Human Papillomavirus Vaccination Among Young Adult Gay and Bisexual Men in the United States

Objectives. We examined human papillomavirus (HPV) vaccination among gay and bisexual men, a population with high rates of HPV infection and HPV-related disease.Methods. A national sample of gay and bisexual men aged 18 to 26 years (n = 428) completed online surveys in fall 2013. We identified correlates of HPV vaccination using multivariate logistic regression.Results. Overall, 13% of participants had received any doses of the HPV vaccine. About 83% who had received a health care provider recommendation for vaccination were vaccinated, compared with only 5% without a recommendation (P < .001). Vaccination was lower among participants who perceived greater barriers to getting vaccinated (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.27, 0.78). Vaccination was higher among participants with higher levels of worry about getting HPV-related disease (OR = 1.54; 95% CI =  1.05, 2.27) or perceived positive social norms of HPV vaccination (OR = 1.57; 95% CI =  1.02, 2.43).Conclusions. HPV vaccine coverage is low among gay and bisexual men in the United States. Future efforts should focus on increasing provider recommendation for vaccination and should target other modifiable factors.Oncogenic human papillomavirus (HPV) types (mainly types 16 and 18) cause an estimated 93% of anal cancers, 63% of oropharyngeal cancers, and 36% of penile cancers among men in the United States.1 Nononcogenic HPV types 6 and 11 cause almost all anogenital warts.2 Gay and bisexual men have high rates of HPV infection and HPV-related disease. A recent review suggests that more than 50% of HIV-negative gay and bisexual men have an anogenital HPV infection.3 About 7% of gay and bisexual men report a history of genital warts.4 Anal cancer is also of great concern, with incidence among HIV-negative gay and bisexual men estimated to be 35 cases per 100 000 population.5 The anal cancer incidence rate among all men in the United States is just 1.6 cases per 100 000 population.6US guidelines began including the quadrivalent HPV vaccine (against HPV types 6, 11, 16, and 18) for males in October 2009.7 The Advisory Committee on Immunization Practices (ACIP) first provided a permissive recommendation that allowed the HPV vaccine to be given to males aged 9 to 26 years but did not include the vaccine in their routine vaccination schedule.7 In October 2011, the ACIP began recommending routine vaccination for boys aged 11 to 12 years with catch-up vaccination for males aged 13 to 21 years.8 Importantly, the ACIP recommends HPV vaccination for men who have sex with men through age 26 years.8The HPV vaccine series consists of 3 doses, with the second dose administered 1 to 2 months after the first dose, and the third dose is administered 6 months after the first dose.7 The quadrivalent HPV vaccine is currently approved to protect males against genital warts and anal cancer.9 Despite recommendations, recent data suggest that fewer than 21% of males in the United States have received any doses of the HPV vaccine.10–14Although several HPV-related disparities exist among gay and bisexual men, little research has addressed HPV vaccination among this population. Past studies have shown that knowledge about HPV and the HPV vaccine tends to be modest among gay and bisexual men.15–19 Many gay and bisexual men have indicated their willingness to get the HPV vaccine, with estimates ranging from 36% to 86%.16,18–20 Data on actual HPV vaccine coverage are sparse; a past study found only 7% of 68 young adult gay and bisexual men had received any doses of the HPV vaccine.11 This study was, however, conducted before the ACIP recommendation for routine vaccination of males.We built on this past research by examining HPV vaccination among a national sample of young adult gay and bisexual men in the recommended age range for HPV vaccination (18–26 years). We identified correlates of vaccination and why young adult gay and bisexual men are not getting the HPV vaccine. These data will help inform future programs for increasing HPV vaccination among this high-risk population.     

Prevalence of Anogenital Warts Among Participants in Private Health Plans in the United States, 2003–2010: Potential Impact of Human Papillomavirus Vaccination

Objectives. We estimated anogenital wart prevalence from 2003 to 2010 by gender and age group in a large US cohort with private insurance to detect potential decreases among people most likely to be affected by human papillomavirus (HPV) vaccination.Methods. We restricted health care claims to those from individuals aged 10 to 39 years with continuous insurance within a given year. We derived anogenital wart diagnoses from a diagnosis of condyloma acuminata, or either a less specific viral wart diagnosis or genital wart medication combined with either a benign anogenital neoplasm or destruction or excision of a noncervical anogenital lesion.Results. Prevalence increased slightly in 2003 to 2006, then significantly declined in 2007 to 2010 among girls aged 15 to 19 years; increased in 2003 to 2007, remained level through 2009, and declined in 2010 among women aged 20 to 24 years; and increased through 2009 but not in 2010 for women aged 25 to 39 years. For males aged 15 to 39 years, prevalence for each 5-year age group increased in 2003 to 2009, but no increases were observed for 2010.Conclusions. These data indicate reductions in anogenital warts among US females aged 15 to 24 years, the age group most likely to be affected by introduction of the HPV vaccine.In mid-2006, a quadrivalent human papillomavirus (HPV) vaccine was licensed in the United States for females (Merck & Co., Inc., Whitehouse Station, NJ). This vaccine is specific against HPV types 16 and 18, which cause approximately 70% of cervical cancers worldwide,1,2 as well as types 6 and 11, which are nononcogenic but can cause benign cervical lesions and anogenital warts.1,3,4 A bivalent vaccine (GlaxoSmithKline, Research Triangle Park, NC), specific for only HPV types 16 and 18, was licensed in late 2009. These vaccines are routinely recommended for girls aged 11 to 12 years, with catch-up vaccination through age 26 years.5,6 In late 2011, the quadrivalent vaccine was recommended for boys aged 11 to 12, with catch-up vaccination through age 21 years.7,8 However, HPV vaccine uptake in the United States is relatively low. In 2011, a national survey found that 53% of girls aged 13 to 17 years had received at least 1 dose of the HPV vaccine series, but only 35% had received all 3 doses.9 Vaccine uptake was extremely low among boys.9Postlicensure monitoring of new vaccines is important to assess the progress of immunization programs, demonstrate population impact, and evaluate policy needs.10–14 Clinical trials have demonstrated the prophylactic efficacy of the quadrivalent HPV vaccine,15,16 and questions of interest about currently available HPV vaccines now center on population effectiveness and cost-effectiveness.17 However, several factors complicate efforts to monitor the population impact of HPV vaccine, including multiple clinical outcomes and variable, often extended, time to outcome development.10,12,14 Cervical cancer is the most important anogenital outcome of HPV infection and may take several decades to develop.18 Cervical intraepithelial neoplasia and adenocarcinoma in situ are the most common cervical cancer precursor lesions, often occurring 1 to 3 years after HPV infection.19–22 In contrast to these outcomes, anogenital warts can develop within months of HPV infection, and therefore monitoring changes in anogenital wart diagnoses can be used to assess the most immediate impact of HPV vaccination.19The objective of this analysis was to estimate annual prevalence of anogenital wart diagnoses during 2003 to 2010 in a large group of privately insured patients, by gender and age group, to detect potential decreases among people most likely to be affected by quadrivalent HPV vaccination.     

Quadrivalent Human Papillomavirus Vaccine Uptake in Adolescent Boys and Maternal Utilization of Preventive Care and History of Sexually Transmitted Infections

Objectives. We examined whether maternal utilization of preventive care and history of sexually transmitted infections (STIs) predicted quadrivalent human papillomavirus vaccine (HPV4) uptake among adolescent boys 1 year following the recommendation for permissive use of HPV4 for males.Methods. We linked maternal information with electronic health records of 254 489 boys aged 9 to 17 years who enrolled in Kaiser Permanente Southern California health plan from October 21, 2009, through December 21, 2010. We used multivariable Poisson regression with robust error variance to examine whether HPV4 initiation was associated with maternal uptake of influenza vaccine, Papanicolaou (Pap) screening, and history of STIs.Results. We identified a modest but statistically significant association between initiation of HPV4 series and maternal receipt of influenza vaccine (rate ratio [RR] = 1.16; 95% confidence interval [CI] = 1.07, 1.26) and Pap screening (RR = 1.13; 95% CI = 1.01, 1.26). Boys whose mothers had a history of genital warts were more likely to initiate HPV4 (RR = 1.47; 95% CI = 0.93, 2.34), although the association did not reach statistical significance (P = .1).Conclusions. Maternal utilization of preventive care and history of genital warts may influence HPV4 uptake among adolescent boys. The important role of maternal health characteristics and health behaviors needs be considered in intervention efforts to increase vaccine uptake among boys.In October 2009, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommended that quadrivalent human papillomavirus vaccine (HPV4) may be given to males aged 9 to 26 years at the discretion of the patient’s health care provider (permissive use) to reduce the likelihood of acquiring genital warts (condyloma acuminata).1 However, uptake among eligible males was low following this recommendation for permissive use, with only an estimated 2% of male adolescents initiating the vaccine.2 As the national data indicated that uptake among females remained suboptimal for a few years following the recommendation for routine vaccination in females,3 human papillomavirus (HPV) vaccination of males offers an opportunity to achieve herd immunity in the whole population. On the basis of these considerations and the clinical trial data indicating HPV4’s high efficacy for prevention of genital warts and grade 2 or 3 anal intraepithelial neoplasia (AIN2/3, a precursor of anal cancer) in males, in October 2011, the ACIP recommended routine use of HPV4 in boys aged 11 or 12 years. The ACIP also recommended vaccination with HPV4 for males aged 13 through 21 years who have not been vaccinated previously or who have not completed the 3-dose series; men aged 22 through 26 years may be vaccinated.4Parents are involved in deciding whether their adolescent children get vaccinated regardless of whether the vaccine is recommended for routine use, because parental consent is typically required for adolescent HPV vaccination.5,6 Previous experience with HPV vaccination in female adolescents suggests that the decision to vaccinate their children with HPV vaccines is often affected by parents’ knowledge about HPV infection, attitudes toward the vaccine, and parental history of sexually transmitted infections (STIs) or HPV-related disease.7,8 In a previous study, we found that mothers’ Papanicolaou (Pap) screening behavior was associated with their daughters’ uptake of HPV4 in an insured population.9 Therefore, we hypothesized that previous maternal utilization of Pap screening might reflect a positive attitude toward prevention of HPV infection. In addition, mothers with a history of STIs, especially genital warts, might be familiar with preventive measures for HPV infection, which might influence their decision to vaccinate their children with HPV4 vaccine. We hypothesized that this influence might be even more important for HPV4 uptake among adolescent boys when the vaccine was initially recommended for permissive use among males in the United States.In this study, we sought to determine whether initiation of HPV4 in a large cohort of insured boys aged 9 to 17 years was associated with maternal utilization of preventive care and history of STIs during the time period when the vaccine was indicated for permissive use in males.     

Longitudinal Predictors of Human Papillomavirus Vaccination Among a National Sample of Adolescent Males

Objectives. We conducted a longitudinal study to examine human papillomavirus (HPV) vaccine uptake among male adolescents and to identify vaccination predictors.Methods. In fall 2010 and 2011, a national sample of parents with sons aged 11 to 17 years (n = 327) and their sons (n = 228) completed online surveys. We used logistic regression to identify predictors of HPV vaccination that occurred between baseline and follow-up.Results. Only 2% of sons had received any doses of HPV vaccine at baseline, with an increase to 8% by follow-up. About 55% of parents who had ever received a doctor’s recommendation to get their sons HPV vaccine did vaccinate between baseline and follow-up, compared with only 1% of parents without a recommendation. Fathers (odds ratio = 0.29; 95% confidence interval = 0.09, 0.80) and non-Hispanic White parents (odds ratio = 0.29; 95% confidence interval = 0.11, 0.76) were less likely to have vaccinated sons. Willingness to get sons HPV vaccine decreased from baseline to follow-up among parents (P < .001) and sons (P = .003).Conclusions. Vaccination against HPV remained low in our study and willingness to vaccinate may be decreasing. Physician recommendation and education about HPV vaccine for males may be key strategies for improving vaccination.Quadrivalent human papillomavirus (HPV) vaccine against types 6, 11, 16, and 18 is approved to protect against genital warts (caused mostly by HPV types 6 and 111) and anal cancer (caused mostly by HPV types 16 and 182) in males.3 About 4% of men in the United States report a previous diagnosis of genital warts,4 and about 2250 new cases of anal cancer occur annually among males in the United States.5 Given the high levels of HPV concordance among sexual partners,6 vaccinating males may also have indirect health benefits for their partners.7 United States guidelines began including HPV vaccine for males in October 2009.8 The Advisory Committee on Immunization Practices first provided a permissive recommendation, recommending the 3-dose quadrivalent vaccine series for males aged 9 to 26 years but not making it part of their routine vaccination schedule.8 In October 2011, the Advisory Committee on Immunization Practices updated its stance on HPV vaccine for males and recommended routine vaccination of boys aged 11 to 12 years with catch-up vaccination for males aged 13 to 21 years.9 The updated recommendation continues to allow HPV vaccine to be given to males aged as young as 9 years and up to 26 years.9Although numerous studies have examined HPV vaccine uptake among females,10 data on HPV vaccine uptake among males are sparse. Despite mostly encouraging early levels of parental acceptability of the vaccine for males,11–13 initial estimates found that only about 2% of male adolescents in the United States had received any doses of HPV vaccine by the end of 2010.14,15 Recent data suggest that this increased to about 8% by the end of 2011.16 We are not aware of any studies that have examined predictors of vaccine uptake among males.Our study addresses several important gaps in the existing literature. We provide the first longitudinal examination of HPV vaccination among males and identify predictors of vaccine uptake. In doing so, we used data from both parents and their adolescent sons because many adolescents are involved in vaccination decisions.17 We also examined longitudinal changes in vaccine acceptability among parents and sons and parents’ reasons for not getting their sons HPV vaccine, because these data may provide valuable insight about future HPV vaccine uptake among males.     

Insurance Continuity and Human Papillomavirus Vaccine Uptake in Oregon and California Federally Qualified Health Centers

Objectives. We examined the association between insurance continuity and human papillomavirus (HPV) vaccine uptake in a network of federally qualified health clinics (FQHCs).Methods. We analyzed retrospective electronic health record data for females, aged 9–26 years in 2008 through 2010. Based on electronic health record insurance coverage information, patients were categorized by percent of time insured during the study period (0%, 1%–32%, 33%–65%, 66%–99%, or 100%). We used bilevel multivariable Poisson regression to compare vaccine-initiation prevalence between insurance groups, stratified by race/ethnicity and age. We also examined vaccine series completion among initiators who had at least 12 months to complete all 3 doses.Results. Significant interactions were observed between insurance category, age, and race/ethnicity. Juxtaposed with their continuously insured peers, patients were less likely to initiate the HPV vaccine if they were insured for less than 66% of the study period, aged 13 years or older, and identified as a racial/ethnic minority. Insurance coverage was not associated with vaccine series completion.Conclusions. Disparities in vaccine uptake by insurance status were present in the FQHCs studied here, despite the fact that HPV vaccines are available to many patients regardless of ability to pay.Cervical cancer is a significant public health challenge in the United States. Approximately 12 300 women were expected to be diagnosed with cervical cancer in 2013, and 4030 were expected to die from the disease.1 The burden of cervical cancer disproportionately affects minority, low-income, and uninsured populations.2–4 The primary risk factor for virtually all cervical cancer is infection with certain types of human papillomavirus (HPV). Effective vaccines have been developed against HPV-16 and HPV-18, which alone are responsible for approximately 70% of cervical cancer cases.5–7 These vaccines hold great potential for reducing disparities in cervical cancer morbidity and mortality, if utilization can be encouraged in populations most at risk for cervical cancer.Federally Qualified Health Centers (FQHCs) serve the primary health care needs of more than 20 million patients in the United States, many of whom are low income, minorities or uninsured,8 and are thus an ideal setting in which to study the utilization of HPV vaccination among populations at highest risk for cervical cancer.9 However, few investigators have directly examined HPV vaccination rates in such settings,9–11 in part because of a lack of readily available data. Consequently, factors affecting HPV vaccine uptake in FQHCs are not well understood. In particular, the role of insurance coverage remains unclear.To date, studies of HPV vaccination rates in FQHCs have modeled insurance as a static variable, determined at a single visit or at the time services were rendered.9–11 This approach might be unsuitable when considering the association between insurance and HPV vaccine series completion, which requires multiple visits over several months,12 and may not accurately reflect the experience of FQHC patients whose coverage can change frequently affecting health care utilization.13–16 Furthermore, defining insurance status from a single visit prevents consideration of insurance duration or coverage continuity as potential factors influencing vaccine uptake. Among Medicaid enrolled patients, who constitute almost 40% of FQHC patients nationally,8 duration of insurance enrollment has been associated with HPV vaccine initiation, with longer enrollment being a predictor for initiating the vaccine series.17,18 Other researchers have demonstrated that, compared with being uninsured or sporadically insured, having continuous insurance coverage is positively associated with the receipt of preventive services in FQHCs, despite the fact that patients can receive care regardless of insurance coverage in these settings.16,19,20Existing studies of HPV vaccination in FQHCs have also been limited to patients younger than 19 years,9–11 precluding examination of insurance effects across the full age range for which the vaccine is recommended (9–26 years).12 In FQHC settings, the role insurance plays in vaccine uptake likely differs with age, as HPV vaccine is free for eligible children and adolescents younger than 19 years through the federal Vaccine for Children (VFC) program,21 but no similar program exists for patients aged 19 to 26 years. A better understanding of how insurance coverage and other factors affect uptake among female FQHC patients aged 19 to 26 years is needed to allow design of future interventions to reduce cervical cancer disparities in underserved populations.We leveraged electronic health record (EHR) data from a network of FQHCs to examine the association between insurance continuity and HPV vaccination in a large cohort of female patients (9–26 years of age) who accessed care between 2008 and 2010. We hypothesized that HPV vaccine uptake in our study population would be affected by insurance continuity, with lower rates of vaccine series initiation and completion among uninsured and discontinuously insured patients, compared with the continuously insured. We also hypothesized that insurance-related disparities would be most pronounced among women older than 18 years, who are ineligible for VFC. Our study helps fill a gap in published research by assessing the uptake of HPV vaccine in FQHC patients, including those older than 18 years, and applying EHRs to gather objective longitudinal data on insurance coverage and HPV vaccination rates in this population.     

Receipt of human papillomavirus vaccine among privately insured adult women in a U.S. Midwestern Health Maintenance Organization

Objectives

To describe human papillomavirus (HPV) vaccine coverage among adult privately insured women including variation in coverage by race/ethnicity.

Methods

This cross-sectional, observational study included women 18–26 years of age with continuous enrollment in a U.S. Midwestern health insurance plan and at least one visit to a plan affiliated practice. Vaccination data came from insurance claims and the electronic medical record. Primary outcomes were: receipt of at least 1 HPV vaccine (HPV1) and completion of the 3-dose HPV vaccine series (HPV3). Coverage was described for the entire cohort and stratified by race/ethnicity. For a subset of women, automated data was compared to personal recall.

Results

As of June 2010, among 2546 privately insured women 18–26 years, 72.7% had received their first HPV vaccine and 57.9% completed the 3-dose series. Compared to white women, African American and Asian women had significantly lower coverage for HPV1 and HPV3. There was 94.5% (95% CI: 88.5–100%) agreement between personal recall and claims/EMR for receiving HPV1.

Conclusions

In this cohort of privately insured women, a majority received HPV1 and more than half completed the 3-dose vaccine series. Marked disparities in receipt of HPV vaccine by race/ethnicity were observed.     

Intent to receive HPV vaccine and reasons for not vaccinating among unvaccinated adolescent and young women: findings from the 2006-2008 National Survey of Family Growth

Background and purpose

HPV vaccine coverage for females has increased in the U.S., although challenges to achieving high coverage remain. HPV vaccine coverage continues to lag behind that of other routinely recommended adolescent vaccines and these gaps in coverage are widening. To inform strategies to improve uptake, we explore correlates of vaccine intention and describe reasons for refusing HPV vaccination among unvaccinated females in a nationally representative sample of adolescents and young adults during early stages of HPV vaccine availability.

Methods

In 2007–2008, 1243 females aged 15–24 years were asked about HPV vaccination in the National Survey of Family Growth (NSFG). For unvaccinated women (n = 955), we evaluated demographic and sexual behavior correlates of likelihood to receive the vaccine in the next 12 months in bivariate and multivariable analyses by age. Correlates to the main reasons for foregoing vaccination are described.

Results

A minority (42.5%) of unvaccinated respondents said they intended to receive HPV vaccine in the next 12 months: 37.6% of adolescents (15–19 years) and 42.0% of young adults (20–24 years). Sexually experienced women were more than twice as likely as non-sexually experienced women to intend to receive HPV vaccine (15–19 years: aOR = 2.39, 95% CI = 1.15, 4.94; 20–24 years: aOR = 2.17, 95% CI = 1.08, 4.33). Having health insurance was associated with being likely to receive HPV vaccine among adolescents. Hispanic young adults were more likely than non-Hispanic Whites to be likely to receive HPV vaccine. The belief of not being at risk for HPV and institutional barriers were the two most commonly cited reasons for foregoing vaccination.Among unvaccinated women who did not intend to get vaccinated, respondents who never had sex were more likely to report not being at risk as the main reason for not needing the vaccine compared to women with sexual experience (44.5 vs. 24.4%) but this finding was only marginally significant in our limited sample.

Conclusion

In the first years immediately post-licensure of an HPV vaccine, the majority of unvaccinated women indicated that they were unlikely to seek vaccination. Intent to receive the HPV vaccine is tied to sexual experience and most women who do not intend to get vaccinated and have never had sex believe they are not at risk of HPV or do not need an HPV vaccine. These findings highlight the need to better communicate information regarding lifetime risk for HPV and the importance of receiving HPV vaccine prior to sexual initiation. These findings should inform strategies to increase vaccine uptake.     

Vaccination Interest and Trends in Human Papillomavirus Vaccine Uptake in Young Adult Women Aged 18 to 26 Years in the United States: An Analysis Using the 2008–2012 National Health Interview Survey

Objectives. Human papillomavirus (HPV) vaccines have been approved since 2006, yet vaccination rates remain low. We investigated HPV vaccination trends, interest, and reasons for nonvaccination in young adult women.Methods. We used data from the 2008–2012 National Health Interview Survey to analyze HPV vaccine uptake trends (≥ 1 dose) in women aged 18 to 26 years. We used data from the 2008 and 2010 National Health Interview Survey to examine HPV vaccination interest and reasons for nonvaccination among unvaccinated women.Results. We saw significant increases in HPV vaccination for all young women from 2008 to 2012 (11.6% to 34.1%); however, Hispanics and women with limited access to care continued to have lower vaccination rates. Logistic regression demonstrated lower vaccination interest among unvaccinated women in 2010 than 2008. Respondents in 2010 were significantly less likely to give lack of knowledge as a primary reason for nonvaccination.Conclusions. Uptake of HPV vaccine has increased from 2008 to 2012 in young women. Yet vaccination rates remain low, especially among women with limited access to care. However, unvaccinated women with limited health care access were more likely to be interested in receiving the vaccine.Human papillomavirus (HPV) is widespread among young females in the United States, with an estimated prevalence of 59.8% in women aged 20 to 24 years in 2007 to 2010.1 Persistent infection with high-risk strains of HPV has been linked to development of certain cancers, including cervical, oropharyngeal, and anal cancers, with an estimated 13.2 per 100 000 women diagnosed annually with HPV-associated cancers between 2004 and 2008.2 Since 2006, 2 HPV vaccines have been approved by the Food and Drug Administration that safely3 and effectively1 prevent infection with several high-risk HPV strains.2Since 2006, the Advisory Committee on Immunization Practices has recommended that 3 doses of the HPV vaccine be administered to young females aged 11 to 26 years, with a focus on early vaccination.4,5 Data for 18- to 26-year-old women from the adult version of the 2007 National Immunization Survey estimated that 10% of young women had initiated the HPV vaccination series.6 For the same year, vaccine initiation among California women aged 18 to 27 years was estimated to be 11.0%.7 In 2011, vaccination rates (≥ 1 dose) among young women aged 19 to 26 years had increased to 29.5%.8 Vaccination rates for adolescents were more favorable (53.8% for ≥ 1 dose, 33.4% for ≥ 3 doses for 13- to 17-year-old adolescents in 2012³), but are far from the national goal of 80% vaccination completion for 13- to 15-year-old adolescents by 2020.9Despite these low vaccine initiation and even lower completion rates, few studies have examined reasons for nonvaccination of young adult women, and no study has specifically studied how these reasons may have changed over time.6,10–13 A recent study focusing on parental attitudes showed an increase in parents not intending to vaccinate adolescent daughters and citing safety concerns as one of the main reasons for nonvaccination.14 Furthermore, previous studies of trends in HPV vaccination have focused primarily on adolescents.3,15,16 However, with high levels of nonvaccination continuing in 2011 for both the main target group and young adults, it is critical to understand trends in vaccination and risk factors for nonvaccination in this age group, as these young women can still benefit from receiving the HPV vaccine and promote greater herd immunity.Therefore, using nationally representative data from the National Health Interview Survey (NHIS) for young women, our aim was to (1) estimate trends in HPV vaccination uptake (≥ 1 dose) in women aged 18 to 26 years from 2008 to 2012, (2) examine HPV vaccination interest among young unvaccinated women in 2008 and 2010, and (3) investigate reasons for nonvaccination among women who were not interested in receiving the vaccine in 2008 and 2010. Both vaccination interest, defined as whether an unvaccinated woman was interested in receiving the HPV vaccine in the survey, and reasons for nonvaccination for unvaccinated women, who were not interested or undecided, were only assessed in the 2008 and 2010 NHIS.     

Protecting our patients from HPV and HPV-related diseases: the role of vaccines

The clinical burden of disease resulting from human papillomavirus (HPV) infection is substantial and extends from genital warts to cytologic abnormalities to cervical, vaginal, and vulvar cancers and their associated precursor lesions. In addition, HPV is implicated in anal, penile, and head and neck cancers. Thus, HPV-related disease constitutes a significant burden for both men and women. Large phase 2 and 3 clinical trials with a quadrivalent preventive HPV vaccine (HPV 6/11/16/18) and phase 2 trials with a bivalent preventive HPV vaccine (HPV 16/18) have demonstrated that both products are highly efficacious in preventing type-specific HPV infections and HPV-related disease and are well tolerated. Nearly all recipients demonstrate a robust immunologic response that currently appears to be durable for 4 or more years. Immunogenicity data among girls 9 to 15 years of age were used to "bridge" efficacy data from quadrivalent HPV vaccine trials completed to date. In June 2006, the US Food and Drug Administration approved the quadrivalent HPV vaccine for use among females 9 to 26 years of age. The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices has recommended the 3-dose series for girls 11 to 12 years of age, catch-up vaccination for girls and women 13 to 26 years of age, and permissive use as early as age 9. Computer models projecting the impact of these preventive HPV vaccines predict that they will be cost-effective and beneficial to the population; the use of preventive HPV vaccines will complement continued cytologic screening programs. Trials are under way to evaluate the duration of immune response as well as efficacy among men and women 27 years of age and older. Girls and women within the targeted age ranges should be offered vaccination to achieve the disease prevention potential of these vaccines.     

Weight Status and Sexual Orientation: Differences by Age and Within Racial and Ethnic Subgroups

Objectives. We determined differences in weight at age 18 years and at current age and weight change by sexual orientation within different racial/ethnic populations, stratifying by gender.Methods. We used 2001–2007 data from the California Health Interview Survey, resulting in an unweighted sample of 120 274 individuals aged 18 to 74 years. Using regression models, we examined overweight status and change in weight by sexual orientation, stratifying by race/ethnicity and gender.Results. Compared with heterosexual women of the same race/ethnicity, White and African American lesbians and bisexuals had increased likelihood of being overweight at age 18 years and maintaining overweight status during adulthood. Sexual minority status was unrelated to weight among Latinas and inconsistently linked to weight among Asian women compared with heterosexual women of the same race/ethnicity. Sexual minority status was protective against unhealthy weight among White, African American, Asian, and Latino men compared with heterosexual counterparts of the same race/ethnicity. This protective effect was seen after age 18 years except among African American bisexual men.Conclusions. Our findings indicate a need for age- and culture-sensitive interventions that reduce weight or prevent weight gain in sexual minority women and men.Obesity is among the most pressing public health issues facing the nation because of the numerous health risks associated with this condition.1 Despite public health efforts, the prevalence of obesity has continued to increase, rising to 68% in the general population.2 Obesity affects some population groups more than others, in that it has been linked to gender, race/ethnicity, and socioeconomic status.3–6 More women than men are obese. Among both genders, Asian individuals have the lowest prevalence of obesity (11.6% for both sexes), followed by non-Hispanic Whites (33% for women and 31% for men) and Mexican Americans (43% for women and 32% for men); non-Hispanic Blacks have the highest prevalence of obesity (51% in women and 37% in men).4,7 The prevalence of obesity among men is about the same for all income and educational levels; among women, those with higher income and greater educational attainment are less likely to be obese than women with less education and lower income.6Research has also linked obesity to sexual orientation. Compared with heterosexual men, gay and bisexual men have a lower body mass index (BMI; defined as weight in kilograms divided by the square of height in meters)8,9 and decreased odds of being overweight or obese.10,11 For women, the relationship between sexual orientation and weight is inverse: studies have consistently concluded that lesbian women have an increased likelihood of overweight and obesity compared with heterosexual women.12–19 Some evidence suggests that the weight disparity between sexual orientation groups may begin at an early age. In a group of predominantly White adolescents, sexual minority females had consistently increased BMI throughout adolescence compared with heterosexual females, whereas sexual minority males had decreased BMI in late adolescence compared with heterosexual males.20 Moreover, data from the Nurses’ Health Study II, a predominantly White cohort, showed that lesbian and bisexual women had significantly greater prevalence of overweight or obesity at age 18 years14 and had an adverse weight gain trajectory from ages 25 to 59 years21 compared with heterosexual women in this cohort.The available evidence establishes the existence of weight disparities by sexual orientation and a need for interventions for sexual minority women. However, there is insufficient information for the planning of targeted interventions, because we know little about the onset of the weight disparity by sexual orientation within a generalizable population of men and women. Furthermore, the racial/ethnic patterns of obesity are understudied in sexual minority populations. To assist program planners in the development of interventions for the most appropriate target groups, we sought to improve the knowledge on these 2 aspects.To generate information about the most appropriate age cohort to be targeted by interventions, we focused first on the relationship between sexual minority status and weight at age 18 years and subsequently assessed this relationship at current adult age. This approach identified whether adult lesbians’ greater likelihood, and gay and bisexual men’s lower likelihood, of overweight and obesity compared with heterosexual populations is already present at age 18 years or acquired during adulthood. Consistent with the recent Institute of Medicine report on lesbian, gay, bisexual, and transgender health, we sought to advance knowledge about obesity by focusing on the intersection of sexual minority status and race/ethnicity.22 This approach recognizes the diversity of sexual minorities, and that among both female and male sexual minorities, the prevalence of obesity may differ by race and ethnicity. To provide data on the intersection of sexual minority status and race/ethnicity for men and women, we examined weight differences by sexual orientation within each racial and ethnic group, focusing on the time periods age 18 years and current age.     

Human papillomavirus (HPV) vaccination and subsequent sexual behaviour: Evidence from a large survey of Nordic women

Objective

To assess whether recipients and non-recipients of the human papillomavirus (HPV) vaccine subsequently differ in terms of sexual risk taking behaviour.

Design

Cross-sectional survey. Sequential analyses constructed from self-reported age at vaccination, age at first intercourse and age at response.

Setting

A random selection of women aged 18–46 years living in Denmark, Norway and Sweden in 2011–2012, eligible for opportunistic or organized catch-up HPV vaccination.

Participants

A total of 3805 women reported to have received the HPV vaccine and 40,247 reported not to have received it. Among vaccinees, 1539 received the HPV vaccine before or at the same age as sexual debut, of which 476 and 1063 were eligible for organized catch-up and opportunistic vaccination, respectively.

Main outcome measures

Self-reported sexual behaviour, compared by hazard ratios and odds ratios for women who received the HPV vaccine before or at the same age as sexual debut versus women who did not receive the HPV vaccine.

Results

HPV vaccination did not result in younger age at first intercourse. Women who received the HPV vaccine before or at the same age as sexual debut did not have more sexual partners than did non-vaccinees. Non-use of contraception during first intercourse was more common among non-vaccinees than among HPV vaccinees. The results were similar for organized catch-up and opportunistic vaccinees.

Conclusion

Women who received the HPV vaccine before or at the same age as sexual debut did not subsequently engage more in sexual risk taking behaviour than women who did not receive the HPV vaccine.     

Health Care Provider Recommendation,Human Papillomavirus Vaccination,and Race/Ethnicity in the US National Immunization Survey

Objectives. Human papillomavirus (HPV) is a common sexually transmitted infection in the United States, yet HPV vaccination rates remain relatively low. We examined racial/ethnic differences in the prevalence of health care provider recommendations for HPV vaccination and the association between recommendation and vaccination.Methods. We used the 2009 National Immunization Survey–Teen, a nationally representative cross-section of female adolescents aged 13 to 17 years, to assess provider-verified HPV vaccination (≥ 1 dose) and participant-reported health care provider recommendation for the HPV vaccine.Results. More than half (56.9%) of female adolescents received a recommendation for the HPV vaccine, and adolescents with a recommendation were almost 5 times as likely to receive a vaccine (odds ratio = 4.81; 95% confidence interval = 4.01, 5.77) as those without a recommendation. Racial/ethnic minorities were less likely to receive a recommendation, but the association between recommendation and vaccination appeared strong for all racial/ethnic groups.Conclusions. Provider recommendations were strongly associated with HPV vaccination. Racial/ethnic minorities and non-Hispanic Whites were equally likely to obtain an HPV vaccine after receiving a recommendation. Vaccine education efforts should target health care providers to increase recommendations, particularly among racial/ethnic minority populations.Human papillomavirus (HPV) is one of the most common sexually transmitted infections in the United States.1,2 In 2006, the Food and Drug Administration (FDA) licensed the first HPV vaccine for use in females aged 9 to 26 years. Subsequently, the Advisory Committee on Immunization Practices (ACIP) recommended routine HPV vaccination of 11- and 12-year-old girls, with ensuing catch-up vaccinations recommended for older female adolescents and young adults.3 However, HPV vaccine coverage of adolescents remains less than 50%,4 and Healthy People 2020 recognizes the facilitation of HPV vaccination as an emerging issue in sexually transmitted diseases.5Health care provider recommendation has been shown to be a strong predictor of vaccination for a wide range of vaccines in older age groups.6–8 Therefore, one potential explanation for the low levels of HPV vaccine coverage is that parents and adolescents are not receiving HPV vaccine recommendations from their health care providers. A previous study indicated that less than 40% of adolescents discussed the HPV vaccine with their health care provider.9African Americans and other minority groups are disproportionately affected by HPV infection and subsequent cervical cancer compared with non-Hispanic Whites.10,11 A better understanding of how to prevent HPV infection among racial/ethnic minorities will have important implications for reducing these health disparities. At the national level, little is known about racial/ethnic differences in the likelihood of receiving an HPV vaccine recommendation by a health care provider. In addition, little is known about the association between receiving a provider recommendation and actual HPV vaccine receipt and whether this association differs by race/ethnicity.Using the National Immunization Survey (NIS), a nationally representative sample of female adolescents aged 13 to 17 years in the United States, we examined racial/ethnic differences in the prevalence of health care provider recommendations for HPV vaccination and in the association between provider recommendation and provider-verified HPV vaccine initiation. In addition, we examined the roles of parental socioeconomic status and health insurance status in influencing the likelihood of provider recommendation and vaccine initiation.     

Reduction of HPV infections through vaccination among at-risk urban adolescents

Introduction

Human papillomavirus (HPV) vaccine trials have demonstrated high efficacy in preventing HPV infections and HPV related disease in females ages 16–26. However, there is no source data to demonstrate the impact of the vaccine in other populations who may be at higher risk for HPV related disease. This study examines the impact of HPV vaccination on subsequent HPV detection and sexual behaviors among urban adolescents in a clinical setting.

Methods

A cohort of adolescent women, ages 14–17, were recruited prospectively and matched to historical controls to assess the impact of HPV vaccination. All women completed the same questionnaire and face-to-face interview that assessed sexual behaviors; all provided a clinician or self-collected vaginal swab that was used to test for sexually transmitted infections, including HPV. Logistic regression models, incorporating random pair effects, were used to assess the impact of the HPV vaccine on HPV detection and sexual behaviors between the two groups.

Results

Each woman recruited (N = 75) was matched to 2 historical controls (HC); most of the recruited women (89.3%) had received one or more doses of the HPV vaccine. At enrollment, detection of quadrivalent vaccine types (HPV 6, 11, 16 and 18) was significantly less in the recruited group (5.3%) as compared to the HC (24%): OR = 5.6 (CI = 1.9, 16.5), p = 0.002. Adolescent women in the HC had a 9.5 times greater odds of HPV infection when the analysis was adjusted to compare those who had 2 or more vaccine doses to their matched controls. The only behavioral difference found was that the recruited women used condoms more frequently.

Conclusion

This study demonstrates that HPV vaccination was associated with fewer vaccine-type HPV infections despite incomplete vaccination and high risk sexual behaviors. These data also suggest that sexual behaviors were not altered because of the vaccine.     

Human papillomavirus prevalence and risk factors among Australian women 9–12 years after vaccine program introduction

BackgroundIn Australia, high and widespread uptake of the quadrivalent human papillomavirus (HPV) vaccine has led to substantial population-level reductions in the prevalence of quadrivalent vaccine targeted HPV genotypes 6/11/16/18 in women aged ≤ 35 years. We assessed risk factors for HPV detection among 18–35 year old women, 9–12 years after vaccine program introduction.MethodsWomen attending health services between 2015 and 2018 provided a self-collected vaginal specimen for HPV genotyping (Roche Linear Array) and completed a questionnaire. HPV vaccination status was validated against the National Register. Adjusted odds ratios (aORs) and 95% confidence intervals (CI) were calculated for factors associated with HPV detection.ResultsAmong 1564 women (median age 24 years; IQR 21–27 years), Register-confirmed ≥ 1-dose vaccine coverage was highest at 69.3% and 68.1% among women aged 18–21 and 22–24 years respectively, decreasing to 42.9% among those aged 30–35 years. Overall prevalence of quadrivalent vaccine-targeted HPV types was very low (2.0%; 95% CI: 1.4–2.8%) and influenced only by vaccination status (5.5% among unvaccinated compared with 0.7% among vaccinated women; aOR = 0.13 (95% CI: 0.05–0.30)). Prevalence of remaining HPV types, at 40.4% (95% CI: 38.0–42.9%), was influenced by established risk factors for HPV infection; younger age-group (p-trend < 0.001), more recent (p < 0.001) and lifetime sexual partners (p-trend < 0.001), but not vaccination status. Prevalence of HPV31/33/45, which shared risk factors with that of non-vaccine targeted HPV types, was also lower among vaccinated (4%) compared with unvaccinated (7%) women (aOR = 0.51; 95% CI: 0.29–0.89), indicative of cross-protection.ConclusionVaccination has changed the epidemiology of HPV infection in Australian women, having markedly reduced the prevalence of vaccine-targeted types, including amongst women with known risk factors for infection. Vaccinated women appear to be benefiting from modest cross-protection against types 31/33/45 afforded by the quadrivalent HPV vaccine. These results reinforce the importance of HPV vaccination.     

Factors associated with human papillomavirus vaccination among young adult women in the United States

Background

Human papillomavirus (HPV) vaccination is recommended to protect against HPV-related diseases.

Objective

To estimate HPV vaccine coverage and assess factors associated with vaccine awareness, initiation and receipt of 3 doses among women age 18–30 years.

Methods

Data from the 2010 National Health Interview Survey were analyzed to assess associations of HPV vaccination among women age 18–26 (n = 1866) and 27–30 years (n = 1028) with previous HPV exposure, cervical cancer screening and selected demographic, health care and behavioral characteristics using bivariate analysis and multivariable logistic regression.

Results

Overall, 23.2% of women age 18–26 and 6.7% of women age 27–30 years reported receiving at least 1 dose of HPV vaccine. In multivariable analyses among women age 18–26 years, not being married, having a regular physician, seeing a physician or obstetrician/gynecologist in the past year, influenza vaccination in the past year, and receipt of other recommended vaccines were associated with HPV vaccination. One-third of unvaccinated women age 18–26 years (n = 490) were interested in receiving HPV vaccine. Among women who were not interested in receiving HPV vaccine (n = 920), the main reasons reported included: not needing the vaccine (41.3%); concerns about safety of the vaccine (12.5%); not knowing enough about the vaccine (11.9%); not being sexually active (8.2%); a doctor not recommending the vaccine (7.6%); and already having HPV (2.7%). Among women with health insurance, 10 or more physician contacts within the past year and no contraindications, 74.5% reported not receiving HPV vaccine.

Conclusions

HPV vaccination coverage among women age 18–26 years remains low. Opportunities to vaccinate are missed. Healthcare providers can play an important role in educating young women about HPV and encouraging vaccination. Successful public health and educational interventions will need to address physician attitudes and practice patterns and other factors that influence vaccination behaviors.     

Initiation of Human Papillomavirus Vaccination Among Predominantly Minority Female and Male Adolescents at Inner-City Community Health Centers

Objectives. We examined the prevalence and correlates of human papillomavirus (HPV) vaccine initiation among adolescents in low-income, urban areas.Methods. The study consisted of electronic health record data on HPV vaccination for 3180 adolescents (aged 10–20 years) at a multisite community health center in 2011.Results. Only 27% initiated the HPV vaccine. The adjusted odds ratio (AOR) of HPV vaccination was lower among older adolescents (AOR = 0.552; 95% confidence interval [CI] = 0.424, 0.718) and those seen by nonpediatric health care providers (HCPs; AOR = 0.311; 95% CI = 0.222, 0.435), and higher among non-English speakers (AOR = 1.409; 95% CI = 1.134, 1.751) and those seen at 2 site locations (AOR = 1.890; 95% CI = 1.547, 2.311). Insurance status was significant only among female and Hispanic adolescents. Language was not a predictor among Hispanic adolescents. Across all analyses, the interaction of age and HCP specialty was associated with HPV vaccination. Dramatically lower HPV vaccination rates were found among older adolescents seen by nonpediatric HCPs (3%–5%) than among other adolescents (23%–45%).Conclusions. Improving HPV vaccination initiation in low-income urban areas is critical to reducing disparities in cervical and other HPV-related cancer, especially among Black, Hispanic, and low-income populations.Human papillomavirus (HPV) infection is a known risk factor for the development of several cancers. Between 2004 and 2008, there was a national average of 33 369 HPV-associated cancers annually, including cervical, vulvar, vaginal, penile, anal, and oropharyngeal cancers.1 The Centers for Disease Control and Prevention estimates 26 000 new HPV-associated cancers each year, 18 000 for women and 8000 for men,1 which could be prevented through the HPV vaccine.According to the US Cancer Statistics Working Group,2 there are pervasive disparities in national morbidity and mortality rates of HPV-related cancers for Black and Hispanic individuals. Cervical cancer is more common among Black and Hispanic women and results in disproportionately higher mortality for Black women. In 2009, the national age-adjusted cervical cancer incidence rates (per 100 000) for Hispanic and Black women (10.9 and 10.0, respectively) were higher than the rate for White women (7.6).2 The national age-adjusted cervical cancer mortality rate (per 100 000) for Black women (4.2) is considerably higher than the rates for White and Hispanic women (2.1 and 2.9, respectively).2 Also, Black women have higher morbidity and mortality rates of vaginal cancer. Morbidity and mortality rates of penile cancers are significantly higher among Black and Hispanic men. Black men have higher morbidity and mortality rates of anal cancer.2 In addition to race/ethnicity, incidence rates of penile, cervical, and vaginal cancers increase with higher poverty rates.3 Factors that contribute to cancer disparities among Black, Hispanic, and low-income populations include higher exposure to risk factors such as smoking, physical inactivity, and HPV infection as well as lack of access to early detection and treatment services.4New Jersey had the 10th highest morbidity rate for cervical cancer nationally for 2006 through 2010.5 According to the New Jersey State Cancer Registry, cervical cancer morbidity from 2005 to 2009 was significantly higher in the Greater Newark area (relative risk = 1.86; the study target area) than other areas in the state, as well as among women who are Black, Hispanic, foreign-born, non–English-speaking, uninsured, with lower income and education, unmarried, unemployed, and living in a rented residence.6 According to a community health needs assessment for the City of Newark in 2013,7 52.4% of the residents are Black, 33.8% are Hispanic, and 30% are foreign-born, compared with 13%, 18%, and 20%, respectively, in the state. Also, 28.4% of the residents are below the federal poverty level compared with 9.4% statewide, and 28% are uninsured compared with 8.4% statewide. A significant proportion of the residents has less than a high-school education (30%) and a low level of English proficiency (25%).7Transmission of HPV can be reduced through limiting the number of sexual partners, delaying the initiation of sexual activity, practicing safe sex, and getting vaccinated.8 Two vaccines have been approved by the Food and Drug Administration for protection against HPV: the quadrivalent vaccine (Gardasil, Merck, Kenilworth, NJ) for female and male individuals aged 9 to 26 years,9 and the bivalent vaccine (Cervarix, GlaxoSmithKline, Middlesex, England) for female individuals aged 10 to 25 years.10 The HPV vaccine requires a series of 3 injections within 6 months. Markowitz et al.11 examined the rates of HPV infection among female individuals before and after the vaccine was introduced in 2006, by using data from the National Health and Nutrition Examination Surveys for 2003 through 2010. They found that for female adolescents aged 14 to 19 years, there was a 55.7% reduction in vaccine-type HPV infection rate (HPV types 6, 11, 16, and 18) and a 50% reduction in high-risk vaccine-type HPV infection rate (HPV types 16 and 18). There was also an 88% decrease among the sexually active women in their rate of vaccine-type HPV infection when they compared those who were vaccinated to those who were not vaccinated.11 Niccolai et al.12 also found significant decline in the rates of high-grade cervical lesions from 2008 to 2011 among women aged 21 to 24 years in Connecticut. Unfortunately, this trend was attenuated in urban areas as well as areas with higher concentrations of Black, Hispanic, and low-income populations.12According to the National Immunization Survey—Teen (NIS-Teen),13 HPV vaccine initiation rates for female adolescents were 44.3% in 2009, 48.7% in 2010, 53.0% in 2011, and 53.8% in 2012. This reflects minimal improvement in 2011, no improvement in 2012, and reaching a plateau for female vaccination at a level dramatically lower than the goal of 80% completion rate for girls aged 13 to 15 years set by Healthy People 2020. In site-based studies, HPV vaccine initiation among female adolescents ranged between 9.4% and 62.9%.14–21 Also, initiation for female adolescents was lower for Spanish speakers,22 those who were uninsured,23–25 those with shorter duration of enrollment in health insurance,26 in nonpediatric settings,21,24 among those who have not had a preventive visit in the past 12 months,21,24,27–30 and with mothers’ lack of knowledge about HPV infection or vaccine.18,27,28,31,32 Some studies reported lower initiation among younger female adolescents,15,18,21,24,29,30 whereas others reported the opposite.21,26 Several studies have shown the importance of health care providers’ (HCPs’) recommendations for HPV vaccine initiation among female adolescents.16,28,30,31,33According to NIS-Teen,13 HPV vaccine initiation rates for male adolescents were 1.4% in 2010, 8.3% in 2011, and 20.8% in 2012. This reflects low but steady improvement in HPV vaccination rates among male adolescents. In site-based studies, HPV vaccine initiation among male adolescents ranged between 1.1% and 30%.14,34–37 Literature is lacking on factors associated with HPV vaccine initiation among male adolescents. One study reported lower levels of knowledge among Black and Hispanic parents about the use of HPV vaccine for male adolescents.35 A few studies indicated the importance of HCPs’ recommendation for HPV vaccine initiation among male adolescents.14,35,36,38Pervasive disparities exist in HPV vaccination among Black, Hispanic, and low-income groups, and more specifically in the study target area. Even though the NIS-Teen data for 2011 and 2012 show slightly higher HPV vaccination among Black and low-income groups,39,40 several studies have demonstrated a significant and continuing trend of lower HPV vaccination among Black and Hispanic adolescents,14,15,17,24,26,41,42 as well as in low-income and urban areas.22,33,41,43 Vaccination disparities in urban areas (compared with suburban or rural areas) may be attributed to residential segregation, differential distribution of health clinics and health professionals, and unequal access to a broad range of services.44–46 As urban areas, particularly the Greater Newark area, have high proportions of immigrants who may be hesitant to seek health care services because of cultural or language barriers or concerns about immigration status,7 a study of adolescents’ adherence to public health recommendations in underserved, inner-city areas is warranted and important.Literature is lacking information on correlates of HPV vaccination among Black and Hispanic adolescents in low-income urban areas, who represent populations with the greatest disparities in cervical cancer and other HPV-related cancers compared with White and higher-income groups. Therefore, the purpose of this study was to examine the correlates of HPV vaccine initiation in a sample of predominantly Black and Hispanic adolescents at inner-city community health centers. The study addresses gaps in knowledge about the correlates of HPV vaccination among both male and female adolescents as well as a low-income predominantly minority population with pervasive disparities in cervical cancer morbidity and mortality.1–3,5,6     

Geographic Poverty and Racial/Ethnic Disparities in Cervical Cancer Precursor Rates in Connecticut, 2008–2009

Objectives. We examined associations of geographic measures of poverty, race, ethnicity, and city status with rates of cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ (CIN2+/AIS), known precursors to cervical cancer.Methods. We identified 3937 cases of CIN2+/AIS among women aged 20 to 39 years in statewide surveillance data from Connecticut for 2008 to 2009. We geocoded cases to census tracts and used census data to calculate overall and age-specific rates. Poisson regression determined whether rates differed by geographic measures.Results. The average annual rate of CIN2+/AIS was 417.6 per 100 000 women. Overall, higher rates of CIN2+/AIS were associated with higher levels of poverty and higher proportions of Black residents. Poverty was the strongest and most consistently associated measure. However, among women aged 20 to 24 years, we observed inverse associations between poverty and CIN2+/AIS rates.Conclusions. Disparities in cervical cancer precursors exist for poverty and race, but these effects are age dependent. This information is necessary to monitor human papillomavirus vaccine impact and target vaccination strategies.Genital human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, with an estimated 6.2 million adolescents and young adults newly infected every year.1 The prevalence of infection ranges from 27% to 45% among young women, and nearly 40% of women acquire HPV within 2 years of initiating sexual activity.2–4 HPV is also an important public health problem because persistent infection with a high-risk HPV type is a necessary cause of cervical cancer.5–7 Women living in poverty and racial/ethnic minorities continue to bear a disproportionate burden of cervical cancer incidence and mortality despite the decrease in rates that has resulted from widespread cervical cancer screening.8,9 In 1998 to 2003, US incidence rates of invasive cervical cancer were 12.6 per 100 000 among Black women, 14.2 among Hispanics, and 8.4 among Whites; mortality rates showed similar disparities.10 This pattern continued through 2007.11 In a study from Massachusetts and Rhode Island, incidence rates in areas with 20% or higher and less than 5% of the population living in poverty were 17.6 and 9.2 per 100 000, respectively.12 Data from a study in New York City revealed neighborhood poverty to be an important predictor of cervical cancer mortality.13Precursors to cervical cancer are cervical intraepithelial neoplasia grades 2, 2/3, and 3 (CIN2+) and adenocarcinoma in situ (AIS). CIN2+/AIS diagnoses are an important public health problem not only because they are precursors to invasive disease, but also because they are common diagnoses that impose substantial health care costs and patient burden. Approximately 500 000 women are diagnosed each year with high-grade cervical disease, and these diagnoses account for annual health care costs of $450 million.14–16 At the individual level, a diagnosis of CIN2+ results in an average of 7 to 8 office visits and 20 months of follow-up.16 Many women also experience adverse psychological consequences following a diagnosis, such as fear of cancer, anxiety, distress, and concern about future fertility, along with medical procedures and difficulties with sexual relationships.17 Disparities in precancerous lesions have not been directly examined, to the best of our knowledge. Data from 2 studies reveal noticeably higher rates of precancerous lesions among low-income women in a national screening program (4.6–7.4/1000 women) than among health plan enrollees (1.5/1000), who were likely of higher socioeconomic status18,19; however this is not a direct or precise comparison.Since 2006, the Food and Drug Administration has approved 2 HPV vaccines that protect against 2 high-risk HPV types (HPV 16/18), which cause approximately 70% of cervical cancers. These vaccines have proven efficacy of 95% or higher in protecting against HPV 16/18–associated cervical lesions in HPV-naive women.20,21 The Advisory Committee on Immunization Practices recommends routine use of either vaccine in a 3-dose regimen for girls aged 11 or 12 years and catch-up vaccination through age 26 years.22 These vaccines have the potential to reduce disparities in cervical cancer. However, the extent to which this is realized will depend on high vaccine coverage for populations at greatest risk for outcomes associated with HPV infection. If vaccine coverage is not adequate and targeted, current disparities in cervical cancer may widen rather than narrow.HPV vaccination programs may affect cervical cancer precursors and associated procedures within years rather than the decades it will take to measure impact on cervical cancer.21,23–26 Therefore, determining the burden of cervical cancer precursors should be a public health priority because this information can be used to target vaccination strategies and provide a baseline for monitoring vaccine impact and disparities over time. We examined disparities in CIN2+/AIS rates in Connecticut, a state with mandatory reporting of these conditions, during prevaccine impact years 2008 to 2009, by geographic sociodemographic measures of poverty, race, ethnicity, and city status. We chose the first 3 measures because they are the most commonly used indicators of disparities in cervical cancer.8,10,12,13 We included a city measure because we hypothesized that disparities may exist along an urban gradient. Our results fill a key knowledge gap because few states mandate CIN2+/AIS reporting, and no statewide analysis of cervical cancer precursors and geographic measures has been reported.     

HPV vaccination intent and willingness to pay for 2-,4-, and 9-valent HPV vaccines: A study of adult women aged 27–45 years in China

ObjectiveThis study aims to investigate acceptance and willingness to pay for HPV vaccination among adult women in China.MethodsAn online survey was sent to mothers aged 27–45 years of primary school pupils in the Fujian province, China. Participants completed questions about HPV related knowledge and health beliefs, intention to take the HPV vaccine and the willingness to pay for bivalent vaccine (2vHPV), quadrivalent vaccine (4vHPV), and 9-valent HPV vaccine (9vHPV).ResultsOf a total of 2339 complete responses, 58.3% reported intent to obtain HPV vaccine. Mothers who were younger in age, residing in urban, working in managerial or professional occupations, who knew someone with cervical cancer and who were able to make independent decisions about the HPV vaccine (vs. joint decision with spouse) were more likely to express intent to have HPV vaccination. Perceived barriers, cues to action and self-efficacy were three of the constructs in the health belief model that significantly influenced HPV vaccination intent. A higher proportion of participants expressed willingness to pay for 2vHPV (81.2%) and 4vHPV (75.9%), as compared to 9vHPV (67.7%).ConclusionAdults women expressed moderate intention to receive the HPV vaccine. Intervention to address barriers to uptake of the HPV vaccine among adult women in China is warranted.     

Papanicolaou Screening Behavior in Mothers and Human Papillomavirus Vaccine Uptake in Adolescent Girls

Objectives. We investigated whether maternal attitude toward prevention, as indicated by history of seeking Papanicolaou (Pap) tests and contracting sexually transmitted infections, influenced human papillomavirus (HPV) vaccine uptake among their adolescent daughters.Methods. We linked the electronic health records of girls aged 9 to 17 years with their mothers at Kaiser Permanente Southern California (n = 148 350 mother–daughter pairs). Personal identifying information was removed from the data set after the matching of daughters and mothers was completed. We used logistic regression models to detect associations between mothers'' history of Pap tests and abnormal results, genital or anal warts, and other sexually transmitted infections and daughters'' HPV vaccine initiation and 3-dose regimen completion.Results. Mothers'' testing history was associated with daughters'' likelihood for vaccination across ethnic and neighborhood socioeconomic strata (overall odds ratio [OR] = 1.47; 95% confidence interval [CI] = 1.43, 1.52). Mothers'' history of sexually transmitted infections was only modestly associated with daughters'' vaccination. Mothers'' testing history was positively associated with daughters'' regimen completion (overall OR = 1.42; 95% CI = 1.31, 1.54).Conclusions. Mothers'' attitude toward prevention may influence HPV vaccine uptake among adolescent girls. The impacts of targeting mothers should be considered by HPV vaccination programs and investigated by further research.The quadrivalent human papillomavirus vaccine (HPV4), Gardasil (Merck & Co, Whitehouse Station, NJ), has been shown to be efficacious in preventing cervical cancer and other conditions caused by HPV types 6, 11, 16, and 18.^1,2 The vaccine is indicated for girls and women aged 9 to 26 years and is given in 3 injections over 6 months.³ The Advisory Committee on Immunization Practice (ACIP) recommends vaccinating adolescent girls before they become sexually active.³ Because of concern that vaccinating against HPV may condone or promote sexual activity in adolescent girls, integration of this procedure into clinical care has been somewhat controversial. Furthermore, the safety and long-term efficacy of the vaccine remain to be elucidated. This controversy and the fact that state law does not require the vaccine may impede its implementation in public health and clinical settings.Parental consent is generally required for medical intervention given to adolescents younger than 18 years old,⁴ so parents'' perceptions about sexuality, vaccination, and sexually transmitted infections (STIs) may play an important role in determining the uptake of the HPV vaccine among adolescent girls. Several studies on HPV and STI vaccine acceptability have reported that parental health beliefs about STIs, personal history of STIs, and knowledge about HPV are significant predictors of parental intent for vaccination.^5,6Because the HPV4 vaccine has potential public health importance, we investigated the hypothesis that uptake of HPV4 among girls aged 9 to 17 years is associated with their mothers'' personal attitude about preventive measures related to cervical cancer as assessed by history of seeking Papanicolaou (Pap) tests and personal experience of STIs. We measured HPV4 uptake by initiation of the vaccination and completion of the 3-dose regimen within 1 year. We took advantage of the electronic health records available at Kaiser Permanente Southern California (KPSC), which allowed linkage of the medical records of mothers and daughters.     

HPV vaccination among lesbian and bisexual women: Findings from a national survey of young adults

Background

Human papillomavirus (HPV) infection and associated cervical disease are common among all women, regardless of sexual identity, yet limited research has examined HPV vaccination among lesbian and bisexual women.

Methods

A national sample of lesbian and bisexual women ages 18–26 (n = 543) completed our online survey during Fall 2013. We used multivariable logistic regression to identify correlates of HPV vaccine initiation (receipt of at least 1 dose) and completion (receipt of all 3 recommended doses among initiators).

Results

Overall, 45% of respondents had initiated HPV vaccine and 70% of initiators reported completing the series. HPV vaccine initiation was higher among respondents who were students, had received a healthcare provider's recommendation, perceived greater positive social vaccination norms, or anticipated greater regret if they did not get vaccinated and later got HPV. Initiation was lower among those who perceived greater HPV vaccine harms or greater barriers to getting the vaccine (all p < .05). HPV vaccine completion was higher among initiators who had a college degree while it was lower among those who perceived a greater likelihood of acquiring HPV or who anticipated greater regret if they got the vaccine and fainted (all p < .05). Among HPV vaccine initiators who had not yet completed the series, about half (47%) intended to get the remaining doses.

Conclusions

Many lesbian and bisexual women are not getting vaccinated against HPV. Healthcare provider recommendations and women's health beliefs may be important leverage points for increasing vaccination among this population.