PATH's Cervical Cancer Prevention Action Planner

HPV vaccination delivery strategies

Target population

As noted earlier, the WHO publication Human Papillomavirus Vaccines: WHO Position Paper states that the primary target population for HPV vaccination should be girls prior to onset of sexual activity, in the age range of 9 or 10 through 13 years. Most developing countries do not routinely vaccinate these older children and adolescents, so systems may need to be created or adapted to reach them. While this can be a challenge, it is also an opportunity to provide adolescents with additional health interventions and guidance.

The target population for HPV vaccination in a given country will depend on the licensing for vaccine use in that country and the country’s policies. Note that the license and the country policy may differ. For example, in the United States, one of the vaccines is licensed for use in 9- through 26-year-old females and 9- through 26-year-old males, and the other for use in 10- through 25-year-old females. However, the committee that makes recommendations for vaccinations, the Advisory Committee on Immunization Practices, has recommended vaccinating only girls and young women. Males may receive the vaccine, but there is no specific recommendation for this.

After deciding on the range of ages for vaccination, countries or regions must determine whether birthdate or some other indicator works best for identifying eligible girls. In cultures in which birthdates are not recorded and people do not keep track of their ages, implementing vaccination by age may not work well. PATH experience in Uganda showed generally that acceptability of HPV vaccine was high among girls, parents, and community members. However, in the district in which an age-based vaccination strategy was implemented (vaccinating all 10-year-old girls), evaluators could not show high coverage in the target group because it was often not possible to conclusively identify those who were 10 years of age, either during vaccination or during a coverage survey afterward. In the district in which vaccinations were given in school to all girls in Primary grade 5, coverage was very high, so within this context, vaccinating by school grade was more successful.

While vaccinating by grade is logistically easier to manage than vaccinating by age, a given classroom may include girls of many different ages, so vaccinating by grade could have implications for reporting systems and evaluation of vaccination coverage, if those are age focused. Managers will need to assess the situation in their areas and craft appropriate solutions.

Each country has its own policies and procedures for how individuals agree to receive vaccinations. For example, this may be done by saturating the area with information on an upcoming program and posting immunization dates, times, and locations, or by asking for verbal assent at the time of vaccination. In the PATH demonstration projects, the goal for obtaining permission for HPV vaccination was to make the process as similar as possible to what governments were currently doing for routine immunizations. For any new vaccination program, EPI personnel should make decisions on the type of agreement or authorization needed in a manner appropriate for their country.

Schools versus clinics or health posts

The rate of school attendance among girls is improving in many low-resource areas, especially in primary schools, making school-based vaccination more feasible than ever. Each of the four PATH country demonstration projects included at least one strategy that involved immunization teams vaccinating on school premises, and compared this with an alternate strategy. If school-based programs are the main strategy in a region, managers will need to develop a complementary strategy for reaching girls who do not attend school.

A challenge in all immunization programs is reaching populations that are mobile or that live in remote areas. For these situations, special consideration must be given to planning, allowances, and logistics. Sensitization and vaccination may need to be conducted by itinerant health teams or incorporated into existing outreach programs.

For school-based programs, close coordination of efforts between education and health systems is essential, so microplanning should involve teachers and administrators as well as district and local health personnel. For example, health workers need to work with schools to obtain names of eligible girls for vaccination rosters and to schedule vaccination days that will not fall during exams or holiday periods. Clear guidelines on the roles of teachers and health workers on vaccination days should be established.

At schools, meeting rooms or libraries often were used as vaccination rooms, temporarily disrupting some regular school activities on vaccination days, but this happened only a few days per year. Teachers and administrative staff were recruited to assist with organizing the sessions, helping with records, and watching for adverse events following immunization (AEFIs, see page 23). Most school employees felt that the time devoted to the vaccination program was a good investment in the health of their students.

In school-based programs, provisions had to be made for missed doses, since some girls were absent on the school vaccination day. In the Peru project, for example, three doses of HPV vaccine were administered in school by a team from the nearest health facility. Girls who missed a vaccination in school were reminded to obtain it at the nearest health center. This was more efficient than sending vaccinators back to schools for follow-up.

Strategies whose primary purpose was to “bundle” HPV vaccination within an existing health outreach program (such as the Child Days Plus program in Uganda) sometimes used a school as the vaccination venue because the existing program already operated there. In some cases, these community outreach programs may be underfunded or inefficient, so additional funding from the HPV vaccination program may be necessary for personnel and transport costs.

For vaccination programs that use health centers or clinics rather than schools, age-based census data can provide information for estimating the total number of girls in the community who may be eligible for vaccination.

In Vietnam, the project compared vaccinations at schools with those given at health centers in three geographical settings: rural, mountainous, and urban. Coverage was high for both strategies in all settings, and was nearly identical for the two strategies in the rural and mountainous settings. In urban areas, the health center strategy attained a slightly higher coverage, but it was noted that health centers tended to be very near to schools, making it easy for girls to get to the clinics.

The project in India used a strategy different from those in the other three project countries. In one district, a “campaign” approach was used, with the first, second, and third vaccine doses given once over a seven-month period. In the second district, a “monthly immunization” approach was used, with vaccinations provided every month over an eight-month period, as for the routine EPI schedule. Both approaches targeted girls aged 10 to 14 years for an initial “catch-up” round, although a regular strategy would more likely focus on a single age cohort.

In summary, by assessing a variety of strategies, the PATH projects found that high coverage could be achieved through programs based in schools, health centers, or existing outreach programs. Since all of these produced reasonable results, the choice of strategy can be based on local conditions and number of eligible girls, in order to optimize the use of available resources.

Table 1 shows the vaccination strategies used in the four country projects.

Table 1. Vaccine delivery strategies by country

Country
Strategy
Eligible population/ indicators for vaccination
Location and method of delivery
India
“Campaign” (vaccination offered only once for each dose in a year, as is done in other vaccination campaigns)
All 10- to 14-year-old girls
Schools for school-going girls; community centers for out-of-school girls
“Monthly” (vaccination offered on fixed days each month, in accordance with the routine EPI schedule)
All 10- to 14-year-old girls
Schools for school-going girls; community centers for out-of-school girls
Peru
School-based
Primary grade 5 girls at least 9 years old
Schools and outreach for doses 2 and 3
Uganda
School-based
Primary grade 5 girls at least 10 years old
Schools and routine outreach to out-of-school 10-year-old girls
Child Days Plus-based (visits to schools every 6 months)
All 10-year-old girls
Child Days Plus program at schools for doses 1 and 3 and outreach for dose 2
Vietnam
School-based
Primary grade 6 girls at least 9 years old
Schools and community outreach for 11-year-old girls in other grades or out of school
Health center-based
All 11-year-old girls
Health center and community outreach
Photo: PATH

Woman and girls


Additional resources

Print version: Implementing HPV Vaccination Programs (RHO Cervical Cancer website)

Watch videoHPV vaccination video and transcript

Case study: HPV vaccination in Africa

Case study: HPV vaccination in Latin America

Shaping Strategies to Introduce HPV Vaccines: Formative Research Results from India, Peru, Uganda, and Vietnam (RHO Cervical Cancer website)

Conducting Formative Research for HPV Vaccination Program Planning (RHO Cervical Cancer website)

Evaluating HPV Vaccination Pilots (RHO Cervical Cancer website)

HPV delivery strategies that achieved high coverage in low- and middle-income countries (PDF)

Vaccination (RHO Cervical Cancer website)

World Health Organization position paper on human papillomavirus vaccines (PDF)

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