Health care professionals and adolescent vaccination. A call for intervention research

In their recently published research study, Gargano et al. found that a physician's recommendation and parental health beliefs had significant effects on adolescent vaccination rates and on parental intentions to vaccinate. This research replicates the findings of a number of human papillomavirus (HPV) vaccine-focused research studies, but explores new territory by focusing on all recommended adolescent vaccines: meningococcal-conjugate (MCV4), HPV, influenza, and tetanus, diphtheria, and acellular pertussis (Tdap) vaccines. Although Gargano et al.'s study is relatively small in scale and focuses on only one county in Georgia, their results are consistent with many other research reports, suggesting that their findings are robust and replicable. Most published intervention studies have targeted parents and young adults, with little focus on health care professionals. However, given the centrality of physician recommendation in adolescent vaccination, as shown by Gargano et al., it is clear that the time has come to develop and evaluate interventions that help physicians and other health care professionals to more effectively implement strong and routine recommendations for all adolescent platform vaccines

There's Much Yet to be Done: Diverse Perspectives on HPV Vaccination

It has been over 10 y since the first HPV vaccines were licensed and introduced in a number of countries around the world. As only the second vaccine (after hepatitis B) that prevents an infection that can lead to the development of cancer, HPV vaccine occupies an important position in our armamentarium of vaccines yet remains underutilized. The number of national HPV vaccination programs has increased steadily; as of June 2017, 91 countries had introduced national HPV vaccination programs,1 with that number now over 100. Over the past 10+ y, several modifications have been made to the vaccination regimen (e.g., moving from three to two doses if the first dose is administered before age 15 y), in the type of vaccine available (e.g., introduction of the 9-valent vaccine), and in the target of vaccination (e.g., many countries have shifted from female-only to gender-neutral vaccination). There is great variability across the globe in terms of HPV vaccination policies and accompanying barriers to the implementation and/or sustainability of programs. It is well known, for instance, that Japan’s initial success with vaccination was undermined by several factors, leading to a precipitous drop in vaccination rates, with little subsequent recovery.2 Other countries, such as the U.S.,3 have struggled to achieve vaccination goals, and still others have faced setbacks but with good recovery (e.g., Denmark and Ireland).4,5 At the same time, many countries, including China,6 still have not implemented national vaccination programs, with the cost of vaccines presenting a significant obstacle, particularly for those countries that are not eligible for reduced pricing through Global Alliance for Vaccines and Immunisation (GAVI) or other mechanisms. Other countries, such as Malaysia, Rwanda, Australia, and the U.K., have achieved sustained high levels of vaccination.7–10 Unwarranted fears about HPV vaccine and the proliferation of misinformation, particularly via social media, have proven to be significant and widespread obstacles to achieving and maintaining high vaccination rate

Interventions to Improve Adolescent Vaccination What May Work and What Still Needs to Be Tested

This article is being published concurrently in the American Journal of Preventive Medicine and Vaccine. The articles are identical except for stylistic changes in keeping with each journalʼs style. Either of these versions may be used in citing this article. See: Dempsey, A. F., & Zimet, G. D. (2015). Interventions to Improve Adolescent Vaccination: What May Work and What Still Needs to Be Tested. Vaccine, 33, Supplement 4, D106–D113. http://doi.org/10.1016/j.vaccine.2015.09.032Since the development of the “adolescent platform” of vaccination in 1997, hundreds of studies have been conducted, identifying barriers to and facilitators of adolescent vaccination. More recent research has focused on developing and evaluating interventions to increase uptake of adolescent vaccines. This review describes a selection of recent intervention studies for increasing adolescent vaccination, divided into three categories: those with promising results that may warrant more widespread implementation, those with mixed results requiring more research, and those with proven effectiveness in other domains that have not yet been tested with regard to adolescent vaccination

The IUPUI Center for HPV Research: Updates 2014-2015

poster abstractBackground: Human papillomavirus (HPV) is a very common infection. High risk (HR) HPV types (particularly types 16 & 18) are causally implicated in many cancers, including cervical, anal, vaginal, vulvar, penile, and head and neck cancers. In an effort to address the problems associated with HPV infection and prevention, the Center for HPV Research at IUPUI (Zimet & Fortenberry, Co-Directors) fosters collaboration among investigators from multiple disciplines and departments at IUPUI, IU Bloomington, Purdue University, and University of Notre Dame. There currently are 32 faculty and 8 pre- and post-doctoral fellows who are members of the Center. The Center for HPV Research was established in July, 2012 with funds from the IUPUI Signature Center Initiative, the Department of Pediatrics, and the IU Simon Cancer Center. Over the past year, Center members had 6 external & internal grants funded, 5 additional grants submitted, 8 peer-reviewed articles published, and gave over 20 scientific conference and invited presentations. In this abstract we highlight a study representing a collaboration among 5 center members, with Dr. Marcia Shew as the lead and including an MPH student. Objectives: Most HR HPV infections do not progress to cancer, but progression is associated with persistent infection. HPV was previously thought to "clear" or persist, but newer studies suggest that HPV may be a latent virus that can be re-detected episodically. This study examined the persistence and/or redetection of HR HPV in young women recruited 6 years after identification of a HR HPV infection during their prior involvement in a longitudinal study of adolescent women. Methods: 30 women from the prior study (the Young Women’s Project) were recruited for 2 visits, 6 weeks apart. During Visit 1 they had a Pap test, HPV DNA testing, HPV serology, and were administered a semi-structured interview. During Visit 2, Pap test results were given, a self-swab for HPV testing was obtained, and a qualitative interview was administered. Results: 15 women had normal Pap test results, 2 were ASCUS, and 3 LGSIL. 12 women had a history of colposcopy for a previous abnormal Pap results and 4 had received treatment for cervical dysplasia. 26 of the women had HPV 16 in the original YWP study. 11 had HPV 16 redetected in the present study, including in 6 women who had apparently "cleared" the infection during the original YWP study. Conclusions: High risk HPV may not always (or ever) "clear" Persistent low viral levels may not be detectible. However, some HPV infections may be episodically detected if changes in immune function lead to increases in viral copies. Questions raised by this research include: 1) who is at risk for episodic detection?; 2) what factors are predictive of episodic detection?; 3) how likely is episodically-detect HR HPV to progress to cervical disease?; 4) what is the predictive value of a negative HPV DNA test?; and 5) what do we tell women with a positive HR HPV DNA screen if they have been sexually abstinent or with a life-long partner ... or if they have a new partner

Reasons for low pandemic H1N1 2009 vaccine acceptance within a college sample

This study examined health beliefs associated with novel influenza A (H1N1) immunization among US college undergraduates during the 2009-2010 pandemic. Undergraduates (ages 18–24 years) from a large Midwestern University were invited to complete an online survey during March, 2010, five months after H1N1 vaccines became available. Survey items measured H1N1 vaccine history and H1N1-related attitudes based on the health belief literature. Logistic regression was used to identify attitudes associated with having received an H1N1 vaccine, and thematic analysis of student comments was conducted to further understand influences on vaccine decisions. Among the 296 students who participated in the survey, 15.2% reported having received an H1N1 vaccine. In regression analysis,H1N1 immunization was associated with seasonal flu vaccine history, perceived vaccine effectiveness, perceived obstacles to vaccination, and vaccine safety concerns. Qualitative results illustrate the relationship of beliefs to vaccine decisions, particularly in demonstrating that students often held concerns that vaccine could cause H1N1 or side effects. Vaccine safety, efficacy, and obstacles to immunization were major considerations in deciding whether to accept the H1N1 pandemic vaccine. Therefore, focusing on those aspects might be especially useful in future vaccine efforts within the college population

Understanding Consumer Responses to Product Risk Information

Two experiments examine how message framing moderates consumer responses to product risk information. The findings suggest that contrary to an influential theory, consumers exposed to loss-framed messages exhibit a general aversion to product risk involving both short-term adverse effects and more permanent harm. In contrast, consumers exposed to gain-framed messages differentiate among different types of product risk. They essentially ignore temporary product risks but give considerable decisional weight to risks of permanent harm. This article discusses the implications of these findings for those who design and regulate promotional messages that contain product risk disclosures

Global Delivery of Human Papillomavirus Vaccines

Worldwide, cervical cancer is the fourth most common cancer among women, with over half a million women diagnosed with cervical cancer in 2012. Human papillomavirus (HPV) vaccination, if broadly implemented, has the potential to significantly reduce global rates of morbidity and mortality associated with cervical and other HPV-related cancers. Over 100 countries around the world have licensed HPV vaccines. As of February, 2015, there were an estimated 80 national HPV immunization programs and 37 pilot programs, including many implemented in low- and middle-income countries. In this article, global implementation of HPV vaccination programs is discussed, including successes and ongoing challenges. Issues such as vaccine financing and different approaches to HPV vaccine delivery are presented

State statutes and regulations related to human papillomavirus vaccination

A cross-sectional analysis of human papillomavirus (HPV) vaccine statutes and regulations from states and the District of Columbia in the United States (U.S.) was conducted from September-November 2018 to advance analyses of policy impact on HPV vaccination uptake. A search was conducted using WestlawNext, a legal research database. Statutes and regulations relevant to the study were analyzed and coded based on their legal attributes into ten broad coding questions and several sub-questions. Of the 212 laws identified by the initial search string, 93 (43.9%) reference HPV vaccination in statute or regulation. An additional three laws were added following subsequent review. There was a total of 52 statutes and 44 regulations from 34 states and the District of Columbia. Most laws were related to developing and distributing HPV vaccination materials for parents, and mechanisms to fund and reimburse for the vaccination. This study can be used by policymakers in jurisdictions that are considering establishing HPV vaccination promotion interventions in state law and highlighting the limited statutory and regulatory efforts that have been implemented to promote HPV vaccination. Importantly, this study can also be used to conduct evaluations of the efficacy of statutory and regulatory strategies in increasing HPV vaccination rates

A model of health care provider decision making about HPV vaccination in adolescent males

Introduction In the U.S., HPV vaccination of adolescent males remains low, despite the recommendation for routine vaccination. Although research has highlighted that health care provider (HCP) recommendation is very influential in HPV vaccine uptake, research on this topic in the male population is lacking. Accordingly, we used a qualitative approach to identify HCP knowledge, attitudes, and behaviors regarding adolescent male HPV vaccination, one year, after routine vaccination of adolescent males was recommended. Method A total of 20 U.S. pediatric HCPs participated in 20–30 min interviews about knowledge, attitudes, and practices regarding male HPV vaccination. Interviews were audio-recorded, transcribed and, analyzed using inductive content analysis. Results The providers had been in practice for 1–35 years, 75% were female, and 75% were White. Opinions on HPV vaccination were shaped by knowledge/perception of the risks and benefits of vaccination. Although all providers frequently offered HPV vaccine to male patients, the strength and content of the offer varied greatly. Vaccination opinions determined what issues were emphasized in the vaccine offer (e.g., stressing herd immunity, discussing prevention of genital warts), while adolescent age influenced if and how they pitched their vaccine offer (e.g., HPV as a STI). Most providers agreed with the ACIP recommendations, however, several expressed that providers’ preexisting opinions might remain unchanged despite the recommendations. Consistent with the literature on determinants of HPV vaccination, providers believed that their own recommendation was a major factor in a family's decision to vaccinate. Barriers to vaccination included the “newness” and sexual nature of the vaccine, lack of insurance coverage, and the vaccine not being mandated. Conclusions Providers’ opinions about, and approaches to offering, HPV vaccination to males were highly variable. Interventions designed to improve male HPV vaccination should focus on helping providers to routinely recommend the vaccine to all of their eligible patients, both males and females

Associations of trust and healthcare provider advice with HPV vaccine acceptance among African American parents

OBJECTIVE: Healthcare providers (HCPs) are advised to give all parents a strong recommendation for HPV vaccination. However, it is possible that strong recommendations could be less effective at promoting vaccination among African Americans who on average have greater mistrust in the healthcare system. This study examines the associations of parental trust in HCPs and strength of HCP vaccination recommendation on HPV vaccine acceptance among African American parents. METHODS: Participants were recruited from an urban, academic medical center between July 2012 and July 2014. We surveyed 400 African American parents of children ages 10-12years who were offered HPV vaccine by their HCPs to assess sociodemographic factors, vaccine beliefs, trust in HCPs, and the HPV vaccine recommendation received. Medical records were reviewed to determine vaccination receipt. RESULTS: In multivariable analysis, children whose parents were "very strongly" recommended the HPV vaccine had over four times higher odds of vaccine receipt compared with those whose parents were "not very strongly" recommended the vaccine. Having a parent with "a lot of" versus "none" or only "some" trust in HCPs was associated with over twice the odds of receiving HPV vaccine. Very strong HCP recommendations were associated with higher odds of vaccination among all subgroups, including those with more negative baseline attitudes toward HPV vaccine and those with lower levels of trust. Adding the variables strength of HCP recommendation and parental trust in HCPs to a multivariable model already adjusted for sociodemographic factors and parental vaccine beliefs improved the pseudo R2 from 0.52 to 0.55. CONCLUSIONS: Among participants, receiving a strong vaccine recommendation and having a higher level of trust in HCPs were associated with higher odds of HPV vaccination, but did not add much to the predictive value of a model that already adjusted for baseline personal beliefs and sociodemographic factors