Female human papillomavirus (HPV) vaccination: global uptake and the impact of attitudes

A systematic literature review of human papillomavirus vaccination strategies in delivery systems within national and regional immunization programs

The uptake of human papillomavirus (HPV) vaccine remains suboptimal despite being a part of routine vaccination within national immunization program(s). This indicates probable challenges with the implementation of HPV immunization program(s) in various countries. The objective of this systematic literature review (SLR) was to identify implementation strategies for HPV vaccination within national and regional immunization programs worldwide with an aim to provide guidance for countries targeting to increase their HPV vaccine coverage rate (VCR). A comprehensive literature search was conducted across Medline and Embase and included articles published between January 2012 and January 2022. Of the 2,549 articles retrieved, 168 met inclusion criteria and were included in the review. Strategies shown to improve HPV vaccination uptake in the reviewed literature include campaigns to increase community awareness and knowledge of HPV, health care provider trainings, integrating HPV vaccination within school settings, coordinated efforts via multi-sectoral partnerships, and vaccination reminder and recall systems. Findings may help national authorities understand key considerations for HPV vaccination when designing and implementing programs aiming to increase HPV VCR in adolescents.

The Role of Scientific Research in Human Papillomavirus Vaccine Discussions on Twitter: Social Network Analysis

BACKGROUND

Attitudes toward the human papillomavirus (HPV) vaccine and accuracy of information shared about this topic in web-based settings vary widely. As real-time, global exposure to web-based discourse about HPV immunization shapes the attitudes of people toward vaccination, the spread of misinformation and misrepresentation of scientific knowledge contribute to vaccine hesitancy.

OBJECTIVE

In this study, we aimed to better understand the type and quality of scientific research shared on Twitter (recently rebranded as X) by vaccine-hesitant and vaccine-confident communities.

METHODS

To analyze the use of scientific research on social media, we collected tweets and retweets using a list of keywords associated with HPV and HPV vaccines using the Academic Research Product Track application programming interface from January 2019 to May 2021. From this data set, we identified tweets referring to or sharing scientific literature through a Boolean search for any tweets with embedded links, hashtags, or keywords associated with scientific papers. First, we used social network analysis to build a retweet or reply network to identify the clusters of users belonging to either the vaccine-confident or vaccine-hesitant communities. Second, we thematically assessed all shared papers based on typology of evidence. Finally, we compared the quality of research evidence and bibliometrics between the shared papers in the vaccine-confident and vaccine-hesitant communities.

RESULTS

We extracted 250 unique scientific papers (including peer-reviewed papers, preprints, and gray literature) from approximately 1 million English-language tweets. Social network maps were generated for the vaccine-confident and vaccine-hesitant communities sharing scientific research on Twitter. Vaccine-hesitant communities share fewer scientific papers; yet, these are more broadly disseminated despite being published in less prestigious journals compared to those shared by the vaccine-confident community.

CONCLUSIONS

Vaccine-hesitant communities have adopted communication tools traditionally wielded by health promotion communities. Vaccine-confident communities would benefit from a more cohesive communication strategy to communicate their messages more widely and effectively.

Factors associated with HPV vaccine acceptability and hesitancy among Black mothers with young daughters in the United States

Introduction

Compared to other-race peers, Black women are disproportionately impacted by human papillomavirus [HPV] infection, related health outcomes, and cervical cancer mortality as a result of suboptimal HPV vaccine uptake during adolescence. Few studies in the United States have examined psychosocial determinants of HPV vaccine acceptability and hesitancy among Black parents. The current study integrated the health belief model and the theory of planned behavior to evaluate the extent to which psychosocial factors are associated with pediatric HPV vaccination intentions among this population.

Methods

Black mothers (N = 402; age range = 25 to 69 years, M = 37.45, SD = 7.88) of daughters ages 9 to 15 years completed an online survey assessing HPV infection and vaccine beliefs and attitudes across four domains: Mother's HPV Perceptions, Mother's Vaccine Attitudes, Cues to Action, and Perceived Barriers to HPV Vaccination. Participants indicated their willingness to vaccinate their daughter on a 5-level ordinal scale ("I will definitely not have my daughter get the vaccine" to "I will definitely have my daughter get the vaccine") which was dichotomously recoded for binomial logistic regressions.

Results

Half of the sample (48%) intended to vaccinate their daughter. Number of daughters, mother's HPV vaccine status, perceived HPV vaccine benefits, HPV vaccine safety concerns, pediatric HPV vaccine peer norms, and doctor recommendations emerged as independent factors of Black mothers' intentions to vaccinate their daughters against HPV when controlling for all other factors.

Discussion

In addition to medical training to increase doctor recommendation of the HPV vaccine for Black girls, population-tailored public health messaging aimed at promoting HPV vaccine acceptance among Black mothers is urgently needed. This messaging should engage community support and emphasize the benefits of vaccination for adolescent Black girls while also addressing parental concerns regarding the safety of pediatric HPV vaccination.

Examining four types of anti-vaccination attitudes prior to and during the COVID-19 pandemic

People hold different anti-vaccination attitudes. Having an understanding of how these attitudes have changed prior to and during the COVID-19 pandemic is critical for combatting anti-vaccination attitudes and increasing vaccine intention and uptake. Data were collected from different samples in the United States at three time points prior to (n = 840) and four time points during (n = 1543) the pandemic. All participants completed a multi-dimensional measure of anti-vaccination attitudes (VAX Scale) through an online platform. Results showed that, when it comes to vaccines, worries about unforeseen side effects, concerns about commercial profiteering, and preference for natural immunity were higher during the COVID-19 pandemic than they were prior to it. However, mistrust of vaccine benefit was lower during the COVID-19 pandemic than prior to it. These differences were found even after controlling for the potential effects of participant sex, education, socioeconomic status, age, and race/ethnicity. Additionally, worries about unforeseen side effects, concerns about commercial profiteering, and preference for natural immunity increased linearly alongside the persistence of COVID-19; whereas, mistrust of vaccine benefit showed no change. Although it might be intuitive to emphasize vaccines' effectiveness to increase uptake, the public's trust in vaccine effectiveness did not appear to be the major concern. Thus, public health efforts to increase uptake of vaccines should also focus on reducing concerns about potential side effects from the vaccine, tempering the attention on financial benefits to pharmaceutical companies, and rebuffing the overreliance on natural immunity.

Perceptions, Knowledge and Attitudes among Young Adults about Prevention of HPV Infection and Immunization

Introduction: Human papilloma virus (HPV) is one of the most common sexually transmitted infections and is widely known as the main causative agent for cervical cancer. The aim of this study was to investigate the perceptions, knowledge and attitudes of young Greek adults concerning prevention of HPV infection and HPV immunization. Material and Methods: This constitutes a cross-sectional online survey. A convenience sample of young Greek adults (n = 883) residing in Greece, aged 17 to more than 35 years was surveyed from December 2020 to March 2021. Two validated questionnaires were used to collect data. Results: Participants demonstrated moderate knowledge about HPV infection and vaccination, with a mean knowledge score of 53.26 (SD ± 20.65) and 38.92 (SD ± 17.58), respectively. Cronbach’s alpha value was 0.77 and 0.80. Female participants were better informed than males. Approximately 52.3% of respondents had been vaccinated and 65.5% were willing to get vaccinated in the future. Vaccination rate was significantly associated with gender (OR = 11.99; 99% CI = 6.59–21.84), knowledge about the HPV vaccine (OR = 1.04; 99% CI = 1.03–1.04) and age (OR = 0.07; 99% CI = 0.03–0.15). Reasons for vaccine refusal were insufficient information (36.8%) and fear of side effects (19%). Correlates of positive vaccination intention were knowledge about HPV (OR = 1.02; 99% CI = 1.01–1.02). Conclusions: The findings suggest that the Greek government’s continuing HPV promotion efforts and education on the risks of HPV infection among young people are likely to increase vaccination acceptance among this group.

A qualitative study of parental associations and beliefs regarding the HPV vaccination for Dutch boys

Background

Human Papillomavirus (HPV) occurs in 80% of the sexually active population and may cause certain types of cancers among men and women. Vaccination against HPV could prevent cancers associated with HPV. The Dutch National Immunization Program (NIP) only includes HPV vaccination for girls, but the HPV vaccination for boys will be implemented in 2022. Little is known about the awareness of parents and their attitudes regarding the vaccination for boys. However, these concepts might influence the intention to vaccinate one’s child. Gaining insight in these factors could lead to more effective communication strategies.

Methods

This qualitative research aimed to explore parental associations and beliefs regarding the HPV vaccination for boys. In total, 16 interviews were conducted with parents. Topics discussed were primary associations with vaccinations, associations with HPV-vaccination and information needs regarding the HPV vaccination for boys.

Results

Most parents were unaware about HPV infections in boys as well as the possibility to vaccinate their sons. Furthermore, after hearing about the vaccine parents reported uncertainties about anticipated adverse effects of the vaccine. Other themes that emerged were difficulties with the proposed age at which boys would be offered the vaccination and low risk perception of the virus.

Conclusion

Public campaigns regarding (the HPV) vaccination should improve (parental) awareness about the virus and the vaccination, and increase knowledge. Moreover, it should address concerns regarding vaccination and be transparent about decision making. For example, a rationale why HPV vaccination is needed for boys who turn 10 years and its advantage to reducing risks for boys to contract HPV related cancers should be provided.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13605-y.

Attitudes Toward HPV Vaccination in Sweden: A Survey Study

Background

While HPV vaccination uptake in Sweden is quite high, at around 80%, vaccine hesitancy remains an issue in countries throughout Europe. The latter can be related to a contemporary context of increased contestation of expert knowledge and of a large share of information on health-related issues including vaccination today being sought via the internet. Still, there is a paucity of recent research on attitudes toward the HPV vaccine in a larger sample of the population in Sweden. This survey study assesses such attitudes and any correlations between vaccine hesitancy and sociodemographic characteristics, trust in healthcare and other societal institutions, and evaluation of the reliability of different sources of information.

Methods

The validated survey questionnaire was distributed to adult women in Sweden (n = 2,000), via a nationally representative web panel. The response rate was 37%. Aside from descriptive statistics, associations between vaccine hesitancy and sociodemographic and other variables were computed using logistic regressions and expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs).

Results

Our results show a positive attitude toward HPV vaccination overall. Still, some degree of HPV vaccine hesitancy was indicated by 33.8% of the respondents, and more pronounced hesitancy by 7.6%. Regarding vaccination in general, a very positive attitude was indicated by 55%. HPV vaccine hesitancy was associated with low education and low income and strongly associated with a lack of confidence in healthcare and other societal institutions. It was also correlated with a self-assessed lack of access to, and ability to assess the origin, quality and reliability of, information about the HPV vaccine.

Conclusion

Efforts to provide transparent information about HPV vaccination should be combined with healthcare providers being open to discuss vaccine concerns with patients and avoiding practices that do not promote trust.

Social and behavioural research prospects for sexually transmissible infection prevention in the era of advances in biomedical approaches

In the past two decades, major advances in biomedical intervention approaches to prevent HIV and many sexually transmissible infections (STIs) have shown great promise. However, challenges to prevention remain in the area of achieving population-level impact for biomedical prevention approaches. In this paper we address what social and behavioural research approaches can contribute beyond well-known behaviour change and counselling interventions. We organise work into five areas. Adherence and disinhibition research is primarily into individual-level constructs pertaining to maximising intervention effectiveness. Coverage research represents a population-level construct germane to maximising efficient prioritisation for prevention. Research covering social determinants, a second population-level construct, contributes to both prioritisation and effectiveness. Finally, disparities and social inequities need to be incorporated into prevention, given the pervasive and persistent disparities found in rates of HIV and STIs and in their antecedents.

Knowledge, Attitude and Practice of Main Stakeholders towards Human Papilloma Virus Infection and Vaccination in Mombasa and Tana-River Counties in Kenya: A Qualitative Study

Following a successful Human Papilloma Virus (HPV) vaccination pilot in 2013-2015 in Kitui county, Kenya introduced the HPV vaccine in October 2019 with a goal to immunize approximately 800,000 girls annually against HPV. Our study assessed the knowledge, attitudes, and practice of affected groups towards HPV infection and vaccination in two counties of Kenya. Semi-structured interviews from children aged between nine and thirteen years and key informants comprising of parents, head teachers, community leaders and health workers involved in HPV vaccination in health facilities from Mombasa and Tana-River counties were conducted. Content was analyzed thematically and coded for emerging themes using the QRS Nvivo 12 Plus (QRS International, Doncaster, Australia) software package. From our findings, a significant proportion of participants, especially children, have limited knowledge of the subject. Vaccination of boys was opposed by most participants. Parents and the community members are not in favor of HPV vaccination, as compared to the other groups. A similar pattern of inadequate knowledge and strongly opposed attitudes was observed in Tana-River and Mombasa. Active community involvement in primary prevention strategies may promote the uptake of the vaccine which can be achieved by robust awareness, modifying the negative beliefs about HPV vaccine and encouraging the perceptibility of HPV vaccination.

Relevance of Human Papillomaviruses in Head and Neck Cancer-What Remains in 2021 from a Clinician's Point of View?

Human papillomaviruses (HPV) cause a subset of head and neck cancers (HNSCC). HPV16 predominantly signs responsible for approximately 10% of all HNSCC and over 50% of tonsillar (T)SCCs. Prevalence rates depend on several factors, such as the geographical region where patients live, possibly due to different social and sexual habits. Smoking plays an important role, with non-smoking patients being mostly HPV-positive and smokers being mostly HPV-negative. This is of unparalleled clinical relevance, as the outcome of (non-smoking) HPV-positive patients is significantly better, albeit with standard and not with de-escalated therapies. The results of the first prospective de-escalation studies have dampened hopes that similar superior survival can be achieved with de-escalated therapy. In this context, it is important to note that the inclusion of p16^INK4A (a surrogate marker for HPV-positivity) in the 8th TMN-classification has only prognostic, not therapeutic, intent. To avoid misclassification, highest precision in determining HPV-status is of utmost importance. Whenever possible, PCR-based methods, still referred to as the "gold standard”, should be used. New diagnostic antibodies represent some hope, e.g., to detect primaries and recurrences early. Prophylactic HPV vaccination should lead to a decline in HPV-driven HNSCC as well. This review discusses the above aspects in detail.

Men's willingness to support HPV vaccination and cervical cancer screening in Nigeria

Cervical cancer is the second most common female cancer in Nigeria, even though it can be prevented by vaccination and screening. The uptake of these preventive services is extremely low due to lack of spousal support and cost. Human papilloma virus (HPV) vaccines and cervical screening require finance as health services are mostly paid out of pocket. This study explored Nigerian men's willingness to encourage and pay for family member to obtain HPV vaccine and cervical screening. This is a cross-sectional study of 352 men aged 18-65 years living in 12 communities in the 6-geopolitical region. We found poor perception of HPV risk, and believed their family was not susceptible to cervical cancer. However, the majority (>80%) believed HPV vaccine and cervical screenings are important. Additionally, a good number (>58%) would encourage and pay for their family member to receive HPV vaccine and cervical screening. Residency, educational level and monthly income were significantly associated with willingness to encourage their family to receive HPV vaccine and cervical screening. Also, age group, marital status, residency, educational level and monthly income were significantly associated with the willingness to pay for HPV vaccine and cervical cancer screening. Majority were willing to encourage and pay for their family member to get vaccinated and receive cervical screening. This supports the findings that lack of male involvement may be an overlooked obstacle to cervical cancer prevention in developing countries.

Different Domains of Dengue Research in Malaysia: A Systematic Review and Meta-Analysis of Questionnaire-Based Studies

This review provided a systematic overview of the questionnaire-related dengue studies conducted in Malaysia and evaluated their reliability and validity used in the questionnaires. An extensive literature search was conducted using various electronic databases, including PubMed, EMBASE, Medline, and ScienceDirect. Systematic reviews and meta-analysis (PRISMA) were selected as the preferred item reporting method. Out of 88 identified dengue-related, 57 published from 2000 to April 2020 met the inclusion criteria and were included. Based on the meta-analysis, a poor mean score was obtained for knowledge (49%), attitude (44%), and preventive practice (55%). The study showed that the level of knowledge on cardinal signs and modes of transmission for dengue virus were highest among health care workers, followed by students (international and local) and lastly community residents. In treatment-seeking behaviours, only half of the respondents (50.8%) would send their child to the nearest health clinics or hospitals when a child became restless or lethargic. The acceptance rate for dengue vaccine, bacteria (Wolbachia), as a vector for dengue control and self-test diagnostic kit for dengue showed considerably high (88.4%, 70%, and 44.8%, respectively). Health belief model (HBM) constructs, such as perceived barriers, perceived severity, perceived susceptibility, self-efficacy, and perceived benefit influence prevention practices. Lastly, only 23 articles (40.3%) had piloted or pretested the questionnaire before surveying, in which three reported Cronbach's alpha coefficient (0.70-0.90). A need for active participation of communities and healthcare personnel, promotion of awareness, and safe complementary medicines, as well as assessment of psychometric properties of questionnaire use in dengue surveys in Malaysia, in order for assessing dengue reliably and valid.

Health systems constraints and facilitators of human papillomavirus immunization programmes in sub-Saharan Africa: a systematic review

Given the vast investments made in national immunization programmes (NIPs) and the significance of NIPs to public health, it is important to understand what influences the optimal performance of NIPs. It has been established that well-performing NIPs require enabling health systems. However, systematic evidence on how the performance of health systems impacts on NIPs is lacking, especially from sub-Saharan Africa. We conducted a qualitative systematic review to synthesize the available evidence on health systems constraints and facilitators of NIPs in sub-Saharan Africa, using human papillomavirus immunization programmes as a proxy. Fifty-four articles published between 2008 and 2018 were found to be eligible. Data extraction was guided by an analytical model on the interface between NIPs and health systems. A cross-cutting thematic analysis of the extracted data was performed. This systematic review provides evidence necessary for informing ongoing health systems strengthening initiatives in sub-Saharan Africa. There is evidence to suggest that NIPs in sub-Saharan Africa have surmounted significant health systems constraints and have achieved notable public health success. This success can be attributed to strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist in service delivery, vaccine communication, community engagement, the capacity of the health workforce and sustainable financing. These constraints could derail further progress if not addressed through health systems strengthening efforts. There is a need to expand the research agenda to include the comprehensive evaluation of health systems constraints and facilitators of NIPs within sub-Saharan Africa.

Eradicating cervical cancer: Lessons learned from Rwanda and Australia

Both Rwanda and Australia have made significant strides to eradicate cervical cancer. To understand the successes in Rwanda and Australia, a comparative policy analysis was conducted based on key informant interviews and a review of peer-reviewed literature and policy briefs. Notable findings were identified that offer lessons for countries across the income spectrum. To address cervical cancer, low- and middle-income countries can leverage foreign aid, international collaboration, and strong political advocacy, as Rwanda did. High-income countries can invest in translational research that builds capacity from basic science research to implementation of novel and impactful health products and services, as Australia did. All countries can consider rolling out HPV vaccination by targeting the social and/or physical environment (e.g., a school-based vaccination program, as both Rwanda and Australia did). Cervical cancer is preventable, and eradication is within reach for countries across the income spectrum around the world. Cervical cancer screening programs are needed to minimize the incidence of and mortality from cervical cancer in the short term, and HPV vaccination programs are the best strategy to eradicate cervical cancer in the long term.

Social capital, trust in health information, and acceptance of Measles-Rubella vaccination campaign in Tamil Nadu: A case-control study

Background

Parents' decision about vaccination of children is influenced by social relationships and sources of information. The aim of this study was to assess the influence of social capital and trust in health information on the status of Measles-Rubella (MR) vaccination campaign in Tamil Nadu.

Materials and Methods

This was a case-control study carried out in Kancheepuram district in Tamil Nadu where the MR vaccination campaign offered by Government of Tamil Nadu had poor acceptance. Cases were parents of children who had refused the MR vaccine and controls were parents having children in the same age group who had accepted the vaccine. Data on social capital and trust in health information were collected by using social capital scale developed by the researchers and trust in the source of information was measured by using simple questions on the level of trust in the information source.

Results

Nonadministration of MR vaccine was high among young parents and parents of younger children. Vaccine acceptance was higher when it was offered at school (P < 0.000) and also among parents who trusted school teachers (P < 0.003) and other school children (P < 0.014) as source of information. MR vaccine acceptance was less among parents who trusted social media and WhatsApp information. Greater levels of health-related physical social capital led to greater vaccine hesitancy. Multivariate analysis revealed that greater the age of the child, better parental attitudes toward vaccination, poorer health-related physical social capital, and greater trust in health information provided by school teachers led to overall greater acceptance of the MR vaccine.

Conclusion

Strong homogeneous bonding social capital had a negative influence on MR vaccine acceptance. Schools and school teachers played a vital role in influencing parental decision to vaccinate.

Knowledge, Attitude, and Barriers Towards Human Papillomavirus (HPV) Vaccination Among Youths of Karachi, Pakistan

Introduction Human papillomavirus (HPV) is the most common infection of the reproductive tract. The introduction of HPV vaccines by WHO aims to reduce the incidence of cervical cancer. Pakistan lacks an effective nationwide HPV vaccination program, thereby making HPV a major threat. In this study, we aimed to assess the knowledge of HPV vaccination in Pakistan and to determine the barriers against it. Methods A cross-sectional study was conducted in Karachi, Pakistan, between April and May 2019. A convenience sampling technique was implemented using a self-administered questionnaire, which was filled by individuals aged 18-26. The questionnaire assessed the knowledge regarding HPV and also evaluated the attitude and acceptability amongst these individuals towards the vaccine. Data were analyzed using Statistical Package for Social Sciences (SPSS), version 20.0. Results The majority of the participants belonged to the monthly household income range of 200,000 rupees and above, which was labeled as the high-income category (n=158, 39.5%). Out of the 18 people who were vaccinated, eight belonged to the aforementioned category. Of these 18, nearly two-thirds (n=11, 61.1%) had gotten vaccinated upon the recommendation of their doctor. A statistically significant difference was found only between those currently enrolled in universities and previously vaccinated for HPV (p=.047). Nearly half of the responders perceived the vaccine to be time-consuming (n=167, 41.8%) and overpriced (n=187, 46.8%). Conclusion The vaccination rate is low in Karachi, Pakistan. Concentrated efforts involving the healthcare system should be made to raise awareness regarding HPV and its vaccine thereby reducing barriers to HPV prevention.

Awareness of HPV and Cervical Cancer Prevention Among University Health Sciences Students in Cyprus

Cervical cancer is preventable; however, despite the existence of primary and secondary means of prevention, its incidence is still higher in certain socioeconomic groups and countries, suggesting gaps in cervical cancer prevention. The objective of this study was to evaluate the knowledge and awareness of health sciences university students in Cyprus regarding HPV and cervical cancer in order to better guide the future development of educational programs to improve cervical cancer prevention. This was a cross-sectional study of 178 university health sciences students in Cyprus using a validated questionnaire on HPV and cervical cancer prevention. Analysis of the completed questionnaires revealed moderate levels of knowledge and awareness with an overall mean score of 23.32 out of 33 on HPV and 8.12 out of 13 on cervical cancer, a score of 9.25 out of 14 on HPV vaccines, and a score of 5.93 out of 9 on cervical cancer screening. Older students achieved higher scores compared to younger students (mean score of 6.76 for 18-22 years old, 9.44 for 23-28 years old, and 10.25 for 29-38 years old; p < 0.001). The study found several gaps in the students' knowledge and awareness on cervical cancer prevention. We suggest the design of education programs targeting this population possibly by incorporation of cervical cancer prevention education within students' curriculum to increase knowledge such that the spread of the virus is minimized and these health sciences students are prepared to educate their communities as part of their future practice in health professions.

[HPV: Carcinogenic implications and preventive measures]

Human oncogenic papillomaviruses (HPV) have an increasingly prominent role in the genesis of many cancers. The oncogenic mechanisms associated with HPV are now better known and make it possible to explain the etiopathogenesis of the association. HPV status is now sought for certain cancers and conditions both prognosis and management of patients. Preventive antiviral vaccination has become a real public health issue and aims to effectively reduce the prevalence of cervical, anal and oropharynx cancer, HPV-associated. However, vaccination against HPV still lags behind. The purpose of this review is to redefine the involvement of HPV in several cancers as well as current therapeutic challenges of HPV-related cancers, notably in term of prevention.

Papillomavirus and cancers: should we extend vaccination to boys in France?

Background

In 2006, the HPV (Human papillomavirus) 6/11/16/18 quadrivalent vaccine was approved by the European Medicines Agency and obtained its marketing authorization in both girls and boys. Currently, the French guidelines recommend and refund vaccination of girls aged 11 to 14 with a catch-up program for females from 15 to 19 years old.

Discussion

In France, HPV vaccination coverage tends to decrease. At the end of 2015, the vaccination coverage with three doses reached only 14% in 16-year-old girls (three doses). Although men are also affected by HPV-related diseases such as anal cancer, ano-genital warts, penile cancer or upper aerodigestive tract cancer, vaccine recommendations in France are for girls only. To face the high prevalence of anal cancer and related diseases, the best option is vaccination. Moreover, by offering men a way to prevent diseases against which they do not have any protection yet, universal vaccination could better take into account the ethical issues of prevention. In this paper, we present the point of view of different medical specialties concerning the potential benefit of extending vaccination to boys.

Conclusion

HPV vaccination of both genders could benefit from a better public acceptance and contribute to a better coverage, especially in countries with low vaccination rates.

Novel Approaches for Vaccination Against HPV-Induced Cancers

To date, more than 5 % of all cancers are as a result of human papillomavirus (HPV) infection, and this incidence is increasing. Early recognition of disease is associated with good survival, but late presentation results in devastating consequences. Prevention is better than cure, and there are now successful prophylactic vaccination programmes in place. We discuss these and the prospect of therapeutic vaccinations in the near future to address a growing need for improved therapeutic options.

Toward economic evaluation of the value of vaccines and other health technologies in addressing AMR

We discuss the need to make economic evaluations of vaccines antimicrobial resistance (AMR)-sensitive and ways to do so. Such AMR-sensitive evaluations can play a role in value-for-money comparisons of different vaccines within a national immunization program, or in comparisons of vaccine-centric and non-vaccine-centric technologies within an anti-AMR program. In general terms, incremental cost-effectiveness ratios and rates of return and their associated decision rules are unaltered by consideration of AMR-related value. The decision metrics need to have their various health, cost, and socioeconomic terms disaggregated into resistance-related subcategories, which in turn have to be measured carefully before they are reaggregated. The fundamental scientific challenges lie primarily in quantifying the causal impact of health technologies on resistance-related health outcomes, and secondarily in ascertaining the economic value of those outcomes. We emphasize the importance of evaluating vaccines in the context of other potentially complementary and substitutable nonvaccine technologies. Complementarity implies that optimal spending on each set of interventions is positive, and substitutability implies that the ratio of spending will depend on relative value for money. We exemplify this general point through a qualitative discussion of the complementarities and (especially the) substitutability between pneumococcal conjugate vaccines and antimicrobial stewardship and between research and development (R&D) of a gonorrhea vaccine versus R&D of a gonorrhea antibiotic. We propose a roadmap for future work, which includes quantifying the causal effects of vaccination and other health technologies on short-term and long-term resistance-related outcomes, measuring the health-sector costs and broader socioeconomic consequences of resistance-related mortality and morbidity, and evaluating vaccines in the context of nonvaccine complements and substitutes.

Persuasive messaging for human papillomavirus vaccination by adolescent providers in a five-country multi-site study

OBJECTIVE

Strong persuasive messaging by providers is a key predictor for patient acceptance of prophylactic human papillomavirus vaccination. We aimed to determine optimal messaging to promote human papillomavirus adolescent vaccination across different geographical sites.

METHODS

Adolescent providers (n = 151) from Argentina, Malaysia, South Africa, South Korea, and Spain were surveyed on messages, family decision makers, and sources of communication to best motivate parents to vaccinate their adolescent daughters overall, and against human papillomavirus. Multivariate logistic regression assessed the likelihood of recommending messages specifically targeted at cervical cancer with providers' characteristics: gender, medical specialization, and previous administration of human papillomavirus vaccination.

RESULTS

Mothers were considered the most important human papillomavirus vaccination decision makers for their daughters (range 93%-100%). Television was cited as the best source of information on human papillomavirus vaccination in surveyed countries (range 56.5%-87.1%), except Spain where one-on-one discussions were most common (73.3%). Prevention messages were considered the most likely to motivate parents to vaccinate their daughters overall, and against human papillomavirus, in all five countries (range 30.8%-55.9%). Optimal messages emphasized cervical cancer prevention, and included strong provider recommendation to vaccinate, vaccine safety and efficacy, timely vaccination, and national policy for human papillomavirus vaccination. Pediatricians and obstetricians/gynecologists were more likely to cite that the best prevention messages should focus on cervical cancer (OR: 4.2, 95% CI: 1.17 to 15.02 vs other medical specialists).

CONCLUSIONS

Provider communication messages that would motivate parents to vaccinate against human papillomavirus were based on strong recommendation emphasizing prevention of cervical cancer. To frame convincing messages to increase vaccination uptake, adolescent providers should receive updated training on human papillomavirus and associated cancers, while clearly addressing human papillomavirus vaccination safety and efficacy.

Low coverage of HPV vaccination in the national immunization programme in Brazil: Parental vaccine refusal or barriers in health-service based vaccine delivery?

Background

The World Health Organization has recommended the introduction of HPV vaccines into national immunization programme (NIP), but vaccination coverage remains low worldwide. We assessed the coverage and the parental acceptance of female and male HPV vaccination in Brazil after its introduction into the NIP.

Methods

We conducted a random-digit-dial survey of parents in seven major Brazilian cities from July-2015 to October-2016. A knowledge, attitude and practices questionnaire was developed and validated by expert analysis, semantic analysis, and pre-testing.

Results

826 out of 2,324 (35.5%) eligible parents completed the interview. Parental acceptance of the HPV vaccine for daughters and sons 18 years of age or less was high (92% and 86%, respectively). Parents refusing vaccination were less likely to know that: HPV is sexually transmitted and causes genital warts, HPV vaccination is more beneficial before sexual debut, and HPV vaccine reactions are minor, and they were more likely to believe HPV vaccination can cause severe adverse events. Parents accepting HPV vaccine for daughters but not forsons were more likely to ignore that the vaccine is recommended for boys. Attitudes associated with HPV vaccine acceptance included: general belief in vaccines, trust in the NIP and in the HPV vaccine efficacy. Among girls eligible for HPV vaccination through the NIP, 58.4% had received a two-dose scheme and 71.1% at least one dose. “No vaccination/missed vaccination at school” was the most common reason for missed HPV vaccination in theNIP.

Conclusions

One year after introduction in the NIP, most parents surveyed in Brazil accepted HPV vaccination for their daughters and sons. Low coverage in the NIP seemed to be due to challenges in adolescent vaccine delivery and HPV vaccination barriers at health-care centers, rather than to vaccine refusal.

Different Culture or Different Mind? Perception and Acceptance of HPV Vaccine in China and in the U.S

Unlike the United States, where human papillomavirus (HPV) vaccines have been available for decades, China recently approved its first HPV vaccines. Setting up a baseline comparison between these two countries, this study examines the influence of message framing, motivational orientation, cultural worldview, knowledge, and gender on young adults' intentions to get vaccinated. Compared to the U.S. participants, Chinese participants perceived HPV as a more severe risk and were more willing to get the vaccine. However, they were also more skeptical about vaccine safety. Inconsistencies with previous research emerged regarding the moderating effects of motivational orientation and cultural worldview. Findings from this study offer important implications for HPV vaccine promotion in China.

Acceptability of two- versus three-dose human papillomavirus vaccination schedule among providers and mothers of adolescent girls: a mixed-methods study in five countries

PURPOSE

The World Health Organization revised its human papillomavirus (HPV) vaccination recommendations to include a two (2-) dose schedule for girls aged ≤ 15 years. We investigated acceptability of 2- versus 3-dose schedule among adolescent vaccination providers and mothers of adolescent girls in five countries.

METHODS

Adolescent vaccination providers (N = 151) and mothers of adolescent girls aged 9-14 years (N = 118) were recruited from Argentina, Malaysia, South Africa, South Korea, and Spain. We assessed providers' preference for a 2- versus 3-dose HPV vaccination schedule via quantitative surveys. Mothers' attitudes towards a 2-dose schedule were assessed through focus group discussions.

RESULTS

Most adolescent providers preferred a 2- over a 3-dose HPV vaccination schedule (overall: 74%), with preference ranging from 45.2% (South Africa) to 90.0% (South Korea). Lower cost, fewer clinic visits, and higher series completion were commonly cited reasons for 2-dose preference among providers and mothers. Safety and efficacy concerns were commonly cited barriers to accepting a 2-dose HPV vaccination schedule among providers and mothers. Mothers generally accepted the reduced schedule, however requested further information from a trusted source.

CONCLUSIONS

Adolescent vaccination providers and mothers preferred the 2-dose over 3-dose HPV vaccination schedule. Acceptability of a 2-dose HPV vaccination could be improved with additional information to providers and mothers on HPV vaccination safety and efficacy.

Effects of an Online Educational Module on School Nurses' Knowledge of HPV Vaccination

BACKGROUND

Results of a previous state-wide survey revealed generally low knowledge levels about HPV vaccination among school nurses in Missouri. A short, online educational module targeted to address the specific low-scoring items was then created.

METHOD

All 440 lead school nurses in Missouri were invited by e-mail to participate in an online HPV educational module and study. The e-mail contained a link to the module that included a consent form, a test, and a downloadable completion certificate. The test consisted of 12 multiple choice and true-or-false items based directly on the content contained in the module. An independent samples t test was used to determine pre-post differences in mean test scores.

RESULTS

Scores improved significantly (p < .05) pre-post intervention; however, surveillance or epidemiology-related questions were still commonly missed.

CONCLUSION

Using brief, targeted, online trainings to improve knowledge of specific health-related content may be a practical option for busy school nurses. J Contin Educ Nurs. 2017;48(9):431-436.

Knowledge and Acceptance of Human Papillomavirus Vaccine for Cervical Cancer Prevention Among Urban Professional Women in Bangladesh: A Mixed Method Study

Prophylactic human papillomavirus (HPV) vaccination is the most effective preventive method against invasive cervical cancer, the second leading cause of cancer-related deaths among women in Bangladesh. Evidence on women's knowledge and perception about cervical cancer and HPV vaccination are needed for effective implementation of national cervical cancer prevention programs. The objective of this study was to assess the knowledge, attitude, and acceptance of cervical cancer, HPV, and HPV vaccination among urban professional women in Bangladesh. We recruited 160 female professionals employed at selected private banks in Bangladesh. Participants were selected using nonprobability-based convenience sampling for interviews through a self-administered questionnaire. Later, in-depth interviews were conducted with nine of these women. Quantitative data were analyzed utilizing descriptive statistics, whereas qualitative data were analyzed using a thematic approach. Ninety-eight percent of participants reported that they had previously heard of cervical cancer, however, only half (51%) reported to have heard of HPV as a cause of the disease. Less than 1% of the 160 participants had previously undergone a pap smear, and only 2% were vaccinated with at least one dose of HPV vaccination. Although knowledge was low, intention for acceptance of vaccination was moderate for women and high for their children. Although the majority of women had heard of cervical cancer, few women had in-depth knowledge of HPV and the etiology of invasive disease. This study draws attention to the urgent need of educational interventions on cervical cancer and its prevention to improve uptake of available HPV vaccination in Bangladesh.

Lessons learned from domestic and international human papillomavirus vaccination programs: a review

Since the development of the human papillomavirus vaccine, many countries have created implementation programs to bolster vaccination rates and protect their populations. Despite demonstrated efficacy with decreased human papillomavirus-related disease abroad, the vaccine's potential to prevent morbidity and mortality in the United States is not being met. The purpose of this review is to discuss strategies of both international and domestic vaccination programs, their impact on human papillomavirus-related diseases, the unique obstacles faced by the United States, and future directions for success.

Parental perspective on human papillomavirus (HPV) vaccination in Serbia: Knowledge, attitudes and practice

STUDY OBJECTIVE

Assessing knowledge and attitudes of parents towards human papillomavirus (HPV) vaccination of their children and estimating factors associated with parental positive attitude towards HPV immunization.

STUDY DESIGN

Cross-sectional.

SETTING

Two Community Health Centers. A total of 282 adult parents of boys and/or girls who presented at the pediatrician's office with their child aged ≤18 years from December 2015 to May 2016.

MAIN OUTCOME MEASURES

HPV vaccination coverage with one dose, knowledge and attitudes towards HPV vaccination. Parental knowledge was tested through a set of 10 items such as the infectious nature of HPV, mode of transmission, symptoms and its association with cervical cancer and circumstances surrounding HPV vaccine in Serbia. Answers were graded on a 5-point Likert scale from "strongly disagree" to "strongly agree".

RESULTS

Coverage with one dose of HPV vaccine was 2.0%. Majority of parents knew that the vaccine existed (71.0%). One quarter of parents confirmed that their child should be vaccinated against HPV. Parents expressed highest level of agreement with the statement that HPV vaccination in Serbia is not sufficiently promoted (4.17 ± 1.21 points). Having female child and more knowledge on HPV were independently associated with positive attitude towards vaccination among parents of children aged <9 years. Having received recommendation for HPV vaccination from a pediatrician was independently associated with positive attitude towards HPV vaccination among parents of children aged ≥9 years.

CONCLUSION

Coverage with one dose of HPV vaccine is low. Health-care authorities are urged to consider inclusion of HPV vaccination in immunization schedule.

Safety and Immunogenicity of the HPV-16/18 AS04-adjuvanted Vaccine in 4-6-year-old Girls: Results to Month 12 From a Randomized Trial

BACKGROUND

The burden of cervical cancer caused by human papillomavirus (HPV) is high in Latin America. The suboptimal HPV vaccination coverage in adolescents could be improved by pediatric immunization. HPV vaccination has not yet been reported in girls <9 years of age.

METHODS

This ongoing phase III, controlled, randomized, single-blind, multicenter study conducted in Colombia, Mexico and Panama (NCT01627561) evaluated the safety and immunogenicity of AS04-HPV-16/18 vaccine in 4-6-year-old girls. Healthy girls (randomized 1:1) received either 2 doses of AS04-HPV-16/18 vaccine (HPV group, N=74) or 1 dose of each measles-mumps-rubella and diphtheria-tetanus-acellular-pertussis vaccines (control group, N=74) 6 months apart. We report the safety and serum anti-HPV-16 and anti-HPV-18 antibodies (measured by enzyme-linked immunosorbent assay) up to 6 months postvaccination, that is, month (M) 12.

RESULTS

Injection site pain was the most frequently reported solicited local symptom in HPV vaccinees. The incidence of other solicited and unsolicited symptoms after each vaccination was similar between the HPV and control group. Until M12, 1 girl in the HPV group and 2 in the control group reported serious adverse events; all serious adverse events were assessed as unrelated to study vaccines. No potential immune-mediated diseases were identified. All girls seroconverted for both antigens after 2 doses of AS04-HPV-16/18. In initially seronegative girls, anti-HPV-16 geometric mean concentrations were 20080.0 enzyme-linked immunosorbent assay units (EU)/mL at M7 and 3246.5 EU/mL at M12; anti-HPV-18 geometric mean concentrations were 10621.8 EU/mL at M7 and 1216.6 EU/mL at M12.

CONCLUSIONS

Two-dose vaccination with AS04-HPV-16/18 was well tolerated and induced adequate antibody responses in 4-6-year-old girls.

Chinese medical students' knowledge, attitude and practice towards human papillomavirus vaccination and their intention to recommend the vaccine

AIM

The human papillomavirus (HPV) vaccine is effective in preventing cervical cancer, but its global uptake rate in vulnerable populations is unsatisfactory. Physician's recommendation is an important determinant for vaccine uptake, but we have limited understanding on the contributing factors of physician's recommendation. This study investigated whether the knowledge, attitudes and vaccination status of medical students would affect their intention to recommend HPV vaccination.

METHODS

This is a population-representative survey of medical schools in Hong Kong.

RESULTS

Participants included 1022 Chinese medical students (46.9% of all in Hong Kong; 46.3% female). Better HPV-related knowledge and a more positive attitude towards HPV vaccination were important factors predicting vaccine uptake and intention to recommend. HPV vaccination status and intention to receive the vaccine were positively associated with intention to recommend among females.

CONCLUSION

Better HPV-related medical education may be a feasible way to promote the HPV vaccine in regions without universal coverage. Medical students who have not received the HPV vaccine should also be encouraged to receive the vaccine.

Factors influencing intention to obtain the HPV vaccine in South East Asian and Western Pacific regions: A systematic review and meta-analysis

Since licensing in 2006, there has been poor uptake of the HPV vaccine among the targeted population in the South East Asia Region (SEAR) and Western Pacific Region (WPR). A systematic review was conducted to identify the studies exploring the relationship between factors and intention for HPV vaccination among women in SEAR and WPR countries. Nineteen studies were identified as suitable for qualitative synthesis, and three as suitable for meta-analysis. Most women had a positive intention to have an HPV vaccine (range 57%-85%). Having a positive intention to vaccinate was significantly higher among women not aware of HPV infection (OR: 1.34, 95% CI: 1.02-1.76) and HPV vaccine (OR: 1.57, 95% CI: 1.26-1.96). Lower knowledge level and less confidence in safety and efficacy of the vaccine, negatively affected intention to vaccinate. Perceiving the vaccine to be expensive, low perception of contracting HPV infection and cervical cancer, and lack of concrete recommendations from healthcare providers also negatively affected intention to vaccinate. This review suggests the decision-making processes of women in SEAR and WPR is influenced by the cost of vaccination, perceived efficacy and safety of vaccine, provision of information on vaccination, and the awareness about HPV infection and the HPV vaccine.

Effective phthalocyanines mediated photodynamic therapy with doxorubicin or methotrexate combination therapy at sub-micromolar concentrations in vitro

To improve a cancer patient's quality of life, short treatment duration resulting in rapid tumour removal while sparing normal tissue are highly desirable. Photodynamic therapy (PDT) commonly applied in a single treatment, while often effective can be limited at low photosensitizer or light doses. Combination therapies can overcome the efficacy limitations while not increasing treatment-associated morbidity. Here the efficacy of combination therapy comprised of doxorubicin (DOX) or methotrexate (MTX) with Photosens mediated PDT was investigated in three cell lines in vitro, employing multiple incubation sequences. Photosense is a mixture of aluminium phthalocyanines with different sulfonation. The results demonstrated higher synergistic effects when DOX or MTX-mediated chemotherapy preceded PDT light activation by 24 h. MTX is marginally more cytotoxic than DOX, when combined with Photosens (AlPcS_2-4) mediated PDT. While MTX and DOX exposure prior to AlPcS_2-4 incubation may enhance mitochondrial localisation photosensitizer, the simultaneous targeting of DNA, proteins, and lipids of the combination therapies leads to the observed high cytotoxicity at sub μM drug doses.

Knowledge of cervical cancer and HPV vaccine in Bangladeshi women: a population based, cross-sectional study

BACKGROUND

The objective of this study was to assess the level of knowledge of cervical cancer among Bangladeshi women and to assess their willingness to receive the human papillomavirus (HPV) vaccine.

METHODS

A population-based, cross-sectional survey was conducted from July to December 2011 in one urban and one rural area of Bangladesh. A total of 2037 ever-married women, aged 14 to 64 years, were interviewed using a structured questionnaire. Data on socio-demographic characteristics and knowledge of cervical cancer were collected. Willingness to receive the HPV vaccine was assessed. Univariate analyses were completed using quantitative data collected. Multivariable logistic regression models were developed to identify factors associated with having heard of cervical cancer and the HPV vaccine.

RESULTS

The majority of study participants reported to have heard of cervical cancer (urban: 89.7%, rural 93.4%; P = 0.003). The odds of having heard of cervical cancer were significantly higher in urban women aged 35-44 years (aOR: 2.92 (1.34-6.33) and rural women aged 25-34 years (aOR: 2.90 (1.24-6.73) compared to those aged less than 24 years. Very few women reported to have detailed knowledge on risk factors (urban:9.1%, rural: 8.8%) and prevention (urban: 6.4%, rural: 4.4%) of cervical cancer. In our sample, one in five urban women and one in twenty rural women heard about a vaccine that can prevent cervical cancer. Among urban women, secondary education or higher (aOR: 3.48, 95% CI: 1.67-7.25), age of 20 years and above at marriage (aOR: 2.83, 95% CI: 1.61-5.00), and high socioeconomic status (aOR: 2.25, 95% CI: 1.28-3.95) were factors associated with having heard of the HPV vaccine. Willingness to receive the HPV vaccine among study participants either for themselves (urban: 93.9%, rural: 99.4%) or for their daughters (urban: 91.8%, rural: 99.2%) was high.

CONCLUSIONS

Detailed knowledge of cervical cancer among Bangladeshi women was found to be poor. Education on cervical cancer must include information on symptoms, risk factors, and preventive methods. Despite poor knowledge, the study population was willing to receive the HPV vaccine.

Factors involved in human papillomavirus (HPV) vaccine hesitancy among women in the South-East Asian Region (SEAR) and Western Pacific Region (WPR): A scoping review

A scoping review was performed to identify factors that may lead to human papillomavirus (HPV) vaccine hesitancy among women in low- and middle-income countries in South East Asian Region (SEAR) and Western Pacific Region (WPR). A systematic search of English and non-English articles using Pubmed, EMBASE, PsycINFO, Cochrane, MEDLINE, and CINAHL plus was conducted. Only 63 studies conducted in SEAR and WPR were included from inception until December 2016. Results of these studies have shown that poor awareness and knowledge of practices on cervical cancer prevention was evident in both SEAR and WPR. Concerns on safety and efficacy of the vaccine, and costs in getting vaccinated were significant barriers. Most women stated that they needed more information, and strongly welcomed a physician's recommendation in both geographical regions. Women also felt they have a low risk of acquiring HPV infection and cervical cancer. Most women in SEAR and WPR were unable to decide on whether to accept HPV vaccination.

Adherence to ACIP Recommendation for Human Papillomavirus Vaccine Among US Adolescent Girls

The objective of this study was to examine correlates of human papillomavirus (HPV) vaccine use according to Advisory Committee on Immunization Practices (ACIP)'s recommendations among US adolescent girls. We used National Immunization Survey of Teens 2013 data. Based on provider-verified (n = 9403) information, 57.3, 39.1 and 19.0 % of adolescent girls, initiated, completed and completed the HPV vaccine according to ACIP's recommendation (by age 12), respectively. Hispanic race/ethnicity, a physician recommendation for HPV vaccine and ≥1 influenza vaccine in the past 3 years were all associated with a higher likelihood of compliance with ACIP's recommendation. Girls from a larger family and those whose immunization provider was a STD/school/teen clinic were less likely to receive the vaccine at the recommended age compared to a girl raised in a smaller sized family and received immunization from a hospital facility, respectively. Only one-fifth of 13-17 yo girls receive the HPV vaccine by age 12 as recommended by ACIP. Physician visits and influenza vaccination settings are opportunities to improve vaccine series completion at the recommended age.

Comparative immunogenicity and safety of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine and 4vHPV vaccine administered according to two- or three-dose schedules in girls aged 9-14 years: Results to month 36 from a randomized trial

This observer-blind study (clinicaltrials.gov NCT01462357) compared the immunogenicity and safety of two doses (2D) of the HPV-16/18 AS04-adjuvanted vaccine (2D of AS04-HPV-16/18) vs. two or three doses of the 4vHPV vaccine [2D or 3D of 4vHPV] in 1075 healthy girls aged 9-14 years. Girls were randomized (1:1:1) to receive 2D of AS04-HPV-16/18 at months (M) 0, 6 (N = 359), 2D of 4vHPV at M0, 6 (N = 358) or 3D of 4vHPV at M0, 2, 6 (N = 358). 351, 339 and 346 girls, respectively, returned for the concluding visit at M36. Superiority was demonstrated at M7 and M12; comparison of the immune response to both vaccine antigens was made between 2D of AS04-HPV-16/18 and 2D or 3D of 4vHPV at subsequent time points in the according-to-protocol immunogenicity cohort (ATP-I; N = 958 at M36) and the total vaccinated cohort (TVC: N = 1036 at M36). HPV-16/18-specific T-cell- and B-cell-mediated immune responses and safety were also investigated. At M36, anti-HPV-16/18 ELISA responses in the 2D AS04-HPV-16/18 group remained superior to those of the 2D and 3D 4vHPV groups. In the M36 TVC, geometric mean titers were 2.78-fold (HPV-16) and 6.84-fold (HPV-18) higher for 2D of AS04-HPV-16/18 vs. 2D of 4vHPV and 2.3-fold (HPV-16) and 4.14-fold (HPV-18) higher vs. 3D of 4vHPV. Results were confirmed by vaccine pseudovirion-based neutralisation assay. Numbers of circulating CD4⁺ T cells and B cells appeared similar across groups. Safety was in line with the known safety profiles of both vaccines. In conclusion, superior HPV-16/18 antibody responses were elicited by 2D of the AS04-HPV-16/18 compared with 2D or 3D of the 4vHPV vaccine in girls aged 9-14 years.

CLINICAL TRIAL REGISTRATION

NCT0146235.

To vaccinate or not to vaccinate? Perspectives on HPV vaccination among girls, boys, and parents in the Netherlands: a Q-methodological study

BACKGROUND

Despite the introduction of Human papillomavirus (HPV) vaccination in national immunization programs (NIPs), vaccination rates in most countries remain relatively low. An understanding of the reasons underlying decisions about whether to vaccinate is essential in order to promote wider spread of HPV vaccination. This is particularly important in relation to policies seeking to address shortfalls in current HPV campaigns. The aim of this study was to explore prevailing perspectives concerning HPV vaccination among girls, boys, and parents, and so to identify potential determinants of HPV vaccination decisions in these groups.

METHOD

Perspectives were explored using Q-methodology. Forty-seven girls, 39 boys, and 107 parents in the Netherlands were asked to rank a comprehensive set of 35 statements, assembled based on the health belief model (HBM), according to their agreement with them. By-person factor analysis was used to identify common patterns in these rankings, which were interpreted as perspectives on HPV vaccination. These perspectives were further interpreted and described using data collected with interviews and open-ended questions.

RESULTS

The analysis revealed four perspectives: "prevention is better than cure," "fear of unknown side effects," "lack of information and awareness," and "my body, my choice." The first two perspectives and corresponding determinants of HPV vaccination decisions were coherent and distinct; the third and fourth perspectives were more ambiguous and, to some extent, incoherent, involving doubt and lack of awareness and information (perspective 3), and overconfidence (perspective 4).

CONCLUSIONS

Given the aim of publically funded vaccination programs to minimize the spread of HPV infection and HPV-related disease and the concerns about current uptake levels, our results indicate that focus should be placed on increasing awareness and knowledge, in particular among those in a modifiable phase.

Cost-effectiveness of two-dose human papillomavirus vaccination in Singapore

INTRODUCTION

Cervical cancer is the tenth most common cancer and the eighth most frequent cause of death among women in Singapore. As human papillomavirus (HPV) infection is the necessary cause of cervical cancer, the risk of cervical cancer can be substantially reduced through vaccination. This study was conducted to evaluate the cost-effectiveness of two-dose HPV vaccination as part of a national vaccination programme for 12-year-old girls in Singapore, from the perspective of the healthcare payer.

METHODS

A lifetime Markov cohort model was used to evaluate the cost-effectiveness of introducing the AS04-adjuvanted HPV-16/18 vaccine (AS04-HPV-16/18v) to the current cervical screening programme in Singapore. Furthermore, the cost-effectiveness of the AS04-HPV-16/18v was compared with the HPV-6/11/16/18 vaccine (4vHPV). Model inputs were derived from local data, where possible, and validated by clinical experts in Singapore.

RESULTS

Introduction of the AS04-HPV-16/18v in Singapore was shown to prevent 137 cervical cancer cases and 48 cervical cancer deaths when compared with screening alone. This resulted in an incremental cost-effectiveness ratio of SGD 12,645 per quality-adjusted life year (QALY) gained, which is cost-effective according to the World Health Organization threshold for Singapore. When discounted at 3%, AS04-HPV-16/18v was dominant over 4vHPV, with cost savings of SGD 80,559 and 28 additional QALYs gained. In the one-way sensitivity analysis, AS04-HPV-16/18v remained cost-effective compared with screening alone and dominant compared with 4vHPV.

CONCLUSION

AS04-HPV-16/18v is the most cost-effective choice for reducing the burden of cervical cancer through universal mass vaccination for 12-year-old girls in Singapore.

Human Papillomavirus Vaccination Uptake in Canada: A Systematic Review and Meta-analysis

Human papillomavirus (HPV) is the most commonly sexually transmitted infection in the world and the primary cause of cervical cancer. Canada introduced publicly funded HPV vaccination programs in 2006. The objectives of this study are twofold and aim to (1) determine the levels and (2) examine the various factors influencing vaccine uptake among the general Canadian population. A literature search was conducted on seven databases, followed by screening, methodological quality review (using modified Newcastle-Ottawa Scale), and data extraction. Pooled meta-analysis and a subgroup analysis were conducted stratifying by a number of variables (age, sex, type of program, and method of payment) determined apriori. A total of 718 peer-reviewed articles were initially identified with 12 remaining after screening and underwent methodological quality review. HPV vaccination uptake in Canada varied from 12.40% (95% confidence interval [CI] 6.77–20.26) to 88.20% (95% CI 85.72–90.39). The pooled random effects model showed the HPV vaccination uptake to be 55.92% (95% CI 44.87–66.65). The subgroup analysis showed that vaccination uptake was 66.95% (95% CI 55.00–77.89) in participants ≤ 18 years as compared to 13.58% (95% CI 10.93–16.46) in participants > 18 years. Uptake for females was higher 57.23% (95% CI: 45.40–68.66) when compared to that of 47.01% (95% CI: 0.82–97.75) in males. HPV vaccine uptake among school-based programs was 69.62% (95% CI 57.27–80.68) as compared to 18.66% (95% CI 6.66–34.92) for community-based programs. Vaccination uptake for publicly funded programs was significantly higher 66.95% (95% CI 55.00–77.89) when compared to 13.58% (95% CI 10.92–16.46) for programs where participants had to pay out of pocket. To prevent infections and reduce the burden of HPV-related diseases (including cervical cancer), communities should be made aware and encouraged to vaccinate their children. There is a documented need to direct effort and focus interventions toward improving HPV vaccination uptake in Canada.

Association between human papillomavirus and prostate cancer: A meta-analysis

Observational studies have suggested an association between human papillomavirus (HPV) infection and the risk of prostate cancer (PCa). However, the association between HPV infection and the risk of PCa remains unclear. The aim of the present meta-analysis study was to investigate whether HPV serves a role in increasing the risk of PCa. Relevant previous studies up to May 2015 were searched in PubMed, Web of Science, Cochrane library, Chinese National Knowledge Infrastructure, China Wan Fang database and China Biomedical Literature Database. A random-effects model or fixed-effects model was employed to determine odds ratios (ORs) with 95% confidence intervals (CIs), when appropriate. Heterogeneity was evaluated using Q and I2 statistical analysis. A total of 24 case-control studies involving 971 patients and 1,085 controls were investigated to estimate the association between HPV infection and PCa risk. The pooled estimate for OR was 2.27 (95% CI, 1.40-3.69). Stratified pooled analyses were subsequently performed according to the HPV detection methods, geographical regions, publication years and types of tissue. Sensitivity analysis based on various exclusion criteria maintained the significance with respect to PCa individually. Little evidence of publication bias was observed. The meta-analysis suggested that HPV infection is associated with increasing risk of PCa, which indicated a potential pathogenetic link between HPV and PCa.

Ecological validity of cost-effectiveness models of universal HPV vaccination: A systematic literature review

BACKGROUND

The protective (herd) effect of the selective vaccination of pubertal girls against human papillomavirus (HPV) implies a high probability that one of the two partners involved in intercourse is immunised, hence preventing the other from this sexually transmitted infection. The dynamic transmission models used to inform immunisation policy should include consideration of sexual behaviours and population mixing in order to demonstrate an ecological validity, whereby the scenarios modelled remain faithful to the real-life social and cultural context. The primary aim of this review is to test the ecological validity of the universal HPV vaccination cost-effectiveness modelling available in the published literature.

METHODS

The research protocol related to this systematic review has been registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42016034145). Eight published economic evaluations were reviewed.

RESULTS

None of the studies showed due consideration of the complexities of human sexual behaviour and the impact this may have on the transmission of HPV.

DISCUSSION

Our findings indicate that all the included models might be affected by a different degree of ecological bias, which implies an inability to reflect the natural demographic and behavioural trends in their outcomes and, consequently, to accurately inform public healthcare policy. In particular, ecological bias have the effect to over-estimate the preference-based outcomes of selective immunisation. A relatively small (15-20%) over-estimation of quality-adjusted life years (QALYs) gained with selective immunisation programmes could induce a significant error in the estimate of cost-effectiveness of universal immunisation, by inflating its incremental cost effectiveness ratio (ICER) beyond the acceptability threshold. The results modelled here demonstrate the limitations of the cost-effectiveness studies for HPV vaccination, and highlight the concern that public healthcare policy might have been built upon incomplete studies.

Acceptability of multipurpose human papillomavirus vaccines among providers and mothers of adolescent girls: A mixed-methods study in five countries

Introduction

Multipurpose vaccines (MPVs) could be formulated to prevent multiple sexually transmitted infections simultaneously. Little is known about acceptability of MPVs among vaccine health care providers (HCPs) or mothers of adolescent girls.

Methods

151 adolescent vaccine providers and 118 mothers of adolescent girls aged 9–14 were recruited from five geographically-diverse countries: Argentina, Malaysia, South Africa, South Korea, and Spain. We assessed providers’ preferences for single-purpose human papillomavirus (HPV) vaccine versus MPVs (including HPV+herpes simplex virus (HSV)−2, HPV+HIV, or HPV+HSV-2+HIV) via quantitative surveys. Maternal MPV attitudes were assessed in four focus group discussions (FGDs) in each country.

Results

Most providers preferred MPVs over single-purpose HPV vaccination, with preference ranging from 61% in Malaysia to 96% in South Africa. HPV+HSV-2+HIV was the most preferred MPV formulation (56–82%). Overall, 53% of the mothers preferred MPVs over single-purpose HPV vaccines, with strongest support in South Africa (90%) and lowest support in South Korea (29%). Convenience and trust in the health care system were commonly-cited reasons for MPV acceptability. Safety and efficacy concerns were common barriers to accepting MPVs, though specific concerns differed by country. Across FGDs, additional safety and efficacy information on MPVs were requested, particularly from trusted sources like HCPs.

Conclusions

Though maternal acceptability of MPVs varied by country, MPV acceptability would be enhanced by having HCPs provide parents with additional MPV vaccine safety and efficacy information. While most providers preferred MPVs, future health behavior research should identify acceptability barriers, and targeted provider interventions should equip providers to improve vaccination discussions with parents.

•

We gauged acceptance of a multipurpose vaccine (MPV) concept to prevent HPV and STIs.

•

Most vaccine providers were willing to administer an MPV for HPV, HSV-2, and HIV.

•

Mothers of teen girls desired safety and efficacy evidence before accepting MPVs.

•

In mothers, MPV acceptability differed by region and daughter's vaccination history.

Health professional feedback on HPV vaccination roll-out in a developing country

BACKGROUND

Worldwide, Zambia has the highest cervical cancer incidence rates (58.4/100,000 per year) and mortality rates (36.2/100,000 per year). The human papilloma virus (HPV) vaccine is considered a vital preventative measure against cervical cancer, particularly in sub-Saharan countries, such as Zambia. Past research suggests health professionals' experiences with HPV vaccination rollout can have practical implications for effective delivery.

OBJECTIVE

To explore health professionals' perspectives on the HPV vaccination programme in Zambia.

METHODS

Researcher travelled to Zambia and conducted semi-structured interviews with fifteen health professionals working in private, government, and missionary clinics/hospitals. Observation was conducted for triangulation purposes. Thematic analysis was used to analyse the data.

FINDINGS

Five main themes emerged; medical misconceptions about the HPV vaccination, particularly with regards to infertility; fear of the unknown, including possible side effects and inadequate empirical research; need for prior desensitisation to resolve cultural barriers prior to vaccination rollout; a rural-urban divide in health awareness, particularly in relation to cancer vaccines; and economic concerns associated with access to the HPV vaccination for most of the Zambian population.

CONCLUSION

Overall, the findings indicate that an essential avenue for facilitating HPV vaccination rollout in Zambia is by implementing a pre-rollout community effort that removes or softens cultural barriers, particularly in rural areas. It is also essential to correct erroneous HPV presumptions health professionals may have around infertility. Affordability remains a seemingly intractable hindrance that hampers HPV vaccination rollout in Zambia.

Results of a Multilevel Intervention Trial to Increase Human Papillomavirus (HPV) Vaccine Uptake among Adolescent Girls

BACKGROUND

Uptake of the human papillomavirus (HPV) vaccine is low in Appalachian Ohio and areas with high cervical cancer rates.

METHODS

We conducted a group-randomized trial among 12 counties in Appalachian Ohio randomized to receive either an HPV vaccine (intervention counties) or influenza vaccine (comparison counties) multilevel intervention (MLI). Parents (n = 337) who had a daughter aged 9 to 17 years who had not received the HPV vaccine were recruited from commercial lists. Clinics (N = 24) and 119 providers from these clinics were also recruited. The primary outcome was medical record-confirmed receipt of the first shot of the HPV vaccine 3 months after receiving the intervention among daughters of parents enrolled in the study. Secondary outcomes included receipt of the first HPV vaccine shot by 6 months and changes in provider knowledge.

RESULTS

According to medical records, 10 (7.7%) daughters of intervention participants received the first shot of the HPV vaccine within 3 months of being sent the intervention materials compared with 4 (3.2%) daughters of comparison group participants (P = 0.061). By 6 months, 17 (13.1%) daughters of intervention participants received the first HPV vaccine shot compared with eight (6.5%) daughters of comparison group participants (P = 0.002). Provider knowledge about HPV increased (P < 0.001, from baseline to after education).

CONCLUSIONS

The MLI increased uptake of the HPV vaccine among girls aged 9 to 17 years; however, uptake was low.

IMPACT

To improve HPV vaccine uptake, attention to additional levels of influence (e.g., policy, community) and more elements within levels (e.g., reminders, automated prompts) may be needed. Cancer Epidemiol Biomarkers Prev; 25(4); 593-602. ©2016 AACR SEE ALL ARTICLES IN THIS CEBP FOCUS SECTION, "MULTILEVEL APPROACHES TO ADDRESSING CANCER HEALTH DISPARITIES".

Dengue vaccine acceptance and willingness to pay

The introduction of new vaccines is accompanied by a variety of challenges. Among these, very important ones concern the questions whether the public is willing to accept and willing to purchase the vaccine. Here we discuss factors associated with these questions in the context of vaccines that are becoming available against dengue virus infection. We reviewed published studies available from PubMed and Embase, conducting a meta-analysis when possible and narrative review when the data did not qualify for meta-analysis. We found that attitude toward vaccination and socioeconomic level had significant associations with dengue vaccine acceptance. In addition, socioeconomic level, knowledge, attitude and practice regarding dengue fever, having personally experienced dengue fever and vaccine price were associated with willingness to pay for dengue vaccine. To improve acceptance and willingness to pay for dengue vaccine, well-designed introduction programs that address the associated factors in a context-specific manner are essential.