Understanding Factors Affecting Health Providers' Perceptions of Pharmacist Roles in HPV Vaccine Administration.

Human papillomavirus (HPV) is a viral infection that sexually active females and males may be exposed to in their lifetime. The HPV vaccine is highly recommended especially among children to protect them before their anticipated exposure to HPV, however, vaccination uptake in Hawai'i remains low. As of 2017, legislation allows pharmacists to vaccinate for adolescent vaccines with the potential to increase access and opportunities for patients to complete the HPV vaccine series. Physicians in Hawai'i were surveyed to examine physicians' awareness of this law, their perceptions of the role of pharmacists, and willingness to send adolescent patients to pharmacies; 137 responses were received and analyzed. Overall, 72% (n=99) of respondents were willing while 28% (n=38) were unwilling to send patients to pharmacies for vaccines. Physicians view pharmacists' role as helpful but have concerns regarding correct administration and tracking doses given. Results show potential for more physician-pharmacist collaborations through further education and trainings for pharmacists and health providers to increase physician referrals for adolescent vaccine services in pharmacies.

Maternal seafood consumption is associated with improved selenium status: Implications for child health.

Selenium (Se) is required for synthesis of selenocysteine (Sec), an amino acid expressed in the active sites of Se-dependent enzymes (selenoenzymes), including forms with essential functions in fetal development, brain activities, thyroid hormone metabolism, calcium regulation, and to prevent or reverse oxidative damage. Homeostatic mechanisms normally ensure the brain is preferentially supplied with Se to maintain selenoenzymes, but high methylmercury (CH3Hg) exposures irreversibly inhibit their activities and impair Sec synthesis. Due to Hg's high affinity for sulfur, CH3Hg initially binds with the cysteine (Cys) moieties of thiomolecules which are selenoenzyme substrates. These CH3Hg-Cys adducts enter selenoenzyme active sites and transfer CH3Hg to Sec, thus irreversibly inhibiting their activities. High CH3Hg exposures are uniquely able to induce a conditioned Se-deficiency that impairs synthesis of brain selenoenzymes. Since the fetal brain lacks Se reserves, it is far more vulnerable to CH3Hg exposures than adult brains. This prompted concerns that maternal exposures to CH3Hg present in seafood might impair child neurodevelopment. However, typical varieties of ocean fish contain far more Se than CH3Hg. Therefore, eating them should augment Se-status and thus prevent Hg-dependent loss of fetal selenoenzyme activities. To assess this hypothesis, umbilical cord blood and placental tissue samples were collected following delivery of a cohort of 100 babies born on Oahu, Hawaii. Dietary food frequency surveys of the mother's last month of pregnancy identified groups with no (0 g/wk), low (0-12 g/wk), or high (12 + g/wk) levels of ocean fish consumption. Maternal seafood consumption increased Hg contents in fetal tissues and resulted in ∼34% of cord blood samples exceeding the EPA Hg reference level of 5.8 ppb (0.029 µM). However, Se concentrations in these tissues were orders of magnitude higher and ocean fish consumption caused cord blood Se to increase ∼9.4 times faster than Hg. Therefore, this study supports the hypothesis that maternal consumption of typical varieties of ocean fish provides substantial amounts of Se that protect against Hg-dependent losses in Se bioavailability. Recognizing the pivotal nature of the Hg:Se relationship provides a consilient perspective of seafood benefits vs. risks and clarifies the reasons for the contrasting findings of certain early studies.

Effects of Prophylactic Oxytocin on Bleeding Outcomes in Women Undergoing Dilation and Evacuation: A Randomized Controlled Trial.

OBJECTIVE: To estimate whether routine use of intravenous oxytocin decreases the frequency of interventions to control excess blood loss during dilation and evacuation (D&E). METHODS: In this multisite, randomized, double-blind, placebo-controlled trial, women undergoing D&E at 18-24 weeks of gestation received 30 units of oxytocin in 500 mL of intravenous fluid or 500 mL of intravenous fluid alone initiated on speculum placement. The primary outcome was the frequency of interventions to control excess bleeding. A sample size of 75 patients per group was needed to detect a 15% decrease in intervention from 20% to 5% with 80% power and two-sided alpha 0.05. Secondary outcomes included measured blood loss, complications, procedure duration, postoperative pain, and patient satisfaction. RESULTS: From November 2014 to February 2018, we screened 337 women and randomized 160 to receive prophylactic oxytocin (n=82) or placebo (n=78). Demographic characteristics were similar between groups. The frequency of interventions for bleeding, our primary outcome, was 7.3% in the oxytocin group vs 16.7% in the placebo group, difference of 9.4% (95% CI -21.0% to 1.9%). Interventions primarily included uterine massage and uterotonic administration. Among our secondary outcomes, median measured blood loss was lower in the oxytocin group at 152 (interquartile range 98-235) mL vs 317 (interquartile range 168-464) mL (95% CI 71.6-181.5). Frequency of hemorrhage, defined as blood loss of 500 mL or more and 1,000 mL or more, was lower in the oxytocin group at 3.7% vs 21.8%, difference of 18% (95% CI -29 to -6.9%) and 1.2% vs 10.3%, difference of 9.0% (95% CI -17 to -0.7%), respectively. Procedures were shorter in the oxytocin group at a median of 11.0 (interquartile range 8.0-14.0) vs 13.5 (interquartile range 10.0-19.0) minutes in the placebo group (95% CI 1.0-4.0). We found no differences in the frequency of nonhemorrhage complications, pain scores, or satisfaction scores between groups. CONCLUSION: Prophylactic use of oxytocin during D&E at 18-24 weeks of gestation did not decrease the frequency of interventions to control bleeding. However, oxytocin did decrease blood loss and frequency of hemorrhage. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT02083809.

Improving Human Papillomavirus (HPV) Vaccination in the Postpartum Setting.

Although the HPV vaccine has been shown to be highly effective in preventing cervical dysplasia, vaccination rates remain low. The objective of this study was to assess the effectiveness of an electronic medical record (EMR) prompt on HPV vaccination rates in the postpartum setting. We conducted a pre-post intervention study among postpartum women ages 18-26 seen at an outpatient clinic from 09/01/2012-08/31/2013 (pre-intervention) and from 10/01/2013-03/31/2014 (post-intervention). The intervention was a drop-down menu that was inserted into the EMR postpartum note template inquiring about the patient's HPV vaccination status and whether or not the vaccine was administered at that visit. HPV vaccination uptake was compared pre and post-intervention. Of the 278 postpartum visits during the study period, 241 were eligible for analysis. There was a significant increase of the HPV vaccine uptake, from 1.2 % (2/173) among pre-intervention visits to 26.5 % (18/68) among post-intervention visits (p < 0.001). After adjusting for age, ethnicity, insurance, and religion, HPV vaccination was significantly higher at postpartum visits during the intervention period, with an adjusted OR = 93.49 [95 % CI 15.29-571.52]. Among visits in which the vaccine was not given, HPV vaccination was not discussed in 46 % and patients refused the vaccine in 40 % of visits. An EMR prompt in the postpartum note could be an effective way to promote HPV vaccination in the postpartum setting. It will likely take a combination of strategies to optimize vaccination uptake.

Promoting and Providing HPV Vaccination in Hawaii: Barriers Faced by Health Providers.

Despite the availability of HPV prophylactic vaccines, uptake has been suboptimal in the US. In the state of Hawaii, HPV vaccine coverage has decreased among females and remains low among males aged 13-17. The reasons for low uptake are unknown and may indicate the existence of critical barriers to HPV vaccination. The purpose of this investigation was to identify policy, system and environmental barriers and promoters of pediatric HPV vaccination in Hawaii. An online 86-item survey addressing knowledge, attitudes, beliefs, practices, and barriers to HPV vaccination was distributed to practicing physicians in Hawaii specializing in Pediatrics, Family Medicine, and Obstetrics-Gynecology. Survey responses were received from a total of 120 physicians. Private practice physicians reported more concerns with vaccine ordering and stocking costs (p < 0.0001), reimbursement levels (p < 0.0001), and insurance coverage (p < 0.0001) compared to physicians in large group practices. Eighty-three percent of providers cited lack of parent knowledge and understanding of HPV infection as a barrier. Over half of physicians (58 %) reported that completion of the 3-dose schedule was a barrier. Most physicians did not use tracking or reminder systems to ensure dose completion. A majority (58 %) of providers cited the lack of school-based vaccination requirements as a barrier. Uptake of HPV vaccination in Hawaii may be impeded by physician perception of parent knowledge and attitudes. Cost-related system barriers are particular barriers among those in private practice. Completion of the 3-dose schedule also remains a challenge.

A Survey of Physicians' Attitudes and Practices about the Human Papillomavirus (HPV) Vaccine in Hawai'i.

The human papillomavirus (HPV) vaccine has the potential to decrease the incidence of several cancers that affect women and men. Despite recommendations by the medical and public health community, and the incorporation of the vaccine into the adolescent immunization schedule, uptake of the vaccine remains well below target goals. To understand potential physician barriers to recommendation and provision of the vaccine, a cross-sectional survey was administered to Hawai'i pediatricians and family physicians from July 2012 to September 2012 on their attitudes, practices, and perceived barriers regarding HPV vaccination. Surveys were mailed to 465 members of the local pediatrics and family medicine professional chapters, and 87 responses were received for a response rate of 19%. After excluding 14 responses, 73 surveys were included in the analysis. Although almost all of the respondents reported stocking and administering the HPV vaccine in their offices, only 71% reported strongly recommending the HPV vaccine to girls 11-12 years, and only 57% strongly recommend the vaccine to boys 11-12 years old. Lack of insurance coverage and other financial considerations were barriers to provision of the vaccine by physicians. Physicians who felt it is necessary to discuss sexuality with patients prior to recommending the vaccine were significantly less likely to strongly recommend the vaccine to boys 11-12 years old. Public health efforts should focus on addressing the financial barriers and encouraging physicians to recommend the HPV vaccine according to the guidelines.