research in rural communities. Strategically implemented policy measures will contribute to reduction in the incidence and mortality from HPV-related cancers through increased access to HPV vaccination in our rural communities.