- Email: [email protected]
Factors Associated With Initiation and Completion of Human Papillomavirus Vaccine Series Among Young Women Enrolled in Medicaid
Journal of Adolescent Health 47 (2010) 596–599
Adolescent health brief
Factors Associated With Initiation and Completion of Human Papillomavirus Vaccine Series Among Young Women Enrolled in Medicaid Robert L. Cook, M.D., M.P.H.a,b,c,*, Jianyi Zhang, Ph.D.c, Jocelyn Mullins, D.V.M., M.P.H.a, Teresa Kauf, Ph.D.d, Babette Brumback, Ph.D.a, Heather Steingraber,c and Chris Mallisonc a
Department of Epidemiology and Biostatistics, University of Florida, Gainesville, Florida b Department of Medicine, University of Florida, Gainesville, Florida c Florida Center for Medicaid and the Uninsured, University of Florida, Gainesville, Florida d Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida Manuscript received March 10, 2010; manuscript accepted September 21, 2010
Abstract
Purpose: To determine age- and race-specific uptake rates of human papillomavirus (HPV) vaccine among females aged 9–20 years who participated in the Florida Medicaid during the first 2 years after approval by the Food and Drug Administration, and to identify factors associated with HPV vaccine initiation and series completion. Methods: Medicaid administrative data were used to identify claims for HPV vaccination together with individual, provider, and practice characteristics linked to each vaccination. Results: As of June 2008, 9.4% of females aged 11–18 years had ever received an HPV vaccination, and 1.8% had completed the three-vaccine series. In multivariate analysis, receipt of an HPV vaccination was found to be associated with age and race/ethnicity. In comparison with their white counterparts, black females were approximately half as likely to complete the three-vaccine series after initiation. Conclusions: The data obtained suggest relatively slow initial uptake and completion of the HPV vaccine series in this population who are at an increased risk for cervical cancer, with racial disparities in vaccine uptake and vaccine series completion. Ó 2010 Society for Adolescent Health and Medicine. All rights reserved.
Keywords:
Adolescent; Healthcare disparities; HPV vaccines; Medicaid; Vaccination
A vaccine targeting human papillomavirus (HPV) was approved by the U.S. Federal Drug Administration in July 2006, and was recommended by the Advisory Committee for Immunization Practice in March 2007 [1]. HPV vaccination is a three-injection series recommended for females aged 11–12 years, with catch-up vaccination recommended till the age of 26 [2]. Early reports suggest a relatively slow uptake of the HPV vaccine, with mixed evidence regarding racial disparities in vaccine uptake [3,4]. Such racial *Address correspondence to: Robert L. Cook, M.D., M.P.H., Department of Epidemiology and Biostatistics, University of Florida, PO Box 100231, Gainesville, FL 32610. E-mail address: [email protected]
disparities are important because cervical cancer rates are highest among black and Hispanic women, especially in the southern United States [5]. Our objectives were to determine initial age- and race-specific uptake rates of HPV vaccine in Medicaid recipients, and to identify factors associated with its initiation and series completion. Methods Medicaid administrative data were obtained from the Florida Agency for Health Care Administration. The study population included all females aged 9–20 who were enrolled in the Florida Medicaid between July 2006 and June 2008 (n ¼ 718,660). The study was approved by the
1054-139X/$ - see front matter Ó 2010 Society for Adolescent Health and Medicine. All rights reserved. doi:10.1016/j.jadohealth.2010.09.015
R.L. Cook et al. / Journal of Adolescent Health 47 (2010) 596–599
University of Florida Institutional Review Board; with funding support from Merck, Inc, without any restrictions pertaining to either analyses or publication. HPV vaccination was identified using the Current Procedural Terminology code ‘‘90649.’’ Additional measures included geographic location of the first shot, number of vaccines received, provider specialty at first vaccination, Medicaid plan, number of Medicaid enrollment months (total and after first vaccination), and having any outpatient visits at the time of enrollment. Age (at each month), race/ ethnicity, and sexual activity data were recorded on the basis of established administrative data criteria [6]. Statistical analyses were conducted using SAS version 9.2 (SAS Institute, Inc., Cary, NC), and were limited to females aged 9–20 who had been enrolled in Medicaid for 6 months (n ¼ 550,048). On a monthly basis, age- and race-specific vaccination rates were calculated as follows: number of females who ever received an HPV vaccination divided by the number of eligible women in that month. We conducted bivariate and multivariate logistic regression analyses to identify factors associated with ever receiving an HPV vaccination among females aged 11–18 years who were enrolled in Medicaid in June 2008 (n ¼ 167,082). Among these young women, the racial distribution was found to be as follows: 28.4% white, 37.8% black, 24.8% Hispanic, and 9.0% other race; 24.1% met the criteria for sexual activity; and 73.1% were enrolled for 18 of 24 possible months of observation. We used similar analyses to identify factors associated with vaccine series completion among 11–18-year-old females who had ever received an HPV vaccination and who had 6 enrollment months after first vaccination (n ¼ 11,986). Results Nearly 2 years after approval by the Food and Drug administration (June 2008), 9.4% of the 11–18-year-old Medicaid-enrolled females had ever received an HPV vaccination and 1.8% had received the three-vaccine series. The majority of initial HPV vaccinations were given by pediatricians (85%), with fewer being provided by family practitioners and/or general practitioners (12%), and the least by obstetricians and/or gynecologists (1%) or internal medicine providers (1%). As of June 2008, the highest HPV vaccination rates were found among females aged 13–15 (11.1%), followed by those aged 11–12 (8.4%), and then those aged 16–18 (8.2%) (Figure 1). Hispanic women aged 9–20 had the highest vaccination rates (9.5%), followed by whites (7.2%), and then blacks (5.1%). Among females aged 11–18 years, the percentages with HPV vaccine initiation were 12.4%, 10%, and 6.8% for Hispanic, white, and black females, respectively. Factors that were significantly associated with ever having an HPV vaccination initiation included being of age 13–15, race/ethnicity (Hispanic > white > black), data suggestive of sexual activity, having any outpatient
597
Figure 1. Age-specific (panel A) and race-specific (panel B) rates of human papillomavirus vaccine initiation in females aged 9–20 years and enrolled in Florida Medicaid between June 2007 and June 2008.
visit, longer duration of enrollment, and geographic region (Table 1). Of those females with 6 months of follow-up after first HPV vaccination, 26.9% completed the 3-vaccine series. Factors significantly associated with vaccine series completion included age, race, duration of enrollment, and geographic region (Table 1). Of note, in comparison with their white counterparts, black females were approximately half as likely to complete the HPV vaccination series (OR: .56; 95% CI: .50–.62).
Discussion These rates of early uptake of HPV vaccination are lower than the 25%–30% rate reported for adolescent females in other studies conducted around the same period as our study [3,4,7,8], including studies on adolescents with private insurance [3]. Black females were significantly less likely as compared with either Hispanic or white females to initiate HPV vaccination or to complete the three-vaccine series, whereas Hispanic females were more likely to initiate vaccination as compared with the other racial groups. These racial differences are important because both black and Hispanic women have higher cancer incidence and death rates from cervical cancer [5]. Vaccination programs can reduce racial disparities in vaccine-preventable diseases [9], but to achieve this effect the vaccine must be received across all racial groups.
598
R.L. Cook et al. / Journal of Adolescent Health 47 (2010) 596–599
Table 1 Factors associated with HPV vaccination initiation and vaccine series completion in females aged 11–18 and enrolled in Florida Medicaid in June 2008: Multivariable analysisa
Risk factor Age category 11–12 13–15 16–18 Race White Black Hispanic Other Sexually active No Yes
Total sample
Initiated HPV vaccinationb
N (%)
N (%)
167,082
15,659 (9.4)
OR
Received three HPV vaccinesc 95% CI
N (%)
OR
95% CI
3,219 (26.9%)
43,775 (26.2) 63,095 (37.8) 60,212 (36.0)
3,662 (8.4) 7,033 (11.2) 4,964 (8.2)
1.00 1.39 .84
– 1.33–1.46 .80–.88
1,042 (27.6) 1,470 (28.1) 707 (23.8)
1.00 1.05 .84
– .95–1.16 .74–.95
47,510 63,086 41,382 15,104
4,750 4,288 5,117 1,504
(10.0) (6.8) (12.4) (10.0)
1.00 .87 1.32 1.04
– .83–.92 1.26–1.39 .96–1.13
1,234 645 1,019 321
(32.4) (19.9) (26.9) (28.2)
1.00 .56 .94 .96
– .50–.62 .83–1.06 .80–1.14
8,816 (6.9) 6,843 (17.0)
1.00 1.19
– 1.15–1.24
1,647 (25.8) 1,572 (28.0)
1.00 1.08
– .99–1.18
(28.4) (37.8) (24.8) (9.0)
126,892 (75.1) 40,190 (24.1)
HPV ¼ human papillomavirus. a Multivariate model for initiation also included geographic region, Medicaid plan type, number of enrolled months, having any outpatient visit, and month of vaccination; multivariate model for series completion also included geographic region, Medicaid plan type, and month of vaccination. b HPV vaccine initiation defined as receipt of any HPV vaccine between July 2006 and June 2008 (n ¼ 167,082). c Vaccine series completion defined among females who received any HPV vaccine and who had 6 months of enrollment after the first vaccination (n ¼ 11,986).
Nearly all HPV vaccinations were provided by pediatricians, and efforts to increase HPV vaccination rates may need to target a broader range of health care providers to ensure vaccination among women of a maximum age of 26 years. Despite having a minimum of 6 months of Medicaid coverage, a greater proportion of black females had no outpatient visits, which could explain part of the racial disparity in vaccine uptake. The requirement for three office visits to receive the three-vaccine series is also a potential barrier. Study limitations include the inability to document HPV vaccinations that were received outside of Medicaid. Therefore, the true HPV vaccination rate would be most likely higher than our present observations. A study sample from a single large state may limit the generalizabilty. Also, our measure of sexual activity was on the basis of administrative data and this may have resulted in misclassification of some women. In summary, it was found that HPV vaccine uptake was initially slow in this population who are at an increased risk for cervical cancer. The recent CDC-sponsored National Immunization Survey-Teen survey suggests that as of 2009, 39% of 13–17-year-old females in Florida had received the HPV vaccine, with continued evidence of racial disparities related to vaccine series completion [10]. The National Immunization Survey-Teen study only included individuals who owned landline telephones, which could have led to undersampling of those with a lower SES. However, findings suggest that HPV vaccination rates have increased since our data collection, but the rates remain to be lower than other recommended vaccinations and racial disparities still persist. School-based vaccination programs and health policy initiatives can influence vaccine uptake and reduce racial disparities
[9]. These and other types of interventions are required to increase the rate of HPV vaccine uptake and series completion, especially in the most vulnerable populations. Acknowledgments Robert Cook conceived the study, oversaw the analysis, and wrote the manuscript; Jianyi Zhang provided data programming, data analysis, and contributed to writing; Jocelyn Mullins contributed to data analysis and writing of this manuscript; Teresa Kauf helped plan the study design, interpreted data, and edited the manuscript; Babette Brumback and Chris Mallison helped plan the study design and provided assistance with data analysis; Heather Steingraber helped plan the study design and edited the manuscript. The study was funded by Merck, Inc, which markets and distributes an HPV vaccine. The funding came without restrictions or limitations pertaining to either publication or presentation of the findings, and the sponsor had no part in the design and conduct of the study; collection, management, analysis, and interpretation of the data. None of the authors report any other potential conflict of interest. The corresponding author had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. References [1] Markowitz LE, Dunne EF, Saraiya M, et al. Quadrivalent human papillomavirus vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007;56 (RR-2):1–24. [2] Centers for Disease Control and Prevention. FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory
R.L. Cook et al. / Journal of Adolescent Health 47 (2010) 596–599
[3]
[4]
[5]
[6]
Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2010;59:626–9. Chao C, Velicer C, Slezak JM, Jacobsen SJ. Correlates for human papillomavirus vaccination of adolescent girls and young women in a managed care organization. Am J Epidemiol 2010;171:357–67. Conroy K, Rosenthal SL, Zimet GD, et al. Human papillomavirus vaccine uptake, predictors of vaccination, and self-reported barriers to vaccination. J Womens Health (Larchmt) 2009;18:1679–86. McDougall JA, Madeleine MM, Daling JR, et al. Racial and ethnic disparities in cervical cancer incidence rates in the United States, 1992-2003. Cancer Causes Control 2007;18:1175–86. Tao G, Walsh CM, Anderson LA, Irwin KL. Understanding sexual activity defined in the HEDIS measure of screening young women for Chlamydia trachomatis. Jt Comm J Qual Improv 2002;28:435–40.
599
[7] Caskey R, Lindau ST, Alexander GC. Knowledge and early adoption of the HPV vaccine among girls and young women: Results of a national survey. J Adolesc Health 2009;45:453–62. [8] Rosenthal SL, Rupp R, Zimet GD, et al. Uptake of HPV vaccine: Demographics, sexual history and values, parenting style, and vaccine attitudes. J Adolesc Health 2008;43:239–45. [9] Staat MA, Meinzen-Derr J, Welch T, et al. Varicella-related hospitalization and emergency department visit rates, before and after introduction of varicella vaccine, among white and black children in Hamilton County, Ohio. Pediatrics 2006;117:e833–9. [10] Centers for Disease Control and Prevention. National, state, and local area vaccination coverage among adolescents aged 13-17 years— United States, 2009. MMWR Morb Mortal Wkly Rep 2010;59: 1018–23.
Adolescent health brief
Factors Associated With Initiation and Completion of Human Papillomavirus Vaccine Series Among Young Women Enrolled in Medicaid Robert L. Cook, M.D., M.P.H.a,b,c,*, Jianyi Zhang, Ph.D.c, Jocelyn Mullins, D.V.M., M.P.H.a, Teresa Kauf, Ph.D.d, Babette Brumback, Ph.D.a, Heather Steingraber,c and Chris Mallisonc a
Department of Epidemiology and Biostatistics, University of Florida, Gainesville, Florida b Department of Medicine, University of Florida, Gainesville, Florida c Florida Center for Medicaid and the Uninsured, University of Florida, Gainesville, Florida d Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida Manuscript received March 10, 2010; manuscript accepted September 21, 2010
Abstract
Purpose: To determine age- and race-specific uptake rates of human papillomavirus (HPV) vaccine among females aged 9–20 years who participated in the Florida Medicaid during the first 2 years after approval by the Food and Drug Administration, and to identify factors associated with HPV vaccine initiation and series completion. Methods: Medicaid administrative data were used to identify claims for HPV vaccination together with individual, provider, and practice characteristics linked to each vaccination. Results: As of June 2008, 9.4% of females aged 11–18 years had ever received an HPV vaccination, and 1.8% had completed the three-vaccine series. In multivariate analysis, receipt of an HPV vaccination was found to be associated with age and race/ethnicity. In comparison with their white counterparts, black females were approximately half as likely to complete the three-vaccine series after initiation. Conclusions: The data obtained suggest relatively slow initial uptake and completion of the HPV vaccine series in this population who are at an increased risk for cervical cancer, with racial disparities in vaccine uptake and vaccine series completion. Ó 2010 Society for Adolescent Health and Medicine. All rights reserved.
Keywords:
Adolescent; Healthcare disparities; HPV vaccines; Medicaid; Vaccination
A vaccine targeting human papillomavirus (HPV) was approved by the U.S. Federal Drug Administration in July 2006, and was recommended by the Advisory Committee for Immunization Practice in March 2007 [1]. HPV vaccination is a three-injection series recommended for females aged 11–12 years, with catch-up vaccination recommended till the age of 26 [2]. Early reports suggest a relatively slow uptake of the HPV vaccine, with mixed evidence regarding racial disparities in vaccine uptake [3,4]. Such racial *Address correspondence to: Robert L. Cook, M.D., M.P.H., Department of Epidemiology and Biostatistics, University of Florida, PO Box 100231, Gainesville, FL 32610. E-mail address: [email protected]
disparities are important because cervical cancer rates are highest among black and Hispanic women, especially in the southern United States [5]. Our objectives were to determine initial age- and race-specific uptake rates of HPV vaccine in Medicaid recipients, and to identify factors associated with its initiation and series completion. Methods Medicaid administrative data were obtained from the Florida Agency for Health Care Administration. The study population included all females aged 9–20 who were enrolled in the Florida Medicaid between July 2006 and June 2008 (n ¼ 718,660). The study was approved by the
1054-139X/$ - see front matter Ó 2010 Society for Adolescent Health and Medicine. All rights reserved. doi:10.1016/j.jadohealth.2010.09.015
R.L. Cook et al. / Journal of Adolescent Health 47 (2010) 596–599
University of Florida Institutional Review Board; with funding support from Merck, Inc, without any restrictions pertaining to either analyses or publication. HPV vaccination was identified using the Current Procedural Terminology code ‘‘90649.’’ Additional measures included geographic location of the first shot, number of vaccines received, provider specialty at first vaccination, Medicaid plan, number of Medicaid enrollment months (total and after first vaccination), and having any outpatient visits at the time of enrollment. Age (at each month), race/ ethnicity, and sexual activity data were recorded on the basis of established administrative data criteria [6]. Statistical analyses were conducted using SAS version 9.2 (SAS Institute, Inc., Cary, NC), and were limited to females aged 9–20 who had been enrolled in Medicaid for 6 months (n ¼ 550,048). On a monthly basis, age- and race-specific vaccination rates were calculated as follows: number of females who ever received an HPV vaccination divided by the number of eligible women in that month. We conducted bivariate and multivariate logistic regression analyses to identify factors associated with ever receiving an HPV vaccination among females aged 11–18 years who were enrolled in Medicaid in June 2008 (n ¼ 167,082). Among these young women, the racial distribution was found to be as follows: 28.4% white, 37.8% black, 24.8% Hispanic, and 9.0% other race; 24.1% met the criteria for sexual activity; and 73.1% were enrolled for 18 of 24 possible months of observation. We used similar analyses to identify factors associated with vaccine series completion among 11–18-year-old females who had ever received an HPV vaccination and who had 6 enrollment months after first vaccination (n ¼ 11,986). Results Nearly 2 years after approval by the Food and Drug administration (June 2008), 9.4% of the 11–18-year-old Medicaid-enrolled females had ever received an HPV vaccination and 1.8% had received the three-vaccine series. The majority of initial HPV vaccinations were given by pediatricians (85%), with fewer being provided by family practitioners and/or general practitioners (12%), and the least by obstetricians and/or gynecologists (1%) or internal medicine providers (1%). As of June 2008, the highest HPV vaccination rates were found among females aged 13–15 (11.1%), followed by those aged 11–12 (8.4%), and then those aged 16–18 (8.2%) (Figure 1). Hispanic women aged 9–20 had the highest vaccination rates (9.5%), followed by whites (7.2%), and then blacks (5.1%). Among females aged 11–18 years, the percentages with HPV vaccine initiation were 12.4%, 10%, and 6.8% for Hispanic, white, and black females, respectively. Factors that were significantly associated with ever having an HPV vaccination initiation included being of age 13–15, race/ethnicity (Hispanic > white > black), data suggestive of sexual activity, having any outpatient
597
Figure 1. Age-specific (panel A) and race-specific (panel B) rates of human papillomavirus vaccine initiation in females aged 9–20 years and enrolled in Florida Medicaid between June 2007 and June 2008.
visit, longer duration of enrollment, and geographic region (Table 1). Of those females with 6 months of follow-up after first HPV vaccination, 26.9% completed the 3-vaccine series. Factors significantly associated with vaccine series completion included age, race, duration of enrollment, and geographic region (Table 1). Of note, in comparison with their white counterparts, black females were approximately half as likely to complete the HPV vaccination series (OR: .56; 95% CI: .50–.62).
Discussion These rates of early uptake of HPV vaccination are lower than the 25%–30% rate reported for adolescent females in other studies conducted around the same period as our study [3,4,7,8], including studies on adolescents with private insurance [3]. Black females were significantly less likely as compared with either Hispanic or white females to initiate HPV vaccination or to complete the three-vaccine series, whereas Hispanic females were more likely to initiate vaccination as compared with the other racial groups. These racial differences are important because both black and Hispanic women have higher cancer incidence and death rates from cervical cancer [5]. Vaccination programs can reduce racial disparities in vaccine-preventable diseases [9], but to achieve this effect the vaccine must be received across all racial groups.
598
R.L. Cook et al. / Journal of Adolescent Health 47 (2010) 596–599
Table 1 Factors associated with HPV vaccination initiation and vaccine series completion in females aged 11–18 and enrolled in Florida Medicaid in June 2008: Multivariable analysisa
Risk factor Age category 11–12 13–15 16–18 Race White Black Hispanic Other Sexually active No Yes
Total sample
Initiated HPV vaccinationb
N (%)
N (%)
167,082
15,659 (9.4)
OR
Received three HPV vaccinesc 95% CI
N (%)
OR
95% CI
3,219 (26.9%)
43,775 (26.2) 63,095 (37.8) 60,212 (36.0)
3,662 (8.4) 7,033 (11.2) 4,964 (8.2)
1.00 1.39 .84
– 1.33–1.46 .80–.88
1,042 (27.6) 1,470 (28.1) 707 (23.8)
1.00 1.05 .84
– .95–1.16 .74–.95
47,510 63,086 41,382 15,104
4,750 4,288 5,117 1,504
(10.0) (6.8) (12.4) (10.0)
1.00 .87 1.32 1.04
– .83–.92 1.26–1.39 .96–1.13
1,234 645 1,019 321
(32.4) (19.9) (26.9) (28.2)
1.00 .56 .94 .96
– .50–.62 .83–1.06 .80–1.14
8,816 (6.9) 6,843 (17.0)
1.00 1.19
– 1.15–1.24
1,647 (25.8) 1,572 (28.0)
1.00 1.08
– .99–1.18
(28.4) (37.8) (24.8) (9.0)
126,892 (75.1) 40,190 (24.1)
HPV ¼ human papillomavirus. a Multivariate model for initiation also included geographic region, Medicaid plan type, number of enrolled months, having any outpatient visit, and month of vaccination; multivariate model for series completion also included geographic region, Medicaid plan type, and month of vaccination. b HPV vaccine initiation defined as receipt of any HPV vaccine between July 2006 and June 2008 (n ¼ 167,082). c Vaccine series completion defined among females who received any HPV vaccine and who had 6 months of enrollment after the first vaccination (n ¼ 11,986).
Nearly all HPV vaccinations were provided by pediatricians, and efforts to increase HPV vaccination rates may need to target a broader range of health care providers to ensure vaccination among women of a maximum age of 26 years. Despite having a minimum of 6 months of Medicaid coverage, a greater proportion of black females had no outpatient visits, which could explain part of the racial disparity in vaccine uptake. The requirement for three office visits to receive the three-vaccine series is also a potential barrier. Study limitations include the inability to document HPV vaccinations that were received outside of Medicaid. Therefore, the true HPV vaccination rate would be most likely higher than our present observations. A study sample from a single large state may limit the generalizabilty. Also, our measure of sexual activity was on the basis of administrative data and this may have resulted in misclassification of some women. In summary, it was found that HPV vaccine uptake was initially slow in this population who are at an increased risk for cervical cancer. The recent CDC-sponsored National Immunization Survey-Teen survey suggests that as of 2009, 39% of 13–17-year-old females in Florida had received the HPV vaccine, with continued evidence of racial disparities related to vaccine series completion [10]. The National Immunization Survey-Teen study only included individuals who owned landline telephones, which could have led to undersampling of those with a lower SES. However, findings suggest that HPV vaccination rates have increased since our data collection, but the rates remain to be lower than other recommended vaccinations and racial disparities still persist. School-based vaccination programs and health policy initiatives can influence vaccine uptake and reduce racial disparities
[9]. These and other types of interventions are required to increase the rate of HPV vaccine uptake and series completion, especially in the most vulnerable populations. Acknowledgments Robert Cook conceived the study, oversaw the analysis, and wrote the manuscript; Jianyi Zhang provided data programming, data analysis, and contributed to writing; Jocelyn Mullins contributed to data analysis and writing of this manuscript; Teresa Kauf helped plan the study design, interpreted data, and edited the manuscript; Babette Brumback and Chris Mallison helped plan the study design and provided assistance with data analysis; Heather Steingraber helped plan the study design and edited the manuscript. The study was funded by Merck, Inc, which markets and distributes an HPV vaccine. The funding came without restrictions or limitations pertaining to either publication or presentation of the findings, and the sponsor had no part in the design and conduct of the study; collection, management, analysis, and interpretation of the data. None of the authors report any other potential conflict of interest. The corresponding author had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. References [1] Markowitz LE, Dunne EF, Saraiya M, et al. Quadrivalent human papillomavirus vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007;56 (RR-2):1–24. [2] Centers for Disease Control and Prevention. FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory
R.L. Cook et al. / Journal of Adolescent Health 47 (2010) 596–599
[3]
[4]
[5]
[6]
Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2010;59:626–9. Chao C, Velicer C, Slezak JM, Jacobsen SJ. Correlates for human papillomavirus vaccination of adolescent girls and young women in a managed care organization. Am J Epidemiol 2010;171:357–67. Conroy K, Rosenthal SL, Zimet GD, et al. Human papillomavirus vaccine uptake, predictors of vaccination, and self-reported barriers to vaccination. J Womens Health (Larchmt) 2009;18:1679–86. McDougall JA, Madeleine MM, Daling JR, et al. Racial and ethnic disparities in cervical cancer incidence rates in the United States, 1992-2003. Cancer Causes Control 2007;18:1175–86. Tao G, Walsh CM, Anderson LA, Irwin KL. Understanding sexual activity defined in the HEDIS measure of screening young women for Chlamydia trachomatis. Jt Comm J Qual Improv 2002;28:435–40.
599
[7] Caskey R, Lindau ST, Alexander GC. Knowledge and early adoption of the HPV vaccine among girls and young women: Results of a national survey. J Adolesc Health 2009;45:453–62. [8] Rosenthal SL, Rupp R, Zimet GD, et al. Uptake of HPV vaccine: Demographics, sexual history and values, parenting style, and vaccine attitudes. J Adolesc Health 2008;43:239–45. [9] Staat MA, Meinzen-Derr J, Welch T, et al. Varicella-related hospitalization and emergency department visit rates, before and after introduction of varicella vaccine, among white and black children in Hamilton County, Ohio. Pediatrics 2006;117:e833–9. [10] Centers for Disease Control and Prevention. National, state, and local area vaccination coverage among adolescents aged 13-17 years— United States, 2009. MMWR Morb Mortal Wkly Rep 2010;59: 1018–23.