Proactive Recommendation Research Articles

Association between hypertension requiring medication and 30-day outcomes in head and neck microvascular surgery.

Hypertension has been shown to be both a protective factor and a risk factor for complications in head and neck reconstructive surgery. Retrospective analysis of microvascular free tissue transfer patients using the National Surgical Quality Improvement Program database. Hypertensive patients (n=1598; 46.9%) had a significantly higher rate of complications, including pneumonia (p < 0.001), myocardial infarction (p=0.003), and intra/post-operative transfusion (p < 0.001). In a multivariable model, hypertension was associated with returning to the operating room (OR=1.45 [95% CI 1.20, 1.76], p < 0.001), post-operative medical complications (OR=1.53 [95% CI 1.24, 1.90], p < 0.001), and surgical complications (OR=1.17 [95% CI 1.00, 1.37], p=0.047). However, no difference in 30-day readmission was found (p > 0.05). Hypertension is a modifiable risk factor for post-operative complications in head and neck free tissue transfer, in which prospective studies are required to establish causation. This study may serve as an impetus for proactive recommendations to manage hypertension before undergoing head and neck microvascular surgery.

Suspension of proactive recommendations for HPV vaccination has led to a significant increase in HPV infection rates in young Japanese women: real-world data.

We have expressed our concern about HPV vaccination coverage in Japan remaining below 1%, which will result in an increase in vaccine-targeted HPV infection rates and cervical cancer morbidity [1–4]. Once again, we have been appealing for the resumption of proactive recommendations for HPV vaccination. Public funding for HPV vaccination became available for girls aged 13–16 years from 2010 in Japan and the vaccine was subsequently included in the national immunization program (NIP) for girls aged 12–16 years from April, 2013.

Effect of a Brief Web-Based Educational Intervention on Willingness to Consider Human Papillomavirus Vaccination for Children in Japan: Randomized Controlled Trial.

BackgroundThe human papillomavirus (HPV) vaccination rate in Japan has fallen to nearly zero since the suspension of governmental proactive recommendations in 2013, owing to the development of purported adverse events.ObjectiveThis study aimed to evaluate the effects of a brief web-based educational intervention using the theory of behavioral insights on the willingness of adults to consider the HPV vaccine for their daughters and sons.MethodsWe recruited 1660 participants aged 20 years or older in March 2018 via a webpage and provided them with a 10-item questionnaire related to the following aspects: awareness regarding HPV infection and vaccination, willingness for immunization, and actions for prevention. We randomly stratified participants based on sex and age with or without a brief educational intervention involving scientific information presented in an easy-to-read format.ResultsOnly 484 (29.2%) of the respondents were aware of the benefits of HPV vaccination. Although only 352 (21.2%) of the respondents displayed a willingness for immunization of their daughters, there were 40 (4.8%) more respondents in the intervention group with this willingness (adjusted odds ratio [aOR] 1.32, 95% CI 1.04-1.69). In a subanalysis, the willingness toward vaccination for daughters in men was significantly higher in the intervention group (aOR 1.46, 95% CI 1.05-2.02). However, such a difference was not observed among women (aOR 1.20, 95% CI 0.83-1.73).ConclusionsThis study suggests that a brief web-based educational intervention increases the willingness of adults to consider the HPV vaccine for their children, especially among men. Thus, providing adequate information to men may be a useful strategy to improve the currently low rates of HPV vaccination.Trial RegistrationUMIN Clinical Trials Registry UMIN000049745 (UMIN-CTR); https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000049745

English

Considerable concern is being paid to the professionalization of education. Professionalising higher education in a way in many countries is trying to build a bridge between theory and practice. First of all, it is important to know and understand that academics cannot be professionalised. This paper aims to explore a way to professionalise higher education. Data for the study is based on books and interviews with business people and university management/entrepreneurship students. A total of 225 interviewees, were distributed as follows: Undergraduate management/entrepreneurship students, 100; MBA students, 61; EMBA students, 14; business people, 50. Frequency distribution table was used to analyse the data collected. The result suggests that some areas of education can be professionalised, by making it practical through the introduction of plays, games, storytelling and using proverbs. The research suggests a democratic approach whereby the opinions of students are listened to and considered in the process of teaching and learning. The conclusion is that, activities such as self-paced design projects of taking students outside the lecture halls or classrooms either for practical work or discussions under a more relaxed and perhaps more conducive, attractive and enabling environments need to be adopted. This approach is likely to provide a new view of teaching and motivations for creative and innovative ideas generation to take place with greater dividends to the overall progress of professionalisation and society.&nbsp; Proactive policy recommendations are progressive. &nbsp; Key words: Academics, creating, excellence creating new teaching environments, professionalisation, practical work, creativity, innovation.

Ten-year questionnaire study on human papillomavirus vaccination targeting new female medical school students: Follow-up to the 2015 report.

We aimed to conduct a fixed-point observation questionnaire survey of changes in young women's human papillomavirus (HPV) vaccination status over the course of 10 years. We also investigated the influence of suspension of governmental recommendation for HPV vaccination since June 2013. During 2011-2020, we conducted a self-completed questionnaire survey among newly enrolled female medical school students in Yokohama, Japan. The questionnaire featured items regarding HPV vaccination status, age, previous sex education, and knowledge about cervical cancer and HPV vaccination. HPV vaccine uptake rates in 2011 (5.4%) and 2012 (13.5%), when vaccination was self-funded, increased after 2013 (48.7%), when vaccination fees were subsidized. The rate dropped drastically in 2019 (14.3%) and 2020 (5.1%), after suspension of recommendation by the government. Comparisons between new students in 2015/2016, who had high vaccination rates (65.2%), and new students in 2019/2020, who had low vaccination rates (9.8%), showed decreased levels of HPV vaccination awareness, with fewer students having covered cervical cancer prevention in sex education and with respondents having less knowledge about the details of HPV vaccination. After the suspension of proactive HPV vaccine recommendation, markedly fewer students have been vaccinated against HPV, even those at the vaccination target age. This situation has substantially influenced the lower awareness about cervical cancer prevention, even among medical school students. To protect young women from cervical cancer in Japan, it is crucial for the government to resume proactive recommendation of HPV vaccines as soon as possible.

Understanding confidence in the human papillomavirus vaccine in Japan: a web-based survey of mothers, female adolescents, and healthcare professionals

ABSTRACT Vaccine confidence reflects social, individual, and political factors indicating confidence in vaccines and associated health systems. In Japan, the government ceased proactive recommendation of the human papillomavirus (HPV) vaccine in June 2013, only several months after the recommendation had begun. Seven years later, as of October 2020, the suspension persists and vaccine coverage has precipitously declined, resulting in many young women being continually exposed to the risk of preventable HPV-related diseases. Accordingly, understanding stakeholder opinions on HPV vaccination issues is critical for informing strategies to improve HPV vaccine confidence and acceptance. In October 2019, we performed a nationwide, web-based survey of 1646 mothers of HPV-vaccination–eligible girls, 562 female adolescents aged 15–19 years, and 919 healthcare professionals (HCPs) in Japan. This survey captured key elements of vaccine confidence (i.e., importance, effectiveness, and safety of the HPV vaccine), awareness, and the willingness to receive (in HPV-vaccination–eligible girls) or recommend (in HCPs) the HPV vaccine, and the factors responsible for these decisions. HPV vaccine confidence was generally higher among HCPs than among mothers or female adolescents. Nearly half of all stakeholders were neutral regarding their willingness to receive/recommend the HPV vaccine. The seriousness of cervical cancer and the HPV vaccine’s effectiveness or safety were important deciding factors for receiving/recommending the HPV vaccine. Besides these factors, sufficient information and free vaccination were crucial. Our results suggest several factors that could help shape public policy and communication strategies to improve HPV vaccine confidence and acceptance in Japan.

What is the current status of Japan's efforts to meet global goals and targets to eliminate cervical cancer?

Following the global call to action by the World Health Organization (WHO), the world is currently moving to eliminate cervical cancer as a public health problem. To eliminate the cancer within this century, which is defined as an age-adjusted cervical cancer incidence rate (ASIR) below 4 per 100,000 women, WHO recommends all countries to achieve "90-70-90" targets for human papilloma virus (HPV) vaccination, cervical cancer screening, and treatment of precancer and cancer by 2030. In Japan, ASIR has been rising since the late 1990s to 11.1 per 100,000 women, and this rise is particularly prominent in women of reproductive age. HPV vaccination coverage is as low as 0.3%, largely due to the Governments ongoing suspension of proactive recommendations for the vaccine. Given the absence of centralized, population-based cervical cancer screening program and a nationwide surveillance system for systematic monitoring, the exact screening participation rate and treatment rate are difficult to estimate. A national survey suggested that only around 40% of women between the ages of 20 and 69 years underwent cervical cancer screening within the last two years. National policies and systems for HPV vaccination and screening should be updated in a more efficient way as new evidence and innovations become available. In the wake of powerful global momentum, actions must be taken now to further enhance cervical cancer control and ensure that Japanese girls and women are no longer left behind.

Risk factors for HPV infection and high-grade cervical disease in sexually active Japanese women

In Japan, recommendations for HPV vaccines were suspended in 2013 due to unfounded safety fears. Although vaccine opponents claim modifying sexual behavior can prevent cervical cancer, no comprehensive data exist on sexual behavior and the risk of high-grade cervical disease in a Japanese population. This study investigates sexual behavior and the risk of HPV infection and cervical disease in 3968 women aged 20–41 yrs undergoing cervical screening between April 2014 and March 2016. Mean age at first intercourse was 18.4 yrs ± 2.8 and 32% of women reported ≥ 6 lifetime sexual partners. In regression analyses, number of partners was a significant risk factor for HPV infection. However, for high-grade disease (CIN2+), when HPV genotype was adjusted for, number of partners was not statistically significant. The greatest risk factor was an HPV16/18 infection (adjusted odds ratio 113.7, 95% CI: 40.8–316.9). In conclusion, we found that having an HPV16/18 infection and not sexual behavior was the most significant risk factor for high grade cervical disease in young Japanese women. These infections can be prevented by a highly effective vaccine and we recommend that the Japanese government resume proactive recommendations for the HPV vaccine immediately.

Contact lenses: So much more than simple correction of refractive error

Krupa Patel, Mark Draper, Zoe Bull and Karen Walsh share new insights into the deeper emotional benefits experienced by contact lens wearers, and how eye care professionals can use their understanding of this to increase proactive recommendation, creating many more satisfied dual wearers of both spectacles and contact lenses. New data on contact lens wearer habits in combination with face masks are also shared.

Cloud-Assisted Mobile Crowd Sensing for Route and Congestion Monitoring

Accurate and reliable real-time urban traffic management can benefit urban citizens’ daily life by reducing stress, travel time and carbon footprint. The provision of reliable and accurate traffic information has however proven to be a major challenge in intelligent transportation systems. Citizens carrying smartphones can be exploited as an important provider of traffic information and the mobile crowd sensing paradigm can be used as a solution to this challenge. In this paper, an urban traffic monitoring system which exploits the power of participatory sensing and cloud messaging is proposed. Crowd intelligence that is used to estimate traffic congestion levels, arrival times, and average road speed is harvested from crowd sensed data. Traffic congestion control at route level is implemented with a route guidance system. Proactive warnings or recommendations to drivers in the vicinity of or on the route to reported events are provided. The drivers can also report short-term traffic events and physical road conditions for road monitoring. Real-world experiments are conducted with a prototype implementation and the results demonstrates both system feasibility and traffic estimation accuracy.

Cooperative Content Replacement and Recommendation in Small Cell Networks

Content caching has limitations on achieving cache gains (e.g., cache hit ratio) in small cell networks, due to limited storages of small base stations (SBSs) and inherent user demand patterns (i.e., initial content preferences). Two effective approaches have been proposed to exploit the potential of content caching: SBS cooperation to utilize cache storage, and proactive content recommendation to shape user demand. In this paper, we investigate cooperative content caching and recommendation to maximize cache gains, while guaranteeing users’ satisfaction by recommending appealing content items. We propose a generic framework for cooperative content caching and recommendation, based on which we propose an online and distributed scheme by designing a continuous-time Markov chain (CTMC). In particular, online content caching (a.k.a., content replacement) is implemented by hopping from one cache state to another in the CTMC, while content recommendation is performed heuristically through sequential fixing at each cache state. Besides, we characterize the performance gap between our proposed scheme and the theoretical optimum in terms of cache hit ratio. Simulation results demonstrate that the proposed scheme achieves better cache hit ratios than other schemes in single-BS scenarios, and provides a competitive solution in multiple-BS scenarios.

Experiences With Involuntary Nursing Home Relocation: The Staff Perspective.

Although involuntary nursing home closures for operational and care-related reasons occur infrequently, few studies have examined the centrality of the actions of staff to facilitate residents' relocation adjustment. We interviewed 18 administrators and 43 staff working at 27 facilities about the relocation process for residents from two facilities that lost their Medicare and State Medicaid certification due to ongoing care deficiencies. Thematic analysis revealed three major themes throughout each aspect of the relocation process: (a) staff expectations were not met, (b) barriers/challenges were persistent, and (c) resident/family involvement was minimal. We offer proactive participant-derived recommendations for policy and practice to strengthen involuntary relocation processes to ensure a cooperative work environment and residents' well-being, regardless of the cause for involuntary closure.

Japan's Ongoing Crisis on HPV Vaccination.

The Japanese government suspended proactive recommendations for the HPV vaccine in June 2013. The suspension is now in its seventh year, despite all the data pointing to the safety of the HPV vaccine. We reported a high vaccine effectiveness in the group of women vaccinated before their first intercourse (93.9%). The prevalence of cross-protected types of HPV 31/45/52 was also lower in the vaccinated group, and the vaccine effectiveness was 67.7%. Furthermore, prevalence of HPV16, 31 and 52 infection rates in the vaccinated group were obviously lower than that in the unvaccinated group, and no one had HPV18 or 45 infection in the vaccinated group. The addition of a cross-protective effect toward HPV types 31/45/52 to HPV types 16/18, which is the direct target of the bivalent HPV vaccine, may possibly prevent around 82% of invasive cervical cancer cases in Japan. With regard to the preventive effect of histological abnormalities, we also reported significant reduction in incidence of cervical intraepithelial neoplasia (CIN)3 or worse. Thus, the efficacy of the vaccine has been demonstrated for precancerous disease, and the diverse symptoms after HPV vaccination are likely functional somatic. For the future of Japanese girls, there is a need to resume the proactive recommendation of HPV vaccination and for immediate action to be taken by the Japanese government.

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.

Human papillomavirus vaccination and postural tachycardia syndrome, deconditioning and exercise-induced hyperalgesia: An alternate interpretation of the reported adverse reactions.

Human papillomavirus vaccination (HPVV) was included in the national immunization program in 2013 in Japan. However, the Japanese government suspended proactive recommendations 2 months after this decision because various adverse events following the vaccination were reported by the media. More than 6 years have already passed since the suspension of proactive recommendations of all available vaccines in Japan. Although no causal relationship between the adverse effects and HPVV has been confirmed, the Japanese government has not withdrawn the suspension. Thus, it is important to show various possible causes of the adverse events other than HPVV. It is attempted to describe the possible contribution of the misunderstanding regarding the symptoms of postural tachycardia syndrome, deconditioning, and exercise-induced hyperalgesia as the adverse effects of HPVV in this review article.

Impact of HPV vaccine hesitancy on cervical cancer in Japan: a modelling study

Funding for human papillomavirus (HPV) vaccination in Japan began in 2010 for girls aged 12-16 years, with three-dose coverage initially reaching more than 70%. On June 14, 2013, 2 months after formal inclusion in Japan's national immunisation programme, proactive recommendations for the HPV vaccine were suspended following reports of adverse events since found to be unrelated to vaccination, but which were extensively covered in the media. Vaccine coverage subsequently dropped to less than 1% and has remained this low to date. We aimed to quantify the impact of this vaccine hesitancy crisis, and the potential health gains if coverage can be restored. In this modelling study, we used the Policy1-Cervix modelling platform. We adapted the model for Japan with use of data on HPV prevalence, screening practices and coverage, and cervical cancer incidence and mortality. We evaluated the expected number of cervical cancer cases and deaths over the lifetime of cohorts born from 1994 to 2007 in the context of the vaccine hesitancy crisis. We assessed a range of recovery scenarios from 2020 onwards, including a scenario in which routine coverage is restored to 70%, with 50% catch-up coverage for the missed cohorts (aged 13-20 years in 2020). To estimate the impact of the vaccine crisis to date, we also modelled a counterfactual scenario in which 70% coverage had been maintained in 12-year-olds from 2013 onwards. The vaccine crisis from 2013 to 2019 is predicted to result in an additional 24 600-27 300 cases and 5000-5700 deaths over the lifetime of cohorts born between 1994 and 2007, compared with if coverage had remained at around 70% since 2013. However, restoration of coverage in 2020, including catch-up vaccination for missed cohorts, could prevent 14 800-16 200 of these cases and 3000-3400 of these deaths. If coverage is not restored in 2020, an additional 3400-3800 cases and 700-800 deaths will occur over the lifetime of individuals who are 12 years old in 2020 alone. If the crisis continues, 9300-10 800 preventable deaths due to cervical cancer will occur in the next 50 years (2020-69). The HPV vaccine crisis to date is estimated to result in around 5000 deaths from cervical cancer in Japan. Many of these deaths could still be prevented if vaccination coverage with extended catch-up can be rapidly restored. National Health and Medical Research Council Australia Centre of Research Excellence in Cervical Cancer Control, Japan Society for the Promotion of Science.

The controversy on HPV vaccination in Japan: Criticism of the ethical validity of the arguments for the suspension of the proactive recommendation

The Human Papillomavirus (HPV) vaccine was integrated into Japan’s national immunization program (NIP) in April 2013. However, numerous instances of serious adverse reactions were widely reported in the media, resulting in the Ministry of Health, Labor, and Welfare (MHLW) suspending the official recommendation of the HPV vaccine on June 14, 2013. Investigating the reported incidents, the Vaccine Adverse Reactions Review Committee (VARRC)—an MHLW advisory committee—found no high-quality evidence supporting a causal relationship between the reported events and the HPV vaccination. However, rather than lifting the suspension, they have opted to maintain a “pseudo informed consent” confirming the perceptions of Japanese citizens regarding the vaccine. Accordingly, there appears to be a fundamental difference in the approach to vaccine policymaking between Japan (MHLW/VARRC) and other countries and the World Health Organization, which base policy decisions on the effectiveness and safety of the vaccine. Consequently, the arguments for the suspension of the HPV vaccine recommendation are not ethically appropriate. Relevant bodies must make a clear decision regarding the HPV vaccine and its status in the NIP: the proactive recommendation must either be reinstated or the HPV vaccine legal framework altered to rely entirely on voluntary individual decisions.

Newspaper coverage before and after the HPV vaccination crisis began in Japan: a text mining analysis

BackgroundThe human papillomavirus (HPV) vaccination coverage rate has fallen sharply in Japan since 2013, when newspapers began covering negative campaigns against the vaccination. We examined and compared contents from newspaper articles before and after the start of this HPV vaccination crisis.MethodsWe collected articles published between January 2005 and September 2017 in the four daily national Japanese newspapers with the highest domestic circulation. We then conducted text mining analysis to chronologically examine content distribution.ResultsFrom among the 1178 articles analyzed, 12 types of contents were identified. Contents related to cervical cancer prevention, such as on the risk of developing cervical cancer, causes of cervical cancer, and the effects of vaccination, were frequently conveyed until 2012. However, after March 2013, they were replaced with anti-vaccination contents, such as on adverse effects to vaccines, alleged victims, and related lawsuits. Meanwhile pro-vaccination contents, such as safety statements from the World Health Organization, scarcely received coverage.ConclusionsNewspaper contents changed profoundly before and after the start of the vaccination crisis. Those newspaper reports potentially had impact on readers’ beliefs and actions. Journalists should strive for impartial coverage so readers can make more-informed decisions. Health professionals should be expected to work with journalists to help improve impartiality in newspaper coverage. The Ministry of Health, Labour and Welfare should discus benefits and risks of the HPV vaccination based on the scientific evidences, and consider to resume the proactive recommendation of HPV vaccination. Well-organized advocacy among medical societies, scientists and health professionals will also be needed to influence the government.

PNS173 EVALUATION OF THE INSTITUTE FOR CLINICAL AND ECONOMIC REVIEW (ICER) PUBLIC ENGAGEMENT PROCESS: STAKEHOLDER COMMENT ANALYSIS

This study evaluated stakeholder comments submitted to the Institute for Clinical and Economic Review (ICER) to quantitatively capture the robustness of ICER’s response and the extent to which comments are reflected in future iterations of ICER’s work. Seven ICER final evidence reports published between January 1, 2017-January 1, 2019 were evaluated: Migraine, Osteoporosis, Ovarian Cancer, Chimeric Antigen Receptor T-cell (CAR-T) therapies, Cystic Fibrosis, Opioid Use Disorder, and Arthritis. Stakeholder comments received in response to respective draft evidence reports were organized by type of stakeholder, type of comment (24 comment categories), and inclusion/exclusion of a solution recommended within the comment provided. Quality of ICER’s response to comments was evaluated based on robustness of the response, and if the comment recommendation was incorporated into future work (ie, final evidence report). The study included 67 stakeholders who submitted 1136 comments (56.8% industry, 25.3% patient advocacy groups, 17.2% clinical societies and clinical experts, 0.8% other) in response to the 7 draft evidence reports. Stakeholders most frequently commented on data accuracy/consistency (22.4%), model inputs and assumptions (17.2%), transparency (10.4%), additional data for consideration (9.5%), and adequacy of existing information (8.1%). Stakeholders provided recommended solutions within 67.3% of the comments. ICER addressed a majority of comments received (92.2%), however, only incorporated 63.3% of comments into future work. Out of the comments incorporated into final evidence reports, a majority (79.2%) included recommended solutions by stakeholders. A common reason for excluding comments from future work was that ICER felt the comment was already adequately addressed by content included in the draft evidence report. There remains a gap between comments addressed by ICER and those incorporated into future iterations of ICER’s work. Stakeholders providing proactive recommendations for solutions may increase likelihood of ICER addressing comments and revising methods based on stakeholder input.

Japanese physicians’ attitudes and intentions regarding human papillomavirus vaccine compared with other adolescent vaccines

IntroductionJapan has experienced extremely low human papillomavirus vaccine (HPVV) coverage following the suspension of proactive governmental recommendations in 2013. Several studies have reported that recommendations from physicians increase adolescents’ vaccine acceptance. In this survey, we evaluated the attitudes and intentions of Japanese physicians related to adolescent immunizations, particularly HPVV. MethodsWe conducted a cross-sectional study using a mailed questionnaire targeting 330 Japanese physicians including 78 pediatricians, 225 internists and 27 obstetricians and gynecologists (OB/GYNs) in Kawasaki City, Japan in 2016. The survey measured physicians’ reported frequency of educating adolescents about vaccines as well as their own perceptions and intentions related to adolescent immunizations. ResultsValid responses were obtained from 148 (45%) physicians. Though 53% agreed that the HPVV should be recommended, only 21% reported educating about HPVV. The majority of respondents (90%) agreed that they would restart HPVV for adolescents if the government reinstated its recommendation. ConclusionsAlthough Japanese physicians reported support for adolescent immunizations, they were less likely to recommend or discuss HPVV compared with other adolescent vaccines. Responses indicated this was, at least in part, due to the lack of governmental support for HPVV, indicating that their recommendations would improve with government endorsement of the vaccine.