Vaccine 33 (2015) 1786–1790

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Human papillomavirus vaccine uptake in boys and girls in a school-based vaccine delivery program in Prince Edward Island, Canada Carol A. McClure ∗ , Mary-Ann MacSwain, Heather Morrison, Carolyn J. Sanford Chief Public Health Office, Department of Health and Wellness, Government of Prince Edward Island, 16 Fitzroy Street, 2nd Floor Sullivan Building, Charlottetown, PE, Canada C1A 7N8

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Article history: Received 4 November 2014 Received in revised form 10 February 2015 Accepted 17 February 2015 Available online 27 February 2015 Keywords: Human papillomavirus HPV HPV vaccination Uptake School-based Public Health Nursing

a b s t r a c t Background: In 2013, Prince Edward Island was the first province to introduce HPV vaccine universally to grade six boys in a school-based program. Because uptake rates in boys are unknown in this type of vaccination program, uptake of HPV vaccination in boys was measured and compared with uptake rates in girls and then analyzed with factors such as county, urban–rural location of the school, and school board to identify where the vaccine program could be improved. Methods: HPV vaccination records from the provincial childhood immunization registry in PEI were merged with Department of Education data containing all grade six girls and boys in PEI. Vaccine uptakes between years and between sexes were compared using two sample tests of proportions. Logistic regression modeling which accounted for the hierarchical nature of the data was used to analyze associations between factors and uptake rates. Results: Although uptake was high in boys and girls, a significantly greater proportion of girls (85%) received all three doses of the HPV vaccine compared to boys (79%; p = 0.004). The odds of grade six girls being fully vaccinated for HPV were 1.5 times greater than of grade six boys, and the odds of students in the English Language School Board receiving all three doses were more than twice as great as the odds of French Language School Board students. Conclusions: HPV vaccination for boys in PEI has had a successful launch, almost reaching the Canadian Immunization Committee recommendations of >80% for the early years of a program. PEI has a highly organized Public Health Nursing program that is involved in all childhood and school-based vaccinations in PEI and in this context very high coverage rates were obtained. Areas to target for improving uptake include the boys and the students in the French Language School Board. © 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction The World Health Organization recognizes human papillomavirus (HPV) as the most common sexually transmitted infection in the world [1]. Although cervical cancer is the most common cancer caused by HPV, other cancers associated with HPV infection are squamous cell carcinomas of the anus, vagina, vulva, penis, and the oropharynx (the base of the tongue, the tonsil, and pharynx) [2]. Approximately 43–88% of these different anogenital cancers worldwide and 56% of oral cancers in North America are associated with HPV infection [3–5]. In addition, HPV (mainly types 6

∗ Corresponding author. Tel.: +1 902 368 5101; fax: +1 902 620 3354. E-mail addresses: [email protected] (C.A. McClure), [email protected] (M.-A. MacSwain), [email protected] (C.J. Sanford).

and 11) cause warts in the anogenital areas including the anus, penis, vagina, and vulva [6]. Genital warts are common having an annual incidence between 1 and 2 cases per 1000 people in North America [7]. They are highly infectious and cause significant direct health care costs as well as indirect costs including psychosocial harm [8–10]. Although rare, recurrent respiratory papillomatosis is also caused by HPV [11]. In the fall of 2008 an HPV vaccination program was initiated in grade 6 girls in Prince Edward Island (PEI)1 , Canada. In February 2010, Health Canada approved the use of the quadrivalent HPV vaccine in boys aged 9–12. By January 2012, the National Advisory Committee on Immunization (NACI) (see footnote 1) recommended

1 Abbreviations: Prince Edward Island (PEI), National Advisory Committee on Immunization (NACI).

http://dx.doi.org/10.1016/j.vaccine.2015.02.047 0264-410X/© 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

C.A. McClure et al. / Vaccine 33 (2015) 1786–1790

the use of HPV vaccine to protect males against intraepithelial neoplasia, anal cancer and anogenital warts [12]. In 2013, PEI was the first province to introduce HPV vaccine universally to boys in grade 6. In 2014, Alberta added boys to their HPV vaccination program [13]. Increasing the proportion of the population that is vaccinated will decrease the risk of individuals becoming infected either directly or indirectly from the herd effect [6,14]. This is a major aim of a successful vaccination program. Unfortunately, vaccination uptake by boys in the United States has been quite variable and not very high [15–18]. Quantification of the uptake of HPV vaccines in both boys and girls in PEI is necessary to ensure successful delivery of the school-based program. The aims of this study were two fold. The first aim was to measure the uptake of HPV vaccination in boys after the first year of the universal school-based program. The second aim was to determine if there were any changes in the girls’ recent uptake rate relative to previous years. Additionally, the relationships between HPV vaccination and factors such as county, urban–rural location of the school, and school board were analyzed to identify areas where the vaccine program could be improved.

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evidence to show a student had moved, received HPV vaccine doses in another province or a previous school year, or refused the vaccine for legitimate medical reasons. Vaccine uptake rates in girls from previous school years (2008–2009, 2011–2012, and 2012–2013) were calculated similarly with the exception of the 2008–2009 school year in which only the number of grade 6 girls attending all PEI schools was provided as a denominator for the uptake rate. Vaccine uptake rates between years and between sexes were compared using two sample tests of proportions. Unconditional associations between predictors and the outcome (fully immunized or not) were tested using chi square analysis, and those with a p-value 80% in the early years of the program. PEI has a highly organized Public Health Nursing program that is involved in all childhood and school-based vaccinations in PEI. Opportunities to speak with nurses educated in HPV vaccination likely contributed to increased uptake and will continue. Investigation into ways of improving uptake will continue as well. In addition, program evaluation should continue to monitor changing incidence of HPV associated conditions. PEI, similar to other provinces, will be considering a two-dose HPV vaccination program in the future. If this significant change is made, increased uptake for all grade 6 children may be realized. Contributions to the study Initial concept: HM, CS. Study design: CM, MM, CS. Data collection and data preparation: MM. Analysis: CM, MM, CS. Interpretation of results: CM, MM, CS. Wrote the manuscript: CM, MM, CS. Critically reviewed the manuscript: all authors.

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Conflict of interest statement There are no conflicts of interest declared by any of the authors. Acknowledgements The authors wish to thank the PEI Public Health Nursing nurses and staff responsible for administering the HPV vaccination program for their valuable input. In addition, we would also like to express our gratitude to Sara Townsend and Sherri-Lynn Laverty for their help with data validation. Dr. Lamont Sweet, Dr. Mitch Zelman, and Anne Neatby are graciously acknowledged for their contributions in the development of vaccination programs in PEI.

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Human papillomavirus vaccine uptake in boys and girls in a school-based vaccine delivery program in Prince Edward Island, Canada.

In 2013, Prince Edward Island was the first province to introduce HPV vaccine universally to grade six boys in a school-based program. Because uptake ...
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