Human papillomavirus vaccine delivery strategies that achieved high coverage in low- and middle-income countries

Factors influencing completion of multi-dose vaccine schedules in adolescents: a systematic review

BACKGROUND

Completion of multiple dose vaccine schedules is crucial to ensure a protective immune response, and maximise vaccine cost-effectiveness. While barriers and facilitators to vaccine uptake have recently been reviewed, there is no comprehensive review of factors influencing subsequent adherence or completion, which is key to achieving vaccine effectiveness. This study identifies and summarises the literature on factors affecting completion of multi-dose vaccine schedules by adolescents.

METHODS

Ten online databases and four websites were searched (February 2014). Studies with analysis of factors predicting completion of multi-dose vaccines were included. Study participants within 9-19 years of age were included in the review. The defined outcome was completion of the vaccine series within 1 year among those who received the first dose.

RESULTS

Overall, 6159 abstracts were screened, and 502 full texts were reviewed. Sixty one studies were eligible for this review. All except two were set in high-income countries. Included studies evaluated human papillomavirus vaccine, hepatitis A, hepatitis B, and varicella vaccines. Reported vaccine completion rates, among those who initiated vaccination, ranged from 27% to over 90%. Minority racial or ethnic groups and inadequate health insurance coverage were risk factors for low completion, irrespective of initiation rates. Parental healthcare seeking behaviour was positively associated with completion. Vaccine delivery in schools was associated with higher completion than delivery in the community or health facilities. Gender, prior healthcare use and socio-economic status rarely remained significant risks or protective factors in multivariate analysis.

CONCLUSIONS

Almost all studies investigating factors affecting completion have been carried out in developed countries and investigate a limited range of variables. Increased understanding of barriers to completion in adolescents will be invaluable to future new vaccine introductions and the further development of an adolescent health platform. PROSPERO reg# CRD42014006765.

Global Delivery of Human Papillomavirus Vaccines

Worldwide, cervical cancer is the fourth most common cancer among women. Human papillomavirus (HPV) vaccination, if broadly implemented, has the potential to significantly reduce global rates of morbidity and mortality associated with cervical and other HPV-related cancers. More than 100 countries around the world have licensed HPV vaccines. As of February, 2015, there were an estimated 80 national HPV immunization programs and 37 pilot programs. This article discusses global implementation of HPV vaccination programs and issues such as vaccine financing and different approaches to HPV vaccine delivery.

Feasibility and acceptability of delivering adolescent health interventions alongside HPV vaccination in Tanzania

BACKGROUND

Human papillomavirus (HPV) vaccination offers an opportunity to strengthen provision of adolescent health interventions (AHI). We explored the feasibility of integrating other AHI with HPV vaccination in Tanzania.

METHODS

A desk review of 39 policy documents was preceded by a stakeholder meeting with 38 policy makers and partners. Eighteen key informant interviews (KIIs) with health and education policy makers and district officials were conducted to further explore perceptions of current programs, priorities and AHI that might be suitable for integration with HPV vaccination.

RESULTS

Fourteen school health interventions (SHI) or AHI are currently being implemented by the Government of Tanzania. Most are delivered as vertical programmes. Coverage of current programs is not universal, and is limited by financial, human resource and logistic constraints. Limited community engagement, rumours, and lack of strategic advocacy has affected uptake of some interventions, e.g. tetanus toxoid (TT) immunization. Stakeholder and KI perceptions and opinions were limited by a lack of experience with integrated delivery and AHI that were outside an individual's area of expertise and experience. Deworming and educational sessions including reproductive health education were the most frequently mentioned interventions that respondents considered suitable for integrated delivery with HPV vaccine.

CONCLUSIONS

Given programme constraints, limited experience with integrated delivery and concern about real or perceived side-effects being attributed to the vaccine, it will be very important to pilot-test integration of AHI/SHI with HPV vaccination. Selected interventions will need to be simple and quick to deliver since health workers are likely to face significant logistic and time constraints during vaccination visits.

Cervical cancer screening in developing countries at a crossroad: Emerging technologies and policy choices

Cervical cancer (CC) represents the fourth most common malignancy affecting women all over the world and is the second most common in developing areas. In these areas, the burden from disease remains important because of the difficulty in implementing cytology-based screening programmes. The main obstacles inherent to these countries are poverty and a lack of healthcare infrastructures and trained practitioners. With the availability of new technologies, researchers have attempted to find new strategies that are adapted to low- and middle-income countries (LMIC) to promote early diagnosis of cervical pathology. Current evidence suggests that human papillomavirus (HPV) testing is more effective than cytology for CC screening. Therefore, highly sensitive tests have now been developed for primary screening. Rapid molecular methods for detecting HPV DNA have only recently been commercially available. This constitutes a milestone in CC screening in low-resource settings because it may help overcome the great majority of obstacles inherent to previous screening programmes. Despite several advantages, HPV-based screening has a low positive predictive value for CC, so that HPV-positive women need to be triaged with further testing to determine optimal management. Visual inspection tests, cytology and novel biomarkers are some options. In this review, we provide an overview of current and emerging screening approaches for CC. In particular, we discuss the challenge of implementing an efficient cervical screening adapted to LMIC and the opportunity to introduce primary HPV-based screening with the availability of point-of-care (POC) HPV testing. The most adapted screening strategy to LMIC is still a work in progress, but we have reasons to believe that POC HPV testing makes part of the future strategies in association with a triage test that still needs to be defined.

Microneedle patches for vaccination in developing countries

Millions of people die of infectious diseases each year, mostly in developing countries, which could largely be prevented by the use of vaccines. While immunization rates have risen since the introduction of the Expanded Program on Immunization (EPI), there remain major challenges to more effective vaccination in developing countries. As a possible solution, microneedle patches containing an array of micron-sized needles on an adhesive backing have been developed to be used for vaccine delivery to the skin. These microneedle patches can be easily and painlessly applied by pressing against the skin and, in some designs, do not leave behind sharps waste. The patches are single-dose, do not require reconstitution, are easy to administer, have reduced size to simplify storage, transportation and waste disposal, and offer the possibility of improved vaccine immunogenicity, dose sparing and thermostability. This review summarizes vaccination challenges in developing countries and discusses advantages that microneedle patches offer for vaccination to address these challenges. We conclude that microneedle patches offer a powerful new technology that can enable more effective vaccination in developing countries.

Implementation of an HPV vaccination program in Eldoret, Kenya: results from a qualitative assessment by key stakeholders

BACKGROUND

Cervical cancer strikes hard in low-resource regions yet primary prevention is still rare. Pilot projects have however showed that Human Papillomavirus (HPV) vaccination programs can attain high uptake. Nevertheless, a study accompanying a vaccination demonstration project in Eldoret, Kenya, revealed less encouraging outcomes: uptake during an initial phase targeting ten schools (i.e., 4000 eligible girls), was low and more schools had to be included to reach the proposed number of 3000 vaccinated girls. The previously conducted study also revealed that many mothers had not received promotional information which had to reach them through schools: teachers were sensitized by health staff and asked to invite students and parents for HPV vaccination in the referral hospital. In this qualitative study, we investigate factors that hampered promotion and vaccine uptake.

METHODS

Focus group discussions (FGD) with teachers (4) and fathers (3) were organized to assess awareness and attitudes towards the vaccination program, cervical cancer and the HPV vaccine, as well as a FGD with the vaccinators (1) to discuss the course of the program and potential improvements. Discussions were recorded, transcribed, translated, and analyzed using thematic analysis In addition, a meeting with the program coordinator was set up to reflect upon the program and the results of the FGD, and to formulate recommendations for future programs.

RESULTS

Cervical cancer was poorly understood by fathers and teachers and mainly linked with nonconforming sexual behavior and modern lifestyle. Few had heard about the vaccination opportunity: feeling uncomfortable to discuss cervical cancer and not considering it as important had hampered information flow. Teachers requested more support from health staff to address unexpected questions from parents. Non-uptake was also the result of distrust towards new vaccines. Schools entering the program in the second phase reacted faster: they were better organized, e.g., in terms of transport, while the community was already more familiarized with the vaccine.

CONCLUSIONS

Close collaboration between teachers and health staff is crucial to obtain high HPV vaccine uptake among schoolgirls. Promotional messages should, besides providing correct information, tackle misbeliefs, address stigma and stress the priority to vaccinate all, regardless of lifestyle. Monitoring activities and continuous communication could allow for detection of rumors and unequal uptake in the community.

Knowledge on HPV Vaccine and Cervical Cancer Facilitates Vaccine Acceptability among School Teachers in Kitui County, Kenya

BACKGROUND

Vaccines against human papillomavirus (HPV) infection have the potential to reduce the burden of cervical cancer. School-based delivery of HPV vaccines is cost-effective and successful uptake depends on school teachers' knowledge and acceptability of the vaccine. The aim of this study is to assess primary school teachers' knowledge and acceptability of HPV vaccine and to explore facilitators and barriers of an ongoing Gavi Alliance-supported vaccination program in Kitui County, Kenya.

METHODS

This was a cross-sectional, mixed methods study in Central Division of Kitui County where the Ministry of Health is offering the quadrivalent HPV vaccine to grade four girls. Data on primary school teachers' awareness, knowledge and acceptability of HPV vaccine as well as facilitators and barriers to the project was collected through self-administered questionnaires and two focus group discussions.

RESULTS

339 teachers (60% female) completed the survey (62% response rate) and 13 participated in 2 focus group discussions. Vaccine awareness among teachers was high (90%), the level of knowledge about HPV and cervical cancer among teachers was moderate (48%, SD = 10.9) and females scored higher than males (50% vs. 46%, p = 0.002). Most teachers (89%) would recommend the vaccine to their daughter or close relatives. Those who would recommend the vaccine had more knowledge than those who would not (p = <0.001). The main barriers were insufficient information about the vaccine, poor accessibility of schools, absenteeism of girls on vaccine days, and fear of side effects.

CONCLUSIONS

Despite low to moderate levels of knowledge about HPV vaccine among school teachers, vaccine acceptability is high. Teachers with little knowledge on HPV vaccine are less likely to accept the vaccine than those who know more; this may affect uptake if not addressed. Empowering teachers to be vaccine champions in their community may be a feasible way of disseminating information about HPV vaccine and cervical cancer.

HPV prophylactic vaccines: lessons learned from 10 years experience

When HPV vaccines were registered in 2006/2007, it was unclear whether these new and type-specific prophylactic vaccines would be accepted by the community for cancer prevention. With an optimal vaccination age of early adolescence, three vaccine doses required, HPV a sexually transmitted infection, and secondary prevention already available in the form of cervical screening, considerable potential challenges were faced. At the time of licensing, vaccine efficacy in males and duration of immunity were not yet unknown. Almost a decade later, with over 230 million doses of the vaccines distributed worldwide and national HPV vaccination programs in place in many countries, it is timely to reflect on current knowledge about the vaccines and some of the lessons learned during implementation.

Underutilization of cervical cancer prevention services in low and middle income countries: a review of contributing factors

This review aims at identifying barriers to utilization of cervical cancer prevention services in low- and middle-income countries. An electronic search was conducted using the following key words, HPV vaccination, screening, barriers, utilization and low and middle income/developed countries. Using the Garrard (1999) Matrix method approach, a modified matrix was designed and used as a data collection tool and data related to each category listed on the tool were entered into a matrix containing columns reflecting the categories. Constant comparative analysis was used to identify thematic categories. 31 articles published between 2001 and 2014 were yielded from the search. Analysis of the contents of the articles showed that the underutilization of cervical cancer screening services in low and middle-income countries is the result of barriers in accessing and utilizing of the prevention services. Though not mutually exclusive, the barriers were categorized in three categories; individual, community and health system related. Individual barriers include lack of awareness and knowledge about risk factors and prevention of cervical cancer. Age, marital status, diffidence, social economic status, cultural and religious belief of the women also determine the women's' willingness to utilize the services. In some communities there is stigma attached to discussing reproductive health issues and this limits the young women's awareness of cervical cancer and its prevention. Understanding individual, community and health system barriers that hinder women's utilization of cervical cancer prevention services is very crucial in designing effective cervical cancer control programs in low- and middle-income countries.

The value of male human papillomavirus vaccination in preventing cervical cancer and genital warts in a low-resource setting

OBJECTIVE

To estimate health benefits and incremental cost-effectiveness of human papillomavirus (HPV) vaccination of pre-adolescent boys and girls compared with girls alone for preventing cervical cancer and genital warts.

DESIGN

Model-based economic evaluation.

SETTING

Southern Vietnam.

POPULATION

Males and females aged ≥9 years.

METHODS

We simulated dynamic HPV transmission to estimate cervical cancer and genital warts cases. Models were calibrated to epidemiological data from south Vietnam.

MAIN OUTCOME MEASURES

Incremental cost-effectiveness ratios (ICERs): cost per quality-adjusted life-year (QALY).

RESULTS

Vaccinating girls alone was associated with reductions in lifetime cervical cancer risk ranging from 20 to 56.9% as coverage varied from 25 to 90%. Adding boys to the vaccination programme yielded marginal incremental benefits (≤3.6% higher absolute cervical cancer risk reduction), compared with vaccinating girls alone at all coverages. At ≤25 international dollars (I$) per vaccinated adolescent (I$5 per dose), HPV vaccination of boys was below the threshold of Vietnam's per-capita GDP (I$2800), with ICERs ranging from I$734 per QALY at 25% coverage to I$2064 per QALY for 90% coverage. Including health benefits from averting genital warts yielded more favourable ICERs, and vaccination of boys at I$10/dose became cost-effective at or below 75% coverage. Using a lower cost-effectiveness threshold of 50% of Vietnam's GDP (I$1400), vaccinating boys was no longer attractive at costs above I$5 per dose regardless of coverage.

CONCLUSION

Vaccination of boys may be cost-effective at low vaccine costs, but provides little benefit over vaccinating girls only. Focusing on achieving high vaccine coverage of girls may be more efficient for southern Vietnam and similar low-resource settings.

TWEETABLE ABSTRACT

Limited cervical cancer reduction from including boys in HPV vaccination of girls in low-resource settings.

Access and Attitudes to HPV Vaccination amongst Hard-To-Reach Populations in Kenya

Background

Sub-Saharan Africa bears the greatest burden of cervical cancer. Human papillomavirus (HPV) vaccination programmes to prevent the disease will need to reach vulnerable girls who may not be able access health and screening services in the future. We conducted formative research on facilitators and barriers to HPV vaccination and potential acceptability of a future HPV vaccination programme amongst girls living in hard-to-reach populations in Kenya.

Methods

Stakeholder interviews with Ministry of Health staff explored barriers to and support for the uptake of HPV vaccination. A situation assessment was conducted to assess community services in Maasai nomadic pastoralist communities in Kajiado County and in Korogocho informal settlement in Nairobi city, followed by focus group discussions (n=14) and semi-structured interviews (n=28) with health workers, parents, youth, and community and religious leaders. These covered marriage, knowledge of cervical cancer and HPV, factors that might inhibit or support HPV vaccine uptake and intention to accept HPV vaccine if a programme was in place.

Results

Reported challenges to an HPV vaccination programme included school absenteeism and drop-out, early age of sex and marriage, lack of parental support, population mobility and distance from services. Despite little prior knowledge of cervical cancer and HPV, communities were interested in receiving HPV vaccination. Adequate social mobilisation and school-based vaccination, supplemented by out-reach activities, were considered important facilitating factors to achieve high coverage. There was some support for a campaign approach to vaccine delivery.

Conclusions

Given the high level of support for a vaccine against cervical cancer and the experience of reaching pastoralist and slum-dwellers for other immunizations, implementing an HPV vaccine programme should be feasible in such hard-to-reach communities. This may require additional delivery strategies in addition to the standard school-based delivery, with vaccine offered at multiple venues, potentially through a campaign approach.

Vaccines against human papillomavirus in low and middle income countries: a review of safety, immunogenicity and efficacy

Currently, there is limited data on the immunogenicity and efficacy of human papillomavirus vaccines in Low and Middle income countries (LMIC). The review aims to summarize the current status from published HPV vaccine safety, immunogenicity and efficacy studies in low and middle income countries (LMIC). Electronic databases (PubMed/MEDLINE and HINARI) were searched for peer reviewed English language articles on HPV vaccination in LMIC that have so far been published from 1st January 2006 up to 30th January 2015. Eligible studies were included if they had used the bivalent (bHPV) or quadrivalent HPV (qHPV) vaccines in a LMIC and investigated safety, immunogenicity and/or efficacy. The main findings were extracted and summarized. A total of fourteen HPV vaccine studies assessing safety, Immunogenicity and efficacy of the bivalent or quadrivalent vaccines in LMIC were included. There are only ten published clinical trials where a LMIC has participated. There was no published study so far that assessed efficacy of the HPV vaccines in Sub-Saharan Africa. From these studies, vaccine induced immune response was comparable to that from results of HICs for all age groups. Studies assessing HPV vaccine efficacy of the bivalent or quadrivalent vaccine within LMIC were largely missing. Only three studies were found where a LMIC was part of a multi center clinical trial. In all the studies, there were no vaccine related serious adverse events. The findings from the only study that investigated less than three doses of the bivalent HPV-16/18 vaccine suggest that even with less than three doses, antibody levels were still comparable with older women where efficacy has been proven. The few studies from LMIC in this review had comparable safety, Immunogenicity and efficacy profiles like in HIC. Overall, the LMIC of Africa where immune compromising/modulating situations are prevalent, there is need for long term immunogenicity as well as surveillance studies for long term clinical effectiveness after two and three dose regimens.

Gavi HPV Programs: Application to Implementation

Developing countries disproportionately suffer from the burden of cervical cancer yet lack the resources to establish systematic screening programs that have resulted in significant reductions in morbidity and mortality in developed countries. Human Papillomavirus (HPV) vaccination provides an opportunity for primary prevention of cervical cancer in low-resource settings through vaccine provision by Gavi The Vaccine Alliance. In addition to the traditional national introduction, countries can apply for a demonstration program to help them make informed decisions for subsequent national introduction. This article summarizes information from approved Gavi HPV demonstration program proposals and preliminary implementation findings. After two rounds of applications, 23 countries have been approved targeting approximately 400,000 girls for vaccination. All countries are proposing primarily school-based strategies with mixed strategies to locate and vaccinate girls not enrolled in school. Experiences to date include: Reaching marginalized girls has been challenging; Strong coordination with the education sector is key and overall acceptance has been high. Initial coverage reports are encouraging but will have to be confirmed in population based coverage surveys that will take place later this year. Experiences from these countries are consistent with existing literature describing other HPV vaccine pilots in low-income settings.

Present status of human papillomavirus vaccine development and implementation

Oncogenic human papillomavirus (HPV) infection is the cause of nearly all cervical cancers and a proportion of other anogenital and oropharyngeal cancers. A bivalent vaccine containing HPV 16 and 18 and a quadrivalent vaccine containing HPV 6, 11, 16, and 18 antigens are in use in vaccination programmes around the world. In clinical trials, three vaccine doses provided 90-100% protection against cervical infection and pre-cancer related to HPV 16 and 18 in women aged 15-26 years who were not infected at vaccination. Partial cross-protection against other HPV types has been reported but its duration is unknown. The vaccines were also efficacious at the prevention of HPV 16 and 18 infections at other anatomical sites in both sexes. Immunobridging studies allowed licensing of the vaccines for use starting at age 9 years for both sexes. Two-dose schedules elicit high antibody concentrations, leading to the recommendation of two-dose schedules for girls aged 9-14 years. Pre-licensure and post-licensure studies have provided data supporting vaccine safety. In 2014, a nonavalent vaccine containing HPV 6, 11, 16, 18, 31, 33, 45, 52, and 58 antigens was licensed by the US Food and Drug Administration. HPV vaccination was first introduced in high-income countries owing to vaccine cost, logistic challenges, and competing health priorities. Since 2011, vaccine prices have lowered, allowing the introduction of the vaccine in some middle-income countries. Funding of the vaccine by the GAVI Alliance in 2012 led to demonstration projects in some low-income countries. By 2014, more than 57 countries had included the HPV vaccine in their national health programmes. Data from several countries have shown the effect of vaccination on HPV infection and associated disease, and provided evidence of herd immunity. Expansion of programmes to countries with the highest burden of disease is beginning, but further efforts are needed to realise the potential of HPV vaccines.

Feasibility of delivering HPV vaccine to girls aged 10 to 15 years in Uganda

BACKGROUND

Cervical cancer is a leading cause of mortality among women in Uganda. The availability of the human papillomavirus (HPV) vaccine presents an opportunity to prevent cervical cancer. The Government of Uganda conducted a demonstration project exploring the feasibility of two delivery strategies.

OBJECTIVE

To explore the feasibility of two HPV vaccine delivery strategies: 1) a stand-alone school-based strategy that selected girls based on their enrolment in grade 5 (known as the "grade-based" strategy; and 2) an age-based strategy that delivered the HPV vaccine based on the girls' age (10-year-olds). This strategy combined the delivery of the vaccine with the distribution of deworming medication and vitamin A through an existing Child Days Plus program.

METHODS

A qualitative study that explored the feasibility of the two delivery strategies from the perspective of health workers, district leaders, and staff of the Uganda National Expanded Programme on Immunization, utilizing in-depth interviews and focus group discussions.

RESULTS

Coverage data showed that more girls (88%) were vaccinated using the grade-based strategy and completed all three doses compared to those (73%) vaccinated using the age-based strategy. Health workers and teachers indicated that determining vaccination eligibility was easier by grade than by age and there were minor disruptions to health services and school programs during vaccinations, as reported by health workers and teachers using the grade-based strategy.

CONCLUSION

HPV vaccine delivery at schools using grade eligibility was more feasible than selecting girls by age. Lessons learned in Uganda could be relevant for countries considering implementing HPV vaccinations.

Knowledge and acceptability of human papillomavirus vaccination and cervical cancer screening among women in Karnataka, India

Cervical cancer is the leading cause of cancer-related mortality among women in India; however, participation in prevention and screening is low and the reasons for this are not well understood. In a cross-sectional survey in August 2008, 202 healthy women in Karnataka, India completed a questionnaire regarding knowledge, attitudes, and practices related to human papillomavirus (HPV) and cervical cancer. Factors associated with vaccination and Papanicolau (Pap) smear screening acceptance were explored. Thirty-six percent of women had heard of HPV while 15% had heard of cervical cancer. Five percent of women reported ever having a Pap smear, and 4% of women felt at risk of HPV infection. Forty-six percent of women were accepting of vaccination, but fewer (21%) were willing to have a Pap smear. Overall, knowledge related to HPV and cervical cancer topics was low. Women with negative attitudes toward HPV infection were 5.3 (95% confidence interval (CI) 2.8-10) times more likely to accept vaccination but were not significantly more likely to accept Pap smear (odds ratio 1.5, 95% CI 0.7-3.0). Cost and a low level of perceived risk were the most frequent factors cited as potential barriers. Improving awareness of HPV and cervical cancer through health care providers in addition to increasing access to vaccination and screening through government-sponsored programs may be feasible and effective methods to reduce cervical cancer burden in India.

A comparative study of two different assay kits for the detection of secreted alkaline phosphatase in HPV antibody neutralization assays

To assess immunogenicity and development of antibodies in the context of vaccination, it is critical to quantify titers of neutralizing antibodies. We have been employing the 293TT cell-based neutralization assay system to quantify anti-HPV neutralizing antibodies. In this system, human papillomavirus (HPV) pseudovirion (PsV) particles encapsidating secreted alkaline phosphatase (SEAP) gene are used to measure infection of 293TT cells in 72-hr cell-culture supernatants. SEAP has traditionally been measured by Great EscAPe™ SEAP Chemiluminescence Kit 2.0 (GE). To reduce the cost, and to potentially increase efficiency, we sought a cheaper kit with better detection capability. Performance characteristics of the newer chemiluminescence kit, ZiVa® Ultra SEAP Plus Assay (Ziva) and GE were compared using the 293TT system. Dose titration of HPV PsV 16 or 18 showed that signal-to-noise ratios at 48 and 72 hr post-infection were higher for ZiVa at nearly all doses. ZiVa was superior to GE as it was able to detect SEAP at 48 hr, as well as when lower numbers of 293TT cells were used. The ability of ZiVa to quantitate HPV-16 and -18 neutralizing antibody titers was tested using sera from Cervarix® immunized individuals. Spearman rank correlational analyses showed excellent correlations between the titers obtained with ZiVa and GE for anti-HPV16 (r = 0.9822, p < 0.0001) and anti-HPV18 (r = 0.9832, p < 0.0001) antibodies. We concluded that ZiVa is superior to GE in detecting SEAP, and the antibody titers in sera of vaccinated individuals were similar to those obtained with GE. Thus, Ziva is a suitable alternative to GE.

Knowledge and Perceptions of HPV and the HPV Vaccine among Pre-adolescent Girls and Their Guardians in Georgetown, Guyana

OBJECTIVES

To examine the knowledge and perceptions of 11-year old girls and their guardians toward the human papillomavirus (HPV), HPV (mandatory) vaccination and cervical cancer and to determine their main sources of health information.

METHODS

A cross-sectional study was done by interviewing two separate study populations ie 11-year old girls from five primary schools in Georgetown and their guardians. Questions were designed to assess level of knowledge as well as perceptions about mandatory vaccination and sources of health information.

RESULTS

A total of 87 girls participated, of whom 10 (11%) had already received the HPV vaccine. Overall, when asked whether they knew of HPV, the HPV vaccine, cervical cancer or the Pap smear, more than half of the girls, in every instance, did not know. Seventy-four guardians took part and most (> 80%) of them claimed that they knew about these parameters except for HPV transmission (40%) and the cause of cervical cancer (30%). Both girls and guardians responded poorly to questions about the detection of cervical cancer. Furthermore, only two of the 14 girls who stated that they knew how HPV was transmitted, actually answered correctly that it was sexual transmission. Girls were almost twice as likely to be in favour of mandatory vaccination as guardians (OR 1.8, 95% CI: 0.9, 3.6) but the difference was not significant (p > 0.05). The girls indicated health centres/clinics (58%), whilst TV/radio (66%) was the preference for the guardians as their most popular health information sources.

CONCLUSIONS

These findings point to a necessity for educational programmes and activities in which children and their guardians can meaningfully participate and be informed about the different aspects of HPV vaccination.

Human papillomavirus knowledge, vaccine acceptance, and vaccine series completion among female entertainment and sex workers in Phnom Penh, Cambodia: the Young Women's Health Study

Human papillomavirus is a common sexually transmitted infection and the causative agent for cervical cancer, a frequently occurring malignant disease among women in developing countries. We assessed human papillomavirus awareness prior to the delivery of a brief information and education intervention, and human papillomavirus vaccine provision to female entertainment and sex workers (N = 220). At baseline, only 23.6% of women had heard of human papillomavirus. Following the educational intervention, 90% answered all the human papillomavirus knowledge questions correctly. Of 192 participants attending the first quarterly cohort visit where vaccine was offered, 149 (78%) were eligible for vaccination; HIV-positive (n = 32) and pregnant (n = 11) women were excluded. Acceptance of vaccine among eligible women was universal, and 79.2% completed the three-dose vaccination series. Women who reported use of amphetamine-type stimulants had significantly and independently lower odds of vaccine completion (adjusted odds ratio [AOR] 0.24; 95% confidence interval [CI] 0.08, 0.69). New pregnancies also had an impact on vaccine completion: 5.4% (8/149 5.4%) who started the series had to stop due to new pregnancy. Results demonstrate the effectiveness of a simple education intervention designed to increase human papillomavirus knowledge and the feasibility of successful human papillomavirus vaccine in a population that is often difficult to engage in preventive health care.

Effect of school-based human papillomavirus (hpv) vaccination on adolescent girls' knowledge and acceptability of the HPV vaccine in Ibanda District in Uganda

From 2008 to 2011, schoolgirls were vaccinated against HPV in two districts in Uganda following sensitization. This study assessed girls' knowledge of cervical cancer and HPV vaccine, and their acceptance of future vaccination of friends and hypothetical daughters. The cross-sectional, mixed methods comparative study was conducted in two districts. Univariate, bivariate, logistic regression and thematic analyses were done. HPV vaccination was positively associated with knowledge (Crude OR: 5.31, CI: 3.19-8.86; p = 0.000); but knowledge (Adjusted OR: 1.13, CI: 0.56-2.28; p = 0.73) and HPV vaccination (Adjusted OR: 0.92, CI: 0.16-5.36; p = 0.93) did not predict vaccine acceptability. Seemingly important motivations for vaccine acceptance were: its role in cancer prevention and advancement of reproductive health, minimal side effects, and positive peer role models. Major deterrents to vaccine acceptance were: rumours and misconceptions about possible side effects, perceived inadequate information about vaccine, and fear of side effects.

Human papillomavirus vaccination: where are we now?

The development of efficacious prophylactic human papillomavirus vaccines provided an opportunity for the primary prevention of related infections and diseases. Certain oncogenic human papillomaviruses that preferentially infect the genital epithelium cause cervical cancer and a substantial proportion of anal, penile, vaginal, vulvar and oropharyngeal cancers. Following extensive clinical trials demonstrating their efficacy and safety, two vaccines have been in global use for over 6 years. This review summarises the accumulated evidence regarding their high level of efficacy, safety in population usage, reductions in genital warts, infections and cervical disease following their adoption, and facilitators and barriers to achieving high vaccination coverage. The review also discusses practical issues and frequently asked questions regarding duration of effect, vaccination of women treated for cervical disease and alternate vaccination schedules, as well as the need to review cervical screening strategies in the post- vaccination environment.

HPV vaccine acceptability in Africa: a systematic review

OBJECTIVE

The objective of this study was to provide a systematic review of peer-reviewed literature on the factors associated with HPV vaccine acceptability among adults in African countries.

METHODS

A systematic search was conducted across five electronic databases: EMBASE, PsychINFO, CINAHL, Global Health and Ovid MEDLINE, to identify studies related to HPV vaccination acceptability in African countries (August 2013). The Health Belief Model was used to guide data abstraction and synthesis.

RESULTS

Fourteen unique studies representing ten sub-Saharan African countries were identified, with more than half published within the last two years. Acceptability of the HPV vaccine for daughters was high (range 59-100%); however, vaccine-related awareness and knowledge were low. Perceived barriers including accessibility and cost concerns were important for acceptance, as were cues to action from healthcare providers and governments.

CONCLUSIONS

This review suggests that acceptability of the HPV vaccine in countries in this region will be high. Broad knowledge gaps were highlighted regarding HPV and cervical cancer and these should be addressed. Education on the vaccine's effectiveness and reducing perceived barriers to vaccination would also be useful. Public endorsement by governments and healthcare providers will likely also increase acceptance.

Implementation science in cancer prevention and control: a framework for research and programs in low- and middle-income countries

Implementation science is a set of tools, principles, and methodologies that can be used to bring scientific evidence into action, improve health care quality and delivery, and improve public health. As the burden of cancer increases in low- and middle-income countries, it is important to plan cancer control programs that are both evidence based and delivered in ways that are feasible, cost-effective, contextually appropriate, and sustainable. This review presents a framework for using implementation science for cancer control planning and implementation and discusses potential areas of focus for research and programs in low- and middle-income countries interested in integrating research into practice and policy.

Determinants of acceptance and subsequent uptake of the HPV vaccine in a cohort in Eldoret, Kenya

The development of Human Papillomavirus (HPV) vaccines provides new opportunities in the fight against cervical cancer. Many acceptability studies have revealed high interest in these vaccines, but acceptance is only a precursor of behavior, and many factors, at personal, community and provider level, may inhibit the translation of willingness to vaccinate into actual uptake. Through a longitudinal study in Eldoret, Kenya, HPV vaccine acceptability was measured before a vaccination program (n = 287) and vaccine uptake, as reported by mothers, once the program was finished (n = 256). In between baseline and follow-up, a pilot HPV vaccination program was implemented via the GARDASIL Access Program, in which parents could have their daughter vaccinated for free at the referral hospital. The program was promoted at schools: Health staff informed teachers who were then asked to inform students and parents. Even though baseline acceptance was very high (88.1%), only 31.1% of the women reported at follow-up that their daughter had been vaccinated. The vaccine was declined by 17.7%, while another 51.2% had wanted the vaccination but were obstructed by practical barriers. Being well-informed about the program and baseline awareness of cervical cancer were independently associated with vaccine uptake, while baseline acceptance was correlated in bivariate analysis. Side effects were of great concern, even among those whose daughter was vaccinated. Possible partner disapproval lowered acceptance at baseline, and women indeed reported at follow-up that they had encountered his opposition. In Kenya, women prove to be very willing to have their daughter vaccinated against cervical cancer. However, in this study, uptake was more determined by program awareness than by HPV vaccine acceptance. School-based vaccination might improve coverage since it reduces operational problems for parents. In addition, future HPV vaccination campaigns should address concerns about side effects, targeting men and women, given both their involvement in HPV vaccination decision-making.

Human papillomavirus vaccination uptake and completion as a preventive health measure among female adolescents

BACKGROUND

National coverage for the human papillomavirus (HPV) vaccine falls short of the targeted goals for Healthy People 2020 with disparities in completion rates noted in minority adolescent female populations. The purpose of this study was to provide a review of the literature on HPV vaccination uptake and completion rates among female minority adolescents as well as a discussion of the financial and policy dimensions of HPV vaccination with implications that impact uptake and completion rates.

METHODS

By reviewing the literature, the authors show that the two human papillomavirus (HPV) vaccines, Gardasil and Cervarix, have presented unprecedented opportunities to prevent morbidity and mortality from cervical cancer.

CONCLUSION

The authors recommend that nurses and advanced practice nurses take an active role at the point of care to educate families about HPV vaccination. Nursing interventions for practice changes are provided to improve vaccination initiation and completion rates in disadvantaged populations.

Knowledge, attitudes and practices on adolescent vaccination among parents, teachers and adolescents in Africa: a systematic review protocol

BACKGROUND

Vaccines are the most successful and cost-effective public health interventions available to avert vaccine-preventable diseases and deaths. Despite progress in the field of adolescent health, many young people in Africa still get sick and die from vaccine-preventable diseases due to lack of vaccination. Parents, adolescents and teachers are key players with regard to implementation of adolescent vaccination policies. Therefore, understanding their knowledge, attitudes and practices towards adolescent vaccination may provide clues on what can be done to improve vaccine uptake among adolescents. The aim of this study is to conduct a qualitative and quantitative systematic review on knowledge, attitudes and practices on adolescent vaccination among parents, teachers and adolescents in Africa.

METHODS

We will include both quantitative and qualitative primary studies. Eligible quantitative studies include both intervention and observational studies. Qualitative studies to be included are focus group discussions, direct observations, in-depth interviews and case ethnographic studies. We will search PubMed, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, WHOLIS, Africa Wide and CINAHL for eligible studies with no time and language limits. We will also check reference lists of included studies for other eligible reports. Two authors will independently screen the search output, select studies and extract data, resolving discrepancies by consensus and discussion. We will analyse qualitative data using thematic analysis where applicable, and quantitative studies findings will be presented in a narrative synthesis form based on the outcomes.

DISCUSSION

The findings from this systematic review will guide the identification of gaps on knowledge, attitudes and practices among the key role players on adolescent vaccination. We anticipate that our findings will guide the development of adolescent-focused vaccination policy in Africa, which is virtually non-existent at present.

SYSTEMATIC REVIEW REGISTRATION

This review is registered with PROSPERO, registration number CRD42014010395.

The levels of anti-HPV16/18 and anti-HPV31/33/35/45/52/58 antibodies among AS04-adjuvanted HPV16/18 vaccinated and non-vaccinated Ugandan girls aged 10-16 years

BACKGROUND

Data on Human Papilloma virus (HPV) vaccine immune response in sub-Saharan Africa is still sparse yet such knowledge is critical for optimal implementation and monitoring of HPV vaccines. Our primary objective was to evaluate levels of anti-HPV-16/18 antibodies and six other 'high risk' HPV (hrHPV) types among the vaccinated and unvaccinated Ugandan girls.

METHODS

We conducted a cross sectional study among AS04-adjuvanted HPV-16/18 vaccinated and unvaccinated school girls aged 10-16 years in Western Uganda using purposive sampling. The vaccinated girls were at 18 months post vaccination. After consenting and assenting, data was collected using interviewer administered questionnaires for demographics and sexual history. Blood was drawn from which serum samples were analysed by the multiplex HPV serology technology to determine anti-HPV antibody levels to HPV-16/18 and six other hrHPV types (31, 33, 35, 45, 52 and 58). The antibody levels were expressed as Median Fluorescent Intensity (MFI). A total of 207 vaccinated [mean age 13.1 years (SD 1.5); range 10-16 years] and 197 unvaccinated girls [mean age 13.6 years (SD 1.3); range 10-16 years] participated in the study. Sexual activity was self reported among 14/207 (6.8%) vaccinated and 5/197 (2.5%) unvaccinated girls. The MFI levels for HPV-16 and HPV-18 were 15 and 20 times higher respectively in the vaccinated girls than in the unvaccinated girls. HPV-16 mean MFI level was 4691(SD 1812; 95% CI: 4438-4958) among the vaccinated compared to 218 (SD 685; 95% CI: 190-252) among the unvaccinated girls. For HPV-18 the mean MFI level was 1615 (SD 1326; 95% CI: 1470-1776) among the vaccinated compared to MFI 103 (SD 506; 95% CI: 88 -121) among unvaccinated girls. In addition antibody levels to non vaccine hrHPV types (31, 33, 35, 45, 52 and 58) were all significantly higher in the vaccinated group than in the unvaccinated group (p<0.01).

CONCLUSION

The AS04-Adjuvanted HPV-16/18 vaccinated girls showed a higher level of antibodies to HPV-16/18 and other non-vaccine hrHPV types compared to the unvaccinated girls. This may translate into protection against HPV-16/18 and other hrHPV types.

Why the time is right to tackle breast and cervical cancer in low-resource settings

The health concerns of women in their mid-adult years - when the prime age of reproduction has passed - have been traditionally given little or no attention by health systems and donors, despite the heavy burden that diseases such as breast and cervical cancer impose on women and their families. The risk of sexually transmitted infections that accompanies sexual relations and the risk of death and morbidity associated with pregnancy have long been recognized and have stimulated major control efforts that are finally yielding positive results. Much less attention has been focused, however, on how experiences in early life can affect women's health in adulthood. Breast and cervical cancers kill more women than any other types of cancer in all parts of the developing world. In most of Asia and Latin America and some African countries, deaths from these two forms of cancer now outnumber pregnancy-related deaths. There are five compelling reasons for focusing on these cancers now to try to reverse these epidemiologic trends: (i) the burden of breast and cervical cancer is large and is growing; (ii) effective screening and treatment are available; (iii) research is generating new knowledge; (iv) there are opportunities for synergy with other health programmes; and (v) noncommunicable diseases are the focus of much current interest.

Lessons learned from HPV vaccine delivery in low-resource settings and opportunities for HIV prevention, treatment, and care among adolescents

BACKGROUND

Human papillomavirus (HPV) vaccines to prevent cervical cancer have become available in recent years and presented a new challenge to health systems, since they prevent a sexually transmitted virus and are most effective if they are delivered to young adolescent girls, a group not widely served by other health programs. Demonstration and pilot HPV vaccination programs undertaken in the past 7-8 years in low-resource settings have produced lessons that may be more broadly applied to other adolescent health interventions, particularly to those that attempt to reduce human immunodeficiency virus (HIV) infection.

METHODS

A systematic literature review was undertaken to identify formal and informal evaluations of HPV vaccine use in low- and middle-income countries. Special attention was devoted to the detailed evaluations carried out on large demonstration projects in India, Peru, Uganda, and Vietnam.

RESULTS

These lessons fall into 2 main categories: service delivery operations and community outreach and mobilization. Operational issues included venue and timing of vaccinations, definition of target population, micro-planning and coordination, integration with other services, and training. Community issues included consent, messages and channels, endorsement and support, and timing of mobilization efforts.

DISCUSSION

Careful planning, good coordination across sectors and levels, and sensitive attention to the expressed needs for information and preferences for communication channels among youth, parents, and communities more broadly were among the key lessons that are relevant for HIV interventions, but many of the smaller details were also important.

CONCLUSIONS

Applying or adapting these lessons to adolescent HIV services could accelerate effective program design and enhance success.

Performance of 21 HPV vaccination programs implemented in low and middle-income countries, 2009-2013

BACKGROUND

Cervical cancer is the third most common cancer in women worldwide, with high incidence in lowest income countries. Vaccination against Human Papilloma Virus (HPV) may help to reduce the incidence of cervical cancer. The aim of the study was to analyze HPV vaccination programs performance implemented in low and middle-income countries.

METHODS

The Gardasil Access Program provides HPV vaccine at no cost to help national institutions gain experience implementing HPV vaccination. Data on vaccine delivery model, number of girls vaccinated, number of girls completing the three-dose campaign, duration of vaccination program, community involvement and sensitization strategies were collected from each program upon completion. Vaccine Uptake Rate (VUR) and Vaccine Adherence between the first and third doses (VA) rate were calculated. Multivariate linear regressions analyses were fitted.

RESULTS

Twenty-one programs were included in 14 low and middle-income countries. Managing institutions were non-governmental organizations (NGOs) (n = 8) or Ministries of Health (n = 13). Twelve programs were school-based, five were health clinic-based and four utilized a mixed model. A total of 217,786 girls received a full course of vaccination.Mean VUR was 88.7% (SD = 10.5) and VA was 90.8% (SD = 7.3). The mean total number of girls vaccinated per program-month was 2,426.8 (SD = 2,826.6) in school model, 335.1 (SD = 202.5) in the health clinic and 544.7 (SD = 369.2) in the mixed models (p = 0.15). Community involvement in the follow-up of girls participating in the vaccination campaign was significantly associated with VUR. Multivariate analyses identified school-based (β = 13.35, p = 0.001) and health clinic (β = 13.51, p = 0.03) models, NGO management (β = 14.58, p < 10(-3)) and duration of program vaccination (β = -1.37, p = 0.03) as significant factors associated with VUR.

CONCLUSION

School and health clinic-based models appeared as predictive factors for vaccination coverage, as was management by an NGO; program duration could play a role in the program's effectiveness. Results suggest that HPV vaccine campaigns tailored to meet the needs of communities can be effective. These results may be useful in the development of national HPV vaccination policies in low and middle-income countries.

Costs of introducing and delivering HPV vaccines in low and lower middle income countries: inputs for GAVI policy on introduction grant support to countries

Background

In November 2011, the GAVI Alliance made the decision to add HPV vaccine as one of the new vaccines for which countries eligible for its funding (less than $1520 per capita income) could apply to receive support for national HPV vaccination, provided they could demonstrate the ability to deliver HPV vaccines. This paper describes the data and analysis shared with GAVI policymakers for this decision regarding GAVI HPV vaccine support. The paper reviews why strategies and costs for HPV vaccine delivery are different from other vaccines and what is known about the cost components from available data that originated primarily from HPV vaccine delivery costing studies in low and middle income-countries.

Methods

Financial costs of HPV vaccine delivery were compared across three sources of data: 1) vaccine delivery costing of pilot projects in five low and lower-middle income countries; 2) cost estimates of national HPV vaccination in two low income countries; and 3) actual expenditure data from national HPV vaccine introduction in a low income country. Both costs of resources required to introduce the vaccine (or initial one-time investment, such as cold chain equipment purchases) and recurrent (ongoing costs that repeat every year) costs, such as transport and health personnel time, were analyzed. The cost per dose, cost per fully immunized girl (FIG) and cost per eligible girl were compared across studies.

Results

Costs varied among pilot projects and estimates of national programs due to differences in scale and service delivery strategy. The average introduction costs per fully immunized girl ranged from $1.49 to $18.94 while recurrent costs per girl ranged from $1.00 to $15.69, with both types of costs varying by delivery strategy and country. Evaluating delivery costs along programme characteristics as well as country characteristics (population density, income/cost level, existing service delivery infrastructure) are likely the most informative and useful for anticipating costs for HPV vaccine delivery.

Conclusions

This paper demonstrates the importance of country level cost data to inform global donor policies for vaccine introduction support. Such data are also valuable for informing national decisions on HPV vaccine introduction.

Achieving high uptake of human papillomavirus vaccine in Cameroon: lessons learned in overcoming challenges

BACKGROUND

Cameroon has the highest age-standardized incidence rate of cervical cancer (30/100,000 women) in Central Africa. In 2010-2011, the Cameroon Baptist Convention Health Services (CBCHS) received donated human papillomavirus (HPV) vaccine, Gardasil, from Merck & Co. Inc. through Axios Healthcare Development to immunize 6400 girls aged 9-13 years. The aim was to inform the Cameroon Ministry of Health (MOH) of the acceptability, feasibility, and optimal delivery strategies for HPV vaccine.

METHODS AND FINDINGS

Following approval by the MOH, CBCHS nurses educated girls, parents, and communities about HPV, cervical cancer, and HPV vaccine through multimedia coverage, brochures, posters, and presentations. Because educators were initially reluctant to allow immunization in schools, due to fear of adverse events, the nurses performed 40.7% of vaccinations in the clinics, 34.5% in community venues, and only 24.7% in schools. When no adverse events were reported, more schools and communities permitted HPV vaccine immunization on their premises. To recover administrative costs, CBCHS charged a fee of US$8 per 3-dose series only to those who were able to pay. Despite the fee, 84.6% of the 6,851 girls who received the first dose received all three doses.

CONCLUSIONS AND LESSONS LEARNED

With adequate education of all stakeholders, HPV vaccination is acceptable and feasible in Cameroon. Following this demonstration project, in 2014 the Global Access to Vaccines and Immunization (GAVI) Alliance awarded the Cameroon MOH HPV vaccine at a price of US$4.50 per dose to immunize sixth grade girls and girls aged 10 years who are not in school in two districts of Cameroon.

Qualitative study of the feasibility of HPV vaccine delivery to young adolescent girls in Vietnam: evidence from a government-implemented demonstration program

Background

Introduction of human papillomavirus (HPV) vaccine in national programs has proceeded apace since 2006, mostly in high-income countries. Recently concluded pilots of HPV vaccination in low-income countries have provided important lessons learned for these settings; however, rigorous evaluations of the feasibility of these delivery strategies that effectively reach young adolescents have been few. This paper presents results from a qualitative evaluation of a demonstration program which implemented school-based and health center–based HPV vaccinations to all girls in grade 6, or 11 years of age, for two years in four districts of Vietnam.

Methods

Using semi-structured interviews of 131 health and education staff from local, district, province, and national levels and 26 focus-group discussions with local project implementers (n = 153), we conducted a qualitative two-year evaluation to measure the impact of HPV vaccinations on the health and education systems.

Results

HPV vaccine delivery at schools or health centers was made feasible by: a. close collaboration between the health and education sectors, b. detailed planning for implementation, c. clearly defined roles and responsibilities for project implementers, d. effective management and supervision of vaccinations during delivery, and e. engagement with community organizations for support. Both the health and education systems were temporarily challenged with the extra workload, but the disruptions were short-lived (a few days for each of three doses) and perceived as worth the longer-term benefit of cervical cancer prevention.

Conclusion

The learning from Vietnam has identified critical elements for successful vaccine delivery that can provide a model for other countries to consider during their planning of national rollout of HPV vaccine.

School nurses' attitudes and experiences regarding the human papillomavirus vaccination programme in Sweden: a population-based survey

BACKGROUND

Sweden introduced a school-based human papillomavirus (HPV) vaccination programme in 2012, and school nurses are responsible for managing the vaccinations. The aim of the present study was to investigate the attitudes and experiences of school nurses regarding the school-based HPV vaccination programme 1 year after its implementation.

METHODS

Data were collected using a web-based questionnaire in the spring of 2013, and 83.1% (851/1024) of nurses responded.

RESULTS

There were strong associations between the nurses' education about the HPV vaccine and their perceived knowledge about the vaccine and a favourable attitude towards vaccination (both p < 0.001). School nurses who received a high level of education were more likely to have a positive attitude to HPV vaccination compared with nurses with little education about HPV vaccination (adjusted odds ratio [OR] = 9.8; 95% confidence interval [CI]: 3.797-25.132). Nurses with high perceived knowledge were more likely to have a positive attitude compared with those with a low level of perceived knowledge (OR = 2.5; 95% CI: 1.299-4.955). If financial support from the government was used to fund an additional school nurse, nurses were more likely to have a positive attitude than if the financial support was not used to cover the extra expenses incurred by the HPV vaccination (OR = 2.1; 95% CI: 1.051-4.010). The majority, 648 (76.1%), had been contacted by parents with questions about the vaccine, mostly related to adverse effects. In addition, 570 (66.9%) stated that they had experienced difficulties with the vaccinations, and 337 (59.1%) of these considered the task to be time-consuming.

CONCLUSIONS

A high level of education and perceived good knowledge about HPV are associated with a positive attitude of school nurses to the HPV vaccination programme. Thus, nurses require adequate knowledge, education, skills and time to address the questions and concerns of parents, as well as providing information about HPV. Strategic financial support is required because HPV vaccination is a complex and time-consuming task.

Not the right time: why parents refuse to let their daughters have the human papillomavirus vaccination

Aim

To explore why parents refused to allow their 10- to 12-year-old daughters to receive the human papillomavirus (HPV) vaccination from the Swedish school-based vaccination programme.

Methods

Individual interviews with 25 parents who had been offered, but not consented to, their daughters receiving the HPV vaccination.

Results

Five themes emerged through the interviews: 1) she is just a little girl, 2) inadequate information, 3) not compatible with our way of life, 4) scepticism about the vaccination and 5) who can you trust? The parents made their decisions with their child's best interests in mind. This was not considered the right time, and the vaccine was perceived as unnecessary and different from other vaccines. Mistrust in Government recommendations and a lack of evidence or information were other reasons to decline.

Conclusion

The decision-making process was complex. These parents preferred to wait until their daughter was older and believed the information they received from the school health system was insufficient. The results indicate that a more flexible HPV vaccination schedule may improve vaccine uptake. This includes more transparent information about the virus and the vaccine and information about who to contact to get the daughter vaccinated at a later date.

Knowledge and awareness of HPV vaccine and acceptability to vaccinate in sub-Saharan Africa: a systematic review

Objectives

We assessed the knowledge and awareness of cervical cancer, HPV and HPV vaccine, and willingness and acceptability to vaccinate in sub-Saharan African (SSA) countries. We further identified countries that fulfill the two GAVI Alliance eligibility criteria to support nationwide HPV vaccination.

Methods

We conducted a systematic review of peer-reviewed studies on the knowledge and awareness of cervical cancer, HPV and HPV vaccine, and willingness and acceptability to vaccinate. Trends in Diphtheria-tetanus-pertussis (DTP3) vaccine coverage in SSA countries from 1990–2011 were extracted from the World Health Organization database.

Findings

The review revealed high levels of willingness and acceptability of HPV vaccine but low levels of knowledge and awareness of cervical cancer, HPV or HPV vaccine. We identified only six countries to have met the two GAVI Alliance requirements for supporting introduction of HPV vaccine: 1) the ability to deliver multi-dose vaccines for no less than 50% of the target vaccination cohort in an average size district, and 2) achieving over 70% coverage of DTP3 vaccine nationally. From 2008 through 2011 all SSA countries, with the exception of Mauritania and Nigeria, have reached or maintained DTP3 coverage at 70% or above.

Conclusion

There is an urgent need for more education to inform the public about HPV, HPV vaccine, and cervical cancer, particularly to key demographics, (adolescents, parents and healthcare professionals), to leverage high levels of willingness and acceptability of HPV vaccine towards successful implementation of HPV vaccination programs. There is unpreparedness in most SSA countries to roll out national HPV vaccination as per the GAVI Alliance eligibility criteria for supporting introduction of the vaccine. In countries that have met 70% DTP3 coverage, pilot programs need to be rolled out to identify the best practice and strategies for delivering HPV vaccines to adolescents and also to qualify for GAVI Alliance support.

Learning lessons from operational research in infectious diseases: can the same model be used for noncommunicable diseases in developing countries?

About three-quarters of global deaths from noncommunicable diseases (NCDs) occur in developing countries. Nearly a third of these deaths occur before the age of 60 years. These deaths are projected to increase, fueled by such factors as urbanization, nutrition transition, lifestyle changes, and aging. Despite this burden, there is a paucity of research on NCDs, due to the higher priority given to infectious disease research. Less than 10% of research on cardiovascular diseases comes from developing countries. This paper assesses what lessons from operational research on infectious diseases could be applied to NCDs. The lessons are drawn from the priority setting for research, integration of research into programs and routine service delivery, the use of routine data, rapid-assessment survey methods, modeling, chemoprophylaxis, and the translational process of findings into policy and practice. With the lines between infectious diseases and NCDs becoming blurred, it is justifiable to integrate the programs for the two disease groups wherever possible, eg, screening for diabetes in tuberculosis. Applying these lessons will require increased political will, research capacity, ownership, use of local expertise, and research funding.

Structural barriers to screening for and treatment of cervical cancer in Peru

Through in-depth interviews with 30 key informants from 19 institutions in the health care system in four regions of Peru, this study identifies multiple barriers to obtaining cervical cancer screening, follow-up, and treatment. Some facilities outside Lima do not have the capacity to take Pap smear samples; others cannot do so on a continuing basis. Variation in procedures used by facilities and between regions, differences in women's ability to pay, as well as varying levels of training of laboratory personnel, all affect the quality and timing of service delivery and outcomes. In some settings, perverse incentives to accrue overtime payments increase the lag time between sample collection and reporting back of results. Some patients with abnormal results are lost to follow-up; others find needed treatment to be out of their financial or geographic reach. To increase coverage for cervical cancer screening and follow-up, interventions are needed at all levels, including an institutional overhaul to ensure that referral mechanisms are appropriate and that treatment is accessible and affordable. Training for midwives and gynaecologists is needed in good sample collection and fixing, and quality control of samples. Training of additional cytotechnologists, especially in the provinces, and incentives for processing Pap smears in an appropriate, timely manner is also required.

Sources of HPV vaccine hesitancy in parents

Despite strong national recommendations to vaccinate adolescents against the human papillomavirus (HPV), only 14% of teenage girls completed all 3 doses in 2010. Parental hesitancy may be one of the strongest reasons behind this low uptake rate. This review investigates sources of parental hesitancy including parental concerns associated with vaccinations in general, parental knowledge as a basis of HPV vaccine hesitancy, social qualms parents may have with regards to the HPV vaccine, and parental attitudes toward allowing their sons to be vaccinated against HPV. By better understanding these sources of hesitancy, we can focus research efforts towards addressing them in an attempt to improve HPV vaccine uptake.

Delivery cost of human papillomavirus vaccination of young adolescent girls in Peru, Uganda and Viet Nam

OBJECTIVE

To estimate the incremental delivery cost of human papillomavirus (HPV) vaccination of young adolescent girls in Peru, Uganda and Viet Nam.

METHODS

Data were collected from a sample of facilities that participated in five demonstration projects for hpv vaccine delivery: school-based delivery was used in Peru, Uganda and Viet Nam; health-centre-based delivery was also used in Viet Nam; and integrated delivery, which involved existing health services, was also used in Uganda. Microcosting methods were used to guide data collection on the use of resources (i.e. staff, supplies and equipment) and data were obtained from government, demonstration project and health centre administrative records. Delivery costs were expressed in 2009 United States dollars (US$). Exclusively project-related expenses and the cost of the vaccine were excluded.

FINDINGS

The economic delivery cost per vaccine dose ranged from US$ 1.44 for integrated outreach in Uganda to US$ 3.88 for school-based delivery in Peru. In Viet Nam, the lowest cost per dose was US$ 1.92 for health-centre-based delivery. Cost profiles revealed that, in general, the largest contributing factors were project start-up costs and recurrent personnel costs. The delivery cost of HPV vaccine was higher than published costs for traditional vaccines recommended by the Expanded Programme on Immunization (EPI).

CONCLUSION

The cost of delivering HPV vaccine to young adolescent girls in Peru, Uganda and Viet Nam was higher than that for vaccines currently in the EPI schedule. The cost per vaccine dose was lower when delivery was integrated into existing health services.

Human papillomavirus (HPV) vaccine implementation in low and middle-income countries (LMICs): health system experiences and prospects

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Multi-method review of challenges introducing HPV vaccine in developing countries.

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HPV vaccine delivery methods can overcome inadequate health systems.

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Political will is essential for successful HPV vaccine roll-out.

Prophylactic vaccines for human papillomavirus (HPV) are being introduced in many countries for the prevention of cervical cancer, the second most important cause of cancer-related death in women globally. This is likely to have a significant impact on the future burden of cervical cancer, particularly where screening is non-existent or limited in scale. Previous research on the challenges of vaccinating girls with the HPV vaccine has focused on evidence from developed countries. We conducted a systematic search of the literature in order to describe the barriers and challenges to implementation of HPV vaccine in low- and middle-income countries. We identified literature published post-2006 to September 2012 from five major databases. We validated the findings of the literature review with evidence from qualitative key informant interviews. Three key barriers to HPV vaccine implementation were identified: sociocultural, health systems and political. A linked theme, the sustainability of HPV vaccines programmes in low- and middle-income countries, cuts across these three barriers. Delivering HPV vaccine successfully will require multiple barriers to be addressed. Earlier research in developed countries emphasised sociocultural issues as the most significant barriers for vaccine roll-out. Our evidence suggests that the range of challenges for poorer countries is significantly greater, not least the challenge of reaching girls for three doses in settings where school attendance is low and/or irregular. Financial and political barriers to HPV vaccine roll-out continue to be significant for many poorer countries. Several demonstration and pilot projects have achieved high rates of acceptability and coverage and lessons learned should be documented and shared.

Human papillomavirus vaccination: current indications and future directions

Human papillomavirus (HPV) is one of the most common sexually transmitted infections affecting both men and women worldwide. The development of the prophylactic HPV vaccines is a significant pharmaceutical innovation with potential to reduce HPV-related morbidity. However, barriers to the universal use and acceptability of the HPV vaccines continue to exist in both economically privileged and disadvantaged countries. It may be decades before the impact of preventive vaccines on HPV-related diseases caused by the considerable burden of HPV infections will be seen. Collaborative efforts must continue to promote vaccine implementation.

A school-based human papillomavirus vaccination program in barretos, Brazil: final results of a demonstrative study

Introduction

The implementation of a public HPV vaccination program in several developing countries, especially in Latin America, is a great challenge for health care specialists.

Aim

To evaluate the uptake and the three-dose completion rates of a school-based HPV vaccination program in Barretos (Brazil).

Methods

The study included girls who were enrolled in public and private schools and who regularly attended the sixth and seventh grades of elementary school (mean age: 11.9 years). A meeting with the parents or guardians occurred approximately one week before the vaccination in order to explain the project and clarify the doubts. The quadrivalent vaccine was administered using the same schedule as in the product package (0–2–6 months). The school visits for regular vaccination occurred on previously scheduled dates. The vaccine was also made available at Barretos Cancer Hospital for the girls who could not be vaccinated on the day when the team visited the school.

Results

Among the potential candidates for vaccination (n = 1,574), the parents or guardians of 1,513 girls (96.1%) responded to the invitation to participate in the study. A total of 1,389 parents or guardians agreed to participate in the program (acceptance rate = 91.8%). The main reason for refusing to participate in the vaccination program was fear of adverse events. The vaccine uptake rates for the first, second, and third doses were 87.5%, 86.3% and 85.0%, respectively. The three-dose completion rate was 97.2%.

Conclusions

This demonstrative study achieved high rates of vaccination uptake and completion of three vaccine doses in children 10–16 years old from Brazil. The feasibility and success of an HPV vaccination program for adolescents in a developing country may depend on the integration between the public health and schooling systems.

A cross-sectional study to assess HPV knowledge and HPV vaccine acceptability in Mali

Despite a high prevalence of oncogenic human papilloma virus (HPV) infection and cervical cancer mortality, HPV vaccination is not currently available in Mali. Knowledge of HPV and cervical cancer in Mali, and thereby vaccine readiness, may be limited. Research staff visited homes in a radial pattern from a central location to recruit adolescent females and males aged 12-17 years and men and women aged ≥ 18 years (N = 51) in a peri-urban village of Bamako, Mali. Participants took part in structured interviews assessing knowledge, attitudes, and practices related to HPV, cervical cancer, and HPV vaccination. We found low levels of HPV and cervical cancer knowledge. While only 2.0% of respondents knew that HPV is a sexually transmitted infection (STI), 100% said they would be willing to receive HPV vaccination and would like the HPV vaccine to be available in Mali. Moreover, 74.5% said they would vaccinate their child(ren) against HPV. Men were found to have significantly greater autonomy in the decision to vaccinate themselves than women and adolescents (p = 0.005), a potential barrier to be addressed by immunization campaigns. HPV vaccination would be highly acceptable if the vaccine became widely available in Bamako, Mali. This study demonstrates the need for a significant investment in health education if truly informed consent is to be obtained for HPV vaccination. Potential HPV vaccination campaigns should provide more information about HPV and the vaccine. Barriers to vaccination, including the significantly lower ability of the majority of the target population to autonomously decide to get vaccinated, must also be addressed in future HPV vaccine campaigns.

Human papillomavirus vaccine in adolescent women: a 2012 update

PURPOSE OF REVIEW

Despite recommendations from the Advisory Committee on Immunization Practices (ACIP) for routine vaccination of adolescents with the human papillomavirus (HPV) vaccine, U.S. coverage among women remains less than 50%, with that of adolescent men below 2%.

RECENT FINDINGS

Ongoing studies document the efficacy and safety of the HPV vaccine. Nevertheless, misconceptions and negative attitudes persist and serve as barriers to vaccine uptake. Additionally, other factors such as age, insurance status, poverty status, and racial or ethnic background have been associated with diminished vaccine uptake and poor completion rates. Internationally, HPV vaccination programs and school-based programs have achieved increased rates of uptake and series completion. HPV vaccination coverage may also be facilitated by improving communication between physicians, parents, and adolescents as well as by addressing common misconceptions about the vaccine.

SUMMARY

This review highlights significant findings of recent literature on HPV vaccination of adolescent women with a special focus on uptake, series completion, communication, disparities in vaccine coverage, and other health outcomes associated with HPV vaccination.

Parental acceptance of HPV vaccine in Peru: a decision framework

Objective and Method

Cervical cancer is the third most common cancer affecting women worldwide and it is an important cause of death, especially in developing countries. Cervical cancer is caused by human papillomavirus (HPV) and can be prevented by HPV vaccine. The challenge is to expand vaccine availability to countries where it is most needed. In 2008 Peru’s Ministry of Health implemented a demonstration project involving 5^th grade girls in primary schools in the Piura region. We designed and conducted a qualitative study of the decision-making process among parents of girls, and developed a conceptual model describing the process of HPV vaccine acceptance.

Results

We found a nonlinear HPV decision-making process that evolved over time. Initially, the vaccine’s newness, the requirement of written consent, and provision of information were important. If information was sufficient and provided by credible sources, many parents accepted the vaccine. Later, after obtaining additional information from teachers, health personnel, and other trusted sources, more parents accepted vaccination. An understanding of the issues surrounding the vaccine developed, parents overcome fears and rumors, and engaged in family negotiations–including hearing the girl’s voice in the decision-making process. The concept of prevention (cancer as danger, future health, and trust in vaccines) combined with pragmatic factors (no cost, available at school) and the credibility of the offer (information in the media, recommendation of respected authority figure) were central to motivations that led parents to decide to vaccinate their daughters. A lack of confidence in the health system was the primary inhibitor of vaccine acceptance.

Conclusions

Health personnel and teachers are credible sources of information and can provide important support to HPV vaccination campaigns.