HPV vaccine uptake in men who have sex with men in Scotland

Human papillomavirus (HPV) vaccines are currently utilised globally in national immunisation programmes. In July 2017, a national HPV vaccine programme for men who have sex with men (MSM) was initiated across Scotland with vaccine being offered in the sexual health clinic setting. During the first year of this targeted vaccination programme, there were 5905 individuals who received at least one dose of HPV vaccine, representing 63.7% of eligible MSM attendees in this period. Vaccine uptake was relatively stable across all age groups (range 49.8–55.5%). The vaccination programme appears to have dovetailed well with pre-existing sexual health services and appears to be popular with MSM attending the service. The MSM HPV vaccine programme is a robust adjunct to the national girls programme but gender-neutral immunisation will reduce stigma and inequality in HPV-driven disease.     

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.     

Immunogenicity and safety of the 9-valent HPV vaccine in men

ObjectivesThis study was designed to evaluate the immunogenicity and tolerability of a prophylactic 9-valent HPV (types 6/11/16/18/31/33/45/52/58) VLP (9vHPV) vaccine in young men 16–26 years of age in comparison to young women 16–26 years of age (the population that was used to establish 9vHPV vaccine efficacy). Safety and immunogenicity data from this study will be used to bridge 9vHPV vaccine efficacy findings in 16–26 year old women to 16–26 year old men.MethodsThis study enrolled 1106 heterosexual men (HM) and 1101 women who had not yet received HPV vaccination. In addition, 313 men having sex with men (MSM) were enrolled and were evaluated separately for immunogenicity because previous results showed that antibody responses to quadrivalent HPV (types 6/11/16/18) VLP (qHPV) vaccine were lower in MSM than in HM. All subjects were administered a 3-dose regimen (Day 1, Month 2, Month 6) of 9vHPV vaccine. Serum samples were collected for anti-HPV assays. Safety information was collected for ∼12 months.ResultsThe geometric mean titers (GMTs) for HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 for HM were non-inferior to those of women at Month 7. For all vaccine HPV types, Month 7 GMTs were numerically lower in MSM than in HM. Over 99.5% of subjects were seropositive at Month 7 for each vaccine HPV type. Administration of 9vHPV vaccine to both 16–26 year old men and women was generally well tolerated.ConclusionsThese results support bridging the efficacy findings with 9vHPV vaccine in young women 16–26 years of age to men 16–26 years of age.     

Going social: Success in online recruitment of men who have sex with men for prevention HIV vaccine research

ObjectiveTo compare the use of four different social media sites to recruit men who have sex with men (MSM) and transgender women to a phase 2b HIV prevention vaccine trial, HVTN 505.DesignRetrospective, observational study.MethodsThe University of Pennsylvania HIV Vaccine Trials Unit (Penn HVTU) employed street outreach and online recruitment methods to recruit participants for HVTN 505 using a combination of national recruitment images/messages with Philadelphia-specific language and imagery. We compared the efficiency (number of enrolled participants per number of completed phone screens) and effectiveness (number of enrolled participants per time interval employed) of each strategy, as well as the demographics and risk behaviors of the populations.ResultsOnline recruitment strategies populated 37% (71/191) of trial participants at our site. Among the four social media strategies employed, 45.1% (32/71) were enrolled through Facebook, 16.9% (12/71) through Craigslist, 15.5% (11/71) through a web-based marketing company (WBMC), and 22.5% (16/71) via GRINDR. The number of participants enrolled per month of strategy and the months the strategy was employed were Facebook - 32(33 months), Craigslist - 12(33 months), WBMC - 11(6 months), and GRINDR - 16(0.56 months). In-person and online recruitment strategies yielded participants of similar demographics and levels of risk behavior.ConclusionUse of several social media recruitment modalities produced large numbers of MSM engaging in high risk behavior and willing to participate in an HIV prevention vaccine trial. In comparison to other social media and online strategies, recruitment via GRINDR was the most effective.     

Health beliefs and attitudes associated with HPV vaccine intention among young gay and bisexual men in the southeastern United States

Gay and bisexual men are at increased risk of anal cancer as a result of human papillomavirus (HPV) infection. Prophylactic vaccination is a potentially effective strategy for preventing anal cancer in this population. The purpose of this study was to identify factors associated with gay and bisexual men's intention to receive HPV vaccine. In the fall of 2010, 179 self-identified gay and bisexual men (mean age 22 years) completed an Internet-based questionnaire assessing beliefs and attitudes toward HPV vaccination. Men were recruited from college-based and Internet venues throughout the southeastern United States. The probability of intent to receive HPV vaccine was modeled using logistic regression. A majority of men (93%) had heard of HPV prior to participation but were generally unaware of the association of HPV with anal, penile, and oral cancers. Only 26% were aware of an HPV vaccine for males. Of the 179 participants, 64 (36%) were likely to be vaccinated. Men most likely to receive HPV vaccine perceived stronger physical and psychological benefits from vaccination and had more positive attitudes toward the vaccine. Conversely, intent to be vaccinated was negatively associated with concern over the financial cost of vaccination. Findings from this study can inform college-based health education programs aimed at increasing vaccine uptake among gay and bisexual men.     

Anal human papillomavirus infections in young unvaccinated men who have sex with men attending a sexual health clinic for HPV vaccination in Melbourne,Australia

The Victorian Government introduced a time-limited quadrivalent human papillomavirus (HPV) vaccination catch-up program targeting gay and bisexual men who have sex with men (MSM) aged up to 26 years in 2017. As of 2017, men aged ≥20 years were not eligible for the school-based HPV vaccination program. This study examined the prevalence of anal HPV among 496 MSM aged 20–26 years before they received the first dose of the HPV vaccine at the Melbourne Sexual Health Centre, Australia. More than half (56.5%) had any high-risk HPV genotypes detected in the anus. Almost half (43.1%) had at least one quadrivalent HPV vaccine-preventable genotype (6, 11, 16 or 18) and one-fifth (21.0%) had HPV 16 detected in the anus. These findings suggest that a targeted catch-up HPV vaccination program for MSM is still beneficial to protect against high-risk HPV genotypes associated with anal cancer, as well as low-risk HPV genotypes.     

Oral and oropharyngeal high-risk HPV prevalence,HIV status,and risk behaviours in a cohort of South African men who have sex with men

Data lag is evident when observing studies focussing on human papillomavirus (HPV) prevalence in the head and neck of men who have sex with men (MSM) in Southern Africa. Sexual behaviours other than anal intercourse, and associated factors are similarly underreported. HPV vaccination has not yet commenced for this population group. One hundred and ninety-nine MSM were enrolled in this study. Participants completed a questionnaire followed by a clinical oral examination, and a rinse-and-gargle specimen in Thinprep^® vials containing Preservcyt^® solution was collected. Detection and genotyping for high-risk HPV were done by an automated system (Abbott^® m2000sp). Six percent of MSM in this cohort had high-risk HPV present in the mouth/oropharynx. This cohort averages 29 years of age, more than half were unemployed (53.3%), and 66.8% were human immunodeficiency virus (HIV) seropositive. The most common sexual practice was anal sex (69.4%) followed by oral sex (28.6%), and by rimming (9.6%). A significant association between oral insertive sex and oral/oropharyngeal HPV status was demonstrated (p = 0.0038; phi coefficient = 0.20). An incidental but significant association between rimming and HIV status was found (p = 0.0046; phi coefficient = 0.19), and HIV seropositive participants had higher oral/oropharyngeal HPV presence. The HPV prevalence of 6% reported in this study is in alignment with global reports. The prevalence of oral/oropharyngeal HPV in this MSM cohort was influenced by sexual practices. MSM participants who practiced rimming appear to be at higher risk of HIV acquisition. Given the transmission routes of HPV in this vulnerable population, vaccination must be urgently studied as an intervention for prevention.     

Design and content validation of a survey questionnaire assessing the determinants of human papillomavirus (HPV) vaccine hesitancy in France: A reactive Delphi study

IntroductionThis study aimed to develop and undertake a preliminary validation of a French Survey Questionnaire for the Determinants of HPV Vaccine Hesitancy (FSQD-HPVH).MethodsWe undertook an electronic-based Delphi consultation among a panel of Francophone experts in two rounds. Round 1 consisted of the assessment of a structured questionnaire comprising of three parts ((i) Contextual influences, (ii) Individual and group influences, and (iii) Vaccine/vaccination-specific issues), in line with the WHO Strategic Advisory Group of Experts (SAGE) Vaccine Hesitancy (VH) Model of Determinants. Items included in this questionnaire were based on a literature review. Definitions of the factors included in the SAGE model were provided in the questionnaire. The panel of experts was asked to score each item using a 3-point Likert scale, in which 1 meant “Essential”, 2 “Useful but not essential”, and 3 “Not necessary”. The panel was also invited to comment on the clarity/comprehension of the questions and suggest reformulations/additional items. Lawshe's Content Validity Ratio (CVR) was computed to assess the level of consensus for each statement. Only items upon which agreement was not reached in Round 1 (CVR < 0.6) and newly proposed items were submitted for evaluation in Round 2, using the same procedure.ResultsFifteen experts completed the two rounds. Of 83 items evaluated in Round 1, 35 (42%) had a CVR ≥ 0.6 and were accepted without modification. In Round 2, 66 items were submitted to the same panel and consensus was reached for 22 (33%) items using the threshold of 0.6. The final FSQD-HPVH version includes 57 items.ConclusionThis study developed a survey instrument for the evaluation of HPV VH in France with good content validity. It will be used to assess the determinants of HPV VH, the first step towards an evidence-based approach to improving HPV vaccination rates in France.     

Mapping information exposure on social media to explain differences in HPV vaccine coverage in the United States

BackgroundTogether with access, acceptance of vaccines affects human papillomavirus (HPV) vaccine coverage, yet little is known about media’s role. Our aim was to determine whether measures of information exposure derived from Twitter could be used to explain differences in coverage in the United States.MethodsWe conducted an analysis of exposure to information about HPV vaccines on Twitter, derived from 273.8 million exposures to 258,418 tweets posted between 1 October 2013 and 30 October 2015. Tweets were classified by topic using machine learning methods. Proportional exposure to each topic was used to construct multivariable models for predicting state-level HPV vaccine coverage, and compared to multivariable models constructed using socioeconomic factors: poverty, education, and insurance. Outcome measures included correlations between coverage and the individual topics and socioeconomic factors; and differences in the predictive performance of the multivariable models.ResultsTopics corresponding to media controversies were most closely correlated with coverage (both positively and negatively); education and insurance were highest among socioeconomic indicators. Measures of information exposure explained 68% of the variance in one dose 2015 HPV vaccine coverage in females (males: 63%). In comparison, models based on socioeconomic factors explained 42% of the variance in females (males: 40%).ConclusionsMeasures of information exposure derived from Twitter explained differences in coverage that were not explained by socioeconomic factors. Vaccine coverage was lower in states where safety concerns, misinformation, and conspiracies made up higher proportions of exposures, suggesting that negative representations of vaccines in the media may reflect or influence vaccine acceptance.     

Human papillomavirus (HPV) vaccine coverage rates (VCRs) in France: A French claims data study

BackgroundThe French Cancer Plan 2014–2019 had a target of 60% HPV vaccine coverage. The PAPILLON study investigated the annual age-specific vaccination initiation rates and cumulative partial and complete vaccination rates in France from 2017 to 2022. It also identified the factors associated with vaccination in different age groups and those associated with the type of completion of the vaccination scheme (partial vs full vaccination).MethodsFor this publication, all females recorded in the French National Claims database who initiated HPV vaccination between 1 July 2007 and 31 December 2018 and were aged between 11 and 19 years at initiation were included. Annual HPV vaccination initiation rates were estimated in 11- to 14-year-old (target population) and 15- to 19-year-old females (catch-up). Cumulative vaccine coverage rates (VCRs) were estimated among those who were 15, 16, 20 and 21 years old. Partial vaccination was defined by dispensing of at least one dose of HPV vaccine by the pharmacy, while full vaccination was defined by two or three doses dispensed by a pharmacy over an 18-month period, according to current French recommendations based on the age at vaccination initiation.ResultsAmong the 465,629 females who initiated HPV vaccination in 2017 or 2018, the initiation rate increased from 7.7 to 11.1% in 11- to 14-year-old girls and from 4.5 to 6.5% in 15- to 19-year-old females. In 2017 and 2018, the cumulative VCRs for partial vaccination by age 15 were 28.2% and 32.8%, respectively, while by age 20, they were 41.6% and 38.8%. The cumulative VCRs for full vaccination were 15.6% and 18.6% by age 16, while they were 25.9 and 23.6% by age 20. HPV vaccination initiation and completion were strongly associated with the use of health services.ConclusionOverall, the HPV VCR substantively increased between 2017 and 2018, which is positive evidence of the resumption of vaccination. Updates in 2022 should confirm these results.     

Vaccine acceptability,uptake and completion amongst men who have sex with men: A systematic review,meta-analysis and theoretical framework

BackgroundDue to an increased risk of sexually transmitted infections (STIs), gay, bisexual and other men who have sex with men (MSM) have been recommended to receive vaccinations against human papillomavirus, meningitis C and hepatitis A/B. This review aimed to compare the rates of vaccine acceptability, uptake and completion, and to identify determinants of vaccine outcomes specific to MSM to inform a theoretical framework.MethodsIn January 2020 four databases were explored to identify vaccination behaviours and associated factors among MSM. A narrative systematic review and meta-analysis were performed. Data were synthesised for theoretical modelling.ResultsSeventy-eight studies, mostly from the USA, were included. The average vaccine acceptability was 63% (median = 72%, range: 30%-97%), vaccine uptake 45% (median = 42%, range: 5%-100%) and vaccine completion 47% (median = 45%, range: 12%-89%). Six categories of factors associated with vaccination acceptability, uptake and completion were conceptualised: Individual (e.g., demographic and psychosocial); Interpersonal (e.g., peer education); Healthcare provider (e.g., vaccine recommendation); Organisational and practice setting (e.g., routine collection of patient sexual orientation information that is integrated into a clinical decision support system); Community environment (e.g., targeted health promotion campaigns); and National, state and local policy environment (e.g., public health guidelines targeting MSM).ConclusionDespite overall high levels of acceptability, uptake and completion rates were below targets predicted by cost-effectiveness modelling across all recommended vaccines. These parameters may need to be adjusted for more precise estimations of cost-effectiveness. Addressing the multiple levels of determinants, as outlined in our theoretical framework, will help guide interventions to increase vaccine completion among MSM.     

福建省3市男男性行为者HIV-1感染率与新发感染率初探

目的了解福建省男男性行为（MSM）人群HIV-1感染的流行状况,为制定防治策略提供依据。方法对2010—2012年福州、泉州和厦门市哨点监测MSM人群进行问卷调查和HIV-1抗体筛查和确证,计算感染率;用BED HIV-1捕获酶联法对HIV抗体阳性样本进行检测,估算HIV-1血清阳转时间在168d内的新发感染率。结果 2010、2011和2012年福州、泉州和厦门市MSM人群HIV-1感染率分别为7.1%（39/553）、8.7%（94/1 078）和9.3%（95/1026）;在HIV抗体阳性者中,新发感染率分别为5.8%、2.2%和10.9%。结论 2010—2012年福建省3地市MSM人群HIV的感染率与新发感染率均达到较高水平,且有上升的趋势。     

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%).     

Declines in HPV vaccine type prevalence in women screened for cervical cancer in the United States: Evidence of direct and herd effects of vaccination

BackgroundHuman papillomavirus (HPV) vaccine has been recommended in the United States since 2006 for routine vaccination of girls at age 11–12 years and through age 26 years for women not previously vaccinated. Changes in vaccine-type HPV (VT) prevalence can be used to evaluate vaccine impact, including herd effects.MethodsWe determined type-specific HPV in cytology specimens from women aged 20–29 years screened for cervical cancer at Kaiser Permanente Northwest in 2007 and in two vaccine era periods: 2012–2013 and 2015–2016. Detection and typing used L1 consensus PCR with hybridization for 37 types, including quadrivalent vaccine types (HPV 6/11/16/18).ResultsAmong 20–24 year-olds in 2012–2013 and 2015–2016, 44% and 64% had a history of ≥1-dose vaccination. VT prevalence decreased from 13.1% in 2007 to 2.9% in 2015–2016 (prevalence ratio [PR] = 0.22; 95% confidence interval [CI] 0.17–0.29). HPV 31 prevalence was also lower in the vaccine periods compared with 2007. VT prevalence in 2015–2016 among 20–24 year-olds was lower in both vaccinated, 1.3% (PR = 0.10; 95% CI 0.06–0.16), and unvaccinated women, 5.8% (PR = 0.45; 95% CI 0.33–0.61). Among 25–29 year-olds, 21% and 32% had a history of ≥1-dose vaccination. VT prevalence decreased from 8.1% in 2007 to 5.0% in 2015–2016 (PR = 0.62; 95% CI 0.50–0.78). Non-VT high risk prevalence was higher in the vaccine periods compared with the pre-vaccine era in both age groups, however, not in 2015–2016 compared with 2012–2013.ConclusionWithin 9–10 years of vaccine introduction, VT prevalence decreased 78% among 20–24 year-olds and 38% in 25–29 year-olds. There were declines in both vaccinated and unvaccinated women, showing evidence of direct and herd protection.     

Temporal trends and determinants of COVID-19 vaccine coverage and series initiation during pregnancy in Ontario,Canada, December 2020 to December 2021: A population-based retrospective cohort study

BackgroundPopulation-based COVID-19 vaccine coverage estimates among pregnant individuals are limited. We assessed temporal patterns in vaccine coverage (≥1 dose before or during pregnancy) and evaluated factors associated with vaccine series initiation (receiving dose 1 during pregnancy) in Ontario, Canada.MethodsWe linked the provincial birth registry with COVID-19 vaccination records from December 14, 2020 to December 31, 2021 and assessed coverage rates among all pregnant individuals by month, age, and neighborhood sociodemographic characteristics. Among individuals who gave birth since April 2021—when pregnant people were prioritized for vaccination—we assessed associations between sociodemographic, behavioral, and pregnancy-related factors with vaccine series initiation using multivariable regression to estimate adjusted risk ratios (aRR) and risk differences (aRD) with 95% confidence intervals (CI).ResultsAmong 221,190 pregnant individuals, vaccine coverage increased to 71.2% by December 2021. Gaps in coverage across categories of age and sociodemographic characteristics decreased over time, but did not disappear. Lower vaccine series initiation was associated with lower age (<25 vs. 30–34 years: aRR 0.53, 95%CI 0.51–0.56), smoking (vs. non-smoking: 0.64, 0.61–0.67), no first trimester prenatal care visit (vs. visit: 0.80, 0.77–0.84), and residing in neighborhoods with the lowest income (vs. highest: 0.69, 0.67–0.71). Vaccine series initiation was marginally higher among individuals with pre-existing medical conditions (vs. no conditions: 1.07, 1.04–1.10).ConclusionsCOVID-19 vaccine coverage among pregnant individuals remained lower than in the general population, and there was lower vaccine initiation by multiple characteristics.     

Social media and HPV vaccination: Unsolicited public comments on a Facebook post by the Western Cape Department of Health provide insights into determinants of vaccine hesitancy in South Africa

On the 4 February 2019, the Western Cape Department of Health’s Facebook page announced the implementation of a school-based vaccination campaign aimed to administer the first doses of human papillomavirus (HPV) vaccine in public schools to Grade 4 girls who are nine years old. This announcement was met with a flurry of social media responses posted on the campaign’s Facebook page. This study identifies determinants of vaccine hesitancy amongst responses provided by social media users to this post. On 8 March 2019, we conducted a qualitative study including all 157 comments to the Facebook post. The post had 659 ‘emotion’ reactions: 574 “likes”, 62 “loves”, 21 “angry faces”, 2 “laughs”, 2 “wows” and 1 “sad face”. An overwhelming majority (636/659 i.e. 97%) of reactions were favourable to the HPV vaccination campaign. Out of the 157 comments, we judged 52 (33%) of them to be ‘hesitant’, suggesting that people with negative reactions though few in number, were more likely to be vocal deniers. Concern around the safety of HPV vaccines including effects on reproductive health was the most common theme identified. Other emerging themes included: risk of cervical cancer perceived as being low, issues around consent, concerns that girls are being used for research, questionable vaccine effectiveness, use of the school-based strategy for the campaign, risk-benefits calculations of HPV vaccination and constraints such as stock-outs. Knowing someone who had been affected or being at risk of cervical cancer, having knowledge about the causes of cervical cancer, confidence in the effectiveness and safety of the vaccine, knowing the vaccine was being used in high income settings, and having strong recommendations from the World Health Organisation and key actors seemed to increase the willingness to accept the vaccine. The magnitude and causes of HPV vaccine hesitancy need to be investigated to ensure the success of this programme.     

Human papillomavirus (HPV) vaccine uptake among a community-recruited sample of gay,bisexual, and other men who have sex with men in the three largest cities in Canada from 2017 to 2019

IntroductionIn 2015/2016, Canada’s largest provinces implemented publicly-funded human papillomavirus (HPV) vaccination programs for gay, bisexual, and other men who have sex with men (GBM) ≤ 26 years old. We sought to describe HPV vaccine uptake among GBM and determine barriers and facilitators to vaccine initiation with a focus on healthcare access and utilization.MethodsEngage is a cohort study among GBM aged 16 + years in three Canadian cities recruited from 2017 to 2019 via respondent driven sampling (RDS). Men completed a comprehensive questionnaire at baseline. By publicly-funded vaccine eligibility (≤26 years old = eligible for vaccination, ≥27 years old = ineligible), we described HPV vaccine uptake (initiation = 1 + dose, completion = 3 doses) and explored factors associated with vaccine initiation using Poisson regression. All analyses were weighted with the RDS-II Volz-Heckathorn estimator.ResultsAcross the three cities, 26–35% and 14–21% of men ≤ 26 years and 7–26% and 2–9% of men ≥ 27 years initiated and completed HPV vaccination, respectively. Vaccine initiation was significantly associated with STI/HIV testing or visiting a HIV care specialist in the past six months (≤26: prevalence ratio[PR] = 2.15, 95% confidence interval[CI] 1.06–4.36; ≥27: PR = 2.73, 95%CI 1.14–6.51) and past hepatitis A or B vaccination (≤26: PR = 2.88, 95%CI 1.64–5.05; ≥27: PR = 2.03, 95%CI 1.07–3.86). Among men ≥ 27 years old, vaccine initiation was also positively associated with accessing PrEP, living in Vancouver or Toronto, but negatively associated with identifying as Latin American and increasing age. Vaccine initiation was twice as likely among men ≥ 27 years with private insurance versus no insurance.ConclusionsSixty-five to 74% of men eligible for publicly-funded vaccine across the three cities remained unvaccinated against HPV by 2019. High vaccine cost may partly explain even lower uptake among men ≥ 27 years old. Men seeking sexual health care were more likely to initiate vaccination; bundling vaccination with these services may help improve HPV vaccine uptake.     

The contagious nature of a vaccine scare: How the introduction of HPV vaccination lifted and eroded MMR vaccination in Denmark

BackgroundHuman papillomavirus (HPV) vaccine coverage was high in Denmark until it plunged following negative media coverage. We examined whether the decline in HPV vaccination undermined uptake of another adolescent vaccine, measles, mumps and rubella (MMR).MethodsThe Danish national health register provided data on uptake of MMR vaccine dose 2 (at age 13) for children born from 1991 to 2003 (n = 827,716). The primary exposure variable comprised three time periods: before HPV vaccine introduction, during high HPV vaccine coverage, and after the drop in HPV vaccine coverage. To examine the effect of HPV vaccination on MMR2 uptake, we estimated MMR2 uptake by age 13 using logistic regression, controlling for gender, birth month, birth year, and maternal education.FindingsMMR2 vaccination coverage was high for both girls and boys (86% and 85%) in 2009. Following the introduction of HPV vaccine for girls in 2009, MMR2 coverage increased for girls even as it decreased for boys (gender gap 4·6 percentage points, 95% CI 4·3 to 4·8). Coverage with MMR2 for girls continued to be high over the following four years, and almost all girls (91%) who received MMR2 vaccination also received HPV1 vaccination within the same week. When negative media coverage led to a decline in HPV vaccination, MMR2 uptake for girls also declined. By 2015, MMR2 coverage for girls and boys had become similar again (80% and 79%). Families with the highest level of maternal education showed the strongest decline in MMR2 coverage for girls.InterpretationConcomitant vaccine provision can increase overall vaccine uptake. However, reduced demand for one vaccine may reduce concomitant vaccination and undermine resiliency of a country’s vaccination program.FundingDrs. Gørtz and Ejrnæs appreciate generous funding from the Novo Nordisk Foundation (grant no. NNF17OC0026542) and from the Danish National Research Foundation through its grant (DNRF-134) to the Center for Economic Behavior and Inequality (CEBI) at the University of Copenhagen.     

Human papillomavirus (HPV) vaccine implementation in low and middle-income countries (LMICs): Health system experiences and prospects

Prophylactic vaccines for human papillomavirus (HPV) are being introduced in many countries for the prevention of cervical cancer, the second most important cause of cancer-related death in women globally. This is likely to have a significant impact on the future burden of cervical cancer, particularly where screening is non-existent or limited in scale. Previous research on the challenges of vaccinating girls with the HPV vaccine has focused on evidence from developed countries. We conducted a systematic search of the literature in order to describe the barriers and challenges to implementation of HPV vaccine in low- and middle-income countries. We identified literature published post-2006 to September 2012 from five major databases. We validated the findings of the literature review with evidence from qualitative key informant interviews. Three key barriers to HPV vaccine implementation were identified: sociocultural, health systems and political. A linked theme, the sustainability of HPV vaccines programmes in low- and middle-income countries, cuts across these three barriers. Delivering HPV vaccine successfully will require multiple barriers to be addressed. Earlier research in developed countries emphasised sociocultural issues as the most significant barriers for vaccine roll-out. Our evidence suggests that the range of challenges for poorer countries is significantly greater, not least the challenge of reaching girls for three doses in settings where school attendance is low and/or irregular. Financial and political barriers to HPV vaccine roll-out continue to be significant for many poorer countries. Several demonstration and pilot projects have achieved high rates of acceptability and coverage and lessons learned should be documented and shared.