374 - Missed HPV Vaccination Opportunities in Sexually Active Adolescents

Publication Number: 2363.374

Priyani Sharma, Childrens Hospital of Philadelphia, Drexel Hill, PA, United States; Mary Kate Kelly, Children's Hospital of Philadelphia, Vincentown, NJ, United States; Maura A. Powell, CHOP, Malvern, PA, United States; Alexander G. Fiks, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Stephanie Mayne, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Brian Jenssen, Children's Hospital of Philadelphia, Philadelphia, PA, United States

Background: Human papillomavirus (HPV) is a major cause of cervical, anal, oropharyngeal, vaginal, vulvar, and penile cancers. Vaccination against HPV prior to the onset of sexual activity is crucial for effective prevention.

Objective: To describe HPV vaccination status at the onset of sexual activity and its association with patient, clinician, and practice characteristics.

Design/Methods: We conducted a cross-sectional analysis of adolescents aged 13-18 years in the Children's Hospital of Philadelphia primary care network using electronic health record data and self-reported Adolescent Health Questionnaire (AHQ) responses. The AHQ is a pre-visit questionnaire completed by adolescents 13+ years before preventive visits, assessing strength and risk-based domains, including sexual activity. Sexual debut was defined as responding yes or maybe to ever having sexual contact. We categorized HPV vaccination status relative to sexual debut into three groups: 1) series completed before sexual debut, 2) only first dose completed before sexual debut, 3) not vaccinated before sexual debut. We described the demographic distribution between vaccination status groups and assessed differences by practice. We used logistic regression followed by marginal standardization to calculate the risk difference in predicted proportion with the outcome across groups, with 95% confidence intervals. The risk difference compares the absolute differences in vaccination status across categories of patient, clinician, and practice characteristics.

Results: We analyzed 10,952 sexually active adolescents (mean age 16.9 years, 46% female, 41% non-Hispanic Black, 44% Medicaid-insured, 33% from very low Child Opportunity Index (COI) neighborhoods). Overall, 1,288 (12%) received no HPV vaccination before sexual debut. Unvaccinated adolescents were disproportionately non-Hispanic White (48%) and commercially insured (59%) (Table 1). Rates of unvaccinated adolescents varied substantially across practices, ranging from 5% to 45% (Figure 1). Higher COI, commercial insurance, and greater practice distance from the main hospital were associated with an increased likelihood of being unvaccinated before sexual debut (Table 2).

Conclusion(s): Despite high overall HPV vaccination rates, more than 1 in 10 sexually active adolescents had not received any HPV vaccine before sexual debut, with significant variation across practices. These findings highlight missed opportunities for timely HPV vaccination and suggest that practice-level interventions may be effective in improving vaccination coverage before adolescents become sexually active.

Table 1: Demographic variables by HPV vaccine timing status among sexually active adolescents including clinician and practice level variables
1Reported as n (column%) unless otherwise listed.
2Distance from CHOP Main Hospital was used as a proxy for urbanicity.
3Sex or sexual intercourse can mean different things to different people and people can have sex with others of the same or different gender. The AHQ question asked "In your entire life, have you had any kind of sexual contact with anyone? Yes* |No |Maybe*". Patients were included if they answered "yes" or "maybe" to having had any kind of sexual contact.
4Trainee includes both fellows and residents.


Table 2: Risk Differences of Not Vaccinated for HPV Before Sexual Debut by Demographic, Provider, and Practice Factors
*Indicates statistically significant differences (p < 0.05). A negative risk difference indicates a more favorable outcome.
1Not vaccinated before sexual debut indicated was coded as 1 = no HPV doses, 0 = one or more HPV doses. Seven unadjusted logistic regression models were run for demographics (sex, payor group and COI level), clinician factors (clinician type, years at CHOP) and practice factors (driving distance from CHOP main hospital).
2Trainee includes both fellows and residents.


Figure 1: Not Vaccinated for HPV Vaccine Before Sexual Debut by Practice (Anonymized).
The bar graph displays the percentage of sexually active adolescents not vaccinated before sexual debut ordered from highest to lowest rate of not vaccinated with each row representing a practice. Counts of the total eligible population (n) are displayed alongside percentage values for each practice.