Trends in HPV Vaccination Initiation and Completion Within Ages 9-12 Years: 2008-2018

Barriers to the assessment and recommendation of HPV vaccination among healthcare providers in Texas

Background

Healthcare providers (HCPs) recommendations for HPV vaccination plays a critical role in increasing vaccination uptake. This study assesses the prevalence of reported barriers to HPV vaccination assessment and recommendation among HCPs in Texas.

Methods

Study data were obtained from a population-based survey of HCPs currently practicing in Texas. Participants were asked about their HPV vaccination assessment and recommendation practices and the reasons for not assessing or recommending the vaccine. Barriers were stratified by HCP characteristics including age, sex, race/ethnicity, location of practice, provider type, and type of facility.

Results

Among the 826 HCPs included in this study, 47.3 % never, 49.6 % sometimes, and 3.0 % often/always assessed a patient's HPV vaccination status. Similarly, 36.0 % never, 36.2 % sometimes, and 27.9 % often/always recommended HPV vaccination. The most frequently reported barriers to assessment and recommendation of HPV vaccination were time constraints (22.9 %), delegating the task to others (15.0 %), lack of effective tools and information to give patients (12.0 %), and requiring additional training (9.2 %). HCPs who were female, less than 35 years old, non-Hispanic black, and nonphysician HCPs (Physician Assistant, Nurse Practitioner) most frequently reported lacking effective tools and information and a need for additional training.

Conclusion

The assessment and recommendation for HPV vaccination among HCPs in Texas is suboptimal. Barriers reported varied based on the provider's characteristics. Addressing these barriers, such as by providing more effective tools and information and offering additional training to HCPs, could potentially increase HPV vaccination rates in Texas. The findings also suggest that interventions should be tailored to specific demographic groups.

Factors Associated with Iatrogenic Laryngeal Injury in Recurrent Respiratory Papillomatosis

OBJECTIVE

To describe iatrogenic laryngeal injury and identify its risk factors in recurrent respiratory papillomatosis (RRP) patients receiving surgical care.

STUDY DESIGN

Case-control.

SETTING

Tertiary care academic hospital in a metropolitan area.

METHODS

Charts of patients with RRP seen at our institution from January 2002 to December 2022 were reviewed. Patients were separated into 2 cohorts based upon whether they experienced any form of iatrogenic laryngeal injury-including anterior commissure synechiae, vocal cord scar, reduced vocal fold pliability, vocal fold motion impairment, and glottic and/or subglottic stenosis. Adjusted logistic regressions were performed to identify factors associated with iatrogenic laryngeal injury.

RESULTS

Of 199 RRP patients, 133 (66.8%) had identifiable iatrogenic laryngeal injury. The most common injuries were anterior commissure synechiae (n = 67; 50.4%) and reduced vocal fold pliability (n = 54; 40.6%). On a multivariate logistic regression, patients with diabetes mellitus (adjusted odds ratio [aOR] [95% confidence interval [CI]]: 2.99 [1.02, 8.79]; P = .04) and who received at least 10 surgeries lifetime (aOR [95% CI]: 14.47 [1.70, 123.19]; P = .01) were at increased risk for iatrogenic laryngeal injury, whereas receiving less than 5 surgeries (aOR [95% CI]: 0.21 [0.09, 0.51]; P < .001) was found to be protective. When treating the lifetime number of surgeries as a continuous variable, a greater number of surgeries was a significant risk factor for iatrogenic laryngeal injury (aOR [95% CI]: 1.32 [1.14, 1.53]; P < .001).

CONCLUSION

These results suggest the importance of strict glucose control for diabetic patients receiving RRP surgical care, and emphasize the clinical need to identify medical therapies to decrease RRP surgical frequency for patients.

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.

Vaccination Effectiveness against Human Papillomavirus in Kazakhstan

OBJECTIVE

The purpose was to determine the effectiveness of human papillomavirus immunization and its impact on cervical cancer development in Kazakhstan.

METHODS

The current research is a case-control study with two groups: a main group and a control group. A total of 725 subjects participated in the research.

RESULTS

The association between vaccination and cervical cancer development was calculated both for the two groups as a whole and for individual patients, who were selected based on criteria of residence, presence of immunodeficiency or chronic cardiac or renal pathology, as well as analysis of age at which the vaccine dose was received. There was a statistically significant association between the absence of the human papillomavirus vaccine and the risk of cervical cancer in all groups. When considering the entire cohort, the chance of finding a risk factor (lack of vaccination) was almost 7 times higher in the main group than in the control group. Thus, an association between vaccination and cervical cancer risk was found in each of the pairs of subjects.

CONCLUSION

The effectiveness of vaccination in preventing cervical cancer was not observed in patients who were vaccinated after 18 years of age, while most patients in the control group were vaccinated in their teens. The practical significance of the research is not only to further study the problem of human papillomavirus (HPV) vaccination in Kazakhstan but also to popularize HPV immunization to prevent cervical cancer (CC).

Framing of national HPV vaccine recommendations and willingness to recommend at ages 9-10

Proactive HPV vaccination at age 9 better prevents infection and improves vaccine series completion. Because national organizations recommend starting the vaccine at different ages, we sought to understand the impact of these recommendation frames. In 2022, we surveyed 2,527 US clinical staff (45% physicians) who provide HPV vaccine for children. We randomized respondents to one of three frames based on HPV vaccine recommendations of national organizations or a no-recommendation control, and assessed willingness to recommend HPV vaccine for children ages 9-10. Respondents also reported perceived benefits of HPV vaccination at ages 9 or 12. Recommending HPV vaccination "at ages 11-12" led to lower willingness to vaccinate at ages 9-10 than control (37% vs. 54%, p < .05). Recommending vaccination "at ages 9-12" led to similar willingness as control. However, "starting at age 9" led to higher willingness than control (63% vs. 54%, p < .05). Results were similar across respondents' training, specialty, or years in practice, or their clinic's rurality or healthcare system membership. More common benefits of recommending at age 9 than 12 were avoiding the topic of sex (24% vs. 10%, OR = 2.78, 95%CI: 2.23, 3.48) and completing the vaccine series before age 13 (56% vs. 47%, OR = 1.44, 95%CI: 1.23, 1.68). Less common benefits for age 9 were having parents ready to talk about HPV vaccine and agreeing to vaccination (both p < .05). An effective way to encourage proactive HPV vaccination is to say that it starts at age 9. Aligning national recommendations to start at age 9 can promote timely vaccination.

The association of initiating HPV vaccination at ages 9-10 years and up-to-date status among adolescents ages 13-17 years, 2016-2020

Recent guidelines from the American Cancer Society stress HPV vaccination series initiation at the youngest opportunity, i.e., age 9 years. There are limited data on the association between initiating HPV vaccination at ages 9-10 years and up-to-date (UTD) status. In this study, we compare nationally representative UTD HPV vaccination rates between adolescents who initiated the series younger (ages 9-10 years) vs. older (≥ age 11 years). Five years of pooled data (2016-2020) from National Immunization Survey-Teen were used to estimate the UTD HPV vaccination prevalence among younger vs. older initiating 13-17-year-olds. Adjusted logistic regression models estimated prevalence ratios (aPRs), differences (aDs), and difference in differences (aDDs) in prevalence of being UTD to assess the overall association of age at initiation with being UTD and differences in sociodemographic predictors of being UTD among younger vs. older initiators. UTD prevalence for younger initiators was 93% compared with 72% among older initiators (aPR: 1.27,95%CI: 1.24,1.31). Among older initiators, UTD prevalence was significantly different by sex, insurance status, and current age; no such differences were observed among younger initiators. Results indicate that younger initiation is associated with a 27% higher UTD prevalence, highlighting the importance of promoting younger initiation, particularly among those with health-care barriers.

HPV vaccine recommendations by age: A survey of providers in federally qualified health centers

Clinician recommendation remains a critical factor in improving HPV vaccine uptake. Clinicians practicing in federally qualified health centers were surveyed between October 2021 and July 2022. Clinicians were asked how they recommended HPV vaccination for patients aged 9-10, 11-12, 13-18, 19-26, and 27-45 y (strongly recommend, offer but do not recommend strongly, discuss only if the patient initiates the conversation, or recommend against). Descriptive statistics were assessed, and exact binomial logistic regression analyses were utilized to examine factors associated with HPV vaccination recommendation in 9-10-y-old patients. Respondents (n = 148) were primarily female (85%), between the ages of 30-39 (38%), white, non-Hispanic (62%), advanced practice providers (55%), family medicine specialty (70%), and practicing in the Northeast (63%). Strong recommendations for HPV vaccination varied by age: 65% strongly recommended for ages 9-10, 94% for ages 11-12, 96% for ages 13-18, 82% for age 19-26, and 26% for ages 27-45 y. Compared to Women's Health/OBGYN specialty, family medicine clinicians were less likely to recommend HPV vaccination at ages 9-10 (p = .03). Approximately two-thirds of clinicians practicing in federally qualified health centers or safety net settings strongly recommend HPV vaccine series initiation at ages 9-10. Additional research is needed to improve recommendations in younger age groups.

Does HPV vaccination initiation at age 9, improve HPV initiation and vaccine series completion rates by age 13?

Vaccination for Human Papillomavirus (HPV) is important to reduce rates of cervical and oropharyngeal cancer. We aimed to evaluate if a program to initiate HPV vaccination at 9 years improved initiation and completion rates by 13 years of age. Data on empaneled patients aged 9-13 years from January 1, 2021 to August 30, 2022 were abstracted from the electronic health record. Primary outcome measures included HPV vaccination initiation and series completion by 13 years of age. The secondary outcome measure was missed opportunities for HPV vaccination. In total, 25,888 patients were included (12,433 pre-intervention, and 13,455 post-intervention). The percentage of patients aged 9-13 with an in-person visit who received at least 1 dose of HPV vaccine increased from 30% pre-intervention to 43% post-intervention. The percentage of patients who received 2 doses of vaccine increased from 19.3% pre-intervention to 42.7% post-intervention. For the overall population seen in-person, initiation of HPV vaccination by age 13 years increased from 42% to 54%. HPV completion increased as well (13% to 18%). HPV vaccination initiation at 9 years of age may be an acceptable and effective approach to improving vaccination rates.

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.

Age nine is possible: Improving age 9 HPV initiation through a national quality improvement initiative during the COVID-19 pandemic

The American Cancer Society collaborated with a range of healthcare partners in 2020-2022 to implement quality improvement clinical interventions with the goal of improving HPV vaccination rates among adolescents' ages 9-13. 2020 was the first cohort for which partners had been asked to submit HPV rate data for patients' ages 9-12. At least 80% of the partners across all reported project years were able and willing to report HPV rates for these ages. Partners submitted HPV initiation rates at the beginning and end of the 12-month project year along with project activities, including evidence-based interventions (EBIs) implemented. Mean initiation rates for ages 9-10 significantly increased 4.1% during 2020 compared to non-significant rate increases of 2.6% and 2.0% for ages 11-12 and age 13, respectively. In 2021, ages 9-10 initiation saw a non-significant increase of 2.2%, whereas ages 11-12 and age 13 decreased non-significantly by 0.3% and 0.1%, respectively. The 2022 cohort saw significant initiation rate increases of at least 4% across all ages, potentially a promising result of the myriad back on track HPV vaccination campaigns designed to reverse the damage of the COVID-19 pandemic on adolescent immunizations. These findings demonstrate an effective adaptation of quality improvement in increasing HPV vaccination coverage among younger ages even during a national pandemic.

Assessing Barriers to Human Papillomavirus (HPV) Vaccination in At-Risk Rural Communities of Western North Carolina, United States

Human papillomavirus (HPV) vaccination among adolescents in rural, western North Carolina (NC) remains suboptimal. Data are needed to understand the barriers to HPV vaccination in these communities. We conducted a cross-sectional pilot study of parental attitudes and provider practices regarding HPV vaccination in rural western NC counties with lower HPV vaccination rates. Eight health department clinics were enrolled in the study. Further, 29 provider and 32 parent surveys were analyzed along with environmental scans. Median provider comfort regarding knowledge of HPV-associated diseases was 85% (IQR = 75-95), on a scale of 0-100% (100% representing complete comfort). Median parental comfort level regarding knowledge of HPV-associated diseases and the HPV vaccine was 75% (IQR = 50-89) and 75% (IQR = 49-96), respectively. Less than 25% of parents rated the HPV vaccine as 'extremely effective' against genital (16.7%) and anal cancers (17.9%). Parents were more likely to rate the vaccine as 'extremely effective' to 'very effective' if their child was female. There was no significant difference between parental- and provider-reported comfort with knowledge about HPV-associated diseases (p = 0.0725) and the HPV vaccine (p = 0.167). This study identified multiple opportunities to increase HPV vaccine coverage among unvaccinated adolescents at parental, provider, and clinic levels. Health education of rural NC residents and providers in public health settings may identify future interventions to increase HPV vaccine uptake.

Public willingness to receive chlamydia, gonorrhea, syphilis, and trichomoniasis vaccines: a scoping review

BACKGROUND

Sexually transmitted infections (STIs) like chlamydia, gonorrhea, syphilis, and trichomoniasis contribute significantly to global morbidity and mortality. Researchers are pursuing vaccines for these STIs, and a clinical trial is currently underway for a chlamydia vaccine. However, there is little research available on individuals' willingness to receive chlamydia, gonorrhea, syphilis, and trichomoniasis vaccines. The purpose of this analysis was to map the existing literature we have on individuals' willingness to receive these bacterial/parasitic STI vaccines and understand what information on vaccine acceptability is still needed.

METHODS

We searched seven databases for literature on STI vaccine acceptability, then conducted title/abstract and full-text reviews to assess eligibility. All reviews and abstractions were conducted blindly by two reviewers, with discrepancies settled by discussion or the input of a third reviewer.

RESULTS

Eight of the original 2,259 texts of interest met inclusion criteria. After data abstraction, we found that gonorrhea was the most commonly examined, followed by chlamydia and syphilis. Trichomoniasis vaccine acceptability was not reported. Most texts reported high acceptability, but there did not appear to be data describing how vaccine characteristics affect acceptability. Similarly, while the literature covers a variety of populations, most of the study populations were based out of the United States or Canada and were patrons of healthcare facilities or participants from a larger health intervention study. Therefore, more information is needed on populations outside North America, and on groups with lower healthcare access and utilization.

CONCLUSION

As the incidence of bacterial and parasitic STIs increase, and as we grow nearer vaccines for these illnesses, understanding how likely the public is to accept and receive these vaccines is crucial to their success. While the existing literature describes STI vaccine acceptability in a variety of populations, their overall number is small. More research into STI vaccine acceptability outside of North America, and especially examining how factors like number of doses, timing, and cost influence vaccine acceptability is needed to ensure effective future vaccine rollouts.

Barriers to human papillomavirus vaccine uptake: role of state religiosity and healthcare professionals' participation in a state vaccine program

BACKGROUND

Despite the known benefits of preventing human papillomavirus (HPV)-related cancers, HPV vaccine coverage is low in the United States. Grounded in Social Ecological theory, we assessed the macro-level (state) and meso-level (organization) factors associated with HPV vaccine initiation and up-to-date.

METHODS

Data from 2020 National Immunization Survey-Teen were used to study a sample of 20 163 US adolescents (aged 13-17 years). The data were collected from each teen's parents or guardians and health-care professionals. Weighted prevalence estimates were calculated, and multivariable regression analyses were conducted.

RESULTS

The prevalence of HPV vaccine initiation was 75.1% and of remaining up-to-date was 58.6%. At the macro level, teens living in states with high and moderate religiosity had lower odds of HPV vaccine initiation (high religiosity adjusted odds ratio [AOR] = 0.63, 95% confidence interval [CI] = 0.50 to 0.78; moderate religiosity AOR = 0.68, 95% CI = 0.55 to 0.85) and up-to-date (high religiosity AOR = 0.69, 95% CI = 0.56 to 0.85; moderate religiosity AOR = 0.74, 95% CI = 0.61 to 0.91) than states with low religiosity. At the meso level, when none of their healthcare professionals ordered vaccine from the state, teens had lower odds of initiation (AOR = 0.68, 95% CI = 0.53 to 0.87) and up-to-date (AOR = 0.76, 95% CI = 0.60 to 0.95) than teens whose healthcare professionals ordered vaccine from the state. In addition, race and ethnicity, age, mother's education level, household income, well-child examination status, and doctor's recommendation were significantly associated with HPV vaccine uptake.

CONCLUSION

A multiprong approach is needed to address religious and systemic barriers to HPV vaccination and expand healthcare professionals' access and enrollment in state vaccine initiatives, such as the Vaccine for Children program.

Trends in Adolescent Human Papillomavirus Vaccination and Parental Hesitancy in the United States

BACKGROUND

Human papillomavirus (HPV) vaccination coverage remains suboptimal in the United States, underscoring the importance of monitoring trends in vaccine hesitancy.

METHODS

Cross-sectional data from the 2011-2020 National Immunization Survey-Teen were used to assess trends in HPV vaccination initiation among 13-17-year-olds, parental intent to initiate vaccination, and primary reasons for parental hesitancy.

RESULTS

Among all sex and race and ethnicity groups, the prevalence of HPV vaccination initiation increased over time, but parental intent to vaccinate against HPV for unvaccinated teens remained consistently low (≤45%). Among hesitant parents, "safety concerns" increased in nearly all demographic groups, with the greatest increases observed for non-Hispanic white female and male teens and no change for non-Hispanic black female teens. In 2019-2020, parents of unvaccinated non-Hispanic white teens were least likely to intend on vaccinating their teens, and the most common reason for hesitancy varied by sex and race and ethnicity (eg, "safety concerns" for white teens and "not necessary" for black female teens).

CONCLUSIONS

Although HPV vaccination initiation increased over time, a substantial fraction of parents remain hesitant, and trends in their reason varied by sex and race and ethnicity. Health campaigns and clinicians should address vaccine safety and necessity.

Barriers and determinants of consistent offering of HPV vaccination by healthcare facilities

Expanding access to HPV vaccination is critical to increasing HPV vaccine uptake. We assessed the determinants and barriers to consistent offering of HPV vaccine among healthcare facilities. This was a cross-sectional survey of healthcare providers (HCPs) in Texas. Prevalence of the reasons healthcare practices do not consistently offer HPV vaccination was estimated. Multivariable regression analyses were conducted. Of 1169 HCPs included in the study, 47.5% (95% CI: 44.6-50.3%) reported their practices do not provide HPV vaccination or do not offer it consistently. Compared to physicians, nurses had 77% lower odds (Adjusted Odds Ratio (AOR): 0.23, 95% CI: 0.16-0.32, p-value: < .001), and physician assistants had 89% lower odds (AOR: 0.11, 95% CI: 0.07-0.16, p-value: < .001) of their healthcare practices consistently offering HPV vaccination. Compared to university/teaching hospitals, the odds of healthcare practices consistently offering HPV vaccination were 44% lower (AOR: 0.56, 95% CI: 0.35-0.91, p-value: 0.019) in solo practices but 266% higher (AOR: 3.66, 95% CI: 2.04-6.58, p-value: < .001) in FQHC/public facilities. The common reasons healthcare practices do not consistently offer HPV vaccination were; HPV vaccination is not within the scope of the practice (48.1%), referrals to other clinics (27.7%), and limited personnel (11.4%). Non-physicians were more likely to report that HPV vaccination was not in their scope and to refer patients than physicians. Moreover, solo practices were more likely to report challenges with acquisition and storage of the vaccine and referral of patients as reasons for not consistently offering HPV vaccination than university/teaching hospitals, FQHC/public facilities, or group practices. System-level interventions including training of non-physicians and expansion of practice enrollment in programs that support HPV vaccine acquisition and storage are needed.

Reasons patients cite to their health-care professional for not initiating or completing human papillomavirus vaccination

BACKGROUND

Vaccination against human papillomavirus (HPV) is critical to the prevention of HPV-associated cancers. This study aimed to describe the reasons patients cited for not initiating or completing the HPV vaccination series, as reported by health-care professionals.

METHODS

Study data were obtained from a University of Texas MD Anderson Cancer Center population-based cross-sectional survey of health-care professionals practicing in Texas. Prevalence estimates of reasons cited for not initiating or completing HPV vaccination were estimated by patient population (parents of children and adult patients).

RESULTS

The study included 973 primary care clinicians, of whom 45.53% were physicians and 54.47% were midlevel care professionals. For parents who did not initiate HPV vaccination for their child, the most commonly cited reasons were the belief that the vaccine was not needed (52.54%, 95% CI = 48.90% to 56.15%), that the child was not sexually active (52.54%, 95% CI = 48.90% to 56.15%), and safety concerns/side effects (47.05%, 95% CI = 43.44% to 50.69%). Among age-eligible adults who did not initiate HPV vaccination, lack of knowledge and awareness was the most commonly cited reason (30.52%, 95% CI = 27.71% to 33.50%). For noncompletion of the HPV vaccine series, parents most commonly cited competing priorities (41.29%, 95% CI = 37.76% to 44.91%), followed by adverse reactions after the first dose (16.05%, 95% CI = 13.56% to 18.90%). Similarly, for noncompletion of the HPV vaccine series among adults, competing priorities was the most cited reason (31.04%, 95% CI = 28.20% to 34.02%).

CONCLUSION

These findings highlight the importance of addressing misconceptions and improving education about HPV vaccination to increase vaccination uptake rates and prevent HPV-related cancers.

Influences of sociodemographic characteristics and parental HPV vaccination hesitancy on HPV vaccination coverage in five US states

BACKGROUND

In the United States (US), half of new human papillomavirus (HPV) infections occur among young people aged 15-24 years. Despite the effectiveness of HPV vaccination in protecting against HPV-associated cancers, its coverage among adolescents remains suboptimal. This study examined the association of sociodemographic characteristics and HPV vaccination hesitancy with HPV vaccination coverage in five US states with disproportionately low adolescent coverage rates compared to the national average.

METHODS

Responses to an online Qualtrics survey from 926 parents of children aged 9-17 years in Arkansas, Mississippi, Missouri, Tennessee, and Southern Illinois in July 2021 were analyzed using multivariate logistic regression to estimate the association of sociodemographic characteristics and HPV vaccination hesitancy with HPV vaccination coverage.

RESULTS

Of the parents, 78 % were female, 76 % were non-Hispanic White, 61.9 % lived in rural areas, 22 % were classified as HPV vaccine hesitant, and 42 % had vaccinated their oldest child between the ages of 9-17 years against HPV. Children of vaccine hesitant parents were less likely to have received any doses of the HPV vaccine than children of non-vaccine hesitant parents (AOR: 0.17, 95 % CI:0.11-0.27). Male children were less likely to have initiated the HPV vaccine series than female children (AOR: 0.70, 95 % CI:0.50-0.97). Older children (13-17 vs 9-12 years), receiving the meningococcal conjugate or most recent seasonal influenza vaccine were all associated with higher likelihoods of receiving any doses of the HPV vaccine (AOR: 6.01, 95 % CI:3.98-9.08; AOR: 2.24, 95 % CI:1.27-3.95; AOR: 2.41, 95 % CI:1.73-3.36, respectively).

CONCLUSIONS

Adolescent HPV vaccination coverage remains low in our targeted states. Children's age, sex, and parental vaccine hesitancy were significantly associated with likelihood of HPV vaccination. These findings offer the opportunity for targeted interventions among parents in regions with low vaccine uptake and underscore the importance of developing and implementing strategies to address parental HPV vaccination hesitancy to improve uptake in the US.

Using Electronic Reminders to Improve Human Papillomavirus (HPV) Vaccinations among Primary Care Patients

The COVID-19 pandemic led to delays in routine preventative primary care and declines in HPV immunization rates. Providers and healthcare organizations needed to explore new ways to engage individuals to resume preventive care behaviors. Thus, we evaluated the effectiveness of using customized electronic reminders with provider recommendations for HPV vaccination to increase HPV vaccinations among adolescents and young adults, ages 9-25. Using stratified randomization, participants were divided into two groups: usual care (control) (N = 3703) and intervention (N = 3705). The control group received usual care including in-person provider recommendations, visual reminders in exam waiting rooms, bundling of vaccinations, and phone call reminders. The intervention group received usual care and an electronic reminder (SMS, email or patient portal message) at least once, and up to three times (spaced at an interval of 1 reminder per month). The intervention group had a 17% statistically significantly higher odds of uptake of additional HPV vaccinations than the usual care group (Adjusted Odds Ratio: 1.17, 95% CI: 1.01-1.36). This work supports previous findings that electronic reminders are effective at increasing immunizations and potentially decreasing healthcare costs for the treatment of HPV-related cancers.

Prevalence of Human Papillomavirus in Different Mucous Membranes in HIV Concordant Couples in Rwanda

BACKGROUND

The prevalence of human papillomavirus (HPV) infections in other anatomical sites besides the uterine cervix is unknown in East Africa. Here, we assessed the prevalence and concordance of HPVs in different anatomical sites in HIV concordant couples in Rwanda.

METHODS

Fifty HIV-positive concordant male-female couples at the HIV clinic at the University Teaching Hospital of Kigali in Rwanda were interviewed, swabbed from the oral cavity (OC), oropharynx (OP), anal canal (AC), vagina (V), uterine cervix (UC) and penis. A pap smear test and a self-collected vaginal swab (Vself) were taken. Twelve high-risk (HR)-HPVs were analyzed.

RESULTS

HR-HPVs occurred in 10%/12% in OC, 10%/0% in OP and 2%/24% in AC (p = 0.002) in men and women, respectively. HR-HPVs occurred in 24% of UC, 32% of Vself, 30% of V and 24% of P samples. Only 22.2% of all HR-HPV infections were shared by both partners (κ -0.34 ± 0.11; p = 0.004). The type-specific HR-HPV concordance was significant between male to female OC-OC (κ 0.56 ± 0.17), V-VSelf (κ 0.70 ± 0.10), UC-V (κ 0.54 ± 0.13), UC-Vself (κ 0.51 ± 0.13) and UC-female AC (κ 0.42 ± 0.15).

CONCLUSIONS

HPV infections are prevalent in HIV-positive couples in Rwanda but concordance within couples is low. Vaginal self-sampling for HPV is representative of cervical HPV status.

Incidence of human papillomavirus-related cancers among males and females aged 15-34 years in the United States

Postmarket surveillance of the incidence of human papillomavirus (HPV)-related cancers is essential to monitor the effectiveness of HPV vaccines. We directly compared HPV-related cancer incidences during the pre- and postvaccine era to assess the effects of HPV vaccination among vaccine-eligible age groups in the United States using data from the US Cancer Statistics database. The 5-year average annual incidence rates for HPV-related cancers decreased in 2015-2019 compared with 2002-2006 among females aged 15-24 years and 25-34 years. Overall, a decrease in young males was not observed, whereas males aged 25-34 years experienced a slight decline in oropharyngeal squamous cell carcinoma between 2005-2009 and 2015-2019. Incidence rates for HPV-related cancers statistically significantly decreased in the vaccine era compared with the prevaccine era among females aged 15-34 years, suggesting the potential early effects of the introduction of HPV vaccination in the United States.

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.

County-Level Factors Associated With HPV Vaccine Coverage Among 11-Year-Olds to 12-Year-Olds Living in Florida in 2019

BACKGROUND

In the United States, human papillomavirus (HPV) vaccine initiation and up-to-date (UTD) status are associated with multiple factors at the individual level such as racial/cultural (e.g., race, immigration status), socioeconomic status (e.g., living below poverty level, education), and healthcare access (e.g., insurance status/type). HPV vaccination rates differ dramatically by US geographic areas and within states. To tailor interventions to local areas, it is important to understand county-level characteristics associated with HPV vaccination rates.

METHODS

Using linear regression, we assessed the association between county-level HPV vaccination initiation and UTD rates for 11-year-olds to 12-year-olds in Florida (collected from the Florida SHOTS immunization registry) and county-level variables. Factors found significant in bivariate analysis and with a variance influence factors <4 were included in multivariable models.

RESULTS

In 2019, county-level HPV vaccine coverage among Florida 11-year-olds to 12-year-olds ranged from 31% to 92% initiation and 3%-36% UTD. Counties with the lowest HPV vaccine coverage were concentrated in Florida's North-Central and Panhandle regions. In multivariable models, counties with primarily rural populations had lower vaccination initiation and UTD coverage. Above and beyond the association with rurality, UTD coverage was associated with family physicians per 100,000 residents and uninsured or Medicaid-enrolled populations.

DISCUSSION

While Florida county-level HPV vaccine initiation rates among 11-year-olds to 12-year-olds varied by county in 2019, UTD rates remained universally low despite recommendations. Tailoring interventions toward healthcare access in rural communities may increase HPV vaccine coverage.

A review of data systems for assessing the impact of HPV vaccination in selected high-income countries

INTRODUCTION

The introduction of effective human papillomavirus (HPV) vaccination, screening, and treatment programs has led the World Health Organization to call for the global elimination of cervical cancer. Assessing progress toward this goal is supported through monitoring vaccination coverage and its impact.

AREAS COVERED

We performed a targeted review to assess the characteristics of HPV-related data systems from seven high-income countries (HICs) that represented varied approaches, including Australia, Canada, France, Italy, Scotland, Sweden, and the United States (US). Included data systems focused on preventive and early detection measures: HPV vaccination and cervical screening programs, as well as HPV-related disease outcomes. Differences were observed in approach to development of data systems, along with variation in geographical scope and methods of data collection.

EXPERT OPINION

A challenge exists in how to best follow-up the ongoing global-scale elimination efforts in a comprehensive manner. These sources provide a wealth of information regarding the strengths and limitations of, and notable variation among, current data systems used in HICs. This review can inform improvements to existing prevention programs and the implementation of new programs in other countries, and thus support optimization of cervical cancer prevention policy.

Provider and Practice Factors Associated With On-Time HPV Vaccination in Primary Care

BACKGROUND

In 2018, only one third of girls and boys completed the 2-dose series of the human papillomavirus vaccine by their 13th birthday, the target for on-time vaccination. The study objective was to identify key patient, provider and practice-level factors associated with on-time vaccination in the primary care setting.

METHODS

We examined data from 20 primary care pediatric practices (89 providers) in St. Louis including: the percentage of eligible patients with on-time vaccination assessed from medical records; providers' knowledge, attitudes and behaviors regarding on-time vaccination assessed with a survey; and practice-level strategies used to optimize vaccine delivery assessed with a 19-item vaccine delivery system score (VDSS). Factors that increased on-time vaccination were identified using logistic regression, controlling for clustering within providers.

RESULTS

Completion of on-time vaccination occurred in 1347/3125 (43.10%) of patients (95% confidence interval [CI], 41.36%-44.86%) and varied among practices (7.39%-64.24%) and among providers (2.63%-82.50%). Independent predictors for higher completion of on-time vaccination included more frequent use by providers of the announcement style for vaccine recommendation (odds ratio [OR] 1.18, 95% CI, 1.04, 1.35), higher provider self-efficacy to deliver the vaccine according to guideline recommendations if parents were hesitant (OR 1.21, 95% CI, 1.05, 1.40), and higher VDSS (OR 1.20, 95% CI, 1.10, 1.31).

CONCLUSIONS

Provider and practice-level factors were identified that may represent modifiable targets for improvement in on-time vaccine uptake. Future research is needed to test interventions built on these findings.

Messaging preferences among Florida caregivers participating in focus groups who had not yet accepted the HPV vaccine for their 11- to 12-year-old child

BACKGROUND

In the United States, human papillomavirus (HPV) vaccination rates remain low. The President's Cancer Panel suggests that effective messaging about the HPV vaccination focus on the vaccine's safety, efficacy, ability to prevent cancer, and recommendation at ages 11- to 12-years. We aimed to develop messages about HPV vaccine that include the President Cancer Panel's suggestions and were acceptable to caregivers of adolescents.

METHODS

From August to October 2020, we conducted one-hour, Zoom videoconference focus groups with caregivers who lived in Florida, had an 11- to 12-year-old child, and had not had any of their children receive the HPV vaccine. Focus group moderators asked caregivers to react to three videos of clinician (i.e., MD, DO, APRN, PA) recommendations and three text message reminders. Thematic analysis was conducted using the constant comparative method and led by one author with qualitative analysis expertise. Two additional authors validated findings.

RESULTS

Caregivers (n = 25 in six groups) were primarily non-Hispanic white (84%) and educated (64% had at least an Associate's degree). Approximately a third of caregivers had delayed (44%) or decided against a vaccine for their child (36%). Caregivers described six preferred message approaches: recognize caregivers' autonomy, balanced benefits and risks, trustworthy sources, increased feasibility of appointment scheduling, information prior to decision point, and preferred personalized information. Caregivers expressed a desire to have the follow-up doses mentioned in the introduction.

CONCLUSIONS

HPV vaccine messages, whether delivered by a clinician or via text message, will be more acceptable to caregivers if they approach HPV vaccination as the caregivers' decision, and include information from trusted sources to help caregivers make an informed choice.

The influence of parent-child gender on intentions to refuse HPV vaccination due to safety concerns/side effects, National Immunization Survey - Teen, 2010-2019

Amid subpar uptake of HPV vaccination in the United States, gender-generated disparities in HPV vaccination uptake have the potential to perpetuate existing disparities in HPV-associated cancers. Yet few studies have investigated the influence of parent-child gender on intentions to refuse HPV vaccination due to safety concerns/side effects. This study used nationally representative data, spanning 2010-2019, from the National Immunization Survey-Teen (NIS-Teen). NIS-Teen respondents are parents/guardians or primary caregivers of adolescents 13-17 years old living in the United States. Over the study period, intentions to refuse HPV vaccination due to safety concerns rose among all parent-child gender pairings but were highest among respondent mothers regarding their unvaccinated daughters. The results revealed a statistically significant increased likelihood of having intentions to refuse HPV vaccination due to safety concerns among all parent-child combinations compared with father-son pairs. These odds were consistently highest among mother-daughter pairs. In 2019, compared with father-son pairs, fathers were 1.94 (95% CI: 1.21-3.12) times more likely to report the intention to not vaccinate against HPV for their daughters, while mothers were 2.23 (95% CI: 1.57-3.17) and 2.87 (95% CI: 2.02-4.09) times more likely to report intentions to refuse HPV vaccination for their sons and daughters, respectively. These findings were persistent and constantly increased over the 10-year study period. Interventions aimed at correcting gender-based misperceptions and countering misinformation about the safety of the HPV vaccine are warranted.

Association of provider HPV vaccination training with provider assessment of HPV vaccination status and recommendation of HPV vaccination

The delivery of strong HPV vaccine recommendations hinges on the expertise of healthcare providers (HCPs) in assessing patients' status and recommending HPV vaccination. We conducted a population-based cross-sectional study of HCPs practicing in Texas to examine the relationship between HPV vaccination training of HCPs and HPV vaccination status assessment and recommendation. Logistic regression analyses were used to assess the association between HCPs' formal training and recency of training in HPV vaccination promotion or counseling with HPV vaccination status assessment and recommendation. Of the 1,283 HCPs who completed the online survey, 43% had received training in HPV vaccination promotion or counseling, 47% often/always assess HPV vaccination status, and 59% often/always recommend HPV vaccination. Compared with HCPs who received no training, those who received training had over four times higher odds (adjusted odds ratio [AOR]: 4.32; 95% CI: 3.06-6.10) of often/always assessing HPV vaccination status and over three and half times higher odds (AOR: 3.66; 95% CI: 2.73-4.90) of often/always recommending HPV vaccination. Furthermore, HCPs who recently received HPV vaccination training had higher odds of HPV vaccination status assessment and recommendations than those without training. Hispanic HCPs had higher odds of often/always assessing HPV vaccination status and recommending vaccination than did non-Hispanic White HCPs. Also, nurses and physician assistants had lower odds of often/always assessing HPV vaccination status and recommending HPV vaccination than did physicians. Targeted and continuous training of HCPs in HPV vaccination promotion or counseling is needed to increase HPV vaccination status assessment, recommendation, and uptake rates.

Healthcare Provider Recommendations and Observed Changes in HPV Vaccination Acceptance during the COVID-19 Pandemic

Healthcare provider (HCP) recommendation of the human papillomavirus (HPV) vaccination is crucial for HPV vaccination acceptance and uptake. It is unclear to what extent the disruptive effect of the COVID-19 pandemic impacted the recommendation and acceptance of HPV vaccination. HCPs practicing in Texas were invited to complete an online survey between January and April 2021. This population-based survey examined the association between HPV vaccination recommendation by HCPs and their observed changes in HPV vaccination acceptance during the COVID-19 pandemic. Of the total 715 HCPs included in this study, 13.9% reported a decrease, 8.7% reported an increase, and 77.5% reported no change in HPV vaccination acceptance during the COVID-19 pandemic. Compared to the HCPs who never/sometimes recommend HPV vaccination, those who often/always recommend HPV vaccination were less likely to observe a decrease (12.3% vs. 22.1%) and more likely to observe an increase in HPV vaccination (9.1% vs. 6.2%), during the COVID-19 pandemic. Furthermore, those who provided recommendations often/always had 46% (odds ratio: 0.54; 95%CI: 0.30–0.96) lower odds of reporting a decrease in HPV vaccination acceptance during the COVID-19 pandemic. This study adds to prior evidence of the positive influence of provider recommendations on HPV vaccination acceptance despite the disruptive effect of the COVID-19 pandemic on cancer prevention services.

HPV Vaccination Uptake, Hesitancy and Refusal: Observations of Healthcare Professionals during the COVID-19 Pandemic

HPV vaccination is highly effective at preventing several types of cancer; however, vaccine uptake is suboptimal. The COVID-19 pandemic has impacted participation in preventive measures such as HPV vaccination. To assess changes and barriers to HPV vaccination during the COVID-19 pandemic, we conducted a statewide cross-sectional survey of healthcare professionals (HCPs) in Texas. Specifically, we evaluated changes observed by HCPs regarding HPV vaccination i) hesitancy, ii) refusal, and iii) uptake, during the COVID-19 pandemic. Decreases in HPV vaccination uptake were reported by 19.3% of HCPs whereas, increased HPV vaccination hesitancy and refusal were reported by 17.1% and 14.8% of HCPs in Texas, respectively. The COVID-19 pandemic had a negative impact on HPV vaccination. Our study identified barriers to HPV vaccination that are unique to the COVID-19 pandemic.

Long-term impact of HPV vaccination and COVID-19 pandemic on oropharyngeal cancer incidence and burden among men in the USA: A modeling study

BACKGROUND

Oropharyngeal cancer (OPC) incidence is rising rapidly among men in the United States of America (USA). We aimed to project the impact of maintaining the current HPV vaccination uptake and achieving 80% national (Healthy People) goal on OPC incidence and burden.

METHODS

We developed an open-cohort micro-simulation model of OPC natural history among contemporary and future birth cohorts of men, accounting for sexual behaviors, population growth, aging, and herd immunity. We used data from nationally representative databases, cancer registries from all 50 states, large clinical trials, and literature. We evaluated the status quo scenario (the current HPV vaccination uptake remained stable) and alternative scenarios of improvements in uptake rates in adolescents (aged 9-17 years) and young adults (aged 18-26 years) by 2025 to achieve and maintain the 80% goal. The primary outcome was to project OPC incidence and burden from 2009 to 2100. We also assessed the impact of disruption in HPV vaccine uptake during the COVID-19 pandemic.

FINDINGS

OPC incidence is projected to rise until the mid-2030s, reaching the age-standardized incidence rate of 9·8 (95% uncertainty interval [UI] 9·5-10·1) per 100 000 men, with the peak annual burden of 23 850 (UI, 23 200-24 500) cases. Under the status quo scenario, HPV vaccination could prevent 124 000 (UI, 117 000-131 000) by 2060, 400 000 (UI, 384 000-416 000) by 2080, and 792 000 (UI, 763 000-821 000) by 2100 OPC cases among men. Achievement and maintenance of 80% coverage among adolescent girls only, adolescent girls and boys, and adolescents plus young adults could prevent an additional number of 100 000 (UI, 95 000-105 000), 118 000 (UI, 113 000-123 000), and 142 000 (UI, 136 000-148 000) male OPC cases by 2100. Delayed recovery of the HPV vaccine uptake during the COVID-19 pandemic could lead to 600 (UI, 580-620) to 6200 (UI, 5940-6460) additional male OPC cases by 2100, conditional on the decline in the extent of the national HPV vaccination coverage and potential delay in rebounding.

INTERPRETATION

Oropharyngeal cancer burden is projected to rise among men in the USA. Nationwide efforts to achieve the HPV vaccination goal of 80% coverage should be a public health priority. Rapid recovery of the declined HPV vaccination uptake during the COVID-19 pandemic is also crucial to prevent future excess OPC burden.

FUNDING

National Cancer Institute and National Institute on Minority Health and Health Disparities of the USA.

U.S. Vietnamese parents' HPV vaccine decision-making for their adolescents: an exploration of practice-, provider-, and patient-level influences

U.S. Vietnamese have high cervical cancer incidence and low human papillomavirus (HPV) vaccine initiation. Using the P3 model, we explored practice-, provider-, and patient-level determinants of U.S. Vietnamese parents’ HPV vaccine decision-making for their adolescents. We conducted a cross-sectional, online survey (04/2020–12/2020) with U.S. Vietnamese parents who had ≥ 1 adolescent ages 9–18. We assessed HPV vaccination outcomes (initiation, willingness to initiate, completion) and provider recommendation. Modified Poisson regressions were used to identify practice-, provider- and patient-level correlates of outcomes. The sample (n = 408) was 44 years old on average; 83% were female and 85% had a Bachelor’s degree. Around half of adolescents were female (51%) and 13–18 year old (54%). Only 41 and 23% of parents had initiated and completed the HPV vaccine series for their child, respectively. Initiation was associated with receiving provider recommendation (either low- or high-quality), while willingness to initiate was associated with receiving high-quality recommendation. Both initiation and willingness to initiate was negatively associated with parental perception that their child was too young for a “sexually transmitted infection (STI)-preventing vaccine.” Provider recommendation was associated with higher parental U.S. acculturation and the child being older and female. Provider-facing interventions should promote high-quality, age-based, gender-neutral HPV vaccine recommendation. These and population- and individual-facing interventions should recognize the need for additional parental education, particularly related to misconceptions regarding STI prevention.

Safety Concerns or Adverse Effects as the Main Reason for Human Papillomavirus Vaccine Refusal: National Immunization Survey-Teen, 2008 to 2019

This secondary analysis assesses safety concerns and adverse effects as reported reasons for HPV vaccine refusal.

Determinants of patient-reported xerostomia among long-term oropharyngeal cancer survivors

BACKGROUND

This study was conducted to identify clinicodemographic risk factors for xerostomia among long-term oropharyngeal cancer (OPC) survivors.

METHODS

This cross-sectional study included 906 disease-free, adult OPC survivors with a median survival duration at the time of survey of 6 years (range, 1-16 years); self-reported xerostomia scores were available for 877 participants. Study participants had completed curative treatment between January 2000 and December 2013 and responded to a survey administered from September 2015 to July 2016. The primary outcome variable was cancer patient-reported xerostomia measured with the MD Anderson Symptom Inventory Head and Neck Cancer Module. Clinicodemographic risk factors for moderate to severe xerostomia were identified via multivariable logistic regression.

RESULTS

Moderate to severe xerostomia was reported by 343 of the respondents (39.1%). Female sex (odds ratio [OR], 1.82; 95% CI, 1.22-2.71; P = .003; Bayesian false-discovery probability [BFDP] = 0.568), high school or lower education (OR, 1.73; 95% CI, 1.19-2.52; P = .004; BFDP = 0.636), and current cigarette smoking at the time of survey (OR, 2.56; 95% CI, 1.19-5.47; P = .016; BFDP = 0.800) were risk factors for moderate to severe xerostomia, and bilateral intensity-modulated radiotherapy (IMRT) combined with proton therapy and ipsilateral IMRT were protective.

CONCLUSIONS

In this large xerostomia study, modern radiotherapy was a protective factor, and continued cigarette smoking at the time of survey, female sex, and high school or lower education were identified as other contributing risk factors associated with moderate to severe xerostomia. Importantly, these findings need to be confirmed in prospective studies. These results can inform future research and targeted patient-centered interventions to monitor and manage radiation therapy-associated xerostomia and preserve quality of life among patients with OPC.