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

Human papillomavirus vaccination uptake and determinant factors among adolescent schoolgirls in sub-Saharan Africa: A systematic review and meta-analysis

Despite the ongoing global vaccination campaign aimed at preventing human papillomavirus (HPV) related health issues, the uptake of the HPV vaccine remains unacceptably low in developing regions, particularly in sub-Saharan Africa (SSA). Therefore, this systematic review and meta-analysis aimed at determining the pooled prevalence and associated factors of HPV vaccine uptake among adolescent school girls in SSA. Electronic bio-medical databases were explored. Pooled prevalence, publication bias, meta-regression, sub-group, and sensitivity analysis were performed. The estimated pooled prevalence of HPV vaccine uptake was 28.53% [95% CI: (5.25, 51.81)]. Having good knowledge and a positive attitude was significantly associated with HPV vaccine uptake in SSA. Subgroup analysis revealed the highest uptake was 62.52% from Kenya and the lowest was 3.77% in Nigeria. The HPV vaccine uptake is low. It underscores the need for community education, school-based immunization, and education programs that promote the uptake of the vaccine to increase coverage.

Actions speak louder than words; pediatricians, gynecologists, nurses, and other mothers' perspectives on the human papillomavirus vaccine: an Istanbul multicenter study

Introduction

Gynecologists and pediatricians have an essential duty to prevent cervical cancer. In this study, we compared the compliance of gynecologists (n = 22) and pediatricians (n = 49) with nurse/midwife (n = 66) and non-medical moms (n = 120) with regards to cervical cancer precautions.

Methods

A questionnaire was used to gather data on their demographics, personal vaccination and screening practices, children's immunization status, and awareness of cervical cancer prevention.

Results

The findings demonstrated that gynecologists and pediatricians were better than others at understanding the risk factors and prevention of cervical cancer. It was noted that compared to other groups, physician mothers and their offspring had higher vaccination rates (n = 13, 18.3%; n = 10, 29.4%, respectively). Medical professionals typically provided thorough and accurate answers to informational questions. More frequent Pap smear tests were performed by gynecologists. It was noted that mothers who worked as pediatricians and nurses/midwives neglected their own screening needs.

Discussion

This questionnaire survey sought to ascertain Istanbul's health professionals' present opinions regarding HPV vaccination. Healthcare professionals should be the first to receive information on HPV vaccination and cervical cancer incidence reduction. The public could then readily use them as an example.

Knowledge, attitude, and uptake of human papillomavirus vaccine among adolescent schoolgirls in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Cervical cancer is an international public health issue. Nearly all cases of cervical cancer are caused by the human papillomavirus. The HPV vaccine prevents more than 75% of cervical cancer. The extent to which adolescent girls' knowledge and uptake of the HPV vaccine have to be investigated in order to build effective promotion strategies and increase the uptake of the vaccine. The evidence that is currently available in this area is controversial and inconclusive. Hence, this study has estimated the pooled proportion of good knowledge, positive attitude, and uptake of the HPV vaccine and its associated factors among adolescent schoolgirls in Ethiopia.

METHODS

PubMed, Google Scholar, AJOL, ScienceDirect, and DOAJ were used to search relevant studies. A total of 10 studies were included. The data were extracted by two reviewers using Microsoft Excel and exported to STATA Version 17 for analysis. A random effects model was applied during the analysis. Heterogeneity and publication bias across the studies were evaluated using I² statistics and Egger's test, respectively. The PROSPERO registration number for the review is CRD42023414030.

RESULT

A total of eight studies comprising 3936 study participants for knowledge and attitude and five studies with 2,481 study participants for uptake of HPV were used to estimate the pooled proportions of good knowledge, a positive attitude, and uptake of the HPV vaccine, respectively. The pooled proportions of good knowledge, positive attitude, and uptake of the HPV vaccine were 55.12%, 45.34%, and 42.05%, respectively. Being an urban resident (OR = 4.17, 95% CI = 1.81, 9.58), having good knowledge (OR = 6.70, 95% CI = 3.43, 13.07), and a positive attitude (OR = 2.04, 95% CI = 1.51, 2.74), were significantly associated with the uptake of the vaccine.

CONCLUSION

The pooled proportions of good knowledge, a positive attitude, and uptake of the HPV vaccine were low in Ethiopia. Being an urban resident and having good knowledge and a positive attitude towards the HPV vaccine were significantly associated with the uptake of the HPV vaccine. We recommend increasing adolescent knowledge, positive attitudes, and uptake of HPV vaccination through school-based seminars, health education, and community mobilization.

Parental Justifications for Not Vaccinating Children or Adolescents against Human Papillomavirus (HPV)

Vaccination coverage against Human Papillomavirus (HPV) is low compared with uptake of other vaccines in many countries, including Brazil. The aim of this study was to examine the main reasons provided by parents or guardians of a target population that did not have the first dose of HPV vaccine in a small rural Brazilian municipality, and to verify the factors associated with the reasons for non-vaccination. This is a cross-sectional study with interviews based on the Health Belief Model (HBM), conducted with parents and guardians of 177 unvaccinated children or adolescents. The outcome of interest was the main reason for not vaccinating the child/adolescent. The exposure factors of interest were knowledge about HPV and its prevention as well as sociodemographic characteristics. The main justifications for not vaccinating were lack of information (62.2%), fear or refusal (29.9%), and logistical issues (7.9%). The justifications associated with adolescents’ sex, fear, or refusal were mentioned by 39.3% (95% CI: 28.8–50.6%) of parents or guardians of girls and by 21.5% (95% CI: 13.7–31.2%) of parents or guardians of boys. The main barrier to HPV vaccination is lack of information. Further training of health professionals in clarifying the benefits of vaccination and differentiating the risks between boys and girls could encourage uptake.

Can the sustainable development goals for cancer be met in Brazil? A population-based study

Background

A one-third reduction in premature mortality (30-69 years) from chronic noncommunicable diseases is goal 3.4 of the United Nations Sustainable Development Goals (UN SDG). The burden of NCDs is expected to continue to increase in low- and middle-income countries, including Brazil.

Objectives

The aim of this study was to assess geographical and temporal patterns in premature cancer mortality in Brazil between 2001 and 2015 and to predict this to 2030 in order to benchmark against the 3.4 SDG target.

Methods

We used data on deaths from cancer in those aged 30-69, by age group, sex and cancer site, between 2001 and 2015 from the National Mortality Information System of Brazil (SIM). After correcting for ill-defined causes, crude and world age-standardised mortality rates per 100,000 inhabitants were calculated nationally and for the 5 regions. Predictions were calculated using NordPred, up to 2030.

Results

The difference in observed (2011-2015) and predicted (2026-2030) mortality was compared against the SDG 3.4 target. Between 2011-2015 and 2026-2030 a 12.0% reduction in premature cancer age-standardised mortality rate among males and 4.6% reduction among females is predicted nationally. Across regions this varied from 2.8% among females in North region to 14.7% among males in South region. Lung cancer mortality rates are predicted to decrease among males but not among females nationally (men 28%, females 1.1% increase) and in all regions. Cervical cancer mortality rates are projected to remain very high in the North. Colorectal cancer mortality rates will increase for both sexes in all regions except the Southeast.

Conclusions and recommendation

Cancer premature mortality is expected to decrease in Brazil, but the extent of the decrease will be far from the SDG 3.4 target. Nationally, only male lung cancer will be close to reaching the SDG 3.4 target, reflecting the government's long-term efforts to reduce tobacco consumption. Projected colorectal cancer mortality increases likely reflect the epidemiological transition. This and, cervical cancer control will continue to be major challenges. These results will help inform strategic planning for cancer primary prevention, early detection and treatment programs; such initiatives should take cognizance of the regional differences highlighted here.

Overall survival analyses of female malignancies in Southern Brazil during 2008-2017: A closer look at breast, cervical and ovarian cancer

Background

The aim of this study was to report the overall survival and baseline factors associated with OS for breast, cervical and ovarian cancer in Florianópolis, Southern Brazil, a region with quality-of-life indicators comparable to high-income countries.

Methods

Cohort study was performed from probabilistic record linkage of the Mortality Information System and the Population-based cancer registry of Florianópolis. It was included breasts, cervical and ovarian cancer diagnosis during the period of 2008-2012 with a follow up of 60 months. Cox regression and Kaplan-Meier method were used for associations with overall survival and risk factors.

Findings

1857 cases of the three malignancies were included in the analysis. We identified 202 deaths in breast cancer subjects, 53 for cervical cancer and 51 for ovarian cancer. Metastatic disease at diagnosis was present in 31%, 9.6%, and 55% of the cases, respectively. Overall survival was statistically correlated with age, educational level and stage for breast cancer; age and stage for cervical cancer; age and stage for ovarian cancer.

Interpretation

Metastatic disease and age are the main prognostic factors for the malignancies studied, as they were associated with both overall survival and risk of death. Better screening and preventive tests for early diagnosis are needed.

Funding

Support of Research and Innovation in the State of Santa Catarina, Research Program for the Unified Health System (FAPESC/MS-DECIT/CNPQ/SES-SC-PPSUS); the Brazilian National Research Council (CNPq); and the Coordination for the Improvement of Higher Education Personnel (CAPES).

Turkish mothers' knowledge and attitude about HPV vaccine

BACKGROUND

The study aimed to evaluate the knowledge and attitude of Turkish mothers about cervix cancer,HPV infection and vaccination.

METHODS

This cross-sectional study was conducted the mothers with children aged under 18 years who applied pediatric outpatient clinic.Research data were collected using a face-to-face survey includes sociodemographic characteristics of patients and mothers' knowledge level and attitude about the vaccination for HPV and cervical cancer.

RESULTS

The rate of mothers who stated that they knew the causes of cervical cancer was 30.3%. Of the 71.5% mothers did not know whether there was a vaccine that protects against cervical cancer.Of the mothers who stated to have heard about the HPV vaccine, 39.2% said that the HPV vaccine is received at 9 years and above, 35.7% said that it could be given to both genders, and 75% knew that the vaccine is not reimbursed. Educational status (p < 0.001), working as a healthcare worker (p < 0.001) and the level of income (p < 0.001), were significantly correlated with the awareness of the causes of cervical cancer in a positive direction. None of the participants vaccinated their child, 91.5% ask for information about HPV and 67.3% stated that they might consider vaccination.

CONCLUSIONS

The development of vaccines against HPV has significantly changed the approach used in the treatment of cervical cancer. Healthcare professionals have a great responsibility to inform the public about the HPV vaccine.

PRACTICE IMPLICATIONS

Healthcare providers can use the results of this study to identify parents at risk for vaccine hesitancy and initiate individualized education to promote on-time childhood vaccination.

HPV vaccination in Latin America: Coverage status, implementation challenges and strategies to overcome it

Cervical cancer remains a leading cause of morbidity and mortality amongst females in Latin America (LATAM). Cervical cancer is a preventable disease and HPV vaccination is a main key strategy towards its elimination. This study analyzes HPV vaccine implementation current status and the main barriers to achieve adequate coverage in the region. Data from the nineteen sovereign states of LATAM (comprised of all Portuguese and Spanish-speaking nations located south of the United States) were collected, including year of HPV vaccine implementation, gender and age targets, the number of doses included in the public program and coverage by dose. Sixteen out of the 19 evaluated countries have already implemented HPV vaccination programs. However, despite its proven efficacy and safety, HPV vaccine uptake in LATAM has been lower than expected. There is an evident decline in adhesion, mainly regarding the second dose. Several reasons are probably involved, of note: limited knowledge of HPV and HPV vaccine, misguided safety concerns, high cost, cultural barriers, and the Covid19 pandemic. Proper strategies to overcome these barriers are needed to ensure successful uptake. Effective policies are: adopting the one dose schedule, delivering the vaccine on both health center and schools, and advising health professionals to recommend the vaccine. Further research regarding HPV vaccine hesitancy in Latin America is needed.

Health vulnerabilities in female sex workers in Brazil, 2016

Female sex workers (FSW) suffer stigma and discrimination that negatively impact their physical and mental health and affect access to health care services. This paper aims to describe selected health indicators among FSW in 12 Brazilian cities in 2016. Brazilian cross-sectional Biological Behavioral Surveillance Survey was conducted in 2016 among 4328 FSW recruited by respondent-driven sampling. The sample weighing was inversely proportional to participant's network sizes and the seeds were excluded from the analysis. Health indicators were estimated with 95% confidence interval and included indicators of health status, symptoms of depression, antenatal care, pap smear coverage, signs and symptoms of sexually transmitted infection, contraception and regular condom use, number of births and children alive per women, human immunodeficiency virus and syphilis testing, usual source of care, and perception of discrimination. Most participants self-rated their health as very good/good (65.8%) and 27.7% were positively screened for major depressive disorder episode on Patient Health Questionnaire-2. Antenatal coverage was 85.8% and 62.3% of FSW had access to pap smear exam in the past 3 years. A total of 67.0% of FSW were using some contraceptive method at the time of the study. Male condom was the most common method (37.1%), followed by oral pill (28.9%). A total of 22.5% FSW had never been tested for HIV and the main reasons were "not feeling at risk" (40.4%) and "being afraid or ashamed" (34.0%). The vast majority of FSW used Brazilian National Health System as their usual source of health care (90.2%). Approximately one-fifth of the participants felt discriminated against or were treated worse for being FSW (21.4%) and only 24.3% disclose their sex work status in health services. The vulnerability of FSW is expressed in all health indicators. Indicators of health status, antenatal care, pap smear coverage, and contraception were worse than in the Brazilian population, and point out to the importance of increase FSW's access to health care services. Also, stigma and discrimination emerged as an important barrier to FSW's health care in all dimensions and need to be struggled.

Cervical Cancer Prevention on Instagram: Content and Social Interaction Analysis of Brazilian Accounts

OBJECTIVE

The aim of the present study was to analyse the content of posts on Instagram about cervical cancer.

METHODS

It was conducted a qualitative analysis using the 50 most popular publicly available Portuguese-language Instagram posts, containing the hashtags #cervicalcancer, #papsmear, #hpv, #papillomavirus, and #hpvvac-cine, during the Brazilian national cervical cancer prevention campaign in March 2018.

RESULTS

Posts recruited using #cervicalcancer provided 60% of posts with contents related to secondary prevention; the #papsmear provided 46% of posts with irrelevant contents; the #hpv and #papillomavirus provided 50% and 64% of posts with informative content, respectively; and the #hpvvaccine provided 58% of posts with content related to primary prevention. The posts that received the highest number of likes were those from the hashtags #hpv and #papillomavirus with 151.33 and 78.00 likes/post, respectively. The majority of posts presented less than 05 comments/post, except for the #hpv, which had 64.76 comments/post. According to the users' profiles, the majority of the posts, regardless of the hashtag used, were made by health professionals.

CONCLUSION

The focus of Instagram posts about cervical cancer is on secondary prevention, which can contribute to the promotion of health behaviours not directed to aspects of primary prevention of the disease.

State-of-the-science concepts of HPV-related oropharyngeal squamous cell carcinoma: a comprehensive review

High-risk (HR) human papillomavirus (HPV) infection is recognized as a primary etiologic factor of anogenital cancers and more recently of a subgroup of oropharyngeal squamous cell carcinomas (OPSCC). The incidence of HPV-related OPSCC has increased dramatically in several developed countries in the past 3 decades and is currently the most common cancer caused by HR-HPV in the United States and Germany, surpassing cervical cancer. Consequently, the patient's demographic and clinicopathologic profile has shifted to nonsmoking and nondrinking younger men with higher schooling level and with a history of multiple oral sex partners. Patients with HPV-related OPSCC often show better treatment outcomes and higher survival rates than their HPV-unrelated counterparts, which has led to a change in tumor staging for HPV-related cases. HPV vaccination is emerging as an effective primary prevention strategy, and systematic screening of HPV DNA in blood and salivary oral rinse samples of HR patients is being examined to determine if it may provide a surveillance method and support early diagnosis of HPV-related OPSCC. In this context, a narrative review was conducted to provide an overview of the state-of-the-art of HPV-related OPSCC, including epidemiology, risk factors, clinicopathologic and molecular features, screening, prevention, management, and prognosis.

Cervical Cancer-Related Knowledge, Attitudes, Practices and Self-Screening Acceptance Among Patients, Employees, and Social Media Followers of Major Brazilian Hospital

BACKGROUND

Brazil has a high burden of cervical cancer, even though it is preventable, traceable and treatable. Hence, this study evaluated levels of knowledge, attitudes and practices (KAP) related to cervical cancer screening and diagnosis and acceptance of self-screening techniques among women aged 24 and greater.

METHODS

A cross-sectional KAP survey was administered to n = 4206 women and spanned questions relating to cervical cancer, HPV, speculum, Pap test and colposcopy. Questionnaire was disseminated through a major hospital's social media platforms, intranet and gynecologic-oncology clinics. Logistic regressions evaluated associations between sociodemographic characteristics and knowledge, attitudes, and preventative behaviors against cervical cancer. Participants indicated willingness to try DNA-HPV self-sampling and cervix self-visualization (self-colposcopy).

FINDINGS

Participants were mostly white individuals (70.5%) with higher education and from social classes A and B. They demonstrated superior levels of KAP than described in the literature, with over 57.8% having answered 80+% of questions correctly. KAP scores were predicted by social class, educational attainment, race, history of premalignant cervical lesions and geographic location. About 80% and 63% would be willing to try DNA-HPV self-sampling and cervix self-visualization, respectively. Interest in self-screening was associated with adequate attitude (OR = 1.85) and inadequate practice (OR = .83).

INTERPRETATION

Adequate KAP are fundamental for the successful implementation of a self-screening program. Participants were interested in methods that provide them with greater autonomy, control and practicality. Self-screening could address barriers for under-screened women such as shame, discomfort, distance from clinics and competing commitments, enabling Brazil to reach the WHO's cervical cancer elimination goals. It could also decrease excess medical intervention in over-screened populations by promoting shared decision-making.

Cervical Cancer Prevention in Low- and Middle-Income Countries

Cervical cancer is one of the commonest cancers afflicting women in low and middle income countries, however, both primary prevention with human papillomavirus vaccination, and secondary prevention with screening programs and treatment of preinvasive disease are possible. A coordinated approach to eliminating cervical cancer, as has been called for by the World Health Organization, requires a complex series of steps at all levels of a health system. This article outlines the current state of cervical cancer prevention in low and middle income countries, the innovations being employed to improve outcomes, and consideration of the next steps needed as we move towards global elimination.

The Lifetime Cost Estimation of Human Papillomavirus-related Diseases in China: A Modeling Study

OBJECTIVES

To estimate the lifetime treatment costs of patients with human papillomavirus (HPV) infection-related diseases in China and to provide cost estimates for the economic evaluation of HPV intervention strategies.

METHODS

We extracted real-world hospital data from 2012 to 2019 and screened for subjects who met the criteria of clinical diagnosis of HPV-related diseases to obtain country-specific inputs into a Markov decision model. The model simulated lifetime treatment costs for HPV from the perspective of a national payer. A 5% discount rate was applied. Costs were converted and inflated to 2020 US dollars (USD).

RESULTS

Using 2021 as the base year, the lifetime costs per patient for carcinoma in situ, local metastasis, and distant metastasis cervical cancer are $24,208 (95%CI: 18,793-30,897), $19,562 (95%CI: 14,456-25,567), and $17,599 (95%CI: 10,604-25,807), respectively. For carcinoma in situ, local metastasis, and distant metastasis vaginal cancer, the lifetime costs are $17,593 (95%CI: 14,962-23,596), $17,120 (95%CI: 13,215-22,417), and $22,411 (95%CI: 12,172-22,249), respectively. The base-case lifetime cost per patient for different stages of vulvar cancer/penile cancer/anal cancer/oral cancer/oropharyngeal cancer/laryngeal cancer falls within $17,120-$58,236.

CONCLUSIONS

Using real-world data, we calculated lifetime treatment costs of HPV-related cancer in China and found that the lifetime cost for patients exceeded $17,000 for various stages of disease. The national burden of HPV-related disease could be significantly reduced by eliminating HPV infection.

Barriers towards HPV Vaccinations for Boys and Young Men: A Narrative Review

Background: HPV vaccination of both girls and boys can protect against infection and eliminate the risk for HPV-associated cancer. Due to a common misconception that the virus only poses risks to women, vaccine coverage is suboptimal among men in many countries. It is urgent to identify barriers to vaccination of boys and men. Methods: We conducted a narrative review of publications examining attitudes and beliefs regarding HPV vaccination for boys and young men. The electronic databases searched were PubMed, PsychInfo and Scopus (December 2020; last update July 2021). A total of 103 original articles were included in the final analysis. Results: The central barriers against vaccination of boys and men are: (1) lack of knowledge, (2) vaccine hesitancy in general, (3) lack of recommendation from and/or discussions with healthcare providers, (4) cost and logistics, and (5) the idea that HPV vaccination may promote promiscuity. Men who have sex with men and families belonging to ethnic minorities express a need for information tailored to their situation. Conclusions: Boys should be included in national immunization programs and men should also be offered catch-up vaccinations. Future studies should focus on addressing vaccine hesitancy and developing interventions to promote pan-gender HPV vaccination.

Nurses' and teachers' perceived barriers and facilitators to the uptake of the Human Papilloma Virus (HPV) vaccination program in Iquitos, Peru: A qualitative study

Globally, over 300,000 women die of cervical cancer annually. Given that human papillomavirus vaccines are highly effective in the primary prevention of cervical cancer, it is important to explore the barriers and facilitators to vaccination uptake in areas where the burden of disease remains high. This study, informed by the socio-ecological model, aimed to qualitatively explore vaccination uptake via in-depth interviews with eleven nurses and ten teachers involved in vaccine delivery in Iquitos, Peru. The results highlighted that vaccine uptake was influenced by multiple factors including individuals’ knowledge and attitudes, community beliefs, geography, and policy level variables. Findings suggested that professionals were informed and supportive of the HPV vaccination program but perceived that parents were uninformed about the vaccine. There is a need for community education programs, for a revision of the process of obtaining parental consent, for improved communication between professionals and for involvement of grassroots staff in policy making.

Vaccine hesitancy in the global south: Towards a critical perspective on global health

The complex phenomenon of vaccine hesitancy has been causing increasing global concern. This systematic review aims at analysing the state of art of scientific literature concerning vaccine hesitancy in Latin America and Africa, observing if: (i) they use the same research trends as the global North; and (ii) the parameters recommended by the World Health Organization (WHO) and taken from the experience of the global North are adequate to the Global South's context. This review analyses empirical, qualitative, quantitative, or mixed-study publications, from 2015 to 2020, available at five different databases. The studies produced in the Global South bring up important context-specific issues, such as issues of access (that are not included in the WHO's definition of vaccine hesitancy), cultural and religious issues, reactions to governments, reactions to recent episodes of vaccine tests on populations, and reactions to past of colonial violence. Initiatives to understand the phenomenon based on methodological and conceptual frameworks from the global North alone can cause wrongful conclusions.

Human papillomavirus vaccination uptake in low-and middle-income countries: a meta-analysis

BACKGROUND

The proportion of incident cases of HPV-attributable cancers is highest in the low- and middle-income countries (LMICs) but many are yet to initiate HPV vaccination programs. This meta-analysis was performed to assess the uptake of HPV vaccination in LMICs at the beginning of the global strategy to eliminate cervical cancer and describes the gaps and challenges.

METHODS

A systematic search was conducted in PubMed, EMBASE, Scopus, Web of Science, and CENTRAL databases for observational studies that reported the uptake of HPV vaccination until October 2020. The meta-analysis was done using a random-effects model to assess the pooled estimate of HPV uptake. CRD42021218429.

FINDINGS

During 2008-2020, an estimated 3.3 million females received at least one dose of HPV vaccine with 61.69% of the target population vaccinated. In countries with high uptake, the pooled estimate of uptake was higher in females than males (45.48% vs 8.45%) and showed significant decline in 2015-2020 compared to 2006-2014 (89.03% vs 41.48%). In countries with low uptake, the estimate of uptake was low in both males and females (5.31% vs 2.93%) and showed increase in uptake in 2015-2020 compared to 2006-2014 (0.76% vs 5.22%). In countries with high uptake, compared to routine programs, the estimate was higher when delivered through demonstration programs (89.94% vs 59.74%).

INTERPRETATION

The major concern was a significant drop in the uptake in countries that started with high uptake, challenges in the maintenance of vaccine uptake, sustainability of funding and the lack of standard monitoring and reporting.

Trends in Premature Deaths among Women Living with HIV/AIDS and Cervical Cancer

OBJECTIVES

There is a lack of updated information on premature death and years of potential life lost (YPLL) among human immunodeficiency (HIV)-positive women with cervical cancer. We hypothesize that increased access to preventive resources such as antiretroviral therapy, preexposure prophylaxis, and human papillomavirus vaccines has reduced premature mortality and YPLL in these women in the previous decades.

METHODS

We used data from the National Inpatient Sample database from 2003 to the third quarter of 2015, and restricted the analysis to HIV-positive women with or without cervical cancer. Joinpoint regression models were run to identify trends in the rates of HIV and cervical cancer. Overall and age-stratified YPLL were calculated for HIV-positive women with cervical cancer. Adjusted survey logistic regression models were built to determine the predictive factors of in-hospital mortality among women living with HIV.

RESULTS

Among hospitalized women, low-income, non-Hispanic Blacks, and patients aged 40 to 59 years experienced greater frequencies of HIV/cervical cancer comorbidity. The prevalence of HIV hospitalizations increased by an average annual percentage of 0.9% (95% confidence interval 0.3-1.6). YPLL decreased in HIV-positive women living with and without cervical cancer by 4.9% and 4.3%, respectively. The trajectory for YPLL was not uniform across age groups. YPLL decreased substantially in women aged 20 to 29 years with HIV/cervical cancer comorbidity. Cervical cancer remained a significant predictor of mortality among HIV-positive women when adjusted for age, race, and insurance coverage.

CONCLUSIONS

Within a large, national sample from 2003 to 2015, we found an overall declining trend in YPLL in women living with HIV/cervical cancer comorbidity. In-hospital mortality among HIV-positive women was associated with cervical cancer, age, race, and insurance coverage. We recommend further investigation into the quality of HIV and cervical cancer treatment and prevention services for the sociodemographic groups described.

Epidemiology and Burden of Human Papillomavirus and Related Diseases, Molecular Pathogenesis, and Vaccine Evaluation

Diagnosed in more than 90% of cervical cancers, the fourth deadliest cancer in women, human papillomavirus (HPV) is currently the most common pathogen responsible for female cancers. Moreover, HPV infection is associated with many other diseases, including cutaneous and anogenital warts, and genital and upper aerodigestive tract cancers. The incidence and prevalence of these pathologies vary considerably depending on factors including HPV genotype, regional conditions, the study population, and the anatomical site sampled. Recently, features of the cervicovaginal microbiota are found to be associated with the incidence of HPV-related diseases, presenting a novel approach to identify high-risk women through both blood and cervical samples. Overall, the HPV repartition data show that HPV infection and related diseases are more prevalent in developing countries. Moreover, the available (2-, 4-, and 9-valent) vaccines based on virus-like particles, despite their proven effectiveness and safety, present some limitations in terms of system development cost, transport cold chain, and oncogenic HPV variants. In addition, vaccination programs face some challenges, leading to a considerable burden of HPV infection and related diseases. Therefore, even though the new (9-valent) vaccine seems promising, next-generation vaccines as well as awareness programs associated with HPV vaccination and budget reinforcements for immunization are needed.

HPV Vaccination Attitudes and Behaviors among General Practitioners in Italy

This cross-sectional electronic online or telephone survey assessed the attitudes and behaviors regarding human papillomavirus (HPV) vaccination and the effect of different factors among a nationally representative random sample of 349 general practitioners (GPs) in Italy. A semi-structured interview was performed between September 2018 and October 2020. Almost all respondents considered the HPV vaccine safe with an overall mean value of 8.8, on a scale ranging from 1 to 10, and 59.9% and 32.6% believed that the vaccination was very effective in preventing the related diseases among 12–26 years’ girls and boys. Multivariate logistic regression analysis showed that GPs who had received information about HPV vaccination from scientific journals were more likely to have positive attitude towards the effectiveness of the vaccine in preventing HPV-related diseases in girls between 12–26 years. A large majority (81.5%) of GPs who provided assistance to girls’ patients aged 11–12 years often or always recommend the HPV vaccine to them, and this behavior was more likely to occur in those who believed that the vaccine was very effective in preventing HPV-related diseases in girls between 12–26 years. GPs were more likely to often or always recommend the HPV vaccine to boys aged 11–12 years if they often or always recommended the vaccine to girls aged 11–12 years, if they believed that the vaccine was very effective in preventing HPV-related diseases in boys between 12–26 years, and if they considered the HPV vaccine very safe. GPs should receive information about the HPV immunization to ensure that they routinely communicate with their patient population in order to achieve better coverage rates.

Vaccination coverage and adherence to a dengue vaccination program in the state of Paraná, Brazil

The success of vaccination programs depends on the level of acceptance of the vaccine to achieve high vaccine coverage rates (VCR). Vaccine hesitancy is a challenge, especially concerning new vaccines. Dengue vaccine, Dengvaxia®, was licensed in Brazil in 2015 and implemented, in a pioneering publicly-funded initiative in the state of Paraná, between 2016 and 2018. The vaccination program took place in five phases in the 30 municipalities most affected by dengue in the state, targeting individuals from nine to 44 years-old in two cities and from 15 to 27 years-old in the other 28 municipalities, totaling a target population of 500,000 individuals. A cross-sectional descriptive study was carried out to assess VCR and adherence to the dengue vaccine in this program. VCR, dropout ratio (DR), and compliance with the vaccination schedule (CVS) were analyzed by sex, age group, and municipality size. A total of 302,603 individuals (60.5%) received ≥ 1 dose, 44.2% received ≥ 2 doses, and 28.6% 3 doses. The DR was 52.8%. Among individuals who started vaccination, 40.6% achieved CVS. The highest VCR, highest CVS, and lowest DR occurred in the age group from 9 to 14 years old and from 28 to 44 years old and in smaller municipalities. A greater proportion of men started vaccination (male 64.0%; female 57.1%) however, the DR was higher in men (male 55.4%; female 49.9%), and a higher percentage of women completed the vaccination schedule according to the recommendations (CVS male 37.8%; female 43.6%). Differences were noted in the CVS according to the initial phase of the program (first phase 50.8%; second phase 18.8%). The heterogeneity in vaccine uptake and compliance according to sex, age, and municipality size suggests the need for differentiated strategies to address challenges with new and multiple-dose vaccines.

Improvement of Parent's awareness, knowledge, perception, and acceptability of human papillomavirus vaccination after a structured-educational intervention

Background

Regardless of the disease burden of human papillomavirus (HPV), the vaccine has not been included in the Indonesia National Immunization Program. Since 2017 there was a demonstration program of the HPV vaccination in Yogyakarta Province. This vaccine was given free to female primary school students in the 5th and 6th grades (11–13 years old). This study aimed to assess whether a structured-educational intervention focus on HPV increases the parental awareness, knowledge, and perceptions toward HPV and the vaccine acceptability.

Methods

We conducted a pre-post structured-educational intervention study from July to August 2017 before the implementation of the HPV vaccination demonstration program, in Kulon Progo District, Yogyakarta Province, Indonesia. Parents of female primary school students grades 5th and 6th were selected using a school-based proportional random sampling. A pediatric resident provided a structured-educational intervention, which consists of the burden and risk of HPV disease, as well as the benefit and safety of the vaccine. Parents were required to complete validated self-administered questionnaires before and after the structured-educational intervention.

Results

A total of 506 parents participated. Before receiving the structured-educational intervention, parents’ awareness of HPV infection and the vaccines were low. Only 49.2% of parents had heard HPV infection, and 48.8% had heard about the vaccine. After the structured-educational intervention, there were significant improvements in parent’s awareness, knowledge, and perceptions of HPV infection, cervical cancer, and HPV vaccination (all p < 0.001). HPV vaccine’s acceptability increased from 74.3 to 87.4% (p < 0.001). There was a significant correlation between increasing HPV vaccine acceptability with the improvement of awareness, knowledge, and perception toward HPV infection, cervical cancer and HPV vaccination (r = 0.32 to 0.53, p < 0.001). After the structured-educational intervention, better knowledge and positive perceptions of HPV vaccination were predictive of HPV vaccine’s acceptability with OR 1.90 (95%CI:1.40–2.57) and OR 1.31(95%CI,1.05–1.63), respectively.

Conclusions

A structured-educational intervention may improve parental awareness, knowledge, and perceptions toward HPV and the acceptability of the vaccine. Further study, a randomized control trial with longer follow-up are needed to evaluate the long-term and actual effectiveness of improving parents’ knowledge, perceptions and HPV vaccine acceptability.

Facebook HPV vaccine campaign: insights from Brazil

The vaccination coverage rate has fallen in recent years in Brazil. Although Brazil is a country influenced by social networking and analysis of social media generated content has emerged as an important area of research, this is the first study to investigate how the HPV vaccine is portrayed on the Facebook page of the Ministry of Health and to interpret the user-generated content. Our work evaluated the posts published by the Ministry of Health as well as posted comments, shares and reactions of the population related to the HPV vaccination campaign on the specific Facebook page between January and July 2018.The data were analyzed in three stages: (i) overview of published posts; (ii) analysis of posted comments; and (iii) sub-group analysis of posted comments. This study makes important contributions from the point of view of using social media as a public health communication tool.

Anal canal cancer in Brazil: why should we pay more attention to the epidemiology of this rare disease?

Anal canal cancer is one of the human papilloma virus (HPV)-associated diseases with increasing incidence. High-risk sexual behaviour and the resurgence of human immunodeficiency virus (HIV) infection, associated with low HPV vaccine coverage, are risk factors for the increased incidence of this cancer. In this paper, the authors point out pertinent questions regarding the greater exposure of the population to some risk factors and discuss the latest epidemiological data of these factors, particularly those of concern to emerging countries like Brazil. The authors also discuss policies adopted that have not been successful to combat the HIV and HPV rise and that have direct consequences on the incidence of anal canal cancer.

HPV vaccine hesitancy among parents in Italy: a cross-sectional study

This cross-sectional survey determined the vaccine hesitancy related to Human papillomavirus (HPV) and the determinants among parents of adolescents aged 12 and 13 years in Italy. Data was collected through a self-administered questionnaire. Two-thirds of the parents (66.7%) had heard of HPV infection and knew that the vaccination was a preventive measure. Parents who had vaccinated their child against the HPV were more likely to have this knowledge. The vast majority (88%) considered the immunization useful for the prevention of HPV-related cancers with an average value of 8.4. This positive attitude was higher among parents who had heard of HPV infection and knew that vaccination was a preventive measure, who had received information from physicians, who had vaccinated their child against the HPV, who were concerned that their child could contract the HPV infection, and who needed information on HPV vaccination. More than half (57.9%) self-reported that they had vaccinated their child against HPV and only 6.2% had delayed the administration of a dose. One-third (33.3%) were hesitant toward anti-HPV vaccination with a total Parent Attitudes about Childhood Vaccines Survey (PACV) score ≥50. Unmarried respondents, those who had not heard of HPV infection and did not know that the vaccination was a preventive measure, who did not believe that the vaccination was useful for the prevention of HPV-related cancers, and who needed information on HPV vaccination were more likely to be hesitant. Communication and education strategies must be undertaken to ensure that parents are fully informed and health-care professionals should provide materials with details regarding the risk of acquiring a HPV infection and vaccine usefulness.

Knowledge about cervical cancer and HPV immunization dropout rate among Brazilian adolescent girls and their guardians

BACKGROUND

Infections with Human Papillomavirus (HPV) are the main cause of cervical cancer. Since 2014, the HPV vaccine was introduced in the Brazilian National Vaccination Calendar. The purpose of this study was to assess the knowledge of adolescent girls and their mothers/guardians about HPV and HPV vaccine, identify the factors associated with this knowledge, and evaluate immunization dropout rate.

METHODS

This was a cross-sectional study involving adolescent girls and their mothers/guardians. Participants underwent an interview that addressed sociodemographic data, sexual and gynecological history, and knowledge about HPV, HPV vaccine and cervical cancer. The third quartile of the total score was established as a cutoff for assessing knowledge. Adolescents who correctly answered more than four questions and mothers/guardians who obtained more than five correct responses were categorized into high knowledge. Poisson regression analysis was performed to identify variables associated with low knowledge. Vaccination records were used to assess immunization dropout rates. Any adolescent who did not complete the two-dose vaccination schedule was considered dropout.

RESULTS

A total of 666 adolescent girls and 623 mothers/guardians were interviewed. Low knowledge was observed in 76.7% of adolescents and 79.8% of mothers/guardians. Most were unaware of the causal relationship between HPV and cervical cancer, signs and symptoms of HPV infection, and had limited knowledge about the HPV vaccine. Factors associated with low knowledge of adolescents were aged 12 years [IRR 1.2 (95% CI 1. 1-1.3)] or less [IRR 1.3 (95% CI (1. 2-1.4)]; household income lower than US$750 [IRR 1.7 (95% CI 1. 1-2.6)] and household income between US$751 and US$1500 [IRR 1.6 (95% CI 1.0-2.6)]. Among mothers/guardians, low knowledge was related to having completed elementary school or less [IRR 1.5 (95% CI 1. 2-2.0)]; and household income lower than US$750 [IRR 1.2 (95% CI 1.0-1.4)]. Knowledge of adolescents and mothers/guardians was not associated with vaccine uptake. HPV immunization dropout rate was considered high (32.3%).

CONCLUSION

Knowledge about HPV and cervical cancer as well as vaccine uptake was low. Results highlight the need for educational interventions about HPV and cervical cancer. These actions may contribute to improve adherence to HPV vaccination.

Brazilian Immigrant Parents' Awareness of HPV and the HPV Vaccine and Interest in Participating in Future HPV-Related Cancer Prevention Study: an Exploratory Cross-Sectional Study Conducted in the USA

This exploratory community-based study assessed Brazilian immigrant parents' awareness of HPV and the HPV vaccine, HPV information sources, and their interest in participating in a future HPV-related cancer prevention study. This study is a cross-sectional analysis of data from a convenience sample of Brazilian immigrant parents living in selected cities in Massachusetts. Participants completed a brief survey in their language of preference (English or Portuguese) administered by bilingual interviewers. Forty-seven Brazilian immigrant parents, each representing a unique family, participated in the study. All participants completed the survey in Portuguese. Although the majority reported being aware of HPV (93.6%, n = 44), only 74.5% (n = 35) were aware of the HPV vaccine. Fewer fathers than mothers had heard of the HPV vaccine (61.9%; n = 13 vs. 84.6%, n = 22; p = 0.04). Of those who were aware of the HPV vaccine (n = 35), 82.6% (n = 29) reported hearing about the HPV vaccine from their child's physician. Additionally, nearly all participants (97.9%, n = 46) reported being interested in participating in future HPV-related cancer prevention study. Findings of this exploratory study indicate parents' low to moderate awareness of the HPV vaccine and high interest in participating in future HPV-related cancer prevention study. These findings are important and serve as a valuable first step toward building a knowledge foundation that is critically needed for developing future studies targeting Brazilians immigrant parents and adolescents living in the USA.

Biological risk for healthcare workers: current Italian law and guidelines on vaccination strategies

The assessment and management of biological risk has always been a primary goal toward which occupational medicine has focused its efforts, in particular in healthcare workplaces. Healthcare professionals represent a category of workers at high risk for infections, many of which are vaccine-preventable diseases. There are various reasons for vaccinating healthcare workers, including to prevent illness among them so as to reduce absenteeism, to ensure an effective health service to users and to reduce social costs. Recently, the issue of vaccinations has been the subject of many debates. Vaccination is not always appreciated by health operators, and the reasons for low vaccination coverage are several and heterogeneous. This paper focuses on current Italian law and vaccination policies, along with the international background, evaluating the effectiveness of current policies and the consequences on public health. Overall, preventing infectious diseases means reducing costs, cases and outbreaks, shows responsibility toward third parties, and improves general welfare.

HPV Vaccine: Updates and Highlights

HPV is the most common sexually transmitted biological agent and is the cause of many conditions in men and women, including precancer lesions and cancer. Three prophylactic HPV vaccines targeting high-risk HPV types are available in many countries worldwide: 2-, 4- and 9-valent vaccines. All the 3 vaccines use recombinant DNA technology and are prepared from the purified L1 protein that self-assembles to form HPV type-specific empty shells. This non-systematic review aims to summarize the HPV epidemiology and the vaccine development to review the landmark trials of HPV vaccine, to present to most remarkable results from clinical trials and the real world, and to stress the challenges and the barriers for HPV vaccine implementation.

Exploring HPV Knowledge, Awareness, Beliefs, Attitudes, and Vaccine Acceptability of Latino Fathers Living in the United States: An Integrative Review

To conduct an integrative review to identify and synthesize studies exploring human papillomavirus (HPV) knowledge, awareness, beliefs, attitudes, and acceptability of the HPV vaccine among Latino fathers living in the United States. The review methodology was informed by those developed by Whittemore and Knafl, which allow for the inclusion of qualitative, quantitative, and mixed methods studies. Using the preferred reporting items for systematic reviews meta-analyses guidelines, five electronic databases (PubMed, Medline, PsycINFO, CINAHL, Science Direct) were searched for peer-reviewed, full-text studies published in English with samples that included Latino fathers and examined knowledge, awareness, beliefs, attitudes about the HPV and the HPV vaccines. Studies that did not provide information on the inclusion of fathers in the sample were excluded. Identified eligible studies were analyzed and synthesized using the matrix method. Eleven eligible studies were identified. Most (n = 10) included mothers and fathers. One study included only fathers, and this study determined that although fathers held positive attitudes toward the HPV vaccine, a notable number of participants were unsure of or had not formed an opinion about the HPV vaccine. Fathers felt that a recommendation from their child's physician would impact whether they vaccinated their child. Moreover, of the ten studies including both parents, only two specifically compared fathers' and mothers' knowledge and awareness about the HPV and vaccine acceptability. These two studies determined that fathers were less aware of the HPV and had lower HPV vaccine-related knowledge than mothers. Nevertheless, all of the 11 examined studies, found moderate to high acceptability of the HPV vaccine among Latino parents despite uncertainty about possible vaccine risks and costs. Only 11 studies were identified that included Latino fathers. Of these studies, only one was conducted exclusively with Latino fathers and two compared fathers and mothers. Additional research focusing on Latino fathers is needed given the central role of the family in the Latino culture and the shared role fathers and mothers have in decision-making related to their children's health.