HPV vaccination and risk of chronic fatigue syndrome/myalgic encephalomyelitis: A nationwide register-based study from Norway

BackgroundVaccination has been suggested to be involved in the aetiology of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). HPV vaccine was introduced in the Norwegian Childhood Immunisation Programme and offered 12 year old girls from 2009. We studied the association between HPV vaccination and risk of CFS/ME and also assessed medical history in relation to both risk of CFS/ME and HPV vaccine uptake.MethodsIndividual data from national registries, including the Norwegian Population Registry, the Norwegian Patient Registry and the Norwegian Immunisation Registry were linked using the unique personal identification number. Yearly incidence rates of CFS/ME for 2009–2014 were calculated among the 824,133 boys and girls, aged 10–17 living in Norway during these 6 years. A total of 176,453 girls born 1997–2002 were eligible for HPV vaccination and included in further analyses. Hazard ratios (HRs) of CFS/ME were estimated using Cox regression. Risk differences (RDs) of vaccine uptake were estimated with binomial regression.ResultsA similar yearly increase in incidence rate of CFS/ME was observed among girls and boys, IRR = 1.15 (95% confidence interval (CI) 1.10–1.19) and 1.15 (95% CI 1.09–1.22), respectively. HPV vaccination was not associated with CFS/ME, HR = 0.86 (95% CI 0.69–1.08) for the entire follow-up period and 0.96 (95% CI 0.64–1.43) for the first two years after vaccination. The risk of CFS/ME increased with increasing number of previous hospital contacts, HR = 5.23 (95% CI 3.66–7.49) for 7 or more contacts as compared to no contacts. Girls with 7 or more hospital contacts were less likely to be vaccinated than girls with no previous hospital contacts, RD = −5.5% (95% CI −6.7% to −4.2%).ConclusionsNo indication of increased risk of CFS/ME following HPV vaccination was observed among girls in the first 6 birth cohorts offered HPV vaccine through the national immunisation programme in Norway.     

Decision-making about HPV vaccination in parents of boys and girls: A population-based survey in England and Wales

BackgroundSchool-based HPV vaccination in the UK will soon be extended to boys. Based on other countries’ experience, uptake may initially be lower in boys than girls. We assessed HPV vaccine attitudes and decision-making in parents of boys and girls, to explore sex differences and inform public health messages.MethodsWe carried out a cross-sectional population-based survey using home-based interviews in spring 2019. Participants were adults in England and Wales, with a child in school years 5–7 (aged 9–12 and eligible for HPV vaccination within 3 years). Measures included awareness of HPV and the vaccine, demographic factors, previous vaccine refusal and (after exposure to brief information) whether participants would allow their child to have the HPV vaccine (decided to vaccinate; decided not to vaccinate; undecided). We also assessed vaccine attitudes. Data were weighted to adjust for non-response. Multinomial logistic regression was used to explore predictors of deciding to (or not to) vaccinate compared with being undecided.ResultsAmong 1049 parents (weighted n = 1156), 55% were aware of HPV and the girls’ vaccination programme, but only 23% had heard of plans to vaccinate boys. After information exposure, 62% said they would vaccinate their child, 10% would not, and 28% were undecided. Parents of girls were more willing to vaccinate than parents of boys (adjusted odds ratio: 1.80 (1.32–2.45)). Positive attitudes and HPV/vaccine awareness were significantly independently associated with deciding to vaccinate. Previous vaccine refusal for a child was the strongest predictor of not wanting the HPV vaccine.ConclusionsOur findings suggest a need for public health campaigns to raise awareness of plans to extend HPV vaccination to boys. Reassuringly only 10% of all parents were unwilling to vaccinate and our data suggest further information, including about safety and efficacy, may be important in supporting undecided parents to make the decision to vaccinate.     

Attitudes toward HPV vaccination among parents of adolescent girls in Mysore,India

This study investigates attitudes toward human papillomavirus (HPV) vaccination among parents of adolescent girls in Mysore, India. Seven focus group discussions were held among parents of adolescent girls stratified by sex, religion and region to explore attitudes about cervical cancer and HPV vaccination. The study found that while parents have limited knowledge about HPV or cervical cancer, most are still highly accepting an HPV vaccine. In addition, high acceptability levels appear to reflect positive attitudes toward the government universal immunization program in general, rather than to the HPV vaccine in particular. The results highlight the need for additional education and health promotion regarding HPV and cervical cancer prevention in India.     

The school nurse, the school and HPV vaccination: a qualitative study of factors affecting HPV vaccine uptake

School nurses in the United Kingdom are largely responsible for delivering the human papillomavirus (HPV) vaccine to 12-13 year old girls. In order to assess the impact of HPV vaccination on school nurses’ roles, we gave a questionnaire to all 33 school nurses who offered Cervarix ™ in two Primary Care Trusts one year ahead of the national vaccine programme. Key organisational issues raised by the school nurses were the size of the team and its skill mix. A few found their schools uncooperative and were dissatisfied with mechanisms for problem resolution. On average, nurses spent an additional 69 h (0.80 h per child) on vaccine-related activities. In semi-qualitative interviews (n = 17), school nurses complained of work overload and described the difficulties of establishing good relationships with some of their schools. Nurses expected schools to take some responsibility for ensuring good uptake and were frustrated when help was not forthcoming. We conclude that variation in uptake between schools in part reflects a difficult relationship with the school nurse which may be attributed to characteristics of the school, schools’ attitudes towards health interventions, organisational problems, multiple school nurse roles and/or personal ability. Some of these issues will need to be addressed to ensure continued high vaccine coverage as HPV vaccination becomes a less prioritised, routine activity.     

Factors associated with HPV vaccine uptake in teenage girls: a systematic review

Background

Since 2006 Human papillomavirus (HPV) vaccination has become available to adolescent girls and women in an increasing number of countries, to protect against the virus causing cervical cancer. The vaccine series is offered in three doses over 6 months, and this study aimed to identify factors associated with initiation and/or completion of the 3 dose series in (pre-) adolescent girls. Previous studies have considered intention to vaccinate rather than actual vaccination uptake.

Methods

A systematic search of Medline, Medline in process, Embase and CINAHL, from 2006 to March 2011 for articles related to HPV-vaccine uptake among adolescent girls and factors potentially associated with uptake yielded 25 studies.

Results

The majority of studies were surveys or retrospective reviews of data, only 5 studies reported data on program completion. Most were conducted in the United States (20/25). Higher vaccine uptake was associated with having health insurance, of older age, receipt of childhood vaccines, a higher vaccine related knowledge, more healthcare utilization, having a healthcare provider as a source of information and positive vaccine attitudes. In US settings, African American girls were less likely to have either initiated or completed the three dose vaccination series.

Conclusions

HPV vaccination programs should focus on narrowing disparities in vaccine receipt in ethnic and racial groups and on providing correct information by a reliable source, e.g. healthcare providers. School-based vaccination programs have a high vaccine uptake. More studies are required to determine actual vaccine course completion and factors related to high uptake and completion, and information from a broader range of developed and developing settings is needed.     

Adolescent attitudes toward influenza vaccination and vaccine uptake in a school-based influenza vaccination intervention: a mediation analysis

BACKGROUND: School‐based vaccination programs may provide an effective strategy to immunize adolescents against influenza. This study examined whether adolescent attitudes toward influenza vaccination mediated the relationship between receipt of a school‐based influenza vaccination intervention and vaccine uptake. METHODS: Participants were recruited from 2 counties participating in a school‐based influenza vaccination intervention trial in rural Georgia (N = 337). Data were collected from surveys distributed to adolescents at pre‐ and post‐intervention time points and from documents indicating vaccine uptake. Guided by the Health Belief Model and the Integrated Behavioral Model, surveys assessed demographic, behavioral, and psychosocial variables. A mediation analysis was used to test whether changes in psychosocial variables from baseline to follow‐up mediated the relationship between study condition and influenza vaccine uptake. RESULTS: Controlling for background variables, step 1 of the mediation analysis revealed a significant relationship between study condition and vaccine uptake (odds ratio = 1.77, p = .038). Step 2 of the mediation analysis revealed a significant relationship between study condition and changes in psychosocial variables from baseline to follow‐up. Steps 3 and 4 of the mediation analysis revealed that there was full mediation of the relationship between study condition and receipt of an influenza vaccination by intention to receive an influenza vaccination. CONCLUSION: Findings suggest that the success of our school‐based influenza vaccination intervention in increasing vaccine uptake was mediated by adolescents' intention to receive an influenza vaccination. Future influenza vaccination efforts geared toward rural adolescents may benefit from addressing adolescent attitudes toward influenza vaccination, particularly increasing intention to receive a vaccine.     

Correlates of HPV vaccination among adolescent females from Appalachia and reasons why their parents do not intend to vaccinate

Limited research has examined HPV vaccination in Appalachia, a region with cervical cancer disparities. We analyzed 2008–2010 National Immunization Survey-Teen data for adolescent females ages 13–17 from Appalachia (n = 1951) to identify correlates of HPV vaccination and reasons why their parents do not intend to vaccinate. HPV vaccine initiation was 40.8%, completion was 27.7%, and follow-through was 67.8%. Vaccination outcomes tended to be higher among females who were older, had visited their healthcare provider in the last year, or whose parents reported receiving a provider recommendation to vaccinate. Only 41.0% of parents with unvaccinated daughters intended to vaccinate in the next year. The most common reasons for not intending to vaccinate were believing vaccination is not needed or not necessary (21.5%) and lack of knowledge (18.5%). Efforts to reduce missed opportunities for vaccination at healthcare visits and address reasons why parents are not vaccinating may help increase HPV vaccination in Appalachia     

Determinants for HPV vaccine uptake in the Netherlands: A multilevel study

In March 2009, a HPV catch-up vaccination campaign was implemented in the Netherlands for girls born between 1993 and 1996. We performed a multilevel study to investigate determinants for HPV vaccination uptake. National coverage for the first dose was 49.9%, with regional uptakes ranging from 31% to 61%. Data was gathered from individual to regional level. Our results suggest that organizing information meetings at schools and communicating with gynaecologists might be beneficial. Lower uptake among various ethnic groups and in areas with higher proportion of voters for Religious Political Parties indicate that communication on HPV vaccine should be adapted to religious and ethnic communities. Furthermore, lower uptake in areas with lower socioeconomic status needs attention since participation to cervical screening is also lower in these areas.     

Human papillomavirus vaccine uptake in boys and girls in a school-based vaccine delivery program in Prince Edward Island,Canada

BackgroundIn 2013, Prince Edward Island was the first province to introduce HPV vaccine universally to grade six boys in a school-based program. Because uptake rates in boys are unknown in this type of vaccination program, uptake of HPV vaccination in boys was measured and compared with uptake rates in girls and then analyzed with factors such as county, urban–rural location of the school, and school board to identify where the vaccine program could be improved.MethodsHPV vaccination records from the provincial childhood immunization registry in PEI were merged with Department of Education data containing all grade six girls and boys in PEI. Vaccine uptakes between years and between sexes were compared using two sample tests of proportions. Logistic regression modeling which accounted for the hierarchical nature of the data was used to analyze associations between factors and uptake rates.ResultsAlthough uptake was high in boys and girls, a significantly greater proportion of girls (85%) received all three doses of the HPV vaccine compared to boys (79%; p = 0.004). The odds of grade six girls being fully vaccinated for HPV were 1.5 times greater than of grade six boys, and the odds of students in the English Language School Board receiving all three doses were more than twice as great as the odds of French Language School Board students.ConclusionsHPV vaccination for boys in PEI has had a successful launch, almost reaching the Canadian Immunization Committee recommendations of >80% for the early years of a program. PEI has a highly organized Public Health Nursing program that is involved in all childhood and school-based vaccinations in PEI and in this context very high coverage rates were obtained. Areas to target for improving uptake include the boys and the students in the French Language School Board.     

The HPV vaccine: framing the arguments FOR and AGAINST mandatory vaccination of all middle school girls

BACKGROUND: Human papillomavirus (HPV), the virus responsible for cervical cancer, is the most common viral sexually transmitted infection in the United States. A vaccine was approved in 2006 that is effective in preventing the types of HPV responsible for 70% of cervical cancers and 90% of genital warts. Proposals for routine and mandatory HPV vaccination of girls have become sources of controversy for parents of school-aged youth, legislators, members of the medical community, and the public at large. METHODS: The purpose of this article was to articulate the arguments used by advocates who either oppose or endorse routine, mandatory administration of the vaccine to school-aged girls, thereby assisting school health personnel in being effective participants in framing the relevant issues. RESULTS: Controversy is grounded in moral, religious, political, economic, and sociocultural arguments including whether concerns that the vaccine increases sexual risk taking, sends mixed messages about abstaining from sexual intercourse, usurps parental authority, and increases the potential for development of new health disparities are offset by the value of administering a cost-effective, age-appropriate public health measure targeting a life-threatening problem. CONCLUSIONS: Careful consideration of the medical evidence and public health implications is critical but understanding the context of the debate is no less important to the task of responding to public concerns. School health personnel have a role in the discussion about HPV immunization. Being able to articulate the arguments presented herein can help authorities' responsiveness to parents and community groups as the dialogue about this particular health issue evolves further.     

Correlates of HPV knowledge in the era of HPV vaccination: a study of unvaccinated young adult women

Until recently, awareness of the sexually transmitted infection human papillomavirus-the virus that causes cervical cancer-was relatively low. The purpose of this study was to identify factors associated with human papillomavirus knowledge now that human papillomavirus vaccines have become widely available. Young adult women (n = 739; aged 18-26 years) attending Florida State University who had not yet initiated human papillomavirus vaccination completed a survey between March-August 2009. The survey assessed human papillomavirus awareness, human papillomavirus knowledge, demographics, socio-political variables, sexual history, and health history variables. Over 97% of participants were aware of human papillomavirus prior to study enrollment; however, knowledge of human papillomavirus was only moderate. A multivariate regression analysis examining factors related to human papillomavirus knowledge revealed five independent correlates: Latina ethnicity, premarital sex values, number of lifetime sexual partners, history of cervical dysplasia, and HIV testing. These variables accounted for 14% of the variance in human papillomavirus knowledge. Less knowledge was observed for Latinas and women opposed to premarital sex. Greater knowledge was observed for women who had been tested for HIV and women with more sexual partners or a history of cervical dysplasia. These findings can inform future human papillomavirus vaccination campaigns and may be particularly useful in developing interventions for individuals with the largest deficits in human papillomavirus knowledge.     

Women's knowledge of human papillomavirus (HPV) and their attitudes toward HPV vaccine: preparing for HPV vaccination in China

To explore women's knowledge of human papillomavirus (HPV) and attitudes toward the HPV vaccine in Zhejiang, China, women attending the checkup clinics were invited to participate. A questionnaire-guided interview was conducted with a representative sample of 1490 women, and 1432 effective questionnaires were obtained. The authors found 39.1% of women in urban areas and 27.1 % in rural areas had heard of HPV, whereas 23.7% and 15.1%, respectively, had heard of the HPV vaccine. The mean score of HPV knowledge was 3.75 in urban areas and 3.18 in rural areas, with a significant difference (P = .016). Of the sample who had heard of the HPV vaccine, the supportive mean score was 2.59 and 2.11, with a significant difference (P = .003). Women with more HPV knowledge were more likely to support the HPV vaccination (r = 0.50 and r = 0.61). The authors conclude that inadequate knowledge and misconceptions about HPV are common. Attitudes toward HPV vaccine are unsatisfactory. Education campaigns targeting different populations are needed prior to the introduction of an HPV vaccine.     

HPV vaccination and sexual health in France: Empowering girls to decide

Objective

Vaccination coverage against HPV in France is among the lowest in the industrialized world, although the public authorities have recently become aware of this issue. Few studies have looked at teenaged girls’ representations of this vaccination, even though they are the most concerned by it. This qualitative study explored the experiences and representations of HPV vaccination by adolescent girls seeing doctors at least occasionally.

HPV vaccine acceptance among adolescent males and their parents in two suburban pediatric practices

PurposeTo measure HPV vaccine acceptance among unvaccinated adolescent males and parents and correlate acceptance with knowledge, awareness, and personal experience.MethodsAdolescent males ages 11–21 years old and their parents completed questionnaires measuring attitudes and knowledge about HPV vaccination and personal experience. Acceptance was defined as wanting the vaccine and conditional acceptance as wanting the vaccine if it would protect against genital warts or cervical cancer.ResultsAdolescent (n = 154) and parent (n = 121) vaccine acceptance was low (16% and 34%, respectively); however, conditional acceptance was higher. While adolescents had similar conditional acceptance for a vaccine against genital warts and cervical cancer, parents reported higher conditional acceptance for protection against genital warts. Independent predictors of acceptance included personal experience and demographic variables.ConclusionsHPV vaccine acceptance among adolescents and parents was low. Conditional acceptance levels highlight the importance of education about a few important benefits of HPV vaccination, which may increase vaccination rates.     

Knowledge and acceptability of the HPV vaccine by school children and their parents in Birmingham

Previous research indicates that knowledge about the HPV vaccine amongst the general public is inadequate 1, 2 and 3. However, since the introduction of the NHS vaccination programme for girls aged 12–13 from autumn 2008 awareness may have increased. We aimed to assess their knowledge about the vaccine, their likelihood of vaccine uptake and whether these were affected by demographic variables such as gender and ethnicity. Questionnaires which were designed to test levels of knowledge about the vaccination programme were distributed to a sample of 12–13 year-old boys and girls and their parents from three schools in Birmingham. In total, 568 questionnaires were distributed, with 434 responses (76.4%).     

Associations between relative income and mortality in Norway: a register-based study

BACKGROUND: Current research on health inequalities suggests that not only an individual's absolute level of income but also his/her relative position in the income hierarchy could have health consequences. This study examines whether relative income was associated with individuals' mortality in Norway during the 1990s. METHODS: Data were formed by linkages of Norwegian administrative registers. This study analyses 1.68 million men and women (age group: 30-66 years) with disposable income (1993) in the range 60,000-210,000 Norwegian Kroner. Relative income was calculated as deviations in per cent from the median income in the surrounding residential area. The outcome variable was deaths in 1994-1999. Effects of relative income on mortality were estimated by multiple logistic regression analyses, separately in 13 narrow brackets of absolute income. Adjustments were made for sex, education, marital status, and other individual-level mortality predictors. RESULTS: Low relative income compared with the median in residential regions with populations above 20,000 inhabitants was associated with higher mortality among those with medium and lower absolute income. The excess risk increased progressively the lower the level of absolute income. Among those with higher absolute income, however, relative income was not associated with mortality. Moreover, when relative income was considered in relation to the median in small municipalities, almost no effect on mortality was observed. CONCLUSION: In Norway during the 1990s, having low relative income constituted an additional mortality risk among individuals with middle or lower absolute incomes and when relative income was calculated in relation to the average in medium-sized or larger regions.     

Awareness of HPV and drivers of HPV vaccine uptake among university students: A quantitative,cross‐sectional study

HPV vaccination is a milestone in primary prevention. However in Italy, vaccine coverage is still nowhere near the target of 95%. We investigated factors associated with inclination to get vaccinated in university students, as they are likely to have just assumed a central role in their healthcare decision‐making. University students aged 18–25 were asked to fill in a questionnaire. The effect of socio‐demographic and behavioural characteristics on HPV awareness was assessed with a logistic regression adjusting for age, gender, nationality, degree course, relationship, age at first intercourse, number of sexual partners, smoking, sexual orientation, past diagnosis of STDs and knowledge of people who had received HPV vaccine. A second regression adjusting also for information sources, awareness and knowledge investigated factors associated with inclination to receive vaccine. Nine thousand nine hundred and eighty‐eight questionnaires were included (response rate 91.3%); awareness of HPV and vaccine was 83.3% and 69.9% respectively. Awareness (AOR: 3.3; 95% CI: 2.3–4.6) and a good knowledge positively affected acceptability, as well as a previous diagnosis of STDs and knowledge of vaccinated people. Healthcare workers (AOR: 1.6; 95% CI: 1.4–1.9) and family members (AOR: 1.7; 95% CI: 1.4–2.1) were the most influencing information sources, even if knowledge of vaccinated people was by far more persuasive (AOR: 2.7; 95% CI: 2.2–3.3). Only 12% of participants were acquainted with skin to skin HPV transmission, while 75% believed in a full effectiveness of condom; less than 22% associated HPV with cancer (other than cervical cancer). Efforts to increase awareness are likely to be worth considering that: awareness is the main determinant of vaccine acceptance; only 50% of individuals not interested in receiving vaccine were aware of it; males are much less aware (AOR: 0.09; 95% CI: 0.07–0.11). Moreover, this study spotlights some misconceptions around HPV and acknowledges a pivotal role of healthcare workers, family and peer influence.     

Resilience of HPV vaccine uptake in Denmark: Decline and recovery

BackgroundImmunization programs’ resilience to shocks is central to their success, but little empirical evidence documents resilience in action. We sought to characterize the decline of HPV vaccination in Denmark after negative media coverage and recovery during a national information campaign.MethodsWe conducted a population-based retrospective cohort study of all girls born in Denmark from 1997 to 2006 (N = 328,779), aged 12–15. The outcome measure was HPV vaccine uptake (first dose), as reported to the Danish national health registry from 2009 to 2019, when HPV vaccine was freely available to girls in primary care clinics in Denmark. Events that created 4 natural time periods for study were HPV vaccine reaching the uptake of other vaccines in the national program (2009), some negative media coverage of HPV vaccination (2013), extensive negative media coverage (2015), and a national information campaign about the vaccine’s safety and effectiveness (2017–2019).ResultsIn the period with some negative media coverage, HPV vaccine uptake fell to 83.6% (95% CI:78.0%–89.7%) of baseline uptake. In the period with extensive negative media coverage, uptake fell even further to 49.6% (95% CI:44.5%–55.2%) of baseline uptake. After the information campaign, HPV vaccine uptake recovered to its baseline level (109.2%, 95% CI:90.1%–132.4%) due in part to catch-up doses. Despite the recovery, an estimated 26,000 fewer girls initiated the vaccine than if uptake had not declined.ConclusionsThe experience in Denmark offers one of the first opportunities to document how a nation grappled with negative media coverage of HPV vaccination and the steadying impact of action by national authorities.