Human papillomavirus vaccine initiation and up-to-date vaccine coverage for adolescents after the implementation of school-entry policy in Puerto Rico

Abstract

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.

Attitudes towards HPV and COVID school-entry policies among adults living in Puerto Rico

“… 8 Despite the reluctance to the HPV vaccine by some community groups, recent analyses by this team from the PR Immunization Registry comparing the period between 2017 (a pre-policy year) to 2019 (post-policy), identified 54% increase in initial HPV vaccination among children aged 11 and 12 (58.3% in 2017 to 89.8% in 2019). 7 , 9 This suggests that mandatory school requirement for the HPV vaccine is an effective strategy to increase HPV vaccine uptake among this group.…”

Attitudes towards HPV Vaccination Policy Strategies to Improve Adolescent Vaccination Coverage among Pediatric Providers in New York State

“…A significant rise in the initiation of the HPV vaccine was observed among 11–12-year-old adolescents in the years 2017 (a pre-policy year), 2018, and 2019, with rates of 58.3%, 76.3%, and 89.8%, respectively. Furthermore, there was a notable reduction in the gap between males and females regarding vaccine initiation and up-to-date coverage over time [ 12 ]. In a separate cross-sectional study conducted in three U.S. jurisdictions with HPV immunization school-entry requirements, notably higher levels of vaccination initiation were observed compared to regions without such policies within the same area.…”