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

Abstract

BackgroundCervical cancer is the third most common cancer in women worldwide, with high incidence in lowest income countries. Vaccination against Human Papilloma Virus (HPV) may help to reduce the incidence of cervical cancer. The aim of the study was to analyze HPV vaccination programs performance implemented in low and middle-income countries.MethodsThe Gardasil Access Program provides HPV vaccine at no cost to help national institutions gain experience implementing HPV vaccination. Data on vaccine delivery model, number of girls vaccinated, number of girls completing the three-dose campaign, duration of vaccination program, community involvement and sensitization strategies were collected from each program upon completion. Vaccine Uptake Rate (VUR) and Vaccine Adherence between the first and third doses (VA) rate were calculated. Multivariate linear regressions analyses were fitted.ResultsTwenty-one programs were included in 14 low and middle-income countries. Managing institutions were non-governmental organizations (NGOs) (n = 8) or Ministries of Health (n = 13). Twelve programs were school-based, five were health clinic-based and four utilized a mixed model. A total of 217,786 girls received a full course of vaccination.Mean VUR was 88.7% (SD = 10.5) and VA was 90.8% (SD = 7.3). The mean total number of girls vaccinated per program-month was 2,426.8 (SD = 2,826.6) in school model, 335.1 (SD = 202.5) in the health clinic and 544.7 (SD = 369.2) in the mixed models (p = 0.15). Community involvement in the follow-up of girls participating in the vaccination campaign was significantly associated with VUR. Multivariate analyses identified school-based (β = 13.35, p = 0.001) and health clinic (β = 13.51, p = 0.03) models, NGO management (β = 14.58, p < 10-3) and duration of program vaccination (β = -1.37, p = 0.03) as significant factors associated with VUR.ConclusionSchool and health clinic-based models appeared as predictive factors for vaccination coverage, as was management by an NGO; program duration could play a role in the program’s effectiveness. Results suggest that HPV vaccine campaigns tailored to meet the needs of communities can be effective. These results may be useful in the development of national HPV vaccination policies in low and middle-income countries.

Global Delivery of Human Papillomavirus Vaccines

“…23,25,38,[41][42][43] Demonstration programs through the international non-governmental organization PATH have achieved high coverage through school-based delivery in Peru (82.6%), Uganda (88.9%) and Vietnam (96.1%). 42 High coverage has also been seen in school-based demonstration projects in South Africa, 44 Brazil, 45 and Nepal.…”

“…The school-based strategy was specifically identified as a factor that positively influenced their vaccine uptake rates. 38 Lastly, in 2011, national implementation of the HPV vaccine in Rwanda achieved 93.2% coverage for girls in grade six, through school-based vaccination and community sensitization and involvement. 23 been very limited implementation of school-based HPV vaccination, though this approach has been identified as an ideal way to reach the largest number of adolescents.…”

“…38,46 Between 2009 and 2012, 21 vaccination programs were implemented in 14 LMICs around the world. 38 The GAPs achieved an average vaccine uptake rate of 88.7% through three delivery strategies including schoolbased, facility-based and mixed approaches. The school-based strategy was specifically identified as a factor that positively influenced their vaccine uptake rates.…”

“…42 Adequate community engagement and sensitization are key factors in successful implementation and overcoming sociocultural barriers. 23,38,42,83,89 …”

“…grade versus age-based criteria), capturing out-of-school girls, coordination of diverse immunization and education stakeholders, as well as scheduling three doses during the academic year; 25,42,80 • Delays or lags in delivery of vaccination programs, caused by stock outs may decrease interest among girls and parents to complete all doses; 38 • Straining health systems and human resources by introducing new vaccines, including the HPV vaccine.…”