Human papillomavirus vaccination 2020 guideline update: American Cancer Society guideline adaptation.

The American Cancer Society (ACS) presents an adaptation of the current Advisory Committee on Immunization Practices recommendations for human papillomavirus (HPV) vaccination. The ACS recommends routine HPV vaccination between ages 9 and 12 years to achieve higher on-time vaccination rates, which will lead to increased numbers of cancers prevented. Health care providers are encouraged to start offering the HPV vaccine series at age 9 or 10 years. Catch-up HPV vaccination is recommended for all persons through age 26 years who are not adequately vaccinated. Providers should inform individuals aged 22 to 26 years who have not been previously vaccinated or who have not completed the series that vaccination at older ages is less effective in lowering cancer risk. Catch-up HPV vaccination is not recommended for adults aged older than 26 years. The ACS does not endorse the 2019 Advisory Committee on Immunization Practices recommendation for shared clinical decision making for some adults aged 27 through 45 years who are not adequately vaccinated because of the low effectiveness and low cancer prevention potential of vaccination in this age group, the burden of decision making on patients and clinicians, and the lack of sufficient guidance on the selection of individuals who might benefit.

Measles.

Measles is a highly contagious, potentially fatal, but vaccine-preventable disease caused by measles virus. Symptoms include fever, maculopapular rash, and at least one of cough, coryza, or conjunctivitis, although vaccinated individuals can have milder or even no symptoms. Laboratory diagnosis relies largely on the detection of specific IgM antibodies in serum, dried blood spots, or oral fluid, or the detection of viral RNA in throat or nasopharyngeal swabs, urine, or oral fluid. Complications can affect many organs and often include otitis media, laryngotracheobronchitis, pneumonia, stomatitis, and diarrhoea. Neurological complications are uncommon but serious, and can occur during or soon after the acute disease (eg, acute disseminated encephalomyelitis) or months or even years later (eg, measles inclusion body encephalitis and subacute sclerosing panencephalitis). Patient management mainly involves supportive therapy, such as vitamin A supplementation, monitoring for and treatment of secondary bacterial infections with antibiotics, and rehydration in the case of severe diarrhoea. There is no specific antiviral therapy for the treatment of measles, and disease control largely depends on prevention. However, despite the availability of a safe and effective vaccine, measles is still endemic in many countries and causes considerable morbidity and mortality, especially among children in resource-poor settings. The low case numbers reported in 2020, after a worldwide resurgence of measles between 2017 and 2019, have to be interpreted cautiously, owing to the effect of the COVID-19 pandemic on disease surveillance. Disrupted vaccination activities during the pandemic increase the potential for another resurgence of measles in the near future, and effective, timely catch-up vaccination campaigns, strong commitment and leadership, and sufficient resources will be required to mitigate this threat.

[The new standard operating procedure of the German standing committee on vaccination (STIKO): history, structure, and implementation]. / Die neue Standardvorgehensweise der Ständigen Impfkommission (STIKO): Entstehung, Struktur und Umsetzung.

In Germany, the Standing Committee on Vaccination (STIKO) develops recommendations on vaccinations and other measures of specific prophylaxis against communicable diseases. Myths, wrong assumptions, and conspiracy theories are able to disturb the implementation of vaccination recommendations. Evidence and transparency of recommendations are needed to rationalize the discussion.In November 2011, STIKO adopted a new standard operating procedure (SOP) for the development of evidence-based vaccination recommendations. Following guidance provided by the SOP, a number of new vaccination recommendations have been developed since 2011. Furthermore, existing recommendations were revised or extended accordingly. This article provides an overview on the methodology of the SOP, describes experiences made so far, and characterizes future challenges.

Impact of an Intervention to Use a Measles, Rubella, and Polio Mass Vaccination Campaign to Strengthen Routine Immunization Services in Nepal.

Background: The potential to strengthen routine immunization (RI) services through supplementary immunization activities (SIAs) is an important benefit of global measles and rubella elimination and polio eradication strategies. However, little evidence exists on how best to use SIAs to strengthen RI. As part the 2012 Nepal measles-rubella and polio SIA, we developed an intervention package designed to improve RI processes and evaluated its effect on specific RI process measures. Methods: The intervention package was incorporated into existing SIA activities and materials to improve healthcare providers' RI knowledge and practices throughout Nepal. In 1 region (Central Region) we surveyed the same 100 randomly selected health facilities before and after the SIA and evaluated the following RI process measures: vaccine safety, RI planning, RI service delivery, vaccine supply chain, and RI data recording practices. Data collection included observations of vaccination sessions, interviews with the primary healthcare provider who administered vaccines at each facility, and administrative record reviews. Pair-matched analytical methods were used to determine whether statistically significant changes in the selected RI process measures occurred over time. Results: After the SIA, significant positive changes were measured in healthcare provider knowledge of adverse events following immunization (11% increase), availability of RI microplans (+17%) and maps (+12%), and awareness of how long a reconstituted measles vial can be used before it must be discarded (+14%). For the SIA, 42% of providers created an SIA high-risk villages list, and >50% incorporated this information into RI outreach session site planning. Significant negative changes occurred in correct knowledge of measles vaccination contraindications (-11%), correct definition for a measles outbreak (-21%), and how to treat a child with a severe adverse event following immunization (-10%). Twenty percent of providers reported cancelling ≥1 RI sessions during the SIA. Many RI process measures were at high proportions (>90%) before the SIA and remained high afterward, including proper vaccine administration techniques, proper vaccine waste management, and availability of vaccine carriers and vaccine registers. Conclusions: Focusing on activities that are easily linked between SIAs and RI services, such as using SIA high-risk village list to strengthen RI microplanning and examining ways to minimize the impact of an SIA on RI session scheduling, should be prioritized when implementing SIAs.

A systematic review of factors that shape implementation of mass drug administration for lymphatic filariasis in sub-Saharan Africa.

BACKGROUND: Understanding factors surrounding the implementation process of mass drug administration for lymphatic filariasis (MDA for LF) elimination programmes is critical for successful implementation of similar interventions. The sub-Saharan Africa (SSA) region records the second highest prevalence of the disease and subsequently several countries have initiated and implemented MDA for LF. Systematic reviews have largely focused on factors that affect coverage and compliance, with less attention on the implementation of MDA for LF activities. This review therefore seeks to document facilitators and barriers to implementation of MDA for LF in sub-Saharan Africa. METHODS: A systematic search of databases PubMed, Science Direct and Google Scholar was conducted. English peer-reviewed publications focusing on implementation of MDA for LF from 2000 to 2016 were considered for analysis. Using thematic analysis, we synthesized the final 18 articles to identify key facilitators and barriers to MDA for LF programme implementation. RESULTS: The main factors facilitating implementation of MDA for LF programmes were awareness creation through innovative community health education programmes, creation of partnerships and collaborations, integration with existing programmes, creation of morbidity management programmes, motivation of community drug distributors (CDDs) through incentives and training, and management of adverse effects. Barriers to implementation included the lack of geographical demarcations and unregistered migrations into rapidly urbanizing areas, major disease outbreaks like the Ebola virus disease in West Africa, delayed drug deliveries at both country and community levels, inappropriate drug delivery strategies, limited number of drug distributors and the large number of households allocated for drug distribution. CONCLUSION: Mass drug administration for lymphatic filariasis elimination programmes should design their implementation strategies differently based on specific contextual factors to improve implementation outcomes. Successfully achieving this requires undertaking formative research on the possible constraining and inhibiting factors, and incorporating the findings in the design and implementation of MDA for LF.

[The epidemiology of varicella disease in Germany after introduction of a vaccination recommendation : Analysis of mandatory and sentinel data between 2002 and 2014]. / Die Epidemiologie der Varizellen in Deutschland unter Einfluss der Varizellen-Impfempfehlung : Auswertung der Sentinel- und Meldepflichtdaten 2002­2014.

BACKGROUND: Since 2004 a single varicella vaccination for all infants aged 11-14 months has been recommended in Germany and since 2009 a second dose at the age of 15-23 months is recommended. Vaccination coverage after 24 months rose from 43% in 2006 to 87.5% in 2012. A mandatory notification system was introduced in the New Federal States (NFS) between 2002 and 2009 and nationwide in 2013. A national sentinel system has been in place since 2005. OBJECTIVE AND METHOD: We analyzed both data sources to describe the varicella epidemiology related to vaccination coverage after initiation of routine childhood varicella vaccination and to evaluate both notification systems regarding informative value and data quality. We looked at trends, age distribution and incidences using Microsoft Excel and Stata12. Vaccination coverage data were available from health insurance claims data. RESULTS: By 2013 a decrease of cases/medical practice/month from 3.47 to 0.43 was observed. The incidence in the NFS declined from 32 to 12 out of 100,000. Sentinel and mandatory notification data showed the largest decrease among the 1-4 year-olds (-94 and -90% resp.). In 2014, varicella incidences increased in all age groups, but not the cases/medical-practice/month by age in the sentinel. DISCUSSION: Increasing vaccination coverage and decreasing varicella cases demonstrate the success of routine childhood varicella vaccination. Mandatory notification data allow incidence calculation; The sentinel system has been providing more detailed information about vaccination status, better data quality and continuous national data since 2005, irrespective of the Infectious disease protection act. Trends and age distribution can be continuously calculated, whereas the nationwide mandatory data collected in the short period since April 2013 can only be evaluated to a limited extent.

The potential impact of BCG vaccine supply shortages on global paediatric tuberculosis mortality.

BACKGROUND: The Bacillus Calmette-Guérin (BCG) vaccine is provided to over 100 million neonates annually to protect against childhood tuberculosis (TB). Recent BCG manufacturing interruptions highlight global supply risks. We estimated the potential impact of BCG shortfalls on global paediatric (<15 years) TB mortality. METHODS: A static mathematical model was employed to estimate the number of paediatric TB deaths avoided by usual levels of BCG coverage, and potential additional TB deaths in the first 15 years of life due to 1-year BCG supply shortfalls of 6.3 % (as occurred in 2015) to 27.6 % (as anticipated without mitigating action in 2015) assuming no catch-up campaigns. RESULTS: BCG coverage without shortfalls, estimated at 90 % globally, was estimated to avoid 117,132 (95 % uncertainty range (UR): 5049-306,911) TB deaths globally per birth cohort in the first 15 years of life. An estimated 11,713 (UR: 505-30,691) additional TB deaths would occur in the first 15 years of life per 10 % (26 million dose) annual supply shortfall. A 16.5 million dose (6.3 %) shortfall as reported at the close of 2015, reflecting 84 % global coverage, was estimated as associated with 7433 (95 % UR: 320-19,477) excess TB deaths in the affected cohort in the first 15 years. A possible 24,914 (UR: 1074-65,278) additional deaths were avoided due to prompt shortfall reduction measures in 2015. CONCLUSIONS: BCG shortages could greatly increase paediatric TB mortality. Although rapid action in 2015 minimised BCG shortfalls, avoiding a large number of potential additional deaths, the possible public health impact of even relatively small shortfalls highlights the critical importance of ensuring secure future manufacturing capacity and global BCG supply continuity.

Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective.

BACKGROUND: Women living in Africa experience the highest burden of cervical cancer. Research and investment to improve vaccination, screening, and treatment efforts are critically needed. We systematically reviewed and characterized recent research within a broader public health framework to organize and assess the range of cervical cancer research in Africa. METHODS: We searched online databases and the Internet for published articles and cervical cancer reports in African countries. Inclusion criteria included publication between 2004 and 2014, cervical cancer-related content pertinent to one of the four public health categories (primary, secondary, tertiary prevention or quality of life), and conducted in or specifically relevant to countries or regions within the African continent. The study design, geographic region/country, focus of research, and key findings were documented for each eligible article and summarized to illustrate the weight and research coverage in each area. Publications with more than one focus (e.g. secondary and tertiary prevention) were categorized by the primary emphasis of the paper. Research specific to HIV-infected women or focused on feasibility issues was delineated within each of the four public health categories. RESULTS: A total of 380 research articles/reports were included. The majority (54.6 %) of cervical cancer research in Africa focused on secondary prevention (i.e., screening). The number of publication focusing on primary prevention (23.4 %), particularly HPV vaccination, increased significantly in the past decade. Research regarding the treatment of precancerous lesions and invasive cervical cancer is emerging (17.6 %), but infrastructure and feasibility challenges in many countries have impeded efforts to provide and evaluate treatment. Studies assessing aspects of quality of life among women living with cervical cancer are severely limited (4.1 %). Across all categories, 11.3 % of publications focused on cervical cancer among HIV-infected women, while 17.1 % focused on aspects of feasibility for cervical cancer control efforts. CONCLUSIONS: Cervical cancer research in African countries has increased steadily over the past decade, but more is needed. Tertiary prevention (i.e. treatment of disease with effective medicine) and quality of life of cervical cancer survivors are two severely under-researched areas. Similarly, there are several countries in Africa with little to no research ever conducted on cervical cancer.

[Cologne Statement for Medical Care of Refugees]. / Kölner Statement zur medizinischen Versorgung von Flüchtlingen.

The Cologne statement resulted from both regional and nationwide controversial discussions about meaning and purpose of an initial examination for infectious diseases of refugees with respect to limited time, personnel and financial resources. Refugees per se are no increased infection risk factors for the general population as well as aiders, when the aiders comply with general hygiene rules and are vaccinated according to the recommendations of the German Standing Committee on Vaccination (STIKO). This is supported by our own data. Based on individual medical history, refugees need medical care, which is offered purposeful, economic, humanitarian and ethical. In addition to medical confidentiality, the reporting obligation according § 34 Infection Protection Act (IPA) and the examination concerning infectious pulmonary tuberculosis according to § 36 (4) IPA must be considered.

[Implementation of seasonal influenza and human papillomavirus vaccination recommendations in gynecological practices in Germany]. / Wie werden die Impfempfehlungen gegen saisonale Influenza und gegen humane Papillomaviren in gynäkologischen Praxen umgesetzt?

In Germany, seasonal influenza vaccination has been recommended for pregnant women since 2010 and human papillomavirus (HPV) vaccination for girls since 2007. Gynecologists play an important role in the communication and vaccination of these two target groups. Moreover, seasonal influenza vaccination is also recommended for healthcare workers, as well as adults aged ≥ 60 years and individuals with underlying chronic diseases. The aim of this study was to gain first insights into the acceptance and implementation of the seasonal influenza und HPV vaccination recommendations in gynecological practices. In the context of the national influenza immunization campaign-which is jointly carried out by the Robert Koch Institute (RKI) and the Federal Centre for Health Education (BZgA)-a questionnaire was sent together with influenza information kits to 7477 gynecologists in September 2014. Data from 1469 (20 %) gynecologists were included in the analysis. 72 % of respondents reported that they themselves received a seasonal influenza shot each year. The majority of gynecologists recommended seasonal influenza vaccination for pregnant women (93 %) and HPV vaccination for girls (97 %). The most commonly stated reasons against influenza vaccination were safety concerns. Those against HPV vaccination were effectiveness concerns. Additionally, for both vaccinations the provision of vaccine-related information to the patient was considered too time consuming.The high acceptance of seasonal influenza and HPV vaccination among gynecologists is discordant with the available vaccination coverage figures in Germany. Gynecologists must be reminded of their important role in the prevention of vaccine-preventable diseases in adolescents and adult women. Immunization and communication skills should be considered more strongly as an integral part of medical education and further training for gynecologists.

Human Papillomavirus Vaccine Uptake in Adolescent Boys: An Evidence Review.

BACKGROUND: Despite evidence-based guidelines recommending routine vaccination against human papillomavirus (HPV) for adolescent boys, ages 11-12 years, vaccine uptake among this population remains low. AIMS: To examine reasons for low HPV quadrivalent vaccine uptake and methods available to increase vaccine uptake among adolescent males, ages 11-12 years. METHODS AND RESULTS: Of 341 identified studies, 30 were included from three databases. The 30 studies were grouped into six categories: population-specific, problem-specific, educational interventions, theory-specific, political implications, and foundational guidelines and Websites. DISCUSSION: Among eight studies, low vaccine uptake was attributed to lack of parental, adolescent, and physician knowledge of HPV4 vaccine availability and recommendations. HPV4 vaccine educational interventions for parents and adolescents were the most effective for promoting vaccine uptake. Theory applications and gain-framed messages were shown to be effective for assessing HPV vaccine attitudes and perceptions. Political implication studies reveal the need for political and financial measures to encourage HPV vaccine acceptability among the population. IMPLICATIONS FOR CLINICIANS: To promote HPV vaccine uptake among adolescent males, providers must remain current with HPV vaccine recommendations and offer parental and adolescent HPV education focusing on benefits of vaccine acceptance and risks of vaccine refusal. LINKING EVIDENCE TO ACTION: The results of this review inform our understanding of effective educational strategies to positively impact HPV vaccine uptake in adolescent males. Based on this review, clinicians can employ several evidence-based educational strategies to facilitate HPV vaccine uptake.

[Initial examination and screening of migrants : What makes sense and what is evidence-based?]. / Erstuntersuchung und Screening von Migranten : Was ist sinnvoll, was ist evidenzbasiert?

The medical treatment of migrants and refugees has recently become an important topic in the German healthcare system due to the large numbers of migrants. Healthcare for migrants includes treatment of acute illnesses and trauma on arrival, screening for chronic communicable and non-communicable diseases and in the long term, the integration into the local healthcare system. As health problems of migrants are diverse and dependent on the region of origin, guidelines should be readily available for all healthcare professionals involved in migrant healthcare. A literature search for comprehensive guidelines for screening and treatment of migrant's health problems detected 47 different guidelines including 2 comprehensive ones from the US Centers of Disease Control and Prevention and the Canadian Collaboration for Immigrant and Refugee Health. Comparative analysis of these guidelines could be a starting point for evidence-based European guidelines on migrant health.

[Recommendations for the diagnosis and prevention of infectious diseases in pediatric and adolescent refugees in Germany : Statement of the German Society of Pediatric Infectious Diseases, the Society of Tropical Pediatrics and International Child Health, and the Professional Association of Pediatricians]. / Empfehlungen zur infektiologischen Versorgung von Flüchtlingen im Kindes- und Jugendalter in Deutschland : Stellungnahme der Deutschen Gesellschaft für Pädiatrische Infektiologie, der Gesellschaft für Tropenpädiatrie und Internationale Kindergesundheit und des Berufsverbandes der Kinder- und Jugendärzte.

Child and adolescent refugees in Germany represent a particularly vulnerable social group and treating infectious diseases forms a crucial part of providing their medical care. From an infectious diseases perspective, refugees themselves, as a result of their difficult personal circumstances, are the ones at highest risk. Even in crisis situations, medical practitioners are medically and ethically obliged to provide a high standard of care. The guidelines presented here propose recommendations for diagnosing and preventing infectious diseases among refugees under 18 in Germany. The guidelines are intended to assist in optimizing vaccine protection and treatment of diseases while taking into consideration factors such as refugees' challenging living conditions, cultural differences and potential language barriers.Upon refugees' arrival at the first housing sites, it is recommended that a basic clinical screening (and not just a brief visual inspection) be provided in order to identify and initiate treatment for acute medical problems and potentially contagious diseases (including tuberculosis), as well as to close gaps in vaccination coverage. Documentation of the clinical findings is critical, both to avoid redundant investigations and to optimize individual medical care. For this, an effective communication system must be established.Once refugees have been transferred into their destination community, outpatient and inpatient care providers should collaborate to bring refugees up-to-date with all vaccines recommended by STIKO (German Standing Committee on Vaccination). The same high standard of medical care should be delivered to refugees as would be to the general population. Due to the high prevalence of multi-resistant organisms (MRO) in the refugees' countries of origin, MRO screening is recommended for most patients receiving inpatient care.

Human papillomavirus vaccination for boys.

QUESTION: In Canada, generally provincial human papillomavirus (HPV) vaccination programs exist for only the female population. What should I recommend when parents and teenage boys ask about male HPV vaccination? ANSWER: The quadrivalent HPV vaccine is effective and will reduce the incidence of disease in boys and girls. The quadrivalent HPV vaccination is approved and recommended for both boys and girls in Canada. Public funding for male vaccination is available in Prince Edward Island and Alberta. The remaining provinces and territories will need to consider cost-effectiveness analyses before expanding their female-only vaccination programs to include the male population.

Evaluation of the impact of the 2012 Rhode Island health care worker influenza vaccination regulations: implementation process and vaccination coverage.

CONTEXT: In October 2012, the Rhode Island Department of Health (HEALTH) amended its health care worker (HCW) vaccination regulations to require all HCWs to receive annual influenza vaccination or wear a surgical mask during direct patient contact when influenza is widespread. Unvaccinated HCWs failing to wear a mask are subject to a fine and disciplinary action. OBJECTIVE: To describe the implementation of the 2012 Rhode Island HCW influenza vaccination regulations and examine their impact on vaccination coverage. DESIGN: Two data sources were used: (1) a survey of all health care facilities subject to the HCW regulations and (2) HCW influenza vaccination coverage data reported to HEALTH by health care facilities. Descriptive statistics and paired t tests were performed using SAS Release 9.2. SETTING AND PARTICIPANTS: For the 2012-2013 influenza season, 271 inpatient and outpatient health care facilities in Rhode Island were subject to the HCW regulations. MAIN OUTCOME MEASURE: Increase in HCW influenza vaccination coverage. RESULTS: Of the 271 facilities, 117 facilities completed the survey (43.2%) and 160 facilities reported vaccination data to HEALTH (59.0%). Between the 2011-2012 and 2012-2013 influenza seasons, the proportion of facilities having a masking policy, as required by the revised regulations, increased from 9.4% to 94.0% (P < .001). However, the proportion of facilities implementing Advisory Committee on Immunization Practices-recommended strategies to promote HCW influenza vaccination did not increase. The majority of facilities perceived benefits to collecting HCW influenza vaccination data, including strengthening infection prevention efforts (83.2%) and improving patient and coworker safety (75.2%). Concurrent with the new regulations, influenza vaccination coverage among employee HCWs in Rhode Island increased from 69.7% in the 2011-2012 influenza season to 87.2% in the 2012-2013 season. CONCLUSION: Rhode Island's experience demonstrates that statewide HCW influenza vaccination requirements incorporating mask wearing and moderate penalties for noncompliance can be effective in improving influenza vaccination coverage among HCWs.

Recommendation for use of immunization information systems to increase vaccination rates.

Based on findings of a systematic review, the Community Preventive Services Task Force recommends immunization information systems on the basis of strong evidence of effectiveness in increasing vaccination rates. Evidence is considered strong, based on the findings from 108 published articles and 132 conference abstracts showing that immunization information systems are effective in increasing vaccination rates and reducing vaccine-preventable disease through their capabilities to (1) create or support effective interventions such as client reminder and recall systems, provider assessment and feedback, and provider reminders; (2) generate and evaluate public health responses to outbreaks of vaccine-preventable disease; (3) facilitate vaccine management and accountability; (4) determine client vaccination status for decisions made by clinicians, health departments, and schools; and (5) aid surveillance and investigations on vaccination rates, missed vaccination opportunities, invalid dose administration, and disparities in vaccination coverage.

Human Papillomavirus Vaccination Among Adults and Children in 5 US States.

CONTEXT: The Centers for Disease Control and Prevention Advisory Committee for Immunization Practices has recommended human papillomavirus (HPV) vaccines for use in children and young adults for preventing HPV-related diseases, but HPV vaccine coverage is low in the United States. OBJECTIVE: To assess HPV vaccination among US adults and children and to identify characteristics associated with HPV vaccination. METHODS: We used the 2010 Behavioral Risk Factors Surveillance System data to examine HPV vaccine initiation and completion among adults aged 18 to 26 years and children aged 9 to 17 years in 5 US states. We performed a multivariate logistic regression to evaluate factors associated with HPV vaccination. RESULTS: We assessed the HPV vaccination status of 706 women and 560 men and 2201 girls and 2292 boys. In 2010, a total of 258 (41.6%) women and 21 (4.3%) men had initiated HPV vaccination. Of those vaccinated women, 182 (75%) completed the 3-dose vaccine series. Rural residence (adjusted odds ratio [aOR] = 0.37) and not having a Papanicolaou test (aOR = 0.44) were negatively associated with HPV vaccine initiation among women. Women who were aged 18 to 20 years (aOR = 2.93) were more likely to complete HPV vaccination. A total of 612 (24.6%) girls and 86 (5.2%) boys received 1 or more doses of HPV vaccines; 308 (50.3%) vaccinated girls and 14 (10.8%) vaccinated boys completed the vaccine series. Younger age (9-12 years: aOR = 0.09) and not receiving a seasonal influenza vaccine (aOR = 0.44) were negatively related to HPV vaccine initiation in girls. Girls were less likely to initiate and complete HPV vaccination if their parents did not have a routine checkup within 1 year. CONCLUSION: HPV vaccination in the United States remains below the Healthy People 2020 objective (80%). To increase HPV vaccination, strategies still need to focus on improving access to HPV vaccines and utilization of health services.

'Rhyme or reason?' Saying no to mass vaccination: subjective re-interpretation in the context of the A(H1N1) influenza pandemic in Sweden 2009-2010.

During the swine flu pandemic of 2009-2010, all Swedish citizens were recommended to be vaccinated with the influenza vaccine Pandemrix. However, a very serious and unexpected side effect emerged during the summer of 2010: more than 200 children and young adults were diagnosed with narcolepsy after vaccination. Besides the tragic outcome for these children and their families, this adverse side effect suggests future difficulties in obtaining trust in vaccination in cases of emerging pandemics, and thus there is a growing need to find ways to understand the complexities of vaccination decision processes. This article explores written responses to a questionnaire from a Swedish folk life archive as an unconventional source for analysing vaccine decisions. The aim is to investigate how laypersons responded to and re-interpreted the message about the recommended vaccination in their answers. The answers show the confusion and complex circumstances and influences in everyday life that people reflect on when making such important decisions. The issue of confusion is traced back to the initial communications about the vaccination intervention in which both autonomy and solidarity were expected from the population. Common narratives and stories about the media or 'big pharma capitalism' are entangled with private memories, accidental coincidences and serendipitous associations. It is obvious that vaccination interventions that require compliance from large groups of people need to take into account the kind of personal experience narratives that are produced by the complex interplay of the factors described by the informants.