An innovative medical school curriculum to address human papillomavirus vaccine hesitancy

BackgroundVaccination rates against Human Papillomavirus (HPV) in the US remain alarmingly low. Physicians can significantly influence a parent’s decision to vaccinate their children. However, medical education often lacks training on specific strategies for communicating with vaccine hesitant parents.MethodsWe created an innovative curriculum designed to teach medical students how to address HPV vaccine hesitancy. The curriculum consisted of (1) a presentation on the epidemiology, biology, and disease morbidity associated with HPV, (2) a video that teaches specific communication strategies and (3) role-playing simulations. This curriculum was delivered to medical students at two separate sites. Medical students were surveyed before and after completing the educational curriculum. The surveys assessed student comfort talking to HPV vaccine hesitant parents and their likelihood to recommend the HPV vaccine.ResultsPre- and post-intervention surveys were completed by 101 of the 132 participants (77% response rate). After the intervention, student awareness of the benefits of the HPV vaccine increased by a mean of 0.82 points (Likert scale 1–5, p < 0.01) and student comfort talking to vaccine hesitant parents increased by a mean of 1.37 points (p < 0.01). Prior to the intervention, students more strongly recommended the HPV vaccine to females compared to males, but this gender disparity was eliminated after the intervention (p < 0.01). Personal vaccination status was independately associated with a higher likelihood of recommending the HPV vaccine both before and after the intervention.ConclusionOur innovative curriculum improved medical student comfort level discussing HPV vaccination with hesitant parents and increased the perceived likelihood of recommending HPV vaccination. The intervention is easy to implement, scalable, and requires minimal resources. Educating future providers on this important topic has the potential to improve vaccination rates nationwide and thus should be considered for all medical students.     

Pre-implementation evaluation for an HPV vaccine provider communication intervention among primary care clinics

ObjectivesInterventions to improve health care provider communication about HPV vaccination can increase vaccine acceptance. Our objectives were to (1) identify clinics in locations with high HPV-associated cancer and low HPV-vaccination rates that would potentially benefit from dissemination of a proposed HPV Provider Communication intervention and (2) use qualitative interviews and a dissemination and implementation framework to assess readiness for change and fit of the HPV Provider Communication intervention to the context of these clinics.MethodsLocal HPV-associated cancer and HPV vaccination rates were assigned to Practice-Based Research Network clinics using data from the Colorado Central Cancer Registry, the Colorado Immunization Information System, and the American Community Survey. Staff from 38 clinics located in areas with high numbers of adolescents not up-to-date for HPV vaccine and high rates of HPV-associated cancers were recruited for qualitative interviews. Interview questions used the Promoting Action on Research Implementation in Health Services (PARIHS) conceptual framework and addressed the proposed intervention, current vaccination practices and prior quality improvement (QI) experience.ResultsTwenty-seven interviews were completed with clinicians, clinic managers, and other staff across 17 clinics (9 pediatric, 5 family medicine, 3 public/school-based health). Most clinics had some prior QI experience and there were few thematic differences between sites with more or less foundation for QI/immunization work. Participants were motivated to improve the health of their patients and valued both guidelines and local experience as important evidence to consider adopting an intervention. Interviewees were more interested in implementing the proposed intervention if it aligned with existing priorities and fit within clinic workflows. Facilitation needs included adequate time and external facilitation support for data tracking and analysis.ConclusionsQualitative interviews to understand clinic context and fit of an HPV Provider Communication intervention can inform implementation in settings with the highest potential for clinical impact.     

Men who have sex with men who do not access sexual health clinics nor disclose sexual orientation are unlikely to receive the HPV vaccine in the UK

BackgroundMen who have sex with men (MSM) are recommended the Human Papillomavirus (HPV) vaccination due to their higher risk of genital warts and anal cancer.PurposeTo examine HPV vaccine acceptability amongst MSM in the UK.MethodsUsing advertisements via Facebook, MSM were recruited to an online survey measuring motivations for HPV vaccination. Logistic regression was performed to identify predictors of HPV vaccine acceptability.ResultsOut of 1508 MSM (median age = 22, range: 14–63 years) only 19% knew about HPV. Overall, 55% of MSM were willing to ask for the HPV vaccine and 89% would accept it if offered by a healthcare professional (HCP). Access to sexual health clinics (SHCs) [OR = 1.82, 95% CI 1.29–2.89], the disclosure of sexual orientation to a HCP [OR = 2.02, CI 1.39–3.14] and HIV-positive status [OR = 1.96, CI 1.09–3.53] positively predicted HPV vaccine acceptability. After receiving information about HPV, perceptions of HPV risk [OR = 1.31, CI 1.05–1.63], HPV infection severity [OR = 1.89, CI 1.16–3.01), HPV vaccination benefits [OR = 1.61, CI 1.14–3.01], HPV vaccine effectiveness [OR = 1.54, CI 1.14–2.08], and the lack of perceived barriers to HPV vaccination [OR = 4.46, CI 2.95–6.73] were also associated with acceptability.ConclusionsAlthough nearly half of MSM would not actively pursue HPV vaccination, the vast majority would accept the vaccine if recommended by HCPs. In order to achieve optimal uptake, vaccine promotion campaigns should focus on MSM who do not access SHCs and those unwilling to disclose their sexual orientation.     

Spatial patterns of HPV and Tdap vaccine dose administration and the association of health department clinic access in Georgia counties

ObjectiveTo characterize counties in GA by quantifying administered doses of the HPV and Tdap vaccines collected by the state health department immunization registry and indicators of Health Department (HD) clinic access.MethodsUsing a cross sectional study design, secondary data were collected from public health data sources for the years 2016 to 2018 for 159 counties of Georgia. The study population was male and female adolescents aged 13–17. The number of administered HPV and Tdap vaccine doses were modeled in relation to number of private and public HD clinics, number of HD clinics registered in the VFC program and the availability of public transportation using Poisson regression, negative binomial regression, and Bayesian spatial analysis.ResultsChoropleth maps showed similar clustering patterns between administered doses of the HPV vaccine and Tdap vaccine and increased counts of administered vaccine doses in counties with both public and private clinics. Administered doses of HPV and Tdap vaccines were found to exhibit spatial dependence across counties. Accounting for spatial dependence, the availability of public transit had a significant positive effect on administered HPV vaccine doses, while the number of private HD clinics had a significant positive effect on administered Tdap vaccine doses.ConclusionsMaps at the county level show vaccination variability, clustering patterns and provide additional insights on the access to health care. Bayesian spatial models are needed to accurately identify and estimate factors associated with administering doses of the HPV and Tdap vaccines. Future work is needed to further examine the utilization of HPV vaccination services among urban groupings.     

Acceptability of using standing orders to deliver human papillomavirus vaccines in the outpatient obstetrician/gynecologist setting

ObjectiveStanding orders, an effective method for increasing vaccination, are not widely used for HPV vaccine. This is especially so among obstetrician/gynecologists (Ob/Gyns) – the specialty many women use as their primary care provider. We sought to understand the acceptability of using standing orders for HPV vaccination among a sample of women attending outpatient Ob/Gyn clinics.Study designFrom February to April 2014, an on-line survey was administered to a convenience sample of 400 women aged 15–26 recruited from 9 Ob/Gyn practices in Colorado. The survey identified attitudes about standing orders for HPV vaccination, demographics and prior experience with HPV vaccines.ResultsThe response rate was 44%. Receipt of prior HPV vaccine doses was reported by 67% of respondents. Approximately half (53%) were comfortable with the idea of standing orders for HPV vaccination at Ob/Gyn clinics among women generally, but only 40% of the 154 women not initially opposed to HPV vaccination indicated they would personally feel comfortable receiving HPV vaccines offered under a standing order policy. General and personal acceptance of standing orders for HPV vaccination was significantly higher among women who reported receiving HPV vaccine doses previously, but not by any demographic or experiential variables. Acceptability of standing orders for HPV vaccines was higher for series completion than initiation (88% vs. 70%, p < 0.001) and was more commonly supported for adult patients (79%) than for adolescents (43%). Acceptability of standing orders increased if the patient was first told that the provider ‘strongly recommended the vaccine’, even for a majority (52%) of those who generally were not comfortable receiving the vaccine using standing orders.ConclusionsBecause standing orders for HPV vaccine are generally acceptable to women attending Ob/Gyn clinics, to increase vaccination uptake among adults Ob/Gyn providers may want to consider adoption of standing orders for HPV vaccine, at least for series completion.     

Decline in prevalence of human papillomavirus infection following vaccination among Australian Indigenous women,a population at higher risk of cervical cancer: The VIP-I study

BackgroundCervical cancer occurrence and mortality are strongly correlated with socioeconomic disadvantage, largely due to unequal access to screening and treatment. Universal human papillomavirus (HPV) vaccination provides the opportunity to greatly reduce this global health disparity. Australian Indigenous women have substantially higher rates of cervical cancer than non-Indigenous women, primarily due to under-screening. We investigated HPV infection rates in Indigenous women 7 years after implementation of the national HPV vaccination program.MethodsWe used a repeat cross-sectional design, with the baseline being provided by an HPV prevalence survey among Indigenous women attending clinics for cervical cytology screening, prior to the start of the vaccination program in 2007. We returned to clinics in four locations during 2014–15, and invited women aged 18–26 years attending for screening to provide a cervical specimen for HPV testing, as well as to complete a short questionnaire and consent to allow access of their records in the National HPV Vaccination Program Register. We used well-established laboratory methods to test specimens for specific HPV genotypes.ResultsA total of 142 women were recruited at participating sites and compared to 155 who had been recruited at the same locations in the 2007 pre-vaccine survey. The two groups were identical in regard to age, with the more recent group having a higher proportion of hormonal contraception users, and a lower proportion of smokers. The proportion found to have any HPV type fell from 58 to 36% with the decline being entirely due to reductions in vaccine types, which fell by 94% from 24 to 1.4%.ConclusionAustralia’s national HPV vaccination program appears to be successfully protecting a very high proportion of Indigenous women against vaccine targeted HPV types, who have in the past been at elevated risk of cervical cancer.     

Pediatric provider vaccine hesitancy: An under-recognized obstacle to immunizing children

ObjectiveTo describe vaccine attitudes among pediatric healthcare providers attending immunization conferences.Study designAttendees of 5 American Academy of Pediatrics (AAP)-sponsored vaccine conferences held between June and November 2013 anonymously completed a questionnaire assessing vaccine attitudes and practices prior to the opening of educational sessions. Pearson's chi-square tests and Fisher's exact tests were used to analyze associations between vaccine attitudes, vaccine practices and provider characteristics.Results680 providers attending AAP-sponsored vaccine conferences were included. 661/666 (99%) enrolled providers state they routinely recommend standard pediatric vaccines, yet, 30 (5%) state that they do not routinely recommend influenza and/or human papillomavirus (HPV) vaccines. These providers expressed vaccine safety (87/680 (13%)) and efficacy (21/680 (31%)) concerns and stated belief in vaccine misperceptions: vaccine causes autism (34/668, 5%), multiple vaccines at a single visit reduces vaccine efficacy (43/680, 6%) or overwhelms the immune system (63/680, 9%), and administering HPV vaccine will increase the likelihood of unprotected adolescent sexual activity (29/680, 4%). Six percent of providers who do not routinely recommend all pediatric vaccines correctly identified themselves as vaccine hesitant.ConclusionVaccine hesitancy is under-recognized among pediatric providers attending AAP-sponsored immunization conferences. Educational interventions tailored to address provider vaccine concerns are needed to improve provider vaccine confidence.     

The impact of an educational forum intervention on East African mothers’ HPV vaccine-related knowledge,attitudes, and intentions to vaccinate their adolescent children

ObjectiveHPV vaccine uptake in U.S. East African adolescents is low. We developed and evaluated a culturally-targeted interactive educational intervention for East African immigrant mothers to increase HPV-vaccine-related knowledge, attitudes, and intentions to vaccinate adolescent children.MethodsEligible mothers had ≥ 1 11–17-year-old child and reported all children’s HPV vaccination status as unvaccinated or unknown. The intervention was delivered via 10 dinners in the Seattle metropolitan area (8 with the Somali community, 2 with the Ethiopian community). Educational presentations and pre/post-tests on knowledge, attitudes, and intentions were conducted in the participants’ native language by a co-ethnic physician. Pre/post differences in responses were evaluated with McNemar’s tests and GEE models. HPV vaccination uptake 6-months post-intervention was evaluated using state immunization registry data.ResultsOf 115 participating mothers, most (84%) were Somali and < 40 years of age (60%). Median years of formal education was 8 (range 0–16), and 61% reported a household income <$25,000. Knowledge of HPV/HPV-vaccines was low pre-intervention, with correct responses ranging from 4% to 39% (61%-91% of responses were “not sure”); correct post-intervention responses ranged from 29% to 97%. Pre-intervention, only 12% of mothers thought they had enough information to make a decision about vaccination, compared to 90% post-intervention. Pre-intervention, only 16% of mothers reported that they were somewhat or very likely to vaccinate their child, compared to 83% post-intervention. All pre/post comparisons were statistically significantly different (p < 0.0001). Although mothers were more likely to report correct HPV-related knowledge and positive vaccine attitudes and intentions post-intervention, only two mothers’ children initiated HPV vaccination within 6 months after the intervention.ConclusionsResults illustrate that a culturally targeted educational intervention effectively increased East African mothers’ HPV vaccine-related knowledge, attitudes, and intentions to vaccinate their adolescent children. Future research should identify additional intervention components that can bridge the gap between intention and behavior to facilitate HPV vaccine uptake.     

Longitudinal assessment of nonavalent vaccine HPV types in a sample of sexually active African American women from ten U.S. Cities

BackgroundChronic infection with high-risk human papillomavirus is a necessary cause for cervical carcinogenesis. This study examined prevalence of nonavalent vaccine preventable HPV types over four months among sexually active women in the United States.MethodsThis sub-study obtained meta-data for 80 of the 1,365 women (18–25 years), enrolled in the BRAVO study, a randomized, open-label trial of home screening and treatment of asymptomatic bacterial vaginosis at high-risk for sexually transmitted infections conducted between 2008 and 2013. Participants were randomized to treatment or standard-of-care, and followed every 2-months for 12 months. Stored vaginal swabs from the first three visits were tested for the nine vaccine preventable HPV types using quantitative PCR. Prevalence and associated 95% confidence intervals for the HPV types were assessed using R (version 3.6.1).ResultsThe average age of the participants was 21.5 (SD ± 2.11) years, with 60% having ever been pregnant and all were African-American. Majority (71%) reported ≥ two sex partners in the prior year with 89% having unprotected vaginal sex and 45% having a new sex partner in the prior year. About 30% had ≥ one of the nine nonavalent vaccine HPV types at all three time points over a period of four months, 15% at two of any three visits, 19% at one of the three visits and 36% were negative for all nine vaccine HPV types at all time points. The most frequently detected HPV vaccine types were 52, 58, 16, and 18. The prevalence of any vaccine HPV types, and high-risk HPV types was 63.8% and 58.8%, respectively.ConclusionsOur findings suggest that HPV vaccination which is currently recommended for all unvaccinated persons through age 26 years, is likely to be more beneficial than previously thought as nonavalent HPV vaccine was not available during the time these data were collected.     

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

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

Acceptability of vaccination against human papillomavirus among women aged 20 to 45 in rural Hunan Province,China: A cross-sectional study

ObjectiveThis study aimed to examine the intentions of and barriers to vaccination against human papillomavirus (HPV) among women aged 20 to 45 in rural areas, and to determine the popular sources to getting information about HPV vaccine and vaccination.MethodsThis cross-sectional study was conducted in 2018 with a sample of women aged 20 to 45 from rural areas of Hunan Province in China. Anonymous self-administered questionnaires were used to collect sociodemographic information and characteristics related to reproductive health of participants, and intentions of and barriers to HPV vaccination. All statistical analysis methods were performed with SPSS 18.0.ResultsA total of 2101 women participated in the study, with 58.55% intended to vaccinate against HPV. Increased intention of HPV vaccination was associated with higher age (adjusted odds ratio [AOR] = 1.35 and 1.50, respectively) and education level (AOR = 1.13 and 1.47, respectively). Women who have heard of HPV vaccine (AOR = 2.67, 95% confidence interval [CI]: 1.20–5.98) and have been aware of that cervical cancer could be prevented (AOR = 2.01, 95%CI: 1.44–2.82) were more willing to vaccinate. Having never heard of HPV vaccine and worry about efficacy and safety of vaccines were the most commonly cited reasons to refuse vaccination. The preferred source to get the knowledge was medical personnel (58.45%), followed by WeChat or Microblog, TV programs, and Internet.ConclusionWe found the intention of HPV vaccination among women aged 20 to 45 in rural China is low. Findings highlighted the importance of knowledge and trust in HPV vaccine, and suggested strengthening educational interventions on HPV vaccine and vaccination through multiple sources, including HPV vaccine coverage in health insurance to increase access.     

Adapting Center for Disease Control and Prevention's immunization quality improvement program to improve maternal vaccination uptake in obstetrics

IntroductionMaternal vaccination is critical for improving maternal and child health. Quality Improvement (QI) models¹, such as the Centers for Disease Control and Prevention’s (CDC) Assessment, Feedback, Incentives, eXchange (AFIX)² model, have not yet been adapted to maternal vaccinations. This study assesses the impact of AFIX-OB, an adapted version of AFIX for obstetric settings, on maternal vaccination rates.MethodsBetween December 2016 and May 2018, state health departments and obstetric practices in Colorado and Georgia implemented the adapted AFIX-OB model. The model addressed unique patterns in patient encounters, practice flow, health records systems and competing clinical priorities in the obstetric setting through a menu of clearly-defined QI strategies, bi-weekly technical assistance meetings with designated immunization champions, incentives for champions/staff, and adapted tools to aid each practice during implementation. Vaccination rates were assessed by random chart reviews pre- and post-intervention.ResultsThe AFIX-OB model was evaluated in eleven obstetric practices in two states as part of a multi-level intervention to increase maternal vaccination. Post AFIX-OB implementation, documented influenza vaccination rates increased from 56% at baseline to 65% (p < 0.01); and tetanus, diphtheria, and acellular pertussis (Tdap) vaccination rates increased from 77% at baseline to 84% (p < 0.02) across all practices.ConclusionsThe AFIX-OB model showed improvement in maternal vaccination rates for both influenza and Tdap vaccines. AFIX-OB may provide a useful framework for obstetric practices, as well as for other health care specialties. The focused goal should be on broader dissemination among those interested in adopting an evidence-based model for increasing vaccine uptake.     

Improving Human Papillomavirus (HPV) Vaccination in the Postpartum Setting

Although the HPV vaccine has been shown to be highly effective in preventing cervical dysplasia, vaccination rates remain low. The objective of this study was to assess the effectiveness of an electronic medical record (EMR) prompt on HPV vaccination rates in the postpartum setting. We conducted a pre-post intervention study among postpartum women ages 18–26 seen at an outpatient clinic from 09/01/2012–08/31/2013 (pre-intervention) and from 10/01/2013–03/31/2014 (post-intervention). The intervention was a drop-down menu that was inserted into the EMR postpartum note template inquiring about the patient’s HPV vaccination status and whether or not the vaccine was administered at that visit. HPV vaccination uptake was compared pre and post-intervention. Of the 278 postpartum visits during the study period, 241 were eligible for analysis. There was a significant increase of the HPV vaccine uptake, from 1.2 % (2/173) among pre-intervention visits to 26.5 % (18/68) among post-intervention visits (p < 0.001). After adjusting for age, ethnicity, insurance, and religion, HPV vaccination was significantly higher at postpartum visits during the intervention period, with an adjusted OR = 93.49 [95 % CI 15.29–571.52]. Among visits in which the vaccine was not given, HPV vaccination was not discussed in 46 % and patients refused the vaccine in 40 % of visits. An EMR prompt in the postpartum note could be an effective way to promote HPV vaccination in the postpartum setting. It will likely take a combination of strategies to optimize vaccination uptake.     

Parent perceptions of dentists’ role in HPV vaccination

IntroductionOffering HPV vaccine in settings beyond the traditional medical home holds promise for increasing the currently low levels of coverage. As adolescents frequently visit dentists, dental practices may be one such alternative vaccination setting. This study assessed parent attitudes about the roles dental providers could play in HPV prevention, including vaccine provision.MethodsIn September 2016, we conducted an online survey using a national sample (n = 1209) of U.S. parents of adolescent children aged 11–17. Adolescents’ mean age was 14; 53% were male and 62% were non-Hispanic white. We identified correlates of parents’ comfort with dentists as HPV vaccinators using multivariable logistic regression.ResultsOverall, 23% of parents reported that they would feel comfortable with their child receiving HPV vaccine from a dentist. In multivariable analyses, parents had greater odds of being comfortable if they had higher trust in their child’s primary care provider (OR = 1.27, 95% CI: 0.96–1.68) and lower odds if their child was female (OR = 0.65, 95% CI: 0.50–0.86). Convenience (20%) and oral health expertise (20%) were the most commonly cited benefits of dentists administering the vaccine. Wanting their child’s regular provider to administer and track vaccinations (61% and 58%, respectively), and lack of insurance coverage (30%) were the most commonly cited concerns. Parents expressed somewhat greater comfort with roles dentists might play in promoting HPV vaccination other than vaccine delivery, such as providing education.ConclusionsParents in this sample had low comfort with dentists as HPV vaccinators. Findings from this study highlight potential concerns to be addressed before dental practices consider offering HPV vaccination in the future. Further research should assess dentists’ perspectives and explore alternative roles for dental providers in HPV prevention efforts.     

The Influence of Deductible Health Plans on Receipt of the Human Papillomavirus Vaccine Series

PurposeTo evaluate whether enrollment in deductible health plans (DHP) with higher patient cost-sharing requirements than traditional health maintenance organization plans (HMP) decreased initiation and completion of the human papillomavirus (HPV) vaccine series recommended for prevention of cervical cancer.MethodsThis was a retrospective observational study of 9- to 26-year-old females at Kaiser Permanente Georgia and Kaiser Permanente Colorado who were HPV vaccine naive at time of enrollment in a self-pay DHP or HMP in 2007. Estimates of rates of initiation and completion of the HPV vaccine series from plan enrollment in 2007 through December 2009 were obtained using Cox proportional hazards regressions (accounting for censoring) on samples matched on the propensity to enroll in a DHP versus HMP.ResultsInitiation of the HPV vaccine series was 22.2% and 24.4% in the DHP and HMP groups, respectively, at Kaiser Permanente Georgia; completion was 12.3% and 14.4% in the DHP and HMP groups, respectively. Human papillomavirus vaccine series initiation was higher at Kaiser Permanente Colorado, but completion was lower. In the Cox proportional hazards regressions, rates of initiation and completion of the HPV vaccine series did not differ significantly (p ≤ .05) by plan type (DHP vs. HMP) at both sites. The primary care visit rate included in these regressions had a significant, positive association with initiation and completion of the HPV vaccine series.ConclusionsEnrollment in a DHP versus an HMP did not directly affect initiation or completion of the HPV vaccine series among age-eligible females. Independent of plan type, more frequent primary care visits increased initiation and completion rates.     

A content analysis of HPV vaccination messages available online

Parents have varied HPV vaccine communication needs, which presents a challenge for healthcare providers. To improve communication resources for providers, we sought to characterize HPV vaccination messages available in existing educational materials. In fall 2016, we searched PubMed, educational material clearinghouses, and Google for English language HPV vaccination messages. We extracted messages that a provider might use when raising the topic of HPV vaccination, answering common questions, and motivating vaccination. Two reviewers independently coded each message. The search identified 267 unique messages about HPV vaccination. Messages generally were long (mean no. of words = 44, standard deviation [SD] = 33) and required a high level of education to read (mean reading grade level = 10, SD = 3). Only 32% of messages were shorter than 25 words, and 12% had a readability at or below grade 6. Most frequent were messages to address common parent questions or concerns (62%); the most common topics were diseases prevented by HPV vaccine (18%) and safety and side effects (16%). Many messages included information about cancer prevention (26%) and same-day vaccination (13%). Few messages (6%) used a presumptive style to recommend HPV vaccination. In conclusion, available messages about HPV vaccination were markedly varied. We identified few messages that were both brief (to facilitate providers memorizing them) and accessible (to facilitate parents understanding them). Future research should identify which messages lead to HPV vaccine uptake.     

Knowledge of human papillomavirus among dental providers: A mixed methods study

Dental professionals are encouraged by the American Dental Association (ADA) to recommend the HPV vaccine to eligible patients. To better understand their comfort level in following this recommendation, we conducted a mixed methods study of dentists and dental hygienists. A total of 173 providers were surveyed and 8 interviewed. The majority felt they had an important role in preventing HPV-related OPC and that they should educate their patients and encourage HPV vaccination. However, most providers had low knowledge about HPV and expressed a need to obtain more information on the topic. In particular, they desired information about the HPV vaccine, its connection to cancer and where to refer patients for vaccination. They also wanted access to visual aids to help them bring up the topic. This study demonstrates the need to develop and disseminate educational programs for dental providers so they can assist with efforts to raise HPV vaccination rates.     

新疆维吾尔自治区2016－2017年免疫规划疫苗损耗调查

目的 了解新疆维吾尔自治区预防接种单位免疫规划（EPI）疫苗的损耗现状，为进一步精细化管理和使用EPI疫苗提供依据。方法 采取分层整群抽样方法抽取135个接种单位，调查2016-2017年6种EPI疫苗接种和使用数据，包括常规免疫和脊髓灰质炎疫苗群体性补充免疫活动中疫苗领发和使用数量、疫苗报废记录，以及接种单位的地区类型、服务模式、接种周期、日均接种量等。采用描述流行病学方法计算和分析疫苗的损耗系数。结果 单人份的无细胞百白破联合疫苗（DTaP）和三价脊髓灰质炎减毒活疫苗（tOPV）损耗系数最低，分别为1.00和1.02；多人份的二价脊髓灰质炎减毒活疫苗（bOPV）、A群脑膜炎球菌多糖疫苗（MPV-A）、白喉破伤风联合疫苗（DT）、卡介苗（BCG）损耗系数分别为1.58、1.67、1.68、3.02。城市、农村、牧区接种单位EPI疫苗损耗系数范围分别为1.00~2.84、1.00~3.71、1.00~2.27；乡级集中、村级集中、分散接种模式的损耗系数分别为1.00~3.00、1.00~4.41、1.00~1.94。接种周期越长或日均接种量越小，损耗系数越大。结论 新疆维吾尔自治区预防接种单位多人份EPI疫苗损耗较高，并受地区和接种服务形式的影响。需根据地区类型、接种单位服务形式等加强精细化的疫苗管理，减少疫苗损耗和浪费。