Understanding the views of adult migrants around catch-up vaccination for missed routine immunisations to define strategies to improve coverage: A UK in-depth interview study.

BACKGROUND: The World Health Organization's (WHO) Immunization Agenda 2030 emphasises ensuring equitable access to vaccination across the life course. This includes placing an emphasis on migrant populations who may have missed key childhood vaccines, doses, and boosters due to disrupted healthcare systems and the migration process, or differing vaccination schedules in home countries. Guidelines exist in the UK for offering catch-up vaccinations to adolscent and adult migrants with incomplete or uncertain vaccination status (including MMR, Td-IPV, MenACWY, HPV), but emerging evidence suggests awareness and implementation in primary care is poor. It is unclear whether patient-level barriers to uptake of catch-up vaccinations also exist. We explored experiences and views around catch-up vaccination among adult migrants from a range of backgrounds, to define strategies for improving catch-up vaccination policy and practice. METHODS: In-depth semi-structured interviews were carried out in two phases with adult migrant populations (refugees, asylum seekers, undocumented migrants, those with no recourse to public funds) on views and experiences around vaccination, involving a team of peer researchers from specific migrant communities trained through the study. In Phase 1, we conducted remote interviews with migrants resident in the UK for < 10 years, from diverse backgrounds. In Phase 2, we engaged specifically Congolese and Angolan migrants as part of a community-based participatory study. Topic guides were developed iteratively and piloted. Participants were recruited using purposive, opportunistic and snowball sampling methods. Interviews were conducted in English (interpreters offered), Lingala or French and were audio-recorded, transcribed and analysed using a thematic framework approach in NVivo 12. RESULTS: 71 participants (39 in Phase 1, 32 in Phase 2) were interviewed (Mean age 43.6 [SD:12.4] years, 69% female, mean 9.5 [SD:7] years in the UK). Aside from COVID-19 vaccines, most participants reported never having been offered vaccinations or asked about their vaccination history since arriving in the UK as adults. Few participants mentioned being offered specific catch-up vaccines (e.g. MMR/Td-IPV) when attending a healthcare facility on arrival in the UK. Vaccines such as flu vaccines, pregnancy-related or pre-travel vaccination were more commonly mentioned. In general, participants were not aware of adult catch-up vaccination but regarded it positively when it was explained. A few participants expressed concerns about side-effects, risks/inconveniences associated with access (e.g. links to immigration authorities, travel costs), preference for natural remedies, and hesitancy to engage in further vaccination campaigns due to the intensity of COVID-19 vaccination campaigns. Trust was a major factor in vaccination decisions, with distinctions noted within and between groups; some held a healthcare professional's recommendation in high regard, while others were less trusting towards the healthcare system because of negative experiences of the NHS and past experiences of discrimination, injustice and marginalisation by wider authorities. CONCLUSIONS: The major barrier to adult catch-up vaccination for missed routine immunisations and doses in migrant communities in the UK is the limited opportunities, recommendations or tailored vaccination information presented to migrants by health services. This could be improved with financial incentives for provision of catch-up vaccination in UK primary care, alongside training of healthcare professionals to support catch-up immunisation and raise awareness of existing guidelines. It will also be essential to address root causes of mistrust around vaccination, where it exists among migrants, by working closely with communities to understand their needs and meaningfully involving migrant populations in co-producing tailored information campaigns and culturally relevant interventions to improve coverage.

Information needs of ethnically diverse, vaccine-hesitant parents during decision-making about the HPV vaccine for their adolescent child: a qualitative study.

BACKGROUND: The English schools-based human papillomavirus (HPV) vaccination programme has the potential to eliminate HPV-related cancers if high uptake is achieved. However, unmet information needs among some parents may contribute to persisting lower uptake among minority ethnic groups. Through this study we aimed to understand the information needs of vaccine-hesitant, ethnically diverse parents during decision-making about the HPV vaccine for their adolescent child, to inform the future development of tailored communication materials. METHODS: Recruitment was facilitated thorough healthcare and community organisations within London and the South West of England. Semi-structured interviews took place between April and August 2023. Thematic analysis was undertaken, assisted by NVivo software. RESULTS: Of the 29 parents interviewed, the majority were mothers (79%), belonged to a minority ethnic group (88%), and had an adolescent child unvaccinated against HPV (72%). Five of the interviews were undertaken in the participants' primary language with translation support. Most parents interviewed had limited knowledge about the HPV vaccine and appeared conflicted as to whether vaccines could offer benefits to health. Misunderstanding around the potential of developing serious side-effects (e.g. fertility issues, developing cancer) were factors that could negatively impact decision-making by parents. Stigma associated with the sexual transmissibility of HPV did not always negatively impact decision-making. However, some parents chose not to vaccinate on the basis of perceptions of low risk and a preference to provide education about sexual behaviours to their adolescent child. CONCLUSIONS: Tailoring communication materials to address misunderstandings could support informed decision-making by vaccine hesitant parents for their adolescent children to be vaccinated against HPV. Future communication materials about the HPV vaccine should highlight the benefits of protection against cancer to increase parents' motivation for protect their adolescent child; provide accurate convincing information in relation to the excellent safety profile; and emphasise the importance of providing HPV vaccine at the recommended age, all alongside communicating the universality and commonality of HPV infection. TRIAL REGISTRATION: N/A.

Human papillomavirus vaccine communication materials for young people in English-speaking countries: A content analysis.

Objective: To undertake a content analysis of human papillomavirus (HPV) vaccine communication materials available to young people. Design: Content analysis. Setting: Majority English-speaking countries. Methods: Between March and April 2020, a web engine was utilised to search for and retrieve relevant communication materials. Content analysis was used to describe how the following key issues were covered: (1) side effects, (2) safety, (3) practicalities related to receiving the HPV vaccine and (4) gender-specific information. Results: A total of 44 separate communication materials were retrieved, predominantly videos, webpages and leaflets. There was a focus on mild side effects of the vaccine (43.2%), with less frequent reference being made to moderate or serious side effects (22.7%). Reassurance concerning the safety profile of vaccine was communicated by referencing the widespread use of the HPV vaccine (31.8%). Information regarding formal criteria for entry into the vaccination programme emphasised country-specific eligibility criteria (59.1%), the setting in which vaccination was offered (38.6%) and the number of doses required (38.6%). Content intended to improve young people's experiences of receiving the HPV vaccine was less often provided (22.7%). Gender-specific content usually related to specific HPV-related diseases (52.3%) and/or the availability of cervical cancer screening programmes (52.3%). Conclusion: A variety of different communication tools were retrieved encompassing a wide variety of formats and content, reflective of different vaccination programmes and the varied priorities of organisations producing the materials. Findings will inform the co-production of a tailored educational package to improve access to information by populations of young people identified as having lower HPV vaccine uptake.

Development of an educational package for the universal human papillomavirus (HPV) vaccination programme: a co-production study with young people and key informants.

BACKGROUND: The English schools-based human papillomavirus (HPV) vaccination programme is routinely offered to all young people aged 12-13 years, to prevent cancers affecting the cervix, vulva, vagina, penis, anus and mouth. Lower uptake among some population groups has been identified, in part, because of unmet information needs among young people. To address these unmet needs we report intervention planning and development processes to co-produce an educational package about the HPV vaccine. METHODS: We used co-production research methodologies and the 'person-based approach' involving the following iterative stages: (i) collating and analysing primary and secondary evidence, including HPV vaccine communication materials, interviews and workshops; (ii) developing guiding principles; (iii) undertaking a behavioural analysis informed by the Behaviour Change Wheel and the Behaviour Change Technique taxonomy; (iv) development of a preliminary logic model; (v) co-production of resources, and; (vi) refinement of resources informed by feedback from young people and key informants. RESULTS: We co-produced EDUCATE, a theory-based educational package, that is designed to be delivered to young people prior to being offered the HPV vaccine to support uptake. Young people and key informants identified the following key issues to include as content: (i) HPV-related information; (ii) how vaccines work; (iii) safety and side-effects of the HPV vaccine; (iii) eligibility for the HPV vaccination programme, and; (iv) preparation of young people to receive the HPV vaccine. A manual for professionals (e.g. immunisation nurses, school staff) delivering the intervention and a PowerPoint presentation, interspersed with five short films, were co-produced with young people and key informants. Following feedback, the content of the EDUCATE package was refined to increase acceptability, engagement, and persuasiveness to the target users. CONCLUSION: Engagement with young people and key informants was integral to the development of our rigorously developed, theory-based intervention to address young people's information needs about the HPV vaccination programme. The acceptability and persuasiveness of the package has been maximised by working closely with young people and key informants to develop the content. An implementation study to examine how the EDUCATE package is implemented in practice and the impact on uptake of the HPV vaccination programme is underway.

In England, young people are offered the human papillomavirus (HPV) vaccine in schools at age 12­13 years to prevent some types of cancer. Some young people have unanswered questions which may stop them getting vaccinated. We report how we developed a lesson about the HPV vaccine jointly with young people and professionals to improve how information about the HPV vaccine is given. First, we reviewed research studies and HPV vaccine information materials designed for young people. Then, we carried out interviews and workshops to ask about the best way to give a lesson and the most important information to include. We worked with creative designers to produce films and animations. Finally, we asked young people and professionals for feedback on the lesson materials. The lesson includes a PowerPoint presentation with five films and guidance for people leading the session. Key topics about the HPV vaccine to be covered were identified by young people. These included information about how vaccines work and ways to improve young people's experience of having the HPV vaccine at school. We made changes to the information in the lesson to ensure that it was relevant to young people. We are now carrying out a study to find out how well the lesson is given and whether it can help more young people get the HPV vaccine if they want it.

Development of a multicomponent intervention to increase parental vaccine confidence and young people's access to the universal HPV vaccination programme in England: protocol for a co-design study.

INTRODUCTION: Persistent infection with HPV can result in cancers affecting men and, especially, women. Lower uptake exists by area and different population groups. Increasing parental confidence about, and adolescent access to, the universal HPV vaccination programme may help reduce inequalities in uptake. However, the evidence-base for interventions to address uptake for schools-based HPV vaccination programmes is currently lacking. This study protocol outlines how a multicomponent intervention to address this evidence gap will be codesigned with parents. METHODS AND ANALYSIS: The proposed research will be undertaken in localities covered by two immunisation teams in London and the south-west of England. The 'person-based approach' to intervention development will be followed. In the first phase, an exploratory qualitative study will be undertaken with key stakeholders (n=8) and parents (n=40) who did not provide consent for their adolescent child to be vaccinated. During the interviews, parents' views on ways to improve parental confidence about, and adolescents' access to, HPV vaccination will be sought. The findings will be used to inform the co-design of a preliminary plan for a targeted, multicomponent intervention. In the second phase, at least two parent working groups (n=8) will be convened and will work with creative designers to co-design communication materials aimed at increasing parents' confidence in vaccination. At least two workshops with each parent group will be organised to obtain feedback on the intervention plan and communication materials to ensure they are fit for purpose. These findings will inform a protocol for a future study to test the effectiveness of the intervention at increasing HPV vaccination uptake. ETHICS AND DISSEMINATION: The National Health Services Research Ethics Service and London School of Hygiene & Tropical Medicine Observational / Interventions Research Ethics Committee provided approvals for the study (reference 22/SW/0003 & 26902, respectively). We will work with parent advisory groups to inform our dissemination strategy and co-present our findings (eg, at community events or through social media). We will disseminate our findings with academics and healthcare professionals through webinars and academic conferences, as well as peer-reviewed publications.

Does electronic consent improve the logistics and uptake of HPV vaccination in adolescent girls? A mixed-methods theory informed evaluation of a pilot intervention.

OBJECTIVES: To evaluate the usability and acceptability of an electronic consent pilot intervention for school-based immunisations and assess its impact on consent form returns and human papilloma virus (HPV) vaccine uptake. DESIGN: Mixed-methods theory-informed study applying qualitative methods to examine the usability and acceptability of the intervention and quantitative methods to assess its impact. SETTING AND PARTICIPANTS: The intervention was piloted in 14 secondary schools in seven London boroughs in 2018. Intervention schools were matched with schools using paper consent based on the proportion of students with English as a second language and students receiving free school meals. Participants included nurses, data managers, school-link staff, parents and adolescents. INTERVENTIONS: An electronic consent portal where parents could record whether they agreed to or declined vaccination, and nurses could access data to help them manage the immunisation programme. PRIMARY AND SECONDARY OUTCOME MEASURES: Comparison of consent form return rates and HPV vaccine uptake between intervention and matched schools. RESULTS: HPV vaccination uptake did not differ between intervention and matched schools, but timely consent form return was significantly lower in intervention schools (73.3% vs 91.6%, p=0.008). The transition to using electronic consent was not straightforward, while schools and staff understood the potential benefits, they found it difficult to adapt to new ways of working which removed some level of control from schools. Reasons for lower consent form return in e-consent schools included difficulties encountered by some parents in accessing and using the intervention. Adolescents highlighted the potential for electronic consent to by-pass their information needs. CONCLUSIONS: The pilot intervention did not improve consent form return or vaccine uptake due to challenges encountered in transitioning to new working practice. New technologies require embedding before they become incorporated in everyday practice. A re-evaluation once stakeholders are accustomed with electronic consent may be required to understand its impact.

Co-production of an educational package for the universal human papillomavirus (HPV) vaccination programme tailored for schools with low uptake: a participatory study protocol.

AIM: To co-produce with young people an educational package about the human papillomavirus (HPV) vaccine that is tailored to increase vaccine uptake in schools and populations with lower uptake. INTRODUCTION: Persistent infection with HPV can result in cancers affecting men and especially women. From September 2019, the English-schools-based HPV vaccination programme was expanded to include young men (in addition to young women) aged 12-13 years. Some young people attending schools with lower uptake of the vaccine have unmet information needs. We hypothesise that mechanisms to address information needs and increase young people's autonomy in consent procedures will result in higher uptake. METHODS AND ANALYSIS: The Medical Research Council's framework for development and evaluation of complex interventions will inform intervention development. Recruitment of young people aged 12-15 years and key stakeholders (National Health Service commissioners, school staff, immunisation nurses and youth workers/practitioners) will be facilitated through existing links with healthcare organisations, schools and youth organisations in areas with lower uptake of the HPV vaccination programme. The proposed research will comprise three phases: (1) a rapid review of adolescent immunisation materials and preliminary qualitative interviews with young people and key stakeholders, (2) theory development and co-production of HPV vaccine communication materials through an iterative process with young people and (iii) testing delivery mechanisms and acceptability of the educational package in four schools with lower uptake. ETHICS AND DISSEMINATION: The University of Bristol's Faculty of Health Sciences and London School of Hygiene and Tropical Medicine's Research Ethics Committees provided approvals for the study. A dissemination event for young people and key stakeholders and webinar with the National Immunisation Network will be organised. The study findings will be published in peer-reviewed journals and presented at conferences. Recommendations for a future larger scale study will be made.

Is flu vaccination opt-out feasible? Evidence from vaccination programme implementers and managers in the English National Health Service.

BACKGROUND: In 2018/19, English NHS trusts (NHSTs) implemented an 'opt-out' policy for seasonal flu vaccination in frontline healthcare workers (HCWs). HCWs declining the vaccination were asked to sign an opt-out form and provide a reason for their decision. In addition, HCWs working in higher risk hospital environments (e.g. oncology) were asked to inform their manager about their declination decision. The policy aimed to provide greater insight into reasons for vaccination decline and information from HCWs in higher risk areas was intended for use in considering HCW redeployment. This study investigated the feasibility, acceptability, and perceived value of the policy during the 2018/19 flu vaccination season. METHODS: We conducted semi-structured interviews across 9 NHSTs in England with different levels of HCW flu vaccination uptake in 2017/18. We interviewed 30 vaccination programme implementers and 27 managers. FINDINGS: The purpose of the policy was poorly understood, and interviewees did not know how data on decliners was being used. Most NHSTs tried to collect the personal details of decliners and, in some instances, these were recorded in Electronic Staff Records and reported to line-managers for action. This created strain on employer-employee relationships, leading to decliners refusing to complete opt-out forms and some vaccinators not implementing the policy. None of the NHSTs had a redeployment policy for decliners, arguing that this was impractical due to strain on staffing levels. CONCLUSION: A flu-vaccination opt-out approach for HCWs did not appear acceptable in our sampled NHSTs, due to a lack of clear messaging about its purpose and complicated implementation. To promote an opt-out approach effectively, there needs to be clear communication of its purpose, which should be to explore reasons for decline rather than identify and 'push' decliners to vaccinate, so as not to damage staff relationships. NHSTs should involve their workforce in developing flu vaccination approaches.

Efficacy and immunogenicity of a single dose of human papillomavirus vaccine compared to no vaccination or standard three and two-dose vaccination regimens: A systematic review of evidence from clinical trials.

OBJECTIVES: This study aimed to systematically review the literature on the efficacy and immunogenicity of single-dose HPV vaccination compared to no vaccination or multi-dose schedules among vaccine trial participants. METHODS: Medline, EMBASE, Global Health Database and Cochrane Central Register of Controlled Trials were searched for publications and conference abstracts (dated January 1999-August 2018) using MeSH and non-MeSH terms for human papillomavirus AND vaccines AND (immunogenicity OR efficacy/effectiveness) AND dosage. Search results were screened against pre-specified eligibility criteria. Data were extracted from included articles, and a narrative synthesis conducted on efficacy against HPV16/18 infection and humoral immunogenicity. RESULTS: Seven of 6,523 unique records identified were included in the review. Six were nested observational studies of participants randomised to receive two or three doses in three large HPV vaccine trials, in which some participants did not complete their allocated schedules. One small pilot study prospectively allocated participants to receive one or no vaccine dose. Frequency of HPV16/18 infection was low (e.g. <1% for 12-month-persistent infection) in all vaccinated participants up to seven years post vaccination and did not significantly differ by number of doses (p > 0.05 in all cases). Frequency of infection was significantly lower in one-dose recipients compared to unvaccinated controls (p < 0.01 for all infection endpoints in each study). HPV16/18 seropositivity rates were high in all HPV vaccine recipients (100% in three of four studies reporting this endpoint), though antibody levels were lower with one compared to two or three doses. CONCLUSIONS: This review supports the premise that one HPV vaccine dose may be as effective in preventing HPV infection as multi-dose schedules in healthy young women. However, it also highlights the paucity of available evidence from purpose-designed, prospectively-randomised trials. Results from ongoing clinical trials assessing the efficacy and immunogenicity of single-dose HPV vaccination compared to currently-recommended schedules are awaited.

Optimising informed consent in school-based adolescent vaccination programmes in England: A multiple methods analysis.

The process of obtaining informed consent for school-based adolescent immunisation provides an opportunity to engage families. However, the fact that parental consent needs to be obtained remotely adds complexity to the process and can have a detrimental effect on vaccine uptake. We conducted a multiple methods analysis to examine the practice of obtaining informed consent in adolescent immunisation programmes. This involved a thematic analysis of consent related data from 39 interviews with immunisation managers and providers collected as part of a 2017 service evaluation of the English adolescent girls' HPV vaccine programme and a descriptive statistical analysis of data from questions related to consent included in a 2017 survey of parents' and adolescents' attitudes to adolescent vaccination. The findings indicated that the non-return of consent forms was a significant logistical challenge for immunisation teams, and some were piloting opt-out consent mechanisms, increasing the proportion of adolescents consenting for their own immunisations, and introducing electronic consent. Communicating vaccine related information to parents and schools and managing uncertainties about obtaining adolescent self-consent for vaccination were the main practical challenges encountered. Survey data showed that parents and adolescents generally agreed on vaccine decisions although only 32% of parents discussed vaccination with their teenager. Parental awareness about the option for adolescents to self-consent for vaccination was limited and adolescents favoured leaving the decision-making to parents. From the interviews and variability of consent forms it was evident that health professionals were not always clear about the best way to manage the consent process. Some were also unfamiliar with self-consent processes and lacked confidence in assessing for 'Gillick competency'. Developing pathways and related interventions to improve the logistics and practice of consent in school-based adolescent immunisation programmes could help improve uptake.

Is partnership the answer? Delivering the national immunisation programme in the new English health system: a mixed methods study.

BACKGROUND: The English national health system experienced a major reorganisation in April 2013. This mixed methods study examined how staff managed to deliver the national immunisation programme within a new health infrastructure and explored the role and contribution of 'partnership working' to programme implementation. METHODS: A cross-sectional online questionnaire survey and a qualitative evaluation of an urban immunisation board were conducted in 2016. The questionnaire included 38 questions about immunisation responsibilities, collaboration, service evaluation and programme support. It was completed by 199 immunisation providers and 70 people involved in the management of the immunisation programme. The evaluation involved 12 semi-structured interviews, 3 observations of forum meetings and the review of forum meeting minutes. Descriptive statistical analysis of the survey data was performed using SPSS version 23 and qualitative data from both study components were uploaded to NVivo 11 and analysed thematically. RESULTS: Screening and Immunisation Teams were cited as responsible for programme leadership by 56% of survey respondents, but concerns were raised about their capacity to oversee larger geographies and a case made for decentralised accountability mechanisms. Only 44% of immunisation managers stated that poor performance was addressed adequately, and half of respondents thought that support given to providers was inadequate. Managers reported that partnership working improved the organisation (83%) and performance (78%) of immunisation, but stated it was more beneficial for information-sharing than implementation. A preference for a "locality working approach" with committees covering smaller health economies rather than larger commissioning areas was voiced. The immunisation board examined in the qualitative evaluation sought to achieve this by forging links with locally based steering committees, but also had to address internal challenges related to the role of the board and contribution of members to programmatic decision-making. CONCLUSIONS: Key challenges in delivering the immunisation programme were rooted in the new health infrastructure, which had created greater distance between commissioners and providers and resulted in the fragmentation of programme responsibilities. Partnership working bridged gaps but more needs to be done to strengthen accountability mechanisms and ensure that collaborative activities are outcome oriented and sustainable in the shifting environment of reorganisation.

Vaccine programme stakeholder perspectives on a hypothetical single-dose human papillomavirus (HPV) vaccine schedule in low and middle-income countries.

BACKGROUND: The World Health Organization (WHO) recommends a 2-dose HPV vaccine schedule for girls aged 9-14 years. As randomised controlled trials assessing the immunogenicity and efficacy of a 1-dose schedule are ongoing, we interviewed immunisation programme managers and advisors in low and middle-income countries (LMIC) about a hypothetical, future reduction in the HPV vaccine schedule. METHODS: We conducted semi-structured interviews with LMIC immunisation programme managers and national immunisation technical advisory group members (key informants; KIs) in 2017, recruited for their knowledge/experience in national HPV vaccine policy and provision. Data were analysed thematically. RESULTS: We conducted 30 interviews with KIs from 18 countries. Perceived advantages of a 1-dose schedule included reduced logistical and financial resources needed for vaccine delivery, fewer cold chain requirements and easier integration into routine immunisation services. Perceived challenges included health worker hesitancy, resources needed to re-mobilise communities and re-train health workers, potential misrepresentation of schedule changes by anti-vaccine groups or the media. Half of interviewees suggested a WHO recommendation would be necessary prior to policy change. CONCLUSIONS: We found wide-ranging support among LMIC immunisation managers and advisors for a 1-dose vaccine schedule if research demonstrated immunological and clinical evidence of efficacy, and WHO provided a formal recommendation.

What works for human papillomavirus vaccine introduction in low and middle-income countries?

Since 2007, low and middle-income countries (LMICs) have gained experience delivering HPV vaccines through HPV vaccination pilots, demonstration projects and national programmes. This commentary summarises lessons from HPV vaccination experiences in 45 LMICs and what works for HPV vaccination introduction. Methods included a systematic literature review, unpublished document review, and key informant interviews. Data were extracted from 61 peer-reviewed articles, 11 conference abstracts, 188 technical reports, and 56 interviews, with quantitative data analysed descriptively and qualitative data analysed thematically. Key lessons are described under five themes of preparation, communications, delivery, coverage achievements, and sustainability. Lessons learnt were generally consistent across countries and projects and sufficient lessons have been learnt for countries to deliver HPV vaccine through phased national rollout rather than demonstration projects. However, challenges remain in securing the political will and financial resources necessary to implement successful national programmes.

Human papillomavirus (HPV) vaccine coverage achievements in low and middle-income countries 2007-2016.

INTRODUCTION: Since 2007, HPV vaccine has been available to low and middle income countries (LAMIC) for small-scale 'demonstration projects', or national programmes. We analysed coverage achieved in HPV vaccine demonstration projects and national programmes that had completed at least 6 months of implementation between January 2007-2016. METHODS: A mapping exercise identified 45 LAMICs with HPV vaccine delivery experience. Estimates of coverage and factors influencing coverage were obtained from 56 key informant interviews, a systematic published literature search of 5 databases that identified 61 relevant full texts and 188 solicited unpublished documents, including coverage surveys. Coverage achievements were analysed descriptively against country or project/programme characteristics. Heterogeneity in data, funder requirements, and project/programme design precluded multivariate analysis. RESULTS: Estimates of uptake, schedule completion rates and/or final dose coverage were available from 41 of 45 LAMICs included in the study. Only 17 estimates from 13 countries were from coverage surveys, most were administrative data. Final dose coverage estimates were all over 50% with most between 70% and 90%, and showed no trend over time. The majority of delivery strategies included schools as a vaccination venue. In countries with school enrolment rates below 90%, inclusion of strategies to reach out-of-school girls contributed to obtaining high coverage compared to school-only strategies. There was no correlation between final dose coverage and estimated recurrent financial costs of delivery from cost analyses. Coverage achieved during joint delivery of HPV vaccine combined with another intervention was variable with little/no evaluation of the correlates of success. CONCLUSIONS: This is the most comprehensive descriptive analysis of HPV vaccine coverage in LAMICs to date. It is possible to deliver HPV vaccine with excellent coverage in LAMICs. Further good quality data are needed from health facility based delivery strategies and national programmes to aid policymakers to effectively and sustainably scale-up HPV vaccination.

Lessons learnt from human papillomavirus (HPV) vaccination in 45 low- and middle-income countries.

OBJECTIVE: To synthesise lessons learnt and determinants of success from human papillomavirus (HPV) vaccine demonstration projects and national programmes in low- and middle-income countries (LAMICs). METHODS: Interviews were conducted with 56 key informants. A systematic literature review identified 2936 abstracts from five databases; after screening 61 full texts were included. Unpublished literature, including evaluation reports, was solicited from country representatives; 188 documents were received. A data extraction tool and interview topic guide outlining key areas of inquiry were informed by World Health Organization guidelines for new vaccine introduction. Results were synthesised thematically. RESULTS: 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, four by PATH and 12 by other means. 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. Early engagement of teachers as partners in social mobilisation, consent, vaccination day coordination, follow-up of non-completers and adverse events was considered invaluable. Micro-planning using school/ facility registers most effectively enumerated target populations; other estimates proved inaccurate, leading to vaccine under- or over-estimation. Refresher training on adverse events and safe injection procedures was usually necessary. CONCLUSION: 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.

Interventions to reduce inequalities in vaccine uptake in children and adolescents aged <19†years: a systematic review.

BACKGROUND: In high-income countries, substantial differences exist in vaccine uptake relating to socioeconomic status, gender, ethnic group, geographic location and religious belief. This paper updates a 2009 systematic review on effective interventions to decrease vaccine uptake inequalities in light of new technologies applied to vaccination and new vaccine programmes (eg, human papillomavirus in adolescents). METHODS: We searched MEDLINE, Embase, ASSIA, The Campbell Collaboration, CINAHL, The Cochrane Database of Systematic Reviews, Eppi Centre, Eric and PsychINFO for intervention, cohort or ecological studies conducted at primary/community care level in children and young people from birth to 19 years in OECD countries, with vaccine uptake or coverage as outcomes, published between 2008 and 2015. RESULTS: The 41 included studies evaluated complex multicomponent interventions (n=16), reminder/recall systems (n=18), outreach programmes (n=3) or computer-based interventions (n=2). Complex, locally designed interventions demonstrated the best evidence for effectiveness in reducing inequalities in deprived, urban, ethnically diverse communities. There is some evidence that postal and telephone reminders are effective, however, evidence remains mixed for text-message reminders, although these may be more effective in adolescents. Interventions that escalated in intensity appeared particularly effective. Computer-based interventions were not effective. Few studies targeted an inequality specifically, although several reported differential effects by the ethnic group. CONCLUSIONS: Locally designed, multicomponent interventions should be used in urban, ethnically diverse, deprived populations. Some evidence is emerging for text-message reminders, particularly in adolescents. Further research should be conducted in the UK and Europe with a focus on reducing specific inequalities.

Social mobilisation, consent and acceptability: a review of human papillomavirus vaccination procedures in low and middle-income countries.

BACKGROUND: Social mobilisation during new vaccine introductions encourages acceptance, uptake and adherence to multi-dose schedules. Effective communication is considered especially important for human papillomavirus (HPV) vaccine, which targets girls of an often-novel age group. This study synthesised experiences and lessons learnt around social mobilisation, consent, and acceptability during 55 HPV vaccine demonstration projects and 8 national programmes in 37 low and middle-income countries (LMICs) between January 2007 and January 2015. METHODS: A qualitative study design included: (i) a systematic review, in which 1,301 abstracts from five databases were screened and 41 publications included; (ii) soliciting 124 unpublished documents from governments and partner institutions; and (iii) conducting 27 key informant interviews. Data were extracted and analysed thematically. Additionally, first-dose coverage rates were categorised as above 90 %, 90-70 %, and below 70 %, and cross-tabulated with mobilisation timing, message content, materials and methods of delivery, and consent procedures. RESULTS: All but one delivery experience achieved over 70 % first-dose coverage; 60 % achieved over 90 %. Key informants emphasized the benefits of starting social mobilisation early and actively addressing rumours as they emerged. Interactive communication with parents appeared to achieve higher first-dose coverage than non-interactive messaging. Written parental consent (i.e., opt-in), though frequently used, resulted in lower reported coverage than implied consent (i.e., opt-out). Protection against cervical cancer was the primary reason for vaccine acceptability, whereas fear of adverse effects, exposure to rumours, lack of project/programme awareness, and schoolgirl absenteeism were major reasons for non-vaccination. CONCLUSIONS: Despite some challenges in obtaining parental consent and addressing rumours, experiences indicated effective social mobilisation and high HPV vaccine acceptability in LMICs. Social mobilisation, consent, and acceptability lessons were consistent across world regions and HPV vaccination projects/programmes. These can be used to guide HPV vaccination communication strategies without additional formative research.

HPV vaccine introduction in Rwanda: Impacts on the broader health system.

OBJECTIVES: Rwanda was the first country in Africa to introduce the human papillomavirus (HPV) vaccine. This was achieved through multi-year school-based campaigns. Our study evaluated the impact of the HPV vaccine introduction on the country's immunisation programme and health system. METHODS: Thirty key informants were interviewed at national and district levels, and in participating schools. Twenty-seven health facilities completed a questionnaire exploring the effects of the new vaccine introduction on six health system building blocks, as defined by the World Health Organization. Routine service activity data were collected during a 90-day period around the introduction. RESULTS: Routine vaccination activities were not disrupted during the delivery, likely due to a strong Expanded Program on Immunization, appropriate planning and a well-resourced operation. Opportunities were seized to co-deliver other interventions targeted at children and adolescents, such as health promotion. Collaboration with the Ministry of Education was strengthened at national level. Although there were some temporary increases in staff workload, no major negative effects were reported. CONCLUSION: Despite its delivery through school-based campaigns, the HPV vaccine integrated well into the immunisation programme and health system. The introduction had no major negative effects. Some opportunities were seized to expand services and collaborations.

The impact of introducing new vaccines on the health system: case studies from six low- and middle-income countries.

OBJECTIVE: We aimed to explore the impacts of new vaccine introductions on immunization programmes and health systems in low- and middle-income countries. METHODS: We conducted case studies of seven vaccine introductions in six countries (Cameroon, PCV;Ethiopia, PCV; Guatemala, rotavirus; Kenya, PCV; Mali, Meningitis A; Mali, PCV; Rwanda, HPV). Inter-views were conducted with 261 national, regional and district key informants and questionnaires were completed with staff from 196 health facilities. Routine data from districts and health facilities were gathered on vaccination and antenatal service use. Data collection and analysis were structured around the World Health Organisation health system building blocks. FINDINGS: The new vaccines were viewed positively and seemed to integrate well into existing health systems. The introductions were found to have had no impact on many elements within the building blocks framework. Despite many key informants and facility respondents perceiving that the new vaccine introductions had increased coverage of other vaccines, the routine data showed no change. Positive effects perceived included enhanced credibility of the immunisation programme and strengthened health workers' skills through training. Negative effects reported included an increase in workload and stock outs of the new vaccine, which created a perception in the community that all vaccines were out of stock in a facility. Most effects were found within the vaccination programmes; very few were reported on the broader health systems. Effects were primarily reported to be temporary, around the time of introduction only. CONCLUSION: Although the new vaccine introductions were viewed as intrinsically positive, on the whole there was no evidence that they had any major impact, positive or negative, on the broader health systems.

How can measles eradication strengthen health care systems?

Elimination and eradication initiatives are generally delivered through a vertical approach, which can potentially hamper health systems. We propose 3 approaches by which a measles eradication initiative can ensure that health systems are left strengthened when the eradication goal has been accomplished. First, focus should be placed on strengthening routine vaccination, which could generate positive trickle-up effects on other primary health care services. Second, increased integration with multifunctional health services should be emphasized. Third, efforts should be made to change traditional donor behavior that prioritizes vaccination campaigns and uses uncoordinated staff incentives.