Vacteens.org: A Mobile Web app to Improve HPV Vaccine Uptake

University of New Mexico University of New Mexico

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Pediatrics Research and Scholarship Pediatrics

1-1-2021

Vacteens.org: A Mobile Web app to Improve HPV Vaccine Uptake Vacteens.org: A Mobile Web app to Improve HPV Vaccine Uptake

W Gill Woodall

Gregory Zimet

Alberta Kong

David Buller

Jeannyfer Reither

See next page for additional authors

Follow this and additional works at: https://digitalrepository.unm.edu/peds_pubs

Authors Authors

W Gill Woodall, Gregory Zimet, Alberta Kong, David Buller, Jeannyfer Reither, Lance Chilton, Valerie Myers,

and Randall Starling

BRIEF RESEARCH REPORT

published: 25 August 2021

doi: 10.3389/fdgth.2021.693688

Frontiers in Digital Health | www.frontiersin.org 1 August 2021 | Volume 3 | Article 693688

Edited by:

Suellen Hopfer,

University of California, Irvine,

United States

Reviewed by:

Amaia Mendez Zorrilla,

University of Deusto, Spain

Palash Chandra Banik,

Bangladesh University of Health

Sciences, Bangladesh

Amalie Dyda,

University of Queensland, Australia

*Correspondence:

W. Gill Woodall

[email protected]

†

These authors have contributed

equally to this work

Specialty section:

This article was submitted to

Connected Health,

a section of the journal

Frontiers in Digital Health

Received: 11 April 2021

Accepted: 19 July 2021

Published: 25 August 2021

Citation:

Woodall WG, Zimet G, Kong A,

Buller D, Reither J, Chilton L, Myers V

and Starling R (2021) Vacteens.org: A

Mobile Web app to Improve HPV

Vaccine Uptake.

Front. Digit. Health 3:693688.

doi: 10.3389/fdgth.2021.693688

Vacteens.org: A Mobile Web app to

Improve HPV Vaccine Uptake

W. Gill Woodall

, Gregory Zimet

2†

, Alberta Kong

3†

, David Buller

1†

, Jeannyfer Reither

Lance Chilton

, Valerie Myers

and Randall Starling

Klein Buendel Inc., Golden, CO, United States,

Division of Adolescent Medicine, Department of Pediatrics, Indiana

University-Purdue University Indianapolis (IUPUI) Center for HPV Research, Indiana University, Indianapolis, IN, United States,

Department of Pediatrics, The University of New Mexico Health Sciences Center, Albuquerque, NM, United States,

Center

on Alcohol, Substance Use and Addictions (CASAA), The University of New Mexico, Albuquerque, NM, United States

U.S. HPV vaccine uptake remains below the Healthy People 2030 goal of 80% series

completion. Parental concerns and misinformation about the efﬁcacy and safety of

the Human Papillomavirus (HPV) vaccine remain, and may be addressed by digital

interventions tailored to their concerns. Reported here are results from a small scale

randomized trial testing a mobile web app for parents and their adolescent daughters

(ages 11–14 years) encouraging HPV vaccination in New Mexico, an ethnically-diverse

U.S. state.

Methods: A clinic-cluster randomized t ria l where pediatric clinics (n = 9) were recruited

and randomized, and parent-adolescent pairs (n = 82) within clinics received either the

Vacteens.org/Vacunadolescente.org mobile web app or Usual and Customary (UC) HPV

Vaccination information. Parents completed online surveys at baseline and 3-months.

Daughters’ HPV vaccine data were collected from the New Mexico State Immunization

Information System 1 year post baseline.

Results: Three month survey results found Vacteens.org/Vacunadolescente.org

parents to have higher positive HPV vaccine beliefs, informed decision making,

intent to vaccinate and vaccine conﬁdence outcomes than UC parents. HPV

vaccine data found higher ﬁrst dose HPV vaccination (Pearson χ

= 6.13,

p = 0.013, Vacteens.org/Vacunadolescente.org group 59.4%, UC group 40.6%),

and higher HPV vaccination series completion (Pear son χ

= 6.49, p = 0.011,

Vacteens.org/Vacunadolescente.org group 68.4%, UC group 31.6%).

Conclusions: The small trial results showed the Vacteens.org/Vacunadolescente.org

web app prompted positive vaccine-related attitudes and beliefs, a nd more HPV

vaccination initiation and series completion. Mobile web apps can make decision-making

tools for HPV vaccination widely available on digital platforms, reducing v ac cine

hesitancy, and confusion and increase HPV vaccine uptake.

Keywords: HPV, vaccination uptake, digital intervention, adolescents, parents

Woodall et al. Vacteens.org

INTRODUCTION

In the U.S. uptake of Human Papillomavirus (HPV) vaccine

remains far below the Healthy People 2030 goal of 80% series

completion (1). Nationally, 54.2% of adolescents aged 13–17

were up-to-date for the Human Papillomavirus (HPV) vaccine

in 2019 [females 56.8%; males: 51.8% (

2)]. In New Mexico, HPV

vaccination completion for this adolescent age range also remains

low (59.8%).

While a number of factors may account for this less than

desirable vaccine uptake, parental concerns, and misinformation

about the eﬃcacy and safety of HPV vaccine remain b arriers

to reaching public health vaccination goals (1, 2). Vaccine

initiation is aﬀected by hea lth beliefs (e.g., vaccine knowledge;

importance of preventive vaccinations; side eﬀects concerns),

while vaccine completion [2 doses if started by age 14; 3

doses if after age 15 (3)] is aﬀected both by logistical barriers

(e.g., forgetting; scheduling diﬃculties; child care; travel time;

physician hesitancy) and health beliefs (

4–10). Health beliefs are

amenable to health education interventions. Research indicates

there is a great deal of (1) confusion and uncertainty about

HPV vaccine and (2) concomitant misinformation about HPV

vaccine, who it is meant for, and the conditions under which it is

maximally eﬀe ct ive.

Identifying eﬀective strategies to improve HPV vaccination

rates is a priority for the Centers for Disease Control and

Prevention (CDC) (11) and the World Health Organization

(WHO) (12). Physician and clinic-based interventions have

shown some positive eﬀect on vaccine uptake (13–15), however

parental concerns and hesitancy remain barriers to HPV vaccine

acceptance. Given that clinicians have limited time to interact

with parents during primary care pediatric and adolescent visits,

parental barriers to HPV vaccination may ideally be addressed

by digital inte rventions (in this c ase, smartphone applications)

that are tailored to their concerns, especially since virtually all

U.S. adults under age 50 use the Internet (

16). As of 2019, there

were few diﬀerences in Internet use by gender, ethnicity, or

urban/rural status, with use exceeding 85% in all groups. Nearly

1 in 5 adults under age 50 of both genders use their smartphone

for online access, with Hispanics and rural adults showing the

highest use of this cellular Internet access (16).

Reported here are ﬁndings from a randomized trial on a

smartphone web app for parents and adolescent girls (ages 11–

14) that was intended to encourage HPV vaccination in New

Mexico, an ethnically-diverse U.S. state. The trial tested the

following hypot heses:

H1: Parents assigned to the Vacteen/Vacunadolescente mobile

web app will express more favorable HPV vaccine beliefs,

informed decision making, intent to vaccinate for HPV, self-

eﬃcacy for HPV vaccination, and beneﬁts and risks of HPV

vaccination for their daughters than parents assigned to the Usual

and Customary (UC) Information control group.

H2: More daughters of parents assigned to the

Vacteen/Vacunadolescente mobile web app will initiate and

complete the HPV vaccination series than daughters of parents

assigned to the UC Information control group.

MATERIALS AND METHODS

Vacteens/Vacunadolescente Mobile Web

app

The current project translated an earlier version of the

website (the GoHealthyGirls website) to a mobile app platform,

Vacteens/Vacunadolescente.org, and provided both English and

Spanish versions. Mobile web apps are mobile device sensitive

web sites designed to function like native operating system

(Android or iOS) apps, but avoid the problems of operating

system exclusivity. They maintain app functionality across

mobile platforms, and are more easily updatable should that be

required. The web app developed in this project was an informed

decision-making website for parents and adolescent daughters

(ages 11–14) that employed both Informed Decision Making

[IDM, (

17)] and Diﬀusion of Innovations Theory [DOI, (18)]

principles in messaging. Informed Decision Making theoretical

principles indicate focusing on beliefs and attitudes parents

hold t hat constitute barriers to vaccination, often based on

misinformation, is important for vaccination messaging. At the

same time, DOI theory suggests that treating vaccination as an

innovation is useful, and messaging on the simple, compatible

with beliefs, and trialable characteristics of HPV vaccination will

improve vaccine adoption. The website was programmed as a

web app for mobile devices with open non-linear navigation.

It had a video introduction by a well-known New Mexican

pediatrics ph ysici an, a Vaccine FAQ section, and ﬁve modules:

(

1) Get Answers! about HPV and vaccines, risks and side eﬀe cts

of the vaccine, risks of HPV, beneﬁts of HPV vaccination and

organizations recommending HPV vaccination; This module

addressed the concerns and misinformation parents have about

the HPV vaccine. (2) Let’s Talk on the communication process

around vaccination, including a video simulation on how to

talk with your daughter about HPV vaccination, guidelines for

talking to family members and physician about HPV vaccination;

This module provides communication examples to be modeled

by parents discussing vaccination with their daughters, and

suggestions for discussions with other family members and the

health care provider. (3) Vaccine How-To with instructions for

making an HPV vaccination appointment; This module contains

location and appointment tools for getting vaccinated that

parents and teens can use for vaccination action plans. (4) Teen

Tools with interactive games for teens, i.e., HPV Challenge Quiz,

and HPV Myth vs. Truth swiping game; This module contains

interactive and engaging activities for both teens and parents, all

focused on providing accurate and motivating information about

the HPV vaccine. (5) We’re Ready providing email and texting

HPV vaccination reminder systems to promote completion of

the vaccination series, accessible from any page in the web app.

This module provides notiﬁcation and reminder tools for the

second and possible third dose of the HPV vaccine. While the

predominant messaging in the web app was focused on parents,

their daughters also had speciﬁc content for their use (Teen

Tools). Overall, the web app content and language were designed

to encourage both parent and adolescent use, both separately

and together.

Frontiers in Digital Health | www.frontiersin.org 2 August 2021 | Volume 3 | Article 693688

Woodall et al. Vacteens.org

Development of the Vacteens/Vacunadolescente

Web app

The Vacteens/Vacunadolescente web app was systematically

developed through developmental research. The GoHealthyGirls

project (funded by the National Institute of Allergy and

Infectious Diseases—U19 AI084081) employed DOI and related

IDM research to guide the iterative development of a website

for parents of young female adolescent daughters (ages 11–

14). It was systematically developed via parent and adolescent

focus groups, navigability and usability tests (

19), and a

beta test with an ethnically-diverse sample of parents and

daughters in New Mexico (20 ). Results indicated the website

to be easy and enjoyable to use and had clear impact on

theoretical antecedents to HPV vaccine uptake (e.g., attitudes,

risk perceptions, consequences, self-eﬃcacy, and intent to get

daughter vaccinated).

Clinic-Cluster Randomized Trial

A clinic-cluster randomized trial was conducted in New Mexico.

Pediatric clinics (N = 9) were recruited and randomized to

receive either the Vacteens/Vacunadolescente.org web app (n = 5)

or the Usual and Customary (UC) HPV vaccination information

(n = 4) available from the Centers for Disease Control and

Prevention (CDC) online. Clinics were randomized before

recruitment of parents and daugh ters, but physicians and clinic

staﬀ were kept blind to treatment assignment. Parents were

recruited from clinics by project staﬀ via telephone contact.

Inclusion c riteria for the trial were to be parents of an 11– 14

year old daughter who had not yet received HPV vaccination.

Exclusion from the trial was to have had the parent’s daughter

already vaccinated for HPV. Participants were qualiﬁed and

registered for the project on a project registration website and

provided online informed consent, daughter assent, and HIPAA

waiver to access daughter vaccination records from the New

Mexico State Immunization Information System (NM-SIIS).

All project procedures were reviewed and approved by the

University of New Mexico Main Campus Institutional Review

Board. Parents of daughters aged 11–14 and the daughters

themselves were recruited from participating pediatric clinics

(N = 82 parent-daughter pairs). Parents were assessed via

online survey at baseline and 3-month post-baseline assessments.

Once parents were qualiﬁed, consented and registered for

the project, and had completed the baseline assessment (see

Parent Surveys on Antecedents to Vaccination), based on their

clinic randomization, t hey were provided a link to either the

Vacteens/Vacunadolescente.org web app or the UC CDC web link.

These links remained active for the year-long project for parents

and their adolescents to browse. HPV Vaccine uptake data

available from NM-SIIS for daughters of participating parents

were colle ct ed at 1-year post-baseline.

Parent Surveys on Antecedents to

Vaccination

Parents were assessed by online surveys via QuestionPro survey

software at baseline and 3-month assessment points. The surveys

measured participants’ demographic characteristics (gender,

age, race/ethnicity, language preference, educational level, and

sociodemographic status), and HPV related variables, including:

HPV knowledge [Cronbach’s α = 0.60 (

21)], HPV vaccine

attitudes, e.g., “It is important to get vaccines because they

prevent disease,” [α = 0.89 (22, 23)], perceived daughters’ risk

of HPV, e.g., “Infection with HPV can lead to serious illness,” [α

= 0.73 (

19, 23)], beliefs about HPV and HPV vaccination, e.g.,

“The HPV vaccine is eﬀective at preventing cervical cancer,” [α

= 0.91 (24)], intention to have daughter vaccinated (single item),

“If you were asked to make a decision right now about getting

your da ughter her ﬁrst HPV shot, what would you decide?,”

HPV informed decision making, e.g., “I know which options are

available to me regarding the HPV vaccine [α = 0.98 (25)].

Vaccination Records

Vaccination records were acquired by matching parent

identiﬁcation information to the NM-SIIS database. Record

acquisition was performed by an honest broker, who was blind to

clinic and parent randomization status. Participants’ parents last

name, adolescents last name, ﬁrst name and birthdate were used

as matching variables in vaccination record acquisition. First and

second shot completion data were recorded from participant

daughters’ records.

Data Analysis

Statistical analyses were conducted with SPSS ver. 27. Both

descriptive statistics and inferential tests for group diﬀerences

were calculated. To evaluate diﬀerences in vaccine beliefs and

attitudes, one-tailed t-tests were used. We chose to use one-

tailed tests because our hypotheses were directional and a

less conservative approach to analysis was believed to be

appropriate for this relatively small sample evaluation [cf. Kirk

(

26)]. The eﬀect of intervention group on HPV vaccine uptake

was determined via non-parametric Chi-Square analyses, as

recommended by Williams and Monge (27). Analyses were

conducted on an unadjusted for clinic cluster eﬀects basis after

determining the Intraclass Correlation (ICC) within clinics for

participant b aseline HPV knowledge variables was near zero.

RESULTS

Participants

Parent participants (N = 82) were 92.5% female, 38.5%

Hispanic, 6.2% American Indian/Native Alaskan, 1.2% Asian,

and 37. 8% Caucasian, with 12.3% unspeciﬁed and 3.7% missing

information. The average age of parent participants was 38.96

years (SD = 9.64), and average age of daughter participants

was 12.05 years (SD = 1.08). Educational attainment was 3.8%

11th grade or less, 33. 8% high school diploma or G.E.D., 25.0%

Associates degree, 18.8% Bachelor’s degree, 8.8% Masters degree,

1.3% Doctorate degree, and 7.5% Other Professional degrees.

Language preference for parent participants was 96.3% English,

with 16.3% additionally speaking Spanish, and 6.3% additionally

speaking a Trib al Language.

Hypothesis 1: Vaccine Antecedents

Three-month follow-up surveys were completed by 38% (n = 31)

of the study sample. The remainder of the participants were not

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Woodall et al. Vacteens.org

available to be surveyed due to early termination of the trial by

the funding agency. A review of all baseline participants found

no statistically signiﬁcant diﬀerences (Pearsons χ

-tests) in

demographics between participants who did and did not respond

to 3-month assessments. Analyses of the available 3-month

assessment data for parents found several statistically-signiﬁca nt

diﬀerences between the Vacteens.org/Vacunadolescente and UC

Information participants. Planned t-tests (p < 0.05, one-tailed,

df = 31) reve aled signiﬁcant between group diﬀerences in the

predicted direction for HPV vaccine beliefs [t

(31)

= 3.87, p =

0.001]; Informed Decision Making [t

(31)

= 4.29, p = 0.047];

parents in the Vacteens.org/Vacunadolescente were also more

likely to intend to vaccinate their d aughters right away than later

or not at all (Pearson χ

= 5.70, p = 0.05. Cohen’s d = 0.94, OR =

6.23). In addition, parents in the Vacteens.org/Vacunadolescente

group were signiﬁcantly more conﬁdent about their vaccination

choices (Informed Decision Making; Pearson χ

= 4.28, p = 0.03,

d = 0.80, OR = 4.92), and a trend toward being more aware of the

beneﬁts and risks of vaccination (Pearson χ

= 2.97, p = 0.08).

Hypothesis 2: Vaccination Outcomes

HPV vaccine upta ke data from the NM-SIIS database was

obtained for all daughters of parents enrolled in the trial

(n = 82). A review of ﬁrst shot date and date of entry

into the study determined that some daughters (n = 13)

had received their initial HPV vaccinations prior to study,

and thus were not qualiﬁed to participate. Data for these

cases were excluded from the analysis; exclusion occurred

equally from the Vacteens.org/Vacunadolescente (n = 7) and

UC Information (n = 6) groups, leaving a ﬁnal N =

69 for analysis. Analyses of ﬁrst dose data revealed a

signiﬁcant treatment group diﬀerence (Pearson χ

= 6.13,

p = 0.013, d = 0.62, OR = 3.45), such that rate of

HPV vaccination initiation in t he Vacteens.org/Vacunadolescente

condition (59.4%) was 18.8% higher than the UC Information

condition (40.6%). Further, HPV vaccination series completion

in the Vacteens.org/Vacunadolescente group was statistically-

signiﬁcantly higher (Pearson χ

= 6.49, p = 0.011, d = 0.64, OR

= 4.53) (68.4%) compared to the UC group (31.6%), an absolute

increase of 36.8%.

DISCUSSION

The results of this trial indicated that the

Vacteens.org/Vacunadolescente mobile web app bolstered

parents’ positive HPV vaccine beliefs, Informed Decision

Making, and intentions to vaccinate, and most importantly led

to higher levels of vaccine initiation (i.e., ﬁrst dose) and series

completion (i.e., se cond dose). The small sample of parent-

daughter pairs may limit conﬁdence in the outcome, but the

eﬀect sizes and odds ratios are in the moderate range, suggesting

a substantial eﬀect of the Vacteens.org/Vacunadolescente web app

that would potentially make large in-roads into vaccine uptak e

when distributed widely.

There are a number of implications that the study results

suggest for deploying the Vacteens.org/ Vacunadolescente mobile

web app. First, it could be used in conjunction with a pediatric

clinic practice, where physicians recommend use of the mobile

web app prior to well-child visits, sports physicals, or vaccination

appointments. Parents who browse the app may make informed

decisions about vaccination before the visit and be ready for

vaccine initiation, saving valuable time in the doctor-patient

interaction, time that is alrea dy at a premium. It also may make

it more comfortable for providers to talk with parents about

HPV vaccination, knowing that the topic was already presented

and many of parents’ concerns were covered in the mobile web

app. Further, tools provided in t h e Vacteens.org/Vacunadolescente

mobile web app, like the text and email follow-up reminders,

could make vaccine dose completion more likely, as our data

show. Thus, in combination with presumptive recommendations

(

13) by pediatricians for HPV vaccination and other clinic-

based techniques, the use of Vacteens.org/Vacunadolescente might

substantially improve vaccine uptake in this age range during

clinical encounters.

A second possibility is that the Vacteens.org/Vacunadolescente

mobile web app could be used by parents independent of

medical clinics. Many vaccinations of all kinds now occur

outside of pediatric or other medical practices in, for example,

pharmacies oriented to vaccine provision. This lessens the

reliance on pediatricians and other medical providers for advice

and recommend at ion for the HPV vaccination, and for vaccine

provision. Other entities involved in vaccination, such as state

health departments, school health oﬃcials, and pharmacy chains,

could promote the use of the Vacteens.org/Vacunadolescente

mobile web app to increase HPV vaccination initiation and

completion at whatever provider to which parents have access

in communities. Further, parents of adolescents in this age

range are often excessively busy, leading to a drop in the

frequency of having their child seen by a pediatrician or

medical professional, often limited to as little as once a

year for a well-child checkup prior to the start of the

school year. Again, these factors may make the use of

Vacteens.org/Vacunadolescente mobile web app outside of the

clinic viable as a way to support and promote vaccination

independent of clinical practice.

The present investigation carries some limitations. The small

sample size is a limitation, and furt her research will be needed

to conﬁrm the impact of the web app on vaccine uptake

and related variables. The ﬁndings are also limited to young

adolescent girls ages 11– 14, even though HPV vaccination is

recommended for boys. We are currently conducting a trial

with a version of the web app tailored to parents of young

male adolescents in the same 11–14 years of age. The loss

of some parents due to already having had their daughter

vaccinated, is of some concern; however, the results remained

statistically signiﬁcant with moderate eﬀect size. It seems that

some parents were simply not sure as to whethe r they had their

daughter vaccinated for HPV. Paper-based methods for tracking

vaccination, especially in adolescence, are now rarely used, and

parents may lose track of vaccination instances. Currently, the

New Mexico Department of Health provides an online portal

where parents can search for their child’s vaccination record

(a number of states have begun to adopt this technology),

but parents may be unaware of th is resource. The loss of a

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Woodall et al. Vacteens.org

substantial amount of 3-month follow-up survey data due to trial

termination by the funding agency is a limitation to the study.

The loss of these data certainly limits conclusions available from

the study survey analyses. In retrospect, the trial termination

(due to insuﬃcient progress in clinic recruitment) is regrettable

given the promising data that the investigation was able to

obtain. The loc a tion of the trial in New Mexico may limit its

generalizability due to it s ethnic mix, containing predominately

Hispanic and Native American minority participants. Whether

the mobile web app would be just as eﬀective with African

American parents or other minority group parents is unknown.

A ﬁnal limitation is the young age of the sample (11–14 years).

HPV vaccination is recommended for individuals up to age 26

and we cannot be certain that the Vacteens.org/Vacunadolescente

mobile web app would convince parents of older daughters

(those ages 16+) to seek the HPV vaccine for them. The

Vacteens.org/Vacunadolescente web app focused its messaging

on t his younger 11–14 years age range, and parents of

older teens (females and males) may need somewhat diﬀerent

messaging that is sensitive to older teens having more agency in

vaccination decisions.

The results of this investigation suggest that mobile web

app technology, systematically developed for ease and

convenience of use on mobile and other computing devices

and guided by DOI and IDM theories of health behavior, that

communicates about parents’ concerns, lack of information, and

misinformation parents hold regarding the HPV vaccination,

can substantially improve HPV vaccine uptake. A recent

review of social media and mobile technology interventions

to improve HPV vaccine uptake (

28) indicates that text

message, e-mail, phone contact and social media groups can

improve HPV vaccine uptake. This investigation a dds mobile

web applications to the list of digital techniques for vaccine

uptake improvement. To prevent a variety of HPV-related

cancers, the use of digital communication outside clinics for

promoting HPV vaccination is well worth considering, especially

as many parents’ lives are replete with digital messaging and

mobile devices.

DATA AVAILABILITY STATEMENT

The raw de-identiﬁed data supporting the conclusions of

this article will be made available by the authors, without

undue reservation.

ETHICS STATEMENT

The studies involving human participants were reviewed

and approved by University of New Mexico Main Campus

Institutional Review Board. Written informed consent to

participate in this study was provided by a dult participants, and

adolescent assent was provided by adolescent participants’ legal

guardian/next of kin.

AUTHOR CONTRIBUTIONS

WW oversaw research project in all aspects, conducted data

analysis, and major amount of manuscript writing. GZ was

involved in message construction, measurement, and manuscript

writing. AK was involved in message construction, clinic

recruitment, and manuscript writing. DB was involved in

message construction, web app deve lopment, testing, and

manuscript writing. JR was message language translation and web

app development. LC was involved in clinic recruitment, message

construction, and vaccine data. VM was involved in message

development and measure assessment. RS was involved in clinic

recruitment. All authors contributed to the article and approved

the submitted version.

FUNDING

This project was supported by a grant from the Patient-Centered

Outcomes Research Institute (PCORI), Award #1511-33018.

ACKNOWLEDGMENTS

The aut hors would like to acknowledge the work and support of

Ms. Lila Martinez, Ms. Marita Brooks, and Mr. Leonel Diaz.

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Conﬂict of Interest: WW, DB, JR, and VM were employed by company Klein

Buendel Inc.

Outside of the present work GZ has served as an external advisory board

member for Merck and Moderna and as a consultant to Merck. In addition, he has

received investigator-initiated research funding from Merck administered through

Indiana University.

The remaining authors declare that the research was conducted in the absence of

any commercial or ﬁnancial relationships t hat could be construed as a potential

conﬂict of interest.

Publisher’s Note: All claims expressed in this article are solely those of the authors

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the publisher, the editors and the reviewers. Any product that may be evaluated in

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Starling. This is an open-access article distributed under the terms of the Creative

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