Search

Background Zimbabwe has one of the highest incidence rates of cervical cancer in the world – 61.7 per 100,000 women. The government of Zimbabwe introduced bivalent HPV vaccine with a 0,12 month schedule to all 10–14 year old girls using a pulsed-campaign approach in May 2018 (dose 1) and May 2019 (dose 2). Methods In August 2019, we conducted a population-based, two-stage cluster survey of households with girls who were eligible for the national HPV vaccination program to determine two-dose HPV vaccination coverage in three districts of Zimbabwe. All households with girls currently aged 11 to 15 years were line-listed through a census conducted in the pre-selected clusters from each district prior to survey administration. A simple random sample of eligible households was selected from these lists to estimate HPV vaccine coverage at sufficient power with a margin of error of +/- 5%. Criteria for district selection included estimated vaccine uptake (low, medium, high), rural/urban/peri-urban, geographic area, estimated number of girls not in school, and recent natural disasters or disease outbreaks. We oversampled households with girls aged 13 or 14 years at the time of dose 1. Results On-time dose 1 uptake ranged from 88 to 94% and two-dose HPV vaccine coverage ranged from 75 to 86% across the three districts. Nearly all vaccinations occurred in schools, and less than 2% of girls did not attend school. There were challenges assessing ages of girls at schools prior to vaccination – 9% of girls vaccinated were less than 10 years old at time of dose 1. Discussion Zimbabwe has demonstrated that high uptake and successful completion of 2-dose HPV vaccination can be achieved with an annual dosing schedule. Efforts going forward will need to focus on minimizing dropout between doses and routinizing annual vaccinations in schools for every subsequent new cohort of eligible girls in the country.

Introduction Human papillomavirus (HPV) vaccination has not been introduced in many countries in South-Central Asia, including Afghanistan, despite the sub-region having the highest incidence rate of cervical cancer in Asia. This study estimates the potential health impact and cost-effectiveness of HPV vaccination in Afghanistan to inform national decision-making. Method An Excel-based static cohort model was used to estimate the lifetime costs and health outcomes of vaccinating a single cohort of 9-year-old girls in the year 2018 with the bivalent HPV vaccine, compared to no vaccination. We also explored a scenario with a catch-up campaign for girls aged 10–14 years. Input parameters were based on local sources, published literature, or assumptions when no data was available. The primary outcome measure was the discounted cost per disability-adjusted life-year (DALY) averted, evaluated from both government and societal perspectives. Results Vaccinating a single cohort of 9-year-old girls against HPV in Afghanistan could avert 1718 cervical cancer cases, 125 hospitalizations, and 1612 deaths over the lifetime of the cohort. The incremental cost-effectiveness ratio was US$426 per DALY averted from the government perspective and US$400 per DALY averted from the societal perspective. The estimated annual cost of the HPV vaccination program (US$3,343,311) represents approximately 3.53% of the country′s total immunization budget for 2018 or 0.13% of total health expenditures. Conclusion In Afghanistan, HPV vaccine introduction targeting a single cohort is potentially cost-effective (0.7 times the GDP per capita of $586) from both the government and societal perspective with additional health benefits generated by a catch-up campaign, depending on the government′s willingness to pay for the projected health outcomes.

There is currently no national cervical screening or HPV immunization program in Vietnam. This study aims to synthesize available data on the burden of disease and to project the burden of cervical cancer to 2049 if no major interventions are implemented. We reviewed published data sources on risk factors for HPV prevalence, high-grade lesions, cervical cancer incidence and mortality in Vietnam from 1990 to 2017. We then used the available data to project the number of new cervical cancer cases for the period 2013–2049. Data on cervical cancer incidence and mortality in Vietnam are limited; two Vietnamese cancer registries have been reported on by the International Agency for Research on Cancer, which cover urban populations representing ∼20% of the national population. The reported age-standardized cervical cancer incidence in Hanoi was 6.7 (1993–1997), compared to 28.8 and 14.1 per 100,000 women in Ho Chi Minh City (1995–1998 and 2009–2012, respectively). Cancer mortality data are not uniformly available from cancer registries or mortality surveys in Vietnam because cause of death has not been routinely ascertained. Based on available urban population registry data, estimated rates in the rural population, and forward projection of existing trends, we estimate that without any further intervention, the number of new cases will increase from 6930 (range 5671–8493) in 2012 to 8562 (range 5775–12,762) in 2049, giving a total of 379,617 (range 276,879–542,941) new cases over the period 2013–2049. These findings help underpin the case for the delivery of HPV vaccination and cervical screening in Vietnam, and support similar initiatives in other low- and middle-income countries.

Background Cervical cancer is responsible for around one-quarter of all cancer deaths among Ghanaian women. Between 2013 and 2015, Ghana conducted a pilot of HPV vaccination among 10–14-year-old girls in four regions; however, the country has yet to introduce the vaccine nationally. This study projected the cost-effectiveness and budget impact of adding HPV vaccination into Ghana’s national immunization program. Methods We used a proportional outcomes model (UNIVAC, version 1.4) to evaluate the cost-effectiveness of introduction with bivalent (Cervarix™) and quadrivalent (Gardasil®) vaccines from government and societal perspectives. Vaccine introduction was modeled to start in 2022 and continue over ten birth cohorts using a combined delivery strategy of school (80%) and community outreach (20%). We modeled vaccination in a single age cohort of 9-year-old girls vs. a multi-age cohort of 9-year-old girls (routine) and 10–14-year-old girls (one-time campaign) compared to no vaccination. Health outcomes included cervical cancer cases, hospitalizations, deaths, and disability-adjusted life years (DALYs). We applied a discount rate of 3% to costs and outcomes. All monetary units are reported in USD 2018. Results National HPV vaccination in Ghana was projected to be cost-effective compared to no vaccination in all scenarios evaluated. The most cost-effective and dominant strategy was vaccination among 9-year-old girls, plus a one-time campaign among 10–14-year-old with the bivalent vaccine ($158/DALY averted from the government perspective; 95% credible range: $19–$280/DALY averted). Projected average annual costs of the vaccine program ranged from $11.2 to $15.4 M, depending on strategy. This represents 11–15% of the estimated total immunization costs for 2022 ($100,857,875 based on Ghana’s comprehensive Multi-Year Plan for Immunization, 2020–2024). Discussion Our model suggests that introducing HPV vaccination would be cost-effective in Ghana under any strategy when willingness-to-pay is at least 40% GDP per capita ($881). Inclusion of a one-time catch-up campaign is shown to create greater value for money than routine immunization alone but would incur greater program costs.

More than 90% of cervical cancer deaths occur in low- and middle-income countries (LMICs), which have limited capacity to mount the comprehensive national screening and precancer treatment programs that could prevent most of these deaths. The development of vaccines against the human papillomavirus (HPV) has dramatically altered the landscape of cervical cancer prevention. As of mid-2020, 56 LMICs (41% of all LMICs) have initiated national HPV vaccination programs. This paper reviews the experience of LMICs that have introduced HPV vaccine into their national programs, key lessons learned, HPV vaccination sustainability and scale-up challenges, and future mitigation measures. As international guidance evolved and countries accumulated experience, strategies for national introduction shifted with regard to target groups, delivery site and timing, preparation and planning, communications and social mobilization, and ultimately monitoring, supervision and evaluation. Despite the successes that LMICs have been able to achieve in reaching large proportions of eligible girls, there are still considerable challenges countries encounter in overcoming rumors, reaching out-of-school girls, completing the vaccine series, estimating target populations, monitoring program performance, and assuring vaccination sustainability. New opportunities, such as the entry of additional vaccine manufacturers and ongoing studies to evaluate one-dose delivery, could help overcome the outstanding barriers to higher coverage and financial sustainability. Effective use of the experience to date and advances on the horizon could enable all LMICs to move towards the coverage levels that are needed to achieve eventual elimination., Highlights • School-based delivery achieves higher coverage but countries concerned about cost. • Trade-offs between age- and grade-based strategy remains complex, country-specific. • Managing rumors and misinformation is critical to success; preparedness is key. • Good coordination between health and education sectors essential for HPV vaccine.

WHO/UNICEF estimates for HPV vaccination coverage from 2010 to 2019 are analyzed against the backdrop of the 90% coverage target for HPV vaccination by 2030 set in the recently approved global strategy for cervical cancer elimination as a public health problem. As of June 2020, 107 (55%) of the 194 WHO Member States have introduced HPV vaccination. The Americas and Europe are by far the WHO regions with the most introductions, 85% and 77% of their countries having already introduced respectively. A record number of introductions was observed in 2019, most of which in low- and middle- income countries (LMIC) where access has been limited. Programs had an average performance coverage of around 67% for the first dose and 53% for the final dose of HPV. LMICs performed on average better than high- income countries for the first dose, but worse for the last dose due to higher dropout. Only 5 (6%) countries achieved coverages with the final dose of more than 90%, 22 countries (21%) achieved coverages of 75% or higher while 35 (40%) had a final dose coverage of 50% or less. When expressed as world population coverage (i.e., weighted by population size), global coverage of the final HPV dose for 2019 is estimated at 15%. There is a long way to go to meet the 2030 elimination target of 90%. In the post-COVID era attention should be paid to maintain the pace of introductions, specially ensuring the most populous countries introduce, and further improving program performance globally.

Since 2006, 115 countries and territories have introduced human papillomavirus (HPV) vaccination programs. Several efforts have been undertaken to evaluate the impact of HPV vaccines. Many countries, mainly high-income and with high screening coverage, are already reporting a visible impact of the HPV vaccine on HPV-related diseases. Others, largely low-income and middle-income countries, are introducing HPV vaccine to control HPV diseases that will undoubtedly generate a similar impact. In this review, we will summarize the compelling evidence of the impact of vaccines in reducing the burden of HPV-related disease. The data support additional efforts to make HPV vaccines widely available to adolescent girls in the countries that bear the vast majority of cervical cancer-related morbidity and mortality.

The realisation of human potential for development requires age-specific investment throughout the 8000 days of childhood and adolescence. Focus on the first 1000 days is an essential but insufficient investment. Intervention is also required in three later phases: the middle childhood growth and consolidation phase (5-9 years), when infection and malnutrition constrain growth, and mortality is higher than previously recognised; the adolescent growth spurt (10-14 years), when substantial changes place commensurate demands on good diet and health; and the adolescent phase of growth and consolidation (15-19 years), when new responses are needed to support brain maturation, intense social engagement, and emotional control. Two cost-efficient packages, one delivered through schools and one focusing on later adolescence, would provide phase-specific support across the life cycle, securing the gains of investment in the first 1000 days, enabling substantial catch-up from early growth failure, and leveraging improved learning from concomitant education investments. Refereed/Peer-reviewed

a b s t r a c t Background: Investigations of vaccine efficacy and immunogenicity for adult females receiving fewer than three doses of human papillomavirus (HPV) vaccine have suggested protection against infection and precancerous lesions. We investigated the immunogenicity of bivalent HPV vaccines among adolescent girls from Uganda who received one, two, or three vaccine doses. Methods: Young girls vaccinated through a government program in Uganda were invited to participate. HPV16- and HPV18-specific antibodies were measured at ≥24 months after the last vaccine dose using an enzyme linked immunoassay in girls who received one (n = 36), two (n = 145), or three (n = 195) doses. Results: Nearly all subjects (99%) were HPV16 and HPV18 seropositive at the time of blood-draw. Geometric mean antibody levels (GMTs) were: HPV161-dose = 230 EU/mL, HPV162-dose = 808 EU/mL, and HPV163-dose = 1607 EU/mL; HPV181-dose = 87 EU/mL, HPV182-dose = 270 EU/mL, and HPV183-dose = 296 EU/mL. The GMT ratio for 2:3 doses was 0.50 (HPV16) and 0.68 (HPV18) and did not meet the non-inferiority criteria (i.e., lower bound of 97.5% confidence interval of the GMT ratio greater than 0.50). The GMT ratio for 1:3 doses for HPV16 and HPV18 was inferior, but absolute GMTs for one dose were higher than adult women who received one dose (HPV16 = 124 EU/mL, HPV18 = 69 EU/mL) where efficacy has been demonstrated. Conclusions: Even though immunogenicity with less than three doses did not meet a priori non-inferiority thresholds, antibody levels measured ≥24 months after last dose were similar to those of adult women who have been followed for more than eight years for efficacy. © 2014 Published by Elsevier Ltd.

Infection with human papillomavirus (HPV) is recognized as one of the major causes of infection-related cancer worldwide, as well as the causal factor in other diseases. Strong evidence for a causal etiology with HPV has been stated by the International Agency for Research on Cancer for cancers of the cervix uteri, penis, vulva, vagina, anus and oropharynx (including base of the tongue and tonsils). Of the estimated 12.7 million new cancers occurring in 2008 worldwide, 4.8% were attributable to HPV infection, with substantially higher incidence and mortality rates seen in developing versus developed countries. In recent years, we have gained tremendous knowledge about HPVs and their interactions with host cells, tissues and the immune system; have validated and implemented strategies for safe and efficacious prophylactic vaccination against HPV infections; have developed increasingly sensitive and specific molecular diagnostic tools for HPV detection for use in cervical cancer screening; and have substantially increased global awareness of HPV and its many associated diseases in women, men, and children. While these achievements exemplify the success of biomedical research in generating important public health interventions, they also generate new and daunting challenges: costs of HPV prevention and medical care, the implementation of what is technically possible, socio-political resistance to prevention opportunities, and the very wide ranges of national economic capabilities and health care systems. Gains and challenges faced in the quest for comprehensive control of HPV infection and HPV-related cancers and other disease are summarized in this review. The information presented may be viewed in terms of a reframed paradigm of prevention of cervical cancer and other HPV-related diseases that will include strategic combinations of at least four major components: 1) routine introduction of HPV vaccines to women in all countries, 2) extension and simplification of existing screening programs using HPV-based technology, 3) extension of adapted screening programs to developing populations, and 4) consideration of the broader spectrum of cancers and other diseases preventable by HPV vaccination in women, as well as in men. Despite the huge advances already achieved, there must be ongoing efforts including international advocacy to achieve widespread-optimally universal-implementation of HPV prevention strategies in both developed and developing countries. This article summarizes information from the chapters presented in a special ICO Monograph 'Comprehensive Control of HPV Infections and Related Diseases' Vaccine Volume 30, Supplement 5, 2012. Additional details on each subtopic and full information regarding the supporting literature references may be found in the original chapters. (C) 2013 Elsevier Ltd. All rights reserved.

Background Immune response to quadrivalent human papillomavirus (HPV) vaccine delivered at 0, 2, and 6 months in young adolescent females plateaus around 24 months after immunization. Antibody levels >24 months postvaccination using extended dosing schedules is unknown. Methods We conducted a follow-up immunogenicity study of adolescent girls in Vietnam who participated in a noninferiority trial to investigate whether immune responses using 3 alternative dosing schedules (0, 3, 9 months; 0, 6, 12 months; or 0, 12, 24 months) are noninferior to the standard schedule at >2 years after immunization. Results Quadrivalent HPV vaccine immunogenicity delivered on 3 alternative dosing schedules was noninferior for types 6, 11, 16, and 18 at 32 months post-dose 3 compared to the standard schedule. Pre-dose 3 antibody levels for the 0, 12, 24 month schedule were similar to those measured 32-months post-dose 3. Conclusions We found similar antibody concentrations ≥29 months after 3 doses of HPV vaccine regardless of dose-timing, and extended schedules do not produce inferior immune responses. Our findings also suggested that 2 doses of HPV vaccine delivered at 0 and 12 months might afford similar protection. Evidence supporting dosing flexibility could be important for national HPV vaccination policies.

To estimate the incremental delivery cost of human papillomavirus (HPV) vaccination of young adolescent girls in Peru, Uganda and Viet Nam.Data were collected from a sample of facilities that participated in five demonstration projects for hpv vaccine delivery: school-based delivery was used in Peru, Uganda and Viet Nam; health-centre-based delivery was also used in Viet Nam; and integrated delivery, which involved existing health services, was also used in Uganda. Microcosting methods were used to guide data collection on the use of resources (i.e. staff, supplies and equipment) and data were obtained from government, demonstration project and health centre administrative records. Delivery costs were expressed in 2009 United States dollars (US$). Exclusively project-related expenses and the cost of the vaccine were excluded.The economic delivery cost per vaccine dose ranged from US$ 1.44 for integrated outreach in Uganda to US$ 3.88 for school-based delivery in Peru. In Viet Nam, the lowest cost per dose was US$ 1.92 for health-centre-based delivery. Cost profiles revealed that, in general, the largest contributing factors were project start-up costs and recurrent personnel costs. The delivery cost of HPV vaccine was higher than published costs for traditional vaccines recommended by the Expanded Programme on Immunization (EPI).The cost of delivering HPV vaccine to young adolescent girls in Peru, Uganda and Viet Nam was higher than that for vaccines currently in the EPI schedule. The cost per vaccine dose was lower when delivery was integrated into existing health services.Estimer les coûts d'administration croissants du vaccin contre le papillomavirus humain (VPH) chez les jeunes adolescentes au Pérou, en Ouganda et au Viet Nam.Des données ont été recueillies auprès d'un échantillon d'établissements qui ont participé à cinq projets de démonstration de l'administration du vaccin contre le VPH: un mode d'administration en milieu scolaire a été utilisé au Pérou, en Ouganda et au Viet Nam, un mode d'administration dans un centre de santé a également été utilisé au Viet Nam, et un mode d'administration intégrée, qui a impliqué les services de santé existants, a également été utilisé en Ouganda. Une approche verticale ascendante (Microcosting) a été utilisée pour guider la collecte de données sur l'utilisation des ressources (personnel, fournitures et équipement), et d'autres données ont été obtenues auprès des gouvernements, et dans les dossiers administratifs des centres de santé et des projets de démonstration. Les coûts d'administration sont exprimés en dollars des États-Unis ($) de 2009. Seules les dépenses liées au projet et les coûts du vaccin ont été exclus.Le coût économique d'administration par dose de vaccin variait de 1,44 $ pour une administration intégrée en Ouganda, à 3,88 $ pour une administration en milieu scolaire au Pérou. Au Viet Nam, le coût le plus bas par dose était de 1,92 $ pour une administration dans un centre de santé. Le profil des coûts a révélé qu'en général, les facteurs les plus importants étaient les coûts de démarrage du projet et les coûts récurrents du personnel. Les coûts d'administration du vaccin contre le VPH sont plus élevés que les coûts indiqués pour les vaccins traditionnels recommandés par le Programme d'immunisation élargi (PIE).Les coûts d'administration du vaccin contre le VPH chez les jeunes adolescentes au Pérou, en Ouganda et au Viet Nam étaient supérieurs à ceux des vaccins actuellement indiqués dans le calendrier du PIE. Le coût par dose de vaccin était le plus bas lorsque l'administration du vaccin était réalisée dans les services de santé existants.Estimar el incremento del coste de la administración de la vacuna contra el virus del papiloma humano (VPH) a adolescentes mujeres en Perú, Uganda y Viet Nam.Se recabaron datos a partir de una muestra de los centros que participaron en cinco proyectos de demostración sobre la administración de la vacuna contra el VPH: en Perú, Uganda y Viet Nam, la administración se efectuó en la escuela; la prestación de asistencia sanitaria en centros de salud se realizó también en Viet Nam; y la entrega administración, que incluía los servicios de salud existentes, también se realizó en Uganda. Se emplearon métodos de microcosteo para orientar la recolección de datos sobre el uso de los recursos (es decir, el personal, los suministros y los equipos). Los datos se obtuvieron del gobierno, de los proyectos de demostración y los registros administrativos del centro de salud. Los gastos de administración se expresaron en 2009 dólares de los Estados Unidos (US$). Se excluyeron los gastos derivados exclusivamente del proyecto y del coste de las vacunas.El coste del envío económico por dosis de vacuna varió de US$ 1,44, en la difusión integrada en Uganda, a US$ 3,88 en la entrega en las escuelas en Perú. En Viet Nam, el coste más bajo por dosis fue de US$ 1,92 para la prestación de asistencia en centros sanitarios. Los perfiles de costes revelaron que, en general, los factores que más contribuyen son los costes de la puesta en marcha del proyecto y los del personal constante. El coste de administración de la vacuna contra el VPH fue mayor que los costes publicados de las vacunas tradicionales recomendadas por el Programa Ampliado de Inmunización (PAI).El coste de la entrega de vacunas contra el VPH a las adolescentes jóvenes en Perú, Uganda y Vietnam fue mayor que el de las vacunas incluidas actualmente en el programa de EPI. El coste por dosis de vacuna fue menor cuando la entrega estaba integrada en los servicios de salud actuales.تقدير تكلفة الإيتاء التكميلية للتطعيم ضد فيروس الورم الحليمي البشري للفتيات المراهقات صغيرات السن في بيرو وأوغندا وفييت نام.تم جمع البيانات من عينة من المرافق التي شاركت في خمسة مشاريع إيضاحية لإيتاء لقاح فيروس الورم الحليمي البشري: تم استخدام الإيتاء المستند على المدارس في بيرو وأوغندا وفييت نام؛ وتم كذلك استخدام الإيتاء المستند على المراكز الصحية في فييت نام؛ كما تم استخدام الإيتاء المتكامل، الذي اشتمل على الخدمات الصحية القائمة، في أوغندا. وتم استخدام طرق التكاليف الجزئية لتوجيه جمع البيانات بشأن استغلال الموارد (أي الموظفين والإمدادات والمعدات) وتم الحصول على البيانات من السجلات الإدارية الخاصة بالحكومة أو المشاريع الإيضاحية أو المراكز الصحية. وتم التعبير عن تكاليف الإيتاء بمبلغ 2009 دولاراً أمريكياً. وتم استبعاد النفقات المرتبطة بالمشروع على نحو حصري وتكلفة اللقاح.تراوحت تكلفة الإيتاء الاقتصادي لكل جرعة لقاح من 1.44 دولاراً أمريكياً بالنسبة للتواصل المتكامل في أوغندا إلى 3.88 دولاراً أمريكياً بالنسبة للإيتاء المستند على المدارس في بيرو. وفي فييت نام، كانت أقل تكلفة للجرعة الواحدة 1.92 دولاراً أمريكياً بالنسبة للإيتاء المستند على المراكز الصحية. وأظهرت مواصفات التكاليف بشكل عام أن تكاليف بدء المشاريع وتكاليف الموظفين المتكررة كانت أكثر العوامل تأثيراً. وكانت تكلفة إيتاء لقاح فيروس الورم الحليمي البشري أعلى من التكاليف المنشورة عن اللقاحات التقليدية التي أوصى بها البرنامج الموسّع للتمنيع.كانت تكلفة إيتاء لقاح فيروس الورم الحليمي البشري للفتيات المراهقات صغيرات السن في بيرو وأوغندا وفييت نام أعلى من تكلفة اللقاحات التي يتضمنها حالياً جدول البرنامج الموسّع للتمنيع. وكانت التكلفة لكل جرعة لقاح أقل عندما تم دمج الإيتاء في الخدمات الصحية القائمة.估算秘鲁、乌干达和越南年轻少女的人类乳头状瘤病毒（HPV）疫苗的配送成本。从参与五个HPV疫苗配送示范项目的设施样本中收集数据：秘鲁、乌干达和越南使用基于学校的配送；越南还使用基于健康中心的配送；乌干达还使用包含现有卫生服务的综合配送。使用微成本计算方法指导资源（即人员、物资和设备）使用相关数据的收集并从政府、示范项目和健康中心行政记录中获取数据。以2009 年美元表示配送成本。不含项目相关的专项费用和疫苗的成本。每剂疫苗的经济配送成本为从乌干达综合推广的1.44 美元到秘鲁基于学校配送的3.88 美元不等。在越南，基于健康中心的最低每剂配送成本是1.92 美元。成本资料显示，一般来说，最大的影响因素是项目启动成本和经常性人力成本。HPV疫苗的配送成本高于由疫苗扩大免疫规划（EPI）建议的传统疫苗公开成本。秘鲁、乌干达和越南年轻少女HPV疫苗配送成本高于EPI规划当前的疫苗成本。如果将配送集成到现有卫生服务中，则每剂成本较低。Оценить увеличение стоимости вакцинации против вируса папилломы человека (ВПЧ) среди девушек в подростковом возрасте в Перу, Уганде и Вьетнаме.Данные были собраны в отдельных выбранных учреждениях, которые принимали участие в пяти демонстрационных проектах по проведению вакцинации против ВПЧ. В Перу, Уганде и Вьетнаме вакцинация проводилась в школах, во Вьетнаме также проводилась вакцинация в медицинских учреждениях. В Уганде также использовалась комплексная вакцинация, с привлечением доступного медицинского обслуживания. Были использованы методы с минимальными затратами на проведение сбора данных по используемым ресурсам (т.е. сотрудникам, материалам и оборудованию), данные также были получены из административных записей государственных учреждений, демонстрационных проектов и центров здравоохранения. Стоимость вакцинации была выражена в 2009 году в долларах США. Расходы, относящиеся исключительно к организации проведения проекта и стоимость самой вакцины были исключены.С экономической точки зрения стоимость вакцинации в расчете на одну дозу варьировалась от 1,44 доллара США для комплексных мероприятий в Уганде до 3,88 долларов США для вакцинации в школах в Перу. Во Вьетнаме самая низкая стоимость дозы составила 1,92 доллара США для вакцинации в центрах здравоохранения. Динамика затрат указывает на то, что в целом наиболее затратными статьями были расходы на организацию проекта и циклическое привлечение персонала. Стоимость проведения вакцинации против ВПЧ была выше опубликованных расходов на традиционные вакцины, рекомендуемые Расширенной программой иммунизации (РПИ).Стоимость вакцинации против ВПЧ среди девушек-подростков в Перу, Уганде и Вьетнаме была выше стоимости вакцин, запланированных в настоящее время РПИ. Стоимость дозы вакцины была ниже, когда вакцинация проводилась в рамках комплексных мероприятий существующих служб здравоохранения.

This study investigates the effect of communication strategies on human papillomavirus (HPV) vaccine uptake in HPV vaccine demonstration projects in Uganda and Vietnam. Secondary analysis was conducted on data from surveys of a representative sample of parents and guardians of girls eligible for HPV vaccine, measuring three-dose coverage achieved in demonstration projects in 2008-2010. Univariate and multivariate logistic regression analysis calculated the unadjusted and adjusted odds of receiving at least one dose of HPV vaccine depending on exposure to community influencers; information, education, and communication (IEC) channels; and demographic factors. This study found that exposure to community influencers was associated with HPV vaccine uptake in a multivariate model controlling for other factors. Exposure to non-interactive IEC channels was only marginally associated with HPV vaccine uptake. These results underscore the need of HPV vaccine programs in low- and middle-income countries to involve and utilize key community influencers and stakeholders to maximize HPV vaccine uptake.

Cancer is an important cause of premature death in low- and middle-income countries (LMIC). Two preventive tools are available that have the potential together to sharply decrease the impact of cervical cancer in LMIC. The combination of human papillomavirus (HPV) vaccination and cervical cancer screening within existing programs is possible. Although there is a great deal of concern about introducing and strengthening HPV prevention efforts in LMIC, recent projects have demonstrated feasibility. Thus, with appropriate prioritization and resources, HPV prevention can be introduced and scaled up. Comprehensive HPV prevention strategies, mainly those geared at preventing cervical cancer, should include both vaccination and screening. The integration of both screening and vaccination will save the most lives, and such strategies are endorsed by many international organizations. However, some vaccine and screening programs are financed almost entirely by special externally-based programs. These more closely resemble demonstration exercises than sustainable national programs. In order for successful demonstration projects to have a broad impact on prevention, sustainable national funding based on strong commitments is essential. There may be challenges to implementing HPV prevention programs, but none should be considered insurmountable. Many LMIC have successfully adopted an HPV prevention agenda despite prevailing pessimism. Failure to act on this issue can perpetuate inequity in sexually transmitted infection and cancer prevention. This article forms part of a special supplement entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

OBJECTIVE: To assess human papillomavirus (HPV) vaccination coverage after demonstration projects conducted in India, Peru, Uganda and Viet Nam by PATH and national governments and to explore the reasons for vaccine acceptance or refusal. METHODS: Vaccines were delivered through schools or health centres or in combination with other health interventions, and either monthly or through campaigns at fixed time points. Using a two-stage cluster sample design, the authors selected households in demonstration project areas and interviewed over 7000 parents or guardians of adolescent girls to assess coverage and acceptability. They defined full vaccination as the receipt of all three vaccine doses and used an open-ended question to explore acceptability. FINDINGS: Vaccination coverage in school-based programmes was 82.6% (95% confidence interval, CI: 79.3-85.6) in Peru, 88.9% (95% CI: 84.7-92.4) in 2009 in Uganda and 96.1% (95% CI: 93.0-97.8) in 2009 in Viet Nam. In India, a campaign approach achieved 77.2% (95% CI: 72.4-81.6) to 87.8% (95% CI: 84.3-91.3) coverage, whereas monthly delivery achieved 68.4% (95% CI: 63.4-73.4) to 83.3% (95% CI: 79.3-87.3) coverage. More than two thirds of respondents gave as reasons for accepting the HPV vaccine that: (i) it protects against cervical cancer; (ii) it prevents disease, or (iii) vaccines are good. Refusal was more often driven by programmatic considerations (e.g. school absenteeism) than by opposition to the vaccine. CONCLUSION: High coverage with HPV vaccine among young adolescent girls was achieved through various delivery strategies in the developing countries studied. Reinforcing positive motivators for vaccine acceptance is likely to facilitate uptake.

Objective. To understand the sociocultural environment, health systems’ capacities, and policy processes related to cervical cancer and HPV vaccines in order to inform HPV vaccine introduction. Material and Methods. Mixedmethod formative research using qualitative and quantitative data collection techniques. Participants included girls, parents, community leaders, health and education officials, and policymakers. Results. Respondents, including policymakers, generally supported HPV vaccine introduction, due partly to appreciation for the benefits of vaccination and the desire to prevent cancer. Community-level concerns regarding safety and quality of services will need to be addressed. The immunization system in Peru is strong and has capacity for including the HPV vaccine. Conclusion. Formative research provides key insights to help shape an effective program for HPV vaccine introduction.

This paper presents findings from a study conducted in 2007 and 2008 in two states in India: Andhra Pradesh and Gujarat. The objectives of the study were to: (i) design effective and appropriate HPV vaccine delivery systems for 10- to 14-year-old girls; (ii) design a communication strategy for HPV vaccine delivery; and (iii) devise an HPV vaccine advocacy strategy. The study populations included girls, parents, and local-, district-, and national-level stakeholders. A mixture of group discussions, visual representation techniques, face-to-face interviews, desk and health facility record reviews, field obser- vations, and consultative workshops were used to collect the data. Study findings showed that the policymakers, health care providers, parents, and adolescents were aware and concerned about cervical cancer; would welcome vaccination if safe, effective, affordable, and accessible. Health systems did not re- quire large infrastructure investments to introduce HPV vaccine; basic cold chain and logistic equipment were available. New outreach systems for adolescent girls need to be tested through demonstration projects. No policies would compro- mise the introduction of HPV vaccination. An HPV vaccine program, requiring public education and provider training, could be delivered. Policymakers' safety and vaccine efficacy concerns can be addressed through targeted advocacy efforts. Three broad approaches were suggested: (i) merge HPV vaccination with already established immunization services; (ii) package HPV immunization with adolescent health services or as a part of a cancer control service; and (iii) deliver HPV vaccinations through either routine immuni- zation services or a campaign using schools as sites for school-going girls and anganwadi or village health centers for non-school-going girls.

This descriptive qualitative study synthesizes health system and immunization financing assessments performed through formative research in India, Peru, Uganda, and Vietnam using a non-probability sample of national and sub-national stakeholders; and recommends appropriate and effective strategies for HPV vaccine delivery in low-resource settings. We conclude that maximum feasibility and acceptability and lowest cost for delivering HPV vaccine can be achieved by implementing through national immunization programs; by partnering with other sectors, such as education and maternal-child health; by strengthening existing human resources and cold chain infrastructures where needed; and finally, by considering schools for reaching the target population.

Background: Introduction of human papillomavirus (HPV) vaccine in national programs has proceeded apace since 2006, mostly in high-income countries. Recently concluded pilots of HPV vaccination in low-income countries have provided important lessons learned for these settings; however, rigorous evaluations of the feasibility of these delivery strategies that effectively reach young adolescents have been few. This paper presents results from a qualitative evaluation of a demonstration program which implemented school-based and health center–based HPV vaccinations to all girls in grade 6, or 11 years of age, for two years in four districts of Vietnam. Methods: Using semi-structured interviews of 131 health and education staff from local, district, province, and national levels and 26 focus-group discussions with local project implementers (n=153), we conducted a qualitative two-year evaluation to measure the impact of HPV vaccinations on the health and education systems. Results: HPV vaccine delivery at schools or health centers was made feasible by: a. close collaboration between the health and education sectors, b. detailed planning for implementation, c. clearly defined roles and responsibilities for project implementers, d. effective management and supervision of vaccinations during delivery, and e. engagement with community organizations for support. Both the health and education systems were temporarily challenged with the extra workload, but the disruptions were short-lived (a few days for each of three doses) and perceived as worth the longer-term benefit of cervical cancer prevention. Conclusion: The learning from Vietnam has identified critical elements for successful vaccine delivery that can provide a model for other countries to consider during their planning of national rollout of HPV vaccine.

Genital Chlamydia trachomatis is the commonest bacterial sexually transmitted infection in the UK with the number of cases diagnosed in genitourinary medicine (GUM) clinics having increased continuously since the early 1990s to over 89 000 in 2003 an 8% increase on the previous year. The prevalence in the UK has been reported between 2% and 29% depending on the testing site population being tested and type of test. As expected the highest rates of diagnoses are reported from GUM clinics and are among 16–19-year-old females (1334/1001000] and 20–24-year-old males (961/1001000). It is estimated that approximately 70% of infections in women and 50% of infections in men are asymptomatic and therefore a large proportion of cases remain undiagnosed. Although easily treatable with oral antibiotics most people remain untreated as they are unaware of their infection. Between 10% and 40% of untreated cases of chlamydia may develop pelvic inflammatory disease (PID) with the risk of long-term sequelae namely ectopic pregnancy and infertility being dependent on the number of PID episodes. Approximately 20% of infertility cases and 43% of ectopic pregnancies are said to be caused by chlamydia. Recent studies suggest chlamydial infections in men may impair a couple’s ability to conceive independent of the presence of tubal damage in the female partner. Research has postulated that chronic chlamydial infection may be a risk factor associated with reproductive tract cancers. (excerpt)

Objective Sayana® Press (SP) is a unique injectable contraceptive (depot medroxyprogesterone acetate, or DMPA) administered subcutaneously in the Uniject TM injection system. 1 1Sayana Press and depo-subQ provera 104 in Uniject are registered trademarks of Pfizer Inc. Uniject is a trademark of BD. SP simplifies the injection process; it requires no assembly of components and is easily disposable. This new technology appears to be well suited for community-based delivery of injectable contraception. The study objective was to evaluate SP management and administration in low-resource settings, focusing on how the delivery logistics, administration time, storage and waste-management requirements compare to the traditional intramuscular DMPA injectable (DMPA IM). Study design We conducted 58 semistructured interviews with clinic providers and community health workers in Senegal and Uganda to identify the merits, challenges and appeal of SP relative to DMPA IM. Results Providers identified logistical challenges with the management and administration of DMPA IM, including stock outs, transportation, storage constraints, and, in a few instances, waste disposal. Most providers (between 63% and 88%, depending on the logistics issue) do not expect SP to either aggravate or solve those problems. Some envisioned that SP could facilitate supply management (5%), storage (11%) and waste disposal (22%). The all-in-one packaging of SP was perceived to reduce the incidence of mismatched supplies (syringes and vials), and its smaller size was expected to ease space constraints and reduce the frequency of safety box incineration. Conclusion Adding SP to the method mix is unlikely to have a profound impact on clinic operations but may lessen logistical problems related to supply, storage and waste management. Implications Community health workers and clinic providers who administer SP may see some modest improvements in service delivery logistics. Particularly in settings where service delivery logistical challenges are more pronounced, offering SP may facilitate injectable contraceptive delivery.

Objective and methodCervical cancer is the third most common cancer affecting women worldwide and it is an important cause of death, especially in developing countries. Cervical cancer is caused by human papillomavirus (HPV) and can be prevented by HPV vaccine. The challenge is to expand vaccine availability to countries where it is most needed. In 2008 Peru's Ministry of Health implemented a demonstration project involving 5(th) grade girls in primary schools in the Piura region. We designed and conducted a qualitative study of the decision-making process among parents of girls, and developed a conceptual model describing the process of HPV vaccine acceptance.ResultsWe found a nonlinear HPV decision-making process that evolved over time. Initially, the vaccine's newness, the requirement of written consent, and provision of information were important. If information was sufficient and provided by credible sources, many parents accepted the vaccine. Later, after obtaining additional information from teachers, health personnel, and other trusted sources, more parents accepted vaccination. An understanding of the issues surrounding the vaccine developed, parents overcome fears and rumors, and engaged in family negotiations-including hearing the girl's voice in the decision-making process. The concept of prevention (cancer as danger, future health, and trust in vaccines) combined with pragmatic factors (no cost, available at school) and the credibility of the offer (information in the media, recommendation of respected authority figure) were central to motivations that led parents to decide to vaccinate their daughters. A lack of confidence in the health system was the primary inhibitor of vaccine acceptance.ConclusionsHealth personnel and teachers are credible sources of information and can provide important support to HPV vaccination campaigns.

Background The GAVI Alliance’s decision in late 2011 to invite developing countries to apply for funding for human papillomavirus (HPV) vaccine introduction underscores the importance of understanding levels of HPV vaccine acceptance in developing country settings. In this paper, we present findings from qualitative research on parents’ rationales for vaccinating or not vaccinating their daughters (vaccine acceptance) and their decision-making process in the context of an HPV vaccination demonstration project in Vietnam (2008–2009). Methods We designed a descriptive qualitative study of HPV vaccine acceptability among parents of girls eligible for vaccination in four districts of two provinces in Vietnama. The study was implemented after each of two years of vaccinations was completed. In total, 133 parents participated in 16 focus group discussions and 27 semi-structured interviews. Results Focus group discussions and in-depth interviews with parents of girls vaccinated revealed that they were generally very supportive of immunization for disease prevention and of vaccinating girls against HPV. The involvement of the National Expanded Program of Immunization in the demonstration project lent credibility to the HPV vaccine, contributing to high levels of acceptance. For parents who declined participation, concerns about side effects, the possibility that the vaccine was experimental, and the possible impact of the vaccine on future fertility rose to the surface. In terms of the decision-making process, many parents exhibited ‘active decision-making,’ reaching out to friends, family, and opinion leaders for guidance prior to making their decision. Conclusion Vietnam’s HPV vaccination experience speaks to the importance of close collaboration with the government to make the most of high levels of trust, and to reduce suspicions about new vaccines that may arise in the context of vaccine introduction in developing country settings.

Although Maine et al. provided a comprehensive overview of the state of cervical cancer prevention today,1 their article presented some inaccuracies and tended to downplay the benefits of vaccination and magnified its challenges. For example, the authors failed to acknowledge that immunization has much less socioeconomic variation than screening does and has very little evidence of gender bias in particular. More importantly, their calculations assumed that the dropout rate for second and third doses of vaccine will be 15% at each step (28% in total), similar to the estimated dropout rates for women making multiple visits for screening and treatment. In demonstration projects in India, Peru, Uganda, and Vietnam, where human papillomavirus (HPV) vaccination was implemented by existing immunization program staff, dropout rates from first to third dose ranged from 0.5% to 17.6%, and all but one were less than 8%2; the rates were generally lowest with school-based vaccination. Furthermore, the authors suggested that because it requires intramuscular injection, the HPV vaccine will be more expensive than other vaccine programs—an odd claim, given that most Expanded Program on Immunization vaccines are also injectable. Maine et al. raised the “humanitarian” concern that with HPV vaccination, older women “will essentially be left to their fate.”1(pp1551-1552) In fact, the contrary is true. Vaccination and its promotion—including the message that screening must still be provided—are creating a demand for screening and a recognition that a comprehensive approach is essential. Although the authors believe that governments cannot do both, several countries are already implementing both screening for older women and vaccination for young adolescent girls. Timetables for scaling up these strategies may vary according to local needs. The World Health Organization (WHO), the United Nations Population Fund (UNFPA), the International Federation of Gynecology and Obstetrics (FIGO), and other international organizations recommend a comprehensive approach. Investments are clearly needed in both screening and vaccination. Countries will need to decide for themselves the best place to start, depending on what they already have in place. Where disease burden is high enough and the immunization program is already functioning well, HPV vaccine is a sensible part of any comprehensive prevention program, especially with GAVI Alliance support for vaccine purchase. In Rwanda, for example, they launched HPV vaccination nationwide in April 2011, while continuing to work on a national screening strategy. Countries have important and difficult decisions to make about allocating scarce resources; accurate and balanced information will be critical in making those decisions.

Background: Formative research is a useful tool for designing new health interventions. This paper presents key findings from formative research conducted in Vietnam to guide human papillomavirus (HPV) vaccine introduction. Methods: We explored the sociocultural environment, health system capacity and the policy-making process using a combined quantitative and qualitative methodology. Data collection was done through literature review, in-depth interviews, focus group discussions, observation checklists and a structured questionnaire on knowledge, attitudes and practices. Populations of interest included 11- to 14-year-old girls, their parents, community leaders, teachers, health workers, health and education officials, and policy-makers at all levels. Results:Although HPV vaccines are new, we found high potential acceptance among parents and girls. HPV vaccine introduction was also favourably supported by health professionals if assurances for system preparedness, e.g. cold chain and human resources, were made. There were no significant barriers from the policy perspective that would prevent the introduction of a new vaccine. However, several concerns related to this new vaccine would need to be adequately addressed before implementation. Conclusion: Our findings provide options for potential vaccine delivery strategies, appropriate communication strategies and targeted advocacy strategies to introduce HPV vaccines in the Vietnamese context.

Objective To determine the range of policies and practices related to the management of genital chlamydial infection employed at termination of pregnancy services in England and Wales. Design Cross-sectional descriptive study. Setting England and Wales. Population Termination of pregnancy providers. Methods Survey questionnaire administered to termination of pregnancy providers Main outcome measures Policies and practices for the management of genital chlamydial infection in women seeking termination of pregnancy with comparison to the national guidelines of the chief medical officer (CMO) and the Royal College of Obstetricians and Gynaecologists (RCOG). Results One hundred and thirty-eight (48%) practices responded to the survey, with representation across England and Wales. Policies for screening and/or treatment of chlamydial infection existed for 70% of providers. We found three practice patterns for the management of genital chlamydial infection among termination of pregnancy attenders: 70% of providers tested their own attenders prior to termination and treated if necessary; about 25% of providers administered prophylaxis without testing; and a small number of providers (

In a recent issue of the Journal of Medical Screening, Verhoeven et al. present their e ndings from a screening trial for Chlamydia trachomatis among women attending 32 general practitioners in Antwerp, Belgium. The reported uptake of testing (75%) using a selfcollected vaginal swab is comparable with the acceptance of urine-based screening in the recent UK pilot of genital chlamydia screening. 1 The acceptance of this specimen collection modality in an apparently low-risk population provides further evidence for the possibility of wider, more generalised screening programmes. Retrospectively applying screening criteria to a population already tested has been a useful method in the past to compare the utility of varying cut-offs in deciding which women to screen. 2‐5

A recent News item by Dinesh Sharma inaccurately reports conclusions from the investigation by the Indian Parliament’s Standing Committee on Health of a human papillomavirus (HPV) vaccine delivery project in India, and perpetuates errors made in the actual investigation’s report. We wish to correct these issues. Programme for Appropriate Technology in Health (PATH), the Indian Council of Medical Research (ICMR), and the state governments of Andhra Pradesh and Gujarat worked on this HPV vaccine project, from 2009 to 2010, to explore suitable strategies for vaccine delivery, and to help to provide information for national health authorities about whether it would be feasible or appropriate to introduce the HPV vaccine in the future to protect girls against HPV, the main cause of cervical cancer. The work in India was part of a four-country project— national immunisation pro grammes in Peru, Uganda, and Vietnam did a similar demonstration project for vaccine delivery. Across the four project countries, the study generated important evidence for feasible ways to give HPV vaccines, and this evidence contributed to GAVI Alliance’s decision to subsidise HPV vaccines for the world’s poorest countries. HPV vaccines were licensed in India by the Drug Controller General of India in 2008, before their use in this project. The parliamentary report itself ignores the extensive evidence about the safety and effi cacy of HPV vaccines, and falsely suggests that deaths were causally linked to the vaccines. WHO has reviewed HPV vaccine safety and confi rmed that there have been no deaths attributable to these vaccines. State investigations of the deaths of seven girls and the enquiry committee report of Nov 9, 2010, both concluded that there was no evidence that any deaths were caused by the vaccines. Contrary to Sharma’s article, the ICMR, India’s most senior medical research authority, reviewed and approved the project protocol, and at their request, PATH ensured the study protocol was reviewed and approved by the Drug Controller General of India, India’s National Health Ministry Steering Committee, the state governments of Andhra Pradesh and Gujarat, two Indian ethics committees, and one international ethics committee. PATH followed all guidance provided by the ICMR and a national project advisory group, which included representatives from India’s National Technical Advisory Group on Immunisation, and other esteemed scientists.

Background Surveillance of adverse events following immunisation (AEFIs) is important for maintaining trust in vaccination. This paper discusses retrospective reports by parents and guardians of girls experiencing AEFIs during human papillomavirus (HPV) vaccine demonstration projects in Uganda and Vietnam. Methods: A secondary analysis of data from a population-based survey measuring HPV vaccine coverage of eligible girls and acceptability among parents and guardians was conducted. Survey data from parents were analysed for frequency and type of AEFI and actions taken. Results: Of the 1700 eligible households contacted, all responded to the survey; of those, 1313 respondents had an eligible child who had received at least one dose of the HPV vaccine. Data were missing from 49 respondents, resulting in 1264 surveys. Twenty-five percent reported an AEFI, with fever (29.1%) and pain or swelling at the injection site (62.0%) being the most common. Events totalled 386 (10.5%) of the 3684 doses administered. Most parents reported that they took no action (63.9%) or cared for girls at home (16.1%) following an AEFI. Thirty-three parents sought advice from health workers or attended a clinic for 46 events (0.8% of all doses). Frequency of reporting varied by respondent identity, geographic location and vaccination location. Conclusions: AEFIs reported were similar to Phase III vaccine trials. Most parents reporting AEFIs took no action or treated the girl at home, suggesting that most AEFIs were not serious enough to contact the health system. AEFI reports were more frequent when solicited in surveys compared with reports from routine monitoring.

Context Human papillomavirus (HPV) vaccine programs may decrease the morbidity and mortality due to cervical cancer seen among women in low-resource countries. However, the 3-dose schedule over a 6-month period is a potential barrier to vaccine introduction in such settings. Objective To determine the immunogenicity and reactogenicity of different dosing schedules of quadrivalent HPV vaccine in adolescent girls in Vietnam. Design, Setting, and Participants Open-label, cluster randomized, noninferiority study (conducted between October 2007 and January 2010) assessing 4 schedules of an HPV vaccine delivered in 21 schools to 903 adolescent girls (aged 11-13 years at enrollment) living in northwestern Vietnam. Intervention Intramuscular injection of 3 doses of quadrivalent HPV vaccine delivered on a standard dosing schedule (at 0, 2, and 6 months) and 3 alternative dosing schedules (at 0, 3, and 9 months; at 0, 6, and 12 months; or at 0, 12, and 24 months). Main Outcome Measures Serum anti-HPV geometric mean titers (GMT) measured 1 month after the third dose of the HPV vaccine was administered; GMT was determined by type-specific competitive immunoassay. Noninferiority of each alternative vaccination dosing schedule was achieved if the lower bound of the multiplicity-adjusted confidence interval (CI) of the type-specific GMT ratio for HPV-16 and HPV-18 was greater than 0.5 (primary outcome). Safety outcomes were immediate reactions, local reactions, fever within 7 days after each dose, and serious adverse events up to 30 days following the last dose. Results In the intention-to-treat analysis, 809 girls who received at least 1 HPV vaccine dose had valid serum measurements 1 month after the third dose. After the third dose, the GMTs for those in the standard schedule group who received doses at 0, 2, and 6 months were 5808.0 (95% CI, 4961.4-6799.0) for HPV-16 and 1729.9 (95% CI, 1504.0-1989.7) for HPV-18; 5368.5 (95% CI, 4632.4-6221.5) and 1502.3 (95% CI, 1302.1-1733.2), respectively, for those whose received doses at 0, 3, and 9 months; 5716.4 (95% CI, 4876.7-6700.6) and 1581.5 (95% CI, 1363.4-1834.6), respectively, for those who received doses at 0, 6, and 12 months; and 3692.5 (95% CI, 3145.3-4334.9) and 1335.7 (95% CI, 1191.6-1497.3), respectively, for those who received doses at 0, 12, and 24 months. Noninferiority criteria were met for the alternative schedule groups that received doses at 0, 3, and 9 months (HPV-16 GMT ratio: 0.92 [95% CI, 0.71-1.20]; HPV-18 GMT ratio: 0.87 [95% CI, 0.68-1.11]) and at 0, 6, and 12 months (HPV-16 GMT ratio: 0.98 [95% CI, 0.75-1.29]; HPV-18 GMT ratio: 0.91 [95% CI, 0.71-1.17]). Prespecified noninferiority criteria were not met for the alternative schedule group that received doses at 0, 12, and 24 months (HPV-16 GMT ratio: 0.64 [95% CI, 0.48-0.84]; HPV-18 GMT ratio: 0.77 [95% CI, 0.62-0.96]). Pain at the injection site was the most common adverse event. Conclusions Among adolescent girls in Vietnam, administration of the HPV vaccine on standard and alternative schedules was immunogenic and well tolerated. The use of 2 alternative dosing schedules (at 0, 3, and 9 months and at 0, 6, and 12 months) compared with a standard schedule (at 0, 2, and 6 months) did not result in inferior antibody concentrations. Trial Registration clinicaltrials.gov Identifier: NCT00524745

Objectives (1) To synthesize sociocultural results from diverse populations related to vaccine decision-making, understanding of cervical cancer and its etiology, experience with previous vaccinations, human papillomavirus (HPV) vaccine concerns, and information needed to foster acceptance; (2) to contextualize findings in light of recent studies; and (3) to discuss implications for communication strategies to facilitate vaccine acceptance. Design Descriptive qualitative synthesis of sociocultural studies in 4 countries using iterative theme-based analyses. Setting Four developing countries: India, Peru, Uganda, and Vietnam. Participants Criterion-based sample of 252 focus-group discussions and 470 in-depth interviews with children, parents, teachers/administrators, health workers/managers, and community/religious leaders. A knowledge, attitudes, and practices survey was administered to 879 children and 875 parents in Vietnam. Results We found that vaccine decision-making was primarily done by parents, with children having some role. Understanding of cervical cancer and HPV was limited; however, the gravity of cancer and some symptoms of cervical cancer were recognized. Vaccination and government-sponsored immunization programs were generally supported by respondents. Sentiments toward cervical cancer vaccines were positive, but concerns about quality of delivery, safety, adverse effects, and the effect on fertility were raised. Communities requested comprehensive awareness-raising and health education to address these concerns. Conclusion Sociocultural studies help elucidate the complexities of introducing a new vaccine from the perspective of children, parents, and communities. Strategies for introducing the HPV vaccine should address community concerns through effective communication, appropriate delivery, and targeted advocacy to make the program locally relevant.

EDITOR—The news article on the coverage of chlamydia screening in England was disappointing.1 Contrary to its suggestion that no “formal” chlamydia screening programme in England exists, the national chlamydia screening programme in England was established in 2002 after a successful pilot study in Portsmouth and Wirral and publication of the government's national sexual health and HIV strategy implementation plan.2 It is currently the only …