Uptake of the Human Papillomavirus Vaccine
Uptake of the Human Papillomavirus Vaccine
Purpose: The aims of this study were to review predictors of knowledge about human papillomavirus (HPV), HPV vaccine, and factors related to HPV vaccine uptake and report a quality assurance project that evaluated HPV vaccine uptake and three-dose completion rates.
Methods: The setting was a small private urban pediatric practice. Chart review was used to describe HPV vaccine uptake and dose completion rates in 2007. The convenience sample included 189 girls aged 12 to 21 years with HPV vaccine uptake.
Results: During 2007, 153 girls aged 12 to 17 years and 42 girls aged 18 to 21 years were seen at well-child care visits. HPV vaccine uptake was 72% (n = 110) for the younger group and 79% (n = 33) for the older group. There was no significant difference in HPV vaccine uptake by group. One quarter (24%, n = 46) received the HPV vaccine dose at an episodic visit. The dose completion rate was 64% (n = 120).
Discussion: HPV vaccine uptake and dose completion rates were higher than rates reported by the Centers for Disease Control and Prevention. Effective strategies are needed to promote HPV vaccine uptake and dose completion.
Cervical cancer is one of the most common types of cancer in women worldwide (Barnholtz-Sloan et al., 2009). Increased compliance with Papanicolaou (PAP) cervical screening in the United States has affected the early identification and treatment of cervical cancer, thus reducing its morbidity and mortality rates. Despite the positive effect that public health education has had on compliance with PAP screening, disparities in cervical cancer among non-White women persist (American Cancer Society, 2010). Although invasive cervical cancer rates have been reported to be on the decline for many races, Hispanic and non-Hispanic African American women have had a much higher incidence than non-Hispanic White women (Barnholtz-Sloan et al., 2009). These statistics signify the importance of reducing cultural barriers to screening and prevention of cervical cancer.
The majority of women have had abnormal results of a PAP smear at some point in their lifetime. Many of these abnormalities are related to human papillomavirus (HPV), a sexually transmitted infection that has been identified as a causative factor in cervical cancer. Multiple oncogenic strains of HPV have been identified, and two strains, HPV 16 and 18, cause 70% of cervical cancers (Keating et al., 2008). The presence of HPV infection also has been associated with external condylomata, and HPV strains 6 and 11 have been found to be a causative factor in most of these lesions (Dunne et al., 2007). Higher HPV prevalence rates have been reported for non-Hispanic Black women compared with non-Hispanic White and Mexican American women (Dunne et al., 2007). Evidence-based educational interventions that are culturally sensitive have the potential to reduce disparities in rates of HPV infection and cervical cancer.
Both GlaxoSmithKline and Merck & Co have received Food and Drug Administration approval to license vaccines to prevent HPV infection. The Advisory Committee on Immunization Practices (ACIP) describes these two available forms of the HPV vaccine: Cervarix by GlaxoSmithKline, a bivalent vaccine that contains inactive strains 16 and 18 of HPV, and Gardasil, a quadrivalent vaccine by Merck & Co. that contains inactive strains 16, 18, 6, and 11 of HPV (Middleman, 2007). Cervarix has been used in the United Kingdom as part of their national immunization program (Brabin et al., 2008) and has been available in the United States since fall 2009. Gardasil has been available in the United States since spring 2006. Both vaccines are available in a three-dose series for administration over a 6-month period to girls and young women aged 9 to 26 years. Furthermore, these vaccines have been reported to be safely administered in conjunction with other vaccines. Parental consent for administration of the HPV vaccine must be obtained prior to the age of 18 years in both countries. The Centers for Disease Control and Prevention (CDC) (2009a), the American Academy of Pediatrics (AAP) (AAP Committee on Infectious Diseases, 2007), and the ACIP (Markowitz et al., 2007) recommend offering the HPV vaccine routinely as part of the annual physical examination in girls aged 11 to 12 years. In response to these recommendations, a public health education campaign was initiated to encourage HPV vaccine uptake (Stanley, 2007).
Clinical trials have demonstrated that Gardasil has 100% efficacy to prevent HPV infection, if one is exposed to the virus, when the three-dose series is administered prior to coital debut (Markowitz et al., 2007). According to Markowitz and colleagues (2007), sustained immunity has been reported at 5 years and seems similar to long-standing immunity reports of the hepatitis B vaccine. Clinical trials also have shown that antibody responses are highest in girls aged 9 to 15 years (AAP Committee on Infectious Diseases, 2007). Reported adverse effects of Gardasil have included pain and redness at the injection site and dizziness with some episodes of syncope (Markowitz et al., 2007). Because the HPV vaccine is frequently given in conjunction with other vaccines, investigators have been unable to determine if syncope is directly related to the HPV vaccine.
Adolescent sexual behaviors have been studied for many years. Among adolescents aged 15 to 17 years, nearly one third reported ever having had sex (Gavin et al., 2009), and 39% reported having had sex during or prior to the 9th grade (U.S. Department of Health & Human Services, 2000). Additionally, adolescents in grades 9 through 12 have been known to practice risky sexual behaviors, including unprotected sex, with rates as high as 15% (U.S. Department of Health & Human Services, 2000). Increasing and alarming risk factors exist for adolescents with early age initiation of sexual activity as well. A high incidence of HPV infection exists in this age group, which can be attributed to such risk factors as physiologic immaturity, early sexual debut, multiple sex partners, and unsafe sex practices. Middleman (2007) reported that several studies found a high cumulative incidence of HPV infection in adolescents aged 13 to 16 years shortly after their sexual debut. Prevalence of HPV infection has been reported as being 25% in adolescents aged 14 to 19 years and 45% in young adults aged 20 to 24 years (Dunne et al., 2007). These statistics provide evidence of the likelihood of contracting HPV infection without the benefit of receiving the HPV vaccination as an adolescent or young adult.
In summary, the HPV vaccine is a primary preventive strategy to reduce the incidence of HPV infection and further reduce cervical cancer rates. Despite the benefit to risk ratio of the HPV vaccine, parents have expressed some hesitancy about having their daughters vaccinated. Understanding the factors that affect parental intention for uptake of the HPV vaccine by their daughters may suggest strategies to improve the HPV vaccine uptake rate. Utilizing culturally sensitive educational methods to promote this cancer-preventing vaccine can potentially reduce disparities in rates of HPV infection and cervical cancer.
The purposes of this article are to:
Abstract and Introduction
Abstract
Purpose: The aims of this study were to review predictors of knowledge about human papillomavirus (HPV), HPV vaccine, and factors related to HPV vaccine uptake and report a quality assurance project that evaluated HPV vaccine uptake and three-dose completion rates.
Methods: The setting was a small private urban pediatric practice. Chart review was used to describe HPV vaccine uptake and dose completion rates in 2007. The convenience sample included 189 girls aged 12 to 21 years with HPV vaccine uptake.
Results: During 2007, 153 girls aged 12 to 17 years and 42 girls aged 18 to 21 years were seen at well-child care visits. HPV vaccine uptake was 72% (n = 110) for the younger group and 79% (n = 33) for the older group. There was no significant difference in HPV vaccine uptake by group. One quarter (24%, n = 46) received the HPV vaccine dose at an episodic visit. The dose completion rate was 64% (n = 120).
Discussion: HPV vaccine uptake and dose completion rates were higher than rates reported by the Centers for Disease Control and Prevention. Effective strategies are needed to promote HPV vaccine uptake and dose completion.
Introduction
Cervical cancer is one of the most common types of cancer in women worldwide (Barnholtz-Sloan et al., 2009). Increased compliance with Papanicolaou (PAP) cervical screening in the United States has affected the early identification and treatment of cervical cancer, thus reducing its morbidity and mortality rates. Despite the positive effect that public health education has had on compliance with PAP screening, disparities in cervical cancer among non-White women persist (American Cancer Society, 2010). Although invasive cervical cancer rates have been reported to be on the decline for many races, Hispanic and non-Hispanic African American women have had a much higher incidence than non-Hispanic White women (Barnholtz-Sloan et al., 2009). These statistics signify the importance of reducing cultural barriers to screening and prevention of cervical cancer.
The majority of women have had abnormal results of a PAP smear at some point in their lifetime. Many of these abnormalities are related to human papillomavirus (HPV), a sexually transmitted infection that has been identified as a causative factor in cervical cancer. Multiple oncogenic strains of HPV have been identified, and two strains, HPV 16 and 18, cause 70% of cervical cancers (Keating et al., 2008). The presence of HPV infection also has been associated with external condylomata, and HPV strains 6 and 11 have been found to be a causative factor in most of these lesions (Dunne et al., 2007). Higher HPV prevalence rates have been reported for non-Hispanic Black women compared with non-Hispanic White and Mexican American women (Dunne et al., 2007). Evidence-based educational interventions that are culturally sensitive have the potential to reduce disparities in rates of HPV infection and cervical cancer.
Both GlaxoSmithKline and Merck & Co have received Food and Drug Administration approval to license vaccines to prevent HPV infection. The Advisory Committee on Immunization Practices (ACIP) describes these two available forms of the HPV vaccine: Cervarix by GlaxoSmithKline, a bivalent vaccine that contains inactive strains 16 and 18 of HPV, and Gardasil, a quadrivalent vaccine by Merck & Co. that contains inactive strains 16, 18, 6, and 11 of HPV (Middleman, 2007). Cervarix has been used in the United Kingdom as part of their national immunization program (Brabin et al., 2008) and has been available in the United States since fall 2009. Gardasil has been available in the United States since spring 2006. Both vaccines are available in a three-dose series for administration over a 6-month period to girls and young women aged 9 to 26 years. Furthermore, these vaccines have been reported to be safely administered in conjunction with other vaccines. Parental consent for administration of the HPV vaccine must be obtained prior to the age of 18 years in both countries. The Centers for Disease Control and Prevention (CDC) (2009a), the American Academy of Pediatrics (AAP) (AAP Committee on Infectious Diseases, 2007), and the ACIP (Markowitz et al., 2007) recommend offering the HPV vaccine routinely as part of the annual physical examination in girls aged 11 to 12 years. In response to these recommendations, a public health education campaign was initiated to encourage HPV vaccine uptake (Stanley, 2007).
Clinical trials have demonstrated that Gardasil has 100% efficacy to prevent HPV infection, if one is exposed to the virus, when the three-dose series is administered prior to coital debut (Markowitz et al., 2007). According to Markowitz and colleagues (2007), sustained immunity has been reported at 5 years and seems similar to long-standing immunity reports of the hepatitis B vaccine. Clinical trials also have shown that antibody responses are highest in girls aged 9 to 15 years (AAP Committee on Infectious Diseases, 2007). Reported adverse effects of Gardasil have included pain and redness at the injection site and dizziness with some episodes of syncope (Markowitz et al., 2007). Because the HPV vaccine is frequently given in conjunction with other vaccines, investigators have been unable to determine if syncope is directly related to the HPV vaccine.
Adolescent sexual behaviors have been studied for many years. Among adolescents aged 15 to 17 years, nearly one third reported ever having had sex (Gavin et al., 2009), and 39% reported having had sex during or prior to the 9th grade (U.S. Department of Health & Human Services, 2000). Additionally, adolescents in grades 9 through 12 have been known to practice risky sexual behaviors, including unprotected sex, with rates as high as 15% (U.S. Department of Health & Human Services, 2000). Increasing and alarming risk factors exist for adolescents with early age initiation of sexual activity as well. A high incidence of HPV infection exists in this age group, which can be attributed to such risk factors as physiologic immaturity, early sexual debut, multiple sex partners, and unsafe sex practices. Middleman (2007) reported that several studies found a high cumulative incidence of HPV infection in adolescents aged 13 to 16 years shortly after their sexual debut. Prevalence of HPV infection has been reported as being 25% in adolescents aged 14 to 19 years and 45% in young adults aged 20 to 24 years (Dunne et al., 2007). These statistics provide evidence of the likelihood of contracting HPV infection without the benefit of receiving the HPV vaccination as an adolescent or young adult.
In summary, the HPV vaccine is a primary preventive strategy to reduce the incidence of HPV infection and further reduce cervical cancer rates. Despite the benefit to risk ratio of the HPV vaccine, parents have expressed some hesitancy about having their daughters vaccinated. Understanding the factors that affect parental intention for uptake of the HPV vaccine by their daughters may suggest strategies to improve the HPV vaccine uptake rate. Utilizing culturally sensitive educational methods to promote this cancer-preventing vaccine can potentially reduce disparities in rates of HPV infection and cervical cancer.
The purposes of this article are to:
1.Review predictors of knowledge about HPV and the HPV vaccine
2.Review predictors of parental intention for uptake of the HPV vaccine by their daughters
3.Review provider factors related to uptake of the HPV vaccine
4.Describe a quality assurance (QA) project in a private practice to evaluate the HPV vaccine uptake rate (≥ 1 dose) and HPV vaccine three-dose completion rate and compare it with the HPV vaccine uptake rate and three-dose completion rate reported in the literature.
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