HPV vaccine initiation at 9 or 10 years of age and better series completion by age 13 among privately and publicly insured children in the US

HPV vaccine standing orders and communication in primary care: A qualitative study

BACKGROUND

Standing orders may improve HPV vaccination rates, but clinical staff's readiness to use them has not been well-explored. We sought to explore benefits and challenges to using HPV vaccine standing orders for adolescents ages 9 to 12, understand clinical staff roles in communication about HPV vaccine, and how standing orders can reduce barriers contributing to vaccine disparities among racial and ethnic marginalized groups.

METHODS

Participants were a sample of 16 U.S. nurses, medical assistants, and healthcare providers working in primary care, recruited from June to September 2022. Trained staff conducted virtual, semi-structured qualitative interviews. We analyzed the resulting data using reflexive thematic analysis.

RESULTS

Themes reflected benefits and challenges to using HPV vaccine standing orders and strategies to address clinic barriers to improve vaccine access and HPV vaccine communication. Benefits included faster and efficient clinic flow; fewer missed vaccine opportunities and promotion of early vaccination; and normalization of HPV vaccination as routine care. Challenges included possible exacerbation of existing HPV vaccine communication and recommendation barriers; and how the complexity of the vaccine administration schedule lessens nurses' and medical assistants' confidence to use standing orders. Strategies to address vaccine access barriers included using nurse-only visits to empower nurse autonomy and catch up on HPV vaccination; engaging clinical staff to follow up with overdue children; and educating parents on HPV vaccine before their child is vaccine eligible.

CONCLUSION

Using HPV vaccine standing orders can promote autonomy for nurses and medical assistants and address vaccine access barriers. Clinical staff engagement and clinic support to mitigate existing vaccine communication barriers are needed to empower staff to use of HPV vaccine standing orders.

Immunogenicity and Safety of Extended-Interval 2-Dose Regimens of 9vHPV Vaccine

BACKGROUND

Nine-valent human papillomavirus (9vHPV) vaccines can be administered in 2 doses 6 to 12 months apart in adolescents. The impact of extended dose intervals is unknown. We report immunogenicity and safety data in adolescents of a second 9vHPV vaccine dose administered ≥1 year after the first.

METHODS

This open-label safety and immunogenicity study (NCT04708041) assessed extended-interval 2-dose regimens of 9vHPV vaccine among adolescents (10 to 15 years) who received 2 9vHPV vaccine doses: the first ≥1 year before enrollment, and second, at enrollment (day 1). We measured serologic responses to vaccine-targeted human papillomavirus (HPV) types at enrollment day 1 (pre-dose 2) and 1 month post-dose 2 (month 1) using a competitive LuminexV® immunoassay. We estimated effects of dose interval on geometric mean titers (GMTs) using regression modeling. Participants reported adverse events (AEs) through 15 days after vaccination.

RESULTS

We enrolled 146 adolescents (mean age 13.3 years) with median 25 months since first 9vHPV vaccine dose (range: 12-53 months). Across vaccine-targeted HPV types, GMTs increased from day 1 to month 1; seropositivity at month 1 was 100%. Anti-HPV GMTs at month 1 were not affected by differences in dose interval of 12 to 53 months, based on regression modeling. The most common AEs were mild-to-moderate injection site reactions; no serious AEs were reported.

CONCLUSIONS

Extending the interval between first and second 9vHPV vaccine doses to 12 to 53 months did not affect antibody responses, with favorable safety profile. These results support feasibility of extended interval regimens for 9vHPV vaccine.

Assessing the long-term implications of age 9 initiation of HPV vaccination on series completion by age 13-15 in the US: projections from an age-structured vaccination model

Introduction

Routine human papillomavirus (HPV) vaccination in the US is recommended at ages 11 or 12 years and can be given at age 9. Vaccination completion rates among adolescents 13-15 years in the US remain below the 80% goal. This study evaluated the long-term effects of increasing proactive HPV vaccination initiation rates at age 9 years in completion rates of adolescents.

Methods

An age-structured vaccination model was developed and parametrized based on the National Immunization Survey-Teen (NIS-Teen) survey data. The model projected vaccination coverage (by vaccination status and age group), for 20 years, for a routine initiation scenario (no increase in initiation rates of 9-year-olds) and different proactive initiation (increased age 9 initiation) scenarios. The time to reach a completion rate of 80% for 13-15-year-olds was estimated. The model also generated projections stratified for subgroups of interest.

Results

Results indicated that vaccine completion rates of 80% in 13-15-year-olds may not be achieved by 2040 under current trends of routine initiation at ages 11 or 12 years. However, increasing initiation rates in 9-year-olds by 1% and 3% annually could shorten the time to achieve 80% completion by 4 and 8 years, respectively. Stratification analyses showed that increasing initiation rates in 9-year-olds can also reduce disparities across subgroups in the time to achieve vaccination completion targets.

Discussion

Increasing HPV vaccination initiation rates in 9-year-olds by as little as 1%-3% annually may be an effective strategy to improve HPV vaccination completion rates in adolescents by age 15 and reach the Healthy People goal of 80% completion much earlier.

Human Papillomavirus Vaccine Completion by 13: A Quality Improvement Initiative in a Large Primary Care Network

OBJECTIVE

Fewer than 40% of U.S. children complete the human papillomavirus (HPV) vaccine series before their 13th birthday. In our large pediatric primary care network, HPV vaccine completion rate by age 13 was 30%. We hypothesized that a phased quality improvement (QI) initiative would increase rates of HPV vaccine completion by age 13 across our network.

METHODS

This QI initiative was conducted in a network of 30 practices located across two states, in urban and suburban settings, consisting of teaching and non-teaching clinics, and ranging in size from three to 50 providers per office. We used a phased approach incorporating multicomponent network-wide and iterative practice-specific interventions. Key interventions included: updating clinical decision support to default order HPV vaccine due at preventive visits starting at age nine instead of 11, data audit and feedback to providers and practices, encouraging use of a strong provider recommendation, and standing orders.

RESULTS

From April 2019 to October 2022, HPV vaccine completion by age 13 across our network increased from 30% to 55% and met criteria for special cause variation on statistical process control charts. A gap in median HPV vaccine completion by age 13 between patients with public insurance and patients with private or commercial insurance decreased from 9% to 1%.

CONCLUSION

A QI initiative was associated with a sustained increase in HPV vaccine series completion by age 13 and reduced variation in care across a large network of 30 primary care practices.

Mothers' perceptions and attitudes about HPV vaccination initiation among 9- and 10-year-olds

HPV vaccination has potential to prevent 90% of HPV-associated cancers. The Advisory Committee on Immunization Practices recommends HPV vaccination for 11- and 12-year-olds, but vaccine initiation can start at age 9. The purpose of this study was to explore perceptions about starting HPV vaccination at a younger age to inform future interventions that promote initiation at ages 9 and 10 years. This was part of a larger study about vaccine hesitancy among racially/ethnically diverse parents of adolescents in the Greater Newark Area of New Jersey. We thematically analyzed transcripts from 16 interviews with English- and Spanish-speaking mothers who had at least one child ≤ 10 years. Analyses focused on perceptions of HPV-related disease risk, attitudes toward HPV vaccination need, and vaccine confidence specifically for 9- and 10-year-olds. Few parents with young adolescents reported receiving vaccination recommendations, and only one reported series initiation before age 11. Mothers' hesitation about younger HPV vaccination initiation revolved around: 1) low perceived necessity among English-speaking mothers due to young adolescents not being sexually active, 2) concerns about potential side effects associated with vaccinating prepubescent adolescents, and 3) a desire for adolescents to be old enough to provide assent. Participants were not opposed to younger initiation but wanted and relied on pediatricians to inform them about vaccination for younger adolescents. These findings suggest mothers are willing to vaccinate at younger ages after clear provider recommendations. Equipping providers with evidence about vaccine safety and cancer prevention communication strategies may promote initiation and timely completion at younger ages.

Effect of immunization registry-based provider reminder to initiate HPV vaccination at age 9, Washington state

Human papillomavirus (HPV) vaccination rates are lower than Tetanus-diphtheria-pertussis (Tdap) and Meningococcal conjugate (MenACWY) rates, although the Advisory Committee on Immunization Practices recommends all three vaccines be given routinely at age 11-12. Evidence is mounting that children who initiate HPV vaccination starting at age 9 are more likely to complete the series on time. Washington state implemented a provider reminder through its immunization information system (WAIIS) in January 2023 to increase HPV vaccine initiation at 9-years-old by updating the forecasted recommended age for HPV from age 11 to 9. The effectiveness of provider reminders when implemented via an immunization information system (IIS) is poorly understood. We evaluated the impact of this forecast update using a seasonally adjusted interrupted time series regression of weekly HPV initiations at 9-years-old before and after implementation. We also examined time series trends of vaccine administration between 2018 and 2023 for HPV initiation at age 9, as well as Tdap, MenACWY and HPV initiation at age 11. The WAIIS forecast update doubled the weekly rate of HPV initiation among 9-year-olds in Washington state, although the weekly count of initiation at 9 remains far lower than initiations at 11. Jurisdictions wanting to increase HPV vaccine initiation at earlier ages should consider updating their forecast algorithm and investing in complementary evidence-based strategies such as provider and parent education, and clinic-based quality improvement efforts. The reach of IIS forecaster updates may be enhanced by working with administrators of electronic medical record systems to ensure parity of provider prompts with IIS.

How to make effective HPV vaccine recommendations starting at age 9

This article provides best and promising practices for recommending HPV vaccination at age 9 as a way to ensure high uptake. An effective method for recommending HPV vaccination is the Announcement Approach, which consists of 3 evidence-based steps. The first step, Announce, involves noting that the child is 9 years old, saying they are due for a vaccine that prevents 6 HPV cancers, and saying you'll vaccinate today. This adapted version of the Announce step simplifies the bundled approach used at ages 11-12 that emphasizes the prevention of meningitis and whooping cough in addition to HPV cancers. For hesitant parents, the second step, Connect and Counsel, involves finding common ground with the parent and communicating the value of starting HPV vaccination at the first opportunity. Finally, for parents who decline, the third step is to Try Again at a later visit. Using the Announcement Approach at age 9 stands to increase HPV vaccine uptake, save time, and lead to high family and provider satisfaction.