Attitudes towards HPV and COVID school-entry policies among adults living in Puerto Rico

Prior to the COVID pandemic, Puerto Rico (PR) had one of the highest Human Papillomavirus (HPV) vaccine rates in the United States. The COVID pandemic and administration of COVID vaccines might have impacted attitudes toward HPV vaccination. This study compared attitudes toward HPV and COVID vaccines with respect to school-entry policies among adults living in PR. A convenience sample of 222 adults (≥21 years old) completed an online survey from November 2021 to January 2022. Participants answered questions about HPV and COVID vaccines, attitudes toward vaccination policies for school-entry, and perceptions of sources of information. We assessed the magnitude of association between the agreement of school-entry policies for COVID and HPV vaccination by estimating the prevalence ratio (PR_adjusted) with 95% Confidence Intervals (95% CI). The most trusted source of information for HPV and COVID vaccines were healthcare providers (42% and 17%, respectively) and the CDC (35% and 55%, respectively), while the least trusted were social media (40% and 39%, respectively), and friends and family (23% n = 47, and 17% n = 33, respectively). Most participants agreed that HPV (76% n = 156) and COVID vaccines (69% n = 136) should be a school-entry requirement. Agreement with school policy requiring COVID vaccination was significantly associated with agreement of school policy requiring HPV vaccination (PR_adjusted:1.96; 95% CI:1.48-2.61) after controlling for potential confounders. Adults living in PR have an overall positive attitude about mandatory HPV and COVID vaccination school-entry policies, which are interrelated. Further research should elucidate the implications of the COVID pandemic on HPV vaccine attitudes and adherence rates.

[Efforts towards the consolidation of public policies for the prevention of HPV-associated cancers in Puerto RicoEsforços realizados em Porto Rico para a consolidação de políticas públicas de prevenção de cânceres associados ao HPV]

The purpose of this special report is to describe chronologically the events that contributed to the development and approval of legislation and subsequent implementation of a school vaccination mandate in order to prevent HPV and HPV-associated cancers in Puerto Rico (PR). Starting in 2010, PR initiated public-policy approvals aimed at improving cancer registries and HPV vaccine coverage through health insurance for adolescents aged 11 to 18 years. In 2014, scientific and community efforts succeeded in documenting the magnitude of morbidity caused by HPV and jointly developing HPV vaccine prevention and promotion strategies. In August 2018, PR became one of the first four territories of the United States of America to implement the HPV vaccine school entry requirement to decrease the incidence of HPV-associated cancers on the island. In 2019, it was enshrined in law that every immunization provider must submit immunization data to the Puerto Rico Immunization Registry. The case of PR demonstrates that public policy-making alongside collaboration between academic, scientific, and community coalitions can achieve population change and measurable outcomes aimed at HPV prevention. Countries with a similar public health problem could adopt efforts similar to those presented herein and align them with the World Health Organization goal of eradicating cervical cancer by 2030.

Abstract PO-027: A Puerto Rico free of preventable diseases: An online education intervention for school staff during the COVID-19 pandemic era in Puerto Rico

Introduction: Puerto Rico Libre de Enfermedades Prevenibles (Puerto Rico Free of Preventable Diseases) was an online, community-based initiative consisting of eight educational training programs regarding school entry vaccines, including HPV vaccine as the most recent requirement. The Community Advisory Board of the HPV-PIVac study (CAB-PIVac) developed this activity in response to barriers identified on school personnel by the HPV-PIVac study: lack of knowledge about the HPV vaccine and its school entry requirement and need for training. In February 2020, CAB-PIVac members collected data through a self-administrated survey to identify potential topics. After several meetings, members identified the topics and resources for these webinar series. Our purpose is to present how the integration of community members into an ongoing research study allowed rapid response to developing an educative initiative to impact school staff concerning preventable diseases and the HPV vaccine. Methods: Eight webinars in four weeks were transmitted in-live through the Zoom platform from June 26 to July 17, 2020. They were on-demand until July 24, 2020. Theme per week: World without vaccine: COVID-19; Teenager vaccine in School; Future free of HPV-related cancer; and Legal aspects of vaccination for the school-entry. The participants received via email an evaluation form to assess the impact of these webinars. Using data from the registration form, we collected the following participants' characteristics: sex, age, education sector, and role in the school. We performed a thematic analysis collecting all the messages posted in the Q & A section of each webinar to identify the topics in which the participants had doubts or more interest. Results: A unique participation of 954 participants were registered, and the range of involvement on the education webinars was 588 to 780 participants. Based on the type of education, 28.8% were private, and 70.9% were from public education. Most of the participants were females (89.6%) and with an average age of 42 years (range: 21 -74). Of the participants who reported their role at their schools (n=648), 31.4% were school nurses, followed by the school director (22.7%). Twelve percent of the participants were teachers. The evaluation was satisfactory (99.7%) considering the tools offered and the clear information presented. The thematic analysis results showed that the two topics discussed in the Q &A section were the immunization registry (problems with system access) and the vaccination series (age to initiate the series). Conclusion: This initiative was developed and performed in less than five months. Many national and international organizations, coalitions, and government agencies are working to achieve the same goal: eradicated HPV-related cancers and strengthen the awareness for HPV prevention. Involve these community members in the research is crucial to secure how the results of the investigation studies could impact the community quickly and accurately.

Citation Format: Diana T. Medina-Laabes, VOCES PR Coalition, JAC-HPV PIVAC PR, Omayra Salgado Cruz, Roxana Soto Abreu, Olga L. Diaz Miranda, Marta M. Sánchez Aracil, Vivian Colón-López. A Puerto Rico free of preventable diseases: An online education intervention for school staff during the COVID-19 pandemic era in Puerto Rico [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-027.

Human papillomavirus vaccine initiation and up-to-date vaccine coverage for adolescents after the implementation of school-entry policy in Puerto Rico

The human papillomavirus (HPV) vaccine has been proven effective in the prevention of infection with high-risk HPV types, which can lead to the development of six HPV-related cancers. Puerto Rico (PR) adopted a mandatory HPV vaccination school-entry policy that took effect in August 2018. While school-entry requirements are generally accepted as an effective approach for increasing vaccination rates, there are few studies that have documented their impact on improving HPV vaccination rates. The objective of this study was to evaluate the impact of the HPV school-entry policy in PR on HPV vaccine coverage. We used a pre-post natural experiment. The study population included adolescents registered in the PR Immunization Registry during 2008-2019. We calculated HPV vaccine initiation and up-to-date (UTD) vaccine coverage rates. We estimated age-standardized rates (ASR) and standardized rate ratio with 95%CI. Vaccine data corresponding to a total of 495,327 adolescents were included for analysis; 50.9% were male and 49.1% were females. After policy implementation, a marked increase in raw HPV vaccine initiation among 11- to 12-year-old adolescents was observed across years 2017 (a pre-policy year), 2018, and 2019 (58.3%, 76.3%, and 89.8%, respectively). UTD coverage also showed a moderate increase after policy implementation among 11- to 12-year-old adolescents. The gap between sexes in vaccine initiation and UTD coverage narrowed over time; the ASRs in 2019 showed an increase of 19% in initiation and 7% increase in UTD relative to 2017 for males and females combined (both significant at p<0.05). This study demonstrated evidence of improvement in HPV vaccination rates following implementation of the school-entry policy and a narrowed sex gap in vaccine rates over time in PR. Future analyses should assess how the policy continues to affect vaccine coverage in subsequent years and how the COVID-19 pandemic has impacted HPV vaccination uptake.

Abstract PO-040: Understanding views against the HPV vaccine school-entry requirement in Puerto Rico

Introduction: Individuals and groups against vaccination have used various outlets, such as mass media, social media, and legislative hearings to express doubts about the human papillomavirus (HPV) vaccine. In 2018, the Puerto Rico Department of Health included the HPV vaccine as a school-entry requirement for children ages 11-12. Currently, the requirement extends to students ages 11-16. Since the announcement in 2017 of the new school-entry requirement as a preventive cancer strategy, many groups have expressed opposition. Although studies have documented the barriers and facilitators for implementing this policy on the island, qualitative studies assessing stakeholders' views against the implementation of the new requirement are lacking. We aimed to describe stakeholders' perspectives who opposed the HPV vaccine and the implementation as a school-entry requirement in PR. Methods: In-depth interviews (n=8) were conducted between March 2019-January 2020. Healthcare providers, religious leaders, and coalition spokespersons were interviewed. The Consolidated Framework for Research Implementation (CFIR) was used to develop the semi-structured interview guide. CFIR domains (and constructs) included were characteristics of individuals (knowledge, attitudes, and beliefs about the HPV vaccination, school-entry requirement, and exemptions), intervention characteristics (current practices, advantages and disadvantages of the implementation), and implementation procedures (planning, commitment of implementers and evaluation). Interviews were audio-recorded and transcribed in Spanish. Transcripts were analyzed using qualitative thematic analysis. Additional constructs were derived from CFIR constructs and emergent codes were included. Results: The most common CFIR domain observed was individual characteristics (knowledge and beliefs), of which HPV hesitancy and vaccine distrust were emergent themes. Arguments against the policy also cited the adverse effects of the vaccine under the intervention characteristics domain (evidence strength and quality). Lastly, excessive government interference was discussed by stakeholders in which concerns regarding the HPV vaccine school-entry requirement and how this policy does not align with their values of religious freedom, parental, educational and sexual rights were mentioned. Conclusion: Despite the recent documented positive impact of the school-entry requirement in HPV immunization rates in PR, many continue to oppose the vaccine mandate. Stakeholders' arguments against the HPV vaccine policy, including knowledge and beliefs, and excessive government interference, echo concerns of other mandated vaccines reported in the literature. Understanding arguments against school-entry requirements is necessary to tailor educational campaigns to increase vaccination rates, which were affected by the COVID-19 pandemic, prevent HPV-related cancers, and reduce the hesitancy in of school-entry policies in the future.

Citation Format: Gloriany Rivas, Roxana Soto-Abreu, Glizette O. Arroyo-Morales, Diana T. Medina-Laabes, Olga L. Díaz-Miranda, Coralia Vázquez-Otero, Vivian Colón-López. Understanding views against the HPV vaccine school-entry requirement in Puerto Rico [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-040.

Effect of Hurricane Maria on HPV, Tdap, and meningococcal conjugate vaccination rates in Puerto Rico, 2015-2019

In September 2017, Hurricane Maria devastated the Caribbean region, among them the US territory of Puerto Rico (PR). Vaccination distribution and uptake suffered from the impact. This study evaluated the trends in monthly vaccination initiation rates for human papilloma virus (HPV), Tdap and meningococcal conjugate (MenACWY) adolescent vaccines from 2015 to 2019, during which it was possible to observe and analyze the impact of Hurricane Maria on vaccine initiation. Monthly initiation rates were estimated. Age-standardized initiation rate ratio (SRR) and 95% CI were estimated. The analysis included 85,340 adolescents; 52.3% were male, and 47.7% were females. September 2017 showed HPV vaccine initiation had the lower rates of all the studied vaccines, with a rate of 75% after the disaster (from a rate of almost 90% in July 2017). Tdap and MenACWY vaccines rates remained above 90% in the same period. The SRR of HPV vaccine for September and October 2017 showed an estimated reduction of 5% and 8% in vaccine initiation rates, respectively for each month, when 2016 was the reference year (p > .05). The SRR of Tdap and MenACWY vaccines for November 2017 showed significant reductions when 2015 and 2016 were reference years (p < .05). HPV vaccine initiation rate was the most severely affected by the Hurricane Maria. Post-natural disaster protocols should strengthen existing programs for facilitate immunization access.

Understanding parents' views toward the newly enacted HPV vaccine school entry policy in Puerto Rico: a qualitative study

BACKGROUND

The Human papillomavirus vaccine (HPV) is an essential tool for the prevention of HPV-related cancers. In Puerto Rico, the Secretary of Health established a school entry requirement of at least one dose of HPV vaccination in girls and boys aged 11 and 12 years, taking effect in August 2018. Our study aimed to examine parents' and guardians' views of unvaccinated children about the process of implementation of the new HPV vaccination school entry policy in Puerto Rico and identify potential barriers and facilitators related to the implementation of this requirement.

METHODS

During April through November 2019, we conducted three focus groups (n = 12) and eight in-depth semi-structured interviews with parents of children aged 11 and 12 who had not yet initiated the HPV vaccine series. The interview topics addressed were: perception of vaccination, HPV vaccine and it is inclusion as new school entry requirement practice, procedure of the sources of information, influencers, and willingness to change. The interviews were recorded and transcribed by our staff members. We identified emergent themes through thematic analysis.

RESULTS

The participants' perspective on the HPV vaccine school requirement was mixed. Lack of information of the HPV vaccines and lack of communication about the school-entry requirement were the themes most mentioned in the interviews. Moreover, previous negative experiences from friends or family members and adverse effects deterred some participants from vaccinating their kids. We discussed barriers in the process of soliciting an exemption.

CONCLUSION

Most barriers mentioned by study participants are modifiable. Information about the HPV vaccine mandate's implementation and educational materials regarding HPV vaccine safety need to be provided to address parents' concerns related to the vaccine's side effects. Schools (teachers, principal directors, and administrative staff), the government, and parent organizations need to be part of these efforts. This multilevel approach will help to improve disseminating information about HPV vaccination to clarify doubts and misinformation among parents.

Implementation of the human papillomavirus school-entry requirement in Puerto Rico: barriers and facilitators using the consolidated framework for implementation research

In 2018, Puerto Rico (PR) enacted a Human papillomavirus (HPV) vaccine school-entry requirement for students ages 11 to 12. Using the Consolidated Framework for Implementation Research (CFIR), we aimed to identify potential barriers and facilitators of this implementation. We conducted 38 qualitative interviews with stakeholders in PR from different organizations (Department of Health, Schools, Healthcare Providers, and Community organizations). We evaluated construct rating variability between the organizations to determine barriers and facilitators. The strongest facilitator determined was stakeholder's awareness of the parent's and student's needs to meet the HPV school-entry requirement. Other facilitators included initiatives for school-entry policies and the relative advantage of this requirement over different strategies. The strongest barriers included was the cost for private providers to administer the HPV vaccine, the negative influence of social media about the vaccine, which affected parents' acceptance, and the lack of school nurses as available staff resources for the school entry requirement. Findings from this study can be used to improve implementation (adaptations/modifications) and inform other states and countries in earlier stages of consideration of the adoption of similar immunization policies. Most barriers can be modifiable with the implementation of educational programs/training across schools, considering that they are the first line of response to parents of this school entry requirement.

Content analysis of digital media coverage of the human papillomavirus vaccine school-entry requirement policy in Puerto Rico

Background

In August 2018, Puerto Rico (PR) became the 4th state or territory in the United States to adopt a human papillomavirus (HPV) vaccine school-entry requirement, for students 11–12 years old. Evidence suggests that the content of media coverage may impact people’s perception of HPV vaccine and their willingness to vaccinate. This study aimed to analyze the content of digital news coverage related to the implementation of the policy in PR.

Methods

A content review was conducted of digital media published from January 2017 through December 2018. The content reviewed was carried out in two steps: 1) creating a matrix to summarize each article’s content about the policy and 2) qualitative analysis using a grounded theory approach.

Results

The search resulted in 34 articles obtained from 17 online local and international news outlets that reported the policy's implementation. Analyses showed that 61% of the news articles did not mention the number of required doses, and 79% discussed the new policy concerning cancer prevention. In 2017, news coverage focused mostly on describing the policy, while 2018 coverage focused on controversies surrounding the implementation. Neutral emergent codes included: 1) Description of the policy; 2) Information about HPV related cancers; and 3) General information about HPV vaccine. Negative emergent codes included: 1) infringement to patient and parental autonomy; 2) Hesitancy from the political sector, and 3) Hesitancy from groups and coalitions. Positive content included: 1) knowledge and acceptance of HPV vaccine for cancer prevention; 2) importance of education and protective sexual behaviors; and 3) new vaccination law proposal.

Conclusions

Most of the media coverage in PR was neutral and included limited information related to the vaccine, HPV, and HPV-related cancers. Neutral and negative themes could influence public concerns regarding the new policy, as well as HPV vaccination rates in PR.

Abstract D047: Human papillomavirus school-entry vaccination mandate in Puerto Rico: Barriers and facilitators from the perspective of key informants

Introduction: School-entry vaccination mandates have been widely used as a mechanism to ensure high immunization coverage rates. In August 2018, Puerto Rico (PR) mandated a Human papillomavirus (HPV) vaccine school-entry policy for student’s ages 11 to 12 years. This new requirement in PR presents an opportunity to study the implementation process across a 5 years period (2018-2023). In this ongoing study, we conducted Key Informant (KI) interviews to document factors that facilitate or impede a successful HPV vaccine school policy implementation in PR. Methods: We conducted 29 KI semi-structured interviews with stakeholders in the Department of Health (DOH), school system, healthcare organizations, community-based organizations and coalitions in PR (in favor and against the school-entry policy) from July 2018 to June 2019. The interview guide included relevant domains based on the Consolidated Framework for Implementation Research, such as Intervention characteristics, Inner setting, Outer setting and Individual characteristics. We transcribed interviews, coded transcripts and analyzed data to identify emergent themes. Results: Potential facilitators of HPV policy implementation included: clear enforcement messages and use of personal anecdotes by nurses from health and school fields, the coverage of the vaccine by medical insurers, and the power of the Secretary of Health to include vaccines required for school-entry. Perceived barriers to the implementation process were: lack of communication between the DOH and the Department of Education, lack of knowledge about the HPV vaccine, uncertainty about the consistency of implementation in schools, lack of vaccine availability and disproportionate burden for regional school nurses. Other barrier to implementation mentioned included: school directors and teachers were detached from the implementation process, and lack of compliance from private health providers and public schools towards the immunization registry. Coalitions against this mandate focused their concerns on the right of parental autonomy. Recommendations from KI focused on: stricter policies to enforce this law in public schools, clear messages about the new mandate and HPV vaccine current coverage by health care insurers in PR. Moreover, KI expresses the need for more support from the DOH (technical and educational training to school principals and teachers, health promotion), and the need for increased education about the HPV vaccine and recommendations. Conclusions: Although school vaccination mandates are an evidence-based strategy for improving vaccination rates, several implementation barriers could affect the impact. Findings from this study can be used for improving policy procedures and implementation, and can inform states/territories considering adopting similar immunization policies. The information generated will help determine adaptations/modifications that may be needed for policy implementation in PR and other populations in the future.

Citation Format: Roxana Soto-Abreu, Manuel E. Rivera-Encarnación, Vilnery Rivera-Figueroa, Glizette O. Arroyo-Morales, Diana T. Medina-Laabes, Olga L. Diaz-Miranda, Pamela C. Hull, Ana P. Ortiz-Martínez, Erick L. Suárez-Pérez, María E. Fernández, Vivian Colón-López. Human papillomavirus school-entry vaccination mandate in Puerto Rico: Barriers and facilitators from the perspective of key informants [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D047.

Abstract D045: Content analysis of online media coverage of the human papillomavirus vaccine as a school-entry policy in Puerto Rico

Introduction: In August 2018, Puerto Rico (PR) adopted a Human Papillomavirus (HPV) vaccine school-entry policy, required for students, 11-12 years old. Previous research suggests that influence from media coverage and content might impact parents’ perception of vaccine efficacy, safety and willingness to vaccinate their children. We analyzed the coverage related to the implementation of the HPV vaccine in PR as a requirement for school-entry policy. Methods: A systematic review was conducted from January 2017 through December 2018. Search terms (in Spanish) included: Virus de Papiloma Humano, VPH, vacuna, vacunación contra VPH, implementación, among others. The search included 17 online websites; 34 articles were gathered, which were included if coverage of the new school entry-policy was mentioned in the content. The following steps were developed to review the content of the articles: 1) a matrix to evaluate the content of the article in relation to the school-entry policy and 2) qualitative analysis using grounded theory approach. Since headlines might promote readers’ perception, three different raters read the article title to document the sentiment (positive, negative or neutral). Fleiss’ Kappa analysis was used to assess intra-rater agreement. Results: Data from the matrix showed that 79% focused on this new school-entry mandate as a policy for cancer prevention and 61% of the news articles did not discuss the HPV doses required. Media reports highlighted the link between HPV and HPV-related cancers, mostly cervical cancer (59%). Limited information regarding other HPV-related cancers such as vaginal (18%), vulvar (20%), anal (12%), penile (21%) and oropharynx (24%) was included. In 2017, prior to policy implementation, news coverage focused mostly on the description of the school-entry policy, while 2018 coverage focused on the controversy of the school policy being mandatory. Most of the emergent themes related to the implementation of the HPV vaccine as a school-entry policy were negative, involving: 1) risk of the vaccine (safety and efficacy); 2) representative hesitancy; 3) parental autonomy; 4) right to be informed; and 5) lack of education about HPV and the vaccine. Positive content included: 1) knowledge and acceptance of the HPV vaccine for cancer prevention; 2) the importance of education and protective sexual behaviors; 3) support from coalitions, health providers and government representatives for implementation. The agreement of the headline sentiment between the three raters was fair (k= 32%; p &lt;0.01). Conclusion: Most of the media coverage about HPV in PR had limited information related to the vaccine, HPV, and HPV-related cancers. Weak concordance of the headline’s sentiments shows how different headlines influence the total impression created by a news story. In the case of HPV and this new policy, this situation could influence negatively public concerns regarding the new school-entry policy, as well as HPV vaccination rates in PR.

Citation Format: Vilnery Rivera-Figueroa, Glizette O Arroyo-Morales, Roxana Soto-Abreu, Manuel E Rivera-Encarnación, Olga L Díaz-Miranda, Diana T Medina-Laabes, Ana P Ortíz-Martínez, Erick L Suárez-Pérez, Maria E Fernández, Pamela C Hull, Vivian Colón-López. Content analysis of online media coverage of the human papillomavirus vaccine as a school-entry policy in Puerto Rico [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D045.