School-based Vaccination Research Articles

What do adolescents think about vaccines? Systematic review of qualitative studies.

Adolescence presents a key opportunity to build vaccine-related health literacy and promote vaccine confidence and uptake. Although adolescents are central to vaccination programs, their views around vaccines are frequently underrepresented in qualitative literature. We reviewed qualitative studies to systematically identify and summarize existing evidence on adolescents' own understanding of vaccines and experiences with vaccine decision-making, including self-consent when applicable. CINAHL; Embase; Ovid Medline; and Psych Info database searches were last updated on May 28, 2022. Data pertaining to general study characteristics, participant demographics, and qualitative content were extracted independently by two reviewers and analyzed using textual narrative synthesis. Out of 3559 individual records, 59 studies were included. The majority of the studies were conducted in high-income countries and 75% focused on human papilloma virus vaccines, with the remaining studies looking at COVID-19, meningococcal, hepatitis B and influenza vaccines or adolescent experiences with vaccines in general. Adolescent self-consent was explored in 7 studies. Perspectives from sexual and gender minorities were lacking across studies. Adolescents often had limited understanding of different vaccines and commonly perceived vaccine information to be directed towards their parents rather than themselves. Many adolescents felt school-based vaccine education and information available through healthcare providers were insufficient to make informed decisions about vaccines. While adolescents described obtaining vaccine information from traditional and online media, face-to-face interactions and opinions from trusted adults remained important. Adolescents generally relied on their parents for vaccine-decision making, even when self-consent was an option. A notable exception to this included marginalized adolescents who could not rely on parents for health-related advice. Qualitative literature about adolescent vaccines would be enriched by studies examining vaccines other than the HPV vaccine, studies examining adolescent vaccine programs in low and middle-income countries, and by deliberately eliciting vaccine experiences of adolescent with diverse sexual orientation and gender identities.

School-based COVID-19 vaccination programmes: An equitable strategy to reduce the impact of COVID-19 on children and their families

School-based COVID-19 vaccination programmes: An equitable strategy to reduce the impact of COVID-19 on children and their families

Challenges and lessons from a school-based human papillomavirus (HPV) vaccination program for adolescent girls in a rural Nigerian community

BackgroundOver 80% of new cervical cancer cases occur in women living in low- and middle-income countries. It is the second highest cause of female cancer deaths in Nigeria. School based vaccination programs are an effective strategy for delivering the HPV vaccine to adolescent girls. This study aims to understand the challenges to implementing school-based HPV vaccination programs, particularly in a remote rural setting where vaccine hesitancy is high.MethodsA 22- item interviewer administered questionnaire was used to evaluate HPV knowledge and willingness to get the HPV vaccinate among 100 female secondary school students as part of an HPV vaccination pilot in a rural community in Kebbi State, Nigeria. Additionally, semi-structured interviews were used to assess community knowledge and attitudes on cervical cancer and HPV vaccination. Data collected were analyzed thematically to understand challenges and generate lessons for vaccine delivery in the study setting.ResultsKnowledge of HPV and cervical cancer among junior secondary school aged girls was fair with a mean score of 66.05%. For senior secondary school aged girls, the knowledge score ranged from 70 to 100% with a mean of 96.25% indicating good knowledge of HPV and cervical cancer. All participants (n = 100) received the first vaccine dose but due to COVID-19, 33 participants were not able to complete the vaccine dosage within the recommended 6-month schedule. Of the parents who provided consent, none could afford the vaccine out of pocket. Challenges to vaccine delivery included operational costs exacerbated by lack of adequate health workforce and infrastructure in the study setting.ConclusionAn exploration of sociocultural perspectives and contextual realities is crucial to understanding the complexities of HPV vaccine introduction from the perspective of the target audience, and the local community. Strategies for introducing the HPV vaccine should address community concerns through effective communication, appropriate delivery, and targeted advocacy to make the vaccination program locally relevant. While school-based HPV immunization programs have been shown to be successful, adequate design, planning and monitoring is important. Additionally, considerations must be made to account for the high operational cost of vaccine delivery in rural, hard to reach areas where human resources and infrastructure are limited.

Modeling the transmission dynamics and vaccination strategies for human papillomavirus infection: An optimal control approach

Human papillomavirus (HPV) vaccines have been introduced in several countries and have shown positive results in reducing HPV infection and related diseases. Nevertheless, immunization programs remain sub-optimal and more effort is needed to design efficient vaccination deployment. We formulate a two-sex deterministic mathematical model that incorporates the most important epidemiological features of HPV infection and associated cancers. To assess the population-level impact of HPV immunization programs, the model incorporates school-based vaccine delivery for juveniles and catch-up vaccination for adults. The dynamics of the model are rigorously analyzed using the next-generation operator, the center manifold theorem, and normal forms theory. We formulate an optimal control problem to determine the best deployment strategy for HPV vaccination for several plausible scenarios. We establish the existence of solutions of the optimal control problem, and use Pontryagin’s Maximum Principle to characterize the necessary conditions for optimal control solutions. The findings suggest that if girls-only programs are complemented with catch-up vaccination for adult females, such program has the potential to achieve HPV-associated cancers eradication even if boys and males do not receive the vaccine. We also find that the optimal vaccine deployment, in terms of minimizing HPV associated diseases and the cost of vaccination, is to allocate as much vaccines as possible at the initial phase of the epidemic and once a high vaccination coverage is reached then gradually decrease vaccination rates.

The needle pricking and two modes of 'doing good' in the Swedish school-based human papillomavirus vaccination programme.

In this article, we draw on science and technology studies literature on care practices to analyse school nurses’ work with human papillomavirus (HPV) vaccination in schools, in the context of a new vaccination policy including all children in the fifth grade in Sweden. Drawing on 21 interviews with school nurses working in municipalities across a larger Swedish region, we focus on the mundane work of handling the vaccination and supporting the children while they are being vaccinated. We utilise the notion of ‘modes of doing good’ to analyse routines and ideals oriented towards specific, and sometimes contradictory, forms of ‘good care’ in HPV vaccination practice. Two modes of doing good are identified: the vaccination as a caring for ‘the flow’ of children getting vaccinated and the vaccination as a caring about the specific child. We analyse three ‘child subjects’ alongside these modes: the informed and already prepared child, the anxious child, and the specific child. By identifying tensions and interferences between different child subjects and modes of doing good, we discuss possible consequences of our findings for how HPV vaccination is envisioned and conceptualised in social science research and in policy settings.

Human Papillomavirus Vaccinations During the COVID-19 Pandemic in Middle Schools in the Rio Grande Valley of Texas.

This quasi-experimental study (a community-based, physician-led human papillomavirus [HPV] education campaign and school-based vaccination program) followed 6481 students at eight Pharr-San Juan-Alamo Independent School District (Rio Grande Valley, Texas) middle schools between August 2016 and March 2021. We describe the successes and challenges experienced during the COVID-19 pandemic. HPV vaccine initiation and completion rates increased 1.29-fold and 1.47-fold, respectively, between June 2019 and March 2021. Between March 2020 and March 2021, 268 HPV vaccine doses were provided through 24 school-based interventions. Our program continued successes seen in increasing HPV vaccination rates and reducing possible HPV-associated cancers. (Am J Public Health. 2022;112(9):1269-1272. https://doi.org/10.2105/AJPH.2022.306970).

HPV vaccination literacy in sexualities education

ABSTRACT Drawing on curriculum examples from Australia and Canada, we outline three key elements to support the development school-based HPV vaccination literacy for young people: (1) knowledge and understanding about HPV and HPV vaccination; (2) the scientific principles underpinning vaccination; and (3) the socio-political factors influencing HPV vaccination. These elements benefit from cross-curricular integration and a whole-of-school approach. Educating young people about HPV and HPV vaccination improves their vaccination knowledge and understanding, health literacy and vaccination-related psychosocial outcomes.

Impact of a Papillomavirus Vaccination Promotion Program in Middle School: Study Protocol for a Cluster Controlled Trial.

BackgroundOn Reunion Island, incidence and mortality for uterine cervical cancer is high, yet coverage rate for human papillomavirus (HPV) vaccination is low.ObjectiveThe main objective of the study is to evaluate the impact of a health promotion program promoting HPV vaccination on the proportion of middle school girls who complete the full HPV vaccination schedule (2 or 3 doses) by the end of school year.MethodsThis study is a cluster controlled intervention study using a superiority design. A combined health promotion program will be offered containing information to students and parents, training of general practitioners, and free school-based vaccination (in a “health bus”). Children who attend this program will constitute the intervention group and will be compared to children from another middle school who will not attend the program constituting the control group.ResultsRecruitment began in October 2020. In the intervention school, of 780 students, 245 were randomly selected in the 12 classes. In the control school, 259 students out of 834 were randomly selected.ConclusionsIn this study, we explore the impact of a health promotion program combining information toward students, parents, and general practitioners with free school-based vaccination. We expect a significantly higher HPV vaccination coverage in the intervention school as compared to the control school, whether it be among girls or boys. The final implication would be an extension of this program in all middle schools on the Island and thus an increase in HPV vaccination coverage.Trial RegistrationClinicalTrials.gov NCT04459221; https://clinicaltrials.gov/ct2/show/NCT04459221International Registered Report Identifier (IRRID)DERR1-10.2196/35695

Evolution of human papilloma virus prevalence in a highly vaccinated region in Belgium: a retrospective cohort study in Flemish women (2010-2019).

In order to lower the incidence of cervical cancer, vaccines against high-risk types of the human papilloma virus (hrHPV) were approved and brought on the market in 2007, with a partial reimbursement for Belgian citizens younger than 18 years old. Since 2010, a school-based vaccination program ensures a high vaccination coverage in young women. In this study, the impact of the Belgian vaccination program on the prevalence of HPV 16/18 is studied, together with the evolution of the prevalence of other hrHPV types and precancerous lesions. Results of HPV typing and cytology in papanicolaou-smears from women aged 20-23 years taken between 2010 and 2019 were used. An older, nonvaccinated group of women of 40-45 years old served as a control group. A significant decrease in prevalence of HPV types 16 and 18 was found in the 20-23-years-old women, whereas no decrease was found in the age group 40-45. Alongside this decrease, a significant decrease in prevalence of subtypes 6, 11 and 31 was observed, whereas type 31 is not included in the administered vaccines. Remarkably, there was no decrease in prevalence of cytological abnormalities in the study group during this study. There was even an increase in prevalence of high-risk types 53, 58 and 67. These findings emphasise the need to maintain the screening programs, even in areas with high vaccination coverage.

Acceptability of COVID-19 vaccine mandates among New York City parents, November 2021

School-based vaccine mandates improve vaccination coverage in children. We conducted a cross-sectional survey of parents in New York City (NYC) in November 2021 to measure acceptability of COVID-19 vaccine mandates for students, and for teachers and school staff. Random address-based sampling was used to recruit parents of children 5–11 years of age. Among 2,506 parents surveyed, 44.3% supported school-based vaccine mandates for students and 69.1% supported mandates for teachers and school staff. Asian parents, male parents, those with higher income, college education, those voting for the 2021 Democratic mayoral candidate and parents from Manhattan were most likely to support vaccine mandates for students. Among all parents, 25.1% said they would not vaccinate their child if required. Our data show only modest support for school-based COVID-19 vaccine mandates for children despite their importance in improving vaccination coverage.

Incidence of anogenital warts after the introduction of the quadrivalent HPV vaccine program in Manitoba, Canada.

The incidence of anogenital warts (AGW) decreased after the introduction of the quadrivalent human papillomavirus (qHPV) vaccine in multiple jurisdictions. We studied how comparing AGW incidence rates with different outcomes affects the interpretation of the qHPV vaccination program. To do this, we replicated multiple study designs within a single jurisdiction (Manitoba). We measured the incidence rates of AGW, AGW-related prescriptions, chlamydia, and gonorrhea (the latter two as sham outcomes) between 2001 and 2017 using several clinical and administrative health databases from Manitoba. We then used incidence rate ratios (IRRs) to compare, for each outcome, the rate for the 1997-1998 birth cohort (the first cohorts eligible for the publicly funded qHPV vaccination program) and the older 1995-1996 birth cohort. AGW incidence in Manitoba dropped 72% (95% confidence interval 54-83%) among 16-18 year-old girls and 51% (14-72%) among boys after the introduction of the female-only qHPV vaccination program. Trends in AGW-related prescriptions were different from trends in AGW diagnoses as these prescriptions peaked shortly after the introduction of the publicly funded qHPV vaccine program. Chlamydia and gonorrhea incidence rates also decreased 12% (5-18%) and 16% (-1-30%), respectively, for 16-18 year-old girls. The publicly funded school-based qHPV vaccine program reduced AGW incidence in Manitoba by three-quarters in young females. AGW-related prescriptions are a poor proxy for medically attended AGW after the introduction of the publicly funded qHPV vaccination program. Different sexual habits in adolescents are, at most, responsible for a small portion of the reduction in AGW incidence.

Measuring school level attributable risk to support school-based HPV vaccination programs

BackgroundIn Australia in 2017, 89% of 15-year-old females and 86% of 15-year-old males had received at least one dose of the HPV vaccine. However, considerable variation in HPV vaccination initiation (dose one) across schools remains. It is important to understand the school-level characteristics most strongly associated with low initiation and their contribution to the overall between-school variation.MethodsA population-based ecological analysis was conducted using school-level data for 2016 on all adolescent students eligible for HPV vaccination in three Australian jurisdictions. We conducted logistic regression to determine school-level factors associated with lower HPV vaccination initiation (< 75% dose 1 uptake) and estimated the population attributable risk (PAR) and the proportion of schools with the factor (school-level prevalence).ResultsThe factors most strongly associated with lower initiation, and their prevalence were; small schools (OR = 9.3, 95%CI = 6.1–14.1; 33% of schools), special education schools (OR = 5.6,95%CI = 3.7–8.5; 8% of schools), higher Indigenous enrolments (OR = 2.7,95% CI:1.9–3.7; 31% of schools), lower attendance rates (OR = 2.6,95%CI = 1.7–3.7; 35% of schools), remote location (OR = 2.6,95%CI = 1.6–4.3; 6% of schools,) and lower socioeconomic area (OR = 1.8,95% CI = 1.3–2.5; 33% of schools). The highest PARs were small schools (PAR = 79%, 95%CI:76–82), higher Indigenous enrolments (PAR = 38%, 95%CI: 31–44) and lower attendance rate (PAR = 37%, 95%CI: 29–46).ConclusionThis analysis suggests that initiatives to support schools that are smaller, with a higher proportion of Indigenous adolescents and lower attendance rates may contribute most to reducing the variation of HPV vaccination uptake observed at a school-level in these jurisdictions. Estimating population-level coverage at the school-level is useful to guide policy and prioritise resourcing to support school-based vaccination programs.

COVID-19 vaccinations in Bhutan – Mix-and-Match to Boosters: An experience

Bhutan – a landlocked least developed country in the Himalayas – vaccinated 94% of its adults with the first dose of COVID-19 vaccine in March-April 2021, 90.2% with second dose in July 2021, and 89.1% with booster (third) dose by March 2022.The country used COVISHIELD (Oxford-Astrazeneca) vaccine for the first dose but decided to pursue a heterologous prime-boost strategy (“mix-and-match”) for the second dose using Moderna’s mRNA vaccine for adults.Bhutan rapidly rolled out Pfizer and Moderna vaccines for 12 to 17-year-olds through a school-based vaccination strategy followed by booster doses: 78.6% of adolescents aged 12–17 years were vaccinated with the first dose by August 2021, 92.8% with second dose by November 2021, and 79.7% with booster (third) dose by March 2022. More than 97% of children aged 5 to 11 years have received Pfizer’s Comirnaty vaccine for their first dose.Bhutan is steadily vaccinating its population and might soon become one of the few least developed countries to achieve herd immunity-level vaccination coverage with more than 80% of its population fully vaccinated.

Disparities in high schools' vaccination coverage (COVID-19). A natural experiment in the Province of Quebec

Teenagers' vaccination has become crucial to limit the COVID-19 transmission in the population. To increase the vaccination rate of this age group, a school-based vaccination campaign was launched in Québec, Canada from June 7 to 18, 2021. This study aimed to analyze trajectories of vaccination coverage over time among students attending 37 high schools. The study explored whether school-based vaccination campaigns contributed to the progression of the vaccination coverage and attenuated disparities in vaccination coverage across schools.On average, first dose coverage quickly increased from 30.6% to 81.5% between June 6 and 18, 2021, after the launch of the campaign. As of August 13, 2021, first dose coverage had reached 87.9% and 64.9% for the second dose coverage. Public schools with poorer student populations had 6.5 points of percentage lower first dose vaccination rates (95%CI 0.3%; 12.6%) compared to other schools. A higher level of concern related to the pandemic among students was associated with a 4.3 points of percentage increased coverage (95%CI 0.7%; 8.0%). The initial uneven distribution in first dose coverage decreased dramatically by the end of the campaign. Similar trends were observed for the second dose, although between schools' inequality at the end of the period of observation was significantly larger.The school-based vaccination campaign might have initially contributed to a prompt rise in vaccination coverage and helped the disadvantaged schools to reach similar vaccination coverage as seen in other schools. In addition to being an efficient way to achieve rapidly high vaccination coverage, the school-based approach might contribute to increase equity in vaccination distribution.

Key stakeholder perspectives on challenges and opportunities for rural HPV vaccination in North and South Carolina

ABSTRACT The objective of this study was to identify factors at the individual, provider, and systems levels that serve as challenges or opportunities for increasing adolescent vaccination—including Human Papillomavirus (HPV) vaccination—in rural communities in the southern United States (US). As part of a broader study to increase HPV vaccine uptake in the southern US, we conducted in-depth interviews with vaccination stakeholders representing public health and education agencies in North Carolina (NC) and South Carolina (SC). Fourteen key stakeholders were recruited using purposive sampling to obtain insights into challenges and solutions to rural-urban disparities in HPV vaccination coverage. Stakeholders were also queried about their experiences and attitudes toward school-based vaccination promotion programs and campaigns. We used a rapid qualitative approach to analyze the data. Stakeholders identified factors at the individual, provider, and systems levels that serve as challenges to vaccination in rural communities. Similar to previous studies, stakeholders mentioned challenges with healthcare access and vaccine-related misconceptions that pose barriers to HPV vaccination for rural residents. Systems-level challenges identified included limited access to high-speed internet in rural areas that may impact providers’ ability to interface with state-level digital systems such as the vaccination registry. Stakeholders identified a number of opportunities to increase HPV vaccination coverage, including through school-based health promotion programs. Stakeholders strongly supported school-based programs and approaches to strengthen confidence and demand for HPV vaccination and to help address persistent social determinants and system level factors that pose challenges to HPV vaccination coverage in many rural areas.

Sustaining Maternal and Neonatal Tetanus Elimination (MNTE) in countries that have been validated for elimination \u2013 progress and challenges

BackgroundAs of October 2021, 47 (80%) of the 59 countries, identified at highest risk for Maternal and Neonatal Tetanus (MNT), had been validated for elimination. We assessed sustainability of MNT elimination (MNTE) in 28 countries that were validated during 2011‒2020.MethodsWe assessed the attainment of the following MNTE sustainability indicators: 1) ≥ 90% coverage with three doses of Diphtheria-Tetanus-Pertussis vaccine (DTP3) among infants < 1 year, 2) ≥ 80% coverage with at least two doses of tetanus toxoid-containing vaccine (TTCV2 +) among pregnant women, 3) ≥ 80% protection at birth (PAB), 4) ≥ 70% skilled birth attendance (SBA), and 4) ≥ 80% first (ANC1) and fourth antenatal care (ANC4) visits. We assessed the introduction of TTCV booster doses. Data sources included the 2020 WHO /UNICEF Joint Reporting Forms, and the latest Demographic and Health Survey (DHS) or Multi-Indicator Cluster Surveys (MICS) for each country, if available. We reviewed literature and used DHS/MICS data to identify barriers to sustaining MNTE.ResultsOf 28 assessed countries, 7 (25%) reported ≥ 90% DTP3 coverage, 4 of 26 (16%) reported ≥ 80% TTCV2 + coverage, and 23 of 27 (85%) reported ≥ 80% PAB coverage. Based on DHS/MICS in 15 of the 28 countries, 10 (67%) achieved ≥ 70% SBA delivery, 13 (87%) achieved ≥ 80% ANC1 visit coverage, and 3 (20%) ≥ 80% ANC4 visit coverage. We observed sub-optimal coverage in many countries at the subnational level. The first, second and third booster doses of TTCV respectively have been introduced in 6 (21%), 5 (18%), and 1 (4%) of 28 countries. Only three countries conducted post-MNTE validation assessments. Barriers to MNTE sustainability included: competing program priorities, limited resources to introduce TTCV booster doses and implement corrective immunization in high-risk districts and socio-economic factors.ConclusionsDespite good performance of MNTE indicators in several countries, MNTE sustainability appears threatened in some countries. Integration and coordination of MNTE activities with other immunization activities in the context of the Immunization Agenda 2030 lifecourse vaccination strategy such as providing tetanus booster doses in school-based vaccination platforms, during measles second dose and HPV vaccination, and integrating MNTE post-validation assessments with immunization program reviews will ensure MNTE is sustained.

Nationwide introduction of HPV vaccine in Zimbabwe 2018-2019: Experiences with multiple cohort vaccination delivery.

The World Health Organization (WHO) recommends the human papillomavirus (HPV) vaccine for girls aged 9-14 years for cervical cancer prevention and encourages vaccinating multiple cohorts in the first year to maximize impact. The HPV vaccine was introduced nationwide in Zimbabwe in 2018 through a 1-week school-based campaign to multiple cohorts (all girls 10-14 years old), followed by a single cohort (grade 5 girls in school and age 10 girls out-of-school) in 2019. During the 2019 campaign, the multiple cohort's second dose was concurrently delivered with the single cohort's first dose. We interviewed national-level key informants, reviewed written materials, and observed vaccination sessions to document HPV vaccine introduction in Zimbabwe and identify best practices and challenges. Key informants included focal persons from government health and education ministries, in-country immunization partners, and HPV Vaccine Strategic Advisory Group members. We conducted a desk review of policy/strategy documents, introduction plans, readiness reports, presentations, and implementation tools. Vaccination sessions were observed in three provinces during the 2019 campaign. Key informants (n = 8) identified high cervical cancer burden, political will, vaccine availability, donor financing, and a successful pilot program as factors driving the decision to introduce the HPV vaccine nationally. The school-based delivery strategy was well accepted, with strong collaboration between health and education sectors and high community demand for vaccine identified as key contributors to this success. Challenges with transitioning from a multiple age-based to single grade- and age-based target population as well as funding shortages for operational costs were reported. Zimbabwe's first multiple cohort, school-based HPV vaccination campaign was considered successful-primarily due to strong collaboration between health and education sectors and political commitment; however, challenges vaccinating overlapping cohorts in the 2019 campaign were observed. Integration with existing health and vaccination activities and continued resource mobilization will ensure sustainability of Zimbabwe's HPV vaccination program in the future.

Impact of the CARD (Comfort Ask Relax Distract) system on school-based vaccinations: A cluster randomized trial

BackgroundThe CARD (Comfort Ask Relax Distract) system is a vaccine delivery framework that integrates evidence-based interventions to reduce stress-related responses and improve the vaccination experience for children undergoing vaccinations at school. In preliminary studies, CARD was acceptable and effective. The objective was to evaluate CARD in a large, pragmatic trial to confirm its effectiveness in real-world settings. MethodsHybrid effectiveness-implementation cluster randomized trial in schools receiving vaccination services from Wellington-Dufferin-Guelph Public Health. Forty schools with grade 7 students (12 years old) were randomized to CARD and control (n = 20/group). Nurses in CARD schools planned clinics with principals and educated students about CARD ahead of time. Principals disseminated information to staff and parents and sent reminders. Vaccination day processes minimized fear and facilitated student self-selected coping strategies. Nurses in control schools followed usual practices, which excluded principal meetings, education, reminders, and systematic integration of fear-reducing or child-selected coping strategies. Outcomes included stress-related symptoms (fear – primary outcome, pain, dizziness, fainting, post-vaccination reactions), use of coping interventions, vaccination uptake, attitudes and implementation outcomes (acceptability, appropriateness, feasibility, fidelity). ResultsAltogether, 1919 students were included. Fear and pain were lower in CARD schools: OR 0.65 (95% CI 0.47–0.90) and OR 0.62 (95% CI 0.50–0.77), respectively. No students fainted in CARD schools compared to 0.8% in control (p = 0.02). Dizziness and post-vaccination reactions did not differ. Student-led coping interventions were used more frequently in CARD schools. Vaccination uptake was 76.1% in CARD schools and 72.5% in control schools (OR 1.13 (95% CI 0.85–1.50)). Staff and students had positive attitudes about CARD and implementation outcomes; however, recommendations were made to improve fidelity. DiscussionCARD reduced stress-related responses in students undergoing vaccinations at school and was positively received by students and public health staff. CARD is recommended to improve the quality of vaccination delivery services.Trial registration: NCT03966300.

Cost of human papillomavirus vaccine delivery at district and health facility levels in Zimbabwe: A school-based vaccination program targeting multiple cohorts

BackgroundAfter a pilot project in 2014–15 Zimbabwe introduced the human papillomavirus (HPV) vaccine nationally in 2018 for girls aged 10–14 years through a primarily school-based vaccination campaign with two doses administered at 12-month intervals. In 2019, a first dose was delivered to a new cohort of girls in grade 5 of girls age 10 years if out-of-school (OOS), along with a second dose to the 2018 multiple cohorts. Additional effort was made to identify and mobilize OOS girls by Village Health Workers (VHWs) in the community. Zimbabwe reported 1,569,905 doses of HPV vaccine administered during the 2018 and 2019 campaigns. This analysis evaluated the cost of Zimbabwe’s national HPV vaccine introduction. MethodsA retrospective, incremental, ingredients-based cost analysis from the provider perspective was conducted in 2018 and 2019. Financial and economic cost data were collected at district and health facility levels using a two-stage cluster sampling approach and four cost dimensions: program activity, resource input, payer, and administrative level. Costs are presented in 2020 US$ in total and per dose. ResultsThe total weighted costs for combined district and health facility administrative levels were US$ 828,731 (financial) and US$ 2,060,943 (economic). For service delivery, the total weighted cost per dose was US$ 0.16 (financial) and US$ 0.59 (economic). The program activities with the largest share of total weighted financial cost were training (37% of total) and service delivery (30%), while the largest shares of total weighted economic costs were service delivery (45%) and training (19%). Efforts by VHWs to reach OOS girls resulted in an additional US$ 2.99 in financial cost per dose and US$ 7.79 in economic cost per dose. ConclusionThe service delivery cost per dose was lower than that documented in the pilot program cost analysis in Zimbabwe and studies elsewhere, reflecting a campaign delivery approach that spread fixed costs over a large vaccination cohort. The additional cost of reaching OOS girls with the HPV vaccine was documented for the first time in low- and middle-income countries, which may provide information on potential costs for other countries.

Human Papillomavirus Vaccination in South Africa: Programmatic Challenges and Opportunities for Integration With Other Adolescent Health Services?

Compared to other regions of the world, sub-Saharan Africa has made limited progress in the implementation and performance of nationwide human papillomavirus (HPV) vaccination programmes. Without urgent intervention, this will serve to undermine cervical cancer elimination efforts in this region. The primary intent of this narrative review is to highlight the programmatic successes and challenges of the school-based HPV vaccination programme in South Africa since its inception in 2014, with the aim of contributing to the evidence base needed to accelerate implementation and improve programme performance in other sub-Saharan African countries. As of 2020, the proportion of adolescent girls aged 15 years who had received at least one dose of the HPV vaccine at any time between ages 9–14 years was 75%, while 61% had completed the full recommended two-dose schedule. This gives some indication of the reach of the South African HPV vaccination programme over the past 6 years. Despite this, vaccine coverage and dose completion rates have persistently followed a downward trend, slowing progress toward attaining global elimination targets. There is evidence suggesting that declining public demand for the HPV vaccine may be a result of weakening social mobilization over time, inadequate reminder and tracking systems, and vaccine hesitancy. Another concern is the disproportionate burden of HPV and HIV co-infections among adolescent girls and young women in South Africa, which predisposes them to early development of invasive cervical cancer. Moving forward, national policy makers and implementers will have to explore reforms to current age eligibility criteria and vaccine dose schedules, as well as implement strategies to support vaccine uptake among populations like out-of-school girls, girls attending private schools, and HIV positive young women. Additional opportunities to strengthen the South African HPV vaccination programme can be achieved by scaling up the co-delivery of other adolescent health services such as comprehensive sexual and reproductive health and rights education, deworming, and health screening. This calls for reinforcing implementation of the integrated school health policy and leveraging existing adolescent health programmes and initiatives in South Africa. Ultimately, establishing tailored, adolescent-centered, integrated health programmes will require guidance from further operational research.