Improving Human Papillomavirus Vaccine Uptake in the Family Practice Setting

Low uptake of the human papillomavirus (HPV) vaccine is a challenging problem in the primary care setting. Interventions are needed to dispel barriers, improve patient education, and increase provider recommendation. The purpose of this quality improvement project was to evaluate the use of a provider-based intervention to help meet this challenge. A survey was used to assess for changes in HPV knowledge, perceived barriers, and vaccine recommendations. The results showed 12% improvement in HPV knowledge and a decrease in perceived provider/system barriers; there was no significant change in recommendations shown. An upward trend in vaccine initiation and completion was appreciated.     

Impact of HPV Vaccine Availability on Uptake

PurposeTo evaluate the impact of human papillomavirus (HPV) vaccine availability on uptake among 19- to 26-year-old female patients of Planned Parenthood of Mid and South Michigan before and after the vaccine became available at the health centers.ResultsAvailability of the HPV vaccine increased vaccine uptake from 11% before clinic availability to 16% after availability. Accessibility, including cost and provider recommendation, may have influenced uptake.ImplicationsImproving availability of the HPV vaccine, while helpful, is not sufficient for a substantial increase in uptake. Issues of accessibility, including cost and provider recommendation, must also be addressed.     

Evidence-Based Practice Model to Increase Human Papillomavirus Vaccine Uptake: A Stepwise Approach

ObjectiveTo increase uptake of human papillomavirus (HPV) vaccination by implementing a stepwise evidence-based practice model to offer HPV education along with a strong provider recommendation to parents of youth and adolescents.DesignEvidence-based practice change model.SettingA nurse practitioner–run, primary care walk-in clinic in a rural area of the southeastern United States.ParticipantsParents of youth and adolescents ages 11 to 17 years.Interventions/MeasurementsEducation targeting parental hesitancy and strong recommendations for immunization was administered by health care providers to parents of youth and adolescents eligible for vaccination. The Parent Attitudes About Childhood Vaccine instrument was used to identify the presence and degree of parental hesitancy. Vaccination uptake was measured and compared to the same time period from the previous year.ResultsData collected from the clinic vaccination log during the same 6-week time period in 2018 identified that four youth/adolescents were vaccinated with the HPV vaccine in 2018. During the same 6-week period in 2019 when the practice change was implemented, 38 parents were approached; 24 met eligibility criteria, and all 24 of their youth/adolescents received HPV vaccination.ConclusionImplementation of an evidence-based practice model that includes standing vaccine orders and reminders and recalls may provide an effective way to ensure completion of the HPV vaccine series. Every missed clinical opportunity to vaccinate youth and adolescents against HPV can contribute to lower vaccination rates and increased risk for genital warts and cancers associated with HPV infection.     

Hip Hop,Health, and Human Papilloma Virus (HPV): Using Wireless Technology to Increase HPV Vaccination Uptake

National incidence rates of cervical cancer are disproportionately higher in African-American women, and cancers related to human papillomavirus (HPV) infection impose an enormous health burden of over $3.7 billion annually. Current efforts to use Hip Hop culture to address health disparities include disease prevention and health promotion. The use of Hip Hop cultural cues for HPV vaccination uptake and education was developed through an interdisciplinary collaboration. Interventions that incorporate youth values and beliefs are needed to reduce an escalating HPV infection trajectory. Prior research has shown that Hip Hop music has a significant influence on the sexual attitudes and behaviors of African-American emerging young women, providing a context within which to prevent risky behaviors. The current study examines the efficacy of a Hip Hop-based HPV vaccination uptake feasibility project that integrates wireless technology among African-American female college students. Findings suggest that cultural relevance of Hip Hop to the lives of young African-American women increases the acceptability of transmitted health messages. Discussion is centered on implications of wireless technology and Hip Hop as a viable approach to increase HPV vaccination, and a formal randomized control trial is planned.     

Race,Ethnicity, and Income Factors Impacting Human Papillomavirus Vaccination rates

Background

Human papillomavirus (HPV) infection and cervical cancer disproportionately affect low-income and minority women. HPV vaccines have the potential to either reduce or exacerbate racial disparities in HPV-related diseases and cervical cancers, depending on the equitability of vaccine uptake.

Objectives

This review aims to identify barriers and facilitators of equitable uptake of HPV vaccination among low-income and minority girls. This review discusses factors related to race, ethnicity, and income that are associated with initiation and completion rates of the 3-dose HPV vaccine series and presents targets for intervention.

Methods

We reviewed relevant English-language literature to identify current vaccination rates and factors associated with vaccine uptake. Study findings related to race (black, Latino, Asian), and incomes were summarized.

Results

Current trends in the United States indicate low uptake among all adolescents, and that rates stagnated between 2011 and 2012. Low-income and minority adolescents are equally or more likely to start the HPV vaccination series than are white and higher-income adolescents, but are less likely to complete all 3 shots. Provider recommendation is a key factor in HPV vaccination, and minorities are less likely to report receiving recommendations for HPV vaccination.

Conclusions

As black, Hispanic, and Asian populations continue to grow in the United States over the next several decades, it is imperative that we not only improve HPV vaccination rates overall, but also focus on high-risk populations to prevent an increase in cervical cancer disparities.     

On surmounting the barriers to HPV vaccination: we can do better

The major impediment to increased human papillomavirus (HPV) vaccination coverage in young males and females is lack of health care provider recommendation. Despite its efficacy in preventing cervical cancer, HPV vaccination in females (49.5%) and males (37.5%) ages 13 through 17 falls well below the Centers for Disease Control and Prevention’s (CDC) Healthy People 2020 target of 80% coverage. Parents’ willingness to vaccinate their child has been shown to be much higher when physicians share personal vaccination decisions for their own children as well as what other parents have done at that particular clinic. Furthermore, the vaccine must be presented presumptively as a “bundle” along with the rest of the standard adolescent vaccine panel. Multiple exemplars presented including in several European countries, low-income countries and Rwanda, demonstrate that school-based health care systems dramatically increase vaccination coverage. Finally, acceptability for vaccination of males must improve by increasing provider recommendation and by presenting the HPV vaccine as a penile, anal and oropharyngeal cancer prevention therapy in males and not merely a vaccine to prevent cervical cancers in females. Paediatricians, obstetrician/gynaecologists and primary care physicians should consider these data as a call-to-action.

• Key messages

• ??Despite recent efforts in the US, only 49.5% of females and only 37.5% of males ages 13 through 17 have received all recommended HPV vaccine doses. These numbers fall well below the 80% target set forth by the Healthy People 2020 initiative.

• ??According to the CDC, if health care providers increase HPV vaccination rates in eligible recipients to 80%, it is estimated that an additional 53,000 cases of cervical cancer could be prevented during the lifetime of those younger than 12 years. Furthermore, for every year that the vaccination rate does not increase, an additional 4400 women will develop cervical cancer.

• ??First and foremost, healthcare providers (HCPs) must make a strong recommendation to vaccinate patients and these recommendations must become routine, including for males.

• ??It is clear that HPV vaccination rates improve significantly when vaccine administration occurs at designated, well-organized sites such as school-based vaccination programmes. Furthermore, HPV vaccination should be a high school requirement and offered in the standard adolescent vaccine panel as a bundle with Tdap and MenACWY vaccines in order to promote maximum adherence.

• ??Finally, research on immunogenicity and antibody titre longevity needs to be done in newborns. The HPV vaccine may be recommended in the newborn panel of vaccines to avoid any issues of sexualization and misplaced fears of sexual disinhibition, akin to the success of the Hepatitis B vaccine in the 1980s.

• ??The HPV vaccine is a vaccine against cancer and should be aggressively marketed as such. As healthcare providers, we need to make every effort to overcome barriers, real or perceived, to protecting our population from potential morbidity and mortality associated with this virus.

     

Increasing Knowledge of Human Papillomavirus Among Young Adults

HPV is the most common sexually transmitted infection, affecting more than 43 million Americans. HPV is a public health concern because it is the leading cause of cervical, oropharyngeal, vulvar, vaginal, and anal cancer. Despite a highly effective vaccine, the rate of HPV vaccine completion among young adults falls below the Healthy People goal. In efforts to combat this public health concern, an educational brochure was distributed as a quality improvement project in an urban primary care office. After this educational intervention was implemented, there was a significant increase in young adults who received the HPV vaccine from their primary care provider.     

Increasing Cervical Cancer and Human Papillomavirus Prevention Knowledge and HPV Vaccine Uptake through Mother/Daughter Education

This evidence-based initiative assessed the impact of language-appropriate cervical cancer and human papillomavirus (HPV) prevention education on knowledge level and HPV vaccine uptake among mothers and their daughters. Forty-one mother/daughter dyads from a low-cost, faith-based clinic for the uninsured in southeastern Texas participated in the nurse practitioner-led cervical cancer prevention educational sessions. Spanish was the primary language for the majority of participating mothers. The project produced appreciable knowledge increase and HPV vaccine uptake intent. Aggregate HPV vaccine uptake numbers for the clinic increased considerably compared to HPV vaccine administration prior to educational intervention.     

889例基于PCR反向点杂交技术的HPV检测回顾性分析

目的分析该院妇产科及泌尿外科就诊的患者HPV感染者比例,HPV高危及低危各亚型的分布及各年龄组高危型HPV优势亚型的分布特点,了解该地区HPV感染情况,为该地区宫颈癌的预防和针对该地区的疫苗研制提供参考依据。方法采用PCR反向点杂交技术检测2014-2015年来该院就诊的889例女性患者宫颈脱落细胞,共检测26种HPV亚型,其中高危型17种,低危型9种。结果 889例细胞样本中,检出HPV阳性者168例,阳性率为18.9%,以单一感染为主,高危亚型检测出142例,占总阳性例数的84.5%。共检出了24种HPV亚型,仅高危亚型HPV45及低危亚型HPV57未检出。检出率排名前三的HPV高危亚型分别为HPV52、HPV16、HPV58,中青年妇女以HPV16和HPV52为优势感染亚型,60岁的妇女主要感染HPV58。结论可据此针对不同年龄研发和采用不同亚型疫苗,防治宫颈癌,提高本地区女性健康水平。     

Establishing physician advocates for human papillomavirus vaccination in British Columbia

Objective

To survey general practitioners in oncology (GPOs) in British Columbia (BC) to identify opportunities for them to serve as public supporters of human papillomavirus (HPV) vaccination.

Design

A mailed or online survey.

Setting

British Columbia.

Participants

Forty-two GPOs who worked in the community in BC.

Main outcome measures

Current practices, knowledge, and resource needs concerning HPV, the vaccine, and the HPV immunization program, and the willingness of respondents to be contacted to participate in stated public HPV vaccine supporter activities.

Results

The survey found that 42% of surveyed GPOs were willing to act as public supporters of the HPV vaccine. The survey also identified education needs among GPOs concerning HPV, the vaccine, and the HPV immunization program in BC.

Conclusion

This study found that GPOs in BC are willing to publicly support the HPV immunization program. This study shows that involving physicians in the promotion of public health programs is a viable option that should be further explored and evaluated.     

Update on immunizations in children and adolescents

Over the past few years, there have been many changes to the recommendations for children and adolescents by the Advisory Committee on Immunization Practices. These include dividing the immunization schedule into two parts (i.e., ages birth to six years and seven to 18 years, with catch-up schedules for each group); expanding the recommendations for influenza vaccine to children ages six months to 18 years without risk factors; expanding coverage for hepatitis A vaccine to include all children at one year of age; initiating routine immunization with oral rotavirus vaccine given at ages two, four, and six months; and adding a booster dose of varicella vaccine at four to six years of age. The tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap), quadrivalent meningococcal conjugate vaccine (MCV4), and quadrivalent human papillomavirus (HPV) vaccine are routinely recommended for adolescents 11 to 12 years of age. Tdap provides pertussis immunity in addition to the tetanus and diphtheria immunity provided by the tetanus and diphtheria toxoids vaccine (Td). MCV4 has improved immunogenicity compared with the older meningococcal vaccine. HPV vaccine protects against serotypes 6, 11, 16, and 18, and is given in three doses, ideally at 11 to 12 years of age; the effectiveness increases when the vaccine is given before the onset of sexual activity. Family physicians play an integral role in implementing new immunization recommendations and properly educating patients and families in the increasingly complex armamentarium of prevention.     

Clinical update of the AS04-Adjuvanted human Papillomavirus-16/18 cervical cancer vaccine,cervarix®

Persistent infection with human papillomavirus (HPV) is a necessary cause of cervical cancer, resulting annually in 274,000 deaths worldwide. Two prophylactic HPV vaccines are licensed in >100 countries, and immunization programs in young, adolescent girls have been widely implemented. HPV-16/18 AS04-adjuvanted vaccine (Cervarix®; GlaxoSmithKline Biologicals, Rixensart, Belgium) has demonstrated type-specific protection against the five most frequent cancer-causing types (16, 18, 31, 33, and 45) that are responsible for 82% of invasive cervical cancers globally. Cervarix® has demonstrated efficacy against HPV-45, which is the third most common HPV type in cervical cancer and adenocarcinoma. Final results of a large phase 3 trial recently showed Cervarix® substantially reduced the overall burden of cervical precancerous lesions (cervical intraepithelial neoplasia 2+) by 70.2% in an HPV-naïve population approximating young girls prior to sexual debut, the target of most current vaccination programs. Protection offered by Cervarix® against nonvaccine types (mainly 31, 33, and 45) might potentially allow for 11%–16% additional protection against cervical cancers, compared to a vaccine only offering protection against HPV-16/18. Another recent study directly compared the antibody response of Cervarix® to that of quadrivalent HPV-6/11/16/18 vaccine (Gardasil®; Merck, Whitehouse Station, NJ, USA). Cervarix® induced significantly superior neutralizing antibody levels as compared with Gardasil® for HPV-16 and HPV-18 in all age groups studied. This may translate into more women having detectable (neutralizing) antibodies in cervicovaginal secretions for HPV-16 and HPV-18 after vaccination with Cervarix® when compared with Gardasil®. Cervarix® induced significantly higher frequencies of antigen-specific memory B-cells and T-cells in responders for HPV-16 and HPV-18 as compared with Gardasil®. Cervarix® continues to show sustained high levels of total and neutralizing antibodies for HPV-16 and HPV-18, 7.3 years after vaccination. This is associated with high efficacy and no breakthrough cases in the HPV-naïve population, and is the longest duration follow-up for safety, immunogenicity, and efficacy for any licensed HPV vaccine to date.     

Intimate Partner Violence and Patient Screening across Medical Specialties

Objectives: The aims of this study were to compare rates of intimate partner violence (IPV) across different medical specialties and health care sites in one metropolitan area, describe demographic characteristics of women with abusive partners, characterize health care provider assessment of IPV, and describe patient characteristics associated with health care assessment for partner violence. Methods: Women (N= 2,465) completed written surveys about partner violence and health care screening for violence in the waiting rooms of five types of health care settings (obstetrician/gynecologist office, emergency department, primary care office, pediatrics, and addiction recovery) across eight different hospitals in the greater Boston area. Results: The overall survey response rate was 62%. The 12‐month prevalence rate of IPV was 14%, with 37% disclosing lifetime prevalence. The highest rates of recent IPV were disclosed in the hospital‐based addiction recovery unit (36%) and in emergency departments (17%). Adjusted demographic risk characteristics for IPV included age (younger than 24 years), low income, and unemployment. Health care providers were more likely to discuss IPV with low‐income women than with middle‐ or high‐income women but were no more likely to assess violence within the youngest age group. Among women who disclosed abuse to their health care provider, 50% reported receiving direct interventions or services as a result. Conclusions: Using the same instrument and protocol, different rates of IPV and detection of IPV were found across medical departments, with the highest rates in emergency departments and an addiction recovery program. It is especially important for assessment of IPV to include young women who present to medical departments.     

人乳头瘤病毒疫苗临床应用中国专家共识

人乳头瘤病毒(human papilloma virus,HPV)疫苗接种是预防HPV感染及相关疾病的有效方法,是防控HPV感染相关疾病的一级预防措施。低龄人群接种效果优于高龄人群,性暴露前接种免疫效果最佳。HPV疫苗不仅适用于普通人群,同样推荐用于高危、特殊人群。对于具有遗传易感、高危生活方式和HIV感染的适龄女性优先推荐接种HPV疫苗。适龄女性无论是否存在HPV感染、细胞学是否异常均可接种HPV疫苗。近期有妊娠计划、妊娠期或哺乳期女性不宜接种HPV疫苗。接种HPV疫苗后仍应进行子宫颈癌筛查。     

蒙古族门诊体检女性220例HPV检测结果分析

目的研究内蒙古地区的蒙古族女性人乳头瘤病毒(HPV)检测的优势亚型,为宫颈癌疫苗的研发和本地区投放应用提供依据。方法通过凯普导流杂交HPV-DNA检测法(HybriMax),对220例门诊体检的蒙古族女性进行HPV21种亚型的检测并分析。结果检测的220例标本中,HPV阳性标本为37例,阳性率为16.8%。HPV感染率由高到低的前6位HPV亚型依次为HPV16(35.4%),58(18.9%),33(8.1%)、52(5.4%)、56(5.4%)、6(5.4%)。高危型HPV在人群中所占的比率合计占91.9%,而低危亚型仅占8.1%,二组相比,差异具有统计学意义(P<0.05)。结论本次研究的蒙古族女性中HPV感染的亚型分布以16、58、33、6型为主,尤其以16亚型所占比率最高。在年龄分组中,30～40岁组中的HPV感染率明显高于其他组。有必要对该地区的重点人群进行HPV疫苗的科普宣传,提高认知程度。     

Issues and challenges in implementing cervical cancer screenings in the emergence of HPV vaccination in Thailand

The discovery of the HPV vaccine has been a major breakthrough in preventing cervical cancer and other HPV-related diseases around the globe. Cervical cancer is a significant public health problem in Thailand. Despite the long-time availability of cervical cancer screening programs in Thailand, the uptake among the target female population remains low. HPV vaccines were approved by the Food and Drug Administration of Thailand in 2007. As of March 2011, due to financial limitations, HPV vaccines have still not been included in the national immunization program under the public health benefit plans although individuals has the option to pay privately for the vaccine. This paper discusses the issues and challenges in implementing cervical cancer screening programs in the era of HPV vaccination in Thailand. Recommendations to increase the uptake of cervical cancer screening and further research to inform a policy regarding the cervical cancer screening measures are proposed.     

Current status of measles in Japan: molecular and seroepidemiological studies

On account of the measles vaccination campaign, with vaccinations carried out on the first birthdays of children, the number of reported cases of measles was reduced to 545 in 2005, which is the lowest so far in Japan. We conducted a molecular epidemiological study of measles virus to determine the circulating measles virus genotypes in Japan since 1984. Different genotypes, C1, D3, D5, and H1, were the major strains isolated in outbreaks in 1984, 1987–1988, 1991–1993, and 2000, respectively. When measles was in the control phase, a sporadic outbreak was reported, but the causative virus was found to be of imported measles virus lineage. We also conducted a seroepidemiological study to investigate the persistence of vaccine-acquired immunity in Himeji City, Japan. Before 1990, vaccine coverage was 84.5% and it increased gradually, to 88.5% in 1991–1995, 92.7% in 1996–2000, and 94.6% after 2000. Measles outbreaks were observed annually before 1978 and in 1980, 1981, 1984, 1990, and 1996; there were no measles cases after 1997 in Himeji City. In 1994–1998, a serological study of 795 sera showed that measles neutralization test (NT) antibodies were sufficiently preserved, even 12 years after the first-dose immunization. In 1999–2003, 26 (3.7%) of 695 sera were negative for NT. The positive rate for measles NT decreased to approximately 90% as the elapsed time after the first-dose immunization increased to 6 or 7 years. The immunity obtained after receiving measles vaccine decays by 6–7 years after the first dose when the measles was controlled. A two-dose schedule of measles vaccine was implemented in Japan in 2006; we should continue molecular and serological surveillance.     

贵州省部分地区妇女宫颈人乳头瘤病毒感染现状调查及分析

目的 了解贵州省部分地区妇女宫颈人乳头瘤病毒(HPV)感染的分布情况及高危因素,为该地区宫颈癌防治及疫苗的投入使用提供一定的依据.方法 采用导流杂交技术对2339例有性生活妇女宫颈脱落细胞进行21种HPV基因型检测及宫颈液基细胞学检测,对其中部分HPV阳性携带者和(或)宫颈液基细胞检查阳性结果 者在阴道镜下取组织活检进行病理检查.分析HPV感染高危因素及各型宫颈病变中HPV亚型感染分布特点.结果 在被调查的2339例妇女中HPV感染总阳性率为30.31%(709/2339),共有20种HPV亚型被检测出来.HPV感染阳性排在前5位的亚型从高到低依次为HPV16、52、18、58、和11,感染率从高到低分别为9.87%(231/2339)、5.64%(132/2339)、4.95%(116/2339)、4.19%(98/2339)和2.99%(70/2339).HPV感染的高峰年龄为31～35岁,初次性生活越早,HPV感染率越高(经趋势X2检验,X2=15.933,P<0.05).病理学检查确诊了366例宫颈上皮内瘤变(CIN)患者及181例宫颈浸润癌患者,CIN患者HPV感染率依次为CIN Ⅰ 34.26%(74/216)、CIN Ⅱ77.78%(56/72)、CIN Ⅲ82.05%(64/78).181例宫颈浸润癌患者中,宫颈鳞癌的HPV感染率为84.52%(131/155),宫颈腺癌的HPV感染率为38.46%(10/26).HPV阳性宫颈鳞癌中16型占61.83%(81/131)、腺癌18型占60%(6/10),HPV16与宫颈鳞癌关系密切(X2=11.948,P<0.001,OR鳞癌/腺癌=5.946),HPV18亚型在宫颈鳞癌和腺癌中分布比较差异无统计学意义(P>0.05).结论 贵州省HPV亚型感染分布以16、52、18、58型为主.宫颈病变程度与HPV感染密切相关,HPV感染高发于中青年妇女,初次性生活年龄较早是HPV感染的高危因素,长期持续高危型HPV感染可能导致宫颈癌.高度鳞状上皮内病变及宫颈癌主要由高危型HPV感染所致.HPV16亚型与宫颈鳞癌关系密切,HPV18亚型在宫颈鳞癌与腺癌中的分布无明显差异.本地区可考虑应用HPV16/18二价疫苗降低宫颈癌的发病率.