Giving It Our Best Shot?
HPV and HBV Immunization Among Refugees
Rachel Stein Berman, MD, MPH
24 March 2015
Feedback Requested
•
More interesting ways to interpret my results
•
What to focus on in the discussion section of a
paper
http://newsomali.net/?p=480
HPV and HBV
Burden of disease
Immunization
•
400K of 500K new cases of
cervical cancer
•
45% of global population
lives in regions highly
endemic for HBV (8%
prevalence), with >60%
lifetime risk of infection
•
93% of adolescents
completed HBV vaccine
series
•
57% of female adolescents
completed HPV vaccine
series
BOTH
Disparities
Objectives
•
To analyze rates of HPV and HBV
immunization among refugees resettled in MA
and to compare these rates to those of the
general US population
•
To examine sociodemographic factors
associated with HPV and HBV immunization
among refugees
Hypotheses
• Older refugees, females, and refugees resettled
later in our study period would have higher rates of
HPV immunization
• Refugees would have lower rates of HPV
immunization than the general US population
Study Design, Setting, and
Sample
Measures
•
Predictor variables
•
Covariates
•
Year of arrival
•
RHAP clinic site
•
Age
•
Date of RHAP clinic visit
•
Nationality
•
Gender
•
Race
•
Acute or chronic medical
condition
•
HBV surface antigen and
antibody status
•
Total number of vaccines
•
Primary outcomes
•
Receipt of one dose of
HPV vaccine
•
Receipt of two doses of
HBV vaccine
Analyses
•
Basic means and standard deviations for
continuous variables
•
Basic frequencies for categorical variables
•
Bivariate analyses (t-test and chi-square) to inform
logistic regression to assess associations between
vaccine receipt and predictor variables
•
Chi-square analyses to compare immunization rates
among refugees to US adolescents
Results
•
2269 refugees 9-26 years old resettled in MA
2011-2013
•
Predominant nationalities: Iraqi (25%), Bhutanese
(24%), Somali (11%)
•
Mean age: 18 years
•
46% female
•
Mean number of vaccines: 9.3
Results
Arrival Year
Refugee Characteristics
Age
900
2000
Region
825
1500
750
East Asia and
Pacfiic
214
9%
675
600
2011
2012
2013
South and
Central Asia
(excluding
Bhutan)
1%
1000
Europe,
Eurasia, and
Western
Hemisphere
7%
Bhutan
24%
500
0
9-12
Iraq
21%
Near East
1%
Somalia
11%
Sub-Saharan
Africa
(excluding
Somalia)
25%
13-26
Years
Results
Refugee vs US Adolescents Receiving One Dose of HPV
Vaccine
RHAP (2011- US
OR
2013)
(2013)(refere
nce)
Total
379 (68%)
8296 (45%)
2.5 (2.1-3.0)
Females 182 (68%)
4991 (57%)
1.6 (1.2-2.1)
Males
3305 (35%)
3.9 (3.1-5.0)
197 (68%)
Results
Refugee vs US Adolescents Receiving One Dose of HPV
Vaccine
2011
RHAP
US
(reference)
OR
Total
105 (60%) 6978 (30%)
3.5 (2.6-4.8)
Females
56 (64%)
5281 (54%)
1.6 (1.0-2.4)
Males
49 (56%)
11,305
(21%)
13.9 (9.121.2)
2012
RHAP
Total
US
(reference)
2013
OR
141 (72%) 6982 (36%) 4.4 (3.2-6.0)
RHAP
Total
US
(reference)
133 (72%) 8296 (45%)
OR
3.1 (2.2-4.2)
Females 67 (72%)
4873 (54%) 2.2 (1.4-3.5)
Females 59 (69%)
4991 (57%)
1.7 (1.1-2.7)
Males
2109 (21%) 9.4 (6.114.4)
Males
3305 (35%)
5.4 (3.4-8.4)
74 (71%)
74 (74%)
Results
Factors Associated with HPV and HBV Immunization
HPV AOR (95% CI)
HBV AOR (95% CI)
Age
9-12 years 1
13-26 years 0.74 (0.60-0.93)
1
0.69 (0.37-0.63)
Arrival year
2011 1
2012-2013 1.6 (1.3-1.9)
1
0.87 (0.70-1.1)
Region (crude)
Iraq 0.94 (0.73-1.2)
0.69 (0.54-0.89)
Near East 0.24 (0.093-0.60)
0.34 (0.15-0.78)
Somalia 0.61 (0.45-0.83)
0.47 (0.35-0.64)
Sub-Saharan Africa, excluding Somalia 1
Bhutan 0.75 (0.59-0.97)
South and Central Asia, excluding Bhutan 0.42 (0.20-0.90)
East Asia and Pacific 0.74 (0.54-1.0)
Europe and Eurasia 0.18 (0.10-0.33)
Western Hemisphere 0.56 (0.36-0.87)
1
1.0 (0.77–1.3)
0.68 (0.31-1.5)
0.92 (0.65-1.3)
0.48 (0.28-0.81)
1.2 (0.71-1.9)
HBV surface antigen
Positive N/A
0.13 (0.07-0.24)
Positive N/A
0.42 (0.34-0.52)
HBV surface antibody
Contrary to Our Expectations
•
Refugee adolescents had
higher rates of HPV
immunization than US
adolescents
•
Refugee males and females
had equal rates of HPV
immunization
•
Younger refugees had higher
rates of HPV immunization
than older refugees
Proposed Explanation
•
Clinician
recommendation
•
Normative
•
Standardized
immunization protocol
Next Steps
Limitations
•
Massachusetts only
•
Unable to determine vaccine series completion
•
Secondary analysis of existing dataset
Conclusions
•
Refugee adolescents resettled in MA have
significantly higher rates of HPV vaccine series
initiation than the general US adolescent population
•
Still relatively low rates compared to Healthy People
2020 goal and compared to rates of HBV
immunization
•
May be explained by standardized clinical protocols
and RHAP campaign to encourage HPV
immunization in 2012
Acknowledgements
•
Paul Geltman, MD, MPH
•
Laura Smock, MPH
•
Jennifer Cochran, MPH
•
Megan Bair-Merritt, MD, MSCE
References
1. Geltman PL, Cochran J. A private-sector preferred provider network model for public health screening of newly resettled
refugees. American Journal of Public Health. 2005;95(2):196-199.
2. Hwang E and Cheung R.Global Epidemiology of Hepatitis B Virus (HBV) Infection. The North American Journal of Medicine
and Science. 2011; 4(1):7-13.
3. World Health Organization. Hepatitis B. 2013. Available at: http://www.who.int/mediacentre/factsheets/fs204/en/. Accessed
February 26, 2015.
4. Elam-Evans LD et al. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 1317 Years – United States, 2013. Morbidity and Mortality Weekly Report. 2014; 63(29):625-633.
5. Gelman A et al. Racial Disparities in Human Papillomavirus Vaccination: Does Access Matter? Journal of Adolescent Health.
2013; 53(6):756-762.
6. Perkins R et al. Why Do Low-Income Parents Choose Human Papillomavirus Vaccination for Their Daughters? The Journal of
Pediatrics. 2010; 157(4):617-622.
7. Brewer NT and Fazekas KI. Predictors of HPV Vaccine Acceptability. Preventive Medicine. 2007; 45 (2-3):107-114.
8. Pierre-Joseph N et al. Knowledge, Attitudes, and Beliefs Regarding HPV Vaccination: Ethnic and Cultural Differences Between
African-American and Haitian Immigrant Women. Women’s Health Issues. 2012; 22(6):e571-e579.
9. Nguyen G, Chen B, Chan M. Pap Testing, Awareness, and Acceptability of a Human Papillomavirus (HPV) Vaccine Among
Chinese American Women. Journal of Immigrant and Minority Health. 2012; 14(5):803-808.
10. Kepka D et al. Low Human Papillomavirus (HPV) Vaccine Knowledge Among Latino Parents in Utah. Journal of Immigrant
and Minority Health. 2015; 17(1):125-131.
11. Do et al. HPV Vaccine Knowledge and Beliefs Among Cambodian American Parents and Community Leaders. Asian Pacific
Journal of Cancer Prevention. 2009; 10(3):339-344.
12. Garcini LM et al. Awareness and Knowledge of Human Papillomavirus (HPV) Among Ethnically Diverse Women Varying in
Generation Status. Journal of Immigrant and Minority Health. 2015; 17(1):29-36.
13. Perkins R et al. Missed Opportunities for HPV Vaccination in Adolescent Girls: A Qualitative Study. Pediatrics. 2014;
134(3):e666-e674.
14. Centers for Disease Control and Prevention. Tips and Time-Savers for Talking with Parents About HPV Vaccine. 2013.
Available at: http://www.cdc.gov/vaccines/who/teens/for-hcp-tipsheet-hpv.html. Accessed March 12, 2015.
15.Weiser T et al. Perspectives in Quality: Designing the WHO Surgical Safety Checklist. International Journal for Quality in
Health Care. 2010; 22(5):365-370.
Results
Refugee Characteristics
Age
n (%)
9-12 years
431 (19%)
2011
696 (11%)
Arrival year
2012-2013 1573 (69%)
Gender
Female 1040 (46%)
Region
Iraq 481 (21%)
Somalia
255 (11%)
Sub-Saharan Africa, excluding Somalia
571 (25%)
Bhutan 538 (24%)
South and Central Asia, excluding Bhutan
29 (1.3%)
East Asia and Pacific 214 (9.4%)
Europe, Eurasia, and Western 160 (6.9%)
Hemisphere
Results
Refugee vs MA Adolescents Receiving One Dose of HPV
Vaccine
RHAP
MA(reference)
Total
379 (68%)
66% (2010)
Females
182 (68%)
62% (2013)
Males
197 (68%)
53% (2013)
OR