Introduction of a National HPV vaccination program into Bhutan

Dorji, Tandin; Tshomo, Ugyen; Phuntsho, Sangay; Tamang, Tshewang; Tshokey, Tshokey; Baussano, Iacopo; Franceschi, Silvia; Clifford, Gary M.

doi:10.1016/j.vaccine.2015.05.078

Cited by 54 publications

(65 citation statements)

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“…National, primarily school‐based, HPV vaccination programmes were started in Bhutan in 2010 and in Rwanda in 2011 . HPV6/11/16/18 vaccine coverage was reported as >90% in the target groups of both countries.…”

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Urine testing to monitor the impact of HPV vaccination in Bhutan and Rwanda

Franceschi

Umulisa

Tshomo³

et al. 2016

Int. J. Cancer

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Bhutan (2010) and Rwanda (2011) were the first countries in Asia and Africa to introduce national, primarily school-based, human papillomavirus (HPV) vaccination programmes. These target 12 year-old girls and initially included catch-up campaigns (13-18 year-olds in Bhutan and ninth school grade in Rwanda). In 2013, to obtain the earliest indicators of vaccine effectiveness, we performed two school-based HPV urine surveys; 973 female students (median age: 19 years, 5th-95th percentile: 18-22) were recruited in Bhutan and 912 (19 years,[17][18][19][20] in Rwanda. Participants self-collected a first-void urine sample using a validated protocol. HPV prevalence was obtained using two PCR assays that differ in sensitivity and type spectrum, namely GP51/GP61 and E7-MPG. 92% students in Bhutan and 43% in Rwanda reported to have been vaccinated (median vaccination age 5 16, 5th-95th: 14-18). HPV positivity in urine was significantly associated with sexual activity measures. In Rwanda, HPV6/11/16/18 prevalence was lower in vaccinated than in unvaccinated students (prevalence ratio, PR 5 0.12, 95% confidence interval, CI: 0.03-0.51 by GP51/GP61, and 0.45, CI: 0.23-0.90 by E7-MPG). For E7-MPG, cross-protection against 10 high-risk types phylogenetically related to HPV16 or 18 was of borderline significance (PR 5 0.68; 95% CI: 0.45-1.01). In Bhutan, HPV6/11/16/18 prevalence by GP51/GP61 was lower in vaccinated than in unvaccinated students but CIs were broad. In conclusion, our study supports the feasibility of urine surveys to monitor HPV vaccination and quantifies the effectiveness of the quadrivalent vaccine in women vaccinated after pre-adolescence. Future similar surveys should detect increases in vaccine effectiveness if vaccination of 12 year-olds continues.National, primarily school-based, HPV vaccination programmes were started in Bhutan in 2010 1 and in Rwanda in 2011. 2 HPV6/11/16/18 vaccine coverage was reported as >90% in the target groups of both countries. In Bhutan, this target was 12 year-old girls, with a one-round catch-up campaign in 2010 for 13-18 year-old girls. In Rwanda, the target was girls attending primary school grade 6 (aged 12 years) in 2011, with three-rounds of catch-up vaccination in 2011, 2012 and 2013 for secondary school grade 3 (aged 15 years). Efforts were also made to reach out-of-school girls in health centres in both countries. 1,2 These two early-introducing countries provide the first opportunity to evaluate the impact of HPV vaccination in low/medium income countries (LMIC), of which the most feasible and informative measure in the medium-term (5-15 years) is type-specific HPV infection in sentinel populations of adolescent girls and young women. To this end, the International Agency for Research on Cancer (IARC) has developed long-term monitoring studies with the ministries of health of the two countries, beginning with two cervical cell surveys in the country capitals (Thimphu and Kigali) to establish robust baseline estimates of HPV prevalence among unvaccinated sexually activ...

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“…In Rwanda, the target was girls attending primary school grade 6 (aged ≥12 years) in 2011, with three‐rounds of catch‐up vaccination in 2011, 2012 and 2013 for secondary school grade 3 (aged ≥15 years). Efforts were also made to reach out‐of‐school girls in health centres in both countries …”

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confidence: 99%

Urine testing to monitor the impact of HPV vaccination in Bhutan and Rwanda

Franceschi

Umulisa

Tshomo³

et al. 2016

Int. J. Cancer

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“…Unfortunately, in countries in which school health programmes are nonexistent, this delivery strategy comes at a higher cost relative to routine delivery in health facilities. Due to these costs, several low-income countries, including Bhutan, have continued to reassess and modify their vaccine delivery model in the years following introduction [20,21]. This underscores the need for programmes to understand the main cost drivers prior to introduction and to develop locally acceptable, affordable, and sustainable delivery strategies.…”

Section: Challenges and Opportunitiesmentioning

confidence: 99%

Vaccination to prevent human papillomavirus infections: From promise to practice

Bloem

Ogbuanu

2017

PLoS Med

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“…The first national programs in LMIC to achieve high (>90%) coverage were carried out in Rwanda and Bhutan . Encouraging progress has been made in lowering the vaccine price.…”

Section: Future Opportunities and Challengesmentioning

confidence: 99%

“…Finally, policy‐makers are understandably afraid of investments that take decades to produce fully accountable results. However, the implementation of HPV vaccination programmes is highly feasible compared with that of other cancer prevention strategies, especially in LIC . Cervical cancer screening, for instance, is a more logistically demanding program to implement.…”

Section: Future Opportunities and Challengesmentioning

confidence: 99%

Eurogin Roadmap 2015: How has HPV knowledge changed our practice: Vaccines

et al. 2016

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This review is one of two complementary reviews that have been prepared in the framework of the Eurogin Roadmap 2015 to evaluate how knowledge about HPV is changing practices in HPV infection and disease control through vaccination and screening. In this review of HPV vaccine knowledge, we present the most significant findings of the past year which have contributed to our knowledge of the two HPV prophylactic vaccines currently in widespread use and about the recently licensed nonavalent HPV vaccine. Whereas anal cancer is dealt with in the companion mini-review on screening, we also review here the rapidly evolving evidence regarding HPV-associated head and neck cancer and priority research areas. Current Knowledge About the Efficacy and Safety of Prophylactic HPV VaccinesIt is now ten years since the first prophylactic HPV vaccine was licensed for use following extensive clinical trials. At the time of licensing, the vaccines were known to be highly efficacious in HPV-na€ ıve individuals at preventing vaccine-type HPV infection and type specific cervical disease and, for the quadrivalent vaccine, genital warts and vulvar/vaginal intraepithelial lesions. We have now direct evidence that both vaccines provide protection for close to a decade, if not longer. Large sentinel cohorts of young Nordic women and smaller cohorts from the original trials are being closely monitored to detect any loss of protection over time.

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Introduction of a National HPV vaccination program into Bhutan

Abstract: Bhutan's lessons for other low/middle-income countries include the superiority of school-based vaccination and the feasibility of a broad catch-up campaign in the first year.

Cited by 54 publications

References 12 publications

Urine testing to monitor the impact of HPV vaccination in Bhutan and Rwanda

Urine testing to monitor the impact of HPV vaccination in Bhutan and Rwanda

Vaccination to prevent human papillomavirus infections: From promise to practice

Eurogin Roadmap 2015: How has HPV knowledge changed our practice: Vaccines

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