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Human Papillomavirus (HPV) vaccination is recommended for children aged 11-12 years in the United States. One factor that may contribute to low national HPV vaccine uptake is parental exposure to misinformation on social media.
This study aimed to examine the association between parents’ perceptions of the HPV vaccine information on social media and internet verification strategies used with the HPV vaccine decision-making stage for their child.
Parents of children and adolescents aged 9-17 years were recruited for a cross-sectional survey in North Texas (n=1192) and classified into 3 groups: children and adolescents who (1) were vaccinated, (2) unvaccinated and did not want the vaccine, and (3) unvaccinated and wanted the vaccine. Multinomial logistic regression models were estimated to identify factors associated with the HPV vaccine decision-making stage with children and adolescents who were vaccinated as the referent group.
Of the 1192 respondents, 44.7% (n=533) had an HPV-vaccinated child, 38.8% (n=463) had an unvaccinated child and did not want the vaccine, and 16.4% (n=196) had an unvaccinated child and wanted the vaccine. Respondents were less likely to be “undecided/not wanting the vaccine” if they agreed that HPV information on social media is credible (adjusted odds ratio [aOR] 0.40, 95% CI 0.26-0.60;
Interventions that promote web-based health literacy skills are needed so parents can protect their families from misinformation and make informed health care decisions.
Human papillomavirus (HPV) causes 34,800 anogenital and oropharyngeal cancer cases in the United States annually [
Parental exposure to health information on the internet and social media platforms may influence HPV vaccine awareness, decisions, and uptake. Most parents use the internet to search for information regarding their child’s health, especially to help prepare for questions when seeing a doctor [
Despite being a source of factual information regarding HPV vaccination, social media and internet sources can increase exposure to
Health literacy and internet verification skills may improve information seeking and help counteract the spread of misinformation. Health literacy refers to how a person accesses, understands, appraises, and uses health information [
We used a purposive sample of parents of children and adolescents aged 9-17 years residing in 13 counties in North Texas. We contracted with 2 survey sampling and administration companies, 2M Research and Qualtrics, to field web-based surveys in English and Spanish. Both companies worked with third party vendors (eg, Marketing System Group and Poll Pay) to sample participants with children and adolescents aged 9-17 years residing in the 13-county catchment areas. Sample sizes for each county were based on county population densities. We used 2 different companies because they deployed different recruitment strategies to ensure a diverse sample. 2M Research mailed potential participants letters written in both English and Spanish introducing the study and directing the parent to the web-based survey URL. Qualtrics pushed the survey link via email to research panel participants. Data were collected in 2018.
The 80-item survey assessed factors hypothesized to influence HPV vaccine decision-making and vaccine hesitancy. Before beginning the survey, parents were oriented to the study and that continuing on to answer questions indicated consent. If parents reported having more than 1 child, the survey instructed them to complete the survey for the child whose age was closest to 11 years. The survey took approximately 15-20 minutes to complete. Only participants who completed the survey were included in the final analysis. Participants received a US $25 gift card.
The University of Texas Southwestern Medical Center Institutional Review Board approved this study (STU 092017-076).
The outcome variable was parental HPV vaccine decision-making for their child (see
Independent variables included those related to perceptions about information on social media, trust in providers, internet verification skills, and demographics. Respondents specified their level of agreement to 2 statements regarding HPV vaccine information on social media (“is credible” and “makes me question the HPV vaccine”; see
The distribution of participant characteristics was reported with descriptive statistics, stratified by child HPV vaccination status. All testing across child HPV vaccine status was reported with descriptive statistics, where the chi-square (categorical data) or Kruskal-Wallis (continuous data) test was used as appropriate. The Dwass-Steel-Critchlow-Fligner method was used for multiple comparisons testing. Univariate and multivariate multinomial logistic regressions were performed to identify factors associated with the 3-category HPV vaccine decision stage (children and adolescents who were vaccinated [referent], unvaccinated and did not want the HPV vaccine or was undecided, or unvaccinated and wanted the HPV vaccine). All data analysis was performed using SAS statistical software (version 9.4; SAS Institute).
Overall, 1192 parents responded to the survey (
Most (n=1070, 89.8%) participants reported trusting their health care providers. With regard to social media, most were neutral about whether they perceived the HPV vaccination information on social media as credible (n=580, 48.7%) and were neutral about whether information on social media made them question the HPV vaccine (n=467, 39.2%). For HPV vaccination status, 533 (44.7%) parents had their child vaccinated for HPV, 463 (38.8%) had an unvaccinated child and did not want the vaccine, and 196 (16.4%) had an unvaccinated child and wanted the vaccine. The HPV vaccine decision stage was significantly associated with the parent’s gender (
Descriptive characteristics of parents of children and adolescents from the Dallas-Fort Worth area by human papillomavirus (HPV) vaccine decision-making status (N=1192).
Characteristic | Vaccinateda (n=533) | Unvaccinated did not want the vaccinea (n=463) | Unvaccinated and wanted the vaccinea (n=196) | Total (N=1192) | ||||||||
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<.001 | |||||||||||
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Female | 325 (61) | 298 (64.4) | 158 (80.6) | 782 (65.6) |
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Male | 208 (39) | 164 (35.4) | 37 (18.9) | 409 (34.3) |
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.02 | |||||||||||
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18-24 | 15 (2.8) | 14 (3) | 7 (3.6) | 36 (3) |
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25-34 | 52 (9.8) | 72 (15.6) | 35 (17.9) | 159 (13.3) |
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35-44 | 228 (42.8) | 208 (44.9) | 82 (41.8) | 518 (43.5) |
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45-54 | 184 (34.5) | 142 (30.7) | 53 (27) | 380 (31.9) |
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55-64 | 48 (9) | 22 (4.8) | 17 (8.7) | 87 (7.3) |
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≥65 | 6 (1.1) | 3 (0.6) | 2 (1) | 11 (0.9) |
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<.001 | |||||||||||
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<11 | 71 (13.3) | 154 (33.3) | 84 (42.9) | 310 (26) |
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11-12 | 133 (25) | 127 (27.4) | 57 (29.1) | 317 (26.6) |
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13-17 | 329 (61.7) | 182 (39.3) | 55 (28.1) | 566 (47.5) |
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.14 | |||||||||||
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White | 325 (61) | 264 (57) | 127 (64.8) | 716 (60.1) |
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Non-White | 208 (39) | 198 (42.8) | 68 (34.7) | 475 (39.8) |
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.11 | |||||||||||
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Did not attend college | 84 (15.8) | 101 (21.8) | 35 (17.9) | 220 (18.5) |
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Some college | 97 (18.2) | 91 (19.7) | 36 (18.4) | 224 (18.8) |
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College graduate | 352 (66) | 270 (58.3) | 124 (63.3) | 747 (62.7) |
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.39 | |||||||||||
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Urban | 227 (42.6) | 173 (37.4) | 71 (36.2) | 471 (39.5) |
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Suburban | 177 (33.2) | 162 (35) | 72 (36.7) | 411 (34.5) |
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Other | 129 (24.2) | 128 (27.6) | 53 (27) | 311 (26.1) |
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.007 | |||||||||||
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1 | 279 (52.4) | 228 (49.2) | 91 (46.4) | 598 (50.2) |
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2 | 194 (36.4) | 167 (36.1) | 82 (41.8) | 443 (37.2) |
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3 | 32 (6) | 55 (11.9) | 18 (9.2) | 106 (8.9) |
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4 | 8 (1.5) | 5 (1.1) | 4 (2) | 17 (1.4) |
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5 | 20 (3.8) | 8 (1.7) | 1 (0.5) | 29 (2.4) |
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<.001 | |||||||||||
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Trust providers | 516 (96.8) | 370 (79.9) | 183 (93.4) | 1070 (89.8) |
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Distrust providers | 17 (3.2) | 93 (20.1) | 13 (6.6) | 123 (10.3) |
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<.001 | |||||||||||
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Agree/strongly agree | 226 (42.4) | 96 (20.7) | 50 (25.5) | 372 (31.2) |
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Neutral | 217 (40.7) | 259 (55.9) | 104 (53.1) | 580 (48.7) |
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Disagree/strongly disagree | 90 (16.9) | 107 (23.1) | 42 (21.4) | 240 (20.1) |
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<.001 | |||||||||||
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Agree/strongly agree | 162 (30.4) | 150 (32.4) | 29 (14.8) | 341 (28.6) |
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Neutral | 155 (29.1) | 236 (51) | 76 (38.8) | 467 (39.2) |
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Disagree/strongly disagree | 216 (40.5) | 75 (16.2) | 91 (46.4) | 383 (32.1) |
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Internet verification scaleb, median (IQR) | 3.9 (3.3-4.4) | 3.6 (3.0-4.1) | 3.8 (3.1-4.2) | 3.8 (3.1-4.2) | <.001 |
aOutcome groups: vaccinated for HPV; unvaccinated and did not want or undecided about HPV vaccination; and unvaccinated and wanted HPV vaccination.
bScale: range 0-9; higher value=more internet verification skills used.
Parents who were undecided or did not want their child to be vaccinated were compared to those with a vaccinated child. In the multivariable model (
Parents who wanted their child vaccinated were compared to those who have already vaccinated their child. In the multivariable model, the following characteristic was significantly associated with
Multinomial logistic regression modeling of the human papillomavirus (HPV) vaccine decision-making stage among parents of children and adolescents in the Dallas-Fort Worth area (N=1192).
Characteristic | Unvaccinated and did not want the vaccinea, aORb (95% CI) | Unvaccinated and wanted the vaccinea, aOR (95% CI) | |||||||
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Female | Reference |
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Reference |
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Male | 1.19 (0.87-1.62) | .28 | 0.42 (0.27-0.64) | <.001 | ||||
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18-24 | Reference |
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Reference |
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25-34 | 1.31 (0.51-3.37) | .57 | 1.06 (0.33-3.34) | .93 | ||||
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35-44 | 1.19 (0.49-2.90) | .70 | 0.76 (0.25-2.28) | .62 | ||||
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45-54 | 1.15 (0.46-2.87) | .77 | 0.74 (0.24-2.31) | .61 | ||||
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55-64 | 0.61 (0.22-1.74) | .36 | 1.12 (0.33-3.85) | .86 | ||||
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≥65 | 1.19 (0.20-7.18) | .85 | 1.51 (0.20-11.33) | .69 | ||||
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<11 | 2.38 (1.56-3.63) | <.001 | 3.07 (1.89-5.00) | <.001 | ||||
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11-12 | Reference |
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Reference |
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13-17 | 0.53 (0.37-0.76) | <.001 | 0.34 (0.21-0.54) | <.001 | ||||
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Did not attend college | Reference |
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Reference |
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Some college | 0.82 (0.51-1.32) | .42 | 0.78 (0.42-1.43) | .42 | ||||
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College graduate | 0.65 (0.43-0.98) | .04 | 0.92 (0.55-1.55) | .76 | ||||
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1 | Reference |
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Reference |
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2 | 1.03 (0.75-1.42) | .86 | 1.17 (0.79-1.74) | .43 | ||||
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3 | 1.42 (0.82-2.46) | .21 | 1.11 (0.56-2.22) | .77 | ||||
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4 | 0.88 (0.22-3.47) | .85 | 1.49 (0.39-5.74) | .57 | ||||
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5 | 0.51 (0.18-1.39) | .19 | 0.18 (0.02-1.49) | .11 | ||||
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Trust providers | Reference |
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Reference |
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Distrust providers | 6.37 (3.58-11.32) | <.001 | 1.84 (0.83-4.07) | .13 | ||||
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Urban | Reference |
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Reference |
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Suburban | 1.34 (0.95-1.89) | .10 | 1.17 (0.76-1.80) | .47 | ||||
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Other | 1.30 (0.90-1.89) | .17 | 1.21 (0.76-1.92) | .42 | ||||
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Agree/strongly agree | 0.40 (0.26-0.60) | <.001 | 0.64 (0.40-1.03) | .07 | ||||
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Neutral | Reference |
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Reference |
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Disagree/strongly disagree | 1.90 (1.25-2.87) | .002 | 1.08 (0.65-1.79) | .77 | ||||
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Agree/strongly agree | 0.95 (0.64-1.41) | .80 | 0.41 (0.23-0.74) | .003 | ||||
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Neutral | Reference |
|
Reference |
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Disagree/strongly disagree | 0.22 (0.15-0.33) | <.001 | 0.98 (0.63-1.51) | .92 | ||||
Internet verification scale | 0.74 (0.62-0.88) | .001 | 0.99 (0.80-1.24) | .96 |
aReference group for outcomes: having a child who was vaccinated.
baOR: adjusted odds ratio.
Proportion of participants who report the use of internet verification skills every time/almost all the time by human papillomavirus (HPV) vaccination status among parents of children and adolescents in the Dallas-Fort Worth area (N=1192).
Internet verification skill | Vaccinated (n=533), n (%) | Unvaccinated and wanted the vaccine (n=196), n (%) | Unvaccinated and did not want the vaccine (n=463), n (%) | |
Check if the website information is up to date | 388 (72.8) | 134 (68.4) | 288 (62.2) | .005 |
Check if the website information is complete with all the need-to-know info | 378 (70.9) | 128 (65.3) | 278 (60) | .007 |
Think about whether the writer is giving facts or opinion | 402 (75.4) | 140 (71.4) | 298 (64.4) | <.001 |
Check other places to see if the information is true | 387 (72.6) | 140 (71.4) | 310 (67) | .15 |
Think about why the author posted the information | 297 (55.7) | 95 (48.5) | 208 (44.9) | .003 |
Check to see who wrote the website | 326 (61.2) | 104 (53.1) | 236 (51) | .01 |
Look for recommendations from someone they know | 289 (54.2) | 83 (42.4) | 209 (45.1) | .01 |
Check to see if the website or author gives contact information | 268 (50.3) | 92 (46.9) | 151 (32.6) | <.001 |
Check to see if the author lists their expertise on the topic | 336 (63) | 113 (57.7) | 246 (53.1) | .004 |
Prior to entering a physician’s office, parents may be exposed to information on HPV vaccination via the internet and social media. Although some information may be useful for informed decision-making on HPV vaccination, misinformation also exists [
Parents of vaccinated children and adolescents reported performing more internet verification behaviors compared to parents in the unvaccinated and unwanted group. These behaviors included checking that the website is up to date and has a credible author and cross-checking with other sources. Our finding may explain why parents with a vaccinated child do not question information they see on social media, because they have the internet verification skills to filter through misinformation. Previous research has found that parents desire guidance on how to search and assess the reliability of information found on the internet [
Overall, many people find it difficult to distinguish credible and noncredible information sources [
Provider recommendation and discussion are imperative to HPV vaccine initiation and completion among adolescents [
Perceptions of credibility of social media HPV vaccination information is relevant for parents’ HPV vaccine decisions. Specifically, parents who did not believe that the information they saw on social media is credible were more likely to not want the vaccine. This finding may be attributed to the types of information parents are exposed to on social media. Although information on HPV vaccination on the internet is both positive and negative [
Similarly, parents who did not want the HPV vaccine were less likely to question the vaccine based on exposure to information on social media than the vaccinated group. In contrast, parents who wanted their child vaccinated were less likely to think the information on social media makes them question the HPV vaccine than parents with a vaccinated child. Thus, persons who do not intend to vaccinate their child for HPV may already be exposed to information that confirms their beliefs on vaccination, whereas persons who intend to vaccinate their children may not have enough information to transition to the vaccine decision-making stage. Social media users on Facebook and Twitter are likely to be exposed to like-minded posts via the echo chamber effect [
Finally, another key finding was that parents who did not want their child vaccinated for HPV were more likely to distrust providers than parents who vaccinated their child. Taken in context with other study findings, the parents who do not want their child vaccinated may be going to social media to corroborate their beliefs or are exposed to misinformation on the internet contributing to their beliefs. Studies are needed to experimentally test how exposure to misinformation and correct information on social media influences decisions for vaccination, and how and who is best to intervene in this evolving setting. Ultimately, a segmented approach to vaccine information dissemination is needed to reach different parental groups on the hesitancy spectrum.
These findings should be recognized in the context of study limitations. First, this study was cross-sectional, and we could not assess the temporality between exposure to information on social media, internet verification skills, and the vaccine decision-making stage. As such, respondents may have adopted attitudes that align with their current behavior to reduce cognitive dissonance. Second, these data were derived from a sample in North Texas and may not be generalizable to other US regions. Additionally, HPV vaccination status was self-reported, and misclassification bias for the outcome variable may be present. Finally, these data were collected prior to the COVID-19 pandemic, and perceptions regarding social media and credibility may have shifted. Internet verification skills and strategies, however, could similarly impact COVID-19 vaccine decision-making. These findings could be relevant to apply toward vaccine hesitancy studies about COVID-19.
Although many strategies to promote HPV vaccination have focused on the provider recommendation during a visit, extensive exposure to social media before a visit may inform parents’ beliefs and attitudes toward HPV vaccination and, ultimately, their decision to vaccinate their child. Thus, interventions that promote web-based health literacy skills are needed so that parents can make informed health care decisions with their providers. Social media will remain an ongoing obstacle to evidence-based health information, and public health responses must adapt to this challenge accordingly.
Survey items used in the analysis.
adjusted odds ratio
human papillomavirus
ELT is a consultant with Merck Pharmaceuticals for human papillomavirus (HPV) vaccination work unrelated to this manuscript.