Lessons Learnt from Human Papillomavirus (HPV) Vaccination in 45 Low- and Middle-Income Countries

This article synthesises lessons learned and determinants of success from human papillomavirus (HPV) vaccine demonstration projects and national programmes in low- and middle-income countries (LAMICs). Between January 2007 and May 2016, over 80 countries or territories commenced national HPV vaccination, and another 38 had completed or started HPV vaccine demonstration projects. Yet country decision-makers face several challenges when applying for support and introducing HPV vaccine, including selecting delivery strategies, communicating effectively with communities, and determining how to maximise coverage. The purpose of this ecological study was to develop recommendations for HPV vaccine delivery and accelerate scale-up of national programmes.

The authors conducted semi-structured interviews with 56 key informants, performed a systematic literature review, and synthesised results thematically. Data were analysed from 12 national programmes and 66 demonstration projects in 46 countries. Among demonstration projects, 30 were supported by the GARDASIL® Access Program, 20 by Gavi, 4 by PATH, and 12 by other means. Lessons learnt, drivers of high coverage, and key mobilisation messages were consistent across types of demonstration project and world regions, i.e., Africa (23 countries), Asia (10), Americas (7), Oceania (4), and Europe (2).

Overall, coverage was reported by 65% of experiences (60/92). Uptake, completion, and final dose coverage achievements were high, with no estimates below 50%. Experiences that achieved high coverage: featured schools as a vaccination venue, had high Expanded Programme on Immunization (EPI) and Ministry of Education (MOE) involvement in both planning and implementation, and included a strategy to reach out-of-school girls if school enrolment rates were variable. Other factors reported to encourage high coverage were: political commitment, good social mobilisation, community engagement, and timely delivery of the vaccine on scheduled dates within one school year.

Other selected communication-related findings:

• Delivery experiences with Ministry of Health (MOH) ownership and high EPI involvement were more likely to achieve good coverage in comparison to others run by external partners or with low EPI involvement. Sources indicated that to be effective, microplanning needed involvement of the MOE, teachers and school administrators, and health representatives.
• HPV vaccination as a cancer prevention method was more frequently emphasised than its role in sexually transmitted infection (STI) prevention, in order to avoid stigmatising the vaccine and to reduce confusion with other STI prevention messages. Messages were designed to reach the whole community with information focused on cervical cancer, the importance of HPV vaccination, government endorsement, doses required, timing and venues, and lack of long-term adverse effects. Problems were reported when social mobilisation occurred less than a month before vaccination and high-level officials did not deal with rumours rapidly.
• Schools were the most commonly used vaccination venue, with 87% (78/89) of delivery strategies using them, with or without additional health facility or outreach components. Results showed that school-based vaccine delivery supplemented with health facility-based delivery for out-of-school girls attained high coverage. There were limited data on facility-only strategies and little evaluation of strategies to reach out-of-school girls. (Almost one-third of experiences (27%) had no reported strategy for reaching out-of-school girls, another third (35%) relied on them attending health facilities for vaccination, and the remaining experiences used outreach.)
• Early engagement of teachers as partners in social mobilisation, consent, vaccination day coordination, and follow-up of non-completers and adverse events were considered invaluable.
• Micro-planning using school/facility registers most effectively enumerated intended populations; other estimates proved inaccurate, leading to vaccine under- or over-estimation.
• Refresher training on adverse events and safe injection procedures was usually necessary.

Key recommendations related to communication include:

• Social mobilisation in communities should begin early (at least one month before vaccination - earlier if possible).
• Messages should focus on: cervical cancer prevention; safety and efficacy, including lack of fertility impact or long-term adverse effects, government endorsement, delivery timing and venues, and the need to return for a second dose.
• Members of government or World Health Organization (WHO) representatives should issue responses to rumours as quickly as possible.
• Consent processes should be consistent with existing routine EPI consent policy to avoid rumours.

Looking ahead, the authors note that most experience to date is with school-based delivery; funders should encourage countries to test different approaches, they say, as more data is needed on more sustainable strategies. If alternative strategies result in unacceptable levels of coverage, LAMIC may need increased funding to deliver school-based programmes. Limited attempts to reach out-of-school girls did not greatly affect coverage in countries that attain over 80% net school enrolment. However, not providing an opportunity for out-of-school girls to be vaccinated perpetuates inequity.

The authors conclude that considerable experience in HPV vaccine delivery in LAMICs is available, lessons are generally consistent across countries, and dissemination of these could improve HPV vaccine introduction.