Adolescent Human Papillomavirus Vaccination Research Articles

Abstract PO-241: A multilevel exploration of determinants of human papillomavirus vaccine initiation among U.S. Vietnamese

Abstract Background: U.S. Vietnamese experience higher cervical cancer incidence and have lower human papillomavirus vaccine (HPVV) uptake compared to other racial/ethnic groups. Limited research has examined multilevel determinants of HPVV uptake among this population. This study used the P3 (practice-, provider-, and patient- level) model to examine multilevel determinants of U.S. Vietnamese parents’ HPVV initiation for their children. Methods: In 2020, we conducted an online cross-sectional survey of Vietnamese parents living in the U.S. who had ≥ one child aged 9-18. Parents were recruited through U.S. Vietnamese community-based organizations, U.S. Vietnamese-focused Facebook groups and listserv, and snowball sampling. Descriptive statistics and Chi-square tests were conducted to understand facilitators of and barriers to HPVV initiation (i.e. 1+ vaccine dose). Results: The sample represented 331 Vietnamese parents in 35 U.S. states. The majority of parents were female (84.6%), had ≥ Bachelor’s degree (87.3%), and an annual household income of $50,000+ (65.6%); 98.8% were born outside of the U.S, and 60.7% had difficulties understanding English medical information. Less than half of parents initiated HPVV for their children (43.5%). HPVV initiation significantly differed by whether parents had seen materials about HPVV at their children’s clinic (62.3% vs 26.2%, p<.001). The most common facilitator of adolescent HPVV initiation was a doctor’s recommendation (80.0%) however, 55.3% reported that they had not received a doctor’s recommendation for HPVV for their children, and 59.7% of non- initiators indicated that not receiving a doctor’s recommendation was a barrier. A higher percentage of parents of female children reported HPVV initiation compared to parents of male children (52.4% vs 33.3%, p<.001). Almost all parents reported a high degree of trust in scientists who develop vaccines, CDC, and FDA (>90%) and believed that vaccines recommended for adolescents are safe (97%). Discussion: While this sample of U.S. Vietnamese parents has overall high socioeconomic status, adolescent HPVV initiation (43.5%) was still much lower than general U.S. populations (68.1% in 2018 NIS-Teen data), necessitating additional efforts to improve HPVV uptake among U.S. Vietnamese. Some findings were well-identified barriers (e.g., a lack of doctor’s recommendation, child’s sex) while others were novel (e.g., lack of access to clinic-based materials about HPVV). Findings regarding high degree of trust in vaccines and regulatory bodies can be incorporated in future interventions. Citation Format: Milkie Vu, Carla J. Berg, Cam Escoffery, Victoria N. Huynh, Robert A. Bednarczyk. A multilevel exploration of determinants of human papillomavirus vaccine initiation among U.S. Vietnamese [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-241.

Vaccipack, A Mobile App to Promote Human Papillomavirus Vaccine Uptake Among Adolescents Aged 11 to 14 Years: Development and Usability Study.

BackgroundMore than 90% of human papillomavirus (HPV)-related cancers could be prevented by widespread uptake of the HPV vaccine, yet vaccine use in the United States falls short of public health goals.ObjectiveThe purpose of this study was to describe the development, acceptability, and intention to use the mobile app Vaccipack, which was designed to promote uptake and completion of the adolescent HPV vaccine series.MethodsDevelopment of the mobile health (mHealth) content was based on the integrated behavioral model (IBM). The technology acceptance model (TAM) was used to guide the app usability evaluation. App design utilized an iterative process involving providers and potential users who were parents and adolescents. App features include a vaccine-tracking function, a discussion forum, and stories with embedded messages to promote intention to vaccinate. Parents and adolescents completed surveys before and after introducing the app in a pediatric primary care setting with low HPV vaccination rates.ResultsSurveys were completed by 54 participants (20 adolescents aged 11 to 14 years and 34 parents). Notably, 75% (15/20) of adolescents and 88% (30/34) of parents intended to use the app in the next 2 weeks. Acceptability of the app was high among both groups: 88% (30/34) of parents and 75% (15/20) of adolescents indicated that Vaccipack was easy to use, and 82% (28/34) of parents and 85% (17/20) of adolescents perceived the app to be beneficial. Higher levels of app acceptability were found among parents with strong intentions to use the app (P=.09; 95% CI –2.15 to 0.15).ConclusionsmHealth technology, such as Vaccipack, may be an acceptable and nimble platform for providing information to parents and adolescents and advancing the uptake of important vaccines.

Multi-component cancer prevention awareness program to improve adolescent HPV vaccine uptake

ABSTRACT Objective We introduced a multi-component cancer prevention awareness program to primary care practices across New York State to evaluate its impact on adolescent human papillomavirus (HPV) vaccination rates. Methods Eight pediatric and three family medicine practices were recruited to participate in this program. On-site training sessions were provided for all practice providers and staff to discuss the importance of HPV vaccine and cancer prevention and teach strategies for delivering a strong vaccine recommendation. Each practice received a study-specific booklet that included HPV vaccine information and other commonly provided cancer prevention guidance. These booklets were distributed to all adolescents and their parents during well visits over a one-year period. Practice specific and county-wide HPV vaccination rates were assessed before and 12 months after the program training session. Results One year after program initiation, aggregate data show statistically higher vaccine series initiation rates among 11–12 and 13–18-year-olds and higher vaccine series completion rates among 13–18-year-olds. The greatest and most consistent improvements were seen in vaccine initiation rates for the 11–12-year-old cohort. Disparities in vaccine uptake were observed by gender and medical specialty. Conclusion Cancer prevention education targeting providers, office staff, patients, and parents, improved adolescent HPV vaccine series initiation rates.

Learning More About Ways to Improve Adolescent HPV Coverage.

Human papillomavirus (HPV) vaccines have been available for use in the United States since 2006 for girls and 2009 for boys.1 Vaccination uptake levels among adolescents, the preferred age for vaccination, have been examined annually through several different mechanisms and found to be continually well below national goals.2 The repetition of these findings is now, sadly, “old news.” So you may be asking yourself, “Do we need yet another study on adolescent HPV vaccination coverage in the United States?” Based on the findings of the study by Chen et al3 presented in this issue of Pediatrics the answer is a definitive “yes!” In this study, the authors provide some new and valuable insights regarding HPV vaccine uptake in the United States. Like researchers in many other studies, these researchers used a nationwide, population-based database to examine HPV vaccination initiation and completion by age, sex, and geographic location. With >7 million children included, researchers in the study were well powered to examine differences in vaccination coverage by these and other factors. And, like in many other studies, Chen et al3 demonstrated increasing vaccination levels over … Address correspondence to Amanda F. Dempsey, MD, PhD, MPH, University of Colorado Denver, 13199 East Montview Blvd, Suite 300, Aurora, CO 80045. E-mail: amanda.dempsey{at}cuanschutz.edu

A Mixed-Methods Analysis of Barriers to and Facilitators of Human Papillomavirus Vaccination Among Adolescents in Montana.

Human papillomavirus (HPV) vaccination rates among adolescents are lower in rural areas than in urban areas of the United States. The objective of this study was to identify barriers to and facilitators of adolescent HPV vaccination in Montana, a large, primarily rural state. Using a mixed-methods design, we integrated quantitative analyses of Montana's National Immunization Survey-Teen (NIS-Teen) data from 2013-2017 with qualitative data collected at a statewide meeting in October 2018 and from stakeholder interviews conducted from October 2018 through June 2019. Using NIS-Teen data, we identified trends and estimated adjusted prevalence ratios (aPRs) to identify factors associated with vaccine uptake. Using directed content analysis of qualitative data, we identified themes related to vaccine uptake. In Montana, initiation of the HPV vaccine series among adolescents aged 13-17 increased from 34.4% in 2013 to 65.5% in 2017. We identified 6 themes related to HPV vaccination from qualitative analyses, including medical providers' recommendation style as a facilitator of vaccination and parental vaccine hesitancy as a barrier to vaccination. In NIS-Teen 2017 data (n = 326 adolescents), receiving a medical provider recommendation was significantly associated with series initiation (aPR = 2.3; 95% CI, 1.5-3.6). Among parents who did not intend to initiate the vaccine series for their adolescent within 12 months (n = 71), vaccine safety was the top concern (aPR = 24.5%; 95% CI, 12.1%-36.9%). HPV vaccination rates have increased in Montana but remain lower than rates for other adolescent vaccines. Future work should focus on reducing missed opportunities, increasing parents' knowledge of and confidence in vaccination, and training medical providers on addressing common vaccine concerns.

Abstract B048: HPV vaccination in Hmong-American adolescents: A multilevel and assets-based qualitative study

Abstract Background: Rates of human papillomavirus (HPV) vaccine uptake in Hmong-Americans, an Asian American and Pacific Islander (AAPI) minority group, are substantially lower than the majority of Americans. In 2015, a community health center (CHC) in Minnesota found that HPV vaccine rates for Hmong children ages 9-17 were 32% in girls and 20% in boys, much lower than nationally published HPV coverage rates in 2017 (47% and 53%, respectively). This qualitative study identified barriers, facilitators, and decision-making processes about HPV vaccinations among Hmong adolescents and parents. Methods: Hmong adolescents (14-17 years old) and their parents were recruited from a local CHC to participate in focus group sessions. Using a community-based participatory action research approach, bilingual community researchers conducted eight focus groups with adolescents and parents. Prior to focus groups, participants provided demographic information and completed a survey about HPV and HPV vaccination. Focus group transcripts were analyzed using participatory thematic analysis. Themes were codified using a socioecological model (multilevel) framework combined with an assets lens. Results: A total of 12 adolescents and 13 parents participated in the focus groups (N = 25). Both survey and focus group results showed that Hmong adolescents and parents had low levels of awareness regarding HPV or the HPV vaccine. At the individual-level, both adolescents and parents reported concerns about side effects and costs as potential reasons for not getting vaccinated. Whereas, an individual-level facilitator for both adolescents and parents included personal agency (i.e., individual desire to want to learn more about HPV and the HPV vaccine). At the community-level, barriers included community narratives around traumatic experiences with vaccine, and facilitators included strong community connections and communications. At the institutional-level, barriers included lack of a school policy requiring HPV vaccinations and structural constraints in health care settings, while facilitators included ease of obtaining vaccines at school-based clinics and provider authoritative decision making. Finally, there was a range of decision-making processes between parents and adolescents and parents and providers. Conclusion: A culturally-appropriate HPV educational program for Hmong adolescents and parents could address barriers and build on facilitators and assets to promote HPV vaccine uptake. These findings have been used in the development of an eHealth application to increase HPV vaccinations in Hmong adolescents. Future research studies that test the feasibility, acceptability, and efficacy of culturally-tailored, multilevel HPV vaccination interventions may provide evidence about the efficacy of culturally-appropriate education in comprehensive vaccine strategies. Citation Format: Serena Xiong, Maiyia Y Kashouaher, Bai Vue, Kathleen A Culhane-Pera, Shannon L Pergament, Jay Desai, Hee Yun Lee. HPV vaccination in Hmong-American adolescents: A multilevel and assets-based qualitative study [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B048.

Abstract C084: Geographic variation in human papillomavirus (HPV) vaccination initiation and completion among adults in the United States

Abstract Background: Approximately 43,000 human papillomavirus (HPV)-associated cancers and 350,000 genital warts are diagnosed annually in the United States. The HPV vaccine can prevent HPV-associated cancers and genital warts. The Advisory Committee on Immunization Practices recommends routine HPV vaccination for adolescents between 11 and 12 years of age, and catch-up vaccination up to 45 years recently. Despite the availability, safety, and efficacy of HPV vaccines, uptake has been suboptimal compared to other routine vaccinations in adolescents, and even worse for adults in the catch-up group. As little is known about geographic variation in HPV vaccine uptake among adults, we explored how HPV vaccine initiation and completion rates among 18–34 year olds (both men and women) varies by geographic region. Methods: We analyzed data from 16 states (Alabama, Arkansas, Connecticut, Georgia, Hawaii, Massachusetts, Mississippi, Missouri, New Hampshire, Nebraska, North Carolina, South Carolina, South Dakota, Tennessee, Texas, and West Virginia) which conducted the adult HPV module survey during 2015–2017 Behavioral Risk Factor Surveillance System. Two variables were used to define geographic region: census region (South, Northeast and Midwest/west) and residential area (urban and rural). HPV vaccine initiation was defined as receipt of at least one dose of the vaccine and completion as receipt of three doses. Weighted, multivariable binary logistic regression models were used to assess the association between geographic region and HPV vaccine uptake, adjusting for demographic, socioeconomic, and healthcare utilization factors. Results: A total of 18,078 adults were included in the study, of whom 80% resided in the South. The overall HPV initiation and completion rates were 23.4% and 11.0%, respectively. Vaccine initiation was higher among those who resided in the Northeast (38.6%) followed by Midwest/west (23.8%) and lowest for those in the South (21.8%). But initiation rates was similar between those who reside in urban (24.1%) and rural (21.0%) areas. Completion rates followed the same trend as initiation for both census region and residential area. In the adjusted models, compared to adults residing in the South, those living in the Northeast were more likely to initiate (adjusted odds ratio: 2.14; 95 % CI: 1.81–2.53) and complete (1.80; 1.47–2.20) the HPV vaccine. There were no significant differences observed for initiation or completion by residential area. Conclusions: Both the South and the Northeast have low HPV vaccination initiation and completion rates compare to the Healthy People 2020 goal of 80%, but vaccine uptake were significantly lower in the South region. No difference in HPV vaccine uptake was observed between the rural and urban areas. This demonstrates the need to develop and implement interventions programs to reduce geographical disparities in HPV vaccine uptake and ultimately to improve HPV vaccine uptake, especially in the South region. Citation Format: Eric Adjei Boakye, Maggie Wang, Wiley D Jenkins, Nosayaba Osazuwa-Peters, Oluwole Babatunde, Min Jee Lee, Minjin Kim. Geographic variation in human papillomavirus (HPV) vaccination initiation and completion among adults in the United States [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C084.

Knowledge and Acceptability of Human Papillomavirus Vaccination and Text Message Reminders for Adolescents in Urban Emergency Departments: A Pilot Study.

PurposeCervical, oropharyngeal and anogenital cancers are vaccine-preventable diseases, but human papillomavirus (HPV) vaccination coverage in the US remains poor overall with regional variations in vaccination rates. We explore the acceptability by adolescents and their parents of HPV vaccination and text message reminders in the non-traditional setting of the emergency department (ED).Patients and MethodsThe modified validated Carolina HPV Attitudes and Beliefs Scale (CHIAS) survey was administered at two urban EDs to adolescents aged 13–18 years and their parents. Demographic information was collected for each participating adolescent. Recruitment occurred with consecutive eligible participants on the ED census list approached within 4-hour blocks from 8am to 8pm.ResultsNinety-six adolescents completed the survey. The mean adolescent and parental knowledge scores were 63% (SD=29.7) and 60% (SD=22.1), respectively. The higher the HPV knowledge score among both adolescents and parents, the more likely they were to accept HPV vaccine in ED. Among the 10 cases where the parents disagreed to the HPV vaccine and the adolescents agreed to the HPV vaccine, the mean knowledge score among parents disagreeing was 47 compared to 62 among the remaining parents (p=0.04). Sixty-seven percent of adolescents and 68% of parents were agreeable to the adolescent receiving vaccination in the ED (kappa = 0.24). Seventy-five percent of adolescents and 71% of parents reported being agreeable to receiving text reminders for HPV vaccines (kappa = 0.20). Adolescent agreement with receiving a text message reminder corresponded with an increased willingness to be vaccinated (OR=3.21, 95% CI=1.07–9.57, p-value=0.0368). Sexually active adolescents were older (mean age, 17 years) than those who reported no sexual activity (mean age, 15 years) (p<0.0001).ConclusionIncreased knowledge about HPV influences vaccine acceptance. Parents and adolescents may disagree in accepting HPV vaccination. A majority of adolescents and their parents were agreeable to receiving HPV vaccination in the ED and subsequent text message reminders. The ED should be explored further as a non-traditional healthcare setting for HPV vaccination of adolescents.

Abstract A066: Inaccuracy in parental reports of adolescent human papillomavirus vaccination: A multilevel analysis of the influences of state-level and individual-level factors

Abstract Background: Accurate reporting of human papillomavirus (HPV) vaccination status is necessary for monitoring coverage and identifying under-vaccinated populations. While parental recall or reports are commonly used to identify adolescent HPV vaccination status, these self-reports may be subjected to bias. The Socioecological Framework suggests that factors at the individual (e.g., education), interpersonal (e.g., interactions with health care provider), community (e.g., state median income), and policy levels (e.g., state-level HPV vaccine policy) can influence the accuracy of parental reports. Objective: We explored potential multilevel correlates of the accuracy of parental reports of adolescent HPV vaccination status. Methods: Data from parents of 19,751 adolescents (2016 National Immunization Survey-Teen) were analyzed using multilevel modeling. We examined the adolescent's age, sex, race/ethnicity, maternal education, and household poverty status (individual-level); the number of health care providers seen (interpersonal-level); state-level median income (community-level); and state policy regarding HPV vaccine (i.e., whether a state has a policy mandating HPV vaccine for school entry or educating residents about HPV vaccine) (policy level). Outcomes included: 1) inaccuracy in reporting vaccine initiation (≥1 dose) and 2) inaccuracy in reporting completion (3 doses). Results: In the sample, 20.6% and 22.2% inaccurately reported initiation and completion, respectively. Compared to parents of White adolescents, parents of those who were Black (OR=1.6 and 1.5), Hispanic (OR=1.4 and 1.7), or of multiple races or other race (OR=1.8 and 1.8) were more likely to inaccurately report initiation and completion, respectively. Households with higher maternal education (OR=0.7 and 0.9) and nonpoverty status (OR=0.5 and 0.6) were less likely to inaccurately report. Compared to those who had seen 0 or 1 provider, those who had seen more providers were less likely to inaccurately report (OR=0.9 and 0.9 for seeing 2 providers, OR=0.8 and 0.9 for 3+ providers). Neither state-level median income nor state HPV vaccine policy was associated with either outcome. Discussion: Parents of racial/ethnic minority adolescents and households with more socioeconomic disadvantages were more likely to inaccurately report HPV vaccine initiation and completion. These results have implications for vaccine estimates drawn from self-reports. Future research can examine and target sources of inaccuracies in these groups, for example, uncertainty in provider communication, low health literacy, or social desirability in reporting. Having seen more providers was associated with higher accuracy, suggesting the importance of increased access to vaccine records. State vaccine policy does not appear to have an impact on the accuracy of parental reports, pointing to a need to further examine differential policy implementation or enforcement. Citation Format: Milkie H. N. Vu, Minh Luu, Regine Haardörfer, Carla J. Berg, Cam Escoffery, Robert A. Bednarczyk. Inaccuracy in parental reports of adolescent human papillomavirus vaccination: A multilevel analysis of the influences of state-level and individual-level factors [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A066.

The effects of health education on health science teachers’ intention to recommend adolescent HPV vaccine for female students in Japan

ABSTRACT The Japanese government suspended proactive recommendation of human papillomavirus (HPV) vaccination due to several reports of adverse events related to it in 2013. After that, the immunization rate of HPV vaccine quickly declined in Japan. Health science teachers (HSTs) are qualified and licensed teachers in charge of health care and health education for students in Japanese schools. HSTs have not recommended HPV vaccination to female students, since active governmental recommendation for HPV vaccination was halted for 5 y. We conducted a primary survey targeting HSTs (N = 39) and university students taking the HST training course (N = 123). In each group, awareness regarding HPV vaccine and disease burden was evaluated and factors related to and barriers to HPV vaccine recommendation were identified. The primary survey found that many HSTs and university students recognized their insufficient knowledge regarding the HPV vaccine. Based on the primary survey’s results, infectious disease specialists, collaborating with Japanese HSTs, developed educational slide sets on HPV vaccine. A secondary survey was conducted before and after the lecture with HSTs (N = 162), where we evaluated their intelligibility and intention to recommend HPV vaccination for female students. In the post-lecture, secondary survey, the number of HSTs who recommended the HPV vaccine to their students had statistically increased from 76 before the lecture, to 103 (p < .05). An educational lecture using appropriate materials improved HSTs’ vaccine confidence and intention to recommend the HPV vaccine to their students, verifying the study’s hypothesis.

Improving vaccination uptake among adolescents.

CITATION: Wiysonge, C. S. U. et al. 2015. Improving vaccination uptake among adolescents. Cochrane Database of Systematic Reviews, 9: Art. No.: CD011895, doi:10.1002/14651858.CD011895.

Impact and Cost-Effectiveness of Human Papillomavirus Vaccination Campaigns

Data to inform evidence-based policy of human papillomavirus (HPV) vaccine delivery strategies in low- and middle-income countries are limited. We examined the cost-effectiveness of campaign compared with routine delivery strategies of adolescent female HPV vaccination in Uganda. We used a multiple modeling approach that captured HPV transmission, cervical carcinogenesis, and population demographics to project health and economic outcomes associated with HPV vaccination. Costs included vaccination and operational costs and cervical cancer costs over the lifetimes of the current female population in Uganda. Health outcomes included number of cervical cancer cases and disability-adjusted life years (DALY). Incremental cost-effectiveness ratios (i.e., cost per DALY averted) were calculated and compared against gross domestic product (GDP) per capita. Compared with routine HPV vaccination of 9-year-old girls at 70% coverage, campaign vaccination yielded greater health benefits if campaigns occurred frequently and targeted a wide age range. Campaign delivery strategies were both less costly and more effective than routine HPV vaccination. Campaign vaccination of 9- to 30-year-old girls/women at a 3-year frequency (40% coverage) was considered cost-effective compared with the GDP per capita threshold for Uganda ($674 in U.S. 2015 dollars). We projected that campaign HPV vaccination would provide substantial population health benefits compared with routine vaccination. Expanding the target age range of campaign vaccination up to age 30 years may be an efficient strategy, depending on the achievable coverage level and campaign frequency. In settings where routine health systems infrastructure may be limited, reaching adolescent populations with a campaign delivery strategy may be an efficient use of resources.

A systematic approach to map the adolescent human papillomavirus vaccine decision and identify intervention strategies to address vaccine hesitancy

ObjectivesUnsubstantiated safety concerns with human papillomavirus (HPV) vaccines continue to linger. This study sought to identify factors that influence the adolescent HPV vaccine decision and systematically identify intervention functions and strategies likely to be effective in reducing vaccine hesitancy. Study designThis is a qualitative focus group study. MethodsFocus groups were conducted with female adolescents (aged 14–16 years) in Cork and Kerry. During focus groups, the trained facilitator used a semistructured, Theoretical Domains Framework (TDF)–based topic guide to prompt discussion. Transcripts were thematically analysed using the TDF and Behaviour Change Wheel. Behaviour Change Technique Taxonomy version 1 was used to suggest intervention functions and strategies for addressing HPV vaccine hesitancy. ResultsA total of 50 adolescents (96% vaccinated), participated in 10 focus groups. The key themes were presented by means of the relevant TDF domains. Seven domains were selected as the most relevant: knowledge, social influences, beliefs about capabilities, optimism, beliefs about consequences, emotion and environmental context and resources. Five intervention functions were identified, education, persuasion, enablement, modelling and environmental restructuring, and linked to 11 relevant Behaviour Change Technique (BCTs). Potential intervention strategies were developed. ConclusionsThis study provided a detailed insight into behavioural factors influencing the vaccine decision-making process. It was identified that awareness and knowledge about HPV and its health sequelae was low. Lack of information is a well-recognised determinant of vaccine hesitancy. Therefore, education was recommended as a key area to address in future intervention studies.

Association of State Legislation of Human Papillomavirus Vaccination with Vaccine Uptake Among Adolescents in the United States.

We assessed the association of state legislation withadolescent human papillomavirus (HPV) vaccination rates in states that legislated information dissemination or administration of HPV vaccination. Using insurance claims, we calculated monthly HPV vaccination rates (November 2009-December 2017) among adolescents in states that passed HPV vaccination legislation during that period: Missouri (July 2010), Kentucky (February 2012), Indiana (March 2013), Oregon (June 2013). We used segmented regression to estimate levels and trends of HPV vaccination rates, comparing pre-legislation to post-legislation segments, adjusting for seasonal vaccination patterns and changes to the vaccination recommendation among males during the study period. Indiana's legislation allowed pharmacists to administer HPV vaccination; legislation in Kentucky, Missouri, and Oregon included provisions HPV and cervical cancer education. No statistically significant increases in HPV vaccination levels or trends were observed in the post-legislation segments among adolescents overall; however, a significant post-legislation increase in vaccination trends was observed among boys in Missouri (β = 0.16, p = 0.03). Evidence for a positive impact of legislation on HPV vaccination rates is limited. The scarcity of policies that directly facilitate or promote HPV vaccination, and the breadth of exemptions to school vaccination requirements, may limit the effectiveness of these policies. Continuing efforts to introduce and pass legislation that directly facilitates HPV vaccination, combined with promoting existing evidence-based interventions, can provide opportunities to identify the most effective strategies to increase adolescent HPV vaccination rates.

National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years - United States, 2018.

The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of persons aged 11-12 years to protect against certain diseases, including human papillomavirus (HPV)-associated cancers, meningococcal disease, and pertussis (1). A booster dose of quadrivalent meningococcal conjugate vaccine (MenACWY) is recommended at age 16 years, and serogroup B meningococcal vaccine (MenB) may be administered to persons aged 16-23 years (1). To estimate vaccination coverage among adolescents in the United States, CDC analyzed data from the 2018 National Immunization Survey-Teen (NIS-Teen) which included 18,700 adolescents aged 13-17 years.* During 2017-2018, coverage with ≥1 dose of HPV vaccine increased from 65.5% to 68.1%, and the percentage of adolescents up-to-date† with the HPV vaccine series increased from 48.6% to 51.1%, although the increases were only observed among males. Vaccination coverage increases were also observed for ≥1 MenACWY dose (from 85.1% to 86.6%) and ≥2 MenACWY doses (from 44.3% to 50.8%). Coverage with tetanus and reduced diphtheria toxoids and acellular pertussis vaccine (Tdap) remained stable at 89%. Disparities in coverage by metropolitan statistical area (MSA)§ and health insurance status identified in previous years persisted (2). Coverage with ≥1 dose of HPV vaccine was higher among adolescents whose parents reported receiving a provider recommendation; however, prevalence of parents reporting receiving a recommendation for adolescent HPV vaccination varied by state (range=60%-91%). Supporting providers to give strong recommendations and effectively address parental concerns remains a priority, especially in states and rural areas where provider recommendations were less commonly reported.

Sociodemographic and clinical correlates of human papillomavirus vaccine attitudes and receipt among Wisconsin adolescents

Few studies have assessed adolescent human papillomavirus (HPV) vaccine attitudes and whether they are associated with vaccination uptake. This study characterized HPV vaccine attitudes among male and female adolescents, identified factors associated with attitude changes, and examined associations between attitudes and vaccination receipt. Surveys were administered to adolescents aged 15–16 years who had not completed the HPV vaccine series. A modified version of the Carolina HPV Immunization Attitudes and Beliefs Scale (CHIAS) was employed to assess barriers, harms, ineffectiveness, and uncertainties scores. Surveys were available from 108 participants; 63% were male and 33% had initiated the HPV vaccine series at baseline. CHIAS scores significantly decreased (i.e., became more favorable) between baseline and follow-up for barriers (p = 0.01) and uncertainties (p < 0.01). At least one sociodemographic/clinical factor was associated with changes in each score. Attitude changes were not associated with receipt of HPV vaccine, although adolescents with higher baseline harms scores were significantly less likely to receive an HPV vaccine dose (OR = 0.67). Adolescents’ HPV vaccine attitudes slightly improved over a one-year period during which an intervention was implemented. More research is needed to learn how parent and adolescent HPV vaccine attitudes form, and how best to address concerns about vaccine harms.

Implementing pharmacy-located HPV vaccination: findings from pilot projects in five U.S. states

ABSTRACT Pharmacies are promising alternative settings for human papillomavirus (HPV) vaccination because of their population reach, convenience, and existing infrastructure for vaccine delivery. However, pharmacies in the US are rarely used for adolescent HPV vaccination. We sought to document challenges and opportunities of implementing pharmacy-located HPV vaccination services in five US states by mapping process evaluation results onto key implementation science constructs: service penetration, acceptability, appropriateness, feasibility, fidelity, adoption, and sustainability. Pilot projects were planned in North Carolina (k = 2 pharmacies), Michigan (k = 10), Iowa (k = 2), Kentucky (k = 1), and Oregon (no pharmacy recruited) with varying procedures and recruitment strategies. Sites had open enrollment for a combined 12 months. Despite substantial efforts in these states, only 13 HPV vaccine doses were administered to adolescents and three doses to age-eligible young adults. We identified two major reasons for these underperforming results. First, poor outcomes on service penetration and appropriateness pointed to engagement barriers: low parent demand and engagement among pharmacy staff. Second, poor outcomes on feasibility, adoption, and sustainability appeared to result from administrative hurdles: lacking third party reimbursement (i.e., billing commercial payers, participation in Vaccines for Children program) and limited integration into primary care systems. In summary, pilot projects in five states all struggled to administer HPV vaccines. Opportunities for making pharmacies a successful setting for adolescent HPV vaccination include expanding third party reimbursement to cover all vaccines administered by pharmacists, increasing public awareness of pharmacists’ immunization training, and improving care coordination with primary care providers.

PIH49 FACTORS INFLUENCING ADOLESCENT HUMAN PAPILLOMAVIRUS VACCINATION UPTAKE IN THE UNITED STATES

Cervical cancer and Human papillomavirus (HPV) affects women, men and children of all races, ethnicity and backgrounds. The objective of this study is to examine the association between adolescent (13–17years) HPV vaccination uptake and the key factors influencing the uptake rates of HPV vaccination. The 2016 NIS-Teen data, an annual survey conducted by the CDC to monitor vaccination uptake in the United States is used for this study. Multivariable logistic regression model was used to estimate the relationship between various factors and HPV vaccine uptake. Male adolescents were 0.26 times less likely to get the HPV vaccines; adolescents covered by private health insurance were 0.18 times less likely to get HPV vaccines; Hispanic adolescents were 1.47 times more likely, adolescents from other races including Asians were 1.75 times more likely to get vaccinated for HPV compared to non-Hispanic white adolescents. Adolescents from the low-income families were 1.21 times more likely to get vaccinated for HPV; adolescents from North-eastern regions of the United States were 1.62 times more likely to get vaccinated; adolescents who are not recommended for vaccination by the family physicians were 0.43 times less likely to get HPV vaccination; adolescents who did not have any safety concerns and concerns about side effects were 3.24 times more likely to get the HPV vaccine; adolescents from households that did have not orthodox religious beliefs were 13.67 times more likely to get vaccinated. Given the low HPV vaccination rates for adolescents in the US, these results provide important evidence to inform public health interventions to increase HPV vaccination among the target groups which are less likely to get vaccinated. Also, knowing the socio-demographic and community level factors associated with HPV vaccination uptake status, health planners can better plan strategies to improve HPV vaccination in their local settings.

Short Message Service Reminders to Parents for Increasing Adolescent Human Papillomavirus Vaccination Rates in a Secondary School Vaccine Program: A Randomized Control Trial

PurposeIn Victoria (Australia), the human papillomavirus (HPV) vaccine is delivered within a state-wide secondary school vaccine program, administered by local government. This study aimed to test the hypothesis that sending a short message service (SMS) reminder to parents who had consented to their child's receiving the HPV vaccine would lead to greater uptake of the vaccine within the program. The secondary aim was to assess the effect of self-regulatory versus motivational message content in the SMS. MethodsA randomized control trial design was used across 31 schools within seven local government areas. Parents of 4,386 consented adolescents were randomized into three study conditions: motivational SMS versus self-regulatory SMS versus no SMS. Follow-up extended beyond the final school visit to the end of the calendar year to capture those who may have attended a catch-up vaccination session. ResultsOn the day of the final school visit, 85.71% of consented students in the control condition received the HPV vaccine, compared with 88.35% (2.64% point increase) in the motivational message condition, and 89.00% (3.29% point increase) in the self-regulatory message condition, χ2 (2, N = 4,386) = 8.31, p = .016. Both intervention messages were similarly effective at increasing vaccination rates. This effect was maintained in the extended follow-up period. ConclusionsThe trial findings supported the hypothesis that SMS reminders to parents/guardians would lead to greater uptake of the HPV vaccine in adolescents participating in school-based vaccination. Also, this effect was observed whether we used a motivational or self-regulatory message framework. Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12617001307392). Registration Date: September 12, 2017. Retrospectively registered.

Pharmacist insights into adolescent human papillomavirus vaccination provision in the United States

ABSTRACT HPV vaccination coverage in the United States (US) falls short of the Healthy People 2020 goal of 80% coverage among 13–15 year-old adolescents. Pharmacies are a promising alternative vaccine delivery site that may increase access to HPV vaccination. Our objective was to assess pharmacists’ insights into HPV vaccination provision to adolescents. We recruited 40 licensed pharmacists in eight states with different pharmacy vaccination laws: Alabama, California, Indiana, Kentucky, Maine, Tennessee, Texas, and Washington. Eligible pharmacists either previously provided or were currently providing HPV, tetanus-diphtheria-pertussis, or meningococcal vaccines to adolescents aged 9–17 years. Pharmacists were administered a semi-structured survey to explore insights into HPV vaccination provision. Forty-five percent of surveyed pharmacies offered HPV vaccination to adolescents. Pharmacists’ reported challenges to providing HPV vaccination were parental consent (28%), tracking and patient recall (17%), perceived stigma of vaccination (17%), and education about or promotion of vaccination (17%). Pharmacists offering HPV vaccination sent patient reminders for vaccines with multiple doses (89%) and utilized telephone reminders (72%). Pharmacists informed patients’ primary care providers of HPV vaccination doses most commonly through fax (72%) and updating electronic medical records (22%). One-third of pharmacists reported vaccination provision using the state immunization information system (IIS). Seventy-five percent reported vaccination rates could be increased at their respective pharmacy. Pharmacies are underutilized, although highly accessible, for HPV vaccination in the US. National efforts should expand educational programs to improve public awareness of in-pharmacy HPV vaccination, and improve the utilization of state IIS for reporting immunization coverage of adolescents by pharmacists.