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

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

Research output: Contribution to journal › Article › peer-review

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 (PR^w, activity ^D_adjusted: 1.08, 95% CI: 1.02, 1.14), and those that expanded the number of pharmacies entering HPV vaccination data (PR^w, activity ^N_adjusted; 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, PR^w, activity ^D_adjusted: 1.10, 95% CI: 1.01, 1.18; PR^w. activity ^N_adjusted: 1.10, 95% CI: 1.05, 1.16), but not in the older group (16–17 years, PR^w, activity ^D_adjusted: 1.05, 95% CI: 0.95, 1.15; PR^w. 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 (PR^w, activity ^E_adjusted: 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.

Original language	English
Article number	e0002852
Journal	PLOS Global Public Health
Volume	4
Issue number	12
DOIs	https://doi.org/10.1371/journal.pgph.0002852
State	Published - Dec 31 2024

Bibliographical note

Publisher 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.

Funding

This work was supported by National Cancer Institute (NCI) (URL: https://www.cancer.gov), grant R01CA232743 (\u201CImplementation of School-Entry Policies for Human Papillomavirus Vaccination\u201D) 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.

Funders	Funder number
University of Puerto Rico Medical Sciences Campus and Comprehensive Cancer Center
National Childhood Cancer Registry – National Cancer Institute	R01CA232743
National Childhood Cancer Registry – National Cancer Institute

ASJC Scopus subject areas

Critical Care and Intensive Care Medicine
Public Health, Environmental and Occupational Health

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1371/journal.pgph.0002852

Cite this

Colón-López, V., Muñoz-Torres, F. J., Escabí Wojna, E., Vega Jimenez, I., Díaz Miranda, O. L., Medina-Laabes, D. T., Wells, K., Ortiz, A. P., Hull, P. C., & Suárez, E. (2024). State and territory immunization program activities and their association with human papillomavirus vaccine initiation in the United States of America: A multilevel approach. PLOS Global Public Health, 4(12), Article e0002852. https://doi.org/10.1371/journal.pgph.0002852

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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 Dadjusted: 1.10, 95\% CI: 1.01, 1.18; PRw. activity Nadjusted: 1.10, 95\% CI: 1.05, 1.16), but not in the older group (16–17 years, PRw, activity Dadjusted: 1.05, 95\% CI: 0.95, 1.15; PRw. activity Nadjusted: 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.",

author = "Vivian Col{\'o}n-L{\'o}pez and Mu{\~n}oz-Torres, \{Francisco J.\} and \{Escab{\'i} Wojna\}, Erika and \{Vega Jimenez\}, Idamaris and \{D{\'i}az Miranda\}, \{Olga L.\} and Medina-Laabes, \{Diana T.\} and Katelyn Wells and Ortiz, \{Ana P.\} and Hull, \{Pamela C.\} and Erick Su{\'a}rez",

note = "Publisher Copyright: {\textcopyright} 2024 Col{\'o}n-L{\'o}pez 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.",

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Colón-López, V, Muñoz-Torres, FJ, Escabí Wojna, E, Vega Jimenez, I, Díaz Miranda, OL, Medina-Laabes, DT, Wells, K, Ortiz, AP, Hull, PC & Suárez, E 2024, 'State and territory immunization program activities and their association with human papillomavirus vaccine initiation in the United States of America: A multilevel approach', PLOS Global Public Health, vol. 4, no. 12, e0002852. https://doi.org/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. / Colón-López, Vivian; Muñoz-Torres, Francisco J.; Escabí Wojna, Erika et al.
In: PLOS Global Public Health, Vol. 4, No. 12, e0002852, 31.12.2024.

Research output: Contribution to journal › Article › peer-review

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T2 - A multilevel approach

AU - Colón-López, Vivian

AU - Muñoz-Torres, Francisco J.

AU - Escabí Wojna, Erika

AU - Vega Jimenez, Idamaris

AU - Díaz Miranda, Olga L.

AU - Medina-Laabes, Diana T.

AU - Wells, Katelyn

AU - Ortiz, Ana P.

AU - Hull, Pamela C.

AU - Suárez, Erick

N1 - Publisher 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.

PY - 2024/12/31

Y1 - 2024/12/31

N2 - 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 Dadjusted: 1.10, 95% CI: 1.01, 1.18; PRw. activity Nadjusted: 1.10, 95% CI: 1.05, 1.16), but not in the older group (16–17 years, PRw, activity Dadjusted: 1.05, 95% CI: 0.95, 1.15; PRw. activity Nadjusted: 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.

AB - 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 Dadjusted: 1.10, 95% CI: 1.01, 1.18; PRw. activity Nadjusted: 1.10, 95% CI: 1.05, 1.16), but not in the older group (16–17 years, PRw, activity Dadjusted: 1.05, 95% CI: 0.95, 1.15; PRw. activity Nadjusted: 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.

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Colón-López V, Muñoz-Torres FJ, Escabí Wojna E, Vega Jimenez I, Díaz Miranda OL, Medina-Laabes DT et al. State and territory immunization program activities and their association with human papillomavirus vaccine initiation in the United States of America: A multilevel approach. PLOS Global Public Health. 2024 Dec 31;4(12):e0002852. 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

Abstract

Bibliographical note

Funding

ASJC Scopus subject areas

UN SDGs

Access to Document

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