Jennifer L. Moss

Do correlates of HPV vaccine initiation differ between adolescent boys and girls

BACKGROUND Guidelines now recommend that adolescents routinely receive human papillomavirus (HPV) vaccine. Because little is known about uptake among boys, we assessed HPV vaccine initiation in a population-based sample of adolescent boys and girls. METHODS We analyzed weighted data from 751 parents who reported on an 11- to 17-year-old son or daughter for the 2010 North Carolina Child Health Assessment and Monitoring Program survey. Stratified multivariate logistic regression analyses identified correlates of HPV vaccine initiation separately for boys and girls. RESULTS Only 14% of sons had received one or more doses of HPV vaccine compared to 44% of daughters (p<0.01). For both sons and daughters, vaccine initiation correlated with age and having received meningococcal vaccine. Among sons, initiation of HPV vaccine was lower for those living in high income households (odds ratio [OR]=0.22, 95% CI, 0.09-0.53) and higher for those whose race was neither white nor black (OR=3.26, 95% CI, 1.06-10.04). When asked to give the main reason for not vaccinating their child against HPV, parents of unvaccinated sons were more likely than those of daughters to report not getting a providers recommendation or not being aware that the vaccine was available for their child, but less likely to report concern about safety (p<0.01). At least 86% of unvaccinated children had missed an opportunity to receive HPV vaccine. CONCLUSIONS HPV vaccine correlates and concerns varied for parents of boys and girls. To improve very low levels of uptake among boys, providers should recommend HPV vaccine concomitant with other adolescent vaccines.

Provider communication and HPV vaccination: The impact of recommendation quality

BACKGROUND Receiving a healthcare providers recommendation is a strong predictor of HPV vaccination, but little is known empirically about which types of recommendation are most influential. Thus, we sought to investigate the relationship between recommendation quality and HPV vaccination among U.S. adolescents. METHODS In 2014, we conducted a national, online survey of 1495 parents of 11-17-year-old adolescents. Parents reported whether providers endorsed HPV vaccination strongly, encouraged same-day vaccination, and discussed cancer prevention. Using an index of these quality indicators, we categorized parents as having received no, low-quality, or high-quality recommendations for HPV vaccination. Separate multivariable logistic regression models assessed associations between recommendation quality and HPV vaccine initiation (≥ 1 dose), follow through (3 doses, among initiators), refusal, and delay. RESULTS Almost half (48%) of parents reported no provider recommendation for HPV vaccination, while 16% received low-quality recommendations and 36% received high-quality recommendations. Compared to no recommendation, high-quality recommendations were associated with over nine times the odds of HPV vaccine initiation (23% vs. 74%, OR=9.31, 95% CI, 7.10-12.22) and over three times the odds of follow through (17% vs. 44%, OR=3.82, 95% CI, 2.39-6.11). Low-quality recommendations were more modestly associated with initiation (OR=4.13, 95% CI, 2.99-5.70), but not follow through. Parents who received high- versus low-quality recommendations less often reported HPV vaccine refusal or delay. CONCLUSIONS High-quality recommendations were strongly associated with HPV vaccination behavior, but only about one-third of parents received them. Interventions are needed to improve not only whether, but how providers recommend HPV vaccination for adolescents.

Increasing adolescent immunization by webinar: A brief provider intervention at federally qualified health centers

OBJECTIVE To evaluate a brief intervention to increase provision of adolescent vaccines at health centers that reach the medically underserved. METHOD In April 2010, clinical coordinators from 17 federally qualified health centers (serving 7827 patients ages 12-17) participated in a competition to increase uptake of recommended adolescent vaccines: tetanus, diphtheria, and pertussis booster; meningococcal conjugate; and human papillomavirus. Vaccination coordinators attended a webinar that reviewed provider-based changes recommended by the CDCs Assessment, Feedback, Incentives, and eXchanges (AFIX) program and received weekly follow-up emails. Data on vaccine uptake came from the North Carolina Immunization Registry. RESULTS Uptake of targeted adolescent vaccines increased during the one-month intervention period by about 1-2% (all p<.05). These small but reliable increases were greater than those observed for non-targeted vaccines (measles, mumps, and rubella; hepatitis B; and varicella). CONCLUSION This AFIX webinar led to small increases in provision of targeted adolescent vaccines over a one-month period. Similar, sustainable programs at healthcare facilities, including federally qualified health centers that function as safety net providers for medically underserved populations could help reach populations with great need.

Increasing Provision of Adolescent Vaccines in Primary Care: A Randomized Controlled Trial

OBJECTIVES: To assess the effectiveness of in-person and webinar-delivered AFIX (Assessment, Feedback, Incentives, and eXchange) consultations for increasing adolescent vaccine coverage. METHODS: We randomly assigned 91 primary care clinics in North Carolina, serving 107 443 adolescents, to receive no consultation or an in-person or webinar AFIX consultation. We delivered in-person consultations in April through May 2011 and webinar consultations in May through August 2011. The states immunization registry provided vaccine coverage data for younger patients (ages 11–12 years) and older patients (ages 13–18 years) for 3 adolescent vaccines: tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap); meningococcal; and human papillomavirus (HPV) vaccines (≥1 dose, females only). RESULTS: At the 5-month follow-up, AFIX consultations increased vaccine coverage among younger adolescents. Patients in the in-person arm experienced coverage changes that exceeded those in the control arm for Tdap (3.4% [95% confidence interval (CI): 2.2 to 4.6]), meningococcal (4.7% [95% CI: 2.3 to 7.2], and HPV (1.5% [95% CI: 0.3 to 2.7]) vaccines. Patients in the webinar versus control arm also experienced larger changes for these vaccines. AFIX did little to improve coverage among older adolescents. At 1 year, the 3 arms showed similar coverage changes. The effectiveness of in-person and webinar consultations was not statistically different at either time point (all, P >.05). CONCLUSIONS: Webinar AFIX consultations were as effective as in-person consultations in achieving short-term increases in vaccine coverage for younger adolescents. AFIX consultations for adolescents need improvement to have a stronger and more durable impact, especially for HPV vaccine.

Trends in HPV Vaccine Initiation among Adolescent Females in North Carolina, 2008–2010

Background: To better target future immunization efforts, we assessed trends and disparities in human papillomavirus (HPV) vaccine initiation among female adolescents in North Carolina over 3 years. Methods: We analyzed data from a stratified random sample of 1,427 parents who, between 2008 and 2010, completed two linked telephone surveys: the Behavioral Risk Factor Surveillance System and the Child Health Assessment and Monitoring Program surveys. Weighted analyses examined HPV vaccine initiation for girls ages 11 to 17 years. Results: HPV vaccine initiation increased modestly over time (2008, 34%; 2009, 41%; 2010, 44%). This upward trend was present within 11 subpopulations of girls, including those who lived in rural areas, were of minority (non-black/non-white) race, or had not recently received a preventive check-up. Looking at differences between groups, HPV vaccine initiation was less common among girls who attended private versus public school, were younger, or lacked a recent check-up. However, the latter difference narrowed over time. The low level of initiation among girls without recent check-ups increased substantially (from 11% to 41%), whereas initiation among girls with recent visits improved little (from 39% to 44%, Pinteraction = 0.007). Conclusions: Although HPV vaccine initiation improved among several groups typically at higher risk for cervical cancer, the lack of progress among girls with recent check-ups suggests that missed opportunities for administration have hampered broader improvements. Impact: Achieving widespread coverage of HPV vaccine will require redoubled efforts to vaccinate adolescents during routine care. Cancer Epidemiol Biomarkers Prev; 21(11); 1913–22. ©2012 AACR.

Evaluation of an intervention providing HPV vaccine in schools.

OBJECTIVES To conduct outcome and process evaluations of school-located HPV vaccination clinics in partnership with a local health department. METHODS Temporary clinics provided the HPV vaccine to middle school girls in Guilford County, North Carolina, in 2009-2010. RESULTS HPV vaccine initiation was higher among girls attending host schools than satellite schools (6% vs. 1%, OR = 6.56, CI = 3.99-10.78). Of the girls who initiated HPV vaccine, 80% received all 3 doses. Private insurance or federal programs paid for most vaccine doses. CONCLUSIONS Lessons learned for creating more effective school-health department partnerships include focusing on host schools and delivering several vaccines to adolescents, not just HPV vaccine alone.

Correlates of human papillomavirus vaccine coverage: a state-level analysis.

Background We tested the hypothesis that states with higher rates of cancers associated with human papillomavirus (HPV) would have lower HPV vaccine coverage. Methods We gathered state-level data on HPV-related cancer rates and HPV vaccine initiation coverage for girls and boys, separately, and HPV vaccine follow-through (i.e., receipt of 3 doses among those initiating the series) for girls only. In addition, we gathered state-level data on demographic composition and contact with the health care system. We calculated Pearson correlations for these ecological relationships. Results Human papillomavirus vaccine initiation among girls was lower in states with higher levels of cervical cancer incidence and mortality (r = −0.29 and −0.46, respectively). In addition, vaccine follow-through among girls was lower in states with higher levels of cervical cancer mortality (r = −0.30). Other cancer rates were associated with HPV vaccine initiation and follow-through among girls, but not among boys. Human papillomavirus vaccine initiation among girls was lower in states with higher proportions of non-Hispanic black residents and lower proportions of higher-income residents. Human papillomavirus vaccine follow-through was higher in states with greater levels of adolescents’ contact with the health care system. Conclusions Human papillomavirus vaccine coverage for girls was lower in states with higher HPV-related cancer rates. Public health efforts should concentrate on geographic areas with higher cancer rates. Strengthening adolescent preventive health care use may be particularly important to increase vaccine follow-through. Cost-effectiveness analyses may overestimate the benefits of current vaccination coverage and underestimate the benefits of increasing coverage.

Comparing in-person and webinar delivery of an immunization quality improvement program: a process evaluation of the adolescent AFIX trial

BackgroundImmunization quality improvement programs are often limited by the cost and inconvenience associated with delivering face-to-face consultations to primary care providers. To investigate a more efficient mode of intervention delivery, we conducted a process evaluation that compared in-person consultations to those delivered via interactive webinar.MethodsThe Centers for Disease Control and Prevention’s Assessment, Feedback, Incentives, and eXchange (AFIX) Program is an immunization quality improvement program implemented in all 50 states. In 2011, we randomly assigned 61 high-volume primary care clinics in North Carolina to receive an in-person or webinar AFIX consultation focused on adolescent immunization. We used surveys of participating vaccine providers and expense tracking logs to evaluate delivery modes on participation, satisfaction, and cost. Clinics served 71,874 patients, ages 11 to 18.ResultsClinics that received in-person and webinar consultations reported similar levels of participation on key programmatic activities with one exception: more webinar clinics reported improving documentation of previously administered, ‘historical’ vaccine doses. Both in-person and webinar clinics showed sustained improvement in confidence to use reminder/recall systems (both p < 0.05). Participants rated delivery modes equally highly on satisfaction measures such as convenience (mean = 4.6 of 5.0). Delivery cost per clinic was

School Entry Requirements and Coverage of Nontargeted Adolescent Vaccines

152 for in-person consultations versus

Opportunities for Increasing Human Papillomavirus Vaccine Provision in School Health Centers.

100 for webinar consultations.ConclusionsIn-person and webinar delivery modes were both well received, but webinar AFIX consultations cost substantially less. Interactive webinar delivery shows promise for considerably extending the reach of immunization quality improvement programs.Trial registrationClinicaltrials.gov, NCT01544764