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1.  Vaccination Coverage Among U.S. Adolescents Aged 13–17 Years Eligible for the Vaccines for Children Program, 2009 
Public Health Reports  2011;126(Suppl 2):124-134.
Objectives
We compared (1) characteristics of adolescents who are and are not entitled to receive free vaccines from the Vaccines for Children (VFC) program and (2) vaccination coverage with meningococcal conjugate (MCV4), quadrivalent human papillomavirus (HPV4), and tetanus-diphtheria-acellular pertussis (Tdap) vaccines among VFC-eligible and non-VFC-eligible adolescents.
Methods
We analyzed data from the 2009 National Immunization Survey-Teen, a nationally representative, random-digit-dialed survey of households with adolescents aged 13–17 years (n=20,066). Differences in sociodemographic characteristics and provider-reported vaccination coverage were evaluated using t-tests.
Results
Overall, 32.1% (±1.2%) of adolescents were VFC-eligible. VFC-eligible adolescents were significantly less likely than non-VFC-eligible adolescents to be white and to live in suburban areas, and more likely to live in poverty and to have younger and less educated mothers. Nationally, coverage among non-VFC-eligible adolescents was 57.1% (±1.5%) for ≥1 dose of Tdap, 55.4% (±1.5%) for ≥1 dose of MCV4, and 43.2% (±2.2%) for ≥1 dose of HPV4. Coverage among VFC-eligible adolescents was 52.5% (±2.4%) for ≥1 dose of Tdap, 50.1% (±2.4%) for ≥1 dose of MCV4, and 46.6% (±3.5%) for ≥1 dose of HPV4. Only 27.5% (±1.8%) of non-VFC-eligible adolescents and 25.0% (±2.9%) of VFC-eligible adolescents received ≥3 doses of HPV4. Vaccination coverage was significantly higher among non-VFC-eligible adolescents for Tdap and MCV4, but not for one-dose or three-dose HPV4.
Conclusions
Coverage with some recommended vaccines is lower among VFC-eligible adolescents compared with non-VFC-eligible adolescents. Continued monitoring of adolescent vaccination rates, particularly among VFC-eligible populations, is needed to ensure that all adolescents receive all routinely recommended vaccines.
PMCID: PMC3113437  PMID: 21815303
2.  Validity of Parent-Reported Vaccination Status for Adolescents Aged 13–17 Years: National Immunization Survey-Teen, 2008 
Public Health Reports  2011;126(Suppl 2):60-69.
Objective
The validity of parent-reported adolescent vaccination histories has not been assessed. This study evaluated the validity of parent-reported adolescent vaccination histories by a combination of immunization card and recall, and by recall only, compared with medical provider records.
Methods
We analyzed data from the 2008 National Immunization Survey-Teen. Parents of adolescents aged 13–17 years reported their child's vaccination history either by immunization card and recall (n=3,661) or by recall only (n=12,822) for the hepatitis B (Hep B), measles-mumps-rubella (MMR), varicella (VAR), tetanus-diphtheria/tetanus-diphtheria-acellular pertussis (Td/Tdap), meningococcal conjugate (MCV4), and quadrivalent human papillomavirus (HPV4) (for girls only) vaccines. We validated parental report with medical records.
Results
Among the immunization card/recall group, vaccines with >20% false-positive reports included MMR (32.3%) and Td/Tdap (36.9%); vaccines with >20% false-negative reports included VAR (35.2%), MCV4 (36.0%), and Tdap (41.9%). Net bias ranged from −25.0 to −0.1 percentage points. Kappa values ranged from 0.22 to 0.92. Among the recall-only group, vaccines with >20% false-positive reports included Hep B (33.9%), MMR (61.4%), VAR (26.2%), and Td/Tdap (60.6%); vaccines with >20% false-negative reports included Hep B (58.9%), MMR (33.7%), VAR (51.6%), Td/Tdap (25.5%), Tdap (50.3%) MCV4 (63.0%), and HPV4 (20.5%). Net bias ranged from −46.0 to 0.5 percentage points. Kappa values ranged from 0.03 to 0.76.
Conclusions
Validity of parent-reported vaccination histories varies by type of report and vaccine. For recently recommended vaccines, false-negative rates were substantial and higher than false-positive rates, resulting in net underreporting of vaccination rates by both the immunization card/recall and recall-only groups. Provider validation of parent-reported vaccinations is needed for valid surveillance of adolescent vaccination coverage.
PMCID: PMC3113431  PMID: 21812170
3.  HPV vaccine decision making in pediatric primary care: a semi-structured interview study 
BMC Pediatrics  2011;11:74.
Background
Despite national recommendations, as of 2009 human papillomavirus (HPV) vaccination rates were low with < 30% of adolescent girls fully vaccinated. Research on barriers to vaccination has focused separately on parents, adolescents, or clinicians and not on the decision making process among all participants at the point of care. By incorporating three distinct perspectives, we sought to generate hypotheses to inform interventions to increase vaccine receipt.
Methods
Between March and June, 2010, we conducted qualitative interviews with 20 adolescent-mother-clinician triads (60 individual interviews) directly after a preventive visit with the initial HPV vaccine due. Interviews followed a guide based on published HPV literature, involved 9 practices, and continued until saturation of the primary themes was achieved. Purposive sampling balanced adolescent ages and practice type (urban resident teaching versus non-teaching). Using a modified grounded theory approach, we analyzed data with NVivo8 software both within and across triads to generate primary themes.
Results
The study population was comprised of 20 mothers (12 Black, 9 < high school diploma), 20 adolescents (ten 11-12 years old), and 20 clinicians (16 female). Nine adolescents received the HPV vaccine at the visit, eight of whom were African American. Among the 11 not vaccinated, all either concurrently received or were already up-to-date on Tdap and MCV4. We did not observe systematic patterns of vaccine acceptance or refusal based on adolescent age or years of clinician experience. We identified 3 themes: (1) Parents delayed, rather than refused vaccination, and when they expressed reluctance, clinicians were hesitant to engage them in discussion. (2) Clinicians used one of two strategies to present the HPV vaccine, either presenting it as a routine vaccine with no additional information or presenting it as optional and highlighting risks and benefits. (3) Teens considered themselves passive participants in decision making, even when parents and clinicians reported including them in the process.
Conclusions
Programs to improve HPV vaccine delivery in primary care should focus on promoting effective parent-clinician communication. Research is needed to evaluate strategies to help clinicians engage reluctant parents and passive teens in discussion and measure the impact of distinct clinician decision making approaches on HPV vaccine delivery.
doi:10.1186/1471-2431-11-74
PMCID: PMC3175168  PMID: 21878128
4.  Safety and Immunogenicity of Tetanus Diphtheria and Acellular Pertussis (Tdap) Immunization During Pregnancy in Mothers and Infants: A Randomized Clinical Trial 
JAMA  2014;311(17):1760-1769.
Importance
Maternal immunization with tetanus toxoid and reduced diphtheria toxoid acellular pertussis (Tdap) vaccine could prevent infant pertussis. The effect of vaccine-induced maternal antibodies on infant responses to diphtheria and tetanus toxoids acellular pertussis (DTaP) immunization is unknown.
Objective
To evaluate the safety and immunogenicity of Tdap immunization during pregnancy and its effect on infant responses to DTaP.
Design, Setting and Participants
Phase I, randomized, double-masked, placebo-controlled clinical trial conducted in private (Houston) and academic (Durham, Seattle) obstetric practices from 2008 to 2012. Forty eight healthy 18–45 year-old pregnant women received Tdap (n=33) or placebo (n=15) at 30–32 weeks’ gestation with cross-over Tdap immunization postpartum.
Interventions
Tdap vaccination at 30–32 weeks’ gestation or post-partum.
Outcome Measures
Primary: Maternal and infant adverse events, pertussis illness and infant growth and development (Bayley-III screening test) until 13 months of age. Secondary: Antibody concentrations in pregnant women before and 4 weeks after Tdap immunization or placebo, at delivery and 2 months postpartum, and in infants at birth, 2 months, and after the third (7 months) and fourth (13 months) doses of DTaP.
Results
All participants delivered healthy newborns. No Tdap-associated serious adverse events occurred in women or infants. Injection site reactions after Tdap immunization were reported in 78.8% (95% CI: 61.1%, 91.0%) and 80% (CI: 51.9%, 95.7%) pregnant and postpartum women, respectively. Injection site pain was the predominant symptom. Systemic symptoms were reported in 36.4% (CI: 20.4%, 54.9%) and 73.3% (CI: 44.9%, 92.2%) pregnant and postpartum women, respectively. Malaise and myalgia were most common. Growth and development were similar in both infant groups. No cases of pertussis occurred. Significantly higher concentrations of pertussis antibodies were measured at delivery in women who received Tdap during pregnancy and in their infants at birth and at age 2 months when compared to infants of women immunized postpartum. Antibody responses in infants of Tdap recipients during pregnancy were modestly lower after 3 DTaP doses, but not different following the fourth dose.
Conclusions and Relevance
This preliminary safety assessment did not find an increased risk of adverse events among women who received Tdap vaccine at 30–32 weeks’ gestation or their infants. Maternal immunization with Tdap resulted in high concentrations of pertussis antibodies in infants during the first 2 months of life and did not substantially alter infant responses to DTaP. Further research is needed to provide definitive evidence of the safety and efficacy of Tdap vaccination during pregnancy.
Trial Registration
ClinicalTrials.gov, study identifier: NCT00707148. URL: http://www.clinicaltrials.gov
doi:10.1001/jama.2014.3633
PMCID: PMC4333147  PMID: 24794369
Maternal immunization; Pertussis; infants; maternal antibodies; response to active immunization
5.  Impact of a physician recommendation and parental immunization attitudes on receipt or intention to receive adolescent vaccines 
Human Vaccines & Immunotherapeutics  2013;9(12):2627-2633.
Four vaccines are recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices for adolescents. Parental attitudes may play a key role in vaccination uptake in this age group. In 2011, we conducted a cross-sectional survey among parents of adolescents in one county in Georgia to identify parental attitudes toward adolescent vaccination, reasons for vaccine acceptance or refusal, and impact of a physician recommendation for vaccination. Physician recommendation was reported as one of the top reasons for receipt or intent to receive any of the vaccines. Physician recommendation of any of the four vaccines was associated with receipt of Tdap (p < 0.001), MCV4 (p < 0.001), and HPV (p = 0.03) and intent to receive Tdap (p = 0.05), MCV4 (p = 0.005), and HPV (p = 0.05). Compared with parents who did not intend to have their adolescent vaccinated with any of the vaccines, parents who did intend reported higher perceived susceptibility (3.12 vs. 2.63, p = 0.03) and severity of disease (3.89 vs. 3.70, p = 0.02) and higher perceived benefit of vaccination (8.48 vs. 7.74, p = 0.02). These findings suggest that future vaccination efforts geared toward parents may benefit from addressing the advantages of vaccination and enhancing social norms. Physicians can play a key role by providing information on the benefits of adolescent vaccination.
doi:10.4161/hv.25823
PMCID: PMC4162064  PMID: 23883781
adolescent; vaccine; attitudes; health belief model, theory of reasoned action
6.  Preliminary study on the immunogenicity of a newly developed GCC Tdap vaccine and its protection efficacy against Bordetella pertussis in a murine intranasal challenge model 
Purpose
Active reduced dose tetanus-diphtheria-acellular pertussis (Tdap) vaccination for adolescents and adults is necessary because waning immunity after primary diphtheria-tetanus-pertussis vaccination is related to the recent emergence of pertussis. This study was conducted to compare the immunogenicity and protection efficacy against Bordetella pertussis between a new GCC Tdap vaccine and a commercially available Tdap vaccine in a murine model.
Materials and Methods
BALB/c mice were immunized with two doses of diphtheria-tetanus-acellular pertussis (DTaP) vaccine for priming and a subsequent Tdap booster vaccination. According to the type of booster vaccine, mice were divided into four groups: commercially available Tdap vaccine in group 1 and GCC Tdap vaccines of different combinations of pertussis antigens in groups 2 to 4. Humoral and cell-mediated immune responses and protection efficacy using a murine intranasal challenge model after booster vaccination were compared among the four groups.
Results
Every group showed significant increases in antibody titers against pertussis antigens such as pertussis toxin, filamentous hemagglutinin, and pertactin after booster vaccination. Spleen cells showed both Th1 and Th2 cell-mediated immune responses stimulated by pertussis antigens in all groups without any significant difference. In the intranasal B. pertussis infection model, bacteria were eradicated in all groups five days after challenge infection.
Conclusion
This preliminary study did not show significantly different immunogenicity or protection efficacy of the new GCC Tdap vaccines compared to the commercially available Tdap vaccine, although a more extensive study is necessary to assess the differing efficacies of the new GCC Tdap vaccines.
doi:10.7774/cevr.2015.4.1.75
PMCID: PMC4313112  PMID: 25649262
Diphtheria-tetanus-acellular pertussis vaccine; Immunogenicity; Efficacy; Mice; Republic of Korea
7.  A Population-Based Evaluation of a Publicly Funded, School-Based HPV Vaccine Program in British Columbia, Canada: Parental Factors Associated with HPV Vaccine Receipt 
PLoS Medicine  2010;7(5):e1000270.
Analysis of a telephone survey by Gina Ogilvie and colleagues identifies the parental factors associated with HPV vaccine uptake in a school-based program in Canada.
Background
Information on factors that influence parental decisions for actual human papillomavirus (HPV) vaccine receipt in publicly funded, school-based HPV vaccine programs for girls is limited. We report on the level of uptake of the first dose of the HPV vaccine, and determine parental factors associated with receipt of the HPV vaccine, in a publicly funded school-based HPV vaccine program in British Columbia, Canada.
Methods and Findings
All parents of girls enrolled in grade 6 during the academic year of September 2008–June 2009 in the province of British Columbia were eligible to participate. Eligible households identified through the provincial public health information system were randomly selected and those who consented completed a validated survey exploring factors associated with HPV vaccine uptake. Bivariate and multivariate analyses were conducted to calculate adjusted odds ratios to identify the factors that were associated with parents' decision to vaccinate their daughter(s) against HPV. 2,025 parents agreed to complete the survey, and 65.1% (95% confidence interval [CI] 63.1–67.1) of parents in the survey reported that their daughters received the first dose of the HPV vaccine. In the same school-based vaccine program, 88.4% (95% CI 87.1–89.7) consented to the hepatitis B vaccine, and 86.5% (95% CI 85.1–87.9) consented to the meningococcal C vaccine. The main reasons for having a daughter receive the HPV vaccine were the effectiveness of the vaccine (47.9%), advice from a physician (8.7%), and concerns about daughter's health (8.4%). The main reasons for not having a daughter receive the HPV vaccine were concerns about HPV vaccine safety (29.2%), preference to wait until the daughter is older (15.6%), and not enough information to make an informed decision (12.6%). In multivariate analysis, overall attitudes to vaccines, the impact of the HPV vaccine on sexual practices, and childhood vaccine history were predictive of parents having a daughter receive the HPV vaccine in a publicly funded school-based HPV vaccine program. By contrast, having a family with two parents, having three or more children, and having more education was associated with a decreased likelihood of having a daughter receive the HPV vaccine.
Conclusions
This study is, to our knowledge, one of the first population-based assessments of factors associated with HPV vaccine uptake in a publicly funded school-based program worldwide. Policy makers need to consider that even with the removal of financial and health care barriers, parents, who are key decision makers in the uptake of this vaccine, are still hesitant to have their daughters receive the HPV vaccine, and strategies to ensure optimal HPV vaccine uptake need to be employed.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
About 10% of cancers in women occur in the cervix, the structure that connects the womb to the vagina. Every year, globally, more than a quarter of a million women die because of cervical cancer, which only occurs after the cervix has been infected with a human papillomavirus (HPV) through sexual intercourse. There are many types of HPV, a virus that infects the skin and the mucosa (the moist membranes that line various parts of the body, including the cervix). Although most people become infected with HPV at some time in their life, most never know they are infected. However, some HPV types cause harmless warts on the skin or around the genital area and several—in particular, HPV 16 and HPV 18, so-called high-risk HPVs—can cause cervical cancer. HPV infections are usually cleared by the immune system, but about 10% of women infected with a high-risk HPV develop a long-term infection that puts them at risk of developing cervical cancer.
Why Was This Study Done?
Screening programs have greatly reduced cervical cancer deaths in developed countries in recent decades by detecting the cancer early when it can be treated; but it would be better to prevent cervical cancer ever developing. Because HPV is necessary for the development of cervical cancer, vaccination of girls against HPV infection before the onset of sexual activity might be one way to do this. Scientists recently developed a vaccine that prevents infection with HPV 16 and HPV 18 (and with two HPVs that cause genital warts) and that should, therefore, reduce the incidence of cervical cancer. Publicly funded HPV vaccination programs are now planned or underway in several countries; but before girls can receive the HPV vaccine, parental consent is usually needed, so it is important to know what influences parental decisions about HPV vaccination. In this study, the researchers undertake a telephone survey to determine the uptake of the HPV vaccine by 11-year-old girls (grade 6) in British Columbia, Canada, and to determine the parental factors associated with vaccine uptake; British Columbia started a voluntary school-based HPV vaccine program in September 2008.
What Did the Researchers Do and Find?
In early 2009, the researchers contacted randomly selected parents of girls enrolled in grade 6 during the 2008–2009 academic year and asked them to complete a telephone survey that explored factors associated with HPV vaccine uptake. 65.1% of the 2,025 parents who completed the survey had consented to their daughter receiving the first dose of HPV vaccine. By contrast, more than 85% of the parents had consented to hepatitis B and meningitis C vaccination of their daughters. Nearly half of the parents surveyed said their main reason for consenting to HPV vaccination was the effectiveness of the vaccine. Conversely, nearly a third of the parents said concern about the vaccine's safety was their main reason for not consenting to vaccination and one in eight said they had been given insufficient information to make an informed decision. In a statistical analysis of the survey data, the researchers found that a positive parental attitude towards vaccination, a parental belief that HPV vaccination had limited impact on sexual practices, and completed childhood vaccination increased the likelihood of a daughter receiving the HPV vaccine. Having a family with two parents or three or more children and having well-educated parents decreased the likelihood of a daughter receiving the vaccine.
What Do These Findings Mean?
These findings provide one of the first population-based assessments of the factors that affect HPV vaccine uptake in a setting where there are no financial or health care barriers to vaccination. By identifying the factors associated with parental reluctance to agree to HPV vaccination for their daughters, these findings should help public-health officials design strategies to ensure optimal HPV vaccine uptake, although further studies are needed to discover why, for example, parents with more education are less likely to agree to vaccination than parents with less education. Importantly, the findings of this study, which are likely to be generalizable to other high-income countries, indicate that there is a continued need to ensure that the public receives credible, clear information about both the benefits and long-term safety of HPV vaccination.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000270.
The US National Cancer Institute provides information about cervical cancer for patients and for health professionals, including information on HPV vaccines (in English and Spanish)
The US Centers for Disease Control and Prevention also has information about cervical cancer and about HPV
The UK National Health Service Choices website has pages on cervical cancer and on HPV vaccination
More information about cervical cancer and HPV vaccination is available from the Macmillan cancer charity
ImmunizeBC provides general information about vaccination and information about HPV vaccination in British Columbia
MedlinePlus provides links to additional resources about cervical cancer (in English and Spanish)
doi:10.1371/journal.pmed.1000270
PMCID: PMC2864299  PMID: 20454567
8.  Organizational correlates of adolescent immunization: Findings of a state-wide study of primary care clinics in North Carolina 
Vaccine  2013;31(40):4436-4441.
Objective
To analyze organization-level correlates of immunization coverage among adolescents served by high-volume primary care providers in North Carolina.
Method
We randomly selected 91 clinics with at least 200 active records for patients ages 11–18 in the North Carolina Immunization Registry. For the 105,121 adolescents served by these clinics, we obtained immunization status for 6 vaccines, including human papillomavirus (HPV) vaccine (females only); meningococcal conjugate; and tetanus, diphtheria, and pertussis booster (Tdap).
Results
Clinics specializing in pediatrics had higher coverage for meningococcal vaccine (OR = 1.79, 95% CI: 1.25–2.55), Tdap vaccine (OR = 1.22, 95% CI: 1.00–1.50), and childhood vaccines. However, pediatric clinics had lower coverage for HPV vaccine initiation (OR = 0.70, 95% CI: 0.52–0.94). Other correlates, which varied by vaccine, included policies related to vaccine documentation and the age at which clinics recommended vaccines.
Conclusion
Overall, adolescents were more likely to receive vaccines, except HPV vaccine, if they attended a pediatric clinic with supportive clinical policies.
doi:10.1016/j.vaccine.2013.06.092
PMCID: PMC3798154  PMID: 23845803
Adolescent health services; Diphtheria Tetanus acellular Pertussis Vaccine; Meningococcal Vaccine; Human papillomavirus Vaccine; Pediatrics; Family Practice
9.  Tetanus, Diphtheria, Acellular Pertussis Vaccine During Pregnancy: Pregnancy and Infant Health Outcomes 
The Journal of pediatrics  2013;163(5):1422-6.e1-4.
Objective
To assess pregnancy and birth outcomes in infants born to women who did or did not receive tetanus, diphtheria, acellular pertussis (Tdap) vaccine during pregnancy.
Study design
Retrospective cohort. Pregnant women 12-45 years of age who received Tdap at Intermountain Healthcare facilities and their infants were identified and compared with mother-infant pairs without documented Tdap from 5/2005-8/2009. Primary measures included pregnancy outcomes and infant health outcomes at birth through twelve months.
Results
From 162,448 pregnancies we identified 138 women (0.08%) with documented Tdap administration during pregnancy (cases). 552 pregnant women without documented Tdap were randomly selected as controls. Of 138 immunized women, 63% received Tdap in the first trimester and 37% after. Tdap was given most commonly as wound prophylaxis. The incidence of spontaneous or elective abortion was no greater in Tdap cases than in controls. There were no significant differences in preterm delivery, gestational age, or birth weight between groups. One or more congenital anomaly was identified in 3.7% (95% CI 1.2%-8.5%) of case infants and 4.4% (95% CI 2.7%-6.5%) of control infants (p=0.749). In infants born to women receiving Tdap during pregnancy, 3.6% (0.8%-10.2%) had ICD-9-CM diagnoses consistent with complex chronic conditions within 12 months compared with 10.4% (95% CI 7.2-14.4%) of infants of controls (p=0.054).
Conclusions
Documented Tdap administration during pregnancy was uncommon and occurred most often in the first trimester as prophylaxis following trauma. No increase in adverse outcomes was identified in infants born to women receiving Tdap compared with infants of controls.
doi:10.1016/j.jpeds.2013.06.021
PMCID: PMC4102585  PMID: 23896191
maternal immunization; infant health outcomes; pregnancy outcomes; pertussis
10.  Immunogenicity and safety results from a randomized multicenter trial comparing a Tdap-IPV vaccine (REPEVAX®) and a tetanus monovalent vaccine in healthy adults 
Human Vaccines & Immunotherapeutics  2012;8(12):1875-1881.
In adults with a tetanus-prone injury, combined vaccines such as Tdap-IPV (REPEVAX®) can boost immunity against several diseases simultaneously. This Phase IIIb, parallel-group, open-label trial compared antibody responses to Tdap-IPV and tetanus monovalent vaccine (TMV; Vaccin Tétanique Pasteur® or Tetavax®) against tetanus toxoid 10 and 28 d post-vaccination. Between July and December 2009, four centers in France and five in Germany recruited healthy adults who had received a tetanus-containing vaccine 5−10 y previously. Participants were randomized 1:1 to receive at the first visit a single dose (0.5 mL) of Tdap-IPV or TMV, with follow-up visits at Day 10 and Day 28. Outcomes: per protocol (PP) population immunogenicity at Day 10 (primary) and at Day 28 (secondary); safety throughout the study. Of 456 adults randomized, 223 received Tdap-IPV and 233 received TMV (PP population: 183 and 199 participants, respectively). All participants receiving Tdap-IPV and 99.0% receiving TMV had an anti-tetanus antibody concentration ≥ 0.1 IU/mL, confirming non-inferiority of Tdap-IPV to TMV (95% confidence interval of the difference: –1.2, 3.6). Number of adverse events reported was comparable in each group. Injection-site reactions were reported by 76.6% participants receiving Tdap-IPV and 74.6% receiving TMV. Systemic events (e.g., malaise, myalgia and headache) were reported in 47.7% and 39.7% of the Tdap-IPV and the TMV groups, respectively. Tdap-IPV is effective and well-tolerated for use in the management of tetanus-prone injuries in emergency settings in persons for whom a booster against diphtheria, pertussis and poliomyelitis is also needed. ClinicalTrials.gov identifier: NCT00928785. Research sponsored by Sanofi Pasteur MSD.
doi:10.4161/hv.22083
PMCID: PMC3656080  PMID: 23032160
REPEVAX®; Tdap-IPV vaccine; immunogenicity; injuries; safety; tetanus toxoid
11.  Uptake of meningococcal conjugate vaccine among adolescents in large managed care organizations, United States, 2005: Demand, supply and seasonality 
Background
In February 2005, the US Advisory Committee on Immunization Practices recommended the new meningococcal conjugate vaccine (MCV4) for routine use among 11- to 12-year-olds (at the preadolescent health-care visit), 14- to 15-year-olds (before high-school entry), and groups at increased risk. Vaccine distribution started in March; however, in July, the manufacturer reported inability to meet demand and widespread MCV4 shortages were reported. Our objectives were to determine early uptake patterns among target (11-12 and 14-15 year olds) and non-target (13- plus 16-year-olds) age groups. A post hoc analysis was conducted to compare seasonal uptake patterns of MCV4 with polysaccharide meningococcal (MPSV4) and tetanus diphtheria (Td) vaccines.
Methods
We analyzed data for adolescents 11-16 years from five managed care organizations participating in the Vaccine Safety Datalink (VSD). For MCV4, we estimated monthly and cumulative coverage during 2005 and calculated risk ratios. For MPSV4 and Td, we combined 2003 and 2004 data and compared their seasonal uptake patterns with MCV4.
Results
Coverage for MCV4 during 2005 among the 623,889 11-16 years olds was 10%. Coverage for 11-12 and 14-15 year olds was 12% and 11%, respectively, compared with 8% for 13- plus 16-year-olds (p < 0.001). Of the 64,272 MCV4 doses administered from March-December 2005, 73% were administered June-August. Fifty-nine percent of all MPSV4 doses and 38% of all Td doses were administered during June-August.
Conclusion
A surge in vaccine uptake between June and August was observed among adolescents for MCV4, MPSV4 and Td vaccines. The increase in summer-time vaccinations and vaccination of non-targeted adolescents coupled with supply limitations likely contributed to the reported shortages of MCV4 in 2005.
doi:10.1186/1471-2334-9-175
PMCID: PMC2781813  PMID: 19887009
12.  Randomized Trial on the Safety, Tolerability, and Immunogenicity of MenACWY-CRM, an Investigational Quadrivalent Meningococcal Glycoconjugate Vaccine, Administered Concomitantly with a Combined Tetanus, Reduced Diphtheria, and Acellular Pertussis Vaccine in Adolescents and Young Adults▿ †  
This study evaluated the safety, tolerability, and immunogenicity of an investigational quadrivalent meningococcal conjugate vaccine, MenACWY-CRM, when administered concomitantly with a combined tetanus, reduced diphtheria, and acellular pertussis (Tdap) vaccine, in subjects aged 11 to 25 years. Subjects received either MenACWY-CRM and Tdap, MenACWY-CRM and saline placebo, or Tdap and saline placebo. No significant increase in reactogenicity and no clinically significant vaccine-related adverse events (AEs) occurred when MenACWY-CRM and Tdap were administered concomitantly. Similar immunogenic responses to diphtheria, tetanus, and meningococcal (serogroups A, C, W-135, and Y) antigens were observed, regardless of concomitant vaccine administration. Antipertussis antibody responses were comparable between vaccine groups for filamentous hemagglutinin and were slightly lower, although not clinically significantly, for pertussis toxoid and pertactin when the two vaccines were administered concomitantly. These results indicate that the investigational MenACWY-CRM vaccine is well tolerated and immunogenic and that it can be coadministered with Tdap to adolescents and young adults.
doi:10.1128/CVI.00436-09
PMCID: PMC2849330  PMID: 20164251
13.  Perceptions of Tetanus-diphteria-acellular pertussis (Tdap) Vaccination among Korean Women of Childbearing Age 
Infection & Chemotherapy  2013;45(2):217-224.
Background
The number of cases of pertussis reported has increased gradually in the last decade. Pertussis vaccination is the most effective strategy for the prevention of infection. Despite the fact that young infants are at the highest risk for pertussis, the rate of tetanus-diphtheria-acellular pertussis (Tdap) vaccination is presumed to be very low among women of childbearing age in Korea. The purpose of this study was to investigate the perceptions of women of childbearing age regarding Tdap vaccination in Korea.
Materials and Methods
Women of childbearing age, who visited the Department of Obstetrics and Gynecology at 3 University hospitals in the Seoul and Gyeonggi-do provinces of Korea, were surveyed. Individual questionnaires were administered from April to May 2012. Demographic data, Tdap vaccination history, general knowledge about pertussis, and information on factors associated with decision on vaccination were collected.
Results
Of the 500 reproductive-age women enrolled, only 4 (0.8%) had received the Tdap. The most common reason for non-vaccination was the lack of awareness of pertussis and information about the Tdap. Totally, 171 (34.2%) responded that they would receive a Tdap vaccination in the future. By multivariate analysis, general confidence in the effectiveness of the vaccine (odds ratio [OR] = 1.88, 95% confidence interval [CI] 1.17 to 3.01) was indicated as an important factor for deciding whether to receive the Tdap vaccine (P < 0.01).
Conclusions
The coverage of Tdap vaccination of women of childbearing age, including pregnant women, is very low because of the lack of awareness of pertussis and the Tdap. Education of women of childbearing age about pertussis is very important to increase Tdap vaccination rates among these women, particularly during the perinatal period.
doi:10.3947/ic.2013.45.2.217
PMCID: PMC3780958  PMID: 24265970
Pertussis; Vaccination; Tdap; Childbearing age; Perception
14.  Cost-Effectiveness of Tdap Vaccination of Adults Aged ≥65 Years in the Prevention of Pertussis in the US: A Dynamic Model of Disease Transmission 
PLoS ONE  2014;9(1):e72723.
Objectives
In February 2012, the Advisory Committee on Immunization Practices (ACIP) advised that all adults aged ≥65 years receive a single dose of reduced-antigen-content tetanus, diphtheria, and acellular pertussis (Tdap), expanding on a 2010 recommendation for adults >65 that was limited to those with close contact with infants. We evaluated clinical and economic outcomes of adding Tdap booster of adults aged ≥65 to “baseline” practice [full-strength DTaP administered from 2 months to 4–6 years, and one dose of Tdap at 11–64 years replacing decennial Td booster], using a dynamic model.
Methods
We constructed a population-level disease transmission model to evaluate the cost-effectiveness of supplementing baseline practice by vaccinating 10% of eligible adults aged ≥65 with Tdap replacing the decennial Td booster. US population effects, including indirect benefits accrued by unvaccinated persons, were estimated during a 1-year period after disease incidence reached a new steady state, with consequences of deaths and long-term pertussis sequelae projected over remaining lifetimes. Model outputs include: cases by severity, encephalopathy, deaths, costs (of vaccination and pertussis care) and quality-adjusted life-years (QALYs) associated with each strategy. Results in terms of incremental cost/QALY gained are presented from payer and societal perspectives. Sensitivity analyses vary key parameters within plausible ranges.
Results
For the US population, the intervention is expected to prevent >97,000 cases (>4,000 severe and >5,000 among infants) of pertussis annually at steady state. Additional vaccination costs are $4.7 million. Net cost savings, including vaccination costs, are $47.7 million (societal perspective) and $44.8 million (payer perspective). From both perspectives, the intervention strategy is dominant (less costly, and more effective by >3,000 QALYs) versus baseline. Results are robust to sensitivity analyses and alternative scenarios.
Conclusions
Immunization of eligible adults aged ≥65, consistent with the current ACIP recommendation, is cost saving from both payer and societal perspectives.
doi:10.1371/journal.pone.0072723
PMCID: PMC3886978  PMID: 24416118
15.  Human papillomavirus (HPV) vaccination for the prevention of HPV 16/18 induced cervical cancer and its precursors 
Introduction
Essential precondition for the development of cervical cancer is a persistent human papillomavirus (HPV) infection. The majority - approximately 70% - of cervical carcinomas is caused by two high-risk HPV types (16 and 18). Recently, two vaccines have been approved to the German market with the potential to induce protection against HPV 16 and HPV 18 among additional low-risk virus types.
Objectives
To analyse whether HPV vaccination is effective with regard to the reduction of cervical cancer and precursors of cervical carcinoma (CIN), respectively? Does HPV vaccination represent a cost-effective alternative or supplement to present screening practice? Are there any differences concerning cost-effectiveness between the two available vaccines? Should HPV vaccination be recommended from a health economic point of view? If so, which recommendations can be conveyed with respect to a (re)organization of the German vaccination strategy? Which ethical, social and legal implications have to be considered?
Methods
Based on a systematic literature review, randomized controlled trials (RCT) looking at the effectiveness of HPV vaccination for the prevention of cervical carcinoma and its precursors - cervical intraepithelial neoplasia - have been identified. In addition, health economic models were identified to address the health economic research questions. Quality assessment of medical and economic literature was assured by application of general assessment standards for the systematic and critical appraisal of scientific studies.
Results
Vaccine efficacy in prevention of CIN 2 or higher lesions in HPV 16 or HPV 18 negative women, who received all vaccination doses, ranges between 98% and 100%. Side effects of the vaccination are mainly associated with injection site reactions (redness, turgor, pain). No significant differences concerning serious complications between the vaccination- and the placebo-groups were reported. Results of base case scenarios in the identified health economic modeling analyses range from approximately 3,000 Euro to 40,000 Euro per additional QALY (QALY = Quality-adjusted life year) and approximately 9,000 Euro to 65,000 Euro per additional life year (LYG), respectively.
Discussion
The included studies show that both available HPV vaccines are effective in preventing HPV 16 and HPV 18 infections and probable resulting premalignant lesions of the cervix. However, the duration of protection is currently unclear. With regard to side effects, the vaccination can be considered as secure. Nevertheless, the number of cases within the clinical studies is not sufficient to determine the occurrence of rarely occurring (severe) adverse events in a reliable way. A reduction in the incidence and induced mortality through cervical cancer in Germany is not only depending on the vaccine’s clinical efficacy. Effects of the new technology on the overall participation rate in screening programs and the resulting vaccination rate and immunization status are also important factors. The results of identified health economic models vary substantially due to the heterogeneity of methodological approaches as well as chosen input parameters. However, almost all model-based analyses reached the conclusion that the implementation of a vaccination with lifelong protection can be considered as cost-effective, if the present screening practice continues. A comparison of the two vaccines shows, that the cost effectiveness ratios are more favorable with the quadrivalent vaccine than with the bivalent alternative when considering QALY as primary outcome parameter. The reason for this finding might be that in the case of the quadrivalent vaccine the prevention of genital warts can also be incorporated into the analysis. Variations of the duration of protection as well as the discounting rate were identified as the primary influencing factors of cost-effectiveness results.
Conclusion
Implementation of HPV vaccination might lead to a reduction of cervical cancer in immunized women. However, uptake of immunization should be accompanied by further studies in order to assess long-term effectiveness and safety aiming at an optimization of possible implementation processes. High numbers of participants are of particular importance regarding immunization. This has to be backed up by programs to optimize early detection – as this affects even those women who already underwent immunization. Since cost-effectiveness evidence might be significantly affected by the unclear duration of protective benefits, a final verdict on the vaccination’s cost-effectiveness in the German setting is not possible. Hence, risk-sharing-agreements between third-party payers and manufacturers would pose an option to balance the consequences of uncertainty towards the duration of protection on cost-effectiveness.
doi:10.3205/hta000066
PMCID: PMC3011291  PMID: 21289891
16.  Role and uptake of human papillomavirus vaccine in adolescent health in the United States 
Both the prophylactic human papillomavirus (HPV) vaccines, Gardasil® and Cervarix®, are licensed for the prevention of cervical cancer in females, and Gardasil is also licensed for the prevention of genital warts and anal cancer in both males and females. This review focuses on the uptake of these vaccines in adolescent males and females in the USA and the barriers associated with vaccine initiation and completion. In the USA in 2009, approximately 44.3% of adolescent females aged 13–17 years had received at least one dose of the HPV vaccine, but only 26.7% had received all three doses. In general, the Northeast and Midwest regions of the USA have the highest rates of HPV vaccine initiation in adolescent females, while the Southeast has the lowest rates of vaccine initiation. Uptake of the first dose of the HPV vaccine in adolescent females did not vary by race/ethnicity; however, completion of all three doses is lower among African Americans (23.1%) and Latinos (23.4%) compared with Caucasians (29.3%). At present, vaccination rates among adolescent females are lower than expected, and thus vaccine models suggest that it is more cost-effective to vaccinate both adolescent males and females. Current guidelines for HPV vaccination in adolescent males is recommended only for “permissive use,” which leaves this population out of routine vaccination for HPV. The uptake of the vaccine is challenged by the high cost, feasibility, and logistics of three-dose deliveries. The biggest impact on acceptability of the vaccine is by adolescents, physicians, parents, and the community. Future efforts need to focus on HPV vaccine education among adolescents and decreasing the barriers associated with poor vaccine uptake and completion in adolescents before their sexual debut, but Papanicolau screening should remain routine among adults and those already infected until a therapeutic vaccine can be developed.
doi:10.2147/AHMT.S15941
PMCID: PMC3804132  PMID: 24155627
human papillomavirus; vaccine uptake; adolescent health
17.  Role and uptake of human papillomavirus vaccine in adolescent health in the United States 
Both the prophylactic human papillomavirus (HPV) vaccines, Gardasil® and Cervarix®, are licensed for the prevention of cervical cancer in females, and Gardasil is also licensed for the prevention of genital warts and anal cancer in both males and females. This review focuses on the uptake of these vaccines in adolescent males and females in the USA and the barriers associated with vaccine initiation and completion. In the USA in 2009, approximately 44.3% of adolescent females aged 13–17 years had received at least one dose of the HPV vaccine, but only 26.7% had received all three doses. In general, the Northeast and Midwest regions of the USA have the highest rates of HPV vaccine initiation in adolescent females, while the Southeast has the lowest rates of vaccine initiation. Uptake of the first dose of the HPV vaccine in adolescent females did not vary by race/ethnicity; however, completion of all three doses is lower among African Americans (23.1%) and Latinos (23.4%) compared with Caucasians (29.3%). At present, vaccination rates among adolescent females are lower than expected, and thus vaccine models suggest that it is more cost-effective to vaccinate both adolescent males and females. Current guidelines for HPV vaccination in adolescent males is recommended only for “permissive use,” which leaves this population out of routine vaccination for HPV. The uptake of the vaccine is challenged by the high cost, feasibility, and logistics of three-dose deliveries. The biggest impact on acceptability of the vaccine is by adolescents, physicians, parents, and the community. Future efforts need to focus on HPV vaccine education among adolescents and decreasing the barriers associated with poor vaccine uptake and completion in adolescents before their sexual debut, but Papanicolau screening should remain routine among adults and those already infected until a therapeutic vaccine can be developed.
doi:10.2147/AHMT.S15941
PMCID: PMC3804132  PMID: 24155627
human papillomavirus; vaccine uptake; adolescent health
18.  Correlates of receiving recommended adolescent vaccines among adolescent females in North Carolina 
Human Vaccines  2011;7(1):67-73.
Background
Immunization is a successful and cost-effective method for preventing disease, yet many adolescents do not receive recommended vaccines. We assessed correlates of uptake of three vaccines (tetanus booster, meningococcal and human papillomavirus [HPV] vaccines) recommended for adolescent females.
Results
Only 17% of parents indicated their daughters had received all three vaccines. Eighty-seven percent of parents indicated their daughters had received tetanus booster vaccine, 36% reported vaccination against meningococcal disease and 36% reported HPV vaccine initiation. Daughters aged 13–15 years (OR = 1.70, 95% CI: 1.09–2.64) or 16–20 years (OR = 2.28, 95% CI: 1.51–3.44) had received a greater number of these vaccines compared to daughters aged 11–12 years. Daughters who had preventive care visits in the last year (OR = 4.81, 95% CI: 3.14–7.34) or whose parents had at least some college education (OR = 1.90, 95% CI: 1.29–2.80) had also received a greater number of these vaccines.
Methods
We examined cross-sectional data from 647 parents of 11–20 year-old females from North Carolina who completed the Carolina HPV Immunization Measurement and Evaluation (CHIME) Project follow-up survey in late 2008. Analyses used ordinal and binary logistic regression.
Conclusions
Few daughters, particularly 11–12 years olds, had received all three vaccines recommended for adolescent females. Ensuring annual preventive care visits and increasing concomitant administration of adolescent vaccines may help increase vaccine coverage.
doi:10.4161/hv.7.1.13500
PMCID: PMC3062241  PMID: 21263224
vaccine; adolescents; HPV; meningitis; tetanus; pertussis; diphtheria
19.  Timeliness Vaccination of Measles Containing Vaccine and Barriers to Vaccination among Migrant Children in East China 
PLoS ONE  2013;8(8):e73264.
Background
The reported coverage rates of first and second doses of measles containing vaccine (MCV) are almost 95% in China, while measles cases are constantly being reported. This study evaluated the vaccine coverage, timeliness, and barriers to immunization of MCV1 and MCV2 in children aged from 8–48 months.
Methods
We assessed 718 children aged 8–48 months, of which 499 children aged 18–48 months in September 2011. Face to face interviews were administered with children’s mothers to estimate MCV1 and MCV2 coverage rate, its timeliness and barriers to vaccine uptake.
Results
The coverage rates were 76.9% for MCV1 and 44.7% for MCV2 in average. Only 47.5% of surveyed children received the MCV1 timely, which postpone vaccination by up to one month beyond the stipulated age of 8 months. Even if coverage thus improves with time, postponed vaccination adds to the pool of unprotected children in the population. Being unaware of the necessity for vaccination and its schedule, misunderstanding of side-effect of vaccine, and child being sick during the recommended vaccination period were significant preventive factors for both MCV1 and MCV2 vaccination. Having multiple children, mother’s education level, household income and children with working mothers were significantly associated with delayed or missing MCV1 immunization.
Conclusions
To avoid future outbreaks, it is crucial to attain high coverage levels by timely vaccination, thus, accurate information should be delivered and a systematic approach should be targeted to high-risk groups.
doi:10.1371/journal.pone.0073264
PMCID: PMC3755000  PMID: 24013709
20.  Do correlates of HPV vaccine initiation differ between adolescent boys and girls? 
Vaccine  2012;30(41):5928-5934.
Background
Guidelines now recommend that adolescents routinely receive human papillomavirus (HPV) vaccine. Because little is known about uptake among boys, we assessed HPV vaccine initiation in a population-based sample of adolescent boys and girls.
Methods
We analyzed weighted data from 751 parents who reported on an 11- to 17-year-old son or daughter for the 2010 North Carolina Child Health Assessment and Monitoring Program survey. Stratified multivariate logistic regression analyses identified correlates of HPV vaccine initiation separately for boys and girls.
Results
Only 14% of sons had received one or more doses of HPV vaccine compared to 44% of daughters (p<0.01). For both sons and daughters, vaccine initiation correlated with age and having received meningococcal vaccine. Among sons, initiation of HPV vaccine was lower for those living in high income households (odds ratio [OR]=0.22, 95% CI, 0.09–0.53) and higher for those whose race was neither white nor black (OR=3.26, 95% CI, 1.06–10.04). When asked to give the main reason for not vaccinating their child against HPV, parents of unvaccinated sons were more likely than those of daughters to report not getting a provider’s recommendation or not being aware the vaccine was available for their child, but less likely to report concern about safety (p<0.01). At least 86% of unvaccinated children had missed an opportunity to receive HPV vaccine.
Conclusions
HPV vaccine correlates and concerns varied for parents of boys and girls. To improve very low levels of uptake among boys, providers should recommend HPV vaccine concomitant with other adolescent vaccines.
doi:10.1016/j.vaccine.2012.07.045
PMCID: PMC3438656  PMID: 22841973
adolescent health; human papillomavirus infections/prevention & control; vaccination/statistics & numerical data; North Carolina
21.  Statewide HPV Vaccine Initiation Among Adolescent Females in North Carolina 
Sexually transmitted diseases  2010;37(9):549-556.
Background
Cervical cancer incidence in the United States may be greatly reduced through widespread human papillomavirus (HPV) vaccination. We estimated the statewide level of HPV vaccine initiation among adolescent girls in North Carolina and identified correlates of vaccine initiation.
Methods
We used data from 617 parents of adolescent females from North Carolina who completed the population-based 2008 Child Health Assessment and Monitoring Program survey. Analyses used weighted multivariate logistic regression.
Results
Overall, 31.3% of parents reported their daughters had received at least 1 dose of HPV vaccine. Vaccine initiation was higher among daughters aged 13 to 15 years (odds ratio [OR] = 2.03, 95% CI, 1.12–3.67) or 16 to 17 years (OR = 3.21, 95% CI, 1.76 –5.86) compared with those 10 to 12 years old. Additional correlates of HPV vaccine initiation included the daughter having a preventive check-up in the last 12 months (OR = 5.09, 95% CI, 2.43–10.67), having received meningococcal vaccine (OR = 2.50, 95% CI, 1.55– 4.01), or being from an urban area (OR = 1.81, 95% CI, 1.02–3.21). Among parents of unvaccinated daughters, intent to vaccinate in the next year was higher among those with daughters aged 13 to 17 years. Parents of unvaccinated non-Hispanic white daughters reported lower levels of intent to vaccinate within the next year compared with parents of unvaccinated daughters of other races.
Conclusions
HPV vaccine initiation in North Carolina is comparable with other US areas. Potential strategies for increasing HPV vaccination levels include reducing missed opportunities for HPV vaccination at preventive check-ups and increasing concomitant administration of HPV vaccine with other adolescent vaccines.
doi:10.1097/OLQ.0b013e3181d73bf8
PMCID: PMC4018582  PMID: 20414146
22.  Combined Reduced-Antigen Content Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Vaccine-Related Erythema Nodosum: Case Report and Review of Vaccine-Associated Erythema Nodosum 
Dermatology and Therapy  2013;3(2):191-197.
Background
Vaccination programs reduce the morbidity and mortality of diphtheria, pertussis, and tetanus. Erythema nodosum is a reactive erythema that can be associated with infections, drugs, and many conditions. The new onset of erythema nodosum after receiving vaccination is uncommon.
Purpose
Combined reduced-antigen content tetanus, diphtheria, and acellular pertussis (Tdap) vaccine-associated erythema nodosum is described and the reports of vaccine-related erythema nodosum are summarized.
Methods
The clinical features of a 39-year-old woman who developed erythema nodosum after receiving Tdap vaccine are reported. Using the PubMed database, an extensive literature search was performed on erythema nodosum, vaccine, and vaccination.
Results
Tdap, the most commonly used booster vaccine against tetanus, diphtheria, and pertussis, is well tolerated in all age groups. Local injection-site reactions are the most common adverse events, whereas headache, fatigue, gastrointestinal symptoms, and fever are the most frequent systemic events. Erythema nodosum has not previously been reported in patients who have received Tdap vaccine. The patient developed erythema nodosum within 48 h after receiving Tdap vaccine; her symptoms cleared and nearly all skin lesions resolved within 2 weeks after initiating oral treatment with ibuprofen, fexofenadine, and prednisone. Vaccine-associated erythema nodosum has previously been reported following vaccination for cholera, hepatitis B, human papillomavirus, malaria, rabies, small pox, tuberculosis, and typhoid.
Conclusion
Vaccine-associated erythema nodosum is uncommon. Erythema nodosum occurring after Tdap vaccination is a rare, yet potential, adverse effect.
doi:10.1007/s13555-013-0035-9
PMCID: PMC3889310  PMID: 24318418
Acellular pertussis; Dermatology; Diphtheria; Erythema nodosum; Tdap; Tetanus; Vaccine; Vaccine-associated; Vaccine-related; Vaccination
23.  Longitudinal Predictors of HPV Vaccine Initiation among Adolescent Girls in a High-Risk Geographic Area 
Sexually transmitted diseases  2011;38(3):197-204.
Background
HPV vaccine uptake is low among adolescent girls in the United States. We sought to identify l ongitudinal predictors of HPV vaccine initiation in populations at elevated risk for cervical cancer.
Methods
We interviewed a population-based sample of parents of 10–18 year-old girls in areas of North Carolina with elevated cervical cancer rates. Baseline interviews occurred in summer 2007 and follow-up interviews in fall 2008. Measures included health belief model constructs.
Results
Parents reported that 27% (149/567) of their daughters had initiated HPV vaccine between baseline and follow-up. Of parents who at baseline intended to get their daughters the vaccine in the next year, only 38% (126/348) had done so by follow-up. Of parents of daughters who remained unvaccinated at follow-up but had seen a doctor since baseline, only 37% (122/388) received an HPV vaccine recommendation.”
Rates of HPV vaccine initiation were higher among parents who at baseline perceived lower barriers to getting HPV vaccine, anticipated greater regret if their daughters got HPV because they were unvaccinated, did not report “needing more information” as the main reason they had not already vaccinated, intended to get their daughters the vaccine, or were not born-again Christians.
Conclusions
Missed opportunities to increase HPV vaccine uptake included unrealized parent intentions and absent doctor recommendations. While several health belief model constructs identified in early acceptability studies (e.g., perceived risk, perceived vaccine effectiveness) were not longitudinally associated with HPV vaccine initiation, our findings suggest correlates of uptake (e.g., anticipated regret) that offer novel opportunities for intervention.
doi:10.1097/OLQ.0b013e3181f12dbf
PMCID: PMC3025264  PMID: 20838362
HPV vaccine; adherence; cervical neoplasia; health belief model
24.  Vaccinating Sons against HPV: Results from a U.S. National Survey of Parents 
PLoS ONE  2014;9(12):e115154.
Purpose
The quadrivalent HPV vaccination was approved for use in males ages 9 to 26 in 2009 and recommended for routine administration in 2011. The purpose of this study was to uncover predictable commonalities amongst parents who chose to vaccinate their 11–17 year old sons against HPV.
Methods
We compiled data from a U.S. national sample of 779 parents with sons 11–17 years old using a web-based survey to gather information about behavioral and sociodemographic factors which predicted receipt of 1 or more HPV vaccine doses based on parental report. Predictors were first modeled individually for univariable associations. Significant predictors (p<0.10) were combined in a multivariable model.
Results
In the adjusted model, independent predictors included receipt of flu vaccination, health insurance coverage and sexual health topic discussions with sons. Sons who had received a flu shot in the last two years more frequently received at least one dose of the vaccine (OR 1.82; 95% CI 1.45–2.26). Sons covered by private health insurance had decreased odds of HPV vaccination (OR 0.56 95% CI 0.37–0.83). Lastly, parents who had discussed sexual health topics with their sons were more likely to vaccinate (OR 1.61; 95% CI 1.37–1.89).
Conclusions
Male vaccination rates in the U.S. have increased, but males continue to be under-immunized. Utilization of health care is an important factor in HPV vaccine uptake; therefore, health care providers should use every contact as an opportunity to vaccinate. Communication about sexual health topics may provide a forum for parents and health care providers to have conversations about HPV vaccination as those more comfortable discussing these topics may also be more comfortable discussing HPV vaccination.
doi:10.1371/journal.pone.0115154
PMCID: PMC4277268  PMID: 25541726
25.  A new meningococcal conjugate vaccine: What should physicians know and do? 
Paediatrics & Child Health  2009;14(8):515-517.
A quadrivalent meningococcal conjugate vaccine for serogroups A, C, Y and W135 (MCV4 [Menactra, sanofi pasteur, Canada]) was introduced in Canada in 2007 for persons two years of age or older. MCV4 adds three serogroups to the meningococcal serogroup C conjugate vaccine, which has been used for several years. The rates of invasive meningococcal serogroup C infection have decreased over the past decade, attributable to the meningococcal C conjugate vaccine. However, the incidence of infection caused by serogroups A, B, Y and W135 have not changed substantially. MCV4 induces the production of protective antibodies to serogroups A, C, Y and W135 in adults and children older than two years of age. Serious adverse events from MCV4 are low. In view of the effectiveness of the meningococcal C conjugate vaccine for young infants and the historic high number of meningococcal serogroup C infections in Canada, physicians should encourage and promote publicly funded immunization programs for infants starting at two months of age. MCV4 should also be given to children aged two years who are at increased risk for meningococcal infection. MCV4 may also be considered for HIV-positive children two years of age or older. All adolescents should be offered a booster dose with MCV4 or a meningococcal C conjugate vaccine at approximately 12 years of age. Both vaccines are generally safe and well tolerated.
PMCID: PMC2780966  PMID: 20885803
Canada; MCV4; Meningococcal infection; Meningococcal vaccine

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