Human Papillomavirus Vaccine Initiation Research Articles

Abstract P018: Differences in guideline-recommended age of human papillomavirus (HPV) vaccine initiation and completion in the United States

Abstract Background: While there has been increase in the uptake of the human papillomavirus (HPV) vaccine, current vaccine rate fell short of the Healthy People 2020 target. The Centers for Disease Control and Prevention (CDC) recommends that the vaccine be routinely administered to children between 11 and 12 years and could begin as early as 9 years of age. However, it is unclear to what extent the CDC’s guideline-recommended age of HPV vaccine uptake is followed. Objective: To test the hypothesis that HPV vaccine uptake is more likely at an older age in the United States rather than the CDC recommended age of 11-12 years. Methods: We analyzed the 2017-2020 nationally representative, cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) for respondents between 9 and 17 years of age, grouped as 9-10 years, 11-12 years, and 13-17 years. Outcome of interest was age of HPV vaccine uptake (initiation and completion), based on the above age groups. We estimated odds of vaccine uptake by age, using logistic regression models, and adjusted for covariates, including sex, race/ethnicity, income, and healthcare access. Results: There were 2,584 participants in our study. However, while 22% were aged 9-10, only 5.7% in this age group had initiated the vaccine. In crude analysis, there was a significant difference in in age of vaccine uptake (both initiation and completion) across age groups (p < .0001). After adjusting for covariates, we found significant associations between age and HPV vaccine uptake. Compared to participants aged 11-12 years, adolescents aged 13-17 years had over double the odds of initiating (aOR = 2.57; 95% CI 1.88, 3.51) or completing (aOR = 2.67; 95% CI 1.76, 4.06) the HPV vaccine series. However, younger individuals between 9-10 years were less likely to initiate (aOR = 0.14; 95% CI 0.09, 0.22) or complete the vaccine series (aOR = 0.19; 95% CI 0.09, 0.37). Conclusions: While the CDC recommends HPV vaccine uptake between 11-12 years of age and as early as 9 years, individuals are significantly more likely to receive the vaccine as adolescents, and less likely to receive the vaccine between 9-10 years of age. Future studies will determine patients vs. provider factors driving this difference in recommended age of vaccine uptake compared to reported age of uptake. Citation Format: Trinity Casimir, Marian F. Talip, Dina K. Abouelella, Mrudula Nair, Daniel J. Rocke, Tammara L. Watts, Nosayaba Osazuwa-Peters, Eric Adjei Boakye. Differences in guideline-recommended age of human papillomavirus (HPV) vaccine initiation and completion in the United States. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P018.

Abstract A124: Disparities in HPV vaccine uptake and provider recommendation by provider facility type

Abstract Background: Approximately 46,000 cases of human papillomavirus (HPV) attributable cancers are diagnosed annually in the United States. The HPV vaccine can prevent over 90% of HPV-attributable cancers, yet national uptake remains lower than the Healthy People 2030 target goal of 80% completion. To devise targeted interventions to increase the uptake of HPV vaccines, it is crucial to understand the vaccination rates across various health care settings. We examined the association between provider facility type and provider recommendation and HPV vaccine uptake among adolescents in the US. Methods: We conducted secondary data analysis of the 2020 National Immunization Survey–Teen data (n=20,162), which provides current, population-based estimates of vaccination coverage among adolescents. Provider facility type was classified as public facilities (i.e., public health department-operated clinic, community health center, rural health clinic, tribal/Indian health facility), hospital-based facilities, private facilities, and mixed facilities (i.e., vaccination provided in more than one of the above-mentioned locations). Self-reported provider recommendation was dichotomized as yes/no. HPV vaccine initiation was defined as the receipt of ≥1 dose of the HPV vaccine, and completion was defined as the receipt of ≥2 doses (if the adolescent received first dose before age 15) or ≥3 doses (if the adolescent was at least 15 years old). Weighted, multivariable logistic regression models estimated the odds of receiving provider recommendation and initiating and completing the HPV vaccine by provider facility type, adjusting for adolescents age, gender, race, poverty level, number of doctor visits per year, and mother’s age, marital status, and education. Results: Approximately 81% of adolescents received a provider recommendation for the HPV vaccine and 47.5% received their vaccination at providers based in private facilities. The prevalence of HPV vaccine initiation was 75.1% and completion was 58.6%. In the adjusted analyses, adolescents who received their vaccination from public facilities (aOR=0.63; 95% CI: 0.51–0.78) were less likely to receive provider recommendation for the vaccine compared to those who received their vaccination at private facilities. Similarly, adolescents who received their vaccination from public facilities were less likely to initiate (aOR=0.73; 95% CI: 0.59–0.90) and complete (aOR=0.62; 95% CI: 0.52–0.77) the HPV vaccination compared to those who received their vaccination at private facilities. There was no difference between hospital and mixed vs. private facilities for both provider recommendation and vaccination. Conclusions: Both the recommendation for and uptake of the vaccine regimen were less common in public facilities than private facilities. Given the populations served in public facilities and the health disparities that exist in these populations, a greater focus is needed on recommendation for vaccination and follow through. Citation Format: Eric Adjei Boakye, Mrudula Nair, Amy Williams, Elizabeth Alleman, Christine Joseph, Dina Abouelella, Oluwole A. Babatunde, Nosayaba Osazuwa-Peters. Disparities in HPV vaccine uptake and provider recommendation by provider facility type [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A124.

Abstract A127: Factors impacting HPV vaccine initiation among English and Spanish speaking parents of Latino adolescents

Abstract Background: Human Papillomavirus (HPV)-associated cancers disproportionately impact Latinos. While data for English-speaking (ES) and Spanish-speaking (SS) Latinos is usually aggregated, differences in acculturation, sociodemographic characteristics, and health behaviors make it important to understand the factors impacting HPV vaccination among these groups separately. This understanding is crucial to improving HPV vaccination disparities as COVID-19 vaccinations have exacerbated issues of vaccine hesitancy and medical mistrust. Methods: Self-administered online surveys examining HPV vaccine hesitancy in an urban, diverse community with low HPV vaccine uptake were completed by parents of adolescents (N=357) in English or Spanish. Bivariate logistic regression analyses were conducted to understand if medical mistrust, vaccine hesitancy, HPV knowledge, healthcare utilization and sociodemographic factors impact adolescent HPV vaccine uptake among ES and SS parents of Latino adolescents ages 12-17. Factors significant at p<.01 in the bivariate analyses were included in multivariable logistic regression models for each group. Results: 136 parents of adolescents aged 12-17 identified as Latino; 56% completed the survey in English and 44% in Spanish. Bivariate analyses found significant associations between decreased HPV vaccine uptake and male parent/caregiver sex, higher HPV vaccine hesitancy, higher HPV knowledge, male adolescent sex, not receiving the flu vaccine and not receiving a provider recommendation to vaccinate against HPV among ES parents. In SS parents, parents aged 41-50 (compared to <40) and higher medical mistrust were associated with higher HPV vaccination; while male adolescent gender, not receiving TDAP immunization, and not receiving a provider recommendation to vaccinate against HPV were associated with lower HPV vaccine uptake. Multivariable regression models found that adolescents of ES parents were less likely to have initiated the HPV vaccine series if the parent/caregiver was male (OR=0.07, 95% CI:0.03,1.28), had higher HPV knowledge (OR=0.53, 95% CI:0.29,0.96), and did not receive a provider recommendation to vaccinate against HPV (OR=0.12, 95% CI:0.003,0.55). SS parents with higher medical mistrust (OR=7.27, 95% CI:1.14,46.41) and those aged 41-50 compared to parents younger than 40 (OR=18.19, 95% CI:0.28,407.78) were more likely to have adolescents who initiated the HPV vaccine series, while those without a provider recommendation to vaccinate had lower odds of HPV vaccine uptake (OR=0.004, 95% CI:<0.01,0.11). Discussion: Aligned with the literature, provider recommendation to vaccinate against HPV significantly impacted vaccination behavior among ES and SS parents. Interventions should focus on improving provider recommendations and communications with Latino parents of adolescents. More research should explore the surprising associations between higher medical mistrust and higher odds of HPV vaccination among SS parents, and more HPV knowledge and lower odds of HPV vaccination among ES parents. Citation Format: Bibiana Martinez, Lourdes Baezconde-Garbanati, Jennifer Tsui. Factors impacting HPV vaccine initiation among English and Spanish speaking parents of Latino adolescents [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A127.

Abstract A126: Human papillomavirus (HPV) vaccination rate by gender identity among US young adults

Abstract Background: While national human papillomavirus (HPV) vaccination estimates vary by sex, little is known about variation by gender identity. We sought to estimate HPV vaccination initiation and completion by gender identity among US young adults. Methods: We used 2018-2020 Behavioral Risk Factor Surveillance System data from individuals reporting both gender identity and HPV vaccination status. Weighted, multivariable logistic regression was used to identify factors associated with vaccination initiation and completion. Results: The 6,484 individuals included 3,300 cismales, 3,130 cisfemales, 31 transmales, and 23 transfemales. Vaccination initiation/completion were low, at 40.1% and 17.6%, respectively, and varied by gender identity: cismale=29.1%/9.6%, cisfemale=51.3%/25.8%, transmale=50.1%/5.9%, and transfemale=34.7%/13.0% (P <.0001). In weighted multivariable models, cismales were significantly less likely than cisfemales to initiate (OR:0.39; 95% CI:0.32-0.48) and complete (OR:0.29; 95% CI:0.22-0.37) vaccination, but no significant differences were observed for transmales and transfemales compared to cisfemale. Factors associated with lower initiation included: non-Hispanic Black race (OR: 0.71; 95% CI: 0.54-0.93), high school diploma (OR: 0.57; 95% CI: 0.42-0.78), rural residence (OR: 0.64; 95% CI:0.45-0.90), no insurance (OR: 0.56; 95% CI:0.43-0.74), and no regular provider (OR: 0.67; 95% CI: 0.53-0.84). Factors associated with lower completion included: non-Hispanic Black race (OR: 0.48; 95% CI: 0.34-0.67), Hispanic race (OR: 0.70; 95% CI: 0.49-0.99), married (OR: 0.76; 95% CI: 0.57-0.95), high school diploma (OR: 0.60; 95% CI: 0.42-0.85), and no regular provider (OR: 0.63; 95% CI: 0.46-0.87). Conclusion: HPV vaccination rates in the U.S. are low across all subsamples and future HPV vaccine uptake studies should account for gender identity. Citation Format: Minjee Lee, Wiley D. Jenkins, Bettina Drake, Sarah Van Vickle-Chavez. Human papillomavirus (HPV) vaccination rate by gender identity among US young adults [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A126.

Abstract B052: Integrating HPV (human papillomavirus) vaccination into HIV prevention: Acceptability and information needs among PrEP (pre-exposure prophylaxis) patients at a federally qualified health center

Abstract Background: Anal cancer disproportionally impacts gay, bisexual, and other male sexual minorities (GBM). Human Papillomavirus (HPV) vaccination is a safe and effective method to prevent anal cancer; however, coverage of HPV vaccination among adult GBM is low. Key barriers to vaccination are lack of awareness and knowledge of anal cancer, low motivation to get vaccinated, and lack of access and availability. For many young GBM, regular interactions with the healthcare system center around HIV prevention. Thus, we propose that federally qualified health centers (FQHCs) can increase uptake and reach of HPV vaccination by integrating and promoting HPV vaccination in ongoing HIV preventive care (e.g., Pre-exposure Prophylaxis [PrEP]). The objectives of this project were to (1) assess the acceptability of integrating HPV vaccination with PrEP management and (2) determine needs for informed decision making. Methods: We conducted a web-based cross-sectional survey of unvaccinated GBM (18-45) who received PrEP care at a FQHC in Philadelphia. Data collection took place in 2021 and 2022. The main outcome was intent to initiate HPV vaccination within 12 months (5-point scale). Other measures included beliefs about HPV vaccination in PrEP care, perceived information needs, and preferred information delivery modes. Descriptive and bivariate statistics were used to analyze the data. Results: The sample (N=59) was ethnoracially diverse (50.0% non-White) and in the catchup (23.7%; 18-26 yrs.) or shared clinical decision making (76.3%; 27-45) age ranges. Most were gay identified (71.2%) cisgender men (74.6%). Just 23.7% were aware they were eligible for HPV vaccination and even fewer knew that vaccination could prevent anal cancer (11.9%). Overall vaccine intentions were high (M=3.7; SD=1.0). Intentions were 26.1% higher (M=4.4; SD=1.0) if HPV vaccination was offered during PrEP appointments. Most (88.7%) agreed that offering HPV vaccination during PrEP visits would increase the likelihood that they would get vaccinated; however, 64.4% strongly/somewhat agreed that they needed more information about HPV vaccination prior to making an informed decision. Perceived information need was inversely associated with vaccine intentions (r=-0.31, p=0.02). Most participants (>50%) indicated they wanted to know more about their risk for anal cancer and effectiveness of HPV vaccination. The majority (71.2%) preferred to get medically accurate information on anal cancer prevention from a website that they could go to on their own time. Other delivery modes were iPads at their doctor’s office (28.8%), printed information given to them by their doctor (28.8%), and text messages from a healthcare provider (25.4%). Conclusion: Offering and promoting HPV vaccination as part of PrEP management visits was highly acceptable among PrEP patients. Interventions should focus on raising awareness about anal cancer and promoting informed decision making for anal cancer prevention. Citation Format: Christopher W. Wheldon, Sarah Bass, Bradley Collins. Integrating HPV (human papillomavirus) vaccination into HIV prevention: Acceptability and information needs among PrEP (pre-exposure prophylaxis) patients at a federally qualified health center [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr B052.

HPV vaccination coverage and factors among American Indians in Cherokee Nation.

We estimated human papillomavirus (HPV) vaccine initiation coverage among American Indian adolescents and identified factors associated with HPV vaccination among parents of these adolescents. We developed, tested, and disseminated a survey to a random sample of 2,000 parents of American Indian adolescents aged 9-17years who had accessed Cherokee Nation Health Services from January 2019 to August 2020. We used log-binomial regression to estimate the unadjusted and adjusted weighted prevalence proportion ratios (PPR) and 95% confidence intervals (CI) for adolescent HPV vaccine initiation. HPV vaccine initiation coverage (≥ 1 dose) was 70.7% among adolescents aged 13-17years. The prevalence of HPV vaccine initiation was higher among American Indian adolescents whose parents were aware of the HPV vaccine (adjusted weighted PPR 3.41; 95% CI 2.80, 4.15) and whose parents received a recommendation from their provider (adjusted weighted PPR 2.70; 95% CI 2.56, 2.84). The most common reasons reported by parents to vaccinate their children were to protect them against HPV-associated cancers (25.7%) and receiving a recommendation from a healthcare provider (25.0%). Parents cited vaccine safety concerns as the main reason for not getting their children vaccinated (33.2%). HPV vaccine initiation coverage among American Indian adolescents in Cherokee Nation was consistent with the national survey estimates. However, allaying parental concerns about vaccine safety and encouraging providers to recommend the HPV vaccine could improve coverage.

Human papillomavirus vaccine uptake among teens before and during the COVID-19 pandemic in the United States

ABSTRACT It is unclear how the COVID-19 pandemic impacted human papillomavirus (HPV) vaccine uptake and which sociodemographic groups may have been most impacted. We aimed to assess differences in HPV vaccine uptake (initiation and completion) before and during the pandemic in the United States. We conducted a cross-sectional study using data from the 2019 to 2020 National Immunization Surveys – Teen (NIS-Teen), comparing vaccine initiation and completion rates in 2019 vs. 2020, based on confirmed reports by a healthcare provider. Weighted logistic regression analysis estimated odds of vaccine initiation and completion for both adolescent and parental characteristics. There were 18,788 adolescents in 2019 and 20,162 in 2020. There was 3.6% increase in HPV vaccine initiation (71.5% vs. 75.1%) and a 4.4% in completion (54.2% vs. 58.6%) rates from 2019 to 2020. In 2020, Non-Hispanic White teens were significantly less likely to initiate (aOR = 0.62, 95% CI: 0.49, 0.79) and complete (aOR = 0.71, 95% CI: 0.58, 0.86) vaccine uptake compared with non-Hispanic Black teens. Additionally, teens who lived above the poverty line were also less likely to initiate HPV vaccination (aOR = 0.63, 95% CI: 0.49, 0.80) or complete them (aOR = 0.73, 95% CI: 0.60, 0.90), compared to those who lived below the poverty line. During the COVID-19 pandemic in 2020, some historically advantaged socioeconomic groups such as those living above the poverty line were less likely to receive HPV vaccine. The impact of the pandemic on HPV vaccine uptake may transcend traditional access to care factors.

Association between Sexual Activity and Human Papillomavirus (HPV) Vaccine Initiation and Completion among College Students.

HPV vaccination is most effective if received before initiation of sexual activity. Previous studies suggested that young adult women who were not sexually active were not interested in receiving the vaccine because they did not think it was necessary. Whether this misperception is still prevalent today-and also shared by men-is unknown. This study examined whether sexual activity was associated with HPV vaccine uptake (initiation and completion) among university students. A cross-sectional study was conducted between February and May 2021 among students (n = 951) at a public Midwestern University. Sexual activity was categorized as "never" or "ever" had oral and/or vaginal sex. Outcome variables were HPV vaccine initiation, defined as receipt of ≥1 dose, and completion, defined as receipt of ≥3 doses. Multivariable logistic regression models estimated the association between sexual activity and HPV vaccine uptake, adjusting for sociodemographic factors. Approximately 18% of students reported never engaging in sexual activity. Overall, 45.5% initiated the HPV vaccine, and 16.5% completed the vaccine series. After adjusting for covariates, compared to students that reported never engaging in sexual activity, those that had ever engaged in sexual activity were more likely to have initiated the vaccine series (aOR = 2.06, 95% CI: 1.34-3.17); however, no difference was observed for completion. HPV vaccination was low; sexually naïve students were less likely to initiate the HPV vaccine. Since sexually naïve students may benefit from receiving the HPV vaccination, targeted interventions should be implemented towards this population to help increase vaccination rates and prevent HPV-associated diseases.

Human papillomavirus vaccine initiation and up-to-date vaccine coverage for adolescents after the implementation of school-entry policy in Puerto Rico.

The human papillomavirus (HPV) vaccine has been proven effective in the prevention of infection with high-risk HPV types, which can lead to the development of six HPV-related cancers. Puerto Rico (PR) adopted a mandatory HPV vaccination school-entry policy that took effect in August 2018. While school-entry requirements are generally accepted as an effective approach for increasing vaccination rates, there are few studies that have documented their impact on improving HPV vaccination rates. The objective of this study was to evaluate the impact of the HPV school-entry policy in PR on HPV vaccine coverage. We used a pre-post natural experiment. The study population included adolescents registered in the PR Immunization Registry during 2008-2019. We calculated HPV vaccine initiation and up-to-date (UTD) vaccine coverage rates. We estimated age-standardized rates (ASR) and standardized rate ratio with 95%CI. Vaccine data corresponding to a total of 495,327 adolescents were included for analysis; 50.9% were male and 49.1% were females. After policy implementation, a marked increase in raw HPV vaccine initiation among 11- to 12-year-old adolescents was observed across years 2017 (a pre-policy year), 2018, and 2019 (58.3%, 76.3%, and 89.8%, respectively). UTD coverage also showed a moderate increase after policy implementation among 11- to 12-year-old adolescents. The gap between sexes in vaccine initiation and UTD coverage narrowed over time; the ASRs in 2019 showed an increase of 19% in initiation and 7% increase in UTD relative to 2017 for males and females combined (both significant at p<0.05). This study demonstrated evidence of improvement in HPV vaccination rates following implementation of the school-entry policy and a narrowed sex gap in vaccine rates over time in PR. Future analyses should assess how the policy continues to affect vaccine coverage in subsequent years and how the COVID-19 pandemic has impacted HPV vaccination uptake.

An opportunity to increase human papillomavirus vaccination rates: Change the guidelines

ABSTRACT Given the low rates of Human Papillomavirus (HPV) vaccination initiation and timely series completion in 11- and 12-year old children, we sought to assess potential opportunities for initiating routine vaccination at a younger age. A cross-sectional study of Latino parents of HPV vaccine-eligible 9- or 10-year–old children in New York City assessed whether there were opportunities to discuss the HPV vaccine during their most recent primary care provider (PCP) visit. Parents were approached between November, 2016 and January, 2018. Of 86 parents who participated, 97% reported having visited the child’s PCP in the previous year for an annual checkup and 85% reported that they had neither discussed the HPV vaccine nor received a recommendation for the vaccine during that visit. In a population of Latino parents, predominantly Mexican immigrants with less than a high school education and limited English proficiency, most 9- to 10-year–old children followed the recommendation for an annual PCP visit. Lowering the recommended age for routine vaccination with the HPV vaccine to 9 − 10 years of age should be considered as an important strategy to increase HPV vaccination rates in this and other populations.

Factors Associated with HPV Vaccine Adherence among Latino/a Adolescents in a Rural, Texas-Mexico Border County.

Completion of human papillomavirus (HPV) vaccine series among Texas Hispanic adolescents is low compared to national data. We examined the association between HPV vaccine initiation and completion among Hispanic adolescents in a rural, Texas-Mexico border county and specific individual and neighborhood-level characteristics. Cross-sectional analysis of data from a broader cancer prevention program. Underserved colonias communities in a Texas-Mexico border county. Hispanic mothers or caregivers (n=712) and adolescents aged 11-17 years (n=1120) linked to publicly available data about their neighborhood. HPV vaccine adherence (ie, initiation and completion) as reported in either the Texas Immunization Registry or adolescents' electronic medical records, measured at the end of the cancer prevention program. Logit and multi-level mixed-effects logistic regression of individual- and neighborhood-level data. Factors associated with HPV vaccine initiation and completion were female gender (P<.01), adolescent insurance status (P<.001), and receipt of required vaccines (P<.001). After controlling for neighborhood-level characteristics, only receipt of required vaccines remained significant. Findings indicate a relationship between Hispanic adolescents' receiving the required vaccine series for school admission and HPV vaccine initiation and completion. In resource-limited settings like federally qualified health centers, further efforts should focus on implementing best practices at both the provider level (eg, education on bundled vaccine recommendation) and practice-level (eg, outreach and support by trained immunization navigators).

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

BackgroundIn the United States, human papillomavirus (HPV) vaccine initiation and up-to-date (UTD) status are associated with multiple factors at the individual level such as racial/cultural (e.g., race, immigration status), socioeconomic status (e.g., living below poverty level, education), and healthcare access (e.g., insurance status/type). HPV vaccination rates differ dramatically by US geographic areas and within states. To tailor interventions to local areas, it is important to understand county-level characteristics associated with HPV vaccination rates. MethodsUsing linear regression, we assessed the association between county-level HPV vaccination initiation and UTD rates for 11-year-olds to 12-year-olds in Florida (collected from the Florida SHOTS immunization registry) and county-level variables. Factors found significant in bivariate analysis and with a variance influence factors <4 were included in multivariable models. ResultsIn 2019, county-level HPV vaccine coverage among Florida 11-year-olds to 12-year-olds ranged from 31% to 92% initiation and 3%–36% UTD. Counties with the lowest HPV vaccine coverage were concentrated in Florida's North-Central and Panhandle regions. In multivariable models, counties with primarily rural populations had lower vaccination initiation and UTD coverage. Above and beyond the association with rurality, UTD coverage was associated with family physicians per 100,000 residents and uninsured or Medicaid-enrolled populations. DiscussionWhile Florida county-level HPV vaccine initiation rates among 11-year-olds to 12-year-olds varied by county in 2019, UTD rates remained universally low despite recommendations. Tailoring interventions toward healthcare access in rural communities may increase HPV vaccine coverage.

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.

Improving HPV Vaccination Rates in a Racially and Ethnically Diverse Pediatric Population.

Nationally, 54.2% of youth are fully vaccinated for human papilloma virus (HPV) with persistent gender and racial/ethnic disparities. We used a quality improvement approach to improve completion of the HPV vaccine series by age 13 years. As a secondary aim, we examined racial/ethnic and gender differences in vaccine uptake. The study setting included 2 pediatric, academic, primary care practices in Massachusetts. We designed a multilevel patient-, provider-, and systems-level intervention addressing parental hesitancy, provider communication, and clinical operations. Rates of HPV series completion by age 13 were monitored using a control p chart. Bivariate and multivariate analyses evaluated vaccine completion differences on the basis of clinic size, gender, and race/ethnicity. Between July 1, 2014, and September 30, 2021, control p charts showed special cause variation with HPV vaccine initiation by age 9 years, increasing from 1% to 52%, and vaccine completion by 13 years, increasing from 37% to 77%. Compared with White and Black children, Hispanic children were more likely to initiate the HPV vaccine at age 9 (adjusted odds ratio [95% confidence interval] = (1.4-2.6)] and complete the series by age 13 (adjusted odds ratio [95% confidence interval] = 2.3 (1.7-3.0). A multilevel intervention was associated with sustained HPV vaccine series completion by age 13 years. Hispanic children were more likely to be vaccinated. Qualitative family input was critical to intervention design. Provider communication training addressed vaccine hesitancy. Initiation of the vaccine at age 9 and clinicwide vaccine protocols were key to sustaining improvements.

Implementation of a provider-focused intervention for maximizing human papillomavirus (HPV) vaccine uptake in young cancer survivors receiving follow-up care in pediatric oncology practices: protocol for a cluster-randomized trial of the HPV PROTECT intervention

BackgroundChildhood cancer survivors are at high risk for developing new cancers (such as cervical and anal cancer) caused by persistent infection with the human papillomavirus (HPV). HPV vaccination is effective in preventing the infections that lead to these cancers, but HPV vaccine uptake is low among young cancer survivors. Lack of a healthcare provider recommendation is the most common reason that cancer survivors fail to initiate the HPV vaccine. Strategies that are most successful in increasing HPV vaccine uptake in the general population focus on enhancing healthcare provider skills to effectively recommend the vaccine, and reducing barriers faced by the young people and their parents in receiving the vaccine. This study will evaluate the effectiveness and implementation of an evidence-based healthcare provider-focused intervention (HPV PROTECT) adapted for use in pediatric oncology clinics, to increase HPV vaccine uptake among cancer survivors 9 to 17 years of age.MethodsThis study uses a hybrid type 1 effectiveness-implementation approach. We will test the effectiveness of the HPV PROTECT intervention using a stepped-wedge cluster-randomized trial across a multi-state sample of pediatric oncology clinics. We will evaluate implementation (provider perspectives regarding intervention feasibility, acceptability and appropriateness in the pediatric oncology setting, provider fidelity to intervention components and change in provider HPV vaccine-related knowledge and practices [e.g., providing vaccine recommendations, identifying and reducing barriers to vaccination]) using a mixed methods approach.DiscussionThis multisite trial will address important gaps in knowledge relevant to the prevention of HPV-related malignancies in young cancer survivors by testing the effectiveness of an evidence-based provider-directed intervention, adapted for the pediatric oncology setting, to increase HPV vaccine initiation in young cancer survivors receiving care in pediatric oncology clinics, and by procuring information regarding intervention delivery to inform future implementation efforts. If proven effective, HPV PROTECT will be readily disseminable for testing in the larger pediatric oncology community to increase HPV vaccine uptake in cancer survivors, facilitating protection against HPV-related morbidities for this vulnerable population.Trial registrationClinicalTrials.gov Identifier: NCT04469569, prospectively registered on July 14, 2020.

Human papillomavirus vaccination uptake among childhood cancer survivors in Western New York.

The risk of human papillomavirus (HPV)-associated cancers is significantly higher among survivors of a childhood cancer compared to the general population. Despite this, their HPV vaccine uptake rates are lower. We examined factors related to HPV vaccine uptake among childhood cancer survivors from Western New York over 13years following the introduction of HPV vaccines. Retrospective review of patients diagnosed with invasive or noninvasive cancerous conditions at age 9 or younger treated at Roswell Park Oishei Children's Cancer and Blood Disorder Program. We matched vaccine date information for patients aged 9-26years between 2006 and 2020 from the New York State Immunization Information System. Demographic and cancer-related information was abstracted from electronic medical records. Cumulative vaccine uptake was assessed by Kaplan-Meier and Cox proportional hazards regression models. A total of 284 patients were included in the analyses. Most were non-Hispanic/White (80.3%) and resided in a metropolitan area (81.7%). Approximately half had leukemia or lymphoma (54.9%), and most received chemotherapy. Females were more likely to initiate the HPV vaccine and did so sooner (median=5.5years) than males (median=5.7years; log-rank p=.301). Patients who were older at vaccine eligibility and males who received blood product transfusions were significantly less likely to initiate the HPV vaccine. While rates of HPV vaccine initiation have been increasing with time among childhood cancer survivors, they remain low overall, with differences seen by treatment and diagnosis. Our findings support the need for further research to optimize HPV vaccine delivery in cancer care.

HPV vaccination coverage for pediatric, adolescent and young adult patients receiving care in a childhood cancer survivor program

Pediatric, adolescent and young adult patients undergoing cancer treatment and/or hematopoietic stem cell transplant are at increased risk for developing a secondary human papillomavirus (HPV)-associated malignancy. The objective of this study was to determine HPV vaccination coverage among individuals participating in a childhood cancer survivor program (CCSP). A retrospective cohort study was conducted among CCSP patients age 11–26 years attending a CCSP visit between 2014 and 2019. Survivors were age-, sex-, and race-matched 1:2 with controls without cancer. Data were abstracted from the electronic health record and state-based vaccination registry. Analysis was limited to Minnesota residents to minimize missing vaccination data. Survivorship care plans (SCPs) were reviewed for vaccine recommendations.592 patients were included in the analyses (200 CCSP patients; 392 controls). By study design, mean age (18.4 years), race (72 % white), and sex (49 % female) were similar in the two groups. Among CCSP patients 22 % resided in a rural area compared to 3.8 % of controls. Vaccination coverage among CCSP patients was not statistically significantly different from controls [60.0 % vs 66.3 %, OR = 0.82, 95 % CI: (0.55, 1.23), p = 0.35]. Completion of 3 doses was not different between groups even though 3 doses is recommended for all CCSP patients regardless of age at initiation (28.5 % vs 30.1 %, p = 0.09). Only 8.0 % of SCPs recommended HPV vaccination.Although patients participating in a CCSP did not have significantly different HPV vaccination coverage compared to controls, HPV vaccination initiation and 3-dose series completion are still suboptimal in a patient population at high-risk of a secondary HPV-associated cancer.

Rural-Urban Disparities in HPV Vaccination Coverage Among Adolescents in the Central Part of the State of Illinois, USA.

Human Papillomavirus (HPV) is associated with six cancers and widespread immunization with HPV vaccine could reduce the number of these cancers. Although HPV vaccination rates are available for the state of Illinois and the city of Chicago, data are limited for specific areas. We assessed rates of HPV vaccine initiation and completion among adolescents in central Illinois and identified factors associated with initiation and completion. This was a retrospective study of adolescents (aged 11-17) who receive care at the Southern Illinois University Medicine Department of Pediatrics. The outcome variables were HPV vaccination initiation (receipt of ≥ 1 dose) and completion (receipt of ≥ 2 or 3 doses, depending on age of initiation). Multivariable logistic regressions were used to identify factors associated with HPV vaccine uptake. A total of 9,351 adolescents were included in the study. Overall, HPV vaccine initiation was 46.2% and completion was 24.7%. In adjusted analyses, adolescents residing in rural areas were 38% and 24% less likely to initiate (aOR = 0.62; 95 CI: 0.54-0.72) and complete (aOR = 0.76; 95 CI: 0.65-0.88) the HPV vaccine compared with those residing in urban areas. Similarly, adolescents were less likely to initiate and complete the HPV vaccine if they were not update to date on the hepatitis A, meningococcal, or Tdap vaccinations. HPV vaccination rates in central Illinois were low, and far below the national average and the Illinois state average. Future directions should include interventions to increase HPV vaccine uptake, particularly in rural areas.

Differences in stakeholder-reported barriers and implementation strategies between counties with high, middle, and low HPV vaccine initiation rates: a mixed methods study

BackgroundA greater understanding of the county-level differences in human papillomavirus (HPV) vaccination rates could aid targeting of interventions to reduce HPV-related cancer disparities.MethodsWe conducted a mixed-methods study to compare the stakeholder-reported barriers and efforts to increase HPV vaccination rates between counties within the highest, middle, and lowest HPV vaccine initiation (receipt of the first dose) rates among 22 northern Florida counties. Between August 2018 and April 2019, we recruited stakeholders (n = 68) through purposeful and snowball sampling to identify potential participants who were most knowledgeable about the HPV vaccination activities within their county and would represent a variety of viewpoints to create a diverse picture of each county, and completed semi-structured interviews. County-level HPV vaccine initiation rates for 2018 were estimated from the Florida Department of Health’s immunization registry and population counts. Implementation strategies were categorized by level of importance and feasibility using the Expert Recommendations for Implementing Change (ERIC) taxonomy. We compared the barriers and implementation strategies for HPV vaccination between tercile groups of counties by HPV vaccine initiation rates: highest (18 stakeholders), middle (27 stakeholders), and lowest (23 stakeholders).ResultsThe majority of the 68 stakeholders were female (89.7%), non-Hispanic white (73.5%), and represented a variety of clinical and non-clinical occupations. The mentioned barriers represented five themes: healthcare access, clinician practices, community partnerships, targeted populations, and cultural barriers. Within themes, differences emerged between county terciles. Within healthcare access, the highest rate county stakeholders focused on transportation, lowest rate county stakeholders focused on lack of clinicians, and middle county stakeholders mentioned both. The number of ERIC quadrant I strategies, higher feasibility, and importance described decreased with the tercile for HPV vaccination: highest = 6, middle = 5, and lowest =3 strategies.ConclusionsThe differing barriers and strategies between the highest, middle, and lowest vaccination rate counties suggest that a tailored and targeted effort within the lowest and middle counties to adopt strategies of the highest rate counties may reduce disparities.

Support for HPV vaccine school-entry requirements in the United States: The role of exemption policies

In the United States (U.S.), only five states or territories require human papillomavirus (HPV) vaccination for school attendance, even though almost all U.S. jurisdictions have debated adopting this type of policy. In this U.S. based study, we sought to estimate the level of support for HPV vaccine school-entry requirements with varying exemption policies and documentation procedures to obtain exemptions. Between July and August 2019, we conducted a web-based survey with a national sample of 1,109 U.S. parents of 11- to 17-year-olds. The survey assessed support for four school-entry vaccine requirement policies: without exemption or with exemption for medical, religious or philosophical reasons. Analyses used multivariable logistic regression to assess correlates of support for each policy. Overall, 38% of parents agreed with laws requiring HPV vaccination for school attendance without exemptions. When including exemption provisions, agreement increased to 45% for philosophical reasons, 50% for religious reasons, and 59% for medical reasons. Parents more often agreed on requirements without any exemptions if they were female (OR = 1.37, 95% CI:1.01–1.87), their child had initiated HPV vaccination (OR = 2.05, 95% CI:1.50–2.87), reported high levels of vaccine confidence (OR = 2.41, 95% CI:1.77–3.27), or reported having values similar to those of the people in their community (OR = 1.85, 95% CI:1.39–2.47). Parents more often agreed with requirements that included religious or philosophical exemptions if they reported having values similar to their community or high levels of psychological reactance (all p <.05). Many parents also supported requiring a written notice signed by a health care provider (40%) or religious leader (49%) to obtain a medical or religious exemption, respectively. In conclusion, exemption policies greatly increase parent support of school-entry requirements for HPV vaccination but may decrease their impact in practice. A large number of U.S. parents support strict documentation to obtain exemptions, signaling a promising area of policymaking to strengthen vaccine policies for school attendance.