Randomised controlled trial of an educational strategy to increase school-based adolescent hepatitis B vaccination

A systematic review and meta-analysis of strategies to promote vaccination uptake

Although immunization can dramatically curb the mortality and morbidity associated with vaccine-preventable diseases, vaccination uptake remains suboptimal in many areas of the world. Here, in this meta-analysis, we analysed the results from 88 eligible randomized controlled trials testing interventions to increase vaccination uptake with 1,628,768 participants from 17 countries with variable development levels (for example, Human Development Index ranging from 0.485 to 0.955). We estimated the efficacy of seven intervention strategies including increasing access to vaccination, sending vaccination reminders, providing incentives, supplying information, correcting misinformation, promoting both active and passive motivation and teaching behavioural skills. We showed that the odds of vaccination were 1.5 (95% confidence interval, 1.27 to 1.77) times higher for intervention than control conditions. Among the intervention strategies, using incentives and increasing access were most promising in improving vaccination uptake, with the access strategy being particularly effective in countries with lower incomes and less access to healthcare.

Increasing vaccinations through an on-site school-based education and vaccination program: A city-wide cluster randomized controlled trial

Vaccination rates for mumps, measles, and rubella (MMR) and tetanus, diphtheria, pertussis, and polio (Tdap-IPV) fall short of global targets, highlighting the need for vaccination interventions. This study examines the effectiveness of a city-wide school-based educational vaccination intervention as part of an on-site vaccination program aimed at increasing MMR and Tdap-IPV vaccination rates versus on-site vaccination alone among sociodemographically diverse students from Berlin, Germany. The study was a 1:1 two-arm cluster randomized controlled trial, with schools randomly assigned to either the Educational Class Condition (ECC) or the Low-Intensity Information Condition (LIIC). Both received an on-site vaccination program, while students in the ECC received an additional educational unit. Primary outcomes were MMR and Tdap-IPV vaccination rates. In total, 6512 students from 25 randomly selected urban area secondary schools participated. For students providing their vaccination documents on the day of the intervention (2273, 34.9%), adjusted Poisson mixed models revealed significant between-group differences in favor of the ECC (MMR: logRR = 0.47, 95%CI [0.01,0.92], RR = 1.59; Tdap-IPV: logRR = 0.28, 95%CI [0.10,0.47], RR = 1.32). When adjusting for socioeconomic and migration background, between-group differences became non-significant for MMR but remained significant for Tdap-IPV. Findings suggest that educational, school-based on-site vaccination appears to be a promising strategy for increasing vaccination uptake in adolescents.

Perceived facilitators and barriers to the uptake of the human papillomavirus (HPV) vaccine among adolescents of Arabic-speaking mothers in NSW, Australia: A qualitative study

Background

Australia has a large immigrant population but there is little data regarding whether human papillomavirus (HPV) vaccination coverage in adolescents varies according to parents' cultural or ethnic background. This work aims to identify facilitators and barriers to HPV vaccination of adolescents as perceived by Arabic-speaking mothers in Western Sydney, South Western Sydney and Wollongong, NSW, Australia.

Methods

A purposive sampling approach was applied to recruit mothers of adolescents from Arabic speaking backgrounds who had at least one child eligible for the HPV school-based vaccination program. Face-to-face semi-structured well as online interviews were conducted in Arabic between April 2021 and July 2021. The interviews were audio-recorded, transcribed, and translated into English and examined using thematic analysis.

Results

Sixteen mothers of adolescents from Arabic backgrounds described facilitators and barriers to HPV vaccination. A) Facilitators of HPV vaccination included: knowledge of HPV disease, trust in the school vaccination program, opportunistic recommendations from healthcare workers, information from friends. B) Barriers to accessing HPV vaccination included communication gaps: breakdown in school-parent information flow, lack of access to the Arabic language version of the information sheet, mother - GP communication barriers, mother-child communication gap; and health system gaps: missed opportunities for vaccination. C) Mothers' suggestions to improve HPV vaccination acceptance: to involve religious and cultural leadership, encourage engagement with GPs, and provide school-based education for parents and students.

Conclusion

Parents could benefit from assistance with HPV vaccination decision making. Interventions via schools, health professionals and religious and cultural organisations could play important roles in HPV vaccination acceptance for Arabic speaking immigrant families and in introducing their adolescent children to this vaccine.

Interventions to Improve Immunization Coverage Among Children and Adolescents: A Meta-analysis

BACKGROUND AND OBJECTIVES

Vaccinations are recognized as a feasible, cost-effective public health intervention for reducing the burden and associated mortality of many infectious diseases. The purpose of this study was to evaluate the effectiveness of potential interventions to improve the uptake of vaccines among children and adolescents.

METHODS

We performed a literature search until December 2020. Eligible studies were identified using Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, and other sources. We included studies conducted on children and adolescents aged 5 to 19 years. Studies comprised of hospitalized children and those with comorbid conditions were excluded. Two authors independently performed the meta-analysis.

RESULTS

Findings from 120 studies (123 articles), of which 95 were meta-analyzed, reveal that vaccination education may increase overall vaccination coverage by 19% (risk ratio [RR], 1.19; 95% confidence interval [CI], 1.12-1.26), reminders by 15% (RR, 1.15; 95% CI, 1.11-1.18), interventions for providers by 13% (RR, 1.13; 95% CI, 1.07-1.19), financial incentives by 67% (RR, 1.67; 95% CI, 1.40-1.99), and multilevel interventions by 25% (RR, 1.25; 95% CI, 1.10-1.41). The impact of school-based clinics and policy and legislation on overall vaccination coverage is still uncertain, and no impact of a multicomponent intervention on overall vaccination coverage was found.

CONCLUSIONS

Educational interventions, reminders, provider-directed interventions, financial incentives, and multilevel interventions may improve vaccination coverage among school-aged children and adolescents.

A school-based educational on-site vaccination intervention for adolescents in an urban area in Germany: feasibility and psychometric properties of instruments in a pilot study

Background

Vaccination rates for measles, mumps, and rubella (MMR) and diphtheria, tetanus, pertussis, and polio (Tdap-IPV) are not optimal among German adolescents. Education in combination with easy access to vaccination may be a promising approach to improve vaccination rates. The present paper describes a pilot study of a planned cluster randomized controlled trial (cRCT) in which we aim to improve MMR and Tdap-IPV vaccination rates together with knowledge and self-efficacy in a school setting.

Methods

The study covered 863 students from 41 classes of four schools. The optimization and feasibility of access to schools, recruitment strategies, intervention, and assessment procedures were examined. The course and content of the educational unit were evaluated with a mixed-methods approach. A pre-post measurement design was tested for the vaccination rate in all schools. Additionally, at two schools, improvement in vaccination-related knowledge and perceived self-efficacy were measured by questionnaire pre-educational unit (n=287) and post-educational unit (n=293). The remaining two schools provided only postintervention data. Finally, we evaluated the psychometric properties (i.e., reliability, retest reliability, and change rates) of the questionnaire, applying Cronbach’s alpha, factor analyses, generalized estimating equations and linear mixed models.

Results

The findings of the pilot study indicated good feasibility. Of the total sample, 437 students (50.9%) brought their vaccination cards to school, 68 students received Tdap-IPV vaccinations, and 11 received MMR vaccinations. Out of six knowledge questions, on average, the students had M=2.84 (95% CI [2.69, 3.10]) correct answers before and M=4.45 (95% CI [4.26, 4.64]) after the class. Ranging from 1 to 4, the self-efficacy scale changed by 0.3 points (p <.001); Cronbach’s alpha was 0.67 and 0.76 pre- and post-educational unit, respectively, and a one-factor solution was found. Content analysis of the five semistructured group interviews (n=12, 58.3% female) showed that all students found the length of the intervention to be appropriate. The teaching methods, including interactive and social media components, were perceived as very good.

Conclusions

A school-based educational and on-site vaccination intervention appears to be feasible in terms of procedures and the adequacy of the instruments for the adolescent target group.

Trial registration

ISRCTN, ISRCTN18026662. Pilot study for main trial registered 8 December 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12443-8.

Improving vaccination uptake among adolescents

BACKGROUND

Adolescent vaccination has received increased attention since the Global Vaccine Action Plan's call to extend the benefits of immunisation more equitably beyond childhood. In recent years, many programmes have been launched to increase the uptake of different vaccines in adolescent populations; however, vaccination coverage among adolescents remains suboptimal. Therefore, understanding and evaluating the various interventions that can be used to improve adolescent vaccination is crucial.

OBJECTIVES

To evaluate the effects of interventions to improve vaccine uptake among adolescents.

SEARCH METHODS

In October 2018, we searched the following databases: CENTRAL, MEDLINE Ovid, Embase Ovid, and eight other databases. In addition, we searched two clinical trials platforms, electronic databases of grey literature, and reference lists of relevant articles. For related systematic reviews, we searched four databases. Furthermore, in May 2019, we performed a citation search of five other websites.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series studies of adolescents (girls or boys aged 10 to 19 years) eligible for World Health Organization-recommended vaccines and their parents or healthcare providers.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened records, reviewed full-text articles to identify potentially eligible studies, extracted data, and assessed risk of bias, resolving discrepancies by consensus. For each included study, we calculated risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI) where appropriate. We pooled study results using random-effects meta-analyses and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 16 studies (eight individually randomised trials, four cluster randomised trials, three non-randomised trials, and one controlled before-after study). Twelve studies were conducted in the USA, while there was one study each from: Australia, Sweden, Tanzania, and the UK. Ten studies had unclear or high risk of bias. We categorised interventions as recipient-oriented, provider-oriented, or health systems-oriented. The interventions targeted adolescent boys or girls or both (seven studies), parents (four studies), and providers (two studies). Five studies had mixed participants that included adolescents and parents, adolescents and healthcare providers, and parents and healthcare providers. The outcomes included uptake of human papillomavirus (HPV) (11 studies); hepatitis B (three studies); and tetanus-diphtheria-acellular-pertussis (Tdap), meningococcal, HPV, and influenza (three studies) vaccines among adolescents. Health education improves HPV vaccine uptake compared to usual practice (RR 1.43, 95% CI 1.16 to 1.76; I² = 0%; 3 studies, 1054 participants; high-certainty evidence). In addition, one large study provided evidence that a complex multi-component health education intervention probably results in little to no difference in hepatitis B vaccine uptake compared to simplified information leaflets on the vaccine (RR 0.98, 95% CI 0.97 to 0.99; 17,411 participants; moderate-certainty evidence). Financial incentives may improve HPV vaccine uptake compared to usual practice (RR 1.45, 95% CI 1.05 to 1.99; 1 study, 500 participants; low-certainty evidence). However, we are uncertain whether combining health education and financial incentives has an effect on hepatitis B vaccine uptake, compared to usual practice (RR 1.38, 95% CI 0.96 to 2.00; 1 study, 104 participants; very low certainty evidence). Mandatory vaccination probably leads to a large increase in hepatitis B vaccine uptake compared to usual practice (RR 3.92, 95% CI 3.65 to 4.20; 1 study, 6462 participants; moderate-certainty evidence). Provider prompts probably make little or no difference compared to usual practice, on completion of Tdap (OR 1.28, 95% CI 0.59 to 2.80; 2 studies, 3296 participants), meningococcal (OR 1.09, 95% CI 0.67 to 1.79; 2 studies, 3219 participants), HPV (OR 0.99, 95% CI 0.55 to 1.81; 2 studies, 859 participants), and influenza (OR 0.91, 95% CI 0.61 to 1.34; 2 studies, 1439 participants) vaccination schedules (moderate-certainty evidence). Provider education with performance feedback may increase the proportion of adolescents who are offered and accept HPV vaccination by clinicians, compared to usual practice. Compared to adolescents visiting non-participating clinicians (in the usual practice group), the adolescents visiting clinicians in the intervention group were more likely to receive the first dose of HPV during preventive visits (5.7 percentage points increase) and during acute visits (0.7 percentage points for the first and 5.6 percentage points for the second doses of HPV) (227 clinicians and more than 200,000 children; low-certainty evidence). A class-based school vaccination strategy probably leads to slightly higher HPV vaccine uptake than an age-based school vaccination strategy (RR 1.09, 95% CI 1.06 to 1.13; 1 study, 5537 participants; moderate-certainty evidence). A multi-component provider intervention (including an education session, repeated contacts, individualised feedback, and incentives) probably improves uptake of HPV vaccine compared to usual practice (moderate-certainty evidence). A multi-component intervention targeting providers and parents involving social marketing and health education may improve HPV vaccine uptake compared to usual practice (RR 1.41, 95% CI 1.25 to 1.59; 1 study, 25,869 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Various strategies have been evaluated to improve adolescent vaccination including health education, financial incentives, mandatory vaccination, and class-based school vaccine delivery. However, most of the evidence is of low to moderate certainty. This implies that while this research provides some indication of the likely effect of these interventions, the likelihood that the effects will be substantially different is high. Therefore, additional research is needed to further enhance adolescent immunisation strategies, especially in low- and middle-income countries where there are limited adolescent vaccination programmes. In addition, it is critical to understand the factors that influence hesitancy, acceptance, and demand for adolescent vaccination in different settings. This is the topic of an ongoing Cochrane qualitative evidence synthesis, which may help to explain why and how some interventions were more effective than others in increasing adolescent HPV vaccination coverage.

Optimising informed consent in school-based adolescent vaccination programmes in England: A multiple methods analysis

The process of obtaining informed consent for school-based adolescent immunisation provides an opportunity to engage families. However, the fact that parental consent needs to be obtained remotely adds complexity to the process and can have a detrimental effect on vaccine uptake. We conducted a multiple methods analysis to examine the practice of obtaining informed consent in adolescent immunisation programmes. This involved a thematic analysis of consent related data from 39 interviews with immunisation managers and providers collected as part of a 2017 service evaluation of the English adolescent girls' HPV vaccine programme and a descriptive statistical analysis of data from questions related to consent included in a 2017 survey of parents' and adolescents' attitudes to adolescent vaccination. The findings indicated that the non-return of consent forms was a significant logistical challenge for immunisation teams, and some were piloting opt-out consent mechanisms, increasing the proportion of adolescents consenting for their own immunisations, and introducing electronic consent. Communicating vaccine related information to parents and schools and managing uncertainties about obtaining adolescent self-consent for vaccination were the main practical challenges encountered. Survey data showed that parents and adolescents generally agreed on vaccine decisions although only 32% of parents discussed vaccination with their teenager. Parental awareness about the option for adolescents to self-consent for vaccination was limited and adolescents favoured leaving the decision-making to parents. From the interviews and variability of consent forms it was evident that health professionals were not always clear about the best way to manage the consent process. Some were also unfamiliar with self-consent processes and lacked confidence in assessing for 'Gillick competency'. Developing pathways and related interventions to improve the logistics and practice of consent in school-based adolescent immunisation programmes could help improve uptake.

The effect of exercise on vaccine-related pain, anxiety and fear during HPV vaccinations in adolescents

INTRODUCTION

With increased school-based vaccinations for improved coverage rates and practicality, the World Health Organization (WHO) recently endorsed research to identify possible interventions to reduce vaccine-related pain in mass clinical and school-based settings. In particular, the lack of research in adolescents indicate a particular need in this population. Acute exercise has analgesic effects and has been used as a behavioural adjuvant to vaccination. Here, we examine the effect of exercise on vaccine-related pain, anxiety and fear in adolescents, during a school-based program for HPV vaccinations.

METHODS

116 students (Female: 61, Male: 55) aged 11-13 years were randomly allocated to either an Exercise (n = 60) or Control (n = 56) group. All participants completed demographic and Trait-anxiety questionnaires prior to receiving the vaccine according to usual care. The Exercise group also performed upper body exercise for 15 min prior to receiving the vaccine. Immediately after the vaccine administration, all participants reported on pain, anxiety and fear at the time of receiving the vaccine.

RESULTS

Female adolescents in the Exercise group reported significantly less pain (3.64; 95% CI, 2.98-4.30) than Controls (4.58; 95% CI, 3.96-5.19; p = 0.04). Further, females reported greater pain and anxiety than males in the Control group but not the Exercise group.

CONCLUSION

This study supports the use of exercise prior to vaccine administration, especially in female adolescents who are particularly vulnerable to negative experiences during vaccination procedures. Furthermore, the ease of application, as well as the benefit of exercise, provides support for the use of simple exercise prior to vaccination in mass vaccination settings. Clinical trial registry: ANZCTR, ACTRN12614001185651.

HPV.edu study protocol: a cluster randomised controlled evaluation of education, decisional support and logistical strategies in school-based human papillomavirus (HPV) vaccination of adolescents

Background

The National Human Papillomavirus (HPV) Vaccination Program in Australia commenced in 2007 for females and in 2013 for males, using the quadrivalent HPV vaccine (HPV 6,11,16,18). Thus far, we have demonstrated very substantial reductions in genital warts and in the prevalence of HPV among young Australian women, providing early evidence for the success of this public health initiative. Australia has a long history of school-based vaccination programs for adolescents, with comparatively high coverage. However, it is not clear what factors promote success in a school vaccination program. The HPV.edu study aims to examine: 1) student knowledge about HPV vaccination; 2) psycho-social outcomes and 3) vaccination uptake.

Methods/Design

HPV.edu is a cluster randomised trial of a complex intervention in schools aiming to recruit 40 schools with year-8 enrolments above 100 students (approximately 4400 students). The schools will be stratified by Government, Catholic, and Independent sectors and geographical location, with up to 20 schools recruited in each of two states, Western Australia (WA) and South Australia (SA), and randomly allocated to intervention or control (usual practice). Intervention schools will receive the complex intervention which includes an adolescent intervention (education and distraction); a decisional support tool for parents and adolescents and logistical strategies (consent form returns strategies, in-school mop-up vaccination and vaccination-day guidelines). Careful process evaluation including an embedded qualitative evaluation will be undertaken to explore in depth possible mechanisms for any observed effect of the intervention on primary and secondary outcomes.

Discussion

This study is the first to evaluate the relative effectiveness of various strategies to promote best practice in school-based vaccination against HPV. The study aims to improve vaccination-related psychosocial outcomes, including adolescent knowledge and attitudes, decision-making involvement, self-efficacy, and to reduce fear and anxiety. The study also aims to improve school vaccination program logistics including reduction in time spent vaccinating adolescents and increased number of consent forms returned (regardless of decision). Less anxiety in adolescents will likely promote more efficient vaccination, which will be more acceptable to teachers, nurses and parents. Through these interventions, it is hoped that vaccination uptake will be increased.

Trial registration

Australian and New Zealand Clinical Trials Registry, ACTRN12614000404628, 14.04.2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2168-5) contains supplementary material, which is available to authorized users.

Does an education seminar intervention improve the parents' knowledge on vaccination? Evidence from Yiwu, East China

BACKGROUND

caregivers' knowledge on vaccination is an important impact factor for their children's vaccination status. The aims of this study were to evaluate the caregivers' knowledge of vaccination, and to assess effectiveness of a health education seminar for improving caregivers' knowledge on immunization.

METHODS

pre- and post-assessment design was adopted for a single group to evaluate the effectiveness of the health education seminar on vaccination. The seminar consisted of a lecture using simple understandable language. Improvements in total knowledge score before and after the seminar were assessed using a validated questionnaire that included ten questions. Description analysis and non-parametric tests were applied to evaluate and compare the vaccination knowledge level before and after the seminar.

RESULTS

378 caregivers participated in this study. The majority were mothers. Of the ten questions, the correct response rates had significantly increased for nine questions after the education seminar. The mean total score of the assessment before the seminar was 5.2 ± 1.2 while that was 8.4 ± 0.9 for the assessment after the seminar, with a significant increase of 3.18 points.

CONCLUSION

a short education seminar designed for caregivers had a remarkable effect on their vaccination knowledge. Health education on vaccination targeting migrant caregivers, caregivers with lower education level or household income, and employed caregivers are needed in future.

Markers of hepatitis B infection and immunity in patients attending Aboriginal community controlled health services

OBJECTIVE

Hepatitis B virus (HBV) infection remains an important cause of morbidity and mortality in Aboriginal and Torres Strait Islander people, who have high rates of infection compared with non-Indigenous Australians. We aimed to increase the evidence base around HBV in Aboriginal and Torres Strait Islander people through an analysis of routine clinical encounter data.

DESIGN

A cross-sectional study of de-identified records from electronic patient systems over 5 years (8 January 2009 to 11 July 2013).

SETTING

Four Aboriginal community controlled health services.

PARTICIPANTS

All patients attending for a clinical visit were included in the study. Hepatitis B testing records were included if at least one serological test for HBV was done.

MAIN OUTCOME MEASURES

Percentage of clinical patients tested for hepatitis B, compliance with guidelines and serological status.

RESULTS

A total of 2959 people aged 15-54 years were screened for HBV, representing 17.2% of all people with a clinical visit in the study period. A total of 865 Aboriginal patients were tested concurrently for hepatitis B surface antigen (HBsAg), hepatitis B core antibody and hepatitis B surface antibody. Of those, 352 (40.7%) were susceptible to HBV infection (95% CI, 37.4%-43.9%) and 34 (3.9%) had either an acute or chronic infection indicated by a positive HBsAg result (95% CI, 2.6%-5.2%). In 329 women with antenatal screening, six (1.8%) returned a positive HBsAg result (95% CI, 0.37%-3.28%).

CONCLUSION

A substantial proportion of patients tested were susceptible to HBV, with a high percentage potentially infectious compared with the general population. High levels of active infection and susceptibility to infection suggest many opportunities for transmission and indicate the potential benefit of routine HBV testing and vaccination in this population.

A qualitative study investigating knowledge and attitudes regarding human papillomavirus (HPV) and the HPV vaccine among parents of immunosuppressed children

Barriers influencing the willingness of parents to vaccinate immunocompetent children include a lack of knowledge about human papillomavirus (HPV) and low perception of risk regarding their child's acquisition of HPV infection. However, it cannot be assumed that the facilitators and barriers of HPV vaccination are the same for parents/guardians of children who are immunocompromised, or who have chronic medical conditions. This study aimed to document the knowledge and attitudes of parents/guardians of immunosuppressed children and adolescents towards HPV infection and the vaccine. A study using qualitative methods which incorporated 27 semi-structured interviews was undertaken with parents/guardians of immunosuppressed children vaccinated against HPV at three hospitals in two states of Australia. Thematic analysis revealed that while participants acknowledged that they had heard of HPV, they did not have a strong sense of what it actually was. The level of concern held about their child acquiring an HPV infection (prior to vaccination) ranged from 'not at all' to 'extremely'. Some believed that their child was at increased risk of developing a severe HPV-related illness because of their underlying condition. The participants supported their child receiving the HPV vaccine, as they did not want to take a risk with a disease that may cause their child to return to hospital for treatment. The majority had little apprehension about the use of the HPV vaccine but expressed some concern that potential adverse effects would be more severe for immunosuppressed children. However, they stressed their belief in the safety of the vaccine and their trust in the child's health team. Our study results show that parents of children with impaired immunity would benefit from further information about the safety of the vaccine and about the important role of the vaccine for boys as well as girls.

Adolescent and young adult HPV vaccination in Australia: achievements and challenges

Australia commenced an ongoing school based government funded human papillomaviruses (HPV) (cervical cancer prevention) vaccination program in April 2007 for adolescent females aged 12-13 years. In addition, up to December 31, 2009, a catch-up program for young females 13-26 years of age was offered: a school-based vaccination program was used to offer HPV vaccine to girls enrolled in school (14-17 years), and general practitioners or other community health provider offered vaccine to young women aged 18-26 years. To date, only the quadrivalent vaccine (HPV 6/11/16/18) has been utilized in the funded program. Acceptance of the vaccine is high with coverage of 3 doses of the HPV vaccine in the school age cohort around 70%, and just over 30% in the older age cohort. Since the vaccination program was initiated, a reduction in new cases of genital warts of 73% among vaccine eligible age females has been evidenced in STI clinics across Australia. A reduction of 44% of new cases in young males (not a part of the free program) was also documented during this same time period, suggesting significant herd immunity. Similarly, in the state of Victoria, a small but significant decrease in high grade abnormalities in Pap screening findings has been reported in young women<18 years for the period 2007-9, as compared to pre-vaccination. Challenges for the future include how we can sustain and improve HPV vaccination coverage in young Australian women, while maintaining cervical cancer screening participation and reviewing cervical cancer screening methods.

A model program for hepatitis B vaccination and education of schoolchildren in rural China

OBJECTIVES

Incomplete hepatitis B virus (HBV) vaccine coverage and poor HBV-related knowledge in China leave millions of children unprotected from this life-threatening infection. To address these gaps, a pilot program for HBV education and vaccination was launched in rural China.

METHODS

In 2006, public and private organizations in the US and China collaborated to provide HBV education and vaccination to 55,000 school-age children in the remote, highly HBV-endemic area of Qinghai Province. The impact of the educational program on HBV-related knowledge was evaluated among more than 2,800 elementary school students.

RESULTS

Between September 2006 and March 2007, the three-shot hepatitis B vaccine series was administered to 54,680 students, with a completion rate of 99.4%. From low pre-existing knowledge levels, classroom educational sessions statistically significantly increased knowledge about HBV risks, symptoms, transmission, and prevention.

CONCLUSIONS

This program offers an effective and sustainable model for HBV catch-up vaccination and education that can be replicated throughout China, as well as in other underserved HBV-endemic regions, as a strategy to reduce chronic HBV infection, liver failure, and liver cancer.

"Is cancer contagious?": Australian adolescent girls and their parents: making the most of limited information about HPV and HPV vaccination

INTRODUCTION

Australia has implemented a nation-wide program providing HPV vaccination to girls at school. To date, there are no published studies that explore knowledge about HPV and HPV vaccine post-implementation of the national school-based HPV vaccination program.

METHODS

A purposive sample of schools was selected to reflect a range of vaccination coverage (high versus lower uptake), and different school types (Catholic, Independent or Government). Semi-structured focus groups and interviews were conducted with girls and their parents respectively, until saturation was reached. Transcripts were analysed, letting themes emerge from the data.

RESULTS

A core theme from both girls and parents was lack of knowledge. Supporting themes were lack of knowledge of HPV, lack of knowledge of vaccine, and realisation of their lack of knowledge. Their lack of knowledge was common in three areas: what HPV is, how HPV is transmitted, and the HPV and cervical cancer connection. The lack of knowledge about HPV vaccination was reflected in what the vaccine protects against, how the vaccine works, HPV vaccination recommendations, the vaccine and Pap smear connection, and myths about HPV vaccination. Both girls and parents wanted more information, had a tendency to defer responsibility, and parents expressed judgment of themselves as parents.

DISCUSSION

Low levels of knowledge and understanding about HPV vaccination among adolescents and parents have implications for adolescents' future health practices, including sexual risk behaviour, condom usage, and cervical screening. Reasons for the low levels of knowledge are explored, as are implications for school-based educational interventions.

Interventions for young people in Australia to reduce HIV and sexually transmissible infections: a systematic review

Background: Like young people in other developed countries, sexually active young Australians can have an increased risk of acquiring sexually transmissible infections (STIs). This paper reviews intervention programs that aim to reduce the incidence and transmission of HIV and STIs among young people in Australia. Methods: Articles were identified from seven databases. Intervention studies conducted in Australia that included young people aged 12–25 years were reviewed. A two-dimensional matrix consisting of ‘setting’ and ‘intervention type’ was developed to categorise each study. Results: Forty-two studies met the inclusion criteria, and the majority were uncontrolled intervention studies. Of these, 23/42 studies measured participation in chlamydia ± other STI testing and found that the highest participation rates took place in non-clinical and non-general practice health care settings. Four studies facilitated access to testing indirectly, through the internet or other media. Ten studies involved the provision of education and measured its impact on factors such as knowledge, attitudes and/or behaviour. Three studies involved novel immunisation strategies for either hepatitis B or human papillomavirus vaccines. Two studies evaluated the impact of enhanced STI surveillance programs on prevalence rates. Conclusions: Proactive STI testing in non-clinical and some health settings appears feasible and achieves higher testing rates than in general practice; however, more evaluation of testing strategies in general practice settings is required. New technologies such as the internet and SMS are useful adjuncts for influencing behaviours such as condom use and STI testing. Media campaigns that promote STI testing can have a positive impact on testing rates.

'It's a logistical nightmare!' Recommendations for optimising human papillomavirus school-based vaccination experience

Introduction: To date, no published studies examine procedural factors of the school-based human papillomavirus (HPV) vaccination program from the perspective of those involved. This study examines the factors that were perceived to impact optimal vaccination experience. Methods: Schools across Sydney were selected to reflect a range of vaccination coverage at the school level and different school types to ensure a range of experiences. Semi-structured focus groups were conducted with girls; and one-on-one interviews were undertaken with parents, teachers and nurses until saturation of data in all emergent themes was reached. Focus groups and interviews explored participants’ experiences in school-based HPV vaccination. Transcripts were analysed, letting themes emerge. Results: Themes related to participants’ experience of the organisational, logistical and procedural aspects of the vaccination program and their perceptions of an optimal process were organised into two categories: (1) preparation for the vaccination program and (2) vaccination day strategies. In (1), themes emerged regarding commitment to the process from those involved, planning time and space for vaccinations, communication within and between agencies, and flexibility. In (2), themes included vaccinating the most anxious girls first, facilitating peer support, use of distraction techniques, minimising waiting time girls, and support staff. Discussion: A range of views exists on what constitutes an optimal school-based program. Several findings were identified that should be considered in the development of guidelines for implementing school-based programs. Future research should evaluate how different approaches to acquiring parental consent, and the use of anxiety and fear reduction strategies impact experience and uptake in the school-based setting.

Recommendations for cervical cancer prevention in Asia Pacific

Asia Oceania includes countries from both the Asia Pacific region and Australasia, which cover very diverse geographical areas and populations as well as bearing 52% of the cervical cancer burden in the world. Human papillomavirus (HPV) genotype distribution in women with normal cytology varies between countries in this region, as well as with the distribution typically observed in worldwide estimates or in Western countries. HPV-16 remains the predominant oncogenic type for high-grade cervical dysplasia and cervical cancer across the region, and HPV-18 is generally among the five most common types. HPV-58 is commonly found in cervical cancer as well as in women with normal cytology, and HPV-31, 33 and 35 are relatively less frequent in these regions compared to the West. While screening programmes have been proposed and implemented in several populations, successful programmes are rather limited and the majority of countries still have no or minimal screening services. Prophylactic HPV vaccination will only be feasible when it becomes affordable, thus the current priority and the short-term goal for cervical cancer control is to identify feasible and effective screening measures, and to find the most effective way to combine vaccination with sustainable screening programmes. This Regional Report has carefully described the disease burden of HPV and cervical cancer and the current situations in cervical cancer prevention for many countries in the Asia Oceania region. These data identify the many challenges and opportunities to be considered for policy decisions for cervical cancer control. Furthermore, this report presents the results of advanced decision analytic models calibrated to countries in the region that provide early insight into what strategies are most promising and those likely to be cost-effective and affordable. It thus provides a synthesis of the available evidence-based scientific information, in the context of a significant and systematic international review, that is likely to be useful to governments and public health providers.

Vaccinating young adults against human papillomavirus: the importance of understanding health decision-making and behaviour

Vaccination of young teenage females against human papillomavirus (HPV) with a newly licenced quadrivalent vaccine designed to prevent cervical cancer and genital warts has recently been recommended by the Australian government and will be implemented through schools from April 2007. In addition, a fully funded 'catch-up' vaccination program for young women up to age 26 years has been approved for a 2-year period, from July 2007. As general practitioners (GPs) will be the main immunisation providers for this age group, in order to achieve high vaccination coverage and maximal impact on disease, it will be critical for GPs to be opportunistic in recommending this vaccine. An initial study of young Australians' attitudes towards HPV vaccination and hypothetical acceptance of the vaccine was published in this journal. We draw on this study and data published elsewhere to discuss issues of HPV vaccine acceptability, and the likely challenges of a mass vaccination initiative in this age group in Australia. We suggest specific strategies to support GPs, and highlight areas for further research in HPV vaccine acceptability.

Hepatitis A vaccination options for Australia

The epidemiology of hepatitis A is changing, with an increasing proportion of the population becoming susceptible to infection. The burden of hepatitis A is comparable to that of other vaccine-preventable diseases for which new vaccines are available. Options for vaccination include selective programmes for high-risk groups, which could involve screening prior to vaccination, or universal programmes for infants and/or adolescents. Selective programmes have been shown to be highly cost-effective if well implemented, but there is evidence that they might be poorly implemented. If a universal vaccination programme were considered for Australia, an infant programme, with doses at 18 months and 2 years, possibly with an additional adolescent programme, would be the recommended option. Universal hepatitis A vaccination for infants and/or adolescents is of comparable cost-effectiveness compared with other preventive strategies, but needs to be considered in the context of competing vaccination options.

Comparative immunogenicity and safety of two dosing schedules of a combined hepatitis A and B vaccine in healthy adolescent volunteers: an open, randomised study

An open, randomised study was undertaken to demonstrate the equivalence in immunogenicity and to determine the reactogenicity and safety of two dosing schedules (0, 6 or 0, 12 month) of an adult formulation of a combined hepatitis A and B vaccine containing 720 EL.U. of inactivated hepatitis A antigen and 20 microg of hepatitis B surface antigen (Twinrix, SmithKline Beecham Biologicals, Belgium) in 240 healthy volunteers aged 12-15 years. The vaccine was well tolerated when administered using either vaccination schedule. At month 7, 98.1% of subjects completing the 0, 6 month vaccination schedule were seroprotected against hepatitis B (anti-hepatitis B surface antigen (anti-HBs) > or =10 mIU/ml) and 100% were seropositive for anti-hepatitis A virus (anti-HAV) antibodies (i.e., > or =33 mIU/ml). The corresponding geometric mean titres (GMTs) were 2791 mIU/ml for anti-HBs and 5992 mIU/ml for anti-HAV antibodies. At month 13, 97% of subjects assigned to the 0, 12 month vaccination schedule were protected against hepatitis B and 99% were seropositive for anti-HAV antibodies. The corresponding GMTs were 4340 and 8472 mIU/ml, respectively. A combined response (i.e., subjects, who were seropositive for anti-HAV antibodies and seroprotected for anti-HBs antibodies) was achieved in 98% of subjects vaccinated according to the 0, 6 month interval and in 96% of subjects vaccinated using the 0, 12 month schedule. The reactogenicity of both vaccination schedules was also equivalent. The results thus show that the combined hepatitis A and B vaccine can be administered using flexible vaccination intervals, which make it suitable for use in large-scale hepatitis immunisation programmes.

Adolescent hepatitis B immunisation--should it be the law?

Universal hepatitis B immunisation of young adolescents was included in the Australian Standard Vaccination Schedule in 1998. However, rates of immunisation among adolescents world-wide have often been inadequate. Australia's experience in this area is no exception, particularly in States where school-based delivery is not carried out. Legislation for pre-school immunisation certification currently exists in several States and this legislation is distinctly different from the compulsory or mandatory immunisation that exists in several other developed countries. There have been demonstrable gains in uptake as a result of mandatory immunisation requirements in the United States and there is evidence to suggest that immunisation certification in Australia has also been beneficial. However, it is important to recognise that both certification and mandatory immunisation legislation have inherent difficulties. In this paper, we argue that legislation for high school immunisation certification, as part of a multi-faceted vaccine delivery strategy tailored to adolescents, is required to achieve the uptake that will lead to interruption of transmission of the hepatitis B virus in Australia. Not only will it substantially reduce incident cases of hepatitis B for the next decade, it will also provide a framework for the successful introduction of future adolescent vaccine initiatives in Australia.