Vaccine Hesitancy Drives Low Human Papillomavirus Vaccination Coverage in Girls Attending Public Schools in South Africa.

Girls aged ≥9 years attending South African public sector schools are provided with free human papillomavirus (HPV) vaccination, through a schools-based programme. HPV vaccine misinformation spread via social media in 2014, was identified as a barrier to obtaining parental informed consent in some districts, including Sedibeng District, which subsequently had the lowest HPV vaccination coverage in Gauteng Province in 2018. This study investigated vaccine hesitancy in caregivers of girls in Grade 4 to 7 aged ≥9 years attending public schools in Sedibeng District. A cross-sectional survey using a self-administered questionnaire was conducted among caregivers of age-eligible girls attending all public schools in Sedibeng District with first dose HPV vaccination coverage of <70%. The questionnaire included demographics; HPV vaccination status of girls; reasons for not being vaccinated; and a 5-item tool measuring the determinants of vaccine hesitancy (5C scale), using a 7-point Likert scale. Data were coded and captured on Microsoft Excel®. Except for collective responsibility which was reverse scored, the other 5C items (confidence, complacency, constraints, and calculation) were captured as follows: 1 = strongly disagree, 2 = moderately disagree, 3 = slightly disagree, 4 = neutral, 5 = slightly agree, 6 = moderately agree and 7 = strongly agree. Descriptive and inferential statistical analyses were conducted using Epi InfoTM. Of the principals of all schools with <70% HPV vaccination coverage, 69.6% (32/46) gave permission. The response rate from caregivers of girls present on the day of data collection was 36.8% (1,782/4,838), with 67.1% (1,196/1,782) of respondents reporting that their daughters had received ≥1 dose of HPV vaccine. Only 63.1% (370/586) of respondents with unvaccinated daughters answered the question on reasons, with 49.2% (182/370) reporting reasons related to vaccine hesitancy. Statistically significant differences between caregivers of vaccinated and unvaccinated daughters were identified for four of the five determinants of vaccine hesitancy: confidence (vaccinated group higher), complacency (unvaccinated group higher), constraints (unvaccinated group higher) and collective responsibility (vaccinated group higher). This is the first South African study to (a) report results of the 5C scale, which was found to be very useful for predicting vaccination uptake; and (b) confirm that the relatively low HPV vaccination coverage in Sedibeng District is largely driven by reasons related to vaccine hesitancy.

Human Papillomavirus Vaccine Hesitancy Highly Evident among Caregivers of Girls Attending South African Private Schools.

The viral spread of social media misinformation and disinformation regarding human papillomavirus (HPV) vaccination safety has resulted in widespread vaccine hesitancy and suboptimal HPV vaccination uptake. We previously reported that only 19.4% of age-eligible private school girls in South Africa in 2018 had received ≥1 HPV vaccine dose. Here, we report on reasons given by caregivers for why their daughters were unvaccinated. An online survey targeting caregivers of girls in grades 4-7 attending South African private schools was conducted. Caregivers of unvaccinated girls provided the most important reason for their daughter not being vaccinated by either selecting from a list of coded reasons or providing a free text reason. Free text reasons were analysed, coded and added to the list of coded reasons, which were categorised according to broad themes. Frequency distributions of reasons and categories were calculated. Most reasons were related to vaccine hesitancy (61.4%), followed by lack of access to the vaccine (21.3%) and lack of information (15.7%). HPV vaccination coverage among age-eligible girls can be improved by including private-sector schools in the South African HPV vaccination programme, training healthcare providers to advocate for HPV vaccination and extending HPV vaccination advocacy campaigns to include private-sector educators.

Misinformation Drives Low Human Papillomavirus Vaccination Coverage in South African Girls Attending Private Schools.

Background: Cervical cancer, caused by persistent human papillomavirus (HPV) infection, is the leading cause of female cancer deaths in South Africa. In 2014, the South African National Department of Health introduced a free public sector school-based HPV vaccination programme, targeting grade 4 girls aged ≥9 years. However, private sector school girls receive HPV vaccination through their healthcare providers at cost. This study investigated HPV vaccination knowledge, attitudes and practices of caregivers of girls aged ≥9 years in grades 4-7 attending South African private schools. Methods: A link to an online survey was circulated to caregivers via an email sent to school principals of all private schools in four provinces enrolling girls in grades 4-7. Following a poor post-reminder response, a paid Facebook survey-linked advert targeting South African Facebook users aged ≥25 years nationally was run for 4 days, and placed on the South African Vaccination and Immunisation Centre's Facebook page for 20 days. Results: Of 615 respondents, 413 provided HPV vaccination data and 455 completed the knowledge and attitudes tests. Most (76.5%) caregivers had good knowledge and 45.3% had positive attitudes. Of their daughters, 19.4% had received ≥1 dose of HPV vaccine. Of caregivers of unvaccinated girls, 44.3% and 41.1%, respectively were willing to vaccinate their daughters if vaccination was offered free and at their school. Caregivers of unvaccinated girls were more likely [odds ratio (OR): 3.8] to have been influenced by "other" influences (mainly online articles and anecdotal vaccine injury reports). Of caregivers influenced by their healthcare providers, caregivers of unvaccinated girls were more likely (OR: 0.2) to be influenced by alternative medical practitioners. Caregivers of vaccinated girls were more likely to have good knowledge (OR: 3.6) and positive attitudes (OR: 5.2). Having good knowledge strongly predicted (OR: 2.8) positive attitudes. Having negative attitudes strongly predicted (OR: 0.2) girls being unvaccinated. Conclusion: Providing free school-based HPV vaccination in the private sector may not increase HPV vaccination coverage to an optimal level. Since misinformation was the main driver of negative attitudes resulting in <20% of girls being vaccinated, an advocacy campaign targeting all stakeholders is urgently needed.

Contextualised strategies to increase childhood and adolescent vaccination coverage in South Africa: a mixed-methods study.

INTRODUCTION: Despite the unparalleled success of immunisation in the control of vaccine preventable diseases, immunisation coverage in South Africa remains suboptimal. While many evidence-based interventions have successfully improved vaccination coverage in other countries, they are not necessarily appropriate to the immunisation needs, barriers and facilitators of South Africa. The aim of this research is to investigate barriers and facilitators to optimal vaccination uptake, and develop contextualised strategies and implementation plans to increase childhood and adolescent vaccination coverage in South Africa. METHODS: The study will employ a mixed-methods research design. It will be conducted over three iterative phases and use the Adopt, Contextualise or Adapt (ACA) model as an overarching conceptual framework. Phase 1 will identify, and develop a sampling frame of, immunisation stakeholders involved in the design, planning and implementation of childhood and human papillomavirus immunisation programmes in South Africa. Phase 2 will identify the main barriers and facilitators to, and solutions for, increasing vaccination coverage. This phase will comprise exploratory qualitative research with stakeholders and a review of existing systematic reviews on interventions for improving vaccination coverage. Using the findings from Phase 2 and the ACA model, Phase 3 will develop a set of proposed interventions and implementation action plans for improving immunisation coverage in South Africa. These plans will be discussed, revised and finalised through a series of participatory stakeholder workshops and an online questionnaire, conducted as part of Phase 3. ETHICS: Ethical approval was obtained from the South African Medical Research Council (EC018-11/2018). No risks to participants are expected. Various steps will be taken to ensure the anonymity and confidentiality of participants. DISSEMINATION: The study findings will be shared at stakeholder workshops, the website of Cochrane South Africa and academic publications and conferences.

Molecular characterization of hepatitis B virus X gene in HIV-positive South Africans.

Hepatitis B virus (HBV) infection is a major public health problem worldwide and the major cause of hepatocellular carcinoma (HCC) in South Africa. The role of HBV in HCC is not well understood, although the HBV X gene has been implicated as a critical factor. Data on the HBV X gene in HIV-positive South Africans are limited; thus, we investigated X gene variability in 24 HIV-infected treatment-naïve patients at Dr George Mukhari Academic Hospital. Quantitative and qualitative HBV DNA tests were conducted using real-time and in-house polymerase chain reaction (PCR) assays, respectively, targeting the complete HBV X gene. In-house PCR-positive samples were cloned using the P-Gem T-easy vector System II and sequenced. By phylogenetic analysis, X gene sequences were classified as subgenotype A1 (n = 15), A2 (n = 4), and D1 (n = 4), and one dual infection with subgenotypes as A1 and C. The basal core promoter mutations T1753C, A1762T, and G1764A were identified in the majority of sequences. Genotype D sequences had a 6-nucleotide insertion. In conclusion, subgenotype A1 was predominant, and a rare dual infection of HBV genotype A and C was detected. The 6-nucleotide insertion could represent a unique variant in the region and highlights the need for functional studies of HBV X gene variants, particularly from resource-limited settings.

Improving skills and institutional capacity to strengthen adolescent immunisation programmes and health systems in African countries through HPV vaccine introduction.

Several African countries have recently introduced or are currently introducing the HPV vaccine, either nationwide or through demonstration projects, while some countries are planning for introduction. A collaborative project was developed to strengthen country adolescent immunisation programmes and health systems in the African Region, addressing unique public health considerations of HPV vaccination: adolescents as the primary target group, delivery platforms (e.g. school-based and facility based), socio-behavioural issues, and the opportunity to deliver other health interventions alongside HPV vaccination. Following a successful "taking-stock" meeting, a training programme was drafted to assist countries to strengthen the integration of adolescent health interventions using HPV vaccination as an entry point. Two workshops were conducted in the Eastern and Southern African Regions. All countries reported on progress made during a final joint symposium. Of the 20 countries invited to participate in either of the workshops and/or final symposium, 17 countries participated: Angola, Botswana, Ethiopia, Kenya, Malawi, Mauritius, Mozambique, Namibia, Rwanda, Seychelles, South Africa, South Sudan, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. Countries that are currently implementing HPV vaccination programmes, either nationally or through demonstration projects, reported varying degrees of integration with other adolescent health interventions. The most commonly reported adolescent health interventions alongside HPV vaccination include health education (including sexually transmitted infections), deworming and delivering of other vaccines like tetanus toxoid (TT) or tetanus diphtheria (Td). The project has successfully (a) established an African-based network that will advocate for incorporating the HPV vaccine into national immunisation programmes; (b) created a platform for experience exchange and thereby contributed to novel ideas of revitalising and strengthening school-based health programmes as delivery platform of adolescent immunisation services and other adolescent health interventions, as well as identifying ways of reaching out-of-school girls through facility and community based programmes; and (c) laid a foundation for incorporating future adolescent vaccination programmes.

An update after 16 years of hepatitis B vaccination in South Africa.

Hepatitis B (HB) virus (HBV) infection is highly endemic with at least 65 million chronic HB surface antigen (HBsAg) carriers in Africa, 25% of whom are expected to die from liver disease. Before the introduction of the HB vaccine, the prevalence of chronic carriage of HBV in black South Africans was 9.6%, with 76% having been previously exposed to HBV. The major transmission route in South Africa is unexplained horizontal transmission between toddlers, with most transmission occurring before the age of 5 years. During adolescence and early adulthood, sexual transmission becomes the dominant route, while healthcare workers (HCWs) are also at risk for parenteral/percutaneous transmission during occupational exposures. In 1995 the South African Department of Health (SADoH) incorporated the HB vaccine, administered as a monovalent, into the Expanded Programme on Immunisation (EPI) at 6, 10, and 14 weeks of age, and studies conducted thereafter have found it to be safe and highly effective. Catch-up vaccination for adolescents was not introduced and there is no schools-based vaccination programme. The SADoH recommends HB vaccination of HCWs, but this is not mandatory and there is no national policy, thus HB vaccination uptake in HCWs is sub-optimal. Since 1995, studies on children have found that the prevalence of chronic HBsAg carriage has decreased, as has the incidence of paediatric hepatocellular carcinoma and HBV-related membranous nephropathy. The SADoH should focus their efforts on attaining a high infant HB vaccine coverage, prepare for introducing a HB birth dose, and consider using a hexavalent vaccine (DTaP-IPV-Hib-HepB). The department may also want to consider including targeted HB vaccination for 12 year-olds, if their Road to Health Cards show they were not vaccinated as infants. A national policy is needed for HCWs to ensure that they are fully vaccinated and protected against HBV infection.