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