Population Attributable Fraction of Nonvaccination of COVID-19 Due to Vaccine Hesitancy, United States, 2021.

Understanding the extent of coronavirus disease 2019 (COVID-19) nonvaccination attributable to vaccine hesitancy versus other barriers can help prioritize approaches for increasing vaccination uptake. Using data from the Centers for Disease Control and Prevention's Research and Development Survey, a nationally representative survey fielded from May 1 to June 30, 2021 (n = 5,458), we examined the adjusted population attribution fraction (PAF) of COVID-19 vaccine hesitancy attributed to nonvaccination according to sociodemographic characteristics and health-related variables. Overall, the adjusted PAF of nonvaccination attributed to vaccine hesitancy was 76.1%. The PAF was highest among adults who were ≥50 years of age (87.9%), were non-Hispanic White (83.7%), had a bachelor's degree or higher (82.7%), had an annual household income of at least $75,000 (85.5%), were insured (82.4%), and had a usual place for health care (80.7%). The PAF was lower for those who were current smokers (65.3%) compared with never smokers (77.9%), those who had anxiety or depression (65.2%) compared with those who did not (80.1%), and those who had a disability (64.5%) compared with those who did not (79.2%). Disparities in PAF suggest areas for prioritization of efforts for intervention and development of messaging campaigns that address all barriers to uptake, including hesitancy and access, to advance health equity and protect individuals from COVID-19.

Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia.

INTRODUCTION: Human papillomavirus (HPV) vaccination protects against HPV-associated cancers and genital warts. Healthy People 2030 goal for HPV vaccine uptake is 80%, but as of 2021, only 58.5% of adolescents are up to date in Georgia. The purpose of the study is to assess the attitudes, vaccine practices, facilitators, and barriers to receiving the HPV vaccine in southwest Georgia. METHODS: We conducted 40 semi-structured interviews in the United States from May 2020-Feburary 2022 with three different audiences (young adults, parents, and providers and public health professionals) guided by the P3 (patient-, provider-, practice-levels) Model. The audiences were recruited by multiple methods including fliers, a community advisory board, Facebook ads, phone calls or emails to schools and health systems, and snowball sampling. Young adults and parents were interviewed to assess their perceived benefits, barriers, and susceptibility of the HPV vaccine. Providers and public health professionals were interviewed about facilitators and barriers of patients receiving the HPV vaccine in their communities. We used deductive coding approach using a structured codebook, two coders, analyses in MAXQDA, and matrices. RESULTS: Out of the 40 interviews: 10 young adults, 20 parents, and 10 providers and public health professionals were interviewed. Emerging facilitator themes to increase the uptake of the HPV vaccine included existing knowledge (patient level) and community outreach, providers' approach to the HPV vaccine recommendations and use of educational materials in addition to counseling parents or young adults (provider level) and immunization reminders (practice level). Barrier themes were lack of knowledge around HPV and the HPV vaccine (patient level), need for strong provider recommendation and discussing the vaccine with patients (provider level), and limited patient reminders and health education information around HPV vaccination (practice level). Related to socio-ecology, the lack of transportation and culture of limited discussion about vaccination in rural communities and the lack of policies facilitating the uptake of the HPV vaccine (e.g., school mandates) were described as challenges. CONCLUSION: These interviews revealed key themes around education, knowledge, importance of immunization reminders, and approaches to increasing the HPV vaccination in rural Georgia. This data can inform future interventions across all levels (patient, provider, practice, policy, etc.) to increase HPV vaccination rates in rural communities.

The importance of immunization in cancer prevention, treatment, and survivorship.

Answer questions and earn CME/CNE A measles outbreak originating in California during 2014 and 2015 called attention to the potential for infectious disease outbreaks related to underimmunized populations in the United States and the potential risk to pediatric patients with cancer attending school when such outbreaks occur. Compliance with vaccine recommendations is important for the prevention of hepatitis B-related and human papillomavirus-related cancers and for protecting immunocompromised patients with cancer, and these points are often overlooked, resulting in the continued occurrence of vaccine-preventable neoplastic and infectious diseases and complications. This article provides an overview of the importance of vaccines in the context of cancer and encourages clinician, health system, and public policy efforts to promote adherence to immunization recommendations in the United States. CA Cancer J Clin 2017;67:398-410. © 2017 American Cancer Society.

Vaccine Attitudes and COVID-19 Vaccine Intention Among Parents of Children With Kidney Disease or Primary Hypertension.

RATIONALE & OBJECTIVE: Children with kidney disease and primary hypertension may be more vulnerable to COVID-19. We examined COVID-19 vaccine hesitancy among parents of children with chronic kidney disease or hypertension. STUDY DESIGN: Sequential explanatory mixed-methods design; survey followed by in-depth interviews. SETTING & PARTICIPANTS: Parents of children aged <18 years with kidney disease or primary hypertension within a large pediatric practice. EXPOSURE: Parental attitudes toward general childhood and influenza vaccines assessed by the Vaccine Hesitancy Scale. Kidney disease classification, demographic and socioeconomic factors, experiences with COVID-19, COVID-19 mitigation activities and self-efficacy, and sources of vaccine information. OUTCOME: Willingness to vaccinate child against COVID-19. ANALYTICAL APPROACH: Analysis of variance (ANOVA) test to compare parental attitudes toward general childhood and influenza vaccination with attitudes toward COVID-19 vaccination. Multinomial logistic regression to assess predictors of willingness to vaccinate against COVID-19. Thematic analysis of interview data to characterize influences on parental attitudes. RESULTS: Of the participants, 207 parents completed the survey (39% of approached): 75 (36%) were willing, 80 (39%) unsure, and 52 (25%) unwilling to vaccinate their child against COVID-19. Hesitancy toward general childhood and influenza vaccines was highest among the unwilling group (P < 0.001). More highly educated parents more likely to be willing to vaccinate their children, while Black race was associated with being more likely to be unwilling. Rushed COVID-19 vaccine development as well as fear of serious and unknown long-term side effects were themes that differed across the parental groups that were willing, unsure, or unwilling to vaccinate their children. Although doctors and health care teams are trusted sources of vaccine information, perceptions of benefit versus harm and experiences with doctors differed among these 3 groups. The need for additional information on COVID-19 vaccines was greatest among those unwilling or unsure about vaccinating. LIMITATIONS: Generalizability may be limited. CONCLUSIONS: Two-thirds of parents of children with kidney disease or hypertension were unsure or unwilling to vaccinate their child against COVID-19. Higher hesitancy toward routine childhood and influenza vaccination was associated with hesitancy toward COVID-19 vaccines. Enhanced communication of vaccine information relevant to kidney patients in an accessible manner should be examined as a means to reduce vaccine hesitancy. PLAIN-LANGUAGE SUMMARY: Children with kidney disease or hypertension may do worse with COVID-19. As there are now effective vaccines to protect children from COVID-19, we wanted to find out what parents think about COVID-19 vaccines and what influences their attitudes. We surveyed and then interviewed parents of children who had received a kidney transplant, were receiving maintenance dialysis, had chronic kidney disease, or had hypertension. We found that two-thirds of parents were hesitant to vaccinate their children. Their reasons varied, but the key issues included the need for information pertinent to their child and a consistent message from doctors and other health care providers. These findings may inform an effective vaccine campaign to protect children with kidney disease and hypertension.

Understanding the Factors Influencing Health Care Provider Recommendations about Adolescent Vaccines: A Proposed Framework.

Health care provider recommendations are among the most important factors influencing parents' decisions to vaccinate their adolescents. However, delivery of high-quality health care provider recommendations for vaccination is not universal. There is wide variation in the strength, timeliness and consistency of the delivery of recommendations for all adolescent vaccines. The factors that influence health care providers' recommendations are multi-level and can be conceptualized in much the same way as vaccine acceptance among parents. Health care providers are influenced by their own attitudes and beliefs about a vaccine and also by the patient they are treating and by the community in which they practice as well as state and national level vaccine policy. We propose a multi-level framework for understanding the factors that influence health care providers' recommendations at the individual, interpersonal and community level to both develop and adapt interventions to improve providers' recommendations.

Prevalence of Human Papillomavirus Among Women Older than Recommended Age for Vaccination by Birth Cohort, United States 2003‒2016.

BACKGROUND: Apparent associations between human papillomavirus (HPV) prevalence and age observed in cross-sectional studies could be misleading if cohort effects influence HPV detection. METHODS: Using data from 2003-2016 National Health and Nutrition Examination Surveys, we evaluated overall and 10-year birth cohort-specific cervicovaginal HPV prevalence estimates (any, high-risk [HR], and non-HR) by 3-year age group among 27 to 59-year-old women born in 1950-1979. Average percent changes (APC) in HPV prevalence by 3-year age were calculated. RESULTS: Overall, prevalence of any HPV declined from 49.9% in 27-29 year olds to 33.8% in 57-59 year olds (APC, -2.82% per 3-year age group; 95% confidence interval [CI], -4.02% to -1.60%) as did prevalence of HR-HPV (APC, -6.19%; 95% CI, -8.09% to -4.26%) and non-HR-HPV (APC, -2.00%; 95% CI, -3.48% to -.51%). By birth cohort, declines by age group were seen in prevalences of any HPV, HR-HPV, and non-HR-HPV for those born in the 1950s and 1970s and in any HPV and HR-HPV for those born in the 1960s (APC range, -14.08% to 0.06%). CONCLUSIONS: Declines in HPV prevalence with age in these cross-sectional surveys cannot be explained by birth cohort differences alone, as associations were observed across all birth cohorts.

MomsTalkShots, tailored educational app, improves vaccine attitudes: a randomized controlled trial.

BACKGROUND: Many pregnant women and parents have concerns about vaccines. This analysis examined the impact of MomsTalkShots, an individually tailored educational application, on vaccine attitudes of pregnant women and mothers. METHODS: MomsTalkShots was the patient-level component of a multi-level intervention to improve maternal and infant vaccine uptake that also included provider- and practice-level interventions. The impact of these interventions was studied using a two-by-two factorial design, randomizing at both the patient- and the practice-level. Study staff recruited pregnant women from a diverse set of prenatal care practices in Colorado and Georgia between June 2017 and July 2018. All participants (n = 2087) received a baseline survey of maternal and infant vaccine intentions and attitudes, and two follow-up surveys at least 1 month and 1 year after their infant's birth, respectively. Half of participants (n = 1041) were randomly assigned to receive educational videos through MomsTalkShots, algorithmically tailored to their vaccine intentions, attitudes, and demographics. Since the practice/provider intervention did not appear impactful, this analysis focused on MomsTalkShots regardless of the practice/provider intervention. RESULTS: By 1 month post-birth, MomsTalkShots increased perceived risk of maternal influenza disease (61% among MomsTalkShots recipients vs 55% among controls; Odds Ratio: 1.61, 95% Confidence Interval: 1.23-2.09), confidence in influenza vaccine efficacy (73% vs 63%; OR: 1.97, 95%CI: 1.47-2.65), and perceived vaccine knowledge (55% vs 48%; OR: 1.39, 95%CI: 1.13-1.72). Among those intending not to vaccinate at baseline, MomsTalkShots increased perceived risk of maternal influenza disease (38% vs 32%; OR: 2.07, 95%CI: 1.15-3.71) and confidence in influenza vaccine efficacy (44% vs 28%; OR: 2.62, 95%CI: 1.46-4.69). By 1 year post-birth, MomsTalkShots increased perceived vaccine knowledge (62% vs 50%; OR: 1.74, 95%CI: 1.36-2.24) and trust in vaccine information from obstetricians and pediatricians (64% vs 55%; OR: 1.53, 95%CI: 1.17-2.00). Among those uncertain about vaccinating at baseline, MomsTalkShots increased perceived vaccine knowledge (47% vs 12%; OR: 6.89, 95%CI: 1.52-31.25) and reduced infant vaccine safety concerns (71% vs 91%; OR: 0.24, 95%CI: 0.06-0.98). CONCLUSIONS: MomsTalkShots improved pregnant women's and mothers' knowledge and perceptions of maternal and infant vaccines and the diseases they prevent, and offers a scalable tool to address vaccine hesitancy. TRIAL REGISTRATION: Registered at Clinicaltrials.gov on 13/09/2016 (registration number: NCT02898688).

U.S. Vietnamese parents' HPV vaccine decision-making for their adolescents: an exploration of practice-, provider-, and patient-level influences.

U.S. Vietnamese have high cervical cancer incidence and low human papillomavirus (HPV) vaccine initiation. Using the P3 model, we explored practice-, provider-, and patient-level determinants of U.S. Vietnamese parents' HPV vaccine decision-making for their adolescents. We conducted a cross-sectional, online survey (04/2020-12/2020) with U.S. Vietnamese parents who had ≥ 1 adolescent ages 9-18. We assessed HPV vaccination outcomes (initiation, willingness to initiate, completion) and provider recommendation. Modified Poisson regressions were used to identify practice-, provider- and patient-level correlates of outcomes. The sample (n = 408) was 44 years old on average; 83% were female and 85% had a Bachelor's degree. Around half of adolescents were female (51%) and 13-18 year old (54%). Only 41 and 23% of parents had initiated and completed the HPV vaccine series for their child, respectively. Initiation was associated with receiving provider recommendation (either low- or high-quality), while willingness to initiate was associated with receiving high-quality recommendation. Both initiation and willingness to initiate was negatively associated with parental perception that their child was too young for a "sexually transmitted infection (STI)-preventing vaccine." Provider recommendation was associated with higher parental U.S. acculturation and the child being older and female. Provider-facing interventions should promote high-quality, age-based, gender-neutral HPV vaccine recommendation. These and population- and individual-facing interventions should recognize the need for additional parental education, particularly related to misconceptions regarding STI prevention.

Fine-tuned Sentiment Analysis of COVID-19 Vaccine-Related Social Media Data: Comparative Study.

BACKGROUND: The emergence of the novel coronavirus (COVID-19) and the necessary separation of populations have led to an unprecedented number of new social media users seeking information related to the pandemic. Currently, with an estimated 4.5 billion users worldwide, social media data offer an opportunity for near real-time analysis of large bodies of text related to disease outbreaks and vaccination. These analyses can be used by officials to develop appropriate public health messaging, digital interventions, educational materials, and policies. OBJECTIVE: Our study investigated and compared public sentiment related to COVID-19 vaccines expressed on 2 popular social media platforms-Reddit and Twitter-harvested from January 1, 2020, to March 1, 2022. METHODS: To accomplish this task, we created a fine-tuned DistilRoBERTa model to predict the sentiments of approximately 9.5 million tweets and 70 thousand Reddit comments. To fine-tune our model, our team manually labeled the sentiment of 3600 tweets and then augmented our data set through back-translation. Text sentiment for each social media platform was then classified with our fine-tuned model using Python programming language and the Hugging Face sentiment analysis pipeline. RESULTS: Our results determined that the average sentiment expressed on Twitter was more negative (5,215,830/9,518,270, 54.8%) than positive, and the sentiment expressed on Reddit was more positive (42,316/67,962, 62.3%) than negative. Although the average sentiment was found to vary between these social media platforms, both platforms displayed similar behavior related to the sentiment shared at key vaccine-related developments during the pandemic. CONCLUSIONS: Considering this similar trend in shared sentiment demonstrated across social media platforms, Twitter and Reddit continue to be valuable data sources that public health officials can use to strengthen vaccine confidence and combat misinformation. As the spread of misinformation poses a range of psychological and psychosocial risks (anxiety and fear, etc), there is an urgency in understanding the public perspective and attitude toward shared falsities. Comprehensive educational delivery systems tailored to a population's expressed sentiments that facilitate digital literacy, health information-seeking behavior, and precision health promotion could aid in clarifying such misinformation.

Public Education Interventions and Uptake of Human Papillomavirus Vaccine: A Systematic Review.

CONTEXT: Human papillomavirus (HPV) vaccine uptake remains suboptimal in the United States. Public education is considered an important aspect of increasing vaccination rates. OBJECTIVES: We systematically reviewed the literature on the impact of public education on HPV vaccine uptake. DESIGN: PubMed was searched to identify studies published between January 1, 2007, and April 30, 2018, meeting the following inclusion criteria: the study was conducted in the US, education was directed toward the public, and the research included HPV vaccine uptake and/or completion as outcomes. RESULTS: A total of 3764 studies were screened, and 30 published studies were included in the review. Among those, 13 focused on parent/guardian education, 8 on young adults, 6 on parent/daughter dyads, 1 focused only on adolescents, and 2 studies recruited a mixed-age population. Studies that included parents and young adults and were delivered by experts led to increased uptake of HPV vaccination (n = 14). A majority of the studies included female and Non-Hispanic White population (n = 20). Less than a third of studies included minority groups: Hispanic (n = 4), African American (n = 1), Cambodian American (n = 1), Indian American (n = 1), Korean American (n = 1), and combined Haitian and African American (n = 1) population. Minority group interventions that provided individually tailored messages, addressed misconceptions, removed barriers to vaccination, and engaged parents and community members improved HPV vaccine acceptance (n = 5). CONCLUSION: Interventions that delivered HPV-related education by authoritative sources and included parents improved HPV vaccination rates among adolescents and young adults. Community engagement played an important role in vaccine uptake among minority populations. Future studies should focus on male participants and minority populations to reduce disparities in HPV-related cancer incidence and HPV vaccine coverage.

Adolescent Consent for Human Papillomavirus Vaccine: Ethical, Legal, and Practical Considerations.

We address ethical, legal, and practical issues related to adolescent self-consent for human papillomavirus (HPV) vaccination. HPV vaccination coverage continues to lag well behind the national goal of 80% series completion. Structural and behavioral interventions have improved vaccination rates, but attitudinal, behavioral, and access barriers remain. A potential approach for increasing access and improving vaccination coverage would be to permit adolescents to consent to HPV vaccination for themselves. We argue that adolescent self-consent is ethical, but that there are legal hurdles to be overcome in many states. In jurisdictions where self-consent is legal, there can still be barriers due to lack of awareness of the policy among healthcare providers and adolescents. Other barriers to implementation of self-consent include resistance from antivaccine and parent rights activists, reluctance of providers to agree to vaccinate even when self-consent is legally supported, and threats to confidentiality. Confidentiality can be undermined when an adolescent's self-consented HPV vaccination appears in an explanation of benefits communication sent to a parent or if a parent accesses an adolescent's vaccination record via state immunization information systems. In the context of the COVID-19 pandemic, which has led to a substantial drop in HPV vaccination, there may be even more reason to consider self-consent. The atmosphere of uncertainty and distrust surrounding future COVID-19 vaccines underscores the need for any vaccine policy change to be pursued with clear communication and consistent with ethical principles.

Young Adult Human Papillomavirus and Influenza Vaccine Coverage: A Comparison Across College Enrollment Status.

To determine human papillomavirus and influenza vaccine coverage among young adults in the US and assess differences in vaccine uptake by college enrollment status, we conducted an online survey of young adults aged 18-26 (n = 417) using Survey Monkey, with recruitment occurring through Amazon's Mechanical Turk (MTurk) platform. We collected data on self-reported preventive health behaviors, including vaccine receipt, current college enrollment status, and other demographics. Overall, 49% of participants reported receiving at least one dose of human papillomavirus vaccine and 57% reported receiving at least one influenza vaccine over the past three years. Vaccine coverage estimates did not differ between college-enrolled and non-enrolled respondents. Low vaccine coverage rates demonstrate the need to improve vaccine strategies for young adults. The strongest predictor of vaccine receipt was having received a provider recommendation. There does not appear to be healthcare utilization differences related to ability to access care through student health or community-based settings. Additional research is needed to develop interventions to improve vaccination coverage among young adults, both currently enrolled and not enrolled in college.

Understanding the impact of state vaccination laws on exemption rates.

PURPOSE OF REVIEW: This review summarizes the current state of school-entry vaccination requirements and related exemption policies in the United States and examines recent changes to these policies. RECENT FINDINGS: With recent infectious disease outbreaks in the United States, there has been heightened awareness on unvaccinated individuals, and the state-level policies that allow individuals to be exempted from school-entry vaccination requirements. Between 2015 and 2017, there have been eleven states that have altered their policies regarding school-entry vaccination requirements and related reporting for which no formal evaluations have been published. One policy change during that period, California SB 277, which became law in 2016, reduced the nonmedical exemption and increased the childhood vaccination coverage rate in that state, though with some evidence of exemption replacement through the use of medical exemptions. Through September 2019, five additional state law changes have been enacted. SUMMARY: The large number of heterogeneous changes to state-level policies for school-entry vaccination requirements in recent years need rigorous evaluation to identify best practices for balancing public health authority and parental autonomy while seeking to achieve the highest level of infectious disease prevention for children.

Concomitant Utilization of Pre-Exposure Prophylaxis (PrEP) and Meningococcal Vaccine (MenACWY) Among Gay, Bisexual, and Other Men Who Have Sex with Men in Los Angeles County, California.

Recent outbreaks of serogroup C meningococcal disease in Southern California have led the California Department of Public Health to recommend the quadrivalent meningococcal vaccine (MenACWY) for gay, bisexual, and other men who have sex with men (GBMSM) in Southern California. High-risk GBMSM have also been advised to utilize pre-exposure prophylaxis (PrEP) for HIV prevention. Data collected from a community-based sample of HIV-negative GBMSM in Los Angeles County (N = 476) were used in a multinomial logit regression analysis to identify patterns in MenACWY and PrEP usage and evaluate factors associated with use of both, one, or neither of these prevention methods. More than half (56%) of participants had neither been vaccinated nor used PrEP. A smaller percentage (34%) had either been vaccinated or were PrEP users, leaving 10% who had concomitant PrEP and MenACWY use. Higher education, more recent sex partners, illicit drug use, and recent receptive condomless anal sex (CAS) were significantly associated with greater odds of using both prevention methods relative to neither. Higher education, prior sexually transmitted infection diagnosis, more recent sex partners, and recent receptive CAS were significantly associated with greater odds of just PrEP use relative to neither. Higher education was the only factor significantly associated with greater odds of just MenACWY immunization relative to neither. Findings highlight important gaps in immunization among PrEP users and opportunities to screen for PrEP eligibility among GBMSM in conjunction with immunization. Public health practitioners should consider the ways in which strategies to increase PrEP and vaccine-preventable illnesses among GBMSM may complement one another.

Practice-, provider- and patient-level facilitators of and barriers to HPV vaccine promotion and uptake in Georgia: a qualitative study of healthcare providers' perspectives.

Georgia experiences higher human papillomavirus (HPV)-associated cancer burden and lower HPV vaccine uptake compared with national estimates. Using the P3 model that concomitantly assesses practice-, provider- and patient-level factors influencing health behaviors, we examined facilitators of and barriers to HPV vaccine promotion and uptake in Georgia. In 2018, we conducted six focus groups with 55 providers. Questions focused on multilevel facilitators of and barriers to HPV vaccine promotion and uptake. Our analysis was guided by the P3 model and a deductive coding approach. We found that practice-level influences included organizational priorities of vaccinations, appointment scheduling, immunization registries/records, vaccine availability and coordination with community resources. Provider-level influences included time constraints, role, vaccine knowledge, self-efficacy to discuss HPV vaccine and vaccine confidence. Patient-level influences included trust, experiences with vaccine-preventable diseases, perceived high costs, perceived side effects and concerns with sexual activity. Findings suggest that interventions include incentives to boost vaccine rates and incorporate appointment scheduling technology. An emphasis should be placed on the use of immunization registries, improving across-practice information exchange, and providing education for providers on HPV vaccine. Patient-provider communication and trust emerge as intervention targets. Providers should be trained in addressing patient concerns related to costs, side effects and sexual activity.

Human Papillomavirus Vaccination Before 13 and 15 Years of Age: Analysis of National Immunization Survey Teen Data.

Human papillomavirus (HPV) vaccination is suboptimally used in the United States. Vaccination before the 13th birthday is recommended by the Advisory Committee on Immunization Practices and vaccination before the 15th birthday requires only 2 doses. We estimated the proportion of adolescents up to date for HPV vaccine using provider-verified vaccination data from the 2016 National Immunization Survey-Teen. Only 16% of US adolescents completed HPV vaccination before turning 13, and 35% completed HPV vaccination before turning 15. With sexual activity initiation increasing throughout adolescence and higher immunogenicity for younger vaccinees, vaccination before the 13th birthday can provide better protection against HPV-related cancers.

Human papillomavirus vaccination among diverse college students in the state of Georgia: who receives recommendation, who initiates and what are the reasons?

Young adulthood is a critical time for catch-up HPV vaccination. We assessed predictors of vaccine recommendation and initiation among college students. We analysed cross-sectional surveys from 2397 students using multivariable logistic regressions. Guided by the Socio-ecological and Health Belief Models, measures included socio-demographic characteristics, intrapersonal measures (e.g. vaccine beliefs), interpersonal measures (e.g. doctor's recommendation) and institutional-level measures (e.g. college settings). The sample included students from private, public, technical and historically black colleges/universities. Of the sample, 64.5% were White; additionally, 48.3% of women (n = 750/1552) and 18.8% of men (n = 159/845) received a doctor's recommendation. Among women, predictors included older age, US-born, higher parental education and attending private schools. Among men, predictors included younger age, being homosexual and attending private schools. HPV vaccine series initiation was low-43.3% of women (n = 672) and 16.7% of men (n = 141). Doctor's recommendation predicted initiation for both sexes. Younger women, women attending technical colleges and men of 'multiple/other' race had lower odds of initiation. Common initiation barriers for both sexes included a lack of doctor recommendation and sexual inactivity. These barriers and the associations between nativity, race and socio-economic status with vaccine recommendation and initiation should be further investigated. Interventions should improve patient-provider communication around HPV vaccine.

A cross-sectional survey of parental attitudes towards Human papillomavirus vaccination exclusion categories in Brazil.

BACKGROUND: In 1988, Brazil established a constitutional right to health and universal access to health care for all Brazilians through the creation of the Unified Health System (SUS). As part of its efforts to fulfill this right, the quadrivalent Human papillomavirus (HPV) vaccine was introduced into the national immunization program in 2014. The non-discriminatory provision of healthcare goods, facilities, and services is a fundamental part of the right to health. Yet HPV vaccination was limited to females aged 9-13, despite the universal nature of SUS and scientific support for the vaccination of males and older females. The purpose of this cross-sectional study was to describe parental attitudes regarding age- and gender-based HPV vaccination exclusions, as well as parental knowledge of HPV and the HPV vaccine. METHODS: Data were gathered from parents with children aged 9-17 in a health post located in the municipality of Mauá (São Paulo, Brazil) through interviewer-administered questionnaires. We analyzed attitudes regarding HPV vaccination and its eligibility guidelines by comparing parents of HPV vaccine eligible and ineligible children. RESULTS: In this low-income population, the majority of the 219 parents surveyed supported the inclusion of males and females over 13 into the HPV vaccination program; support for the non-discriminatory provision of the HPV vaccine was high among parents - especially if financially accessible. Additionally, there were high levels of knowledge and positive parental attitudes regarding HPV vaccination safety and efficacy among both parent groups suggesting information accessibility - a key component of the right to health and informed decision-making. CONCLUSIONS: Support for the expansion of HPV vaccination for excluded populations exists, and is not based on current eligibility, or differential knowledge and attitudes about the vaccine. Moving forward, careful consideration of gender- based eligibility for vaccination, informed decision-making, and the importance of community participation in health policy development and implementation may be gleaned from the case of Brazil and beyond.

HPV Vaccine-Related Research, Promotion and Coordination in the State of Georgia: A Systematic Review.

Human papillomavirus (HPV) vaccine was first recommended for female adolescents in the United States in 2006, and for male adolescents in 2011. In 2016, national HPV vaccine coverage was 43.4%, and slightly higher in Georgia (45.6%). Little is known about sub-state-level variation in HPV vaccination or Georgia specific research conducted to improve HPV vaccine uptake. We aimed to describe current uptake of HPV vaccination and synthesize Georgia-specific research of HPV vaccine uptake. We reviewed existing published and grey literature for different development, implementation and best practices related to vaccine uptake in adolescents. Studies measuring HPV vaccine uptake in Georgia utilizing quantitative, qualitative, or mixed-methods approaches were included alongside state-level information from National Immunization Survey-Teen, Community Health Needs Assessments, Behavioral Risk Factor Surveillance and Georgia Adolescent Immunization Surveys. Key findings across these reports were summarized. Forty-two titles and abstracts were identified through electronic database search for literature published between 2006 and 2017. Of these, five were from database sources and 37 were from additional sources. The most often mentioned barriers of HPV vaccine uptake in Georgia include cultural norms, vaccination education and a misalignment of vaccine uptake goals between the state and regional hospital community needs assessments. Increasing knowledge and uptake of HPV vaccine in Georgia requires significant research and to understand the vast socioeconomic, cultural and geographic barriers preventing uptake among adolescents. Georgia-specific efforts have been limited, however ongoing collaborations spearheaded by the Georgia Cancer Control Coalition provide opportunities for state-level support of research to address these barriers.