The role of human papillomavirus vaccination in promoting delivery of other preventive and medical services

Combining cervical cancer screening for mothers with schoolgirl vaccination during human papillomavirus (HPV) vaccine implementation in South Africa: results from the VACCS1 and VACCS2 trials

OBJECTIVE

The platform provided by human papillomavirus (HPV) vaccination for linked public health interventions to improve cervical cancer prevention remains incompletely explored. The Vaccine And Cervical Cancer Screen (VACCS) cross-sectional observation trials aimed to evaluate the efficacy of school-based HPV vaccination linked with maternal cervical cancer screening.

METHODS

Girls from 29 schools in two provinces in South Africa were invited in writing to receive HPV vaccination. Two approaches to informed consent were compared, namely an audiovisual presentation (VACCS1) and in written format (VACCS2). Markers of vaccine uptake and coverage were calculated, namely uptake among the invited and consented cohorts, and rates of completion and sufficient vaccination. Mothers and female guardians received educational material about cervical cancer, and either a self-sampling device or an invitation to attend existing screening facilities. Knowledge was assessed via structured questionnaires (before and after), and screening uptake was self-reported and directly assessed and compared between these approaches.

RESULTS

Vaccine acceptance among 5137 invited girls was similar for the two methods of consent; 99.3% of consented girls received a first dose; overall completion rate was 90.5%. More girls were vaccinated using a two-dose (974/1016 (95.9%)) than a three-dose regimen (1859/2030 (91.6%)). The questionnaire (n=906) showed poor maternal knowledge which improved significantly (p<0.05) after health education; only 54% of mothers reported any previous screening. The offer of a self-sampling device (n=2247) was accepted by 43.9% of mothers, but only 26% of those invited to screen at existing facilities (n=396) reported subsequent screening.

CONCLUSIONS

Successful linking of primary health interventions to control cervical cancer was demonstrated. School-based HPV vaccination, linked to health education, self-sampling, and molecular screening resulted in significant improvements in knowledge and screening.

Using HPV vaccination for promotion of an adolescent package of care: opportunity and perspectives

Background

Adolescents are a difficult population to access for preventive health care, particularly in less resourced countries. Evidence from developed countries indicates that the HPV vaccine schedule may be a useful platform from which to deliver other adolescent health care services. We conducted a qualitative cross sectional study to assess the potential for using the HPV vaccine in the South African public health care system as an opportunity for integrated health care services for adolescents.

Methods

Parents, young adolescents, community members and key informants participated in interviews and focus group discussions about feasibility and acceptability, particularly the use of the HPV vaccination as the basis for an integrated adolescent package of care. Health care providers in both provinces participated in focus group discussions and completed a pairwise ranking exercise to compare and prioritise interventions for inclusion in an adolescent package of care.

Results

Participants were in favour of integration and showed preference for detailed information about the HPV vaccine, general health information and specific sexual and reproductive health information. Among health care workers, results differed markedly by location. In North West, prioritisation was given to information, screening and referral for tobacco and alcohol abuse, and screening for hearing and vision. In Gauteng integration with referral for male circumcision, and information, screening and referral for child abuse were ranked most highly.

Conclusions

There is generally support for the delivery of adolescent preventive health services. Despite national priorities to address adolescent health needs, our data suggest that national policies might not always be appropriate for vastly different local situations. While decisions about interventions to include have traditionally been made at country level, our results suggest that local context needs to be taken account of. We suggest low resource strategies for ensuring that national policies are introduced at local level in a manner that addresses local priorities, context and resource availability.

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.

Coordinating the delivery of vaccinations and other preventive health care recommendations for adolescents

Although recommendations for annual preventive care for adolescents have been in place for decades, the need to bring adolescents to the medical setting for newly recommended vaccines has placed this issue in the public health spotlight. Aggressive efforts have been ongoing to increase adolescent adherence to new vaccine recommendations--a measured outcome variable, and the hope has been that enhanced adherence to comprehensive health care visits will follow. Evidence indicates that the implementation of more comprehensive preventive health care elements among adolescents may be improving; however, a passive approach to bringing more adolescents to preventive health visits using vaccine as an incentive may not be effective for all youth. This paper reviews the history of recommendations for new vaccines as well as comprehensive health care visit recommendations for adolescents, how these recommendations may synergistically improve preventive care for adolescents, and how we may need to continue to think creatively to further access all youth for preventive health care using vaccination implementation as a model for reaching out beyond the providers' office walls.