Document text
Human papillomavirus vaccination at age 9 or 10 years
to increase coverage – a systematic review and
narrative review of the literature
Sarah Brewer, PhD, MPH
Division of Viral Diseases
Advisory Committee on Immunization Practices
October 24, 2024 National Center for Immunization & Respiratory Diseases
Background
2
•Since HPV vaccine was first licensed and recommended in 2006 for females, the wording of the
routine age recommendation has remained the same
•While HPV vaccination coverage has increased since HPV vaccination was first recommended,
uptake continues to be lower than other vaccines recommended in adolescence
•There have been many efforts to increase HPV vaccination in the United States
•In the past few years there has been increasing enthusiasm for HPV vaccine initiation at age 9
years to increase coverage Background
3
•Critically evaluate publications investigating HPV vaccination at age 9 –10 years
-Systematic review and narrative summary of literature
-Describe methodologies used
-Provide data summaries and interpretationsObjective
4
Selection criteria
•Dates and location: 2014 –2024, United States
•Population:
-Individuals ≥9 years of age who are eligible to receive HPV vaccination
-Parents/caregivers of persons ≥9 years of age
-Clinicians, providers, or other clinical staff who administer the HPV vaccine
•Evaluation:
-HPV vaccination at ages 9 –10 years
•Outcomes:
-HPV vaccine initiation
-HPV vaccine series completion
-Acceptability among providers and caregivers of routine HPV vaccination at ages 9 –10 years
-Feasibility of routine HPV vaccination at ages 9 –10 years where HPV vaccination is offered
5
PRISMA flow chart for study inclusion in systematic review
6
Study descriptionsStudy Completion Initiation Provider
perspectives/behaviorCaregiver
perspectives
Kajtezovic 2023 X
Saxena 2023 X
St. Sauver 2016 X
Goodman 2023 X
Minihan 2023 X
Hirth 2024 X
Bednarczyk 2023 X
Liu 2016 X
Inguva 2020 X
Kashani 2019 X
Donahue 2015 X
Perkins 2020 X X
Zorn 2022 X X
Goleman 2018 X
Cox 2022 X X
O’Leary 2023 X X
Casey 2022 X X
Huang 2023 X X
Christensen 2023 X
Strasel 2023 X
Isher -Witt 2023 X
Brodie 2018 X
Bowden 2017 X
Kong 2022 X
Biancarelli 2020 X
Vielot 2023 X
Lake 2023 X
Kahn 2023 X
Kohler 2023 X
Aragones 2022 XRetrospective cohort/
observational coverage
studies
Quality
improvement/intervention
coverage projects
Provider/caregiver
behavior and perspectives
7
Retrospective cohort/observational studies (N=11)
Study Completion Initiation Provider
perspectives
/behaviorCaregiver
perspectives
Goodman X
Minihan X
Bednarczyk X
Hirth X
Kajtexovic X
Saxena X
Liu X
St. Sauver X
Inguva X
Kashani X
Donahue XNIS-Teen
Marketscan
Other
8
9 explored impact of initiation at age 9 –10 vs. age ≥11 years on completion or up -to-date
status of the vaccination series
-Many looked at series completion by age 13, but others evaluated up -to-date status at older ages
or used an outcome defined by time to complete the series after receiving first dose
-All but one found higher on time completion of the HPV vaccination series when initiated at ages
9–10 years
-1 also assessed impact of age at initiation on association between race/ethnicity and series
completion; increased odds of series completion across all racial/ethnic groups when initiating at
age 9 –10 years compared to age 12 years
1 assessed association of initiation timing in relation to other routine adolescent vaccines
on series completion
-HPV vaccine series completion higher if HPV vaccination initiated before Tdap or meningococcal
1 investigated predictors of initiation for children aged 9 –13
-The same characteristics were associated with initiation, regardless of age at initiationSummary: retrospective cohort/observational studies
(N=11)
9
Interpretation: retrospective cohort/observational
studies (N=11)
10 *Some studies evaluated completion, but not by age 13 yearsHigher vaccination series completion* when initiating at age 9 –10 vs. 11 –12,
but study limitations preclude a cause -and-effect interpretation
A small percentage of vaccinated adolescents had initiated at age 9 –10 in
most studies (2 –8%)
No information on reasons for initiation at age 9 –10; may have been
differences in those initiating at age 9 –10 vs. 11 –12
There may be differences between providers vaccinating at age 9 –10 and
those vaccinating at age 11 –12
Quality improvement/intervention (N=12)
Study Completion Initiation Provider
perspectives
/behaviorCaregiver
perspectives
Perkins X X
Zorn X X
Goleman X
Cox X X
O’Leary X X
Casey X X
Huang X X
Christensen X
Strasel X
Isher -Witt X
Brodie X
Bowden X
11
All 12 studies evaluated initiation:
-Interventions were multipronged, with one component focused on initiation at ages 9 –10 years
-All studies observed an increase in initiation for all ages at initiation (9 –10 years and ≥11 years),
or at a clinic population level
•Magnitude of increases varied across age groups
•Increases were not sustained in all studies
•Initiation rates at 9 –10 years still lower than initiation at ≥11 years
6 Studies evaluated initiation and completion:
-Increases in completion rates observed in the majority of studiesSummary: quality improvement/intervention studies
(N=12)
12
Quality improvement/intervention (N=12)
N=6 Focus on initiation only
Author EMR
changeProvider/
staff
trainingPatient
educationQI team/
data
feedbackClinic
incentivesStanding
ordersPatient
reminders
Goleman x x x x
Isher -Witt x x x x
Strasel x x
Christensen x*
Brodie x x
Bowden x x x x
*Analysis attempted to measure association with change in electronic medical record (EMR) only, but there may have been other undocumented
concurrent events that influenced HPV initiations that were not incorporated into the model
13
Quality improvement/intervention (N=12)
N=6 Focus on both initiation and completion
Author EMR
changeProvider
/staff
trainingPatient
educationQI team/
data
feedbackClinic
incentivesStanding
ordersPatient
reminders
Perkins x x x x x
Casey x x x x x
Zorn x x x
Cox x x x x x x x
Huang x x x x
O’Leary x x
14
In the majority of QI/Intervention studies, there were increases
in initiation and completion; however:
•Due to multi -pronged interventions, it is unclear if the component focused on
initiation at ages 9 –10 was responsible for any of the increase in coverage
•Within the QI/Intervention studies, vaccination at age 9 was feasible, but not
necessarily better than at ages 11 –12Interpretation: quality improvement/intervention
studies (N=12)
15
Provider/caregiver perspectives and behavior studies
Study Completion Initiation Provider
perspectives/
behaviorCaregiver
perspectives
Vielot X
Biancarelli X
Kong X
Lake X
Kahn X
Kohler X
Aragones XInterviews:
Providers
Surveys:
Providers
Interview/
Survey:
Caregivers
16
2 Clinician Interviews :
-1 intervention study: providers reported a positive experience with recommending vaccination at age 9–10
-1 qualitative study: providers had mixed opinions
3 Clinician Surveys :
-1 survey: among not currently recommending at age 9, family medicine physicians were more willing to
recommend the vaccine at ages 9 –10
-1 survey: strong recommendation differed by age group and specialty
-1 survey: recommendation framing mattered when initiating at ages 9 –10
-Perceived benefits of vaccination varied by initiation age
2 Caregiver Studies:
-Few caregivers reported receiving information or recommendations to vaccinate children before age 11
-Most reported willingness to vaccinate at ages 9 –10Summary: provider/caregiver behavior and perspective
studies (N=7)
17
Interpretation: provider/caregiver behavior and
perspective studies (N=7)
18In limited settings, and mostly small studies, vaccination at ages 9 –10
years was acceptable by caregivers and providers
•We conducted a systematic review evaluating HPV vaccination at ages 9 –10 years
•Data from 30 studies published 2014 –2024 were summarized in a narrative review
•3 general types of studies
-Within retrospective cohort studies, HPV vaccine initiation at ages 9 –10 years was associated with higher
completion by age 13; this was a small proportion of initiators in all studies
•There could have been meaningful differences between children initiating at ages 9 –10 vs 11 –12
or providers vaccinating at ages 9 –10 vs those vaccinating at the routine age
-Within QI/ intervention studies findings show vaccination at age 9 was feasible , but not necessarily better
•Due to the multifaceted approaches; contribution of the recommendation for initiation at age 9 –
10 years on increases in coverage is unclear
-Vaccination at ages 9 –10 years may be acceptable to caregivers and providersOverall summary
19
For more information, contact CDC
1-800-CDC-INFO (232 -4636)
TTY: 1 -888-232-6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.
Acknowledgements
Ruth Stefanos
Lauri Markowitz
Shannon Stokley
Neil C. Murthy
Amimah Asif
21Kajtezovic , S., et al. (2023). "Optimizing timing of adolescent vaccines: Impact of initiating HPV vaccination before Tdap or meningoco ccal vaccination
on timely completion of the HPV vaccine series." Hum Vaccin Immunother . 19(1): 2175541.
Saxena, K., et al. (2023). "HPV vaccine initiation at 9 or 10 years of age and better series completion by age 13 among priva tely and publicly insured
children in the US." Hum Vaccin Immunother . 19(1): 2161253.
St. Sauver, J. L., et al. (2016). "Younger age at initiation of the human papillomavirus (HPV) vaccination series is associat ed with higher rates of on -time
completion." Prev Med. 89: 327 -333.
Goodman, E., et al. (2023). "Early Initiation of HPV Vaccination and Series Completion in Early and Mid -Adolescence." Pediatrics 151(3): e2022058794.
Minihan , A. K., et al. (2023). "The association of initiating HPV vaccination at ages 9 –10 years and up -to-date status among adolescent s ages 13 –17
years, 2016 -2020." Hum Vaccin Immunother . 19(1): 2175555.
Hirth , J., et al. (2024.). "Effect of age at initiation of the human papillomavirus vaccine on the association between race/ethnic ity and completion of
the vaccine series." Vaccine .
Bednarczyk , R. A. and H. M. Brandt (2023). "Descriptive epidemiology of age at HPV vaccination: Analysis using the 2020 NIS -Teen." Hum Vaccin
Immunother . 19(1): 2204784.
Liu, G., et al. (2016). "HPV vaccine completion and dose adherence among commercially insured females aged 9 through 26 years in the US."
Papillomavirus Res. 2: 1-8.
Inguva , S., et al. (2020). "Factors influencing Human papillomavirus (HPV) vaccination series completion in Mississippi Medicaid." Vaccine 38(8): 2051 -
2057.
Kashani , B. M., et al. (2019). "Human Papillomavirus Vaccination Trends, Barriers, and Promotion Methods Among American Indian/Alask a Native and
Non -Hispanic White Adolescents in Michigan 2006 –2015." J Community Health. 44(3): 436 -443.
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References – Retrospective/cohort studies
22Perkins, R. B., et al. (2020). "Improving HPV vaccination rates: a stepped -wedge randomized trial." Pediatrics 146(1).
Zorn, S., et al. (2023). "Multi -level quality improvement strategies to optimize HPV vaccination starting at the 9 -year well chi ld visit: Success stories from
two private pediatric clinics." Hum Vaccin Immunother . 19(1): 2163807.
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769-775.
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References – Quality improvement/intervention studies
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Kahn, B. Z., et al. (2023). "Framing of national HPV vaccine recommendations and willingness to recommend at ages 9 -10." Hum Vaccin Immunother .
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Vaccin Immunother ., 18(6), 2136444. https://doi.org/10.1080/21645515.2022.2136444 References – Provider/caregiver behavior and perspectives studies