El propósito de este informe especial es describir cronológicamente los eventos que contribuyeron al desarrollo y aprobación de la legislación e implementación del requisito escolar de vacunación en Puerto Rico (PR), con el fin de prevenir el VPH y los cánceres asociados a este. A partir del 2010, PR inició las aprobaciones de políticas públicas con el objetivo de mejorar el registro de casos de los cánceres y la cobertura de la vacuna contra el VPH a través de los planes médicos en adolescentes de 11 a 18 años. En el 2014, los esfuerzos científicos y comunitarios lograron documentar la magnitud de las enfermedades causadas por el VPH, y desarrollar en conjunto, estrategias de prevención y promoción de la vacuna contra el VPH. En agosto de 2018, PR logró ser uno de los primeros cuatro territorios de los Estados Unidos de América en implementar la vacuna contra el VPH como requisito escolar con el fin de disminuir la incidencia de cánceres asociados al VPH en la isla. En el 2019 se garantizó por ley que todo proveedor de vacunación debe reportar al Registro de Inmunización. El caso de PR demuestra que el desarrollo de políticas públicas junto con colaboraciones entre coaliciones académicas, científicas y comunitarias, logran cambios poblacionales y resultados medibles dirigidos a la prevención de VPH. Países con una problemática de salud pública similar podrían adoptar esfuerzos similares a los presentados, y alinearlos al objetivo de la Organización Mundial de la Salud: erradicación del cáncer cervical para 2030.
Background In August 2018, Puerto Rico (PR) became the 4th state or territory in the United States to adopt a human papillomavirus (HPV) vaccine school-entry requirement, for students 11–12 years old. Evidence suggests that the content of media coverage may impact people’s perception of HPV vaccine and their willingness to vaccinate. This study aimed to analyze the content of digital news coverage related to the implementation of the policy in PR. Methods A content review was conducted of digital media published from January 2017 through December 2018. The content reviewed was carried out in two steps: 1) creating a matrix to summarize each article’s content about the policy and 2) qualitative analysis using a grounded theory approach. Results The search resulted in 34 articles obtained from 17 online local and international news outlets that reported the policy's implementation. Analyses showed that 61% of the news articles did not mention the number of required doses, and 79% discussed the new policy concerning cancer prevention. In 2017, news coverage focused mostly on describing the policy, while 2018 coverage focused on controversies surrounding the implementation. Neutral emergent codes included: 1) Description of the policy; 2) Information about HPV related cancers; and 3) General information about HPV vaccine. Negative emergent codes included: 1) infringement to patient and parental autonomy; 2) Hesitancy from the political sector, and 3) Hesitancy from groups and coalitions. Positive content included: 1) knowledge and acceptance of HPV vaccine for cancer prevention; 2) importance of education and protective sexual behaviors; and 3) new vaccination law proposal. Conclusions Most of the media coverage in PR was neutral and included limited information related to the vaccine, HPV, and HPV-related cancers. Neutral and negative themes could influence public concerns regarding the new policy, as well as HPV vaccination rates in PR.
The human papillomavirus (HPV) vaccine has been proven effective in the prevention of infection with high-risk HPV types, which can lead to the development of six HPV-related cancers. Puerto Rico (PR) adopted a mandatory HPV vaccination school-entry policy that took effect in August 2018. While school-entry requirements are generally accepted as an effective approach for increasing vaccination rates, there are few studies that have documented their impact on improving HPV vaccination rates. The objective of this study was to evaluate the impact of the HPV school-entry policy in PR on HPV vaccine coverage. We used a pre-post natural experiment. The study population included adolescents registered in the PR Immunization Registry during 2008–2019. We calculated HPV vaccine initiation and up-to-date (UTD) vaccine coverage rates. We estimated age-standardized rates (ASR) and standardized rate ratio with 95%CI. Vaccine data corresponding to a total of 495,327 adolescents were included for analysis; 50.9% were male and 49.1% were females. After policy implementation, a marked increase in raw HPV vaccine initiation among 11- to 12-year-old adolescents was observed across years 2017 (a pre-policy year), 2018, and 2019 (58.3%, 76.3%, and 89.8%, respectively). UTD coverage also showed a moderate increase after policy implementation among 11- to 12-year-old adolescents. The gap between sexes in vaccine initiation and UTD coverage narrowed over time; the ASRs in 2019 showed an increase of 19% in initiation and 7% increase in UTD relative to 2017 for males and females combined (both significant at p<0.05). This study demonstrated evidence of improvement in HPV vaccination rates following implementation of the school-entry policy and a narrowed sex gap in vaccine rates over time in PR. Future analyses should assess how the policy continues to affect vaccine coverage in subsequent years and how the COVID-19 pandemic has impacted HPV vaccination uptake.
In September 2017, Hurricane Maria devastated the Caribbean region, among them the US territory of Puerto Rico (PR). Vaccination distribution and uptake suffered from the impact. This study evaluated the trends in monthly vaccination initiation rates for human papilloma virus (HPV), Tdap and meningococcal conjugate (MenACWY) adolescent vaccines from 2015 to 2019, during which it was possible to observe and analyze the impact of Hurricane Maria on vaccine initiation. Monthly initiation rates were estimated. Age-standardized initiation rate ratio (SRR) and 95% CI were estimated. The analysis included 85,340 adolescents; 52.3% were male, and 47.7% were females. September 2017 showed HPV vaccine initiation had the lower rates of all the studied vaccines, with a rate of 75% after the disaster (from a rate of almost 90% in July 2017). Tdap and MenACWY vaccines rates remained above 90% in the same period. The SRR of HPV vaccine for September and October 2017 showed an estimated reduction of 5% and 8% in vaccine initiation rates, respectively for each month, when 2016 was the reference year ( p > .05). The SRR of Tdap and MenACWY vaccines for November 2017 showed significant reductions when 2015 and 2016 were reference years ( p < .05). HPV vaccine initiation rate was the most severely affected by the Hurricane Maria. Post-natural disaster protocols should strengthen existing programs for facilitate immunization access.
Introduction: School-entry vaccination mandates have been widely used as a mechanism to ensure high immunization coverage rates. In August 2018, Puerto Rico (PR) mandated a Human papillomavirus (HPV) vaccine school-entry policy for student’s ages 11 to 12 years. This new requirement in PR presents an opportunity to study the implementation process across a 5 years period (2018-2023). In this ongoing study, we conducted Key Informant (KI) interviews to document factors that facilitate or impede a successful HPV vaccine school policy implementation in PR. Methods: We conducted 29 KI semi-structured interviews with stakeholders in the Department of Health (DOH), school system, healthcare organizations, community-based organizations and coalitions in PR (in favor and against the school-entry policy) from July 2018 to June 2019. The interview guide included relevant domains based on the Consolidated Framework for Implementation Research, such as Intervention characteristics, Inner setting, Outer setting and Individual characteristics. We transcribed interviews, coded transcripts and analyzed data to identify emergent themes. Results: Potential facilitators of HPV policy implementation included: clear enforcement messages and use of personal anecdotes by nurses from health and school fields, the coverage of the vaccine by medical insurers, and the power of the Secretary of Health to include vaccines required for school-entry. Perceived barriers to the implementation process were: lack of communication between the DOH and the Department of Education, lack of knowledge about the HPV vaccine, uncertainty about the consistency of implementation in schools, lack of vaccine availability and disproportionate burden for regional school nurses. Other barrier to implementation mentioned included: school directors and teachers were detached from the implementation process, and lack of compliance from private health providers and public schools towards the immunization registry. Coalitions against this mandate focused their concerns on the right of parental autonomy. Recommendations from KI focused on: stricter policies to enforce this law in public schools, clear messages about the new mandate and HPV vaccine current coverage by health care insurers in PR. Moreover, KI expresses the need for more support from the DOH (technical and educational training to school principals and teachers, health promotion), and the need for increased education about the HPV vaccine and recommendations. Conclusions: Although school vaccination mandates are an evidence-based strategy for improving vaccination rates, several implementation barriers could affect the impact. Findings from this study can be used for improving policy procedures and implementation, and can inform states/territories considering adopting similar immunization policies. The information generated will help determine adaptations/modifications that may be needed for policy implementation in PR and other populations in the future. Citation Format: Roxana Soto-Abreu, Manuel E. Rivera-Encarnación, Vilnery Rivera-Figueroa, Glizette O. Arroyo-Morales, Diana T. Medina-Laabes, Olga L. Diaz-Miranda, Pamela C. Hull, Ana P. Ortiz-Martínez, Erick L. Suárez-Pérez, María E. Fernández, Vivian Colón-López. Human papillomavirus school-entry vaccination mandate in Puerto Rico: Barriers and facilitators from the perspective of key informants [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D047.
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