State and territory immunization program activities and their association with human papillomavirus vaccine initiation in the United States of America: A multilevel approach

Vivian Colón-López; Francisco J Muñoz-Torres; Erika Escabí Wojna; Idamaris Vega Jimenez; Olga L Díaz Miranda; Diana T Medina-Laabes; Katelyn Wells; Ana P Ortiz; Pamela C Hull; Erick Suárez

doi:10.1371/journal.pgph.0002852

State and territory immunization program activities and their association with human papillomavirus vaccine initiation in the United States of America: A multilevel approach

PLOS Glob Public Health. 2024 Dec 31;4(12):e0002852. doi: 10.1371/journal.pgph.0002852. eCollection 2024.

Affiliations

¹ Cancer Control and Population Sciences, Comprehensive Cancer Center, University of Puerto Rico, San Juan, Puerto Rico.
² Association of Immunization Managers, Rockville, MD, United States of America.
³ Department of Behavioral Science, College of Medicine, Markey Cancer Center, University of Kentucky Lexington, Lexington, KY, United States of America.

Abstract

This study evaluates the association between immunization program (IP) activities aimed at increasing HPV vaccination among adolescents and their impact on initiation rates. Our data sources are: (i) 2016 AIM Annual Survey and (ii) 2019 National Immunization Survey-Teen. We estimated the prevalence of HPV vaccine initiation using a multilevel Poisson model, combining state-level IP data and individual characteristics of adolescents. We calculated the prevalence ratio (PR) of HPV initiation among adolescents to compare the effects of IP activities, adjusting for state of residence, age, sex, maternal education, and ethnicity. A total of 17,390 teens aged 13 and 17 were evaluated. States with publicly available school-based adolescent coverage rates and/or exemptions (PRw, activity Dadjusted: 1.08, 95% CI: 1.02, 1.14), and those that expanded the number of pharmacies entering HPV vaccination data (PRw, activity Nadjusted; 1.06, 95% CI: 1.02, 1.10) in Immunization Information Systems (IIS), had higher HPV vaccine initiation rates compared to states that did not implement these strategies. When stratifying, these findings were present in the younger group (13-15 years, PRw, activity D adjusted: 1.10, 95% CI: 1.01, 1.18; PRw. activity N adjusted: 1.10, 95% CI: 1.05, 1.16), but not in the older group (16-17 years, PRw, activity D adjusted: 1.05, 95% CI: 0.95, 1.15; PRw. activity N adjusted: 1.00, 95% CI: 0.94, 1.06). States that expanded the number of school-located programs entering HPV vaccine records in IIS (PRw, activity Eadjusted: 1.08, 95% CI: 1.01, 1.15) had higher vaccine initiation prevalence in the younger group but not in the older group. Limitations include a lack of operational definitions for IP activities, potential biases in the NIS-Teen survey, and reliance on provider-reported HPV vaccination. Nonetheless, these results highlight immunization activities that support national efforts to increase HPV vaccine uptake and inform public health programs on effective HPV vaccine promotion.

Copyright: © 2024 Colón-López et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Grants and funding

This work was supported by National Cancer Institute (NCI) (URL: https://www.cancer.gov), grant R01CA232743 (“Implementation of School-Entry Policies for Human Papillomavirus Vaccination”) within University of Puerto Rico Comprehensive Cancer Center to VCL. The National Cancer Institute had no role in the study design; collection, analysis, and interpretation of the data; writing of the manuscript; or decision to publish. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NCI.