Factors Associated with HPV Vaccine Refusal among Young Adult Women after Ten Years of Vaccine Implementation

Exploration of individual socioeconomic and health-related characteristics associated with human papillomavirus vaccination initiation and vaccination series completion among adult females: A comprehensive systematic evidence review with meta-analysis

INTRODUCTION

Human papillomavirus (HPV) vaccination rates among females are lower than the World Health Organization target and vaccination rates specifically among adult females are even much lower.

METHODS

We systematically evaluated individual socioeconomic and health-related characteristics associated with HPV vaccination initiation and vaccination series completion among adult females (PROSPERO: CRD42023445721). We performed a literature search on December 14, 2022, and supplemented the search on August 1, 2023. We pooled appropriate multivariable-adjusted results using an inverse variance random-effects model and expressed the results as odds ratios with associated 95 % confidence intervals. A point pooled significantly increased/decreased odds of 30-69 % was regarded to be strongly associated, and ≥ 70 % was very strongly associated.

RESULTS

We included 63 cross-sectional studies. There were strongly increased odds of vaccination initiation among White women compared with Black or Asian women, and those with higher education, health insurance, a history of sexually transmitted infection (STI), receipt of influenza vaccination in the preceding year, not married/cohabiting, not smoking, using contraception, and having visited a healthcare provider in the preceding year. We observed very strongly increased odds of vaccination initiation among those younger and having been born in the country of study. Similarly, there were strongly increased odds of completing the vaccination series for the same variables as initiating vaccination, except for higher education, prior STI, smoking and contraception use. Additional variables associated with strongly increased odds of vaccination series completion not seen in initiation were higher annual household income, being lesbian/bisexual, and having a primary care physician. We observed very strongly increased odds of vaccination series completion similar to vaccination initiation but including for White compared with Black women, higher education, and prior cervical cancer screening.

CONCLUSIONS

These individual characteristics may be the key to identifying women at increased risk of not being vaccinated against HPV and could inform targeted messaging to drive HPV vaccination.

Risk perception and trust in the relationship between knowledge and HPV vaccine hesitancy among female university students in China: a cross-sectional study

BACKGROUND

Cervical cancer poses a heavy health burden in China, with the second highest incidence and mortality rate among female tumors, yet human papillomavirus (HPV) vaccination rate among female university students remain remains low. This study conducted a cross-sectional survey to assess the degree of HPV vaccine hesitancy among female university students and to explore the potential association between knowledge, risk perception, trust, and HPV vaccine hesitancy.

METHODS

A total of 1,438 female university students from four Chinese cities were recruited through stratified, multistage, cluster sampling method. The mediation model was constructed using the Bootstrap method, introducing trust and risk perception as mediating variables to examine the effect of knowledge on HPV vaccine hesitancy.

RESULTS

The study found that 8.9% (95%CI:7.4%∼10.4%) of the female university students exhibited HPV vaccine hesitancy. Pearson's correlation analysis revealed a negative association between vaccine hesitancy and knowledge, risk perception, and trust. The mediation model showed that knowledge had significant indirect effects on HPV vaccine hesitancy through trust (indirect effect: -0.224, 95% CI: -0.293 ∼ -0.167) and risk perception (indirect effect: -0.013, 95% CI: -0.033 ∼ -0.002).

CONCLUSION

HPV vaccine hesitancy among female university students has mitigated, but still needs to be addressed. In addition, trust and risk perception are mediators mediating the relationship between knowledge with HPV vaccine hesitancy. Therefore, there is a need to strengthen public health education to improve knowledge, with a particular focus on providing information about trust and risk perception to reduce HPV vaccine hesitancy.

Factors influencing human papillomavirus vaccination uptake in European women and adolescents: A systematic review and meta-analysis

OBJECTIVE

Cervical Cancer (CC) lingers as a severe public health issue due to low vaccination coverage and poor screening addressability. Hence, this systematic review explored psychological factors influencing the Human Papilloma Virus (HPV) vaccination uptake in European women.

METHODS

As of September 2022, PubMed, EMBASE, Scopus, and Web of Science were systematically searched to include English studies assessing diverse factors influencing vaccination uptake in European women. Only studies comparing vaccinated with unvaccinated women were included. Quality assessment, publication attrition assessment, and sensitivity analyses were performed.

RESULTS

Eighteen studies were included, totaling a population of 18,611 participants. Results indicated that knowledge about HPV infection could positively influence vaccination rates with an Odds Ratio (OR) of 1.82 and a confidence interval (CI) between 1.27 and 2.61, showing statistical significance at a Z value of 3.24 with a p-value of 0.001. Neither knowledge about HPV vaccination (OR = 1.39, CI: 0.73-2.65, Z = 1.01, p = 0.31) nor knowledge about CC screening (OR = 1.05, CI: 0.55-1.98, Z = 0,14, p = 0.89) seem to affect vaccination rates. Regardless, intention to undertake CC screening (CCS) showed an OR = 1.68 in favor of the group intending to perform it, with a CI between 1.37 and 2.07, showing statistical significance at a Z = 4.94 and p = 0.00001. Other aspects affecting vaccination uptake were fear of side effects, insufficient information, and belief that chances of being infected are low.

CONCLUSIONS

Results demonstrated that diverse aspects could affect the vaccination intent, while personalized interventions focusing on population and country characteristics need to be assembled to mitigate vaccination coverage.

Knowledge about cervical cancer risk factors and human papilloma virus vaccine among Saudi women of childbearing age: A community-based cross-sectional study from Saudi Arabia

Objective

To examine the knowledge of cervical cancer risk factors and human papilloma virus (HPV) vaccine among Saudi women of childbearing age.

Methods

An anonymous, survey-based, cross-sectional study was conducted from November 2022 to March 2023.

Results

Overall, 422 participants were included in the current study. Most participants were within the age group of 15-25 years old (42.9%), single (47.9%), and educated with a bachelor's degree (70%). Out of a total of 14 points, the average knowledge score for all participants was 7.3 ± 2.31 (range: 2-14). More than three-quarters of the surveyed participants correctly identified the following risk factors for cervical cancer: multiple sexual partners (78.2%), having weakened immunity (82.7%), infection with HPV (82.9%), and positive family history of cervical cancer (88.9%). Concerning HPV vaccine, 153 (36.3%) participants heard about HPV vaccine and only 20 (4.4%) of them were vaccinated. Only 128 (30.3%) participants stated correctly that 9-13 years old is the best age to start HPV vaccine, whereas 51 (12.1%) participants correctly stated the number of HPV vaccine doses to be three over six months. Overall, 167 (39.6%) participants declined to receive the HPV vaccine. The three most frequently reported reasons included not hearing about HPV vaccine (35.3%), fear from HPV-related side effects (30.5%), and apprehension from HPV vaccine injection (16.2%). Among several socio-demographic characteristics, occupation was statistically significantly associated with knowledge score (p < 0.001), with students in health specialties tended to have the highest knowledge score compared with others.

Conclusion

Most participants displayed good knowledge about cervical cancer risk factors, but not about HPV vaccine. Very alarmingly, less than 5% of the participants received HPV vaccine and close to 40% of them declined to receive the HPV vaccine. Mechanisms to increase public awareness about HPV vaccine and its acceptance by women are recommended.

Evaluation of the Knowledge and Attitude of Adolescents Regarding the HPV Infection, HPV Vaccination and Cervical Cancer in a Region from the Northwest of Romania

Purpose

In Romania, after reaching the age of 18, teenage girls can make an informed decision about vaccination. The aim of the study was to evaluate both knowledge and attitudes related to HPV infection, HPV vaccination, cervical cancer, as well as intentions, reservations, reasons that could influence the decision related to vaccination.

Patients and Methods

We applied an anonymized questionnaire to 690 teenage girls in the 18-19 age group, recruited from 15 high schools in Bihor County. Based on the answers to the question corresponding to item 14 of subscale 3, 2 groups were identified: the group with a hesitant behavior called the non-vaccine group (GNV) and the group with a positive behavior called the pro-vaccine group (GPV). The statistical analysis was processed by using IBM-SPSS 22.

Results

The analysis revealed significant differences between the groups in terms of the level of knowledge and attitudes related to vaccination, the adolescent girls in the GPV being more aware of the role and importance of HPV vaccination and more open to the idea of vaccination. For the GNV, the behavior can be explained by the fact that even if they have heard about the HPV infection being transmitted through unprotected sex and they think that vaccination in general is necessary to prevent certain diseases, they do not know if HPV vaccination would be effective in protecting them in the future. Adolescents from GPV declare they would accept HPV vaccination if it would be offered to them or they are already vaccinated.

Conclusion

Alongside interventions targeting parents and health-care professionals, it is necessary to improve the level of knowledge of adolescents about HPV infection, HPV vaccination and cervical cancer, by organizing information campaigns in schools, campaigns in which professionals in the field should be involved, but also by implementing education programs addressed to them.

Psychological mechanisms and interventions directed at vaccination attitudes

Attitudes about vaccination impact not only the individual but also society. Therefore, understanding the underlying psychological processes of those who disagree with vaccination is critical for creating compassion through understanding and change through promoting autonomy. The current review aimed to fill a gap in the literature, outlining the state of the recent research on vaccination attitudes, specifically on the underlying mechanisms driving anti-vaccination movements and individuals' thoughts and behaviors. In addition, we aimed to evaluate current research on the effectiveness of interventions targeting these mechanisms. Overall, results indicated that those declining vaccines had beliefs related to distrust in the scientific community and pharmaceutical companies and moral preferences for purity and liberty. In addition, our review identified the potential for utilizing motivational interviewing techniques as an intervention. This literature review provides a platform for further research and enhances the current understanding of vaccination attitudes.

Models of determinants of COVID-19 vaccine hesitancy in non-pregnant and pregnant population: Review of current literature"

Vaccination has proven to be the most effective tool in controlling the COVID-19 pandemic. While pregnant individuals are considered to be a high-risk population and are more likely to experience adverse effects from COVID-19, vaccination rates among pregnant individuals are significantly lower than in the general population. The Health Belief Model (HBM), Theory of Planned Behavior (TPB), 3C model, 5C model, and 5A model have been used to assess vaccination hesitancy behaviors. In this paper, we review the use of each of these models to address vaccine hesitancy, with a focus on the pregnant population and the COVID-19 vaccine. The HBM, TPB, 3C model, and 5C model have demonstrated great versatility in their ability to evaluate, explain, and modify vaccine hesitancy and behavior. Up to date, the HBM and 3C models appear to be the most effective models to study and address vaccination hesitancy within the pregnant persons.

Acceptability of HPV Vaccination in Young Students by Exploring Health Belief Model and Health Literacy

Evidence on the human papillomavirus (HPV) vaccine shows that it is effective in reducing the burden of HPV-related diseases. For more than 15 years the HPV vaccine has been offered free of charge in Italy to girls from the age of 12. Over time, the free offer of the HPV vaccine has also been extended to boys and to young adults at risk of developing HPV lesions. Despite the HPV vaccine’s effectiveness and availability, vaccination coverage is low in Italy, with a reported value of 46.5% in 2020. Furthermore, in the southern administrative regions, vaccination coverage is even lower than national values, with 25.9% coverage in Sicily. A cross-sectional study was conducted among university and high school students in the Palermo area (Sicily, Italy) in order to identify the determinants of HPV vaccination adherence by using a questionnaire that investigated factors of HPV vaccine practice. The study explored the behavioral attitude by using the Health Belief Model (HBM), and also used the SILS test and the METER test to investigate the level of health literacy (HL). Overall, 3,073 students were enrolled, and less than a third reported they had completed the vaccination schedule (n = 925, 30.1%). Multivariable analysis showed that the factors directly associated with the adherence to HPV vaccination were female sex (OR = 4.43, p < 0.001), high HBM total score (OR = 4.23, p < 0.001), good HL level (OR = 1.26, p = 0.047), parents (OR = 1.78, p = 0.004), general practitioner (OR = 1.88, p = 0.001), and educational material provided by public vaccination services (OR = 1.97, p = 0.001) as HPV vaccine information sources. Further health-promotion programs focused on improving HL and perception of the HPV vaccine’s benefits should be implemented in order to achieve the desirable 95% vaccination coverage.

Factors Influencing the Decision to Vaccinate against HPV amongst a Population of Female Health Students

Background: In Switzerland, HPV vaccination has been recommended since 2007 for all adolescent girls aged between 11 and 14 years. More than 10 years after the introduction of this recommendation, immunization coverage targets have not been met. Very few studies at a national level describe the reasons for the reluctance of some young women to become vaccinated. The aim of this study is to describe the socio-demographic characteristics of a population of vaccinated and unvaccinated female health students and then to compare the different factors that may have influenced their vaccine choice. Method: Female health students in the French-speaking part of Switzerland, aged between 18 and 31, were invited to participate in the study. A total of 234 female students completed a questionnaire that included questions about their socio-demographic data, sexual behavior and vaccination status. Results: 69% of the participants received at least one dose of the vaccine. Women who had not yet had sex were less likely to be vaccinated than sexually active women (ORa: 0.1, 0.0–0.4, 95% CI), the same as those who did not express an opinion about the importance of vaccination (ORa: 0.1: 0.0–0.6, 95% CI). The main reasons given for refusing vaccination were fear of side effects (26.0%), parental opposition (24.6%) and reluctance of the attending physician (13.6%). Conclusions: The main results of this study highlight a good rate of vaccine coverage in the sample population. Reasons for nonvaccination demonstrate the need to provide information on the vaccine to the target audience, as well as to parents and health professionals.

Effect of educational intervention for compliance of school adolescents with the human papillomavirus vaccine

ABSTRACT Objective: to assess the effects of “Piss off, HPV!”, an educational intervention to increase adolescents’ knowledge, attitude and compliance with human papillomavirus vaccination. Method: a randomized clinical trial by cluster, carried out in six schools in two municipalities in Ceará, with 238 girls. The control group (n = 120) received routine instructions, and the intervention group (n = 118), printed message cards about the quadrivalent HPV vaccine. A pre- and post-intervention knowledge, attitude and practice survey was applied to both groups. The McNemar test, to analyze knowledge, attitude and pre- and post-intervention practice, the chi-square test, to compare compliance in relation to knowledge and attitude, and a logistic regression model, to assess vaccine compliance, were carried out. A significance level of 5% was adopted. Results: pre-intervention, knowledge was inadequate and attitude was adequate in both groups. Post-intervention, adequate knowledge and practices became greater in the intervention group. Adequate post-intervention knowledge and attitude, in addition to being 12 years of age or older, increase the chance for vaccination, explaining 70% of the practice. Conclusion: the educational intervention was effective for adolescents’ knowledge and compliance with the quadrivalent HPV vaccine. UTN: U1111-1254-5546; ReBEC: RBR-107hzdqt.

Efeito de intervenção educativa para adesão de adolescentes escolares à vacina contra o papilomavírus humano

RESUMO Objetivo: avaliar os efeitos da intervenção educativa “Sai fora, HPV!” para aumento do conhecimento, atitude e adesão de adolescentes à vacinação contra o papilomavírus humano. Método: ensaio clínico randomizado por conglomerado, realizado em seis escolas de dois municípios cearenses, com 238 meninas. O grupo controle (n = 120) recebeu orientações rotineiras, e o grupo intervenção (n = 118), cartões-mensagem impressos sobre a vacina HPV quadrivalente. Aplicou-se inquérito conhecimento, atitude e prática pré- e pós-intervenção em ambos os grupos. Realizaram-se Testes de McNemar, para analisar conhecimento, atitude e prática pré- e pós-intervenção, do Qui-Quadrado, para comparar adesão em relação ao conhecimento e atitude, e modelo de regressão logística, para avaliação da adesão à vacina. Adotou-se nível de significância 5%. Resultados: pré-intervenção, conhecimento era inadequado e atitude adequada em ambos os grupos. Pós-intervenção, conhecimento e práticas adequados se tornaram maior no grupo intervenção. Conhecimento e atitude adequados pós-intervenção, além da idade maior ou igual a 12, aumentam a chance para vacinação, explicando 70% da prática. Conclusão a intervenção educativa foi efetiva para conhecimento e adesão da vacina HPV quadrivalente pelas adolescentes. UTN: U1111-1254-5546; ReBEC: RBR-107hzdqt.

What do Young People Think About HPV and HPV Vaccination? The Role of Health Education Interventions and Health Professionals

Background

Human papillomavirus (HPV) is the most common sexually transmitted infection worldwide and its highest prevalence is observed in adolescents and young adults. This review examined studies that explore awareness about HPV among adolescents and young adults, as well as their attitudes and willingness towards the HPV vaccine. Besides, the impact of health professionals and health education interventions on HPV awareness and attitudes towards HPV vaccine is identified.

Objective

The aim of this review is, firstly, to systematically identify the studies that explore awareness about HPV among adolescents and young adults, as well as their attitudes and willingness towards the HPV vaccine. Secondly, the aim is to identify the impact of health professionals and health education interventions on HPV awareness and attitudes towards HPV vaccine among the same group.

Methods

The systematic review was conducted in the international databases PubMed, Scopus, and Google Scholar, between 2016-2019.

Results

The review revealed low to moderate levels of awareness and knowledge regarding HPV (10 studies), while a more favorable attitude towards the HPV vaccine (3 studies). The role of health professionals was ineffective (4 studies), while studies focused on the impact of health education interventions showed a positive impact on knowledge and awareness of HPV (4 studies).

Conclusion

Continuous training of health personnel is necessary and new studies are needed to identify barriers to adolescents not being vaccinated.

HPV vaccine acceptance and hesitancy - lessons learned during 8 years of regional HPV prophylaxis program in Wroclaw, Poland

In 2019, the WHO has announced that it will intensify efforts to eliminate cervical cancer worldwide by increasing coverage of the HPV (Human Papillomavirus) vaccine. Finding reasons for low HPV vaccine coverage and looking for solutions to address the problem should be the priorities for public health. The municipality of Wroclaw (Poland) attempted to meet the challenge earlier by introducing a Prophylaxis Program against HPV in 2010. The core of the program are educational meetings at schools and free vaccinations offered at GP offices. After five successful years (vaccination coverage >80% fully vaccinated), vaccination uptake declined to 61.8%. A survey was carried out in 2015 to verify the experience concerning the Program among 1360 volunteers. Three groups were surveyed: parents (n = 509), teenage girls (n = 748) and nurses who performed the vaccinations (n = 103). What is noteworthy in the results there are factors that positively influenced vaccine acceptance: education offered within the program; the fact that the vaccinations are offered free of charge and the experience of earlier vaccination. It turned out that fear of side effects and the lack of trust in vaccination effectiveness were the most common reasons for vaccination refusal. Most nurses underestimated their role in building vaccination acceptance and 7.1% of them felt uncertain administrating the vaccination. Conslusions: the vaccination delivery strategy should be reconsidered; interventions to raise the nurses' awareness of their role in building vaccine acceptance should be improved; the 13th year of life is the best moment to offer a vaccination.

Understanding the perceptions of Chinese women of the commercially available domestic and imported HPV vaccine: A semantic network analysis

BACKGROUND

A domestic human papillomavirus (HPV) vaccine, Cecolin, that protects against HPV strains 16 and 18 was introduced to the Chinese market at a relatively low price in May 2020.This study has explored Chinese women's perceptions of both domestic and imported HPV vaccines, which differ in price and valency.

METHODS

Sentiment analysis and semantic network analyses were performed based on a sample of 45,729 domestic HPV vaccine-related posts from females on the Sina Weibo between April 17 and May 2, 2020. The geographic distribution was also analyzed based on the users' locations, which were retrieved from the database.

RESULTS

Most of the posts were positive and neutral (85%), although 15% were negative (e.g., expressions of anger, sadness, fear and disgust). Semantic analyses of the negative posts revealed that Chinese women generally had positive attitudes towards the HPV vaccine and were willing to be vaccinated. However, obvious geographical variations were identified. Women who lived in economically developed areas expressed a stronger desire to obtain imported quadrivalent or nonavalent vaccines due to concerns regarding effectiveness and quality. The women expressed disgust and anger mainly regarding difficulties in making an appointment, age restrictions for the nonavalent vaccine and gender restrictions. However, the population targeted by the domestic vaccine, namely women who lived in economically undeveloped areas and had relatively low incomes, had a low awareness of the HPV vaccine.

CONCLUSION

Government should provide programs, which educate females that bivalent HPV vaccine can offer protection against the majority of high-risk HPV types. Increasing awareness of the domestic vaccine among the population in economically undeveloped areas and provision of free domestic bivalent HPV vaccination/screening for low-income high-risk women would help to prevent cervical carcinoma. This issue also depends on rebuilding trust and repairing damage to the relationship between government/domestic vaccine manufacturers and the public.

Burden and Prevention of HPV. Knowledge, Practices and Attitude Assessment Among Pre-Adolescents and their Parents in Italy

Despite infections due to HPV nowadays represent the most common sexually transmitted diseases worldwide with recognized effective and safe preventive strategies, knowledge, attitudes; however, awareness on HPV is considerably low. The present study has two main objectives: 1. To conduct a literature review to analyze the evolution of preventive tools, the complexity of the vaccine choice process, and the challenges posed by HPV vaccine hesitancy and refusal among pre-adolescents and their parents; 2. To assess knowledge, practices and attitudes toward HPV infection and vaccination in a sample of Italian pre-adolescents and their parents. The observational study was carried out through the use of two anonymous and self-administered pre- and post-intervention questionnaires dedicated to the target populations. Between the administrations of the pre- and post-intervention questionnaires, an educational intervention on HPV infection and related diseases, and prevention strategies was conducted. All participants demonstrated suboptimal knowledge and positive attitudes in the pre-intervention questionnaire. Higher levels of knowledge and attitudes were observed among pre-adolescents thatused social networks and had heard of sexually transmitted diseases at home/school/physician and from parents and also who had heard of HPV from General Practitioners, Gynecologists, family members and newspapers. A significant increase in HPV vaccination awareness was observed among pre-adolescents after the educational sessions. Health education programs aimed at increasing knowledge, attitudes and awareness on HPV are needed to implement the outcomes of HPV immunization programs, especially if supported by the physicians involved in counselling and recommendation processes.

The Role of Vaccination and Screening in Limiting the Worldwide Disease Burden of Preventable Female Cancers: A Review

Cancer represents one of the most common causes of death worldwide. Among women, breast cancer is the most diagnosed cancer and the principal cause of death due to malignant disease, while cervical cancer ranks fourth for both incidence and mortality. The present review aims to analyze the epidemiology of cervical and breast cancer (incidence, mortality, survival rates, and trends). Moreover, the most important primary and secondary preventive strategies (reduction of risk factors, exposure, vaccination, cancer screening) intended to reduce the future burden of cervical and breast cancer, that should be adopted actively and free of charge, were discussed in accordance to more recent and evidence-based findings.

Vaccination and Vaccine Effectiveness: A Commentary of Special Issue Editors

The Special Issue “Vaccination and Vaccine Effectiveness”, published in the journal Vaccines, has the main aim to increase international literature data on vaccine effectiveness and safety and on vaccination strategies in order to reduce vaccine hesitancy and improve vaccination coverage rates. The main topics included in the call for papers were vaccines administered to infants, adolescents, adults, elderly people, at-risk populations (due to comorbidities and personal risk factors) and healthcare workers and strategies adopted to promote vaccination adherence among these categories. This Special Issue started from the assumption that, despite vaccination being universally recognized as one of the best strategies to increase duration and quality of life during the last centuries, vaccination coverage rates are often under the levels recommended to reduce circulation and to extinguish vaccine-preventable diseases. Vaccine hesitancy involves at least 15% of the general population, and healthcare workers also sometimes demonstrate doubts on vaccination effectiveness and safety. At the end of the six-month submission period, 16 articles (15 research article and one review) were accepted after the peer-review processes and published online.

Human papillomavirus vaccine effectiveness within a cervical cancer screening programme: cohort study

OBJECTIVE

To assess the effectiveness of an HPV vaccination programme in reducing the risk of cervical abnormalities identified at subsequent screening.

DESIGN

Retrospective cohort study using administrative health data.

SETTING

General population of Ferrara Province, Italy.

POPULATION

Female residents born in 1986-1993 and participating in the organized cervical screening programme in 2011-2018, who were eligible for HPV vaccination in catch-up cohorts.

METHODS

Logistic regression to evaluate the potential association between abnormal cervical cytology and one, two, three or at least one dose of HPV vaccine.

MAIN OUTCOME MEASURES

Cervical abnormalities, as predicted by low-grade or high-grade cytology, by number of vaccine doses, stratified by age.

RESULTS

The sample consisted of 7785 women (mean age 27.5 years, SD 2.3). Overall, 391 (5.0%) were vaccinated with ≥1 dose and 893 (11.5%) had abnormal cytology. Women receiving at least one vaccine dose were significantly less likely to have an abnormal cytology (adjusted odds ratio 0.52; 95% confidence interval 0.34-0.79). Similar results were observed for women receiving a single dose, for both bivalent and quadrivalent vaccines, and applying buffer periods (excluding cytological outcomes within 1 month, 6 months and 1 year of the first dose).

CONCLUSIONS

In the context of an organised cervical screening programme in Italy, catch-up HPV vaccination almost halved the risk of cytological abnormalities.

TWEETABLE ABSTRACT

Among Ferrara women, vaccination against human papillomavirus halved the risk of screening cervical abnormalities.

Progress in Vaccination of Prophylactic Human Papillomavirus Vaccine

The human papillomavirus (HPV) vaccine plays an important role in preventing a series of diseases caused by HPV. Recent studies have shown that as a primary prevention measure, it can considerably prevent HPV infection and HPV-associated cervical cancer. However, studies on the safety, efficacy, and coverage of the HPV vaccine remain insufficient, especially in developing countries. Therefore, in this review, we outlined the recent studies of the HPV vaccine in terms of immunogenicity, safety, efficacy, latest vaccination concepts, and strategies. This review may provide a theoretical basis for use of the HPV vaccine.

Human Papilloma Virus Infection and Vaccination: Pre-Post Intervention Analysis on Knowledge, Attitudes and Willingness to Vaccinate Among Preadolescents Attending Secondary Schools of Palermo, Sicily

In recent years, vaccination coverage rates against Human Papilloma Virus (HPV) in Europe have shown a decreasing trend and remain below the required standard. The present study aims to assess knowledge and attitudes regarding HPV infection and vaccination among a representative sample of preadolescents of Palermo, Italy. A survey was carried out throughout two questionnaires, before and after carrying out an educational intervention scheduled during school hours. A total of 1702 students attending first-grade secondary schools of the province of Palermo were enrolled (response rate 68.9%). Students attending third classes (adj OR = 1.18; CI 95% 1.03-1.36), being of higher socioeconomic status (adj OR = 1.35; CI 95% 1.05-1.73), who had previously received information about sexually transmitted diseases (STDs) at home (adj OR = 1.62; CI 95% 1.27-2.07) or at school (adj OR = 2.15; CI 95% 1.70-2.71) and who had ever heard in the past about HPV (adj OR = 1.80; CI 95% 1.42-2.29) showed a significantly higher baseline level of knowledge regarding HPV. Willingness to receive HPV vaccination, in a 10-point Likert scale, significantly increased between the pre- (8.51; SD ± 1.79) and post- (9.01 SD ± 1.52) intervention questionnaires (p < 0.001). A total of 188 out of 272 (69.1%) preadolescents attending five out eighteen schools involved in the project, who had not previously received the HPV vaccine, were vaccinated. During past years, education campaigns on HPV were mainly dedicated to adult women, excluding teenagers and omitting young males. It should therefore be of primary importance that school-based education and vaccination programmes be standardized.

Evaluation of the Burden of HPV-Related Hospitalizations as a Useful Tool to Increase Awareness: 2007-2017 Data from the Sicilian Hospital Discharge Records

In light of the implementation of human papillomavirus (HPV) prevention strategies, epidemiological studies in different geographical areas are required in order to assess the impact of HPV-related diseases. The purpose of the present study was to describe the burden of HPV-related hospitalizations in Sicily. A retrospective observational study estimated 43,531 hospitalizations attributable to HPV from 2007 to 2017. During the observed period, there was a decrease for all HPV-related conditions with a higher reduction, among neoplasms, for cervical cancer (annual percent change (APC) = −9.9%, p < 0.001). The median age for cervical cancer was 45 years old, with an increasing value from 43 to 47 years (p < 0.001). The age classes with greater decreases in hospital admissions for invasive cancers were women aged 35 years or more (APC range from −5.5 to −9.86) and 25–34 years old (APC = −11.87, p < 0.001) for women with cervical carcinoma in situ. After ten years for vaccine introduction and sixteen years for cervical cancer screening availability, a relatively large decrease in hospital admissions for cervical cancer and other HPV-related diseases in Sicily was observed. Some clinical characteristics of hospitalization, such as increasing age, are suggestive clues for the impact of preventive strategies, but further research is needed to confirm this relationship.

[HPV vaccination: not only female adolescents and not only prophylactic. Review and position paper of the Italian HPV Study Group (IHSG)]

HPV vaccination has been introduced in clinical practice in recent years and represents the most effective strategy of primary prevention of cervical carcinoma and of female genital preneoplastic conditions. One of the major issues of the subject is represented by vaccination coverage of the target population. Since its introduction, HPV vaccine efficacy has been progressively demonstrated also towards extragenital HPV-correlated conditions and in males too. Moreover, even subjects of older age groups or subjects who already had HPV infections have been demonstrated to received benefits from vaccination, due to improvements of their immunological response. Recently, vaccine efficacy has also been investigated in terms of adjuvant administration after treatments of preneoplastic or benign conditions of the female lower genital tract caused by HPVs; preliminary results indicate an interesting and promising field of application. On this basis, in this article an analysis of the state of the art has been performed, with specific regard to the Italian scenario and with the focus of future perspectives of implementation of the HPV vaccination policy. From the available evidences, the Italian HPV Study Group recommends the extension of systematic HPV vaccination to males too, to adult subjects and also after conservative treatment of genital HPV correlated conditions.

Current issues facing the introduction of human papillomavirus vaccine in China and future prospects

The introduction of human papillomavirus (HPV) vaccination in China aims to prevent HPV infection in all women. The issues that China might face include high cost of vaccines made in other countries, shortage in HPV vaccine supply, negative events attributed to vaccination (whether justified or not) that jeopardizes the general public's confidence in the HPV vaccine, cultural and literacy barriers, and sensitivity to receiving a vaccine for a sexually transmitted disease. Ensuring the effective delivery of the HPV vaccine in China, a country with vast economic, geographical, and cultural complexities, will require a commitment of significant resources. In light of the high price of imported vaccines, the availability of locally manufactured HPV vaccines would greatly facilitate the national HPV vaccination program. New evidence supporting the efficacy of a two-dose regime in younger adolescents would also be advantageous in terms of affordability and logistical simplicity of vaccine administration. Furthermore, it would potentially enhance the compliance and uptake, especially for hard to reach women in remote regions.

Immunization Campaigns and Strategies against Human Papillomavirus in Italy: The Results of a Survey to Regional and Local Health Units Representatives

Objective. The study aimed to assess the impact of HPV immunization campaigns organizational aspects, the characteristics of immunization program (vaccination targets and type of offer), and communicative strategies adopted by four Italian administrative regions on vaccination coverage observed. Methods. From November 2017 to March 2018, regional and Local Health Units (LHUs) representatives were invited to complete an online survey including 54 questions evaluating vaccination invite systems, access systems to vaccination centres, reminder and recall systems, and adverse events surveillance. An overall descriptive analysis was conducted. Since observed vaccine coverage (VC) obtained in females (2002-2004 birth cohorts) was lower than objectives fixed by the Italian Ministry of Health, variables were assessed using the national VC mean obtained in the 2003 girls birth cohort as outcome. Results. Twenty-six LHUs belonging to 4 Northern and Southern Italian regions participated in the study. Organizational aspects significantly related to VC lower than the national mean were access to vaccine centres without appointment and parents' reservation as appointment planning system. Recall systems for both the first and the second dose, including the appointment in the invitation letter, the availability of regional immunization registry, and education of healthcare workers on universal HPV immunization strategies, instead, were related to higher VC. As regards preadolescent immunization strategies, both VC obtained in girls and boys were far from the Ministerial goals. Only 20% of LHUs introduced multicohort female strategies while all LHUs adopted copayment targeting both men and women. Immunizations strategies targeting subjects at risk were implemented only in half of participating LHUs. Conclusions. VC observed in participating LHUs are largely lower than the national objectives in all anti-HPV vaccine targets. Both organizational and educational strategies have to be implemented to improve the VC goals.

Characteristics of HPV-unvaccinated undergraduate health students in Switzerland, a cross sectional study

Background

Human Papillomavirus (HPV) vaccination, intended for young women aged 11-14 years old, has been introduced in Switzerland in 2007. Ten years after its introduction, only a few studies have explored the reasons associated with uptake and non-uptake of the vaccination. Our objective was to identify the sociodemographic characteristics of a population of vaccinated and unvaccinated undergraduate healthcare female students, to define the reasons of non-uptake of vaccination, and compare our findings with those found in other Swiss cantons.

Methods

Between January and November 2017, women studying in Health Sciences School and Medical School in Geneva, aged 18-31 years old, were recruited in a large trial assessing HPV prevalence. As part of a smaller, observational study nested in this larger trial, women were invited to complete a questionnaire. Self-reported HPV vaccination uptake or non-uptake, as well as knowledge and attitude about HPV vaccination were assessed. T-Test and Chi square test were used to compare characteristics of vaccinated and unvaccinated women.

Results

Overall, 409 women were recruited in the study. The majority of them (69.1%) reported having been vaccinated for HPV, while 30.9% of them had never received any dose of the HPV vaccine. The only factor associated with a higher vaccination rate was the participants' origin, as women from Geneva were more represented in the vaccinated group than women from other Swiss regions or countries. Unvaccinated women were more likely to consider HPV vaccination as less important than the vaccinated ones (50.4% vs 3.5% p < 0.001).

Conclusion

Although no typical profile can be established in this studied population of unvaccinated women, a lack of information was a major reason of non-uptake of vaccination among the study participants. An effort by health authorities and carefully designed messages are essential to increase the population's awareness over cervical cancer and its prevention.

Trial registration

The trial was registered under cliniclatrials.gov with the identifier: NCT03474211.

Human Papillomavirus Vaccine Predictors Among U.S. Adults Aged 18 to 45 by Sexual Orientation

Despite increased incidence rates of human papillomavirus (HPV)-associated cancers among sexual minorities, their HPV vaccine uptake remains suboptimal. This cross-sectional, correlational study aimed to investigate factors associated with HPV vaccination among a nationally representative sample of U.S. young adults by sexual orientation. We used the 2014 to 2017 Behavioral Risk Factor Surveillance System data for adults aged 18 to 45 years. HPV vaccination initiation was associated with being female and Hispanic, having higher educational attainment, and having ever been tested for HIV, whereas completion was associated with being female and non-Hispanic White and having higher educational attainment. Compared with those who reported identifying as straight, the lesbian or gay respondents were found to have been less likely not to complete the series. Providers should play a crucial part in addressing missed opportunities for HPV vaccination by implementing culturally competent communication strategies to empower sexual minorities to make informed HPV vaccine decisions.

The Socio-Economic Health Deprivation Index and its association with mortality and attitudes towards influenza vaccination among the elderly in Palermo, Sicily

Introduction

Socio-economic status (SES) seems to be a determinant of health and is associated with vaccination coverage among older and at-risk populations. The aim of this study was to evaluate trends in health outcomes and the Socio-Economic and Health Deprivation Index (SEHDI) among elderly people in the city of Palermo.

Methods

In the 2015 CCM project, the Palermo Unit collected mortality data for use in validating the SEHDI. Italian census data from 2009 to 2015 on overall mortality and causes of death were used. The outcome used to validate the SEHDI was vaccination coverage from the 2009-2010 to 2014-2015 influenza seasons among the elderly in Palermo.

Results

The SEHDI correlated significantly with all-cause mortality (p < 0.05), though this correlation displayed a decreasing trend. Regarding mortality due to influenza or pneumonia, however, the significant correlation (p < 0.05) showed an increasing trend. A linear trend was observed in the inverse correlation between the SEHDI and vaccination coverage rates (p < 0.05), with an overall 27% vaccination coverage among older people. Elderly subjects living in a census district with more regular immigrants, divorced people and single-parent families were more reluctant to undergo influenza vaccination.

Conclusions

This study allowed us to identify subgroups of elderly people who are less likely to adhere to influenza vaccination, and to whom health promotion interventions could be addressed in order to facilitate "healthy aging".

Addressing HPV vaccine myths: practical information for healthcare providers

Human papillomavirus (HPV) vaccine uptake consistently lags behind that of other adolescent vaccines. In 2017, uptake of a single HPV vaccine dose and HPV vaccine series completion was 66% and 49%, respectively, compared to uptake of tetanus, diphtheria, and acellular pertussis vaccine (89%) and quadrivalent meningococcal conjugate vaccine (85%). Reasons for not vaccinating adolescents again HPV are varied, and in many cases, are rooted in commonly spread myths and misperceptions about the vaccine. In this review, we address five key myths - HPV vaccination is not effective at preventing cancer; Pap smears are sufficient to prevent cervical cancer; HPV vaccination is not safe; HPV vaccination is not needed since most infections are naturally cleared by the immune system; 11-12 years of age is too young to vaccinate. For each myth, we summarize the scientific evidence refuting the myth and provide speaking prompts for healthcare professionals to communicate about HPV vaccination.