The Vaccine and Cervical Cancer Screen (VACCS) project: Acceptance of human papillomavirus vaccination in a school-based programme in two provinces of South Africa

Abstract

Cervical cancer remains an important cause of morbidity and mortality in South Africa (SA). [1] The age-standardised incidence rate of cervical cancer in southern Africa is approximately 27/100 000, [2] and most cases are diagnosed in late stages. Persistent infection with oncogenic human papillomavirus (HPV) is an essential step in the development of invasive cervical cancer. [3] HPV is highly infectious, but does not cause disease in all cases, and most individuals will clear infections. Since HPV is almost exclusively an epithelial disease, most transient HPV infections do not confer longterm immunity owing to a poor immune response. A national cervical cancer prevention programme was launched in SA in 2000, offering three Papanicolaou smears in a woman's lifetime, starting after the age of 30 at 10-year intervals, but has had limited success in reducing the incidence of HPV-associated disease. Some provinces in SA have fairly well-developed cytology screening services, but there is poor uptake of prevention services for cancer. Among women with abnormal cytology, there is also significant loss to follow-up after the initial screening test. [4] Since the introduction of effective HPV vaccines, a primary preventive strategy became available to combat the epidemic. Currently there are two vaccines registered in SA: the bivalent vaccine Cervarix, containing virus-like particles (VLPs) for HPV types 16 and 18, and the quadrivalent vaccine Gardasil, containing VLP antigens for HPV types 16 and 18 as well as non-oncogenic HPV types 6 and 11. VLPs are combined with an adjuvant, which leads to an improved immune response and long-term efficacy. Both vaccines have been extensively tested in large populations, and have also been found to be safe and immunogenic among African populations. [5] The bivalent HPV vaccine has also shown sustained immune responses in HIV-positive women, and was well tolerated. [6] Local reactions such as pain, swelling and redness can occur, as may systemic adverse events including fever, nausea, dizziness, fatigue, headache and myalgia. Cost-effectiveness studies have shown universal, femaleonly HPV vaccination before exposure to be an effective and economically viable option in developed countries. [7] Recently there has been increasing emphasis on the inclusion of low-and middle-income countries in the drive to reduce the global cancer burden. Evidence from qualitative studies suggests that South Africans will support introduction of HPV vaccination, but that education remains a key ingredient in any roll-out. [8] Adolescent health was identified as an area for development in the SA National Health Initiative Green Paper, with preventive health an important part of this plan. This focus is linked to a re-engineered primary healthcare plan and a newly developed school health programme (SHP). In May 2013, Dr Aaron Motsoaledi, national Minister of Health, announced during the health budget speech that: '... we shall commence to administer the HPV vaccines as part of our SHP ... '. This courage...

School-based human papillomavirus vaccination: An opportunity to increase knowledge about cervical cancer and improve uptake of screening

“…Outcomes of the vaccination programme and the main results of the selfscreening study have been reported elsewhere. [12] …”

Interventions to Improve HPV Vaccine Uptake: A Systematic Review

“…A feasibility trial for the upcoming government-funded program in England had high rates of HPVV initiation after the first year (70.6%), despite challenges with vaccine delivery and multiple missed appointments. 57 Programs in Brazil and South Africa included education campaigns and free vaccination, demonstrating uptake rates of 85% 64 (completion) and 58.6% 56 (at least 1 dose), respectively. Similar implementation challenges faced both programs: parents refusing to participate (up to 41%) 56 or not attending educational classes.…”

“…57 Programs in Brazil and South Africa included education campaigns and free vaccination, demonstrating uptake rates of 85% 64 (completion) and 58.6% 56 (at least 1 dose), respectively. Similar implementation challenges faced both programs: parents refusing to participate (up to 41%) 56 or not attending educational classes. 56 Two school-based VPs in the United States included free HPVV.…”

“…Similar implementation challenges faced both programs: parents refusing to participate (up to 41%) 56 or not attending educational classes. 56 Two school-based VPs in the United States included free HPVV. 66,73 One summoned students to the health center for vaccination and demonstrated an initiation rate similar to national averages (59%) but a dramatic improvement over the preintervention rate of 5%.…”

Editor's Choice

“…Importantly, medical aids are encouraging vaccination of boys also! In this issue we publish the first of a series of three papers that trumpet the success of the Vaccine and Cervical Cancer Screen (VACCS) project, [1,2] a school-based HPV vaccination project that gives reality to the announcement in May 2013 by Dr Aaron Motsoaledi, Minister of Health, that '… we shall commence to administer the HPV vaccines as part of our school health programme ... ' against a background of an uncontrolled cervical cancer epidemic resulting from high prevalences of HPV and HIV and a relatively unsuccessful cervical cancer screening programme.…”