By Mitchell Linder, MD
Assistant Professor, Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Strong Memorial Hospital, Rochester, NY
SYNOPSIS: In this cohort study, results from two years of an inpatient postpartum HPV vaccination program are presented. Overall, their results show an increased rate of immunization (hazard ratio of 2.51) and an increased proportion of women completing the vaccination series (35.8% of those receiving an inpatient dose completed the series compared to 9.3% of those who did not get the inpatient dose).
SOURCE: Avni-Singer L, Oliveira CR, Torres A, et al. Evaluation of an inpatient postpartum human papillomavirus immunization program. Obstet Gynecol 2020;136:1006-1015.
This cohort study looked at the time from delivery to discharge as a critical window of opportunity to provide either first or catch-up doses of the human papillomavirus (HPV) vaccine. Eligible women were younger than 27 years of age, received prenatal care from a single hospital-based OB/GYN clinic, and had not completed the HPV series at the time of delivery. The program began in April 2017, and data in this study were from the first two years, until April 2019. The HPV vaccine was provided from a drug-only grant from Merck & Co. The protocol had the program coordinator identify eligible patients and the on-call provider place an electronic order for vaccination. Counseling and consenting prior to vaccination were done by the clinic team. Patients were scheduled for their next doses per Centers for Disease Control and Prevention (CDC) age-based guidelines.
From April 2017 to April 2019, 666 women delivered at the intervention site hospital. A total of 394 (59.2%) of the 666 women were eligible to receive a dose while they were inpatient and postpartum. The remainder were noted to have completed their series prior to delivery. Of the 394 eligible patients, 277 were Black or Hispanic, 297 had public insurance, and 82 had no insurance at all. One hundred four women identified Spanish as their preferred language and 316 of the patients had not received any prior doses of HPV vaccine. Of the 394 women who were eligible, 265 (67.3%) received their first dose during their hospitalization. For 36 (13.6%) of the 265, the inpatient dose marked the completion of their series. Of the 358 patients eligible for either their first or second shot while hospitalized, 177 (49.4%) had a dose in the hospital. The proportion of women who were eligible and went on to have a subsequent outpatient vaccine was 30.1% higher (95% confidence interval [CI], 19.6% to 40.4%) in the group who received the inpatient dose (60.3% vs. 30.2%). The overall proportion of women completing the series also was higher in the group that had received the inpatient dose (35.8% to 9.3%; odds ratio [OR], 5.45; 95% CI, 2.86-10.38).
Analysis showed Hispanic women (OR, 2.14; 95% CI, 1.07-4.30), those with Spanish as their preferred language (OR, 3.03; 95% CI, 1.41-5.67), and those who had already received two doses prior (OR, 2.72; 95% CI, 1.10-6.72) were significantly more likely to receive an inpatient dose. Married women were less likely to receive an inpatient dose (adjusted odds ratio [aOR], 0.59, 0.37-0.96). There was no significant difference when comparing public vs. private insurance. Women who received an inpatient dose had a higher probability of receiving subsequent outpatient doses (hazard ratio, 2.51; 95% CI, 1.76-3.58). The odds of receiving an outpatient dose of HPV in the first 12 months postpartum were higher in Hispanic women (OR, 2.60; 95% CI, 1.15-5.90) and those whose preferred language was Spanish (OR, 2.11; 95% CI, 1.22-3.64). For every additional outpatient visit attended, the odds of getting a dose increased almost threefold (aOR, 2.88; 95% CI, 2.08-3.99).
Looking at missed opportunities to receive the vaccine, the numbers were significantly lower in those patients getting an inpatient dose (23.4% lower; 95% CI, 9.4% to 23.3%). On average, there were 30.7 fewer missed opportunities (95% CI, 5.8-55.6; P < 0.02) for every 100 eligible visits in those who received an inpatient dose compared to those who did not.
COMMENTARY
Despite evidence that the HPV vaccine series is effective at preventing genital warts and HPV-related cervical cancer, only 39.9% of eligible adult patients (aged 18 to 26 years) in the United States had received at least one dose in 2018. The number of patients in that group who had completed the series was 21.5%.1 Pregnancy is a time when many patients first interact with the healthcare system, especially in underserved populations. In fact, in many states, becoming pregnant is a health insurance-qualifying event, and as such, some patients only become insured during their pregnancy. Unfortunately, HPV vaccination is not recommended to be given during pregnancy. These three facts make the immediate postpartum time period an excellent intervention window.
Given that cervical cancer incidence is higher in Black and Hispanic women, the authors noted success in their project by finding that the odds that women whose preferred language was Spanish were nearly three times more likely to get a dose inpatient vs. women whose preferred language was English. The authors thought this likely is the result of historical gaps in opportunities for Hispanic Spanish-speaking women to have been offered the vaccine in the past. Barriers to successful implementation of a similar program are noted to be HPV vaccine supply (in this study, the vaccine was provided through a grant at no cost to the patient) and the need for a program coordinator for identifying eligible patients.
Limitations noted for this study were that it was a single-site study with patients from a single hospital-based clinic and the fact that the vaccines were supplied from an outside source. Other limitations included immunization history capture by the electronic health record (in both the eligibility evaluation phase and the data collection phase). Lastly, the researchers noted that almost 50% of eligible women did not receive subsequent vaccination doses after leaving the hospital.
This study seems to be an excellent intervention to help increase the number of patients receiving HPV vaccination. The fact that in 2019 the CDC’s Advisory Committee on Immunization Practices recommended patients ages 27 to 45 years have a shared decision-making discussion with their providers about HPV vaccination makes even more patients eligible for this intervention and, therefore, shows an even larger need for programs such as this one. In addition, the American Rescue Plan Act of 2021 includes a provision for extending maternity-related insurance coverage to up to 12 months after delivery, again increasing opportunities for health-related interventions.2
At this time, I think it would be reasonable for most hospitals to look into making routine offering of HPV vaccine part of their regular postpartum care, similar to measles, mumps, and rubella and other vaccinations.
REFERENCES
- Boersma P, Black LI. Human papillomavirus vaccination among adults aged 18-26, 2013-2018. NCHS Data Brief 2020; Jan:1-8.
- Congress.gov. H.R. 1319– American Rescue Plan Act of 2021. https://www.congress.gov/bill/117th-congress/house-bill/1319
