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.     

Age-Based Programs for Vaccination against HPV

Background:  The risk of infection with human papillomavirus (HPV) increases with age. Answering the question of which age groups are appropriate to target for catch-up vaccination with the newly licensed quadrivalent HPV vaccine (types 6/11/16/18) will be important for developing vaccine policy recommendations.
Objectives:  To assess the value of varying female HPV vaccination strategies by specific age groups of a catch-up program in the United States.
Methods:  The authors used previously published mathematical population dynamic model and cost-utility analysis to evaluate the public health impact and cost-effectiveness of alternative quadrivalent HPV (6/11/16/18) vaccination strategies. The model simulates heterosexual transmission of HPV infection and occurrence of cervical intraepithelial neoplasia (CIN), cervical cancer, and external genital warts in an age-structured population stratified by sex and sexual activity groups. The cost-utility analysis estimates the cost of vaccination, screening, diagnosis, and treatment of HPV diseases, and quality-adjusted survival.
Results:  Compared with the current screening practices, vaccinating girls and women ages 12 to 24 years was the most effective strategy, reducing the number of HPV6/11/16/18-related genital warts, CIN grades 2 and 3, and cervical cancer cases among women in the next 25 years by 3,049,285, 1,399,935, and 30,021; respectively. The incremental cost-effectiveness ratio of this strategy when compared with vaccinating girls and women ages 12 to 19 years was $10,986 per quality-adjusted life-year gained.
Conclusion:  Relative to other commonly accepted health-care programs, vaccinating girls and women ages 12 to 24 years appears cost-effective.     

HPV Vaccination and Sexual Behavior in a Community College Sample

Many US parents are concerned that vaccinating daughters against human papillomavirus (HPV) will communicate implicit approval for sexual activity and be associated with early or risky sexual behavior (Scarinci et al. in J Womens Health 16(8):1224–1233, 2007; Schuler et al. in Sex Transm Infect 87:349–353, 2011) [7, 8]. The aims of this study were to understand (a) whether the HPV vaccine was associated with risky sexual behavior among a diverse sample of female adolescents and young adults, and (b) to better understand the chronology of HPV vaccination and sexual behavior. An anonymous web-based survey was used to collect data from 114 female community college students. T test and Chi square analyses were used to compare vaccinated and unvaccinated groups on age at first intercourse and proportion who had ever had sexual intercourse. Linear multiple regression was used to predict frequency of condom use and number of sexual partners in the past year, using vaccination status and demographic factors as predictors. About 38 % reported receiving at least one dose of the HPV vaccine. Many of those vaccinated (45 %) received the vaccine after having initiated sexual activity. The proportion of women who were sexually experienced did not differ by HPV vaccine status, nor did age at first intercourse, number of partners in the past year, or frequency of condom use. Current findings suggest that HPV vaccination is not associated with riskier sexual activity for the young women in this sample. Adolescents and their parents may benefit from education about the need to receive the HPV vaccine before onset of sexual activity.     

Eradication of Hepatitis B: A Nationwide Community Coalition Approach to Improving Vaccination, Screening, and Linkage to Care

Infection with the hepatitis B virus (HBV) is a significant public health concern in the US, disproportionately affecting Americans of Asian, Native Hawaiian and Pacific Islander descent, despite the availability of a simple blood test, approved treatments, and an effective vaccine. Hep B United, a national campaign to support and leverage the success of community-based HBV coalitions, convened a partner summit in 2012 to develop a strategic response to the HHS Action Plan for the Prevention, Care, and Treatment of Viral Hepatitis. The resulting community action plan focuses on advancing three areas of the HHS plan: educating providers and communities to reduce health disparities; improving testing and linkage to care to prevent HBV-related liver disease and cancer; and eliminating perinatal HBV transmission.     

Improving Provider Communication about HPV Vaccines for Vaccine-Hesitant Parents Through the Use of Motivational Interviewing

Human papillomavirus (HPV) vaccine uptake is below that of other routine adolescent vaccines. This is due in part to the fact that the HPV vaccine is often not routinely recommended by providers to all eligible adolescents. While providers’ recommendations are crucial, even a strongly stated recommendation can be insufficient among HPV vaccine-hesitant parents. Providers must be prepared to respond to parental concerns following giving the recommendation for the HPV vaccine. This paper presents the analysis of implementation of an intervention aimed at improving provider communication with HPV vaccine-hesitant parents. Healthcare providers and staff at eight pediatric and family medicine clinics received communication training that included motivational interviewing (MI) techniques. Process evaluation in the form of serial surveys, as well as program evaluation in the form of focus groups with participating providers and staff, assessed the perceived efficacy of the intervention. Outcomes included time spent discussing the HPV vaccine during clinical visits, providers’ self-efficacy for addressing parental HPV vaccine hesitancy, and their general perceptions of the effectiveness of MI techniques. Overall, findings indicate the intervention improved providers’ communication with HPV vaccine-hesitant parents and providers reported the use of MI played a central role in improved HPV vaccine acceptance. Lessons learned and recommendations for future interventions are also discussed.     

The Sexual Ethics of HPV Vaccination for Boys

Human papillomavirus (HPV) is one of the most common sexually transmitted infections. It is a leading cause of cervical cancer in women but the virus is increasingly being linked to several other cancers in men and women alike. Since the introduction of safe and effective but also expensive vaccines, many developed countries have implemented selective vaccination programs for girls. Some however argue that these programs should be expanded to include boys, since (1) HPV constitutes non-negligible health risks for boys as well and (2) protected boys will indirectly also protect girls. In this paper we approach this discussion from an ethical perspective. First, on which moral grounds can one justify not reimbursing vaccination for the male sex? We develop an ethical framework to evaluate selective vaccination programs and conclude that, in the case of HPV, efficiency needs to be balanced against non-stigmatization, non-discrimination and justice. Second, if vaccination programs were to be expanded to boys as well, do the latter then also have a moral duty to become immunized? Two arguments in favor of such a moral duty are well known in vaccination ethics: the duty not to harm others and to contribute to the public good of public health. However, we argue that these are not particularly convincing in the context of HPV. In contrast, we believe a third, more powerful but also more controversial argument is possible. In our view, the sexual mode of transmission of HPV constitutes an additional reason to believe that boys in fact may have a moral obligation to accept vaccination.     

Factors Associated with HPV Vaccination in Young Males

Human papilloma virus (HPV) affects both men and women; however, recommendations for HPV vaccination among men were not issued in the United States until 2011. The purpose of this study was to describe and compare characteristics of men who did and did not report receiving at least one dose of the HPV vaccine. Data from the ten states that completed the HPV vaccination module in the 2013 Behavioral Risk Factor Surveillance System (BRFSS) were included in the study. Young men ages 18–26 were included (N?=?1624). Categorical variables were compared between those who did and did not receive the HPV vaccine using Chi square. Logistic regression was used to examine the odds of HPV vaccination by the above factors. Only 16.5% of men reported at least one dose of HPV vaccine. Having health insurance, having a primary doctor, and receiving an HIV test were predictive of HPV vaccination. Men in Texas were more likely to report HPV vaccination than all other states. Overall, HPV vaccination is low in men. Targeted interventions for improving HPV vaccination rates in men are warranted, especially for those without health insurance or a routine source of care.     

Singaporean Women's Knowledge of Human Papillomavirus (HPV) and Attitudes Toward HPV Vaccination

With a vaccination program currently planned to protect Singaporean women from human papillomavirus, a need arises for assessing Singaporean women's knowledge of human papillomavirus and attitudes toward human papillomavirus vaccination to identify barriers to a successful program and to help inform health education campaigns. A representative sample of 2,145 women aged between 18 and 49 years were randomly selected from households throughout Singapore and interviewed with a similar questionnaire to that used in a recent study of Australian women. Although Singaporean women's knowledge of human papillomavirus was poor, with only 20% having heard of it, attitudes toward human papillomavirus vaccination were generally positive. The most trusted sources of information about human papillomavirus and vaccination were gynecologists and general practitioners. Based on our findings, an urgent need exists in Singapore for accurate and accessible information about human papillomavirus and the benefits of vaccination.     

Fostering Connections Among Diverse Individuals Through Multi-Sensorial Storytelling

A growing number of health institutions are employing medical interpreters, bilingual individuals who facilitate communication between health care providers and patients. Organizations working to establish the professional status of medical interpreting have articulated codes of ethics that prescribe a number of different roles for interpreters in their clinical work. Interviews obtained from 17 medical interpreters support the observation that the code of ethics, based primarily on a conduit model of interpreter communication, does not provide consistent guidance in clinical practice. I discuss the role of communication theory in developing improved models for interpreter practice.     

Reaching Children Never Previously Vaccinated for Influenza Through a School-Located Vaccination Program

Objectives. We determined the success of the school-located vaccination (SLV) program, implemented in 2009 in New York City to deliver pandemic influenza A (H1N1) monovalent vaccine (pH1N1), versus provider offices in reaching children who had never previously received influenza vaccine.Methods. We compared the immunization history of children vaccinated in school versus provider offices. We included records in the Citywide Immunization Registry with pH1N1 administered between October 2009 and March 2010 to elementary school-aged children.Results. In total, 96 524 children received pH1N1 vaccine in schools, and 102 933 children received pH1N1 vaccine in provider offices. Of children vaccinated in schools, 34% had never received seasonal influenza vaccination in the past, compared with only 10% of children vaccinated at provider offices (P < .001). Children vaccinated in schools were more likely to have received a second dose of pH1N1 in 2009–2010 than those vaccinated in provider offices (80% vs 45%).Conclusions. The SLV program was more successful at reaching children who had never received influenza immunization in the past and should be considered as a strategy for delivering influenza vaccine in routine and emergency situations.Improving vaccination coverage in children may lead to decreased morbidity and mortality in the general population, including decreasing influenza deaths and illness in adults.1–4 In 2006, the Advisory Committee on Immunization Practices recommended influenza vaccine for healthy children aged 6 months to 4 years5 and expanded their recommendation in subsequent years to include children aged 5 to 18 years.6 The goal of vaccinating all children annually raises a significant operational question of how to target children most effectively.Pediatricians provide the majority of immunizations given to children. However, after the 4- to 6-year-old well child visits, children may not visit medical providers regularly. School-located vaccination (SLV) offers a convenient alternative because it reaches the majority of children regardless of their access to medical care,7 and schools have been successfully used for hepatitis B vaccination administration in the past.8,9 SLV also offers parents the convenience of not having to make a trip to the provider’s office or even be present. Jurisdictions such as Hawaii have routinely offered influenza vaccine through schools and have achieved vaccination rates as high as 46% in children aged 5 to 13 years.10Despite the potential advantages of SLV, to our knowledge, whether it successfully reaches children who otherwise would have gone unvaccinated is unknown. We examined this issue in New York City (NYC) in 2009 when the NYC Department of Health and Mental Hygiene offered pandemic influenza A (H1N1) monovalent vaccine (pH1N1) through an elementary school–located campaign. During this influenza season, because of a late-emerging strain of novel H1N1, pH1N1 vaccine was developed and offered separately from routine seasonal influenza vaccination. Using data on pH1N1 vaccination from the Citywide Immunization Registry (CIR), the NYC Department of Health and Mental Hygiene’s Immunization Information System, we compared the demographic characteristics and immunization history of children vaccinated through the SLV campaign with those of children vaccinated in medical provider offices. We examined the proportion of children in each setting for whom the pH1N1 vaccine was the first influenza vaccine ever received to determine the potential for SLV programs to effectively reach children who have not previously received an influenza vaccination and who therefore might be unlikely to get vaccinated in the current season as well. We also predicted the probability of being vaccinated at schools controlling for demographic characteristics and immunization history.     

Mothers' and Adolescents' Beliefs about Risk Compensation following HPV Vaccination

PurposeTo examine the prevalence and predictors of the belief that human papillomavirus (HPV) vaccination will result in “risk compensation,” that is, will increase risky sexual behavior.MethodsTwo surveys were carried out: with 332 mothers (Study 1) and 360 adolescent girls (Study 2). The outcome measure was the score on a risk compensation scale tapping beliefs that HPV vaccination would increase risky sexual behavior.ResultsAmong mothers, those from the lowest income group (F = 4.38, p < .01), from ethnic minority backgrounds (F = 7.41, p < .01), and who did not attend cervical screening (F = 9.96, p < .01), had the highest risk compensation scores. Among adolescents, girls with lower educational attainment (F = 4.14, p < .05), from ethnic minority backgrounds (F = 6.60, p < .001), and who felt themselves to be less sexually experienced than their peers (F = 3.31, p < .05), had the highest scores. Girls showed lower belief in risk compensation in relation to their own behavior (personal compensation) than for “girls in general” (general compensation; t = 13.68, p < .001). Lower knowledge of HPV was associated with higher personal risk compensation beliefs (F = 4.26, p < .05).ConclusionsA significant minority of mothers and adolescents themselves say that HPV vaccination would increase the chance of risky sexual behavior. Because risk compensation beliefs are likely to predict HPV vaccine acceptance, identifying the basis for these beliefs and providing appropriate information and education to parents and adolescents will be vital. Following the introduction of vaccination, it will be important to discover whether risk compensation actually takes place, and every effort should be made to ensure it does not.     

HPV Infection Awareness and Self-Reported HPV Vaccination Coverage in Female Adolescent Students in Two German Cities

Low levels of human papillomavirus (HPV) awareness and knowledge have been observed in the few studies conducted among school-going adolescents. Such data are lacking in Germany. To assess awareness of HPV and of vaccination status among girls attending grades 8–13 in Bremen and Bremerhaven, two German cities. Participants completed a questionnaire in school including questions on demographic characteristics, about HPV awareness and on vaccination status. We analysed the relationship between awareness of HPV, of vaccination status and vaccine uptake and several variables including age and migrant background using univariate and multivariate logistic regression. Six hundred and thirty-two girls aged 12–20?years completed the questionnaire. 50?% had no awareness of HPV, 12?% reported being vaccinated against HPV and 57?% did not know whether or not they were vaccinated against HPV. In multivariate analyses, ever had sex was associated with awareness of HPV, and ever been to a gynaecologist with awareness of vaccination status. Our results may be an indication that female adolescents in Germany are not adequately informed and counselled about HPV and associated issues.