National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years - United States, 2017

HPV Vaccination and Awareness Programs at Maryland Colleges and Universities

CONTEXT

About half of adolescents aged 13 to 17 in United States are not fully vaccinated against human papillomavirus (HPV). As they age into young adulthood, colleges may be an excellent target population nexus for implementing interventions to improve HPV vaccination uptake.

OBJECTIVES

Our study goal was to generate knowledge about HPV vaccine offerings and awareness programs at colleges to ascertain the extent of campus-facilitated access to HPV immunization and education in 1 state.

DESIGN

An electronic survey was designed and emailed to 32 of 47 Maryland colleges for which relevant campus contacts could be identified.

SETTINGS

The study took place at Johns Hopkins Bloomberg School of Public Health in consultation with the Maryland Cancer Collaborative and the Maryland Department of Health.

PARTICIPANTS

Maryland colleges and universities.

MAIN OUTCOME MEASURES

HPV vaccine and awareness program offerings on college and university campuses.

RESULTS

Twenty Maryland colleges responded. Two colleges offer awareness programs only. Ten colleges offer HPV vaccine, covering about 39% of Maryland college students. Of these, 4 colleges schedule "periodic" campus health clinics or provide an immunization prescription, which is filled at nearby pharmacies. In all colleges, which offer HPV vaccine, immunization is offered to everyone (both men and women) at no out-of-pocket cost.

CONCLUSIONS

In cooperation with the Maryland Cancer Collaborative, the implementation arm for the Maryland Cancer Control Plan, we showed that college campuses are an excellent target site for implementation of interventions to improve access of college age students to HPV vaccine and awareness programs. We lay the groundwork for recommendations, programs and policies that can improve HPV vaccine offerings among college students thus raising the HPV vaccination rate in young adults. Simple inexpensive alternatives to offering vaccine at college health centers may be periodic campus health clinics and arrangements with nearby pharmacies.

Trusted health system implementation strategies to increase vaccination (TRUE SYNERGI): a stepped-wedge cluster randomized trial to reduce HPV-related cancers

BACKGROUND

Despite the availability of highly effective HPV vaccines that can reduce HPV-associated cancer mortality, HPV vaccination rates in Texas rank 48th nationwide. Although evidence shows Latino parents are more accepting of HPV vaccination than non-Hispanic parents, this disparity in vaccination rates underscores the importance of understanding Latino parental HPV vaccine hesitancy. Latinos/as typically receive healthcare at Federally Qualified Health Centers (FQHCs), which often need support implementing and improving access to evidence based preventive services. However, the current literature around implementation comes from large integrated healthcare systems and there is limited research around what works in the FQHC settings with Latino/a patients. Preliminary data from our previous work suggest practice facilitation is a feasible approach for building the capacity in FQHCs to select and implement provider- and practice-level strategies for increasing vaccination rates.

METHODS

This proposal considers the HPV vaccine as the evidence-based intervention and describes the rational and study design for "TRUsted hEalth SYstem implementatioN stratEGIes to increase vaccination (TRUE SYNERGI)", a hybrid type 2 study that uses previously-piloted implementation strategies (i.e., practice facilitation, provider education, among others) to influence provider recommendations (implementation outcome) and practice-level vaccination rates (effectiveness outcome). To test whether these facilitator-driven implementation strategies influence our implementation and effectiveness outcomes, we will use a stepped-wedge cluster randomized trial and randomize three FQHCs (n = 9 practices, 3 per FQHC) to three clusters. We will conduct baseline assessments at each practice, which will provide data to assist the practice facilitator in engaging with the providers and leadership to develop a tailored implementation plan for each practice. In addition, we will employ theory-guided, qualitative methods, to assess the complexity associated with context and the recipients involved in the implementation of strategies in practices, along with sustainability.

DISCUSSION

The study will advance our understanding of what it means to conduct implementation research in resource limited practices that work with populations experiencing substantial disparities. Findings from the current study will inform national implementation efforts and contribute towards future research targeting dissemination and scale-up, key foci for health equity focused implementation research.

TRIAL REGISTRATION

Registered in ClinicalTrials.gov (NCT06598475) on September 9, 2024.

Cost Analysis of a Scalable Clinician Communication Intervention to Increase HPV Vaccine Initiation

BACKGROUND AND OBJECTIVE

For a previous longitudinal cluster randomized controlled trial (2018-2019), we randomized 48 primary care pediatric practices to online communication training vs usual care. Online communication training reduced missed opportunities (MOs) for initial human papillomavirus (HPV) vaccination at well-child care (WCC) visits by 6.8 percentage points among children aged 11-17 years. The current study estimated implementation costs of the communication training intervention at WCC visits.

METHODS

We analyzed monthly surveys completed by intervention practice lead clinicians to track clinician plus office staff personnel hours devoted to implementing the intervention. We converted personnel time into 2019 US dollars using national median hourly wages for physicians and other health care workers; we tracked nonpersonnel costs. We calculated costs per practice (overall and by practice size) and estimated costs per averted MO for HPV vaccine initiation using an effectiveness estimate determined by grouped logistic regression at the practice level.

RESULTS

Practices varied from 1 to 24 clinicians (mean = 7.5) and from 241 to 8866 visits (mean = 2353) during the 6-month intervention. Total intervention costs varied substantially across the 24 intervention practices from $370 to $6653, with a mean of $2003 (95% CI, $1377-$2762) and median of $1305. The incremental cost per averted MO for HPV vaccine initiation at WCC visits averaged $110 ($212 in practices with 1 or 2 physicians and $94 in practices with 3 or more physicians).

CONCLUSIONS

The implementation cost per averted MO for HPV vaccine initiation at WCC visits of this online communication training intervention was modest, particularly among larger pediatric practices.

STEPS (Study To Examine Parent, Patient/Dental Provider Systems) to Prevent Human Papillomavirus (HPV)-Related Cancers: A Piloted Dental Patient and Provider Evaluation of Current and Future HPV Education

Oropharyngeal human papillomavirus (HPV) cancers are prevalent, but HPV education in dental clinics is uncommon. The purpose of this study was to evaluate dental provider and patient knowledge from, attitudes towards, and preferences for HPV education, then assess perceptions of existing HPV educational materials for use at dental visits. Appalachian Ohio dental patients (n = 13) and general/pediatric dental providers (n = 10) completed an initial, close-ended survey on current HPV knowledge and HPV educational attitudes, participation, and resource preferences. Select individuals reviewed existing HPV educational videos and toolkits via virtual focus groups (n = 9) or independent review surveys (n = 6). Using a discussion guide, participants responded to overall, visual, auditory, and content satisfaction statements, orally (focus groups) or with Likert scales (independent reviews). Surveys were summarized with frequencies/percentages; transcripts were qualitatively coded to identify potential material modifications. Dental providers and patients were more comfortable with HPV and oral cancer education (87% and 96%, respectively) and screening (96%) than with HPV vaccine education (74%) and referrals (61%) during dental visits. Providers were neither sharing HPV educational materials (80%) nor initiating educational conversations with dental patients (100%). The American Cancer Society videos and the "Team Maureen" toolkit were the most liked resources (i.e., fewer negative/disagree statements) by all participant groups. Findings indicate that future dental HPV educational efforts should be informed by currently available materials. Additional interventions are needed to promote dental provider discussions and sharing of educational materials with patients to increase education and promotion of the HPV vaccine and reduce oropharyngeal cancers.

Human papillomavirus vaccination coverage among adolescent boys and girls in the United States: A birth year cohort analysis of the National Immunization Survey-Teen, 2016-2022

OBJECTIVE

To evaluate human papillomavirus (HPV) vaccination coverage among adolescents in the U.S. using birth cohort analysis.

METHODS

We conducted a birth cohort analysis among adolescents born during 1999-2009 using National Immunization Survey-Teen (NIS-Teen), a random-digit dialed household telephone survey that also includes vaccination data from providers. We analyzed 131,553 records from 2016 to 2022 NIS-Teen data to determine: trends in coverage with ≥1 HPV vaccine dose before age 13 years and cumulative coverage from age 13-17 years; sociodemographic factors associated with HPV vaccination before age 13 years; missed HPV vaccination opportunities and the potential achievable coverage if opportunities were not missed; and trends in completion of HPV vaccination series. Regression analysis and Kaplan-Meier method provided the average percentage increase in coverage, and cumulative coverage from age 13-17 years stratified by birth cohorts, respectively.

RESULTS

HPV vaccination initiation before age 13 years increased from 27.0 % among adolescents born in 1999 to 69.8 % among those born in 2009. Overall, cumulative percent with ≥1 HPV vaccine dose increased from 51.3 % before age 13 years to 74.9 % through age 17 years. Having a preventive visit at ages 11-12 years and being insured were associated with higher ≥1 HPV vaccine dose coverage. Among the 38,568 (29.3 %) adolescents unvaccinated for HPV, 31,513 (82.5 %) missed ≥1 HPV vaccination opportunity. The potential achievable coverage if opportunities were not missed was 94.8 %. Completion of HPV vaccination series before age 13 years increased from 10.3 % among adolescents born in 1999 to 42.2 % among those born in 2009.

CONCLUSIONS

Coverage with ≥1 HPV vaccine dose increased by birth cohort among adolescents born 1999-2009 but remained suboptimal, especially among uninsured adolescents. Missed opportunities may be reduced by effective HPV vaccination implementation and uptake strategies and by administering all recommended vaccines during the same visit.

Association Between a Mother's Cervical Cancer Screening and Child's Human Papillomavirus (HPV) Vaccination Status

OBJECTIVES

To investigate the association between maternal cervical cancer (CC) screening status and child human papillomavirus (HPV) vaccination uptake. To understand if child sex or social deprivation index (SDI) modify this association.

METHODS

We used a national cohort of children linked to at least one parent using electronic health record (EHR) data from a network of community health centers across the United States. We used SDI scores and child sex as moderating variables. We performed the analysis (1) for the whole sample (with SDI and child sex added as covariates), (2) stratified by SDI quartile (with child sex added as a covariate), and (3) stratified by SDI quartile and child sex, to examine whether associations vary by SDI quartile and by child sex.

RESULTS

N = 52,919 linked mother-child pairs. Mother's receipt of CC screening was positively associated with the linked child's odds of receiving HPV vaccination [adjusted odds ratio (AOR) 1.39, 95% confidence interval (CI) 1.32, 1.47]. Neither sex or SDI modified this association. There were no significant differences in odds of HPV vaccination in children between SDI quartiles or between male and female children.

CONCLUSIONS FOR PRACTICE

An effective way to improve rates of HPV vaccination among children and adolescents may be to target attention towards increasing CC screening rates among mothers. Further, focusing resources and efforts on CC screenings and care of both mothers and their children may be more worthwhile than isolated efforts targeting HPV vaccination for children and adolescents.

Quadrivalent Conjugate Vaccine and Invasive Meningococcal Disease in US Adolescents and Young Adults

Importance

Beginning in 2005, the US implemented routine immunization of adolescents with a quadrivalent conjugate vaccine (MenACWY) for the prevention of invasive meningococcal disease (IMD).

Objectives

To assess whether MenACWY immunization was associated with a reduced IMD burden among the US adolescent population and how the downward trajectory of IMD that began in the mid-1990s might have evolved in the absence of vaccination efforts.

Design, Setting, and Participants

In this decision analytical study, a bayesian hierarchical Poisson regression model was developed to investigate the potential trajectory of IMD among US adolescents and young adults without vaccination and evaluate the direct association of vaccination with IMD burden. The model included the entire age-stratified US population and was fitted to national incidence data for serogroups C, W, and Y from January 1, 2001, to December 31, 2021, with stratification by vaccination status for IMD cases.

Intervention

Simulated counterfactual scenario of absent vaccination from 2005 to 2021, while retaining the incidence rate of IMD for unvaccinated individuals estimated during model fitting.

Main Outcomes and Measures

The main outcomes were the estimated numbers of IMD cases and deaths averted by MenACWY vaccination among US adolescents and young adults aged 11 to 23 years.

Results

Among the entire US population from 2005 to 2021, MenACWY vaccination prevented an estimated 172 (95% credible interval [CrI], 85-345) cases of IMD among US adolescents 11 to 15 years of age and 328 (95% CrI, 164-646) cases of IMD among those aged 16 to 23 years. Absent vaccination, the cumulative incidence of IMD in these age groups would have been at least 59% higher than reported over the same period with vaccination. Using case fatality rates of unvaccinated individuals derived from national data, vaccination averted an estimated 16 (95% CrI, 8-31) deaths among adolescents aged 11 to 15 years and 38 (95% CrI, 19-75) deaths among those aged 16 to 23 years.

Conclusions and Relevance

This decision analytical model suggests that the MenACWY vaccination program in the US was associated with a reduced burden of meningococcal disease. Without vaccination, the incidence rates per 100 000 adolescents and young adults would have been substantially higher than those observed during the vaccine era.

Contemporary provider perspectives on how to address HPV vaccine hesitancy in the US: A qualitative study

Introduction

Despite over 15 years of real-world data that supports the safety and efficacy of the human papillomavirus (HPV) vaccine, in the United States vaccine hesitancy persists. Many studies have focused on vaccine-hesitant parents, but fewer have examined provider perspectives on how to address HPV vaccine hesitancy.

Methods

Between July 2021-April 2022, we recruited providers in Maryland and the broader Mid-Atlantic region who practiced pediatrics, primary care, family medicine, or adolescent medicine and who provided outpatient care for children ages 10-17. Semi-structured virtual interviews focused on provider-reported strategies to address HPV vaccine-hesitant parents, as well as perceived barriers to successful vaccination and provider perspectives on specific interventions to address parental hesitancy. Audio recordings were transcribed and analyzed via a combination of deductive and inductive coding. Higher-level themes within the domains of strategies, barriers, and perspectives on specific proposed interventions were identified.

Results and discussion

A total of sixteen providers completed an interview. Within the domain of provider-reported strategies, the following themes emerged: 1) leveraging continuity of care and established parental trust, 2) supporting parental autonomy, 3) tailoring the approach to specific concerns of vaccine-hesitant parents, 4) normalizing the HPV vaccine, and 5) focusing on health prevention and cancer prevention. Barriers providers identified were: 1) limited time, 2) lack of common ground with parents, 3) parent-child decision discordance, 4) availability of misinformation, and 5) parental concerns such as safety and necessity. In the domain for proposed interventions, providers favored interventions that saved time or were not resource-intense, that did not single out the HPV vaccine as different, were patient friendly, and leveraged efficiency through the electronic medical record. The insights from this study can help inform the development of provider-acceptable and feasible tools and interventions to address parental HPV vaccine hesitancy.

Comparing Cervical Cancer Screening Strategies in an Incarcerated Population

Objective: To describe the prevalence of cervical intraepithelial neoplasia (CIN), high-risk human papillomavirus (hrHPV) infection, and cervical cancer in a high-risk, underscreened incarcerated population and to evaluate the performance of current cervical cancer screening options to detect cervical precancer (CIN 2/3) in this population. Study Design: Deidentified data were obtained from all cytological, hrHPV DNA, and histopathological testing of cervical biopsies performed on people incarcerated at the North Carolina Correctional Institute for Women between January 1, 2013, and December 31, 2020. These were linked to corresponding demographic data. The proportions of histopathological diagnoses of CIN2+ and CIN3+ immediately preceded by abnormal cytology testing or hrHPV testing were determined, and prevalence differences and 95% confidence intervals were calculated. Results: A total of 15,319 individuals incarcerated at the North Carolina Correctional Institute for Women had at least one cytology result during 2013-2020. Of these, 2,829 (18%) had abnormal cervical cytology, and 3,724 (24.3%) had positive hrHPV testing. The detection of CIN2+ was 95.9% by preceding abnormal cervical cytology, 89.9% by preceding positive hrHPV testing (p = 0.03), and 96.5% by preceding positive co-testing. The detection rate of CIN3+ was 96.6% by preceding abnormal cervical cytology, 90.8% by preceding positive hrHPV testing (p = 0.12), and 96.6% by positive co-testing. Conclusion: In our sample, primary cytology and co-testing detected CIN2+ at higher rates when compared with primary hrHPV testing. This reinforces that incarcerated populations do not fall into average-risk populations for which current cervical cancer screening options are designed, which should be considered when performing screening in this population.

Prevalence and genotype distribution of HPV combined with cervical pathological results in women from Sichuan, China: A cross-sectional study based on post-vaccination period 2019 to 2023

BACKGROUND

Human papillomavirus (HPV) screening and vaccination exert efficacy in controlling the progression of cervical cancer. Thus, examinations into HPV prevalence, age-stratified specificity, genotype distribution, and their correlation with pathological outcomes can furnish robust evidence for customizing high-quality population screening and management.

METHODS

A cohort of 17,923 women attending clinics in the Jintang area, Sichuan, from January 2019 through August 2023 were enrolled in the study. Genotyping of HPV was conducted using real-time polymerase chain reaction (RT-PCR). The epidemiology and the relationship between HPV infection and histologic/cytologic abnormalities were subjected to analysis.

RESULTS

HPV infection was identified in 4387 women. The outpatient group exhibited a significantly higher HPV infection rate compared to the healthy examination group (26.5% vs. 17.5%, p < 0.05). The distribution of infection rates across different age groups exhibited a U-shaped pattern, with the highest infection rate in the group ≤20 years of age, succeeded by those >60 years of age. The 31-40 age group demonstrated the lowest prevalence of infection, but upon infection, its prevalence of the precancerous lesion CIN2-3 reached a maximum of 29.0%, constituting a novel finding. The most prevalent genotype was HPV52, followed by HPV16, 58, 53, 68, and 18. In the cytologic and histologic abnormalities group, the most common types were HPV52, 16, and 58. HPV16 predominantly appeared in high-grade intraepithelial neoplasia and carcinoma in situ, constituting over 60% of cases. While HPV type 52 was not individually detected in cervical cancer cases. And some other non-vaccine-covered HPV subtypes also showed high prevalence in Sichuan. The single infection rates of NH9-HPV (high-risk HPV subtypes covered by the non-nine-valent vaccine) in CIN2-3 and cervical cancer patients were 6.5% and 2.6%, respectively. Among them, HPV51, HPV53, HPV59, and HPV35 exhibited a significant preponderance, which even higher than HPV45 and HPV31 covered by the nine-valent vaccine types. And in NL9-HPV (low-risk HPV subtypes covered by the non-nine-valent vaccine), HPV42 accounted for the highest percentage in CIN2-3. A similar decreasing trend was observed in annual infection rates in the healthy examination population and in the 31-40 and 51-60 age groups, while the ≤20 age group showed an increase. Regarding type-specificity, HPV16 and HPV58 exhibited the most rapid declines.

CONCLUSION

This study furnishes the latest insights into the characteristics of HPV infection rate, age distribution, and genotype prevalence in Sichuan.

An In Vitro Investigation of the Antiproliferative and Antimetastatic Effects of Levosimendan: Potential Drug Repurposing for Cervical Cancer

Cervical cancer presents a significant challenge to the global health of women. Despite substantial advances in human papillomavirus (HPV)-related cervical cancer vaccines, non-HPV-related cervical cancer is still waiting novel therapeutic options. Drug repurposing has provided a promising approach to improve cancer therapy in recent years. Our study aimed to explore the potential in vitro antineoplastic effects of levosimendan on cervical cancer cells. The antiproliferative effects of levosimendan were investigated on cervical cancer cells using a standard MTT assay. Fluorescent double staining was performed to identify its ability to induce apoptosis and necrosis. The possible mechanism of action of levosimendan was explored using cell-cycle analysis. Furthermore, antimetastatic effects were investigated using a wound-healing assay and a Boyden chamber assay. Our results revealed that levosimendan exhibited the highest growth-inhibitory effect in the HPV-negative C33A cell line. However, the effects were modest compared to the standard agent, cisplatin. Cell-cycle analysis detected that levosimendan can induce cell-cycle arrest in C33A cells by increasing the G1 and G2/M phases, decreasing the S phase, and enhancing the hypodiploid subG1 population. Levosimendan inhibited cell migration and invasion in a concentration-dependent manner. As levosimendan showed antimetastatic efficacy, it could be considered for repurposing to contribute to overcoming resistance to therapy in cervical cancer.

Knowledge, Attitudes, Beliefs, Practices Regarding Human Papillomavirus (HPV), and Barriers to Vaccination Against HPV Infection: A Cross-Sectional Survey of Guam Residents

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and is linked to several cancers. In Guam, the HPV vaccination rate falls short of the National Healthy People 2030 goal. Only half of eligible Guam teens have received the HPV vaccination series. Additionally, research on Guam HPV vaccination is limited. A cross-sectional survey was conducted, and a representative sample of Guam residents (n=775) was surveyed to examine their knowledge, attitudes, beliefs, practices regarding HPV, and barriers to HPV vaccination. Aggregated scores were calculated for these scale items: attitude, knowledge, subjective norms, and perceived behavioral control regarding HPV. One-way Analysis of Variance (ANOVA) was used to compare the means of the scores and check for significant differences. Binary logistic regression helped to identify significant predictors of HPV vaccination among respondents with children. Significant differences were found for sex, education, income, and ethnicity. Women and those with higher education and income demonstrated higher positive attitudes and knowledge about HPV vaccination. Also, those with health insurance and those who were advised by their physician were more likely to get their children vaccinated. These results will guide the implementation of effective strategies for developing targeted behavioral and other appropriate interventions to increase HPV vaccination in Guam.

A Multivariate Probit Regression of the Uptake of Adolescent Vaccines Among Racial/Ethnic Minority Adolescents Before and During the COVID-19 Pandemic

PURPOSE

The uptake of adolescent vaccines has improved over the years. However, research of the effects of the COVID-19 pandemic on this uptake among racial/ethnic minority adolescents has been limited. This study was conducted to compare the probability of uptake of the human papillomavirus (HPV); tetanus, diphtheria, and acellular pertussis (Tdap); and quadrivalent meningococcal conjugate (MenACWY) vaccines among racial/ethnic minority adolescents ages 13-17 years in 2019, 2020, and 2021.

METHODS

Using a cross-sectional design to examine data from the National Immunization Survey-Teen (2019-2021), multivariate probit regression was used to model variation in uptake of these three adolescent vaccines (n = 38,128). The outcome measures were HPV, Tdap, and MenACWY vaccine uptake.

RESULTS

The probability of uptake of HPV vaccine was higher in 2020 (Coef = 0.09 [95% confidence interval (CI), 0.03-0.16]) and 2021 (Coef = 0.07 [95% CI, 0.00-0.15]) than in 2019. The probability of uptake of MenACWY vaccine was higher in 2020 (Coef = 0.08 [95% CI, 0.02-0.15]) than in 2019. The probability of uptake of recommended vaccines varied among racial/ethnic minorities with non-Hispanic Black adolescents exhibiting higher probability of uptake of HPV vaccine (Coef = 0.10 [95% CI, 0.01-0.19]) than Tdap vaccine. U.S. Census region and insurance status were associated with the uptake of all recommended vaccines.

DISCUSSION

Progress in the uptake of these recommended vaccines may not have been interrupted by the COVID-19 pandemic. Also, disparities in uptake of the recommended vaccines still exist despite increased uptake during the pandemic. Future research should examine the disparities as well as examine regional differences in the uptake of these three adolescent vaccines.

Meningococcal serogroup B vaccination series initiation in the United States: A real-world claims data analysis

In the United States (US), meningococcal serogroup B (MenB) vaccination has been recommended for 16-23-year-olds (preferably 16-18 years) based on shared clinical decision-making since 2015. MenB vaccine coverage (≥1 dose) by age 17 years has been reported, but initiation at older ages and by insurance type is unknown. In this retrospective cohort study, MarketScan claims data were analyzed to assess MenB vaccine series initiation (i.e. receipt of a first dose) during 2017-2020 among US commercially insured and Medicaid-covered individuals aged 16-18 and 19-23 years. Kaplan-Meier curves were generated to estimate series initiation at various times from index (latest of 1/1/2017 or 16^th/19^th birthday, depending on the cohort). Multivariable analyses were conducted to identify factors associated with series initiation. Among 1,450,354 Commercial and 1,140,977 Medicaid 16-18-year-olds, MenB vaccine series initiation rates within 3 years of each person's first eligibility were estimated to be 33% and 20%, respectively; among 1,857,628 Commercial and 747,483 Medicaid 19-23-year-olds, 3% and 1%, respectively. Factors identified to be significantly associated with increased likelihood of initiating a MenB vaccine series included co-administration of meningococcal serogroups ACWY (MenACWY) vaccine, younger age, female sex, nonwhite race (Medicaid only), New England or Middle Atlantic location (Commercial only), urban residence, and previous influenza vaccination. MenB vaccine series initiation among the studied US adolescents and young adults was low. There is a need for continued efforts to better understand barriers to the uptake of vaccines that are recommended based on shared clinical decision-making.

Primary Prevention of Cancer: A Multilevel Approach to Behavioral Risk Factor Reduction in Racially and Ethnically Minoritized Groups

ABSTRACT

Cancer continues to be the second most common cause of death in the United States. Racially and ethnically minoritized populations continue to experience disparities in cancer prevention compared with majority populations. Multilevel interventions-from policy, communities, health care institutions, clinical teams, families, and individuals-may be uniquely suited to reducing health disparities through behavioral risk factor modification in these populations. The aim of this article is to provide a brief overview of the evidence for primary prevention among racially and ethnically minoritized subpopulations in the United States. We focus on the epidemiology of tobacco use, obesity, diet and physical activity, alcohol use, sun exposure, and smoking, as well as increasing uptake of the Human Papillomavirus Vaccine (HPV), as mutable behavioral risk factors. We describe interventions at the policy level, including raising excise taxes on tobacco products; within communities and with community partners, for safe greenways and parks, and local healthful food; health care institutions, with reminder systems for HPV vaccinations; among clinicians, by screening for alcohol use and providing tailored weight reduction approaches; families, with HPV education; and among individuals, routinely using sun protection. A multilevel approach to primary prevention of cancer can modify many of the risk factors in racially and ethnically minoritized populations for whom cancer is already a burden.

Human Papillomavirus Vaccines

Human papillomavirus (HPV) vaccines are highly effective in preventing the transmission of HPV and thus downstream HPV-related lower genital tract neoplasias. First introduced in 2006, the HPV vaccine has demonstrated clinical efficacy in both men and women. Several commercially available vaccines now exist, but only one is available in the United States. Both prelicensure and postlicensure studies demonstrate robust safety profiles. HPV vaccines should be made available to everyone between the ages of 9 and 26 years of age. Newer vaccination recommendations in expanded populations rely on patient-provider shared decision making. Currently, available HPV vaccines offer little therapeutic benefit. Recent research has identified several new DNA vaccines and delivery modifications with early demonstrated success at eliminating prevalent HPV infections and precancerous lesions. Despite the success of the HPV vaccine, vaccination hesitancy and disinformation continue to threaten our ability to eliminate these deadly cancers. Informational, behavioral, and environmental interventions have mixed success in increasing vaccination rates, but several strategies do exist to increase rates of vaccination.

The Future of Sexually Transmitted Infection Research: Understanding Adolescent Perspectives for Implementation of a Chlamydia Vaccine

PURPOSE

Despite advancements in developing a vaccine for Chlamydia trachomatis (CT), vaccine hesitancy has historically limited the adoption of sexually transmitted infection immunization. This report investigates adolescent perspectives toward a potential CT vaccine and vaccine research.

METHODS

As part of the Technology Enhanced Community Health Nursing (TECH-N) study, conducted from 2012-2017, we surveyed 112 adolescents and young adults aged 13-25 years who presented with pelvic inflammatory disease regarding their perspectives on a CT vaccine and willingness to participate in vaccine research. Descriptive statistical analyses were conducted.

RESULTS

Most participants were African American (95%), on Medicaid (89%), and sexually experienced (100%). Most respondents would accept a vaccine (95%) and preferred a provider's recommendation (86%) over parents, partners, or friends. A majority (70%) would not be embarrassed to participate in research.

DISCUSSION

Respondents showed favorable attitudes toward CT vaccination and research in this high-risk study population.

The Role of Health Information Technology in Improving Awareness of Human Papillomavirus and Human Papillomavirus Vaccine Among U.S. Adults

Objective: Although human papillomavirus (HPV) vaccines prevent cancer-causing HPV infections and cervical precancers, there is suboptimal awareness and limited global accessibility of HPV and HPV vaccine. Emerging evidence suggests that health information technology (HIT) may influence HPV-related awareness and improve vaccine adoption. The objective of this study was to evaluate the link between HIT and HPV-related awareness Methods: Data were obtained from 1,866 U.S. adults aged 18-45 years who completed the 2017 and 2018 Health Information National Trends Survey. We conducted multivariable logistic regression to analyze the association between HIT utilization and HPV-related awareness. Results: Awareness of HPV and HPV vaccine were 72.7% and 67.5%, respectively. Participants who used electronic means to look up health information (adjusted odds ratio [aOR] = 3.05; p = 0.001), communicate with health care provider (aOR = 1.68; p = 0.026), look up test results (aOR = 1.94; p = 0.005), and track health costs (aOR = 1.65; p = 0.04) were more likely to report HPV awareness than those who did not. Participants who used an electronic device to look up health information (aOR = 3.10; p = 0.003), communicate with clinicians (aOR = 1.72; p = 0.008), look up test results (aOR = 1.63; p = 0.021), and track health care charges (aOR = 1.90; p = 0.006) were more likely to report HPV vaccine awareness than those who did not. Discussion and Conclusion: Our findings suggest a positive association between HIT utilization and HPV-related awareness. Given the rapid and exponential increase in mobile technology access globally, these results are encouraging and offer a potential opportunity to leverage digital technology in primary cancer prevention for HPV-related cancers, especially in low- and middle-income countries with unsophisticated health infrastructures.

Characterizing U.S. mothers with high human papillomavirus vaccine intent yet unvaccinated adolescents

HPV vaccination rates remain suboptimal in the United States. While the current literature focuses on expressly hesitant parents, few studies have examined parents with "high intent", or those indicating they definitely will vaccinate and have had the opportunity but not yet vaccinated their adolescents. Our objective was to differentiate characteristics of mothers with high intent from those who already vaccinated their adolescents using various socioeconomic, previous vaccine decision-making, and healthcare provider relationship-related variables. English-speaking mothers or female guardians of adolescents ages 11-14 years living in low HPV vaccine uptake states within the U.S. in September 2018 were recruited from a national survey panel as part of a larger study. We assessed HPV vaccine status of their adolescents and categorized respondents into two categories: Already Vaccinated and High Intent. We assessed differences using a multivariable logistic regression model. Among 2406 mothers, 18% reported high intent vs. 82% already having vaccinated. Mothers with high intent were more likely to identify as non-Hispanic White (p = 0.01), to have a younger adolescent (p < 0.001), and to report not receiving a provider HPV vaccination recommendation (p < 0.001). Mothers who estimated that half/more (vs. less) of their child's friends have received/will receive the vaccine had higher odds of already vaccinating (p < 0.001). Our findings suggest that clinicians may be able to improve HPV vaccination uptake within their practices by giving repeated, high-quality recommendations to parents of children who are not yet vaccinated. Additionally, these findings indicate perceived social norms may play a large role in on-time vaccine uptake. Reassuring hesitant parents that most parents accept the vaccine may also improve uptake in clinical practice.

Lower human papillomavirus vaccine initiation and completion among Asian American adolescents compared to their peers: National Health and Nutritional Examination Survey 2011-2018

PURPOSE

To compare human papillomavirus (HPV) vaccination initiation and completion between Asian American adolescents and their peers.

METHODS

HPV vaccine initiation and completion of adolescents aged 9-17 years old were analyzed using the National Health and Nutritional Examination Survey data from 2011 to 2018. The outcomes were HPV vaccine initiation percentage among all adolescents and completion percentage among initiators. Odds ratios for initiation or completion among Hispanics, Blacks, and Asians (referred to as racial/ethnic minorities) versus Whites were compared using logistic regression, adjusted for adolescent's age, annual family income, parent education, and insurance coverage.

RESULTS

From 2011 to 2018, overall initiation was less than 40% among U.S. adolescents. The initiation increased among boys (from 10% in 2011-12 to over 30% in 2017-2018) but not among girls. Compared to White girls, Black and Hispanic girls were more likely, while Asian girls were less likely to initiate vaccination. Although not statistically significant, Asian girls had ORs ranging from 0.65 to 0.99 for initiation compared to White girls in each of the four survey cycles. Black and Hispanic boys were more likely to initiate vaccination compared to White boys. Initiation among Asian boys increased to 39% in the 2017-2018 survey cycle. Racial/ethnic minority girls were less likely to complete the series compared to White girls, while the opposite was seen in Black boys.

CONCLUSION

HPV vaccination status varies among racial/ethnic groups. Future efforts should be made to achieve the Healthy People 2020 goal of 80% vaccination among U.S. adolescents and address the gap among Asian American girls.

Quality Improvement Project to Increase Human Papillomavirus Two-Dose Vaccine Series Completion by 13 Years in Pediatric Primary Care Clinics

PURPOSE

The human papillomavirus (HPV) causes genitourinary and oropharyngeal cancers. The HPV vaccine is safe and effective in preventing those diseases; however, vaccine series completion rates remain low in the United States. Our quality improvement (QI) project aimed to increase HPV-vaccination series completion rates to 70% from 2017 to 2020 for the 13-year patient population in an extensive academic pediatric primary care network that serves predominantly minority and Medicaid-insured children in Columbus, OH.

METHODS

The outcome measure was the percentage of 13-years Nationwide Children's Hospital Primary Care Network patients who completed the two-dose vaccine series by their 13th birthday. Four QI implemented interventions were utilized. Electronic medical records alert informed providers when the HPV vaccines are due. We studied monthly data for the network and for individual clinics using statistical process control, displaying data on a control chart. We followed two process measures, captured opportunity rate, and the number of HPV vaccines given.

RESULTS

We substantially increased HPV-vaccination series completion rates overall in the 13-year teen population from 27% to 65%, and three clinics reached the 70% goal for at least one quarter. Latino children had the highest completion rate of 80% and White children had the lowest completion rate at 64%.

DISCUSSION

Our QI project used four measures to improve HPV-vaccination series completion rates in the 13-year patient population that serves minority and low-income teens predominantly. Further QI studies are needed to improve HPV vaccine completion rates in teens.

Factors Related to Human Papillomavirus Positivity among Oral Cavity and Pharynx Cancers from Surveillance, Epidemiology and End Results (SEER) Program Data

BACKGROUND

As human papillomavirus positive (HPV+) oral cavity and pharynx cancer (OCPC) incidence increases significantly, our objective was to determine whether selected sociodemographic and clinical factors were associated with HPV+ OCPCs overall and by oropharyngeal and non-oropharyngeal sites.

METHODS

Surveillance, Epidemiology and End Results (SEER) Program data were used in this study. Specifically, univariate and logistic regression models were used to examine the relationships between HPV+ and HPV- OCPC cases and age, sex, race, ethnicity, marital status, factors of neighborhood socioeconomic status (i.e., nSES/Yost index) and rurality/urbanity, first malignancy status, histology, reporting source, stage at diagnosis, and OCPC anatomic site. The same approach was used to identify risk factors for HPV positivity for oropharyngeal and non-oropharyngeal OCPCs separately.

RESULTS

In all OCPCs, cases that were male, <80 years old, lived in the four highest nSES categories, diagnosed with a non-"gum and other mouth" OCPC (ref = hypopharynx), not locally staged at diagnosis, and a first malignancy had higher odds of being HPV+. Cases that were American Indian/Alaska Native and Asian or Pacific Islander (ref = White), Spanish-Hispanic-Latino ethnicity, non-married/partnered, and not reported by a hospital/clinic had lower odds of being HPV+. Associations were maintained in oropharyngeal OCPCs and only age and race remained significant for non-oropharyngeal OCPCs.

CONCLUSIONS

Sociodemographic and clinical differences in HPV+ and HPV- OCPC, overall and for (non)oropharyngeal, cases exist.

IMPACT

Identification of OCPC and (non)oropharyngeal risk factors for HPV positivity may assist in discovering high-risk groups that should receive enhanced public health efforts to reduce the U.S. OCPC burden.

Clinic-level differences in human papillomavirus vaccination rates among rural and urban Oregon primary care clinics

PURPOSE

Human papillomavirus (HPV) infection contributes to vaccine-preventable malignancies. Rural populations experience lower HPV vaccination rates despite similar rates of other childhood vaccinations. Individual- and clinic-level characteristics likely contribute to this disparity, but little is known about the separate roles of each. We compared clinic-level HPV vaccination rates among rural versus urban primary care clinics, identified factors associated with HPV vaccination, and separately assessed the impact of individual- and clinic-level characteristics on rural disparities in HPV vaccination.

METHODS

This cross-sectional study included 537 Oregon primary care clinics participating in the Vaccines for Children (VFC) program during 2019. Vaccination status was assessed using Oregon's ALERT Immunization Information System and included HPV vaccine ≥ 1 dose for ages 11 and 12; HPV vaccination up to date (UTD) for ages 13-17, and coadministration with tetanus, diphtheria, and acellular pertussis (Tdap). Rural versus urban clinic-level outcomes were assessed using negative binomial regression.

FINDINGS

Participating clinics were 24.5% rural and 75.6% urban. Family medicine clinics comprised 71.1%; pediatrics, 16.9%; and mixed, 12.1%. Across clinics, the average proportion of patients qualifying for VFC was 43%, and non-White patients were 14.1%. The mean rate of HPV vaccine ≥1 dose was lower among rural clinics (46.9% vs 51.1%, P = .039), as was vaccination UTD (40.5% vs 49.9%, P < .001). Adjusting for differences in individual- and clinic-level characteristics, rural disparities were no longer statistically significant.

CONCLUSIONS

Both individual- and clinic-level characteristics play a role in rural disparities in HPV vaccination, and modifiable clinic-level differences may be opportune targets to address these disparities.

HPV Vaccination Initiation and Completion Among Pediatric, Adolescent, and Young Adult Cancer Survivors and a Comparison Population Sample Receiving Primary Care

Human papillomavirus (HPV) vaccinations can reduce pediatric, adolescent, and young adult (PAYA) cancer survivors' susceptibility to HPV-related subsequent cancers. We examined differences in HPV vaccination initiation and completion among a Utah-based cohort of PAYA cancer survivors and a cancer-free population sample. Participants received primary care at 1 of 2 health care systems during study follow-up: 2006-2016. Vaccination records were identified from these health care systems, statewide vaccination records, and an all-payer claims database. HPV vaccination initiation (1 dose) and completion (3 doses) were compared between cancer survivors (N=1579) and age-matched and sex-matched cancer-free population sample (N=4513). Individuals were 9 to 21 years old at cohort entry. Mixed-effects Poisson regression estimated incidence rate ratios (IRRs) and 95% confidence intervals (CIs). Relative to the population sample, cancer survivors were less likely to initiate vaccination (IRR=0.8, 95% CI: 0.73-0.98). The most severe disparity compared with the population sample for vaccine initiation (IRR=0.5, 95% CI: 0.31-0.74) or completion (IRR=0.5, 95% CI: 0.28-0.89) was observed for Hispanic survivors. PAYA cancer survivors are less likely to initiate HPV vaccination series than noncancer counterparts. Targeted interventions should be directed at PAYA survivors to raise HPV vaccination with emphasis on high-risk groups such as Hispanic survivors.

Racial and ethnic disparities in cervical and breast cancer screenings by nativity and length of U.S. residence

OBJECTIVE

Previous studies of disparities in breast and cervical cancer screenings have focused on broad racial/ethnic groups or nativity status without accounting for immigration histories. Recent theoretical work argues for using intersectional approaches and examining within-group inequalities. Utilizing multiple years of National Health Interview Survey (NHIS) data, we examined between- and within-group Papanicolaou (Pap) test and mammogram screening based on nativity and length of U.S. residence for Asian and Hispanic women, along with non-Hispanic Black and White women.

DESIGN

The study samples consist of 54,900 women ages 21-64 without a hysterectomy who responded to questions about Pap test screening and 36,300 women ages 40-64 who responded to questions about mammogram screening. Asian and Hispanic women were further stratified by nativity and, for immigrants, length of time in the United States. Logistic regression analysis was used to identify significant associations with Pap test and mammogram screenings.

RESULTS

Recent Asian and Hispanic immigrants had the lowest Pap test and mammogram rates among all other groups, while Black (and White women for mammograms) women had the highest rates. After accounting for age, marital status, health insurance, education, employment status, and income, both Asian groups had lower odds, and Black and all Hispanic groups had higher odds of Pap test screening compared with White women. Similar results were observed for mammogram screening, except that long-term immigrant/U.S.-born Asian and U.S.-born Hispanic women did not have significantly different odds compared with White women. In general, the strength and direction of most sociodemographic variables were similar across groups for Pap test screening but differed for mammogram screening.

CONCLUSIONS

The between-group differences identified emphasize the disparities in screening between racial/ethnic groups while the within-group differences suggest the need to examine whether more targeted outreach efforts and prevention messages can increase screening for specific groups.

"We will do whatever it takes": Understanding Socioecological Level Influences on Hmong-American Adolescents and Parents' Perceptions of the Human Papillomavirus Vaccine

Human papillomavirus (HPV) vaccination completion rates in Asian-American populations are substantially lower than most White Americans. Our objective was to identify the knowledge, perceptions, and decision-making processes about HPV vaccinations in the Hmong population, an Asian-American group with increased risks of HPV-related cancers. We conducted eight focus groups with Hmong adolescents (n = 12) and parents (n = 13) to learn about barriers, facilitators, and decision-making processes regarding general vaccinations and the HPV vaccine. The focus group results were analyzed using thematic analysis, informed by the socioecological model and asset lens. Findings showed that at the individual level, Hmong adolescents and parents had low HPV and HPV vaccine awareness levels (barrier) and strong desires to learn about HPV and the HPV vaccine (facilitator). Community-level barriers included salient narratives about traumatic experiences with vaccines and vaccine research, while facilitators included strong community connections. At the institutional level, barriers included structural constraints in health care settings, while facilitators included ease of obtaining vaccines at school-based clinics and provider authoritative decision-making. Additionally, a range of decision-making processes between parents, adolescents, and providers were present, with parents expressing a strong appeal to engage in more shared decision-making with providers. A linguistically and culturally specific HPV educational program for Hmong adolescents and parents could address the barriers and build on facilitators and assets to promote HPV vaccine uptake in this growing Asian-American community.

Factors influencing human papillomavirus school-based immunization in Alberta: A mixed-methods study protocol

More than 1,300 Canadians are diagnosed with cervical cancer annually, which is nearly preventable through human papillomavirus (HPV) immunization. Across Canada, coverage rates remain below the 90% target set out by the Action Plan for the Elimination of Cervical Cancer in Canada (2020-2030). To support this Plan, the Canadian Partnership Against Cancer has commissioned the Urban Public Health Network (UPHN) to coordinate a quality improvement project with Canada's school-based HPV immunization programs. In Alberta, the UPHN partnered with Alberta Health Services (AHS) for this work. This study has one overarching research question: what are parent/guardian and program stakeholder perceived barriers, enablers and opportunities to immunization for youth as part of the school-based HPV immunization program in Alberta? This study uses a mixed-methods sequential explanatory design. A survey will be emailed to a sample of Albertans with children aged 11-17 years. Questions will be based on a Conceptual Framework of Access to Health Care. Subsequent qualitative work will explore the survey's findings. Parents/guardians identifying as vaccine hesitant in the survey will be invited to participate in virtual, semi-structured, in-depth interviews. Stakeholders of the school-based immunization program will be purposively sampled from AHS' five health zones for virtual focus groups. Quantitative data will be analyzed using SAS Studio 3.6 to carry out descriptive statistics and, using logistic regression, investigate if Framework constructs are associated with parents'/guardians' decision to immunize their children. Qualitative data will be analyzed using NVivo 12 to conduct template thematic analysis guided by the Framework. Study results will provide insights for Alberta's public health practitioners to make evidence-informed decisions when tailoring the school-based HPV immunization program to increase uptake in vaccine hesitant populations. Findings will contribute to the national study, which will culminate in recommendations to increase HPV immunization uptake nationally and progress towards the 90% coverage target.

Barriers to human papillomavirus (HPV) vaccination among young adults, aged 18–35

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Most HPV vaccine eligible adults are not at all likely to get vaccinated for HPV.

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Motivational barriers include the belief that the vaccine is unnecessary and unsafe.

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When other barriers are present, lack of provider recommendation is not associated.

In the United States (US), an estimated 35,900 human papillomavirus (HPV)-related cancers are diagnosed annually. HPV vaccines are projected to eliminate ∼90% of these cancers. Routine vaccination is recommended at age 11–12 with “catch-up” vaccination through age 26 and shared clinical decision making for ages 27–45. However, vaccine uptake has been slow with many young adults remaining unvaccinated. This study examined barriers to HPV vaccination among individuals aged 18–35 years and assessed likelihood of future HPV vaccination.

Age-eligible participants (n = 499) recruited through Facebook advertisements, Facebook posts, and clinics (6/2019–3/2020) completed an online survey. Descriptive statistics and bivariate analysis examined HPV vaccine barriers and intent. Logistic regression models examined predictors of HPV vaccine intent.

Most (57.1%) reported they were not at all likely to get vaccinated for HPV in the future. Lower intent was associated with belief that the vaccine is not necessary (aOR: 0.134, 95% CI: 0.073, 0.246) and not safe (aOR: 0.312, 95% CI: 0.126, 0.773). Intent was positively associated with the belief that health insurance would not cover vaccination (aOR: 2.226, 95% CI: 1.070, 4.631). Provider recommendation was not significantly associated with vaccine intention.

This study highlights challenges to HPV vaccine uptake for young adults. Though several successful interventions exist, most target adolescents and their parents or providers. Future steps should use this evidence to inform development of targeted interventions to increase HPV vaccine intention and uptake in adults, ultimately reducing the burden of HPV-related cancers.

Is tailored messaging more effective? An analysis of a digital health intervention to promote HPV vaccination intent among Latinx

Latinx populations have unique barriers to HPV vaccination. In the current study, we assessed the effectiveness of an online intervention to increase HPV vaccination intentions among patients of clinics that principally serve a Latinx population (n = 85%) as part of a randomized control trial (RCT). Participants viewed on an iPad either an individually tailored educational website (CHiCOS) or untailored information derived from the Vaccine Information Sheet (VIS) for HPV. Vaccination intention and related covariates were assessed via survey items administered before (pre-test) and after (post-test) viewing the material. No statistically significant differences were seen in changes of intention to vaccinate between groups (N = 1294). However, 16% of all (tailored and untailored combined) participants increased in their intention to vaccinate, while 7% decreased in intention. Overall 72% of participants had high intentions to vaccinate, yet far fewer actually received a vaccine dose. The current study explores implications of the demonstrated intention-behavior gap. As such, it presents opportunities to improve future interventions-specifically those that employ tailored messaging.

Assessing Dental Students' HPV Health Literacy and Intention to Engage in HPV-Related Oropharyngeal Cancer Prevention

Oropharyngeal cancer has become the new face of HPV-related cancers, and this alarming growth highlights the pivotal role dentists can play in prevention. This study aims to identify current HPV-related curricula taught across US dental schools and evaluate HPV health literacy and intention to engage in HPV prevention among US dental students. The dental school curricula included responses from 40 Academic Deans (61% response rate). The 4-item survey focused on understanding HPV-related content in dental school curricula and was administered via Qualtrics. A 31-item paper survey was administered to dental students (N = 109) at a southeastern dental school assessing HPV health literacy, scope of practice, willingness to administer HPV vaccine, self-efficacy in HPV prevention, and basic demographics. Data were collected between February and May 2018. Over 40 courses were identified and included HPV-related content in multiple disciplines including oral and general pathology, immunology, oral medicine, microbiology, infectious diseases, public health, and oral health management among others. Among dental students, over half were female (61%), non-Hispanic White (61%), with a mean age of 26 and in their first (48%) or third year of dental school (52%). Results indicate some HPV knowledge gaps. Most dental students believe HPV prevention is within their scope of practice; however, 56% reported feeling somewhat/not at all confident in recommending the vaccine and performing oral cancer exams. Our data supports the timeliness and need to strengthen HPV-related content in dental school curricula to effectively train and engage future dental providers in HPV prevention.

Factors contributing to missed opportunities for human papillomavirus vaccination among adolescents, ages 11 to 13, in Iowa

Introduction

Rates of human papillomavirus (HPV) vaccination remain low and missed opportunities for HPV vaccination are widespread. Researchers have identified factors related to HPV vaccination, but less is known about missed opportunities.

Methods

We used medical claims data from a large Midwestern insurance provider to explore relationships between adolescent and provider characteristics and missed opportunities for HPV vaccination. We stratified models by initiation status with adolescents who had received one or more HPV vaccinations in one group (n = 6,123) and adolescents with no record of an HPV vaccination in the other (n = 8,107).

Results

There were significant differences in comparisons of all variables between initiators and non-initiators. Notably, non-initiators had lower rates of vaccination for HPV and other adolescent vaccinations, and fewer well-child visits. For all adolescents, birth year, having other recommended vaccines, and number of well-child visits were significantly associated with missed opportunities. Additionally, among initiators, pediatrician as a primary care provider and being in a rural area were significantly associated.

Discussion

Overall, adolescents with greater healthcare utilization had more missed opportunities, indicating that, despite increased numbers of visits, providers are not taking advantage of these opportunities to vaccinate. Future research should prioritize developing a deeper understanding of why these missed opportunities are occurring and implementing new and existing strategies to prevent them. Reducing missed opportunities will help to prevent future HPV-related cancers and the significant morbidity and mortality that they can cause.

Sexually transmitted infection prevention behaviours: health impact, prevalence, correlates, and interventions

Sexually transmitted infections (STIs) remain a major public health threat, disproportionately affecting young people, and men who have sex with men. In this narrative review of the current state of behavioural science research on STI prevention, we consider the definition, health impacts, correlates and determinants, and interventions to promote STI prevention behaviour. Research on STI prevention behaviour has extended from a focus on abstinence, partner reduction and condom use, to also include novel preventive behaviours, notably treatment-as-prevention, pre-exposure prophylaxis (i.e., the preventive use of medicines by uninfected people), and vaccination for some STIs. Social-cognitive factors specified by, for instance the theory of planned behaviour, are critical proximal determinants of STI prevention behaviours, and related interventions can effectively promote STI prevention behaviours. Social-ecological perspectives highlight that individual-level determinants are embedded in more distal environmental influences, with social stigma especially affecting STI prevention behaviours and requiring effective intervention. Further to providing a major domain of application, STI prevention also poses critical challenges and opportunities for health psychology theory and research. We identify a need for health behaviour theory that addresses the processes linking multiple levels of influence on behaviour and provides practical guidance for multi-level behaviour change interventions adapted to specific contexts.

Helping Children to Participate in Human Papillomavirus-Related Discussions: Mixed Methods Study of Multimedia Messages

BACKGROUND

Human papillomavirus (HPV) can cause several types of cancers and genital warts. A vaccine is available to prevent HPV infections, and several efforts have been made to increase HPV education and, eventually, vaccination. Although previous studies have focused on the development of messages to educate children about HPV and the existence of the HPV vaccine, limited research is available on how to help children better communicate with their parents and health care professionals about the HPV vaccination. In addition, limited research is available on the target audience of this study (Italian children).

OBJECTIVE

This manuscript describes a study assessing the feasibility of using an evidence-based animated video and a web-based game to help children (aged 11-12 years) participate in discussions about their health-in particular when such conversations center around the HPV vaccination-and improve several HPV-related outcomes. The study also compares the effects of these 2 educational multimedia materials on children's knowledge and perceptions of HPV prevention.

METHODS

A mixed methods approach consisting of focus group discussions and an experiment with children (N=35) was used to understand children's experiences with, and perceptions of, the animated video and the game and to measure possible improvements resulting from their interaction with these materials.

RESULTS

Both the animated video and a web-based game increased children's knowledge and positive perceptions about HPV and HPV vaccination. Any single message was not more effective than the others. The children discussed aspects of the features and characters they liked and those that need improvements.

CONCLUSIONS

This study shows that both materials were effective for improving children's education about the HPV vaccine and for helping them to feel more comfortable and willing to communicate with their parents and health care professionals about their health. Several elements emerged that will allow further improvements in the design and development of the messages used in this study as well as the creation of future campaigns.

The Clinical and Economic Impact of Measles-Mumps-Rubella Vaccinations to Prevent Measles Importations From US Pediatric Travelers Returning From Abroad

BACKGROUND

Pediatric international travelers account for nearly half of measles importations in the United States. Over one third of pediatric international travelers depart the United States without the recommended measles-mumps-rubella (MMR) vaccinations: 2 doses for travelers ≥12 months and 1 dose for travelers 6 to <12 months.

METHODS

We developed a model to compare 2 strategies among a simulated cohort of international travelers (6 months to <6 years): (1) No pretravel health encounter (PHE): travelers depart with baseline MMR vaccination status; (2) PHE: MMR-eligible travelers are offered vaccination. All pediatric travelers experience a destination-specific risk of measles exposure (mean, 30 exposures/million travelers). If exposed to measles, travelers' age and MMR vaccination status determine the risk of infection (range, 3%-90%). We included costs of medical care, contact tracing, and lost wages from the societal perspective. We varied inputs in sensitivity analyses. Model outcomes included projected measles cases, costs, and incremental cost-effectiveness ratios ($/quality-adjusted life year [QALY], cost-effectiveness threshold ≤$100 000/QALY).

RESULTS

Compared with no PHE, PHE would avert 57 measles cases at $9.2 million/QALY among infant travelers and 7 measles cases at $15.0 million/QALY among preschool-aged travelers. Clinical benefits of PHE would be greatest for infants but cost-effective only for travelers to destinations with higher risk for measles exposure (ie, ≥160 exposures/million travelers) or if more US-acquired cases resulted from an infected traveler, such as in communities with limited MMR coverage.

CONCLUSIONS

Pretravel MMR vaccination provides the greatest clinical benefit for infant travelers and can be cost-effective before travel to destinations with high risk for measles exposure or from communities with low MMR vaccination coverage.

Social media-assisted interventions on human papillomavirus and vaccination-related knowledge, intention and behavior: a scoping review

Social media holds the potential to engage adolescents and young adults and to facilitate interventions improving Human Papillomavirus Vaccine (HPVV). This article systematically reviewed the literature on Cochrane Library, PubMed, Web of Science, EMBASE, Scopus and CINAHL. Interventions delivered or facilitated by social media with outcomes of HPV-related knowledge, awareness, attitude, vaccination intention and behavior were included. Standardized forms were used to abstract the basic characteristics, settings, guiding theories and key findings of the interventions. Twenty-four studies met the eligibility criteria. Sixteen were educational interventions, and the other eight investigated the effect of social media message contents on improving Human Papillomavirus (HPV)-related outcomes. The studies were published between 2015 and 2021. The most frequently used social media platforms were Facebook, and the most commonly adopted theory was the health belief model (HBM). Existing interventions have shown preliminary but promising effects in improving HPV awareness and knowledge. Still, such improvements have not always been translated to improved behavioral intentions and vaccination rates. The contents and phrasing of social media messages and pre-existing individual characteristics of social media users moderated intervention effectiveness. Social media could be a valuable tool for engaging participants and delivering HPV interventions. Future interventions should apply stronger theory bases.

Current Resources for Evidence-Based Practice, March 2022

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of systemic racism and its effect on maternal health in the United States and commentaries on reviews focused on barriers and facilitators to HPV vaccination and delayed cord clamping in preterm infants.

Disparities in HPV vaccine knowledge and adolescent HPV vaccine uptake by parental nativity among diverse multiethnic parents in New Jersey

Background

Suboptimal human papillomavirus (HPV) vaccination rates persist among adolescents in the United States (U.S.). New Jersey (NJ), among the top, most racially/ethnically diverse states in the U.S., had among the lowest HPV vaccine initiation rates, prior to 2018. This study examined parental HPV vaccine knowledge and adolescent HPV vaccine initiation among multiethnic parents in NJ, where access to language concordant HPV vaccine information and vaccination services may differ, for immigrant parents.

Methods

We surveyed parents of adolescents (ages 11–18) at community events in NJ to examine parental HPV vaccine knowledge and adolescent HPV vaccine uptake. Vaccine knowledge was assessed using an 11-item question stem that covered vaccine efficacy, gender recommendation, vaccine protection, and myths. Multivariable models assessed the association of parent nativity on HPV vaccine knowledge scores and adolescent HPV vaccine initiation, controlling for sociodemographic factors.

Results

Of the 77 parents, most parents (84%) were aware of the HPV vaccine. However, knowledge scores were low and differed by parent nativity. Non-U.S. born parents had significantly lower knowledge scores − 1.7 [− 3.1, − 0.4] and lower odds of adolescent children initiating the HPV vaccine 0.3 [0.1, 0.9] compared to U.S.-born parents after adjusting demographic characteristics.

Conclusions

Our findings reveal that parental HPV vaccine knowledge remains low among suburban dwelling, immigrant parents, even though they have higher education and access to health care. Multilevel strategies to reduce missed opportunities for HPV vaccine education among parents and HPV vaccination for adolescents are needed, including for suburban, immigrant communities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12573-7.

Serogroup B meningococcal disease in persons previously vaccinated with a serogroup B meningococcal vaccine - United States, 2014-2019

Since serogroup B meningococcal (MenB) vaccines became available in the United States, six serogroup B meningococcal disease cases have been reported in MenB-4C (n = 4) or MenB-FHbp (n = 2) recipients. Cases were identified and characterized through surveillance and health record review. All five available isolates were characterized using whole genome sequencing; four isolates (from MenB-4C recipients) were further characterized using flow cytometry, MenB-4C-induced serum bactericidal activity (SBA), and genetic Meningococcal Antigen Typing System (gMATS). Three patients were at increased meningococcal disease risk because of an outbreak or underlying medical conditions, and only four of the six patients had completed a full 2-dose MenB series. Isolates were available from 5 patients, and all contained sub-family A FHbp. The four isolates from MenB-4C recipients expressed NhbA but were mismatched for the other MenB-4C vaccine antigens. These four isolates were relatively resistant to MenB-4C-induced SBA, but predicted by gMATS to be covered. Overall, patient risk factors, incomplete vaccine series completion, waning immunity, and strain resistance to SBA likely contributed to disease in these six patients.

Human Papillomavirus Vaccination and Human Papillomavirus-Associated Cancer Rates Within Florida Counties

INTRODUCTION

To direct interventions, the Florida counties with the greatest risk of current and future human papillomavirus‒associated cancers were identified by estimating county-level (1) percentages of adolescents aged 13-17 years who initiated (≥1 dose) and were up to date (2-3 doses) for the human papillomavirus vaccine and (2) human papillomavirus‒associated cancer incidence rates.

METHODS

Records were obtained for human papillomavirus vaccinations from the Florida immunization registry (2006-2019), incident cancer cases from the Florida registry (2013-2017), and annual population counts from the Florida Department of Health (2006-2019). In 2020, annual county-level human papillomavirus vaccine initiation, human papillomavirus vaccine up-to-date, and age-adjusted human papillomavirus‒associated cancer incidence rates were estimated.

RESULTS

Among adolescents aged 13-17 years, average 2018-2019 county-specific human papillomavirus vaccine initiation ranged from 38% to 100% for females and from 34% to 96% for males. Up-to-date estimates ranged from 20% to 72% for females and from 24% to 77% for males. The majority (78%) of counties with initiation and up-to-date estimates within the lowest tercile were located in Northern Florida. County-specific 2013-2017 annualized, adjusted human papillomavirus‒associated cancer incidence rates ranged from 0 to 29.8 per 100,000 among females and from 5.4 to 24.1 per 100,000 among males. Counties within the highest tercile for human papillomavirus‒associated cancers were primarily (90% for females and 77% for males) located in Northern Florida.

CONCLUSIONS

Human papillomavirus‒associated cancer risk varies widely across Florida counties, with particularly high risk within Northern Florida. Targeting interventions toward counties with low vaccination and high cancer rates may reduce human papillomavirus‒associated cancers.

Association of Maternal Cervical Disease With Human Papillomavirus Vaccination Among Offspring

IMPORTANCE

Barriers to childhood vaccination against vaccine-preventable diseases, such as those due to human papillomavirus (HPV), are well known. However, the role of salience bias-the change in perception of risk due to increased familiarity with the outcome-in decisions to vaccinate children has not been explicitly studied.

OBJECTIVE

To assess for salience bias in parental decisions to vaccinate children.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used a time-to-event (survival) analysis to compare vaccination rates of children whose mothers had a history of cervical cancer or a cervical biopsy, who have experienced adverse vaccine-preventable outcomes, and for whom vaccination may be more salient, with a control group of children whose mothers had no such history. Participants were accrued from the MarketScan Commercial Database, including US children who turned 11 years old, when HPV vaccination is recommended, from January 1, 2014, to December 31, 2018. Data were analyzed from December 29, 2020, to September 17, 2021.

EXPOSURES

Maternal history of cervical cancer or cervical biopsy.

MAIN OUTCOMES AND MEASURES

Vaccination against HPV.

RESULTS

A total of 757 428 children (370 878 girls [49.0%] and 386 550 boys [51.0%]) were identified, of whom 38 366 had mothers with a history of cervical biopsy alone and 1084 had mothers with a history of cervical cancer. Overall, 54.2% of children (55.7% of girls and 52.7% of boys) received at least 1 vaccination by 16 years of age. In a time-to-event analysis, HPV vaccination did not differ between children whose mothers had cervical cancer vs those whose mothers did not (hazard ratio [HR] for girls, 0.99 [95% CI, 0.86-1.13]; HR for boys, 1.08 [95% CI, 0.94-1.24]). Maternal history of cervical biopsy was associated with a minimally increased hazard of vaccination (HR for girls, 1.06 [95% CI, 1.04-1.09]; HR for boys, 1.04 [95% CI, 1.01-1.06]). There were no clinically meaningful differences between groups for the tetanus/diphtheria/acellular pertussis and meningococcal vaccinations, which are also recommended at 11 years of age.

CONCLUSIONS AND RELEVANCE

In this analysis of salience bias in childhood vaccination decisions, mothers' personal history of cervical cancer or cervical biopsy was not associated with greater vaccination rates among children against HPV. These findings suggest that salience of vaccine-preventable outcomes may not have a major impact on childhood vaccine hesitancy in HPV; the role of salience should be investigated for other vaccines.

Pharmacists' Perceived Barriers to Human Papillomavirus (HPV) Vaccination: A Systematic Literature Review

About 45:000 cancers are linked to HPV each year in the United States alone. The HPV vaccine prevents cancer and is highly effective, yet vaccination coverage remains low. Pharmacies can play a meaningful role in increasing HPV vaccination access due to their availability and convenience. However, little is known about pharmacists’ perceived barriers to HPV vaccination. The objective of this systematic review was to summarize existing literature on perceived barriers to administering HPV vaccination reported by pharmacists. Barriers identified from selected studies were synthesized and further grouped into patient, parental, (pharmacist’s) personal, and system/organization barrier groups. Six studies were included in this review. The cost of the HPV vaccine, insurance coverage and reimbursement were commonly reported perceived barriers. Adolescent HPV vaccination barriers related to parental concerns, beliefs, and inadequate knowledge about the HPV vaccine. Perceived (pharmacist’s) personal barriers were related to lack of information and knowledge about HPV vaccine and recommendations. At the system/organization level, barriers reported included lack of time/staff/space; difficulty in series completion; tracking and recall of patient; perceived competition with providers; and other responsibilities/vaccines taking precedence. Future strategies involving pharmacy settings in HPV-related cancer prevention efforts should consider research on multilevel pharmacy-driven interventions addressing barriers.

Vaccine initiation and 3-dose series completion of 4vHPV vaccine among US insured males 2012-2016

OBJECTIVE

The quadrivalent human papillomavirus vaccine (4vHPV, GARDASIL®⁾, was approved in the US in 2009 for use in males aged 9 to 26 for the prevention of HPV-related genital warts, and in 2010 for the prevention of certain HPV-related anogenital diseases. A regimen was approved in 2016 for those who initiate the vaccine series between the ages of 9 to 14 years. We describe patterns of 4vHPV administration among US males before this modification.

METHODS

The study used a US health insurance claims database, and included males, age 9 to 26 years, who initiated 4vHPV between 2012 and 2016. Time from first dose to subsequent doses was estimated. Logistic regression identified factors associated with regimen completion.

RESULTS

Among 100,786 males who initiated 4vHPV (corresponding to ∼ 13% of male birth cohorts), 50,573 (50.2%) and 25,763 (25.6%) received a second and third dose, respectively. Annual administration was common, with 47% of males receiving 3 doses over 3 years (1 dose per year) as compared to 12% receiving the 3-dose series in the recommended 6-month timeframe. Receipt of 4vHPV was 2.2 (range 1.5 to 2.9) times as likely to occur in summer months compared to other times of the year. Individuals aged 18 to 21 years and those living in Western states or rural regions were less likely to complete the 3-dose regimen.

CONCLUSIONS

The real-world patterns of 4vHPV vaccination observed, particularly the low uptake and regimen completion, suggest that better strategies are needed for males to improve 4vHPV vaccine use in males.

Factors Associated With Receipt of Meningococcal B Vaccine Among United States Adolescents, National Immunization Survey-Teen, 2017-2018

PURPOSE

In this study, we evaluated factors associated with receipt of meningococcal serogroup B (MenB) vaccine among adolescents in the United States.

METHODS

We used public use data files from the National Immunization Survey-Teen from 2017 to 2018. Logistic regression was used to model associations among sociodemographic, healthcare, and vaccination variables of interest and MenB vaccine receipt (≥1 vs. 0 dose). To explore associations between state-level meningococcal vaccination requirements and MenB vaccine uptake, we performed a secondary analysis stratified by presence of a quadrivalent meningococcal (MenACWY) vaccination requirement for secondary school attendance in the adolescent's state of residence (no requirement vs. a one- or two-dose requirement).

RESULTS

Among 7,288 adolescents, MenB vaccine receipt was significantly associated with up-to-date human papillomavirus (adjusted odds ratio [aOR] 1.74, 95% confidence interval [CI] 1.29-2.35) and MenACWY (aOR 5.81, 95% CI 4.14-8.13) vaccination status in multivariable analysis. Adolescents with private insurance were less likely to be vaccinated (aOR .61, 95% CI .46-.79) compared to adolescents with other health insurance types. In secondary analyses, health insurance was no longer significantly associated with MenB vaccine uptake among adolescents in states with a MenACWY requirement.

CONCLUSIONS

We found that MenB vaccination is associated with receipt of other vaccines recommended for use in adolescents. Adolescents with private health insurance were less likely to be vaccinated against MenB, although state MenACWY requirements appeared to modify the effect of insurance on MenB vaccine receipt. Further work to understand how these factors may influence delivery and acceptance of MenB vaccine can inform interventions and strategies to improve uptake.

Do Norms Matter? Examining Norm-Based Messages in HPV Vaccination Promotion

This research examines the influence of norm-based messages (positively worded descriptive vs. negatively worded descriptive vs. injunctive vs. basic information) on intentions and risk perceptions about receiving human papillomavirus (HPV) vaccination among young adults aged 18-29. Results from an experiment show that compared to the basic information condition, additional exposure to injunctive normative messages increased intention to seek further information about HPV vaccination, which in turn enhanced intention to get the vaccine. Negatively worded descriptive normative messaging should be used with caution since it resulted in the highest risk perceptions of the HPV vaccine, compared to positively worded descriptive norms and basic information messages. Theoretical and practical implications are further discussed.