School-based vaccination programmes: a systematic review of the evidence on organisation and delivery in high income countries

Lessons Learned From Bhutan on extending Girls-Only HPV Vaccination Program to Boys: A Qualitative Study

In 2020, Bhutan pioneered a school-based gender-neutral human papillomavirus (HPV) vaccination program, achieving an impressive 96% vaccination coverage rate by 2021. This study, conducted through 49 in-depth interviews with community leaders, policymakers, parents, teachers, and health workers, and 12 focus group discussions with boys who received HPV vaccination. We used conventional content analysis to analyze the data. Enablers of the extension of gender-neutral HPV vaccination included social mobilization and advocacy efforts, which encompassed community engagement and leadership and collaborations with schools. Equally crucial were proficient program management and the strategic use of digital interventions. Challenges included tracking and reaching eligible adolescents. Vaccinated boys perceived school-based vaccination to be a key enabler of vaccine update. The study concludes that extending a girls-only HPV vaccination program to gender-neutral is feasible and acceptable in Bhutan. Findings related to challenges and ways for overcoming them can support other countries interested in gender-neutral HPV vaccination program.

Lessons from a school-based vaccination response following a Diphtheria outbreak in eThekwini district, SA

Diphtheria is a life-threatening respiratory tract infection that causes outbreaks in susceptible populations. Between April and May 2018, an outbreak of diphtheria occurred in the eThekwini district. A school-based outbreak vaccination response was initiated to target vulnerable children and adolescents.

Contribution

This study adds to the limited data describing a school-based vaccination in an outbreak response and highlights successes and challenges. School-based outbreak vaccination response can rapidly increase vaccine coverage; however, additional community engagement may be required in vaccine-hesitant populations.

"I Thought It Was Better to Be Safe Than Sorry": Factors Influencing Parental Decisions on HPV and Other Adolescent Vaccinations for Students with Intellectual Disability and/or Autism in New South Wales, Australia

The uptake of human papilloma virus (HPV) and other adolescent vaccinations in special schools for young people with disability is significantly lower than in mainstream settings. This study explored the factors believed to influence parental decision making regarding vaccine uptake for students with intellectual disability and/or on the autism spectrum attending special schools in New South Wales, Australia, from the perspective of all stakeholders involved in the program. Focus groups and interviews were conducted with 40 participants, including parents, school staff, and immunisation providers. The thematic analysis identified two themes: (1) appreciating diverse parental attitudes towards vaccination and (2) educating parents and managing vaccination questions and concerns. While most parents were described as pro-vaccination, others were anti-vaccination or vaccination-hesitant, articulating a marked protectiveness regarding their child's health. Reasons for vaccine hesitancy included beliefs that vaccines cause autism, concerns that the vaccination may be traumatic for the child, vaccination fatigue following COVID-19, and assumptions that children with disability will not be sexually active. Special school staff regarded the vaccination information pack as inadequate for families, and nurses described limited educational impact resulting from minimal direct communication with parents. More effective communication strategies are needed to address vaccine hesitancy among parents with children with disability.

Beyond Averages: Unpacking Disparities in School-Based Vaccination Coverage in Eastern Sydney: An Ecological Analysis

School vaccination programs are crucial for achieving high immunisation coverage among adolescents, but substantial disparities exist across schools and regions. This ecological study aimed to determine associations between school characteristics and vaccination coverage for diphtheria-tetanus-acellular pertussis (dTpa) and human papillomavirus (HPV) vaccines among year 7 students in southeastern Sydney. An analysis of data from 70 mainstream schools participating in the 2019 South Eastern Sydney Local Health District School Vaccination Program utilised quasi-Poisson regression models to assess associations between vaccination coverage and school attendance, socio-educational status, Aboriginal enrolments, language background other than English (LBOTE), school sector (government, Catholic, or independent), and coeducation status. Median school coverage was 88% for dTpa, 88% for HPV-girls, and 86% for HPV-boys, with interquartile ranges of 82-93%, 84-92%, and 78-91%, respectively. Higher school attendance was associated with increased dTpa vaccination coverage (PR 1.14, 95% CI 1.02-1.27). Single-sex schools showed higher HPV vaccination coverage compared to coeducational schools for both girls (PR 2.24, 95% CI 2.04-2.46) and boys (PR 1.89, 95% CI 1.72-2.08). No significant associations were found for ICSEA, Aboriginal enrolments, LBOTE, or school sector. School attendance and coeducational status significantly influenced vaccination coverage, with differential impacts on dTpa and HPV vaccines. These findings highlight the need for targeted strategies to address disparities in school-based vaccination programs. Research using qualitative methods could be useful to understand the beliefs and attitudes contributing to these disparities in vaccine uptake so that programs can be tailored to maximise participation.

Increasing vaccinations through an on-site school-based education and vaccination program: A city-wide cluster randomized controlled trial

Vaccination rates for mumps, measles, and rubella (MMR) and tetanus, diphtheria, pertussis, and polio (Tdap-IPV) fall short of global targets, highlighting the need for vaccination interventions. This study examines the effectiveness of a city-wide school-based educational vaccination intervention as part of an on-site vaccination program aimed at increasing MMR and Tdap-IPV vaccination rates versus on-site vaccination alone among sociodemographically diverse students from Berlin, Germany. The study was a 1:1 two-arm cluster randomized controlled trial, with schools randomly assigned to either the Educational Class Condition (ECC) or the Low-Intensity Information Condition (LIIC). Both received an on-site vaccination program, while students in the ECC received an additional educational unit. Primary outcomes were MMR and Tdap-IPV vaccination rates. In total, 6512 students from 25 randomly selected urban area secondary schools participated. For students providing their vaccination documents on the day of the intervention (2273, 34.9%), adjusted Poisson mixed models revealed significant between-group differences in favor of the ECC (MMR: logRR = 0.47, 95%CI [0.01,0.92], RR = 1.59; Tdap-IPV: logRR = 0.28, 95%CI [0.10,0.47], RR = 1.32). When adjusting for socioeconomic and migration background, between-group differences became non-significant for MMR but remained significant for Tdap-IPV. Findings suggest that educational, school-based on-site vaccination appears to be a promising strategy for increasing vaccination uptake in adolescents.

An ecological analysis of socio-economic determinants associated with paediatric vaccination coverage in the Campania Region: A population-based study, years 2003-2017

Introduction

Vaccines are the most cost-effective and straightforward intervention against severe infectious diseases. However, in Europe and in Italy, paediatric vaccination coverage for certain vaccines remains suboptimal, with considerable regional differences in Italy. Vaccine coverage varies significantly due to socio-economic and organisational factors. Aim of this study was to assess the influence of the Deprivation Index, the density of General Practitioners and General Paediatricians per inhabitants on the coverage of both mandatory and non-mandatory paediatric vaccinations across local health authorities and health districts in the Campania Region for birth cohorts from 2001 to 2015.

Materials and methods

Population-based, ecological time series analysis focusing on the Campania Region, most populous region in the south of Italy. Vaccination coverage data were extracted from the regional immunization database, whilst information on the Deprivation Index and number of primary care doctors and primary care paediatricians per local health district were extracted from public health records. Univariate descriptive statistics were employed to describe study characteristics, as appropriate, whilst and mixed-effect linear regression models were employed to assess the associations between variables of interest and vaccination coverage.

Results

Overall vaccination coverage has generally increased, except for the MMR vaccine, which showed coverage fluctuations. An increase in the Deprivation Index, indicative of less favourable socio-economic conditions, was associated with decreased vaccination coverage in the 24-month age group for some mandatory vaccines (DTaP: Coef -0.97, 95% CI -1.77 | -0.17; Poliomyelitis: Coef -0.98, 95% CI -1.78 | -0.17; Hepatitis B: Coef -0.90, 95% CI -1.71 | -0.10). Moreover, areas with a greater density of General Paediatricians per inhabitants saw increased coverage for Haemophilus influenzae type b in the 6-year age group (Coef 9.78, 95% CI 1.00 | 18.56).

Conclusions

It is necessary to target public health policies to address vaccination inequalities. These efforts should include expanding vaccination campaigns, enhancing catch-up programs, and increase resource allocation in primary care settings to facilitate the role of General Practitioners and Paediatricians in fostering awareness and adherence.

Effectiveness of Multifaceted Strategies to Increase Influenza Vaccination Uptake: A Cluster Randomized Trial

Importance

Influenza vaccination rates remain low among primary school students and vary by school in Beijing, China. Theory-informed, multifaceted strategies are needed to improve influenza vaccination uptake.

Objective

To evaluate the effectiveness of multifaceted strategies in improving influenza vaccination uptake among primary school students.

Design, Setting, and Participants

This cluster randomized trial was conducted from September 2022 to May 2023 across primary schools in Beijing, China. Schools were allocated randomly in a 1:1 ratio to multifaceted strategies or usual practice. Schools were deemed eligible if the vaccination rates in the 2019 to 2020 season fell at or below the district-wide average for primary schools. Eligible participants included students in grades 2 and 3 with no medical contraindications for influenza vaccination.

Intervention

The multifaceted strategies intervention involved system-level planning and coordination (eg, developing an implementation blueprint, building social norms, and enhancing supervision), school-level training and educating school implementers (eg, conducting a 1-hour training and developing educational materials), and individual-level educating and reminding students and parents (eg, conducting educational activities and sending 4 reminders about vaccination).

Main Outcomes and Measures

The primary outcomes were influenza vaccination uptake at school reported by school clinicians as well as overall vaccine uptake either at school or outside of school as reported by parents at 3 months. Generalized linear mixed models were used for analysis.

Results

A total of 20 schools were randomized. One intervention school and 2 control schools did not administer vaccination on school grounds due to COVID-19, resulting in a total of 17 schools (9 intervention and 8 control). There was a total of 1691 students aged 7 to 8 years (890 male [52.6%]; 801 female [47.4%]) including 915 in the intervention group and 776 in the control group. Of all participants, 848 (50.1%) were in grade 2, and 1209 (71.5%) were vaccinated in the 2021 to 2022 season. Participants in the intervention and control groups shared similar characteristics. At follow-up, of the 915 students in the intervention group, 679 (74.5%) received a vaccination at school, and of the 776 students in the control group, 556 (71.7%) received a vaccination at school. The overall vaccination rates were 76.0% (695 of 915 students) for the intervention group and 71.3% (553 of 776 students) for the control group. Compared with the control group, there was significant improvement of vaccination uptake at school (odds ratio, 1.40; 95% CI, 1.06-1.85; P = .02) and overall uptake (odds ratio, 1.49; 95% CI, 1.12-1.99; P = .01) for the intervention group.

Conclusions and Relevance

In this study, multifaceted strategies showed modest effectiveness in improving influenza vaccination uptake among primary school students, which provides a basis for the implementation of school-located vaccination programs of other vaccines in China, and in other countries with comparable programs.

Trial registration

Chinese Clinical Trial Registry: ChiCTR2200062449.

Impact of COVID-19 on HPV Vaccination Rates in New York City and Long Island

BACKGROUND

In the United States, uptake of human papillomavirus (HPV) vaccination has been exceptionally low as compared with other vaccines. During the coronavirus disease (COVID-19) pandemic, routine vaccinations were deferred or delayed, further exacerbating HPV vaccine hesitancy. The specific effect of the pandemic on HPV vaccination rates in the United States has not been yet described.

METHODS

We aimed to determine the percentage of children achieving full HPV vaccination (2 doses) by age 15 years and to compare prepandemic to pandemic rates of HPV vaccination at pediatric practices across our institution. A retrospective chart review was performed to compare HPV vaccination rates in the "prepandemic" and "pandemic" periods for all children 9 through 14 years of age. Additionally, peaks in COVID-19 positivity were compared with HPV vaccination rates.

RESULTS

Of children 9-14 years old, 49.3% received at least 1 dose of HPV vaccine in the prepandemic period, compared with 33.5% during the pandemic ( P < 0.0001). Only 33.5% of patients received the full 2-dose series of HPV prepandemic, compared with 19.0% of patients during the pandemic ( P < 0.0001). When COVID-19 positivity rates peaked, HPV vaccination also declined.

CONCLUSIONS

The issue of low HPV vaccination rates was amplified due to the COVID-19 pandemic, as illustrated by the correlation between peaks in COVID-19 positivity and low rates of HPV vaccination.

Identifying implementation strategies to address barriers of implementing a school-located influenza vaccination program in Beijing

BACKGROUND

The school-located influenza vaccinations (SLIV) can increase influenza vaccination and reduce influenza infections among school-aged children. However, the vaccination rate has remained low and varied widely among schools in Beijing, China. This study aimed to ascertain barriers and facilitators of implementing SLIV and to identify implementation strategies for SLIV quality improvement programs in this context.

METHODS

Semi-structured interviews were conducted with diverse stakeholders (i.e., representatives of both the Department of Health and the Department of Education, school physicians, class headteachers, and parents) involved in SLIV implementation. Participants were identified by purposive and snowball sampling. The Consolidated Framework for Implementation Research was adopted to facilitate data collection and analysis. Themes and subthemes regarding barriers and facilitators were generated using deductive and inductive approaches. Based on the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change (CFIR-ERIC) matching tool, practical implementation strategies were proposed to address the identified barriers of SLIV delivery.

RESULTS

Twenty-four participants were interviewed. Facilitators included easy access to SLIV, clear responsibilities and close collaboration among government sectors, top-down authority, integrating SLIV into the routine of schools, and priority given to SLIV. The main barriers were parents' misconception, inefficient coordination for vaccine supply and vaccination dates, the lack of planning, and inadequate access to knowledge and information about the SLIV. CFIR-ERIC Matching tool suggested implementation strategies at the system (i.e., developing an implementation blueprint, and promoting network weaving), school (i.e., training and educating school implementers), and consumer (i.e., engaging students and parents) levels to improve SLIV implementation.

CONCLUSIONS

There were substantial barriers to the delivery of the SLIV program. Theory-driven implementation strategies developed in this pre-implementation study should be considered to address those identified determinants for successful SLIV implementation.

Applying the COM-B behaviour model to understand factors which impact school immunisation nurses' attitudes towards designing and delivering a HPV educational intervention in post-primary schools for 15-17 year old students in Northern Ireland, UK

INTRODUCTION

Human Papilloma Virus (HPV) is responsible for the development of cervical, vaginal, vulvar, penile, oropharyngeal and anal cancers. Throughout the UK, Immunisation nurses (IMNs) deliver school-based HPV vaccinations to students 12-13 years old. Providing HPV education to 15-17 year old students may promote decision-making regarding their sexual health and award opportunity for unvaccinated students to self-consent to the vaccination. This study aims to explore the perceptions of IMNs regarding the value of providing HPV education to 15-17 year old students and to explore whether IMNs feel that the design/delivery of this education should form part of their professional role.

METHODS

Six focus groups were conducted online with IMNs from all five Health and Social Care Trusts in Northern Ireland, UK, between January-June 2021. Data were analysed using the COM-B model to identify factors that might influence IMNs' behaviour towards designing/delivering this education for 15-17 year old students.

RESULTS

IMNs were highly motivated to design and deliver this HPV education. Facilitators promoting this behaviour included their specialist training, their previous sexual health teaching experience and their desire to educate young people. Barriers negatively influencing this behaviour included lack of time/resources, parental influences, lack of school support and lack of teaching/presentation skills training.

CONCLUSION

IMNs feel that they are the most appropriate professionals to design/deliver HPV education for 15-17 year old students. National policy change, based on collaboration between the Public Health Agency and Education Authority, is a key factor in facilitating IMNs to implement this school-based HPV education intervention.

Assessing the longitudinal effects of the continuation and discontinuation of the school-located influenza vaccination programme on parental vaccine hesitancy in Hong Kong

BACKGROUND

School-located influenza vaccination programme (SIVP) can effectively promote childhood seasonal influenza vaccination (SIV). However, the longitudinal effects of continuation and discontinuation of the SIVP on parents' vaccine hesitancy remained unknown.

METHODS

A two-wave longitudinal study recruited adult parents who had at least one child attending a kindergarten or primary school using random-digital-dialled telephone interviews. Generalized estimating equation and structural equation modelling were used to examine the impact of changes in schools' SIVP participation status on parents' vaccine-related attitudes, and childhood SIV acceptance over 2 years in Hong Kong.

RESULTS

Children's SIV uptake varied by the schools' SIVP participation status. The highest SIV uptake was found in schools that consistently participated in SIVP (Consistent participation group) (2018/2019: 85.0%; 2019/2020: 83.0%) but lowest in the Consistent non-Participation group (2018/2019: 45.0%; 2019/2020: 39.0%). SIV uptake increased in the Late Initiation group but declined in the Discontinuation group. An increasing trend of parental vaccine-hesitant attitudes was observed in the Consistent non-Participation group.

CONCLUSIONS

Initiation and continuation of the SIVP can reduce parental vaccine hesitancy to achieve a high childhood SIV uptake. Conversely, discontinuation of the SIVP or persistent resistance to the implementation of SIVP can increase parental vaccine hesitancy and reduce childhood SIV uptake.

Identifying and addressing the impacts of the COVID-19 pandemic on school-based immunisation programmes in the Canadian Maritimes: a mixed methods study protocol

INTRODUCTION

The COVID-19 pandemic highlighted the importance of keeping up to date on routine vaccinations. Throughout the pandemic, many routine vaccine programmes in Canada were paused or cancelled, including school-based immunisation programmes (SBIP). This resulted in decreased coverage for many vaccine-preventable diseases. While the effects of the pandemic on SBIP have been described in other provinces, its effects in the Maritime region (ie, Nova Scotia, New Brunswick and Prince Edward Island) have yet to be understood. We aim to determine how these programmes were affected by COVID-19 and associated public health measures in the Canadian Maritimes by (1) identifying and describing usual and interim catch-up programmes; (2) exploring stakeholders' perceptions of SBIP through interviews; and (3) designing recommendations with stakeholders to address gaps in SBIP and vaccine coverage.

METHODS AND ANALYSIS

A sequential, explanatory mixed methods study design will be used to address the objectives during the study period (September 2022-December 2023). First, an environmental scan will describe changes to SBIP and vaccine coverage over a period of five school years (2018/2019-2022/2023). Findings will inform semistructured interviews (n=65) with key stakeholders (eg, health officials, healthcare providers, school officials and parents and adolescents) to explore perceptions of SBIP and changes in parental vaccine hesitancy during the pandemic. These data will be integrated to design recommendations to support SBIP during two stakeholder engagement meetings. Analysis will be guided by the behaviour change wheel, a series of complementary tools and frameworks to simplify behaviour diagnosis and analysis in public health research.

ETHICS AND DISSEMINATION

Ethics approval for this study has been obtained from Dalhousie University's Health Sciences Research Ethics Board (Ref: 2022-6395). Informed consent will be obtained from participants prior to participating in an interview or stakeholder engagement meeting. Study findings will be disseminated through conference presentations, publications and infographics.

Lessons Learned from All for Them: Best Practices for a Cross-Collaboration Approach to HPV Vaccination in Public Schools

The Community Preventive Services Task Force endorses vaccination programs in schools to increase access to vaccinations. However, implementing a school-based approach requires substantial coordination, planning, and resources. All for Them (AFT) is a multilevel, multicomponent approach to increase HPV vaccination among adolescents attending public schools in medically underserved areas in Texas. AFT comprised a social marketing campaign, school-based vaccination clinics, and school nurse continuing education. Process evaluation metrics and key informant interviews to understand experiences with AFT program implementation informed lessons learned. Lessons emerged in six domains: strong champion, school-level support, tailored and cost-effective marketing approaches, mobile provider collaboration, community presence, and crisis management. Strong support at district and school levels is vital for gaining principal and school nurse buy-in. Social marketing strategies are integral to program implementation and should be adjusted to maximize their effectiveness in motivating parents to vaccinate children against HPV, which also can be achieved through increased community presence of the project team. Preparing contingency plans and flexibility within the program can facilitate appropriate responses to provider restrictions in mobile clinics or in the event of unforeseen crises. These important lessons can offer useful guidelines for the development of prospective school-based vaccination programs.

Disparities in Implementing COVID-19 Prevention Strategies in Public Schools, United States, 2021-22 School Year

During the COVID-19 pandemic, US schools have been encouraged to take a layered approach to prevention, incorporating multiple strategies to curb transmission of SARS-CoV-2. Using survey data representative of US public K-12 schools (N = 437), we determined prevalence estimates of COVID-19 prevention strategies early in the 2021-22 school year and describe disparities in implementing strategies by school characteristics. Prevalence of prevention strategies ranged from 9.3% (offered COVID-19 screening testing to students and staff) to 95.1% (had a school-based system to report COVID-19 outcomes). Schools with a full-time school nurse or school-based health center had significantly higher odds of implementing several strategies, including those related to COVID-19 vaccination. We identified additional disparities in prevalence of strategies by locale, school level, and poverty. Advancing school health workforce and infrastructure, ensuring schools use available COVID-19 funding effectively, and promoting efforts in schools with the lowest prevalence of infection prevention strategies are needed for pandemic preparedness.

Why school is crucial to increase vaccination coverage for children: Evaluation of school vaccination check program in South Korea 2021-2022

The School Vaccination Check Program (SVCP) is a public health measure that aims to achieve high levels of National Immunization Program (NIP) vaccination coverage for children by checking the completion of the vaccination schedule for students when they enter elementary or middle school. Due to the COVID-19 pandemic, the SVCP was stopped in 2020 and 2021, and restarted in June-August 2022. In this study, we examined and quantified the relationship with SVCP and the vaccination uptake by comparing the vaccination coverage of 2021 and 2022. Based on the standard schedule, the vaccination records of DTaP5, IPV4, MMR2 and IJEV4 were evaluated for elementary school students. The Tdap6, IJEV5 and HPV1 were evaluated for the students from middle school. Using a difference-in-difference study design and national level big data, the study compared vaccination coverage as of August 2021 and 2022. The study found that the SVCP was effective in increasing vaccination coverage for targeted vaccinations such as DTaP5, IPV4, MMR2 and IJEV4 for elementary school students, and Tdap6, IJEV5 for middle school students. However, the SVCP did not show a statistically significant effect on increasing vaccination coverage on HPV1 for middle school students. School can play an important role to improve vaccination coverage. Therefore, close collaboration with health and education authority is crucial to accomplish successful vaccination program reducing vaccine preventable disease outbreaks in schools.

Formative Research on HPV Vaccine Acceptance among Health Workers, Teachers, Parents, and Social Influencers in Uzbekistan

Human papillomavirus (HPV) vaccines effectively prevent cervical cancer, most of which results from undetected long-term HPV infection. HPV vaccine introduction is particularly sensitive and complicated given widespread misinformation and vaccination of young girls before their sexual debut. Research has examined HPV vaccine introduction in lower- and middle-income countries (LMICs), but almost no studies attend to HPV vaccine attitudes in central Asian countries. This article describes the results of a qualitative formative research study to develop an HPV vaccine introduction communication plan in Uzbekistan. Data collection and analysis were designed using the Capability, Opportunity, and Motivation for Behaviour change (COM-B) mode for understanding health behaviours. This research was carried out with health workers, parents, grandparents, teachers, and other social influencers in urban, semi-urban, and rural sites. Information was collected using focus group discussions (FGDs) and semi-structured in-depth interviews (IDIs), and data in the form of participants' words, statements, and ideas were thematically analysed to identify COM-B barriers and drivers for each target group's HPV vaccine-related behaviour. Represented through exemplary quotations, findings were used to inform the development of the HPV vaccine introduction communication plan. Capability findings indicated that participants understood cervical cancer was a national health issue, but HPV and HPV vaccine knowledge was limited among non-health professionals, some nurses, and rural health workers. Results on an opportunity for accepting the HPV vaccine showed most participants would do so if they had access to credible information on vaccine safety and evidence. Regarding motivation, all participant groups voiced concern about the potential effects on young girls' future fertility. Echoing global research, the study results highlighted that trust in health workers and the government as health-related information sources and collaboration among schools, municipalities, and polyclinics could support potential vaccine acceptance and uptake. Resource constraints precluded including vaccine target-aged girls in research and additional field sites. Participants represented diverse social and economic backgrounds reflective of the country context, and the communication plan developed using research insights contributed to the Ministry of Health (MoH) of the Republic of Uzbekistan HPV vaccine introduction efforts that saw high first dose uptake.

Human Papillomavirus Vaccination Uptake in the Rio Grande Valley: Results from a Pilot Community-Based Educational and School-Based Vaccination Program and Its Expansion

Human papillomavirus (HPV) vaccine is a safe and effective strategy for reducing HPV morbidity and mortality. Schools have become an increasingly attractive setting for delivering vaccinations and supporting vaccination health literacy and decisional support. This study assesses the effectiveness of a community-based, physician-led HPV education campaign (starting in 2016) and onsite middle school-based HPV vaccination program across six school districts (2017, 2019, 2020) in a rural, medically underserved Texas area (Rio Grande Valley). Pre- and post-intervention HPV vaccination rates were tracked against the 2016 National Immunization Survey-Teen target rates (initiation: 49.3%; completion: 32.9%). Summary statistics were stratified by gender, school district, and grade level. The study reached 19,951 students who received HPV vaccines directly or indirectly through our program (10,289 females; 9662 males) (August 2016-August 2022). Of those, 2145 students (1074 females; 1071 males) were vaccinated directly through our program. The overall HPV up-to-date (UTD) rates were 58.8%. The overall median age at HPV vaccine initiation and HPV-UTD (range) was 11 years (9-21) and 12 years (9-20). The overall median interval between HPV vaccine doses (range) was 291 days (146-2968). Recommending HPV vaccine initiation at younger ages increases HPV vaccine completion and providing access to HPV vaccines encourages on-time vaccination and completion.

Factors influencing human papillomavirus school-based immunization in Alberta: A mixed-methods study protocol

More than 1,300 Canadians are diagnosed with cervical cancer annually, which is nearly preventable through human papillomavirus (HPV) immunization. Across Canada, coverage rates remain below the 90% target set out by the Action Plan for the Elimination of Cervical Cancer in Canada (2020-2030). To support this Plan, the Canadian Partnership Against Cancer has commissioned the Urban Public Health Network (UPHN) to coordinate a quality improvement project with Canada's school-based HPV immunization programs. In Alberta, the UPHN partnered with Alberta Health Services (AHS) for this work. This study has one overarching research question: what are parent/guardian and program stakeholder perceived barriers, enablers and opportunities to immunization for youth as part of the school-based HPV immunization program in Alberta? This study uses a mixed-methods sequential explanatory design. A survey will be emailed to a sample of Albertans with children aged 11-17 years. Questions will be based on a Conceptual Framework of Access to Health Care. Subsequent qualitative work will explore the survey's findings. Parents/guardians identifying as vaccine hesitant in the survey will be invited to participate in virtual, semi-structured, in-depth interviews. Stakeholders of the school-based immunization program will be purposively sampled from AHS' five health zones for virtual focus groups. Quantitative data will be analyzed using SAS Studio 3.6 to carry out descriptive statistics and, using logistic regression, investigate if Framework constructs are associated with parents'/guardians' decision to immunize their children. Qualitative data will be analyzed using NVivo 12 to conduct template thematic analysis guided by the Framework. Study results will provide insights for Alberta's public health practitioners to make evidence-informed decisions when tailoring the school-based HPV immunization program to increase uptake in vaccine hesitant populations. Findings will contribute to the national study, which will culminate in recommendations to increase HPV immunization uptake nationally and progress towards the 90% coverage target.

From Human Papillomavirus to COVID-19: Adolescent Autonomy and Minor Consent for Vaccines

Adolescent minors in every state can give their own consent for some health care. Although parent consent is generally required for vaccination, there are exceptions in some states. Completion rates are low for recommended adolescent vaccines; allowing adolescents to consent may improve coverage, although more study is needed on barriers to vaccine completion and the feasibility of changes in consent laws. The COVID-19 pandemic highlights the importance of vaccines and related challenges. This policy brief reviews laws governing adolescent consent for health care, including vaccines, and recommends advocacy to support increased adolescent access to vaccines and improved public health.

Disparities in high schools' vaccination coverage (COVID-19). A natural experiment in the Province of Quebec

Teenagers' vaccination has become crucial to limit the COVID-19 transmission in the population. To increase the vaccination rate of this age group, a school-based vaccination campaign was launched in Québec, Canada from June 7 to 18, 2021. This study aimed to analyze trajectories of vaccination coverage over time among students attending 37 high schools. The study explored whether school-based vaccination campaigns contributed to the progression of the vaccination coverage and attenuated disparities in vaccination coverage across schools. On average, first dose coverage quickly increased from 30.6% to 81.5% between June 6 and 18, 2021, after the launch of the campaign. As of August 13, 2021, first dose coverage had reached 87.9% and 64.9% for the second dose coverage. Public schools with poorer student populations had 6.5 points of percentage lower first dose vaccination rates (95%CI 0.3%; 12.6%) compared to other schools. A higher level of concern related to the pandemic among students was associated with a 4.3 points of percentage increased coverage (95%CI 0.7%; 8.0%). The initial uneven distribution in first dose coverage decreased dramatically by the end of the campaign. Similar trends were observed for the second dose, although between schools' inequality at the end of the period of observation was significantly larger. The school-based vaccination campaign might have initially contributed to a prompt rise in vaccination coverage and helped the disadvantaged schools to reach similar vaccination coverage as seen in other schools. In addition to being an efficient way to achieve rapidly high vaccination coverage, the school-based approach might contribute to increase equity in vaccination distribution.

Cost-utility analysis of increasing uptake of universal seasonal quadrivalent influenza vaccine (QIV) in children aged 6 months and older in Germany

Seasonal influenza causes many cases and related deaths in Europe annually, despite ongoing vaccination programs for older adults and people at high-risk of complications. Children have the highest risk of infection and play a key role in disease transmission. Our cost-utility analysis, based on a dynamic transmission model, estimated the impact of increasing the current vaccination coverage with inactivated quadrivalent influenza vaccine in Germany to all (healthy and high-risk) children under 5 years of age (40% uptake), or under 18 years (40% uptake), or only high-risk children under 18 years (90% uptake). Eight influenza complications were modeled, hospitalization and death rates were based on age and risk status. All three vaccination strategies provided more health benefits than the existing vaccination situation, reducing influenza cases, complications, hospitalizations and deaths across the entire population. The strategy targeting all children under 5 years was highly cost-effective (€6/quality-adjusted life-year gained, payer perspective). The other strategies were cost saving from the payer and societal perspectives. The vaccination strategy targeting all children under 18 years was estimated to provide the most health benefits (preventing on average 1.66 million cases, 179,000 complications, 14,000 hospitalizations and 3,600 deaths due to influenza annually) and the most cost savings (annually €20.5 million and €731.3 million from payer and societal perspectives, respectively). Our analysis provides policy decision-makers with evidence supporting strategies to expand childhood influenza vaccination, to directly protect children, and indirectly all other unvaccinated age groups, in order to reduce the humanistic and economic burden on healthcare systems and society.

Best Practices for COVID-19 Mass Vaccination Clinics

PURPOSE

The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented global public health crisis. Mass vaccination is the safest and fastest pandemic exit strategy. Mass vaccination clinics are a particularly important tool in quickly achieving herd immunity. Primary care physicians have played a crucial role in organizing and running vaccination clinics. In this special report, we synthesize existing guidelines and peer-reviewed studies to provide physicians with practical guidance on planning and implementing COVID-19 mass vaccination clinics.

METHODS

PubMed, Ovid MEDLINE and Embase were used to search for relevant literature using search terms that included COVID-19, mass vaccination, and best practice. We also identified and analyzed national and international guidelines.

RESULTS

Forty-six relevant articles, reports, and guidelines were identified and synthesized. Articles included mass vaccination clinic guidelines and studies before and during the COVID-19 pandemic. Key considerations for COVID-19 mass vaccination clinics include leadership and role designation, site selection, clinic layout and workflow, day-to-day operations, infection prevention, and communication strategies.

CONCLUSIONS

Planning and implementing a successful COVID-19 mass vaccination clinic requires several key considerations. Primary care plays an important role in organizing clinics and ensuring populations made vulnerable by social and economic policies are being reached. Ongoing data collection is required to evaluate and continuously improve COVID-19 mass vaccination efforts. As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine rollout occurs in various countries, research will be required to identify the main factors for success to inform future pandemic responses.VISUAL ABSTRACT.

Needle Fear among Children during Mass Measles Rubella (MR) Injectable Vaccination Campaign in North India: an Observational Study

The cross-sectional observational study evaluated the prevalence and predictors of needle-fear among school-going children during mass Measles-Rubella (MR) immunization campaign (year 2017) in the north Indian city of Chandigarh. Fear of needle was assessed using a single-item self-report global question, anxiety was assessed using the Likert scale (score 1-5) and the standardized "Children Faces Scale" where facial responses were graded from 0 to 4. Out of a total sample of 2568 school children, 1225 (47.7%) reported needle fear (95% CI: 45.8%-49.6%) on a global single item assessment. On an anxiety related Likert scale, 52.3% did not respond (mainly younger children) and among those who responded, 42.6% (523/1226) showed significant anxiety (score of ≥3 on Likert scale of 1 to 5). Finally, 17.4% children (95% CI: 15.9%-18.9%) (n = 446/2568) scored 2 or above (indicating significant needle fear) on the 'Children Faces Scale' during the actual vaccination procedure. The needle fear were significantly increased among girl students as compared to boys (adjusted OR 2.58; 95% CI: 2.05-3.24, p < 0.001) as well as children accompanied by their parents (adjusted OR 2.05; 95% CI:1.57-2.69, p < 0.001). On the other hand, needle fear was significantly lowered in children studying in private schools as compared to public school children (adjusted OR 0.45; 95% CI: 0.28-0.74, p = 0.002). The needle fear, which was an overriding concern in the minds of girls, children accompanied by their parents, and public-school students, must be proactively addressed for successful mass vaccination campaigns. These findings assume further importance with recent international roll out of COVID 19 vaccine.

Parents' reasoning about HPV vaccination in Sweden

INTRODUCTION

The aim of this study was to describe parents' reasoning in making decisions about vaccinating their daughters against human papilloma virus (HPV), a part of the Swedish vaccination programme.

METHOD

Twenty parents whose daughter had been offered HPV vaccination participated. Semi-structured individual interviews were conducted and analysed using thematic analysis.

RESULTS

The findings reveal that the decision-making process is complex. The parents trusted the vaccination programme and saw it as beneficial to society. They also described using different resources to decide about HPV vaccination, but they did not include their daughters in making the decision.

DISCUSSION

Parents need better vaccine and health literacy to be able to decide, based on evidence and in consultation with their daughters, on HPV vaccination. School nurses can play an important role in evidence-based decision-making about HPV vaccination and introducing children to this health-promoting intervention.

Moving towards a strategy to accelerate cervical cancer elimination in a high-burden city-Lessons learned from the Amazon city of Manaus, Brazil

The World Health Organization Call to Eliminate Cervical Cancer resonates in cities like Manaus, Brazil, where the burden is among the world's highest. Manaus has offered free cytology-based screening since 1990 and HPV immunization since 2013, but the public system is constrained by many challenges and performance is not well-defined. We obtained cervical cancer prevention activities within Manaus public health records for 2019 to evaluate immunization and screening coverage, screening by region and neighborhood, and the annual Pink October screening campaign. We estimated that among girls and boys age 14-18, 85.9% and 64.9% had 1+ doses of HPV vaccine, higher than rates for age 9-13 (73.4% and 43.3%, respectively). Of the 90,209 cytology tests performed, 24.9% were outside the target age and the remaining 72,230 corresponded to 40.1% of the target population (one-third of women age 25-64). The East zone had highest screening coverage (49.1%), highest high-grade cytology rate (2.5%) and lowest estimated cancers (38.1/100,000) compared with the South zone (32.9%, 1.8% and 48.5/100,000, respectively). Largest neighborhoods had fewer per capita screening locations, resulting in lower coverage. During October, some clinics successfully achieved higher screening volumes and high-grade cytology rates (up to 15.4%). Although we found evidence of some follow-up within 10 months post-screening for 51/70 women (72.9%) with high-grade or worse cytology, only 18 had complete work-up confirmed. Manaus has successfully initiated HPV vaccination, forecasting substantial cervical cancer reductions by 2050. With concerted efforts during campaigns, some clinics improved screening coverage and reached high-risk women. Screening campaigns in community locations in high-risk neighborhoods using self-collected HPV testing can achieve widespread coverage. Simplifying triage and treatment with fewer visits closer to communities would greatly improve follow-up and program effectiveness. Achieving WHO Cervical Cancer Elimination goals in high-burden cities will require major reforms for screening and simpler follow-up and treatment.

A Mixed-Methods Study to Evaluate Elementary School Staff's Acceptability, Delivery Challenges, and Communication Regarding the Implementation of School-Located Influenza Vaccination Program in Hong Kong

This was a mixed-methods study comprising a questionnaire-based survey, a qualitative study, and analysis of school newsletters to evaluate elementary school staff's acceptability, delivery challenges and communication about school-located influenza vaccination program (SIVP) in Hong Kong. We found that school staff with lower intention to implement SIVP perceived greater logistical difficulties in arranging SIVP. Challenges regarding program delivery included schools' limited infrastructure, the burden of paperwork, the fear of being overwhelmed by multiple school-based vaccination schedules, lacking confidence in communicating with parents about influenza vaccines, and the difficulties in managing vaccination-related anxiety among children with intellectual disability. School staff were generally passive in communicating with parents and students about influenza vaccines. We also found that schools may use the school newsletters as a substitute of the formal informed consent forms. Good partnerships among government, service providers and schools should be established to minimize the burden of paperwork for school staff, facilitate early planning of SIVP, and support schools with limited infrastructure and the vaccination of children with intellectual disabilities. Training is needed to enhance school staff's confidence in communicating with parents and students about influenza vaccines and improve information delivery to support parents' informed decisions for children's vaccination.

Strengthening HPV vaccination delivery: findings from a qualitative service evaluation of the adolescent girls' HPV vaccination programme in England

BACKGROUND

In 2014, the number of HPV vaccine doses given to adolescent girls as part of the English school-based immunization programme was reduced from three to two. This was based on evidence that a two-dose schedule provides long-lasting protection against HPV infection. In 2015/16 a small decline in HPV vaccination coverage in adolescent girls was noted; from 86.7% for the three-dose schedule in 2013/14 to 85.1% for the two-dose schedule. This evaluation examined whether service-related factors contributed to this decline.

METHODS

In May-August 2017, we conducted semi-structured qualitative interviews with 39 participants responsible for commissioning or delivering immunization programmes in six local authorities in the South West, North Central Midlands and South Central Midlands, England.

RESULTS

Effective planning and data management were key for successful service provision of HPV vaccination, as well as close collaboration between commissioners, service providers and data system managers, a team skill mix with experienced staff, pro-active engagement with schools and service providers equipped to respond to parental concerns.

CONCLUSIONS

To maintain and improve the high HPV adolescent girls' vaccine coverage rates achieved in England, in the context of an expanding school-based immunization programme, it is essential to strengthen the organizational capacity of the delivery system.

School-based HPV vaccination positively impacts parents' attitudes toward adolescent vaccination

INTRODUCTION

This qualitative study aimed to explore parental attitudes, knowledge and decision-making about HPV vaccination for adolescents in the context of a gender-neutral school-based Australian National Immunisation Program (NIP).

METHODS

Semi-structured interviews with parents of adolescents eligible for HPV vaccination were undertaken as part of an evaluation of a cluster-randomised controlled trial of a complex intervention in 40 schools (2013-2015). In this qualitative study, we purposively recruited a nested sample of parents from 11 schools across two Australian jurisdictions. Interviews explored parent knowledge and understanding of the HPV vaccine program; HPV vaccination decision-making; their adolescent's knowledge about HPV vaccination; and their adolescent's understanding about HPV vaccination, sexual awareness and behaviour. Transcripts were analysed using inductive and deductive thematic analysis.

RESULTS

Parents' of 22 adolescents had positive attitudes towards the program; the school-based delivery platform was the key driver shaping acceptance of and decision-making about HPV vaccination. They had difficulty recalling, or did not read, HPV vaccination information sent home. Some adolescents were involved in discussions about vaccination, with parents' responsible for ultimate vaccine decision-making. All parents supported in-school education for adolescents about HPV and HPV vaccination. Parents' knowledge about HPV vaccination was limited to cervical cancer and was largely absent regarding vaccination in males.

CONCLUSIONS

Parents' positive attitudes towards the NIP and inclusion of the HPV vaccine is central to their vaccine decision-making and acceptance. More intensive communication strategies including school education opportunities are required to improve parents' knowledge of HPV-related disease and to promote vaccine decision-making with adolescents.

Measles, mumps, rubella prevention: how can we do better?

INTRODUCTION

Measles, mumps, and rubella incidence decreased drastically following vaccination programs' implementation. However, measles and mumps' resurgence was recently reported, outbreaks still occur, and challenges remain to control these diseases.

AREAS COVERED

This qualitative narrative review provides an objective appraisal of the literature regarding current challenges in controlling measles, mumps, rubella infections, and interventions to address them.

EXPERT OPINION

While vaccines against measles, mumps, and rubella (including trivalent vaccines) are widely used and effective, challenges to control these diseases are mainly related to insufficient immunization coverage and changing vaccination needs owing to new global environment (e.g. traveling, migration, population density). By understanding disease transmission peculiarities by setting, initiatives are needed to optimize vaccination policies and increase vaccination coverage, which was further negatively impacted by COVID-19 pandemic. Also, awareness of the potential severity of infections and the role of vaccines should increase. Reminder systems, vaccination of disadvantaged, high-risk and difficult-to-reach populations, accessibility of vaccination, healthcare infrastructure, and vaccination services management should improve. Outbreak preparedness should be strengthened, including implementation of high-quality surveillance systems to monitor epidemiology. While the main focus should be on these public health initiatives to increase vaccination coverage, slightly more benefits could come from evolution of current vaccines.

Benchmarking public health pain management practices during school immunizations

Background

Pain and fear during immunizations can affect children and their future behaviour toward immunization. These negative experiences can be amplified when children receive vaccines as part of school-based immunization programs, where parental or tutor supports are missing. In 2015, HELPinKIDS&ADULTS, a Canadian network of experts, published a clinical practice guideline (CPG) on the management of pain and fear during immunization. This guideline has been endorsed by international, national and provincial organizations. However, the level of integration and implementation of the CPG into local and community immunization programs such as school-based immunization clinics is unclear.

Methods

An investigation whether public health units in Ontario integrated and implemented the pain and fear interventions recommended by the CPG into school-based immunization policies and practices was concluded.

Results

The study shows that the majority of public health units do have pain and fear policies and procedures in place, but interventions are not integrated in a consistent and formal manner, leading to suboptimal uptake of interventions during immunizations at school.

Conclusion

For pain interventions to be applied with sufficient fidelity and in enough individuals to have a meaningful effect, organizational leaders need to create directives and procedures that support implementation in a systematic and accountable manner.

Safety and Immunogenicity of a Quadrivalent Meningococcal Conjugate Vaccine in Healthy Meningococcal-Naïve Children 2-9 Years of Age: A Phase III, Randomized Study

BACKGROUND

Invasive meningococcal disease is a major cause of meningitis in children. An investigational meningococcal (serogroups A, C, Y, and W) tetanus toxoid conjugate vaccine (MenACYW-TT) could offer protection against invasive meningococcal disease in this population. This phase III study assessed the immunogenicity and safety of MenACYW-TT in children compared with a licensed quadrivalent meningococcal vaccine conjugated with diphtheria protein CRM197 (MenACWY-CRM).

METHODS

Healthy children 2-9 years of age in the United States, including Puerto Rico, were randomized (1:1) to receive MenACYW-TT (n = 499) or MenACWY-CRM (n = 501) (NCT03077438). Meningococcal antibody titers to the 4 vaccine serogroups were measured using a serum bactericidal antibody assay with human complement (hSBA) before and at day 30 after vaccination. Noninferiority between the vaccine groups was assessed by comparing seroresponse rates (postvaccination titers ≥1:16 when prevaccination titers were <1:8, or ≥4-fold increase if prevaccination titers were ≥1:8) to the 4 serogroups at day 30. Safety was monitored.

RESULTS

The proportion of participants achieving seroresponse at day 30 in the MenACYW-TT group was noninferior to the MenACWY-CRM group (A: 55.4% vs. 47.8%; C: 95.2% vs. 47.8%; W: 78.8% vs. 64.1%; Y: 91.5% vs. 79.3%, respectively). Geometric mean titers for serogroups C, W, and Y were higher with MenACYW-TT than for MenACWY-CRM. Both vaccines were well-tolerated and had similar safety profiles.

CONCLUSIONS

MenACYW-TT was well-tolerated in children and achieved noninferior immune responses to MenACWY-CRM against each of the 4 vaccine serogroups.

Investigating the Relationship between Iranian EFL Teachers' Empowerment and their Self-Efficacy as a Consequence for their Educational Improvement

INTRODUCTION

Teacher empowerment is thought to improve student learning by fostering teaching quality. Therefore, the purpose of this study is investigating the relationship between empowerment and self-efficacy of Iranian English as Foreign Language teachers.

MATERIALS AND METHODS

The present study is an experimental study; the population of the study includes all the English language teachers of the universities of Ilam, Iran. Among whom by random sampling, the sample which was consisted of 60 teachers were selected. Participants in this study answered the School Participant Empowerment Scale questionnaire (Short and Rinehart, 1992) as the instrument of the study. The Pearson product-moment correlation was computed to determine the relationship between teacher empowerment and teacher self-efficacy.

RESULTS

The results showed that there was a positive correlation between teacher empowerment and their self-efficacy (r = 0.55, P < 0.01) and differences among teachers' self-efficacy is not significant according to age (r = -0.14, P = 0.23).

CONCLUSIONS

Based on the results of the study, empowerment and self-efficacy have interactive relationships; i.e. self-efficacy in teachers leads to empowerment and empowerment in teachers leads to self-efficacy.

Operational analysis of school-based delivery models to vaccinate children against influenza

Large-scale immunisation programmes against seasonal influenza are characterised by logistical challenges related to the need for vaccinating large cohorts of people in a short amount of time. Careful operational planning of resources is essential for a successful implementation of such programmes. We focused on the process of child vaccination in schools and analysed the staffing and workflow aspects of a school-aged children vaccination programme in England. Our objectives were to document vaccination processes and analyse times and costs associated with different models deployed across England. We collected data through direct non-participatory observations. Statistical data analysis enabled us to identify potential factors influencing vaccine delivery time and informed the development of a tool to simulate vaccination sessions. Using this tool, we carried out scenario analyses and explored trade-offs between session times and costs in different settings. Our work ultimately supported the local implementation of school-based vaccination.

Factors Affecting Delivery of the HPV Vaccination: A Focus Group Study With NHS School-Aged Vaccination Teams in London

This study sought to identify barriers and facilitators to delivery of human papillomavirus (HPV) vaccination in schools. Four focus groups were conducted with 28 staff members, from four National Health Service school-aged vaccination (SAV) teams in London. Data were analyzed using thematic analysis. School engagement and support, and understanding and education about the vaccination (or conversely, a lack of) were identified as both barriers and facilitators. Limited school and team resources, fear of the vaccination, and poor consent form return were identified as barriers. Explanations for why some girls do not complete the vaccination series were provided. Individualizing approaches used to promote and encourage the vaccination was identified as a facilitating factor. Optimal delivery of the HPV vaccination program is dependent on school engagement and the allocation of time for SAV teams to promote vaccination uptake. Immunization program providers should work with schools to improve understanding and support of the HPV vaccination program.

School-based vaccination programmes: An evaluation of school immunisation delivery models in England in 2015/16

Schools are increasingly being used to deliver vaccines. In 2015/16 three school-based vaccination programmes were delivered to adolescents in England: human papillomavirus (HPV), meningococcal groups A, C, W and Y disease (MenACWY) and tetanus, diphtheria and polio (Td/IPV). We assessed how school delivery models impact vaccine coverage and how a delivery model for one programme may impact another. Routinely collected national data were analysed to ascertain the school grade achieving highest coverage within each one-dose programme and to compare two-dose delivery models (within year vs across years) for the HPV vaccine. We also assessed whether the HPV delivery model was associated with coverage in other programmes. MenACWY and Td/IPV coverage was highest in younger school grades. Overall similar HPV coverage was achieved with both models (86.7% two doses within one year, 85.8% two doses across two years, p = 0.20). High two-dose HPV coverage in 2015/16 was reported in areas that achieved high HPV coverage in 2013/14 when three doses were required. Areas with high three-dose coverage in 2013/14 achieved higher coverage with a within-one-year approach (92.0% vs 85.2%, p < 0.001), whilst areas reporting low coverage in 2013/14 achieved lower but similar coverage in 2015/16 with both models (79.2% vs 80.9% p = 0.29). MenACWY and Td/IPV coverage were higher in areas with high HPV coverage in 2013/14. Among high HPV coverage areas, MenACWY coverage was higher when HPV doses were delivered within year. School-based programmes should be offered as early as feasible and acceptable to optimise coverage. The choice of delivery model for HPV should take into account local performance and provider experience. Single providers may delivery multiple vaccines and the delivery for one programme may affect the performance of other programmes. Providers should consider local circumstances including past and current vaccine coverage and factors influencing coverage when deciding what delivery model to adopt.

Acceptance and feasibility of school-based seasonal influenza vaccination in Singapore: A qualitative study

INTRODUCTION

Influenza is a major cause of disease in children. School-based seasonal influenza vaccination can be a cost-effective tool to improve vaccine uptake among children, and can bring substantial health and economic benefits to the broader community. The acceptance and feasibility of school-based influenza vaccination are likely to be highly context-specific, but limited data exist from tropical settings with year-round influenza transmission. We conducted a qualitative study to assess acceptability and feasibility of a school-based seasonal influenza vaccination programme in Singapore.

METHODS

We conducted qualitative in-depth interviews with key stakeholders, including healthcare professionals, representatives of relevant ministries, preschool principals and parents to understand their perspectives on a proposed school-based seasonal influenza vaccination programme. Interviews were transcribed verbatim and analysed using thematic analysis.

RESULTS

We conducted 40 interviews. Although preschool-aged children are currently the recommended age group for vaccination, stakeholders suggested introducing the programme in primary and/or secondary schools, where existing vaccination infrastructure would facilitate delivery. However, more comprehensive evidence on the local influenza burden and transmission patterns among children is required to develop an evidence-based, locally relevant rationale for a school-based vaccination programme and effectively engage policy-makers, school staff, and parents. Extensive, age-appropriate public education and awareness campaigns would increase the acceptability of the programme among stakeholders. Stakeholders indicated that an opt-out programme with free or subsidised vaccination would be the most likely to achieve high vaccine coverage and make access to vaccination more equitable.

CONCLUSIONS

Overall, participants were supportive of a free or subsidised school-based influenza vaccination programme in primary and/or secondary schools, although children in this age group are not currently a recommended group for vaccination. However, a better informed, evidence-based rationale to estimate the programme's impact in Singapore is currently lacking. Extensive, age-appropriate public education and awareness campaigns will help ensure full support across key stakeholder groups.

School-based delivery of routinely recommended vaccines and opportunities to check vaccination status at school, a global summary, 2008-2017

School-based vaccination (SBV) and checking students' vaccination records at school have the potential to optimize vaccination coverage among school-aged children. The primary aim of this paper is to describe adoption of SBV by countries from 2008 to 2017, including target age groups and vaccines delivered in 2017, as reported annually through the World Health Organization (WHO)-United Nations Children's fund (UNICEF) Joint Reporting Form (JRF). Expanding upon previous analyses, country-specific rates of primary school enrollment and home-based record (HBR) ownership were linked to the WHO-UNICEF JRF data, to identify countries with high potential to implement vaccination record checks at school. The proportion of countries reporting delivery of at least one routinely recommended vaccine dose in school settings increased from 95 (of 163 reporting; 58%) in 2008 to 108 (of 181 reporting; 60%) in 2017. The 13 additional countries that reported using SBV in 2017 were among 31 countries for which SBV data from the JRF were unavailable in 2017. The most common antigens delivered through SBV in 2017 were tetanus (94 countries), diphtheria (89 countries), and human papillomavirus (52 countries). Among 93 countries with data available for net primary school enrollment and HBR ownership, 52 (56%) countries had both ≥80% net primary school enrollment and ≥80% of children aged 12-23 months ever owning an HBR; 33 (63%) of these used SBV. If not already doing so, these 33 countries represent an opportunity to introduce routine checking of vaccination status at entry to, or during primary school. With the growing number of new vaccines and booster doses of childhood vaccines targeting school-age children, implementation of SBV and checking of student vaccination records at school may help improve vaccination coverage; however, additional data are needed to assess global prevalence of checking vaccination status at school and to identify factors facilitating optimal implementation of this strategy.

Comparison of the implementation of human papillomavirus and hepatitis B vaccination programs in the United States: Implications for future vaccines

Vaccines for two viruses which cause cancer, human papillomavirus (HPV) and hepatitis B virus (HBV), are recommended for all children in the United States. Numerous parallels exist between the two vaccines in addition to their roles in cancer prevention, including transmission through sexual contact, multiple doses needed for series completion, and vaccine administration in adolescence for HPV and in the initial phase of the HBV vaccination program. All of these factors were viewed as potential barriers to achieving high rates of coverage, yet the ultimate success of the HBV vaccination program led to predictions that similarly high rates of coverage could be achieved for the HPV vaccine. However, currently, only the recommendation for HBV vaccination is supported by mandates for school entry in most states. Uptake of the HPV vaccine has lagged far behind U.S. goals for public health promotion. The aim of this paper is to examine factors which may account for the divergent pathways of the two vaccines. Four main factors are identified: logistical challenges of vaccine administration, attitudes of parents and healthcare providers, safety concerns, and cost. For each factor examined, recommendations are offered to confront similar barriers likely to arise for future vaccines. The authors conclude that gender-neutral state mandates coupled with school-located vaccination programs, stronger gender-neutral messaging from pharmaceutical companies and healthcare providers, and younger age of vaccine administration, if approved, present the most promising approaches to improving uptake of the HPV vaccine, and similar vaccines down the road.

Education, income and occupation and their influence on the uptake of cervical cancer prevention strategies: A systematic review

AIMS

To report a systematic review of the literature exploring how education, income and occupation influence the uptake of cervical screening and HPV vaccination among eligible women in developed countries, including the United Kingdom, United States, Spain, Germany and Norway.

BACKGROUND

Cervical cancer remains a highly prevalent disease despite it being largely preventable through cervical screening and HPV vaccination. Incidence and mortality of cervical cancer are unequally distributed among socioeconomic groups, warranting research into how individual socioeconomic factors contribute to this unbalanced uptake of prevention strategies.

DESIGN

Systematic review and narrative synthesis.

METHODS

The PRISMA guidelines (PLoS Medicine, 6, 2009, e1000097) guided the selection of papers. MEDLINE, CINHAL, PsychINFO, Science Citation Index and HMIC were searched. Ten articles were suitable. Key findings were then extracted, and a narrative synthesis was completed, using suitable guidance and the AXIS tool.

RESULTS

Obtaining high school or college education is associated with uptake of both cervical screening and HPV vaccination. Total household income and income in respect of the countries' poverty line was measured less frequently than education, but associated with screening and vaccination in some studies. Occupation was infrequently measured in comparison to education and income, limiting conclusions of its association to uptake.

CONCLUSION

Education and income have an association with uptake of cervical screening and HPV vaccination among women. However, evidence is insufficient to affirm a relationship between occupation and uptake of screening and vaccination. Further research would be advised to strengthen these findings.

RELEVANCE TO CLINICAL PRACTICE

Interventions to promote cervical cancer prevention strategies should be targeted at women and girls with lower education levels and lower income. However, differences are displayed in the relationships between the individual socioeconomic factors and uptake of preventative strategies between countries and populations and so they should be considered separately. Nurses play a considerable role in people's perceptions and experiences of cervical screening and HPV vaccination. The review findings offer new insight that can inform future policy and nursing practice on targeting interventions to promote uptake among women who are underusing cervical cancer prevention programmes.

Pre-vaccination screening strategies for the use of the CYD-TDV dengue vaccine: A meeting report

The first licensed dengue vaccine, CYD-TDV (Dengvaxia) is efficacious in seropositive individuals, but increases the risk for severe dengue in seronegative persons about two years after administration of the first dose. For countries considering the introduction of Dengvaxia, WHO recommends a pre-vaccination screening strategy whereby only persons with evidence of a past dengue infection would be vaccinated. Policy-makers need to consider the risk-benefit of vaccination strategies based on such screening tests, the optimal age to introduce the vaccine, communication and implementation strategies. To address these questions, the Global Dengue and Aedes-transmitted diseases Consortium (GDAC) organized a 3-day workshop in January 2019 with country representatives from Asia and Latin America. The meeting discussions highlighted many challenges in introducing Dengvaxia, in terms of screening test characteristics, costs of such tests combined with a 3-dose schedule, logistics, achieving high coverage rates, vaccine confidence and communication; more challenges than for any other vaccine introduction programme. A screening test would require a high specificity to minimize individual risk, and at the same time high sensitivity to maximize individual and population benefit. The underlying seroprevalence dependent positive predictive value is the best indicator for an acceptable safety profile of a pre-vaccination screening strategy. The working groups discussed many possible implementation strategies. Addressing the bottlenecks in school-based vaccine introduction for Dengvaxia will also benefit other vaccines such as HPV and booster doses for tetanus and pertussis. Levels of public trust are highly variable and context specific, and understanding of population perceptions and concerns is essential to tailor interventions, monitor and mitigate risks.

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.

Did school characteristics affect the uptake of meningococcal quadrivalent vaccine in Greater Manchester, United Kingdom?

OBJECTIVES

The objective of this study was to assess if school characteristics were associated with the uptake of the meningococcal ACWY (MenACWY) vaccine in Greater Manchester in 2017/18.

STUDY DESIGN

This is an ecological cross-sectional study.

METHODS

We analysed data on all 129 schools in seven local authorities in Greater Manchester from the Department for Education and from local child health information systems to determine whether school characteristics, including school type and Ofsted effectiveness score, were associated with vaccine uptake. Schools with no eligible pupils were excluded. We undertook single-variable and multivariable analysis and considered key interactions.

RESULTS

The overall uptake rate was 80.7%, with a median uptake per school of 80.6% (interquartile range, 69.0%-87.4%). Lower vaccination rates were associated with lower overall effectiveness scores (odds ratio [OR]: 3.54, 95% confidence interval [CI]: 3.00-4.19) and lower numbers of pupils eligible for vaccination (OR: 1.39, 95% CI: 1.28-1.51). Schools with a lower percentage of pupils for whom English is a second language and high deprivation were associated with lower uptake (OR: 1.58, 95% CI: 1.41-1.78). In addition, community schools (the schools with the most local authority oversight) had lower vaccination rates than other categories of schools.

CONCLUSIONS

In this study, uptake rates of the MenACWY vaccine were associated with all five school characteristics considered. Effectiveness scores for schools had the largest association with vaccine uptake, with poorer schools having lower uptake. These characteristics should be used by vaccination providers to prioritise their interventions to increase immunisation rates.

Challenges and opportunities of school-based HPV vaccination in Canada

Primary prevention of human papillomavirus (HPV) through vaccination is a high priority in Canada's cancer prevention efforts. All Canadian provinces and territories have introduced publicly funded, school-based vaccination programs against HPV, but vaccine uptake remains suboptimal in some jurisdictions. We conducted a descriptive qualitative study to better understand the determinants of low HPV vaccine uptake and identify strategies to enhance vaccine acceptance using the socio-ecological model. In Quebec, interviews and focus groups were held in 2015-2016 with 70 key informants including immunization managers, school nurses, school principals, teachers and parents of Grade 4 students (9 years of age). Our findings showed that HPV vaccine uptake was dependent on many interrelated factors at the individual and interpersonal level (e.g. knowledge and attitudes of the different players involved in the vaccination system), at the community level (e.g. social group values and norms, media coverage around the HPV vaccine), at the organizational level (e.g. allocated resources, information provision, consent process, immunization setting and environment) and at the policy level (e.g. changes in provincial HPV vaccine program). We are using the data collection and interpretation tools and approaches developed by our team and used in Quebec to expand our study to four other provinces (British Columbia, Alberta, Ontario and Nova Scotia). We are conducting environmental scans, semi-structured interviews and a survey to better understand the determinants of low HPV vaccine uptake and identify strategies to enhance vaccine acceptance. Having an in-depth understanding of the determinants of HPV vaccination in school settings is critical in order to identify root causes of the suboptimal vaccine uptake and to develop tailored interventions to address these on both supply- and demand-side issues.

Examining Socioeconomic and Computational Aspects of Vaccine Pharmacovigilance

BACKGROUND

Vaccine pharmacovigilance relates to the detection of adverse events, their assessment, understanding, and prevention, and communication of their risk to the public. These activities can be tedious and long lasting for regulatory authority scientists and may be affected by community practices and public health policies. To better understand underlying challenges, we examined vaccine adverse event reports, assessed whether data-driven techniques can provide additional insight in safety characterization, and wondered on the impact of socioeconomic parameters.

METHODS

First, we integrated VAERS content with additional sources of drug and molecular data and examined reaction and outcome occurrence by using disproportionality metrics and enrichment analysis. Second, we reviewed social and behavioral determinants that may affect vaccine pharmacovigilance aspects.

RESULTS

We describe our experience in processing more than 607000 vaccine adverse event reports and report on the challenges to integrate more than 95500 VAERS medication narratives with structured information about drugs and other therapeutics or supplements. We found that only 12.6% of events were serious, while 8.97% referred to polypharmacy cases. Exacerbation of serious clinical patient outcomes was observed in 8.88% VAERS cases in which drugs may interact with vaccinations or with each other, regardless of vaccine activity interference. Furthermore, we characterized the symptoms reported in those cases and summarized reaction occurrence among vaccine-types. Last, we examine socioeconomic parameters and cost-management features, explore adverse event reporting trends, and highlight perspectives relating to the use and development of digital services, especially in the context of personalized and collaborative health-care.

CONCLUSIONS

This work provides an informative review of VAERS, identifies challenges and limitations in the processing of vaccine adverse event data, and calls for the better understanding of the socioeconomic landscape pertaining vaccine safety concerns. We expect that adoption of computational techniques for integrated safety assessment and interpretation is key not only to pharmacovigilance practice but also to stakeholders from the entire healthcare system.

Systematic review searches must be systematic, comprehensive, and transparent: a critique of Perman et al

A high quality systematic review search has three core attributes; it is systematic, comprehensive, and transparent. The current over-emphasis on the primacy of systematic reviews over other forms of literature review in health research, however, runs the risk of encouraging publication of reviews whose searches do not meet these three criteria under the guise of being systematic reviews. This correspondence comes in response to Perman S, Turner S, Ramsay AIG, Baim-Lance A, Utley M, Fulop NJ. School-based vaccination programmes: a systematic review of the evidence on organization and delivery in high income countries. 2017; BMC Public Health 17:252, which we assert did not meet these three important quality criteria for systematic reviews, thereby leading to potentially unreliable conclusions. Our aims herein are to emphasize the importance of maintaining a high degree of rigour in the conduct and publication of systematic reviews that may be used by clinicians and policy-makers to guide or alter practice or policy, and to highlight and discuss key evidence omitted in the published review in order to contextualize the findings for readers. By consulting a research librarian, we identified limitations in the search terms, the number and type of databases, and the screening methods used by Perman et al. Using a revised Ovid MEDLINE search strategy, we identified an additional 1016 records in that source alone, and highlighted relevant literature on the organization and delivery of school-based immunization program that was omitted as a result. We argue that a number of the literature gaps noted by Perman et al. may well be addressed by existing literature found through a more systematic and comprehensive search and screening strategy. We commend both the journal and the authors, however, for their transparency in supplying information about the search strategy and providing open access to peer reviewer and editor's comments, which enabled us to understand the reasons for the limitations of that review.