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Low 3-dose completion and
missed opportunities for the HPV vaccine
in Utah
DEANNA KEPKA, PHD, MPHINVESTIGATOR, HUNTSMAN CANCER INSTITUTEASSISTANT PROFESSOR, COLLEGE OF NURSING
UNIVERSITY OF UTAH
BackgroundCervical cancer
• The most preventable gynecologic cancer - Vaccine, screening, & treatments are available and effective
• Worldwide, the 4th most common cancer among women
• Predominantly a problem of access to preventative health care services
• In U.S. 12,000 women are diagnosed with cervical cancer yearly; 4,000 will die from it every year
Human papillomavirus (HPV)
• Causes most cervical cancer, and some anogenital and oropharyngeal cancers in both sexes
• HPV also causes genital and laryngeal warts
U.S. HPV Cancer Statistics
Source: Accelerating HPV Vaccine Uptake, President’s Cancer Panel Report 2012-2013
Background• The Healthy People 2020 objective for HPV vaccination series
completion among females ages 13-15 is 80%
• More than six years after HPV vaccine approval, only 33% of U.S. females and 7% of males ages 13-17 years have completed the series
• Despite increases in the 3-dose completion rate among female teens in Utah, the rate is significantly below the national rate
• In 2012, Utah ranked 4th lowest (24.1%) for 3-dose completion
Uptake of adolescent vaccines
Research Question
What factors are related to HPV vaccine uptake and completion among adolescent females in Utah?
Methods
Participants & Data Analysis• We gathered our data from the 2012 National Immunization Survey -
Teen (NIS - T) (survey of parents of adolescents ages 13-17 years).
• NIS-T is constructed using a complex survey sampling design.
• Using Stata-13.1 statistical software, percentages and two-sided 95% confidence intervals were estimated using appropriate survey weights.
• Appropriate weighting adjustments were likewise made for the subpopulation percentages and confidence intervals.
• Exclusions: • Adolescents without provider validated vaccination history
• Respondents from the U.S. Virgin Islands
Results
Table 1: Demographic characteristics of females ages 13-17, 2012
UT (N=163) U.S. (N= 9058)
Age (Mother/ Parent) n (weighted %) 95% CI n (weighted %) 95% CI
≤34 years35 years - 44 years≥45 years
8 (5.52)78 (53.96)77 (40.52)
(2.2-13.2)(43.5-64.1)(30.9-51.0)
671 (10.04)3709 (45.33)4678 (44.64)
(8.8-11.4)(43.5-47.2)(42.3-46.5)
Education (Mother/ Parent)
<High schoolHigh school>12 years (Non-college)College graduate
9 (9.57)31 (20.05)59 (34.90)64 (35.48)
(4.4-20.0)(12.7-30.2)(25.7-45.3)(26.3-46.0)
905 (14.29)1723 (24.02)2547 (27.76)3883 (33.93)
(12.8-15.9)(22.4-26.0)(26.1-29.5)(32.3-36.0)
Marital status of mother
MarriedNot married
139 (79.15)24 (20.85)
(68.3-87.0)(13.0-31.7)
6691 (63.98)2367 (36.02)
(62.1-65.9)(34.1-38.0)
Table 2: Vaccination history among females ages 13-17, 2012UT (N=163) U.S. (N= 9058)
Ever received doctor recommendation for HPV n (weighted %) 95% CI n (weighted %) 95% CI
YesNoDon’t know
86 (52.19)67 (42.81)
9 (5.01)
(41.6-62.6)(32.7-53.6)(2.0-11.9)
5832 (61.71)2747 (32.80)
404 (5.49)
(59.8-63.6)(31.1-34.6)
(4.5-6.7)
Received at least 1 HPV (recall)*
YesNoDon’t know
59 (40.51)80 (48.63)13 (6.95)
(30.4-51.6)(38.2-59.2)(3.4-13.8)
3710 (39.83)4186 (46.00)
471 (8.09)
(38.1-41.7)(44.1-47.9)
(7.0-9.4)
Received at least 1 HPV (provider)
YesNo
78 (44.34)85 (55.66)
(34.3-55.0)(45.1-65.8)
4158 (53.85)4900 (46.15)
(52.0-55.7)(44.3-48.0)
Received at least 3 doses HPV (recall)*
YesNoDon’t know
32 (21.96)103 (65.88)
17 (8.25)
(13.8-33.2)(55.1-75.3)(4.4-15.0)
1934 (19.65)5772 (64.4)660 (9.93)
(18.3-21.1)(62.5-66.1)(8.7-11.3)
Received at least 3 doses HPV (provider)
YesNo
47 (24.14)116 (75.86)
(16.7-33.4)(66.5-83.3)
3246 (33.43)5812 (66.57)
(31.7-35.2)(64.8-68.3)
*Received at least 1 HPV missing for: Utah=11, U.S.=691; Received at least 3 HPV missing for: Utah=11, U.S.=692
*Not recommended by doctors, cost, safety/side effects concern, not needed/not necessary missing for: Utah=81, U.S.=5825
Table 3: Reasons for not vaccinating in next 12 months among females ages 13-17, 2012 with HPV vaccine
UT (N=163) U.S. (N= 9058)
Not recommended by doctors (significant)* n (weighted %) n (weighted %)
YesNoDon’t know
16 (15.34)63 (33.71)
3 (3.06)
515 (6.49)2574 (28.87)
144 (1.88)
Cost*
YesNoDon’t know
1 (0.56)78 (48.48)
3 (3.06)
60 (0.55)3029 (34.81)
144 (1.88)
Safety/side effects concern*
YesNoDon’t know
9 (4.23)70 (44.81)
3 (3.06)
434 (4.79)2655 (30.56)
144 (1.88)
Not needed/not necessary*
YesNoDon’t know
14 (9.77)65 (39.27)
3 (3.06)
633 (6.76)2456 (28.60)
144 (1.88)
Uptake of HPV vaccine
Table 1: Demographic characteristics of females ages 13-17 who have received 1 dose of the HPV vaccine, 2012
UT (N=78) U.S. (N=4900)
Age (Mother/ Parent) n (weighted %) n (weighted %)
≤34 years35 years - 44 years≥45 years
4 (4.91) 34 (50.71)40 (44.38)
407 (11.05)1990 (45.34)2503 (43.61)
Education (Mother/ Parent)
<High schoolHigh school>12 years (Non-college)College graduate
5 (8.24)14 (14.41)33 (47.84)26 (29.51)
575 (17.66)944 (25.11)1313 (24.77)2068 (32.47)
Health Insurance
Employer/UnionOther
60 (74.43)18 (25.57)
3108 (53.91)1751 (46.09)
11-12 year old exam*
YesNoDon’t know
56 (78.49)0 (0.00)3 (3.47)
3988 (79.43)226 (5.67)100 (2.17)
Doctor ever recommended HPV
YesNoDon’t know
55 (73.52)20 (23.19)3 (3.29)
3810 (73.58)856 (21.49)213 (4.93)
*11-12 year old exam missing for: Utah=19, US=586
Missed Opportunities
Uptake of HPV vs. Tdap
Table 1: Female adolescent vaccination in Utah vs. U.S.
Utah U.S.
% (95% CI) % (95% CI)
> 1 HPV 44.3(±10.4) 53.9(±1.9)
> 3 HPV 24.1(±8.4) 33.4(±1.7)
> 1 TDAP 81.5(±6.3) 84.6(±0.9)
≥1 Meningococcal 56.5(±7.0) 74.0 (±1.1)
NIS Teen 2012
3-dose completion of HPV vaccine
Table 1: Demographic characteristics of females ages 13-17 who have received 3 doses of the HPV vaccine, 2012
UT (N=47) U.S. (N=3246)
Age (Mother/ Parent) n (weighted %) 95% CI n (weighted %) 95% CI
≤34 years35 years - 44 years≥45 years
2 (2.86)22 (56.93)23 (40.20)
(.7-11.6)(40.0-55.0)(35.8-50.4)
217 (10.37)1304 (44.24)1725 (45.39)
(8.1-13.2)(41.2-47.4)(42.4-48.5)
Education (Mother/ Parent)
<High schoolHigh school>12 years (Non-college)College graduate
1 (1.68)8 (19.20)
18 (38.89)20 (40.22)
(.22-11.9)(6.4-45.1)
(22.0-58.9)(22.4-58.9)
352 (16.69)615 (23.67)836 (24.09)
1443 (35.54)
(14.1-20.0)(21.0-26.5)(21.6-26.7)(32.8-38.4)
Poverty status of mother
Above poverty (<$75K)Above poverty (≤$75k)Below poverty
27 (51.96)17 (34.56)3 (13.49)
(33.3-70.1)(18.6-55.0)(2.9-45.0)
1472 (34.42)1101 (35.93)587 (29.65)
(31.7-37.3)(32.9-39.1)(26.6-32.9)
Health Insurance
Employer/UnionOther
38 (77.81)9 (22.19)
(53.2-91.6)(8.5-46.8)
2102 (55.63)1118 (44.37)
(52.4-58.8)(41.2-47.6)
11-12 year old exam*
YesNoDon’t know
37 (79.13)0 (0.00)2 (3.71)
(62.6-89.6)(0-0)
(.9-14.5)
2765 (83.62)129 (4.48)62 (2.33)
(80.9-86.0)(.3-6.5)
(1.5-3.7)
*11-12 year old exam missing for: Utah=8, US=290;
Table 2: Vaccination history among females ages 13-17 who have received at least 3 doses of the HPV vaccine, 2012
UT (N=47) U.S. (N=3246)
n (weighted %) 95% CI n (weighted %) 95% CI
≥1 TDAP ages 10-13 (provider)
YesNo
40 (88.53)7 (11.47)
(74.8-95.3)(4.8-25.2)
2465 (72.40)781 (27.60)
(69.3-75.3)(24.7-30.7)
≥1 Meningococcal (provider)
YesNo
38 (87.63)9 (12.37)
(75.1-94.3)(5.7-24.9)
2916 (90.67)330 (9.33)
(88.5-92.4)(7.6-11.5)
*Hepatitis A missing for: Utah=14, U.S.=478; Meningitis missing for: Utah=7, U.S.=603
Focus Groups
Provider Comment (UT Focus Group)
“You have them there, the needle ready and then they go, ‘Oh I have to go check my insurance and plan to
come back.’
They actually have to plan to come back three times
because of the length of the series…these are
adolescents and it’s hard to get them in anyway.”
Provider Comment (UT Focus Group)
“I don’t think [its] been in the forefront of anyone’s desire to make changes [i.e., reminder
system]...I mean, we’ve talked about some sort of a reminder
process for patients before, but …that’s probably as far as it went.”
Parent Comment (Latino Parents Focus Group)“I think that if anyone here
had his son or daughter vaccinated it’s because the
doctor provided all the necessary information and
the person accepted to receive it. But if [anyone] here has [not chosen to
have the vaccine] it’s because we’re not
informed.”
Conclusions
Discussion & Future Steps
Room for improvement in uptake and completion of HPV vaccine◦ Missed opportunities◦ Low 3-dose completion ◦ Parent education
Providers and parents provide valuable feedback for future interventions◦ Provider buy-in is important◦ Focus on strong provider recommendation to parents◦ Reminder systems to improve completion rates
Acknowledgements Funding: Huntsman Cancer Institute, College of Nursing, Primary Children’s Hospital Foundation
Michael Spigarelli & Kathi Mooney – Mentorship Team
Qian Ding, Echo Warner, Djin Lai, Beth Adkins, & Guadalupe Tovar
Alliance Community Services & Comunidades Unidas
Thank you & Questions?
1. Centers for Disease Prevention and Control. (2011). Human Papillomavirus (HPV) Infection, Sexually Transmitted Diseases. Retrieved from http://www.cdc.gov/std/treatment/2010/hpv.htm
2. Centers for Disease Prevention and Control. (2014). CDC grand rounds: Reducing the burden of HPV-associated cancer and disease. Morbidity and Mortality Weekly Report (MMWR), 63(4), 69-72
3. Kepka D., Ding Q., Bodson J., Warner EL., & Mooney K. (2014). Latino parents’ awareness of the HPV vaccine in Salt Lake City. Manuscript in preparation.
4. Kepka, D., Ulrich, A.K., & Coronado, G.D. (2012). Low knowledge of the three-dose HPV vaccine series among mothers of rural Hispanic adolescents. Journal of Health Care for the Poor and Underserved, 23(2), 626-636.
5. Kepka D., Warner EL, Kinney A.Y., Spigarelli M. & Mooney, K. (2014). Low human papillomavirus (HPV) vaccine knowledge among Latino parents in Utah. Journal of Minority and Immigrant Health.
6. National Cancer Institute (2012). HPV and Cancer, National Cancer Institute Fact Sheet. Retrieved from http://www.cancer.gov/cancertopics/factsheet/Risk/HPV
7. The President’s Cancer Panel. (2014). Accelerating HPV vaccine uptake: Urgency for action to prevent cancer: A report to the president of the United States from the President’s Cancer Panel. Retried from http://deainfo.nci.nih.gov/advisory/pcp/annualReports/HPV/index.htm
References